Examination of the eye

1. EXAMINATION OF
THE EYE
Dr. Nick Sargent
1) Talk
2) Practical

2. Include
 Vision
 General look
 Anterior segment (lids, conjunctiva, cornea, iris, lens)
 Posterior segment (vitreous, retina, optic nerve)
 Pupils
 Eye movements
 Orbit examination
 Ptosis examination
 General exam (neurological, cardiovascular, thyroid, etc)
 Other investigations (e.g. ultrasound)

3. VISION
1) Visual acuity
2) Visual field
3) Colour vision
4) Amsler chart (metamorphopsia)

4. VISUAL ACUITY
Resolving power of the eye

5. Snellen Acuity (using Snellen
chart)
 At 6 metres, it is considered that the
eye is in a relaxed state, free of
accommodative effort. Therefore, test
done conventionally at 6 metres
 Top figure (numerator): distance at
which the patient can see the smallest
letter possible, usually at 6 metres
 Bottom figure (denominator): distance
that a normal person could see the
same sized letter

6. Example
 6/12: means that the patient sees at 6
metres what a normal person can see at
12 metres.

7. Examples
 6/5: better than normal
 6/6: normal
 3/60: has to see the top letter at 3 metres

8. United States
 Use feet instead of metres (imperial
system)
 Numerator is 20 feet
 20/20 = 6/6
 20/60 = 6/18
 20/200=6/60

9. For illiterate or language difficulties
 Landolt’s broken ring test types

10. For illiterate or language difficulties
 E-test: various sizes of ‘E’ are on different
faces of a cube

11. For illiterate or language difficulties
 Sheridan-Gardiner test

12. Crude bed-side tests
 Wrist watch
 Wall clock
 Newspaper/ book
 Watch how patient walks into the room and if
they can locate your hand to shake it
 Point to a bright light

13. ‘Hundreds and thousands’
sweet test
Preferential looking with
Cardiff cards
Visual acuity tests in preverbal children

14. Preferential looking using
Teller acuity cards

15. NEAR VISION

16. VISUAL FIELD
EXAMINATION
Confrontation method

17.  Should include:
 finger movement
 finger counting
 red or white pin
 Get on same level as patient
 Check that patient can see out of each eye
by covering each eye in tur and present
the object for confrontation
VISUAL FIELD EXAMINATION

18.  Check peripheral field for hemianopia,
quadrinopia.
 Check also if the lesion obey the midline
 Check central scotoma with a red pin
VISUAL FIELD EXAMINATION

19. OTHER THINGS TO DO
 blind spot examination (usually not required
unless no other abnormality seen)
 red saturation between the two eyes (optic
neuritis)
 red comparison between quadrants of one eye
(abnormal in early bitemporal hemianopia)

20. Most common cases in exams
 bitemporal hemianopia (also look for evidence of
pituitary abnormality such as acromegaly or
hypopituitarism)
 homonymous hemianopia / quadrinopia ( look
for any evidnece of hemiparesis)
 central scotoma (the patient may have multiple
sclerosis, look for spastic paresis or nystagmus)

21. COLOUR
VISION
Ishihara colour vision test

22. Colour vision testing
 Ishihara colour vision test
 Sensitive test for optic nerve dysfunction
and macular disorders

23. Amsler Chart
 Grid with boxes
 Patient asked if lines looked distorted,
crooked, bent, missing (metamorphopsia)
 Particularly useful for testing macular
function

24. GENERAL LOOK

25. GENERAL LOOK
 stand back and observe the whole patient
for a few seconds before carrying out the
examination.
 Sometimes, observation alone is sufficient
to give you the diagnosis and the
examination only serves to confirm it.
 Observation is especially rewarding in
pupillary examination.

26. Skin
 Rashes
 Naevi
 Discolouration
 Swellings

27. Common mistakes with general
look include:
 Mistaking pseudoptosis for example in a
patient with hypotropia
 Mistaking a prosthetic eye for unreactive
pupil
 Mistaking a big eye for proptosis.

