1. HISTORY COLLECTION:
1.Name
2. Age
3.Education
4. Occupation
5.Marital status
6. Date of admission
7. HISTORY
Ocular History
1. What does the patient perceive to be the problem?
2. Is visual acuity diminished?
3. Does the patient experience blurred, double, or distorted vision?
4. Is there pain; is it sharp or dull; is it worse when blinking?
5. Is the discomfort an itching sensation or more of a foreign body sensation?
6. Are both eyes affected?
7. Is there a history of discharge? If so, inquire about color, consistency, odor.
8. Describe the onset of the problem (sudden, gradual). Is it worsening?
9. What is the duration of the problem?
10. Is this a recurrence of a previous condition?
11.How has the patient self-treated?
12. What makes the symptoms improve or worsen?
13. Has the condition affected performance of activities of daily living (ADLs)?
14. Are there any systemic diseases? What medications are used in their treatment?
15. What concurrent ophthalmic conditions does the patient have?
16. Is there a history of ophthalmic surgery?
2. 17. Have other family members had the same symptoms or condition?
8. Visual Acuity :
Snellen chart
1.The Snellen chart, which is composed of a series of progressively smaller rows of letters, is used
to test distance vision.
2. The fraction 20/20 is considered the standard of normal vision. Most people can see the letters
on the line designated as 20/20 from a distance of 20 feet.
3. The patient is positioned at the prescribed distance, usually 20 feet, from the chart • Right eye is
tested and recorded first.
4. Completely occlude the left eye using palm
5. Ask the patient to read the smallest line that he or she can see. The patient should wear distance
correction (eyeglasses or contact lenses) if required.
6. Patients should be encouraged to read more letters and to guess, if necessary. The patient
should be encouraged to read every letter possible.
7. If patient can not see largest snellen letters proceed as follows
8. Reduce the distance
9. Ask the patient to count the fingers and then hands
9. External Eye Examination
1. After the visual acuity has been recorded, an external eye examination is performed.
2. The position of the eyelids is noted. Commonly, the upper 2 mm of the iris are covered by the
upper lid.
3. The patient is examined for ptosis (drooping eyelid) and for lid retraction (too much of the eye
exposed).
4. Sometimes, the upper or lower lid turns out, affecting closure. The lid margins and lashes should have
no edema, erythema, or lesions. The examiner looks for scaling or crusting, and the sclera is inspected.
5. A normal sclera is opaque and white. Lesions on the conjunctiva, discharge, and tearing or blinking are
noted.
6. The room should be darkened so that the pupils can be examined. The pupillary response is checked
with a penlight to determine if the pupils are equally reactive and regular.
3. 7. A normal pupil is black. An irregular pupil may result from trauma, previous surgery, or a disease
process.
8. The patient’s eyes are observed, and any head tilt is noted. A tilt may indicate cranial nerve palsy.
9. The patient is asked to stare at a target; each eye is covered and uncovered quickly while the
examiner looks for any shift in gaze. The examiner observes for nystagmus (ie, oscillating movement of
the eyeball).
10. The extraocular movements of the eyes are tested by having the patient follow the examiner’s finger,
pencil, or a hand light through the six cardinal directions of gaze (ie, up, down, right, left, and both
diagonals).
10. Pupillary reaction
1. It should be round and equal in dm, although less than 1 mm in equality may be normal
2. Poor pupillary reaction in dim light may indicate sympathetic nervous system dysfunction.
3. Poor pupillary reaction in bright light may indicate para sympathetic nervous system dysfunction.
11. Pinhole Testing:
1. The pinhole testing device can determine if a problem with acuity is the result of refractive error.
2. The pinholes only allow the passage of light which is perpendicular to the lens, and thus does not
need to be bent prior to being focused onto the retina.
3. The patient is instructed to view the Snellen chart with the pinholes up and then again with them in
the down position. If the deficit corrects with the pinholes in place, the acuity issue is related to a
refractive problem.
12.Observation of External Structures:
1. Occular Symmetry:
Occasionally, one of the muscles that controls eye movement will be weak or foreshortened, causing
one eye to appear deviated medially or laterally compared with the other.
2. Eye Lid Symmetry :
Both eye lids should cover approximately the same amount of eyeball. Damage to the nerves controlling
these structures (Cranial Nerves 3 and 7) can cause the upper or lower lids on one side to appear lower
then the other
3. Sclera
4. The normal sclera is white and surrounds the iris and pupil. In the setting of liver or blood disorders that
cause hyperbilirubinemia, the sclera may appear yellow, referred to as icterus.
4. Conjunctiva
The sclera is covered by a thin transparent membrane known as the conjunctiva, which reflects back
onto the underside of the eyelids. Normally, it's invisible except for the fine blood vessels that run
through it. When infected or otherwise inflamed, this layer can appear quite red, a condition known as
conjunctivitis. Alternatively, the conjunctiva can appear pale if patient is very anemic. By gently applying
pressure and pulling down and away on the skin below the lower lid, you can examine the conjunctival
reflection, which is the best place to identify this finding.
