OnExam

Vitals

Visual Acuity

  • Snellen chart
    • Ask patient to wear their glasses or contact required to see distance
    • Ensure adequate lighting and contrast of the chart
    • Ask the patient to cover one eye (usually the left eye first by convention)
    • Record the best visual acuity where more than half of the letters are identified correctly
      • Next record the best visual acuity with pinhole
      • Remind the patient to look in the top portion of their glasses if they are wearing bifocals
    • Use Tumbling E chart for illiterate patients and Allen chart for infants 2-5
      • For infants under 2, you can only test visual function by passing an interesting object (e.g. keys, toy, etc.) and watch how infant follows the object
  • Pocket chart
    • Used to access near vision or glasses for distance vision is inaccessible
    • Ask patient to wear their glasses required for reading
    • Ensure adequate lighting and contrast of the chart
      • Most charts are held 35 centimetres (14 inches) away
    • Ask the patient to cover one eye (usually the left eye first by convention)
    • Record the best visual acuity where more than half of the letters are identified correctly
      • Remind the patient to look in the top portion of their glasses if they are wearing bifocals
  • Low vision
    • Ensure patient cannot identify the lowest visual acuity level on a Snellen chart; which is usually 6/60 (i.e. 20/200)
    • Ensure adequate lighting
    • Hold up your fingersat varying distances of less than 1 metre and check whether the patient can count them
      • Record vision as counting fingers (CF) is patient is able to do so
    • If patient is unable to count fingers, wave your hand at varying distances of less than 1 metre and check if patient is able to see this
      • Record vision as hand motion (HM) if patient is able to do so
    • If the patient is unable to see hand movements, shine a flashlight toward his/her eye and check if patient is able to see this
      • Record vision as hand motion (LP - Light Perception) if patient is able to do so
      • Record vision as no light perception (NLP) if patient is unable to perceive light

Visual Fields

  • Ensure adequate lighting
  • Sit 1 metre in front of the patient
  • Ask patient to cover their left eye with their left hand while the you cover your right eye with your right hand
    • Static: ask patient to count the fingers of the examiner in each of the 4 quadrants
    • Moving: target should start outside the usual visual field, then move slowly to a more central position until the patient confirms visualization of the target

Extraocular Muscles

  • Ensure adequate lighting
  • Sit 1 metre in front of the patient
  • Sit at the patient's eye level and ask patient to follow your fingers with their eyes while not moving their head
  • Assess for lagopthalmos (inability to close the eyelids completely) when having the patient looking down
  • Move your fingers along each cardinal directions of gaze and note any deficits in ocular movement in each eye
    • Ask the patient if they experience any diplopia, especially at the outer limits of extraocular movement
    • Ask the patient if there's pain on extraocular movement at this time
    • Note any Nystagmus by pausing during upward and lateral gaze
  • Test for Developmental dysconjugate gaze with cover-uncover test
  • Eye_chart_1

Eye Pressure (Tono-pen)

  • Ensure the patient does not have allergies to latex or anaesthetic before putting on a new sterile cover on the tono-pen transducer and apply anaesthetic drops
  • For the first measurement of the day you should calibrate the tono-pen
    • Turn on the tono-pen, then press the user button twice rapidly to enter calibration mode (Many models will have an LED display reading "CAL")
    • Then point the transducer straight down
    • After 15 second you will hear a audible beep, at which you point the transducer straight up
    • A functional tono-pen will then beep once more (Many models will have an LED display reading "GOOD")
    • Press the operator button once if you are ready to take measurements
  • Once the tono-pen is calibrated or if this is a repeat measurement, you are ready to begin
    • Press the user button once, the tono-pen should beep and the first measurement is ready to be taken
    • Brace the patients eyelids open with one hand, telling the patient to look straight ahead
    • Hold the pen with your other hand like a pencil and brace this hand against the patient's maxillar region for stability
    • Tap the corneal surface lightly four time to get a reading with the statistical reliability (two beeps will be heard after a statistical reading is made)
      • Indentation of the cornea is not required and may lead to inaccurate readings.

Pupil Size

  • Document bilateral pupil reaction to accommodation
    • Instruct patient to focus on your finger and sit on equal level as patient
    • Start by having finger 1 metre away from patient, then move finger towards patient until it is at the tip of the patient's nose
  • Test for Relative afferent pupillary defect with the swinging light test.