28. Dysmorphic features and
congenital defects

30. GLASSES, PRISMS, OCCLUSION,
SHADES

31. SLIT-LAMP EXAMINATION

33. Describe the basic
concepts of the slit lamp?

34. SLIT-LAMP
 Binocular microscope
 Adjust light beam to examine for different things
 Can examine fundus by holding a lens in front of
the eye held in the hand
 Have system of looking from front of eye to back

35. ANTERIOR SEGMENT
Basic signs to look out for……

37. Lashes e.g. Trichiasis
• Posterior misdirection of normal lashes
• Most frequently affects lower lid
Complications
• Inferior punctate epitheliopathy
• Corneal ulceration and pannus
Signs

38. LIDS

40. Swelling e.g. Acute allergic
oedema

42. Rash, e.g. Herpes zoster ophthalmicus
• Crusting ulceration
Treatment - oral antivirals
• Painful vesicles and pustules
• Periorbital oedema - may be
bilateral

44. Look at lacrimal drainage system
e.g. Acute dacryocystitis
• May develop into abscess

46. Look at lid margin: e.g. Molluscum contagiosum
• Painless, waxy, umbilicated nodule• Chronic follicular conjunctivitis
• May be multiple in AIDS patients • Occasionally superficial keratitis
Signs Complications

48. See if lid drooping out: Ectropion

50. Or if lid is drooping in : Entropion

51. CONJUNCTIVA & SCLERA

53. Discharge

55. Evert the lids: Papillae

57. Follicles

58. Redness: diffuse of localised

59. CONJUNCTIVA
 Check all 4 quadrants (ask the patient to
look in 4 positions)
 Remember to examine the fornix (scars,
foreign bodies) and superior bulbar
conjunctiva for a trabeculectomy.

60. CORNEA

61. Look for general distortion: e.g.
Keratoconus

62. Look for Corneal opacities

63. Look for Corneal opacities

64. Look for Corneal opacities

65. Look for Corneal opacities

66. Look for other anomalies

67. Look for other anomalies

68. Look for other anomalies

69. Look for other anomalies

70. Look for other anomalies

71. ANTERIOR CHAMBER

74. Hypopyon
Hyphaema

75. Can look at the iridocorneal
structures (‘the angle’)

76. Can look at the iridocorneal
structures (‘the angle’)

77. IRIS

82. LENS

87. INTRAOCULAR
PRESSURE

88. Goldman Indentation Tonometry

89. PUPILS

90.  Anisocoria (unequal pupil sizes)
 Heterochromia (difference in iris colour)
Pupillary Examination: Observe

91. Pupillary Examination:
Anisocoria
 most cases in exams:
 Horner's
 Adie's
 Third nerve palsy
 Less commonly:
 siderosis bulbi
 traumatic.
 Although physiological anisocoria is the most
common cause, it seldoms appear in an
examination

93. Pupillary Examination:
Heterochromia
 congenital Horner's
syndrome
 siderosis bulbi

94. Pupillary Examination: Differences in
pupil size in light and shade
 An abnormally small pupil in one eye more
obvious in shade
 An abnormally large pupil in one eye is
more obvious in bright light

95. PUPIL REFLEXES

96. Reaction to direct and consensual light
 Should know already
 Shine light in right eye once looking for
constriction in right eye
 Shine light in right eye again to look for
consensual reaction in left eye
 Do same for other eye

97. Why is the above technique frowned upon
by the examiner?

98. Answer to the question:
 Miosis occurs with accommodation.
 To see clearly the pupil reaction to light,
the patient should be instructed to look at
a distant object to reduce accommodation.
 By standing in front of the patient, the
candidate stimulates
accommodation and hence miosis.

99. What is the neurological
pathway for the pupil reflex?

100. Applied anatomy of afferent conduction defect
Anatomical pathway Signs
• Equal pupil size
• ipsilateral direct is absent or
diminished Light reaction
- consensual is normal
• Near reflex is normal in both eyes
• Total defect (no PL) = amaurotic pupil
• Relative defect = Marcus Gunn pupil
3rd

101. Swinging light test for afferent
pupillary defects.
 More sensitive test
 With direct and consensual test, both eyes
may constrict despite an anomaly in the
afferent pathway
 Good for certain retinal and optic
neuropathies e.g. central retinal vein
occlusion, retinal detachments, glaucoma,
optic neuritis

