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Basic Eye Exam
Basic Eye Exam
Objectives
Inordertoevaluate thevisualsystemyoushouldbeable
torecognizethesignificantexternalandinternalocular
structuresofthenormaleyeandtoperformabasiceye
examination.
Toachievetheseobjectives,youshouldlearn
Theessentialsofocularanatomy
Tomeasureandrecordvisualacuity
Toassesspupillaryreflexes
Toevaluateocularmotility
Tousethedirectophthalmoscopeforasystematic
fundusexaminationandassessmentoftheredreflex
Todilatethepupilsasanadjuncttoophthalmoscopy
Toperformtonometry
Toevaluatevisualfieldsbyconfrontation
Relevance
The proper performance of a basic eye examination is a
crucial skill. Systematic examination of the eye enables
the examiner to evaluate ocular complaints and provide
either definitive treatment or appropriate referral to an
ophthalmologist. Furthermore, many eye diseases are
"silent,"orasymptomatic,whileseriousoculardamageis
occurring.Performingabasiceyeexaminationcanreveal
suchconditionsandensurethatpatientsreceivethetimely
care they need. A basic eye examination may provide
earlywarningsignsofanyofthefollowingconditions:
Blindingeyediseasethatarepotentiallytreatableif
discoveredearlyincludecataract,glaucoma,
diabeticretinopathy,maculardegeneration,and,in
youngchildren,amblyopia.
Systemic disease that may involve the eye include
diabetes, hypertension, temporal arteritis, and an
embolismfromthecarotidarteryortheheart.
Tumororotherdisordersofthebraininclude
meningioma,aneurysms,andmultiplesclerosis.
Anatomy
EyelidsTheouterstructuresthatprotecttheeyeballandlubricatetheocular
surface.Withineachlidisatarsalplatecontainingmeibomianglands.
Thelidscometogetheratthemedialandlateral
canthi. The space between the two open lids is called the palpebral
fissure.
Sclera Thethickoutercoatoftheeye,normallywhiteandopaque.
Limbus Thejunctionbetweenthecorneaandthesclera.
Iris The colored part of the eye that screens out light, primarily via the
pigmentepithelium,whichlinesitsposteriorsurface.
Pupil Thecircularopeninginthecenteroftheiristhatadjuststheamountof
lightenteringtheeye.Itssizeisdeterminedbytheparasympathetic and
sympatheticinnervationoftheiris.
Conjunctiva The thin, vascular tissue covering the inner aspect of the
eyelids(palpebralconjunctiva)andsclera(bulbarconjunctiva).
CorneaThetransparentfront"window"oftheeyethatservesasthemajor
refractivesurface.
Extraocular muscles The six muscles that move the globe medially
(medial rectus), laterally (lateral rectus), upward (superior rectus and
inferioroblique),downward(inferiorrectusandsuperioroblique),and
torsionally(superiorandinferiorobliques).Thesemusclesaresupplied
bythreecranialnerves:cranialnerveIV,whichinnervatesthesuperior
oblique cranial nerve VI, which innervates the lateral rectus and
cranial nerve III, which controls the remainder of the extraocular
musclesaswellasthelevatorandtheirissphincter.
Anterior chamber The space that lies between the cornea anteriorly and
the iris posteriorly. The chamber contains a watery fluid called
aqueoushumor.
LensThetransparent,biconvexbodysuspendedbythezonulesbehindthe
pupilandirispartoftherefractingmechanismoftheeye.
Ciliary bodyThe structure thatproducesaqueoushumor.Contractionof
theciliarymusclechangestensiononthezonularfibersthatsuspendthe
lens and allows the eye to focus from distant to near objects
(accommodation).
PosteriorchamberThesmallspacefilledwithaqueoushumorbehindthe
irisandinfrontofthevitreous.
Vitreous cavity The relatively large space (4.5 cc) behind the lens that
extends to the retina. The cavity is filled withatransparentjellylike
materialcalled vitreoushumor.
RetinaTheneuraltissueliningthevitreouscavityposteriorly.Essentially
transparent except for the blood vessels onitsinnersurface,theretina
sendstheinitialvisualsignalstothebrainviatheopticnerve.
Macula Theareaoftheretinaattheposteriorpoleoftheeyeresponsiblefor
fine,centralvision.Theovaldepressioninthecenterofthemaculais
calledthe fovea.
Choroid The vascular, pigmented tissue layer between the sclera and the
retina. The choroid provides the blood supply for the outer retinal
layers.
Optic disc The portion of the optic nerve visible within the eye. It is
comprised of axons whose cell bodies are located in the ganglion cell
layerof theretina.
