EYE EXAMINATION

VISUAL ACUITY

Assessment of Visual Acuity: Far Vision using Snellen Chart: Testing Done
Done Not Done
Central Cranial Nerve II (Optic Nerve) Properly
1. Wash and dry the occluder and pinhole.
2. Darken area of the examination.
3. Ensure good natural light or illumination on Snellen chart.
4. Position the patient 20 feet (6 meters) away from Snellen chart.
5. Starting with the "bad eye" without corrective lenses then with
corrective lenses while covering the other eye lightly with the occlude
shield. Record.
6. No pressure to the covered eye or not to use the patient's palm.
Method 1
7. Read the Snellen chart from the largest point.
Method 2
Read the letters as the examiner points.
Method 3
Identify all the letters beginning at any line.
8. Record the visual acuity as a fraction e.g. 20/200-2
9. Note whether the visual acuity was done without any corrective
glasses (sc) e.g. "20/200-2, (sc)"
10. Repeat the testing procedure for the other eye without the
corrective glasses.
11. Patient to wear his/her corrective glasses.
12. Report the visual acuity with corrective glasses indicated. e.g.
"20/20, (cc)" or "20/40-1, corrected"
13. If 20/20 (normal vision) is not achieved, test one eye at a time
with a pinhole occluder (plus any current spectacles) and repeat the
above procedure at 20 feet.
14. Repeat the procedure for the second eye.
15. Summarize the VA of both eyes:
16. If the patient cannot read the largest (top) letter at 20 feet, move
him/her closer.
17. If the top letter cannot be read at less than 2 feet (2/200), hold
up, fingers.
18. Stand approximately 3 feet away from the patient with fingers
wiggling and ask the patient to identify how many fingers he/she can
see, then approach by foot.
19. If the patient cannot count fingers, test his/her ability to see
motion (HM). Record as VA = HM
20. If the patient cannot see hand movements, shine a flashlight
toward his/her eye from four direction of a quadrant.
21. Repeat the steps for the other eye.
22. Record this as perception of light (LP or ), or no light perception
(NLP or x).
 Assessment of Visual Acuity: Near Vision: Testing Cranial Nerve II Done
Done Not Done
(Optic Nerve) Properly
1. Secure Jaeger chart or Rosenbaum pocket vision screener, if not
available, newspaper or magazine can do.
2. Ensure good natural light or illumination on the chart.
3. Ask the seated patient to read aloud the chart or newspaper held
35 cm from the eyes.
4. Cover his/her "bad eye" with an occluder or any shield.
5. Without any corrective glasses.
6. The other eye.
7. With corrective glasses, left eye covered with an occluder.
8. Cover the other eye with corrective glasses this time with the
occluder.

Assessment of Visual Acuity: Testing Cranial II (Optic Nerve)

Done
Peripheral Vision (Visual Fields) using Confrontation Test: Screening: Done Not Done
Properly
Dynamic
1. Position yourself directly in front of patient so face is level with
that of patient approximately 2 feet or 1 meter away (either sitting or
standing).
2. Ask the patient to look with both eyes directly to your eyes.
3. Return the patient's gaze, fully extend your arms lateral to the
patient's ears.
4. Instruct the patient to point to your fingers once they are seen.
5. Slowly move your wiggling fingers from the patient's ears towards
his/her line of gaze until he/she identifies them moving.
6. Slowly move your wiggling fingers now at the left towards his/her
line of gaze until he/she identifies them moving.

