The Eye Examination

ANATOMY

AnatomyExtraocular movements

MedialLateralUpward Downward

Visual Acuity General physical examination should include :Visual acuityPupillary reactionExtraocular movementDirect ophthalmoscope Dilated exam (in case of visual loss or retinal pathology)Distance or NearDistance visual acuity at age 3early detection of amblyopia

Distance Visual Acuity TestingVA - Visual acuity OD - ocular dexterOS - ocular sinisterOU - oculus uterque

20/20 (6/6;5/5,1.0)

Distance between the patient and the eye chart _____________________________________________Distance at which the letter can be read by a person with normal acuity

Distance Visual Acuity TestingPlace patient at 20 ft (6m) from Snellen chart OD then OSVA is line in which > letters are read Pinhole if < 20/20 or < 6/6

Snellen eye chart Rosenbaum pocket chart

Distance Visual Acuity TestingIf VA < 20/400 or < 6/60Reduce the distance between the pt and the chart and record the new distance (eg. 5/400)If < 5/400 (< 6/60)CF (include distance)HM (include distance)LPNLP

Near Visual Acuity TestingUsually done when Patient complains about near visionDistance testing difficult/impossible But after check the distance we have to check the near acuity alsoDistance specified on each card (35cm)

Anterior SegmentInspection of:EyelidsConjunctiva and scleraCorneaAnterior chamberIrisPupil lens

Anterior chamber depth assessment

Likely shallow if 2/3 of nasal iris in shadow

Pupillary ExaminationDirect penlight into eye while patient looking at distance

Direct Constriction of ipsilateral eyeConsensual Constriction of contralateral eye

Ocular Motility

Rt superior rectusLt inferior oblique Lt superior rectusRt inferior obliqueRt lateral rectusLt medial rectusLt lateral rectusRt medial rectusRt inferior rectusLt superior oblique Lt inferior rectusRt superior oblique

Direct Ophthalmoscopy Tropicamide or phenylephrine for dilationunless shallow anterior chamberunless under neurological evaluationUse own OD to examine OD with Right hand to hold the ophthalmoscopeSame for OS

Posterior SegmentDirect Ophthalmoscopy

Evaluated:Papil Nervus Opticus Blood Vessel of Retina (arteri vein ratio, bleeding, vena microaneurysm)Retina (subhyaloid bleeding, dot blot, flame shape, oedem macula)

Intraocular Pressure Measurement

Range: 10 22Gold standard: Goldmann Aplanation tonometryMore simple device for GP:Digital palpation of IOPSchiotz tonometry

Schiotz toometryAplanation tonometryNon Contact tonometry

Schiotz Tonometry callibaration

Summary of steps in eye examVisual AcuityVisual fields ( confrontation )Extraocular movementsInspection of anterior Segmentlid and surrounding tissue, conjunctiva and sclera,cornea, anterior chamber, iris, Pupillary examination, Lens clarityTonometry (Schiotz, Digital palp)Fundus examinationFundus reflex, Optic Nerve (Cup &Disc ratio, margin, color), vitreous, vessels and macula

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