Optics
ModifiedfromBersonFG.BasicOphthalmologyforMedicalStudentsandPrimaryCareResidents.AmericanAcademyofOphthalmology,1993
Eye Exam.doc
Thecorneaandthelensmakeuptherefractivesurfacesof
theeye.Thecorneaprovidesapproximatelytwothirdsof
therefractivepoweroftheeye,andthelensapproximately
onethirdtoformanimageontheretina.Reducedvisual
acuitywillresultiftheaxiallengthoftheeyeiseithertoo
short (ie, hyperopia also called hypermetropia) or too
long (ie, myopia) for the refracting power of the cornea
and lens. Visual acuity also is reduced if the refracting
power of thecorneaandlensisdifferentinonemeridian
than in another (ie, astigmatism). These optical defects
can be corrected by the use of either eyeglass lenses or
contact lenses. A pinhole placed directly in front of the
eye will narrow the effective pupillary aperture and
thereby ntinimize the blurring induced by a refractive
error.
Theabilityoftheciliarymuscletocontractandthelensto
become more convex is called accommodation. With
increasing age, the lens of every eye undergoes a
progressive hardening, with loss of ability to change its
shape. Loss of accommodation is manifested by a
decreasedabilitytofocusonnearobjects(ie,presbyopia),
while corrected distance visual acuity remains normal.
Presbyopia develops progressively with age but becomes
clinically manifest in the early to mid 40s, when the
ability to accommodate atreadingdistance(35to40cm)
is lost. Presbyopia is corrected by eyeglass lenses, either
as reading glasses or as the lower segment of bifocal
lenses, the upper segment of which can contain a
correction for distance visual acuity if needed. Some
myopic patients with presbyopia simply remove their
distance glasses to read, because they do not need to
accommodateinanuncorrectedstate.
WhentoExamine
Allpatientsshouldhaveaneyeexaminationaspartofa
general physical examination by the primary care
physician. Visual acuity, pupillary reactions, extraocular
movements,anddirectophthalmoscopythroughundilated
pupils constitute a minimal examination. Pupillary
dilation for ophthalmoscopy is required in cases of
unexplained visual loss or when fundus pathology is
suspected(eg,diabetesmellitus).
Distance visual acuity measurement should be performed
in all children as soon as possible after age 3 because of
the importance of detecting amblyopia early. The
tumblingEchartisusedinplaceofthestandardSnellen
eye chart. Depending on what the examination reveals
and on the patient's history, additional tests may be
indicated(listedbelow).
History
An ophthalmic history is no different than any medical
history.Symptomssuchastransientandpersistentvision
loss,blur,flashinglights,diplopia,tearing,redness,visual
distortion, field loss should be defined in terms of its
onset, course, character, exacerbating or ameliorating
factors,treatmentthusfar,andassociatedsymptoms.The
tempooftheappearanceofasymptomisoneofthemost
important factors detecting the urgency for further
evaluation by an ophthalmologist. The sudden, recent
onsetofanyeyesymptom,suchasvisualloss,periorbital
swelling,orsevereeyepainmayallrepresentophthalmic
emergencies and so should be referred to an
ophthalmologist as soon as the preliminary evaluation is
complete. A history of past eye problems and other
medical problems should be elicited after the present
symptomsaredefined.
PhysicalExam
Pleaseseetheappended"HieroglyphicsoftheEyeExam"
forconventionsandabbreviationsusedindocumenting
theeyeexam.
VisualAcuity
Visualacuityisameasurementofthesmallestobjecta
personcanidentifyatagivendistancefromtheeye.The
followingarecommonabbreviationsusedtodiscussvisual
acuity:
OD(oculusdexter) righteye
OS(oculussinister) lefteye
OU (oculusuterque) botheyes
Distance visual acuity is usually recorded as a ratio or
fraction comparing patient performance with an agreed
upon standard. In this notation, the first number
represents the distance between the patient and the eye
chart (usually the Snellen eye chart) the second number
representsthedistanceatwhichtheletterscanbereadby
apersonwithnormalacuity.Visualacuityof20/80thus
indicatesthatthepatientcanrecognizeat20feetasymbol
that can be recognized by a personwithnormalacuityat
80feet.
Visual acuity of 20/20 represents normal visual acuity.
Many"normal"individualsactuallyseebetterthan20/20,
forexample,20/15oreven20/12.Ifthisisthecase,you
should record it as such. Alternative notations are the
decimal notation (eg, 20/20=1.020/40=0.520/200=
Eye Exam.doc
asfollows:
1.
Visualacuityistestedmostoftenatadistanceof20feet,
or 6 meters. Greater distances are cumbersome and
impractical at shorter distances, variations in the test
distance assume greater proportional significance. For
practical purposes, a distance of 20 feet may be equated
withopticalinfinity.