Assessment of Visual Acuity: Testing Cranial Nerve II (Optic Nerve)

Done
Peripheral Vision (Visual Fields) Using Confrontation test: Further Done Not Done
Properly
Testing: Dynamic
1. Position yourself directly in front of patient so face is level with
that of patient, approximately two (2) feet or 1 meter away (either
both sitting or standing).
2. Cover your right eye (optional) with an occluder or a card and
instruct patient to cover his/her left eye with an occluder or card, so
the open eyes are directly opposite each other.
3. Ask the patient to look at your uncovered eye.
4. While you return the patient's gaze, fully extend your arm midway
between you and the patient lateral to the patient's left ear.
5. Instruct patient to point to your fingers once they are seen.
6. Using your left visual field as the reference in assessing the
patient's right eye, slowly move your wiggling fingers from the
patient's right ear towards his/her line of gaze until he/she identifies
them moving.
7. Sequentially, slowly move your wiggling fingers coming from the
inferotemporal quadrant towards his/her line of gaze.
8. Slowly move your wiggling fingers coming from the superonasal
quadrant towards his/her line of gaze.
9. Slowly move your wiggling fingers coming from the inferonasal
quadrant of the visual field and asks patient to identify fingers
wiggling as soon as it is noted in his/her line of gaze.
10. Repeat steps for other eye.
 Assessment of Visual Acuity: Testing Cranial Nerve II (Optic Nerve)
Done
Peripheral Vision (Visual Fields) using Confrontation Test: Further Done Not Done
Properly
Testing: Static
1. Position yourself directly in front of patient so your face is level
with that of patient, approximately 2 feet or 1 meter away (either
sitting or standing).
2. Cover your right eye with an occluder or a card while at the same
time instruct patient to cover his/her left eye with an occluder or
card, so the open eyes are directly opposite each other.
3. Patient to look at your uncovered eye.
4. While you return the patient's gaze, fully extend your arm midway
between you and the patient lateral to the patient's left ear.
5. Patient to point to your fingers once they are seen.
6. Slowly move your left hand with one or two fingers briefly help up
from the patient's left ear towards his/her line of gaze until he/she
identifies them and tells how many finger/s is/are seen.
7. Slowly and sequentially move your left hand with one or two
fingers briefly held up coming from the temporal inferior quadrant
towards his/her line of gaze until he/she identifies them and tells
how many finger/s is/are seen.
8. Slowly move your left hand with one or two fingers briefly held up
coming from the nasal superior quadrant towards his/ her line of gaze
until he/she identifies them and tells how many finger/s is/are seen.
9. Slowly move your left hand with one or two fingers briefly held up
coming from the nasal inferior quadrant of the visual field and ask
patient to identify how many fingers are seen as soon as it is noted in
his/her line of gaze.
10. Repeat steps for other eye.

EXTERNAL EYE EXAMINATION

Done
External Eye Examination Done Not Done
Properly
1. Stand in front of patient sitting on the examining table.
2. Inspect for symmetry or alignment of eyes.
3. Stand behind the patient and ask him to tilt his head backward.
4. Observe the distance from the brow.
5. Inspect any lid movements.
6. Inspect eyebrows.
7. Inspect eyelashes.
8. Inspect eyelids.
9. Note the lid margin distance from the center of the pupil.
10. Note any marked eversion of the edge of the lower eyelid
(ectropion).
11. Note any marked inward turning of the eyelid.
12. Note crusting, redness, swelling of the eyelid margins
(blepharitis).
13. Instruct patient to look up. Pull down lower lid of each eye to
expose inferior sclera and lower palpebral conjunctiva. Using a
penlight, inspect sclera and lower palpebral conjunctiva of lower
eyeball.
14. Instruct patient to look down. Pull up upper lid of each eye to
expose superior sclera and conjunctiva. Using a penlight, inspect
sclera and conjunctiva of upper eyeball.
15. Inspect cornea with oblique and direct lighting.
16. Inspect size, shape, markings, definition, and color of the iris.
 Done
Inspection and Palpation of the Lacrimal Apparatus Done Not Done
Properly
1. Sit facing the patient at same level or slightly higher.
2. Using a penlight, inspect the punctual opening just lateral to the
inner cantus.
3. Using your thumb of the other hand, pull down the patient's lower
eyelid.
4. Gently palpate with your index finger the nasolacrimal duct just
medial to the lower orbital rim.