102. Swinging light test for afferent
pupillary defects.
 If have a relative afferent defect, also
called a Marcus Gunn pupil
 Works on basis that the drive for
constriction in the affected eye is delayed
compared to the relative drive for dilatation
from the unaffected eye

103. Swinging light test for afferent
pupillary defects.

104. EFFERENT DEFECT
 E.g. with a 3rd nerve palsy caused by a
cerebral aneurysm
 If affected side is the right 3rd nerve
 Shining light in right eye, get constriction of
left eye only
 Shining light in left eye, get constriction of left
eye only

105. Reaction to accommodation
 Method:
 Get patient to look into distance
 Then to look at a close object
 Then look in to distance again (tonic pupil)
 Causes of light-near dissociation

106. Slit-lamp examination of pupil and
iris
 Synechiae and inflammation
 Iris atrophy
 Old trauma
 Vermiform movements (tonic pupil)

107. If find an anomaly, think what additional
examination would want to do
 RAPD :this indicate optic nerve disease or extensive
retinal dysfunction.
Look for optic disc pallor, advanced glaucoma cupping or
total retinal detachment.
 Horner's syndrome (neck or chest scar )
 Third nerve (ocular motility )
 Adie's pupil (slit-lamp for vermiform iris movement and
knee jerk )
 Argyll-Robertson's pupil ( interstitial keratitis, deafness )

108. Horner syndrome
• Caused by oculosympathetic
palsy
• Usually unilateral mild
ptosis and miosis
• Slight elevation of lower lid
• Normal pupillary reactions
• Iris hypochromia if
congenital or longstanding
• Anhydrosis if lesion is below
superior cervical ganglion

109. HORNER’S SYNDROME

110. Important causes of Horner syndrome
Central
(first order neurone)
• Brainstem disease
(vascular, demyelination)
• Spinal cord disease
(syringomyelia, tumours)
Pre-ganglionic
(second order neurone)
• Intrathoracic lesions
(Pancoast tumour, aneurysm)
• Neck lesions
(glands, trauma)
Post-ganglionic
(third order neurone)
• Internal carotid artery disease
• Cavernous sinus mass
Posterior hypothalamus
Ciliospinal centre of
Budge( C8 - T2 )
Superior cervical
ganglion

111. PHARMACOLOGICAL TESTS
FOR PUPIL DEFECTS

112.  Horners:
 cocaine drops (to confirm Horners),
 hydroxyamphetamine (to help distinguish a 3rd
order neurone horners from a 1st and 2nd
order)
 Adies pupil: pilocarpine 0.125%

113. DIRECT
OPHTHALMOSCOPY

114. Direct ophthalmoscopy
 Dim the light to give better contrast.
 Ask patient to fixate on distance object.
 Do not block vision to fellow eye.

115. Use your right eye to examine
patient’s right eye

116. Red reflex
 Quickly look from 10 cm with plus for red
reflex and anterior segment.
Leukocoria
Vitreous haemorrhage

117. DIRECT OPHTHALMOSCOPY
 Examine structures in a methodical sequence.
 Disc (think of the 3 Cs: cup, colour and contour)
 Macula
 Vessels
 Periphery
 Vitreous

118. Disc changes
 Disc swelling
 Optic atrophy
 Cupping

119. MACULAR CHANGES
 ARMD
 Drug-induced
 Diabetic odema

120. VESSELS
 Atherosclerotic changes
 Diabetic retinopathy
 New vessels
 Emboli

121. PERIPHERY
 Retinitis pigmentosa
 Laser burns

122. TUMOURS

123. INDIRECT
OPHTHALMOSCOPY

125. 3 MIRROR CONTACT LENS

126. EYE MOVEMENTS
1) Cover / Uncover test
2) Ocular motility

127. Cover / Uncover test

128. Cover / Uncover test
 1. Observe any abnormal head posture
For example:
 face turn (sixth nerve palsy, Duane's syndrome)
 head tilt (fourth nerve palsy)
 chin up (vertical muscle weakness, V and A pattern
strabismus, ptosis)