To test distance visual acuity with the conventional
Snelleneyechart,followthesesteps:
1.Placethepatientatthedesignateddistance,usually20
feet (6 meters'), from a wellilluminated Snellen chart.If
glasses are normally wornfordistancevision,thepatient
shouldwearthem.
2.Byconvention,therighteyeistestedandrecordedfirst.
Completelyoccludethelefteyeusinganopaqueoccluder
or the palm of your hand alternatively, have the patient
covertheeye.
3. Ask the patient to read the smallest line in which he
candistinguishmorethanonehalfoftheletters.(IftheE
chart is being used, have the patient designate the
directioninwhichthestrokesoftheEpoint.)
4. Record the acuity measurement as a notation (eg,
20/20)inwhichthefirstnumberrepresentsthedistanceat
which the test is performed and the second number
representsthenumericdesignationforthelineread.
5.Repeattheprocedurefortheothereye.
6. If visual acuity is 20/40 or less in one or both eyes,
repeat the test with the subject viewing the test chart
throughapinholeoccluderandrecordtheseresults.The
pinholeoccludermaybeusedoverthesubject'sglasses.
IfapatientcannotseethelargestSnellenletters,proceed
2.
3.
4.
oftheorbitalrimandlidsmaybeindicated,dependingon
the history and symptoms. Inspection of the conjunctiva
andscleraisfacilitatedbyusingapenlightandhavingthe
patient look up while the examiner retracts the lower lid
orlookdownwhiletheexaminerraisestheupperlid.The
penlightalsoaidsintheinspectionofboththecorneaand
theiris.
UpperLidEversion
Upper lid eversion is sometimes required to search for
conjunctival foreign bodies or other conjunctival signs.
The patient is asked to look down and the examiner
grasps the eyelashes of the upper lid between the thumb
andtheindexfinger.Acottontippedapplicatorisusedto
press gently downward over the superior aspect of the
tarsal plate as the lid margin is pulled upward by the
lashes . Pressure is maintained on the everted upper lid
while the patient is encouraged to keep looking down.
The examiner should have a penlight within reach to
inspect the exposed conjunctival surface of the upper lid
foraforeignbodyorotherabnormality.Toreturnthelid
to its normal position, the examiner releases the lid
marginandthepatientisinstructedtolookup.
FluoresceinStainingofCornea
Cornealstainingwithfluorescein(ayellowgreendye)is
usefulindiagnosingdefectsofthecornealepithelium.
Fluoresceinisappliedintheformofasterilefilterpaper
strip,whichismoistenedwithadropofsterilewateror
salineandthentouchedtothepalpebralconjunctiva.A
fewblinksspreadthefluoresceinoverthecornea.Areas
ofbrightgreenstainingdenoteabsentordiseased
epithelium.Viewingtheeyeundercobaltbluelight
enhancesthevisibilityofthefluorescence.
Two precautions to keep in mind when using fluorescein
are
1. Use fluoresceinimpregnated strips instead of stock
solutions of fluorescein because such solutions are
susceptibletocontaminationwithPseudomonasspecies.
2. Have the patient remove soft contact lenses prior to
applicationtoavoiddiscolorationofthelenses.
PupillaryReactionTesting
ExternalInspection
CornealReflexMeasurements
EyePosition(Hirschberg)
1mm=15D
2mm=30D
4mm=45D
limbus=60 D
45o
10mm
30o
15o
Esotropiaisamanifestoculardeviationinwhichtheeyes
are relatively crossed. Temporal or outward deviation is
called an exotropia and hypertropias refer to vertical
misalignments. Latent deviations are known as phorias
(esophoria,exophoriaetc.)
EyePositionTerms
ESO
EXO
RHYPER
OcularMotility
Evaluation of ocular motility includes an assessment of
static eye position (or alignment) in primary gaze and
conjugateeyemovements(orgaze)ineachofthecardinal
positions (up, down, left and right). Spontaneous eye
movements such as seen in patients with nystagmus
should also be evaluated for frequency, direction and
amplitude.
OD
10mm
Ausefulmethodofassessingalignmentandgazeemploys
corneal reflection from a penlight i.e. Hirschberg reflex.
When the eyes are perfectly aligned and viewing a
fixationtarget,thecornealreflexfallsonthecenterofthe
pupillaryaxis.Displacementofthecornealreflexfromthe
300
300
OS
10mm
10mm
reflexwillfallabout710mmfromthelimbus.
Ophthalmoscopy
Eye Exam.doc
DirectOphthalmoscopy
PupillaryDilation
3.
Toperformdirectophthalmoscopy,followthesesteps:
1.
2.
4.
5.
6.
7.