Done
Inspection of the Lacrimal Gland and Upper Palpebral Conjunctivae Done Not Done
Properly
1. Inspect the lacrimal gland by gently everting the upper eyelid.
2. Patient to look downward with eyes slightly open.
3. Gently grasp the upper eyelid between your thumb and forefinger
at the upper eyelid/eyelash junction.
4. The other hand places a cotton-tipped applicator against the lower
portion of the upper eyelid while at the same time pulling the
eyelashes up to evert the lid, careful not to press the eyeball against
the applicator.
5. Upon upper eyelid eversion, move the cotton tipped applicator
away while holding the eyelid against the upper bony orbit.
6. After the inspection, gently pull the everted upper eyelid forward
and release grip as the upper eyelid reverts back to its normal position
and ask patient to blink.
7. Perform the same procedure on the other eye.

Extra-ocular Movements Testing Cranial Nerve III (Occulomotor Done

Done Not Done
Nerve) IV (Trochlear) VI (Abducens) Properly
1. Patient to keep his/her head stationary.
2. Instruct patient to follow your index finger or pen with his/her eyes
only.
3. Move your index finger to either the extreme right or left.
4. Move fingers slowly to extreme position of each of the 6 cardinal
positions of gaze returning to the central starting point before
pointing toward the next field.
A. Up right
B. Right
C. Up left
D. Down right
E. Left
F. Down left
5. Lift the patient's upper eyelids while patient looks down to the left
and right.
6. The path may trace out the letter H.
7. When the patient looks toward the most distal point in the lateral
and vertical fields, carefully note eyeball movements.
 Done
Test for Lid Lag (Von Graefe's Sign) Done Not Done
Properly
1. Patient to follow your index finger in a vertical plane as it moves
from ceiling to floor.
2. Observe for the supposedly smooth coordinated movement of the
sclera and the upper eyelid without exposure of the sclera (no lid lag).

Done
Test for Balance of Extraocular Muscles (Corneal Light Reflex) Done Not Done
Properly
1. Direct a light source at the nasal bridge from a distance of about 30
cm
2. Patient to fixate the light or small print material shown beside the
light. Hold a light in front of your eyes and direct it into the patient's
eyes.
3. Observe if the light reflex is centered in each pupil.

Done
Test for Strabismus (Cover-Uncover Test) Done Not Done
Properly
1. Patient to stare straight ahead at a nearby fixed point that is held
approximately one foot away.
2. Cover one eye of the patient and observe the uncovered eye for
any movement as it focuses on the designated point.
3. Remove the cover on the other eye and observe the newly
uncovered eye for any movement as it focuses on the designated
point.
4. Repeat the process covering the other eye.

Pupillary Reflexes Testing Cranial Nerve II (Optic Nerve) Afferent Limb Done
Done Not Done
Cranial Nerve III (Occulomotor Nerve) Efferent Limb Properly
Direct
1. Darken the room of turn the patient away from direct light source.
2. Patient to look at a distant object.
3. Illuminate both eyes with the least amount of light to discern pupil
size and shape or
Patient to cover one eye while a light source from the side is reflected
towards the pupil of the uncovered eye.
4. Check for pupillary constriction.
5. Repeat testing with other eye.
Consensual
6. Shine the light source toward one eye from the side and observe
both pupils.
7. Note for the constriction of the eye that is not receiving the direct
light (consensual response).
 Done
Swinging Light Test Done Not Done
Properly
1. Darken the room or turn the patient away from the direct light
source.
2. Patient to look into distant object.
3. Shine the pen light directly into the right eye for less than 5
seconds.
4. Check for pupillary response (constriction) of the right eye.
5. Swing the penlight quickly over the bridge of the nose, shine it in
the left eye and check for its pupillary response
6. Swing the light back into the right eye and observe for the pupillary
response.
7. Swing the light back and forth for at least five times.
8. Observe if any one of the pupil consistently dilates instead of
constricting as the light shines on it.