13. Extraocular movements and cranial nerves •
1. Normally, the eyes move in concert (e.g. when the left eye moves left, the right eye moves left to a
similar degree). This coordinated movement depends on 6 extraocular muscles that insert around the
eye balls, allowing them to move in all directions.
2. Each muscle is innervated by one of 3 Cranial Nerves (CNs):
CNs 3 (Oculomotor),
4 (Trochlear) and
6 (Abducens).
elevation (pupil directed upwards)
depression (pupil directed downwards)
adbduction (pupil directed laterally)
adduction (pupil directed medially)
extorsion (top of eye rotating away from the nose)
intorsion (top of eye rotating towards the nose)
cranial nerve testing
1. examiner can observe eye movements in all directions.
2. Stand in front of the patient.
3. Ask them to follow your finger with their eyes while keeping their head in one position
5. 4. Using your finger, trace an imaginary "H" or rectangular shape in front of them, making sure that your
finger moves far enough out and up/down so that you're able to see all appropriate eye movements (ie
lateral and up, lateral down, medial down, medial up).
5. At the end, bring your finger directly in towards the patient's nose. This will cause the patient to look
cross- eyed and the pupils should constrict, a response referred to as accommodation.
14. DIAGNOSTIC TESTS Ophthalmoscope:
1. Visualise lens, vitreous humor, retina, optic disc
2. Priorly phenylphrine solution is instilled to dilate the pupil thus permits better view of inner eye
3. Have the patient seated comfortably
4. Instruct the patient to look at a point not to move
5. Begin to look at right eye about 1 foot from patient
6. Use your right eye with opthalmoscope in your right hand
7. Place your free hand on patients forehead or shoulder to keep yourself steady
8. Slowly come close to the patient
9. Examine optic disc, retinal blood vessel, retinal back ground
15. Slit-Lamp Examination :
1. The slit lamp is a binocular microscope mounted on a table.
2. This instrument enables the user to examine the eye with magnification of 10 to 40 times the real
image.
3. The illumination can be varied from a broad to a narrow beam of light for different parts of the eye.
16. Color Vision Testing
1.color vision test is performed using Ishihara polychromatic plates.
2. On each plate of this booklet are dots of primary colors that are integrated into a background of
secondary colors.
3. The dots are arranged in simple patterns, such as numbers
4. Patients with diminished color vision may be unable to identify the hidden shapes.
5. Patients with central vision conditions (eg, macular degeneration) have more difficulty identifying
colors than those with peripheral vision conditions (eg, glaucoma) because central vision identifies color
6. 17. Amsler Grid
1. it consists of a geometric grid of identical squares with a central fixation point.
2. Hold the Amsler grid approximately 14 to 16 inches from your eyes.
3. Cup your hand over one eye while testing the other eye.
4. The grid should be viewed by the patient wearing normal reading glasses.
5. Each eye is tested separately. The patient is instructed to stare at the central fixation spot on the grid
and report any distortion in the squares of the grid itself.
6. For patients with macular problems, some of the squares may look faded, or the lines may be wavy.
Switch to the other eye and repeat.
18. Optical Coherence Tomography
1. Light is used to evaluate retinal and macular diseases as well as anterior segment conditions.
2. Series of retinal 2 D and 3 D images are taken
3. This method is noninvasive and involves no physical contact with the eye.
19. Color Fundus Photography
1. The patient’s pupils are widely dilated before the procedure.
2. A fundus camera or retinal camera is a specialized low power microscope with an attached camera
designed to photograph the color image of interior surface of the eye, including the retina, retinal
vasculature, optic disc, macula, and posterior pole (i.e. the fundus).
20. Fluorescein Angiography
1. Fluorescein angiography evaluates macular edema, documents macular capillary nonperfusion, retinal
blood supply
2. It is an invasive procedure in which fluorescein dye is injected, usually into an antecubital vein.
3. Within 10 to 15 seconds, this dye can be seen coursing through the retinal vessels.
4. Over a 10-minute period, serial black-and-white photographs are taken of the retinal vasculature.
21 Indocyanine Green Angiography
1. It is used to evaluate abnormalities in the choroidal vasculature, conditions often seen in macular
degeneration.
7. 2. Indocyanine green dye is injected intravenously, and multiple images are captured using digital
videoangiography over a period of 30 seconds to 20 minutes.
Left – FA • Right - IGA
22. Tonometry
1. Tonometry measures IOP
2. Normal IOP 12-22 mm Hg.
3.The procedure is noninvasive and usually painless.
4. A topical anesthetic eye drop is instilled in the lower conjunctival sac.
23. Perimetry Testing
1. To do the test, you sit and look inside a bowl-shaped instrument called a perimeter.
2. While you stare at the centre of the bowl, lights flash. You press a button each time you see a flash.
3.A computer records the spot of each flash and if you pressed the button when the light flashed in that
spot.