RedReflex
Lightreflectedoffthefundusofthepatientproducesared
reflex when viewed through the ophthalmoscope at a
distance of 1 foot. Anormalredreflexisevenlycolored
andisnotinterruptedbyshadows.Opacitiesinthemedia
appear as black silhouettes and can be best appreciated
whenthepupilhasbeendilated
OpticDisc
Inmostcases,whenviewedthroughtheophthalmoscope,
the normal optic disc is slightly oval in the vertical
meridian and has a pink color. A central depression in
thesurfaceofthedisciscalledthephysiologiccup.The
opticdisccanbethoughtofastheyardstickoftheocular
fundus. Lesions seen with the ophthalmoscope are
measured in disc diameters (1 disc diameter equals
approximately1.5mm).
Agreatdealofnormalvariationexistsintheappearance
of the optic disc. The size of the physiologic cup varies
amongindividuals.Normalcup:discdiameterratiois.3to
.6 . Larger C/D ratios may be a sign of glaucoma. The
pigmentedcoatsoftheeyetheretinalpigmentepithelium
andthechoroidfrequentlyfailtoreachthemarginofthe
optic disc, producing a hypopigmented crescent. Such
Eye Exam.doc
RetinalBackground
The normal retinal background is a uniform redorange
color due primarily to the pigmentation of the retinal
pigment epithelium. The blood and pigment of the
choroid also contribute to the appearance of the retinal
background.Forexample,inheavilypigmentedeyes,the
fundusmayhaveadarkercolorduetoincreasedchoroidal
pigmentcontent.
lntraocularPressureMeasurement
Intraocular pressure (IOP) is determined largely by the
outflow of aqueous humor from the eye. Thegreaterthe
resistance to outflow, the higher the intraocularpressure.
Alterations in the actual production of aqueous humor
alsohaveaneffectontheintraocularpressure.Intraocular
pressure varies among individuals. An IOP of 15
millimetersofmercury(mmHg)representsthemeanina
"normal"population.
However,anIOPintherangefrom10to21.5mmHgis
acceptable, and falls within 2 standard deviations of the
mean.
Measurement of IOP is an essential part of a glaucoma
screening examination, along with ophthalmoscopic
assessment of the optic cup. IOP determination is
especially helpful for diagnosing patients in the early
stages of chronic openangle glaucoma, when pressure is
elevated but pathologic cupping has not yet developed.
IOP determination is also useful when the diagnosis of
acuteangleclosureglaucomaisbeingconsidered.
Intraocularpressureismeasuredbytonometry.Anumber
of instruments are available for measuring IOP.
Goldmann applanation tonometry, an accurate method of
determining IOP, requires special equipment and is used
primarily by ophthalmologists. Other methods of
measuringIOPincludethenoncontactairpufftonometer,
electronic tonometer, handheld applanation tonometer,
andgaspneumotonometer.
One relatively simple method of measuring IOP is
Schiotz, or indentation, tonometry. The Schiotz
tonometer is inexpensive and widely available but has
largely been replaced by the Tonopen, a handheld
electronictonometer.
ConfrontationFieldTesting
Macula
Thenormalmacula,locateddirectlytemporaltotheoptic
disc, usually appears darker than the surrounding retina
because the specialized retinal pigment epithelial cellsof
the macula are taller and more heavily pigmented. In
some eyes, the macula may appear slightly yellow due to
the xanthophyll pigment in the retina. The central
depression of the fovea may act as a concave mirror
during ophthalmoscopy and produce a light reflection
known as the foveal reflex.. Examination of the macular
and retinal background should be directed at detecting
hemorrhages,exudates,orwhite/yellowdeposits.
Theexaminertakesapositioninfrontofthepatient.The
patient isaskedtocoverthelefteyewiththepalmofthe
left hand the examiner closes the right eye. Thus, the
field of the examiner's left eye is used as a reference in
assessingthefieldofthepatient'srighteye.Thepatientis
asked to fixate on the examiner's left eye and then count
the fingers of the examiner in each ofthefourquadrants
of the visual field. Wiggling the fingers as a visual
stimulus is not desirable. After the patient's right eye is
tested, the procedure is repeated forthelefteye,withthe
patient covering the right eye with the palm of the right
hand,andtheexaminerdosingthelefteye.
Eye Exam.doc
SummaryofStepsinEyeExamination
Measurethevisualacuityforeacheye.
Testthepupilsfordirectandconsensualresponses.
Testtheextraocularmovements.
Inspectthelidsandthesurroundingtissues.
Inspectinorder:conjunctiva,sclera,corneaandiris.
Assesstheanteriorchamberfordepthandclarity.
Assessthelensforclaritythroughdirect
ophthalmoscopy
Use the ophthalmoscope to study the fundus,
includingthedisc,vessels,andmacula.
Performaconfrontationfieldtestforeacheye.
Performtonometrywhenindicated.
Eye Exam.doc