The document outlines various methods for eye examination, including external examination, visual acuity assessment, color vision testing, and more. Each method is described in detail along with the tools and techniques used for the evaluation. The document serves as a comprehensive guide for ophthalmic examinations, highlighting essential assessments such as pupillary reaction, extraocular motility, and advanced diagnostic tools like tonometry and gonioscopy.

1. METHODS OF
EYE
EXAMINATION
By: Qurat-ul-ain
Ophthalmic Medical
Technologist/ MBA Health &
Hospital management

2. PREAMBLE
External Examination
Visual Acuity Assessment
Color-vision Testing
Pupillary Examination
Extraocular Motility and Alignment
Binocular Vision Testing
Amsler Grid
Slit-lamp Bi-microscopy
Indirect Ophthalmoscope
Tonometry
Gonioscopy
Central Corneal Thickness

3. EXTERNAL EXAMINATION:
• Look for any ptosis.
• Look for lagophthalmos
• Note any unusual growths or lesions that may require a biopsy.
• Measure proptosis or enophthalmos with an exophthalmometer.
• Perform a full cranial nerve exam for patients with diplopia or other
neurologic symptoms.

4. VISUAL ACUITY
(VA)
• Monocularly
• Un-aided VA
• VA with glasses
• BCVA (Best Corrected VA)
• Binocularly VA
• Pinhole VA (if BCVA is worse)
If patient is unable to see the biggest
optotype, the progression is:
• CF (Counting Fingers)
• HM (Hand Movement)
• Perception of Light (PL) with projection
• PL without projection
• No Light Perception (NPL)
VA is measured first for the
distance then for near. Most
commonly carried out using
a Snellen chart, with the
subject reading the chart
from the standard distance.
Steps for evaluating VA:

5. • Children who are too young to
use “Allen pictures” employ the
Central Steady Maintain (CSM)
approach.
Near VA:
• Near VA is a sensitive indicator
for the macular disease.
• Near chart held at comfortable
reading distance.
• Patient wear necessary distance
correction together with a
presbyopia correction.
TOOLS:
• Snellen chart
• Log MAR chart
• ETDRS chart
• Computer chart
• Jaeger chart

6. COLOR VISION TESTING:
• It is useful in the evaluation of optic nerve disease and
in determining the presence of a congenitally
anomalous color defect.
• Color vision depends on 3-populations of retinal cones
with specific peak sensitivity:
Blue (tritan): 414-424nm
Green (deuteron): 522-539
Red (protan): 549-570nm
• If any cone pigment may be deficient (e.g.;
protanomaly-red weakness) or entirely absent
(protanopia- red blindness)
• Acquired macular disease tends to produce blue-yellow
defects, and optic nerve lesions red-green defects.
TOOLS:
• Ishihara test
• City University test
• Hardy-Rand-Rittler test
• Farnsworth-Munsell
100-hue test

7. PUPILLARY EXAM:
• Look for anisocoria, if present check for the pupil size
• Check the reactivity of each pupil with a pen light or Finoff trans-illuminator.
• Use the swinging flash light test to look for a relative afferent pupillary
defect.

8. EXTRAOCULAR MOTILITY AND
ALIGNMENT:
• Test with both eyes open to test versions in six cardinal positions of gaze.
• Repeat monocularly to test ductions.
• Use cover/uncover tests to assess for heterotropias.
• Use the alternate cover test to assess the total amount of deviation.

9. BINOCULAR VISION TESTING:
• Evaluating the sensory status of children is an essential part of the
pediatric eye examination
• Testing stereo acuity is an excellent way of screening for various
conditions that may interfere with the development of binocular
depth perception.
There are two different types of stereo tests:
• Contour stereopsis tests like Titmus test
• Random dot tests like Randot or Lang tests.

10. AMSLER GRID:
• Evaluates 20 of the visual field
centered on fixation.
• Useful for screening and
monitoring macular disease. It
measures between 5 and 6 mm
in diameter.
• Patients with risk of
CNV(Choroidal
Neovascularization) should
provided with an Amsler grid
for regular use at home.
• Relative scotoma
• Absolute scotoma
• Metamorphopsia
• Micropsia
• Macropsia

11. SLIT-LAMP BI-MICROSCOPY:
Anterior Segment:
• Direct illumination: use to detect
gross abnormalities
• Scleral scatter: to detect stomal
haze, cellular or lipid infiltration.
• Retro-illumination: use after pupil
dilation to detect fine epithelial and
endothelial changes.
• Specular reflection: shows
abnormalities of the endothelium
Posterior Segment:
Different dioptric power lenses are
used to view fundus and optic nerve.
60D
90D
78D

12. INDIRECT OPHTHALMOSCOPE:
• Used to refer to the head mounted technique.
• It allows retinal visualization through a greater degree of media
opacity than slit lamp bi-microscopy.
• Lens of various powers are available:
20D
28D
40D

13. TONOMETRY:
Goldmann Tonometry:
• It states that for an ideal, dry, thin-walled sphere, the pressure inside the
sphere (P) equals the force necessary to flatten its surface (F) divided by the
area of flattening (A) i.e. P=F/A
• It is an accurate variable-force tonometer consisting of a double prism.
Other forms of Tonometry:
• Pneumo-tonometry
• Portable applanation tonometry
• Dynamic contour tonometry
• Electronic indentation/applanation tonometry

14. GONIOSCOPY:
• It is a method of evaluating the anterior chamber angle (ACA) and
can be used therapeutically for procedures such as laser
trabeculoplasty and goniotomy.
Other means of angle assessment:
• Anterior Segment Optical Coherence Tomography (AS-OCT)
• High frequency ultrasound biomicroscopy (UBM)

15. CENTRAL CORNEAL THICKNESS
(CCT):
• It can be measured using pachymetry or by Orbscan,
• The normal distribution is 540 ± 30 microns.
• Eyes with a thin cornea have a true IOP that is greater than the
measured IOP.
• Eyes with a thick cornea have a true IOP that is lower than the
measured IOP.
• Patients with NTG tends to have thin CCT measurement.
• It is a vital element when determining the risk of conversion to
glaucoma in individuals with raised IOP.

16. RESOURCES:
• https://www.aao.org/young-ophthalmologists/yo-info/article/how-to-
conduct-eight-point-ophthalmology-exam
• Harley’s Pediatric Ophthalmology (6th Edition) by Leonard B. Nelson and
Scott E. Olitsky
• Kanski’s Clinical Ophthalmology (9th Edition)

17. THANK YOU!