129. Cover / Uncover test
 2. Light target (pen torch) :
Observe corneal reflexes in primary position

130. Strabismus: Cover / Uncover test
 3. Look for deviation with
 cover/uncover test in primary position for
near and distance (usually 6 m is
sufficient). Use accommodative object for
near
 alternate cover test as above
 if the patient were to wear glasses the eyes
should be examined with and without
glasses

131. most common cases in exams are:
 Infantile esotropia ( observe for
dissociated vertical deviation, latent
nystagmus)
 accommodative esotropia ( lood for
orthophoria with glasses)
 fourth nerve palsy

132. Ocular motility

133. Ocular motility
 Ask if the examiner want you to begin with
cover/uncover test
 Examine the eye movements in the nine cardinal
positions noting:
 restriction of motility
 nystagmus
 associated signs such as lid narrowing/widening or ocular
retraction

134. Ocular motility
 Check saccades both horizontal and vertical
 Check accommodation (convergence)

135. The most common cases in exams
are:
 third nerve palsy
 fourth nerve palsy
 sixth nerve palsy
 Duane's syndrome
 Brown's syndrome
 Myasthenia gravis

136. Orbit Examination

138. Orbital trauma (RTA) proptosis or
left enophthalmos ???

139. Orbit Examination
 Observe
 lid retraction
 arterialisation of scleral vessels
 Confirm proptosis from side and behind
and above

140. Orbit Examination
 Measure with ruler or Hertel's
exophthalmometer

141. Orbit Examination
 Use ruler to assess if proptosis is axial or
non-axial

142. Orbit Examination
Palpate the orbit for:
 mass
 retropulsion

143. Orbit Examination
 Test ocular motility
 Other:
 listen for bruit
 test optic nerve function

144. DIFFERENTIAL DIAGNOSIS OF
PROPTOSIS
 The most common case in orbit examination is thyroid eye disease.
 However, do not forget the differential diagnosis of proptosis. The
mnemonic VEIN allows easy recall:
V = vascular for eg. cavernous fistula, cavernous haemangioma
E = endocrine as in thyroid eye diseases
I = inflammatory or infectious conditions such as orbital
cellulitis. It is unlikely that you would get acute patient in
fellowship / membership examination
N= neoplastic which has a wide differential diagnosis including optic
nerve glioma, meningioma, lacrimal gland tumour or mucocele from
the frontal

145. CRANIAL NERVE
EXAMINATION

146. CARDIOVASCULAR
EXAMINATION

147. Systemic causes of lid oedema
• Myxoedema
• Renal disease
• Congestive
heart failure
• Obstruction of
superior vena
cava
• Fabry disease

148. THYROID EXAMINATION
(INCLUDING THYROID
STATUS)

149. Other methods of eye examination
and investigations
 Ultrasound
 Electrodiagnostics
 FFA
 Corneal topography

150. THE END

153. Strabismus: Cover / Uncover test
 4. In vertical deviation perform
 three step test

154. Ptosis Examination

155. Ptosis Examination
 Observe
 anisocoria / heterochromia
 ocular alignment
 scars on the forehead or lids from previous surgery

156. Marcus Gunn jaw-winking syndrome
• Accounts for about 5% of all cases of congenital ptosis
• Retraction or ‘wink’ of ptotic lid in conjunction with
stimulation of ipsilateral pterygoid muscles
Opening of mouth Contralateral movement of jaw

157. Bell’s phenomenon
Upward rotation of globe on lid closure
Good Poor - risk of postoperative
corneal exposure

158. Some guides to observation in the relevant techniques:
pupil
look for anisocoria, heterochromia iridis, ptosis, scar over
the temple from temporal artery biopsy.
ptosis anisocoria, heterochromia
slit-lamp exam. heterochromia, aphakic glasses, hearing aids
ophthalmoscopy
hearing aids, aphakic glasses or high myopic glasses (risk of
retinal detachment)
orbital exam. neck scar for thyroidectomy
ocular motility hypermetropic glasses, prisms, head tilt
visual field exam features of acromegaly
neurological exam nystagmus
thyroid status neck scar from thyroidectomy

159. Visual field defects in pituitary adenomas
LE RE
HM
CF
Decussating fibres
are most vunerable

160. OTHER EQUIVALENTS