Inspection

  • From a distance, note the patient's eye alignment and symmetry of eye position and pupil size
  • Note any lesions or deformities around the eyes, such as:
    • Traumatic wounds and entry sites of infection (e.g. cuts, ecchymosis, etc.)
    • Erythema
    • Rashes
    • Exudates
    • Previous surgical sites
    • Lesions (e.g. skin cancers, papillomas, etc.)
    • Allergic shiner in the adnexal region
    • Eye protruding from the orbit (exophthalmos)
    • Enopthalmos (eye sunken into the orbit)
  • Palpate for preauricular lymphadenopathy
  • Palpate for scalp tenderness when giant cell arteritis is in the differntial
  • N.B. Any lesion larger than 1mm should be measured
  • Preform either cover-uncover test or Hirschberg test for strabismus
  • Test for Colour vision defects using the Ishihara test

Lids and Lashes (L/L)

  • From a distance, note the patient's lid function and symmetry
    • Note any ptosis (eye lid drop) or lagopthalmos (inability to close the eyelids completely)
  • Assess the eyelid position in relation to the globe, look for:
    • Ectropion - condition where the lower eyelid turns outwards
    • Entropion - condition where the eyelid (usually the lower lid) folds inward
  • Proceed to the slit lamp exam and look for lesions on the eyelid and lid margins; look for:
    • Deformities
    • Erythema
    • Masses
    • Foreign bodies
    • Previous surgical sites
    • Uleceration
  • Inspect the glands of Moll and Zeis along the lid margin
    • Look for prominent glands and blocked glands
  • Inspect the lacrimal puncta at the nasal end of the lid margin
  • Evert the eyelids and look for
    • Papules (cobblestone arrangement of flattened nodules with central vascular cores)
    • Follicles (small, dome-shaped nodules without a prominent central vessel)
    • Masses
    • Lesions
    • Foreign bodies
  • To evert the upper eyelids
    • Applying a drop of anaesthetic to the eye may be necessary to ensure patient comfort
    • Ask patient to look down
    • Push down on the tarsal plate with the blunt end of a cotton swab, as you grasp the lashes and pull up
    • Have patient look up once you are done inspecting the tarsal conjunctiva
  • Inspect the lashes and look for
    • Eyelash loss
    • Inverted eyelashes
    • Signs of blepharitis
  • N.B. Any lesion larger than 1mm should be measured with the lamp slit beam

Conjunctiva and Sclera (C/S)

  • To fully expose the conjunctiva/sclera for inspection, you must instruct the patient to look in the opposite direction you wish to exam (e.g. ask patient to look down to examine the superior bulbar conjunctiva)
  • Using the slit lamp assess the following:
    • Scleral colour
    • Note any scleral or conjunctival lesions
    • Observe the contour and thickness of the conjunctiva
      • Chemosis is edema of the conjunctiva and will cause an uneven thickness
    • Note any injection of the conjunctiva or sclera
      • Note if injection is mobile when manipulated with a cotton swab
        • Conjunctival vessels are mobile when manipulated
        • Scleral vessels are deeper and remain in place when manipulated
        • Note any ciliary flush which presents as circumferential injection surrounding the limbis
    • Document any subconjunctival hemorrhage
    • Note any previous surgical sites (e.g. bleb from trabeculectomy)
  • N.B. Any lesion larger than 1mm should be measured with the lamp slit beam
  • Test for Keratoconjunctivitis sicca (dry eye syndrome) with Schirmer test

Cornea (K)

  • Using the slit lamp assess the following
    • Corneal thickness
      • Using a narrow slit beam at an angle, pass through the entire corneal surface, any local areas of corneal thinning will be noted by a change in the beam's thickness
    • Corneal shape
      • Using a narrow slit beam at an angle, pass through the entire corneal surface, any change in corneal shape will be noted by a change in the beam's contour
    • Note any corneal foreign bodies
    • Assess the limbis for pannus
    • Assess the colour of the peripheral cornea and limbis (e.g. Kayser-Fleischer ring, arcus senilis)
    • Corneal clarity
      • Note the shape and size of any corneal opacity and look for corresponding epithelial defects
      • Note any corneal haze
    • Assess corneal reflex before applying anesthetic if viral keratitis is in the differential
      • Apply pressure to the suspected corneal opacity with the tip of a tissue
      • Assess the patient's blink reflex, a decreased or absent response signifies decreased corneal sensitivity
    • Note any epithelial defect using fluorescein and anaesthetic drops
      • Option 1: apply fluorescein drops to eyes
      • Option 2: wet the tip of a fluorescein strip with anesthetic drops, apply fluorescein strip to lower tarsal or bulbar conjunctiva
      • Turn on cobalt blue filter for slit lamp
      • Note any focal fluorescein uptake which is immobile with blinking
    • Note any folds in Descemet's membrane
    • Note any lesions on the endothelium such as:
      • Guttata
      • Keratic precipitates
      • Krukenberg's spindle
  • Note any previous surgical sites (e.g. corneal transplant, corneal incisions)
  • To look for leakage from anterior chamber, preform the Seidel test
  • N.B. Any lesions, foreign bodies, opacities larger than 1mm should be measure with the lamp slit beam

Anterior Chamber (AC)