Accommodation and Convergence Cranial Nerve III (Occulomotor

Nerve) - accommodation, Cranial Nerve III (Occulomotor Nerve) - Done
Done Not Done
convergence EOM and Ciliary Muscle Contraction for Lens, IV Properly
(Trochlear) Convergence EOM, VI (Abducens) Convergence EOM
1. Hold your index finger approximately 2 feet from the patient's eyes.
2. Patient to focus on the index finger as you move it toward the
patient's nose.
3. Observe pupillary constriction as the finger moves closer
(accommodation) and crossing of the eyes (convergence).

OPHTHALMOSCOPIC EXAMINATION

Ophthalmoscopic Examination: Proper Positioning and Visualizing the Done

Done Not Done
Red Reflex Properly
1. Darken the room or turn the patient away from the direct light
source.
2. Stand in front of patient sitting on the examining table.
3. Patient to look at a distant point.
4. Grasp the ophthalmoscope with your right hand when examining
the patient's right eye such that your middle finger is resting on the
lower, front aspect of the head of the ophthalmoscope.
5. Turn on the light source of the ophthalmoscope.
6. Initially choose to set the aperture wheel to the small spot that is
generally used for general undilated fundus examination.
7. Set ophthalmoscope's lens initially at 0.
8. Position yourself at arm's length from the patient.
9. Place your left hand on the patient's forehead with left thumb over
the patient's left eyebrow with gently upward traction on the top
eyelid with the left thumb, or
Place your left hand on the patient's shoulder.
10. War or remove your own corrective glasses, but the patient's
should be taken off.
11. Shine the ophthalmoscope towards the pupil of the right eye and
look through the ophthalmoscope's viewing hole from an angle of
about 15-20 degrees lateral to the patient's line of vision.
12. Keep both eyes open when performing the exam.
13. Note the red reflex from retina.
 Done
Inspecting the Anterior Chamber, Lens and Vitreous Body Done Not Done
Properly
1. Look through the viewing window and focus on the red reflex. Set
the lens dial at 0 and slowly move closer towards the patient until
your forehead touches your thumb on the patient's forehead and
until these structures become clear.

2. Note for any lens opacities (cataracts) that may interfere with red
reflex visualization. If present, change the aperture wheel to a larger
spot.
3. Slowly rotate the adjustment wheel of the ophthalmoscope using
the index finger up or down until the structures becomes clear.
4. Turn the diopter disc counterclockwise for convex (plus) lenses,
which are printed in black: 0, +1, +2, +3, +4, +5, +6, +8, +10, +12, +16,
+20D or
Turn the diopter disc clockwise for concave (minus) lenses, which are
printed in red: 0. -1. -2, -3. -4, -5, -6, -8, -10, -16, -20, -25, -35D until
the sharpest focus is achieved.

Done
Visualization of the Optic Disc Done Not Done
Properly
1. Focus further on the retinal structures such as a vessel of the optic
disc while further rotating and adjusting the lens until the sharpest
focus is achieved.
2. Trace the path to the optic disc by using any retinal vessel as a
reference point. Find a blood vessel and follow it in the direction in
which the vessel thickens leading, you visually to the disc.
3. Describe the shape, color and border of the optic disc.
4. Compare the color of the physiologic cup to that of the optic disc.
Take note of the cup:disc ratio.
Inspection of the Retinal Vessel and the Retina
1. Evaluate the retinal vessels from the disk to the periphery.
2. Examine and compare the character of the arterioles and veins, its
color, diameter, and presence of the light reflex.
3. Note the AV ratio and changes in the caliber of the vessels.
4. Note the color of the retina
5. Note underlying retinal lesions.
Inspection of the Macula
1. Inspect the macula by asking the patient to look directly to the
ophthalmoscope light.
2. Assess the other eye.