  • Using the slit lamp, assess chamber depth using the Van Herick's test.
  • Look for hypopyon (pus in the anterior chamber)
  • Look for hyphema (blood in the anterior chamber)
  • Look for microscopic white blood cells in the chamber
    • Turn slit lamp on high intensity
    • Rotate slit beam to 30-45 degrees
    • Adjust to 1.6 magnification
    • Adjust beam height and width to 1mm x 1mm
    • Focus on the iris, and then pull back the slit beam to focus in front of the iris
    • Check for floating white cells
    • Check for "flare" which is a haze along the slit beam due to high concentration of protein in the anterior chamber
  • Look for microscopic red blood cells in the chamber
    • Set up slit lamp in the same manner as looking for white cells
    • Switch to red free filter on the slit lamp, red blood cells will appear black
  • Look for any previous surgical sites (e.g. Shunt or tube in the anterior chamber, anterior chamber lens)

Iris (I)

  • Assess iris colour and pupil contour
  • Look for congenital defects of the iris
  • Look for neovascularization by using high magnification along the papillary border
  • Look for lesions of the iris (e.g. nevi, neoplasm)
  • Retroilluminate to look for iris defects and iridotomies
    • Turn slit lamp to maximum intensity
    • Rotate slit beam to 90 degree (i.e. perpendicular to the eye)
    • Shine slit beam through the pupil
    • Look for light shining through the iris
  • Appreciate any anterior or posterior synechiae
  • N.B. Any lesions larger than 1mm should be measured with the lamp slit beam

Lens (L)

  • Note the patient's lens status
    • Natural lens
      • Assess lens clarity
      • Assess lens position
      • Assess lens colour
      • Look for Pseudoexfoliation
    • Without lens (aphakia)
    • Artificial lens (pseudophakic)
      • Document the lens position
      • Assess the lens clarity by retroillumination
        • Turn slit lamp to maximum intensity
        • Rotate slit beam to 90 degree (i.e. perpendicular to the eye)
        • Shine slit beam through the pupil
        • Look for light shining through the iris

Anterior Vitreous (Avit)

  • Focus on the anterior vitreous by shining slit beam through pupil
    • Have patient look up, down, and then straight ahead in rapid succession
    • Appreciate any floaters that have changed position after movement
  • Note the colour of the anterior vitreous (e.g. pinkish hue in vitreous due to intravitreal bleed)

Fundus

OnExam will focus on the basic fundus exam with an ophthalmoscope. A full-dilated fundus exam with indirect ophthalmoscopy will not be discussed.

Preparation

  • Sit at the patient's eye level, a dim room will help with fundoscopy
  • To examine the right eye, hold the ophthalmoscope in your right hand and in front of your right eye (while keeping both eyes open)
  • Approach the patient at a 30 degree angle and find the red reflex
    • Note the presence or absence of a red reflex
    • Note the presence of a white reflex
  • Follow the red reflex until you approach to within 5 cm of the patient's eye
  • Rotate the diopter wheel until the retina comes into focus
    • Use the “0” lens if examiner does not wear glasses or if the examiner if wearing glasses to correct his/her vision during the exam
    • Use “minus” (red numbers) lenses if you are myopic and are not wearing glasses for fundoscopy
    • Use “plus” (black numbers) lenses if you are hyperopic and are not wearing glasses for fundoscopy

Examination

  • Retinal vessels
    • Assess for venous pulsations (veins are often wider, darker in colour and have a dimmer reflex then arteries)
  • Find a retinal vessel and follow it towards it's branching points until you reach the optic disk, assess the disk by looking at
    • Sharpness of the disk margin
    • Disk colour
    • Cup to disk ratio
    • Disk hemorrhages
    • Assess for papilledema
  • ask patient to look directly into the light to view the macula
    • Note the foveal reflex
  • Tilt the ophtalmoscope to view the peripheral retina
    • Note the colour of the retina
    • Look for microaneurysms by using the red free filter
    • Look for lesions and comment on
      • Location
      • Colour
      • Shape
      • Size (by disk diameter, if possible)

References

  1. Bickley LS, Szilagyi PG. Bates' Guide to Physical Examination and History-Taking, 11th ed. Baltimore: Lippincott Williams & Wilkins; 2011.
  2. Gerstenblith AT, Rabinowitz MP. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease, 6th ed. Baltimore: Lippincott Williams & Wilkins; 2012.
  3. Harper RA. Basic Ophthalmology, 9th ed. San Francisco: American Academy of Ophthalmology; 2010.
  4. Stevens S. Test distance vision using a Snellen chart. Community Eye Health 2007; 20(62): 52. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2040251/ (accessed 10 September 2014).
  5. Knoop KJ. Slit lamp examination. http://www.uptodate.com/contents/slit-lamp-examination (accessed 10 September 2014).
  6. Goldberg C. The Eye Exam. http://meded.ucsd.edu/clinicalmed/eyes.htm (accessed 10 September 2014).
  7. Hu E. How to Conduct an Eight-Point Ophthalmology Exam. http://www.aao.org/yo/newsletter/2013-print/article05.cfm (accessed 10 September 2014).