OPHTHALMOLOGY: LE 1 | TRANS 1

Eye Symptoms and Eye Examination

BELTRAN ALEXIS A. ACLAN, MD, MHCM, DPBO | 01/16/2024

→ O-nset
OUTLINE
→ L-aterality / Location
I. Introduction III. Ophthalmic PE
→ D-egree
A. Ocular History A. Visual Acuity Testing
→ E-xacerbating Factors
B. Ocular Examination B. External Eye Examination
→ R-elieving Factors
C. Diagnosis and Management C. Ocular Motility Testing
→ S-igns and Symptoms (associated)
D. Symptom Elucidation D. Visual Field Examination
II. Eye Symptoms E. IOP Determination II. EYE SYMPTOMS
A. Abnormalities in Vision F. Fundoscopic Exam ● Classified in three categories:
B. Abnormalities in IV. Summary A. Abnormalities in vision
Appearance V. Review Questions B. Abnormalities in appearance
C. Abnormalities in Sensation VI. References C. Abnormalities in ocular sensation
SUMMARY OF ABBREVIATIONS A. ABNORMALITIES IN VISION
EOR Error of Refraction VISUAL LOSS
MS Muscle ● Decline in visual acuity may be due to abnormalities along the
RAPD Relative Afferent Pupillary Defect optical and neurological pathway
VA Visual Acuity ● May be caused by:
→ Errors of refraction

❗️
Must know
📣
Lecturer
📖
Book
📋
Previous Trans → Ptosis
→ Ocular media disturbances
LEARNING OBJECTIVES → Retinal diseases
→ Optic nerve diseases
By the end of the lecture, learners are expected to:
→ Intracranial visual pathway abnormalities
✔ Recognize & differentiate between various common eye symptoms
✔ Know & discuss the potential underlying causes associated with
each eye symptom
✔ Discuss the rationale behind each part of the eye examination
✔ Confidently perform a systematic eye examination
I. INTRODUCTION
A. OCULAR HISTORY
● Obtain an ocular and systemic history
→ Determine the optical and health status of the eye, visual
system and related structures by history
→ Identify risk factors for ocular and systemic diseases
B. OCULAR EXAMINATION
● Perform a systemic and complete ocular examination.
→ Detect and diagnose ocular abnormalities and disease Figure 1. Visual loss algorithm [Lecturer’s PPT]
→ Establish and document the presence or absence of ocular
VISUAL ABERRATIONS
signs of systemic diseases
● Anything that affects visual perception
C. DIAGNOSIS AND MANAGEMENT
Table 1. Visual Aberration
● Come up with an evaluation & plan of management for the case
Aberration Possible Causes
→ Discuss the nature of the findings and its implications with the
patient Glare/Photophobia Corneal edema, cataract
→ Initiate an appropriate response (e.g. further diagnostic tests, Visual Distortion Central serous chorioretinopathy,
treatment or referral when indicated) age-related macular degeneration
Flashing/Flickering lights Posterior vitreous detachment,
D. SYMPTOM ELUCIDATION retinal detachment
● Symptoms should be asked based on: Floating spots Vitreous condensation
→ Onset (gradual or progressive) Oscillopsia Nystagmus
→ Duration (acute or chronic)
Diplopia Strabismus
→ Frequency (continuous, intermittent, or episodic)
→ Degree of complaint (mild, moderate, or severe) ● It does not mean that if the patient has strabismus, they will suffer
→ Location (focal or diffuse, unilateral or bilateral) diplopia
→ Progression (worsening of symptoms) ● Children born with strabismus will usually not develop diplopia due
→ Associated signs and symptoms to a compensatory mechanism called suppression, where they
→ Aggravating signs and symptoms could shut off one eye to prevent diplopia
→ Alleviating signs and symptoms
● Other questions:
→ What treatment initiated?
▪ Did the patient self medicate? Was the previous
consultation done?
→ What factors provoke or relieve the symptoms?
▪ Are there seasonal variations with the symptoms? Whether
they are provoked by certain allergens.
→ Is this the first time the symptom was experienced the
symptom/s?
→ What are the associated signs and symptoms? Figure 2. Normal vision (L), Eye with cataract (R) [Lecturer’s PPT]
● Mnemonic
→ C-haracteristic

LE 1 TRANS 1 TG-B6: Lee, Legacion, Leunberger TE: G. Garcia, D. Ortiz AVPAA: I. Nayal Page 1 of 14

Figure 3. Eye with diabetic retinopathy (L); Eye with macular
Degeneration (R) [Lecturer’s PPT]
Figure 7. Other color abnormalities[Lecturer’s PPT]
PTOSIS
● Drooping of the eyelids
● “Kirat ang mata” or “bumabagsak ang mata”
● Hardly see the pupils and reflex coming from the eye

Figure 8. Ptosis[Lecturer’s PPT]

FOCAL GROWTH OR MASS
Figure 4. Eye with late-stage glaucoma [Lecturer’s PPT] ● Any growth found in the eyelids or surface of the eye
B. ABNORMALITIES IN APPEARANCE ● “Butlig”, “bukol”, “namamaga”
RED EYE ● Pinguecula
● Differentiate redness from the lids and periocular area from that of → Amorphous, yellowish growth on the conjunctiva
the globe ● External hordeolum (see Figure 5)
● Red eye that affects the lid: → Focal growth on the eyelid, red, quite huge
→ External hordeolum
→ Pre-septal cellulitis
▪ More mild and subtle inflammation of the eyelids
→ Orbital cellulitis
▪ Important to differentiate from pre-septal cellulitis as orbital
cellulitis might lead to cavernous sinus thrombosis that may
lead to patient’s demise Figure 9. Focal growth or mass [Lecturer’s PPT]
▪ Affects extraocular muscles
▪ Refer to Figure 5: Patient attempts to look upward, but his PROPTOSIS
left eyes are quite frozen already due to inflammation ● Protrusion of the eyeball
● “Lumuluwa ang mata”, “dilat ang mata”
● Seen in patient with Graves’ diseases, eyes are proptosed

Figure 5. Red eye that affects the lids. Lecturer’s PPT]

Figure 10. Proptosis[Lecturer’s PPT]
● Causes redness of the globe:
→ Bacterial conjunctivitis OCULAR DEVIATION/ MISALIGNMENT
▪ With purulent discharge ● Esodeviations (inward turning)
▪ Gonococcal conjunctivitis - discharge is purulent, when
you wipe, there’s pus that already comes out
→ “Naduduling”
→ Esotropia 📋
▪ Convergent manifest deviation
→ Nodular episcleritis
▪ Nodule, hyperemic ▪ “Crossed eyes”
→ Diffuse episcleritis ▪ Example: Left esotropia
→ Subconjunctival hemorrhage − Light reflex is centered on R pupil but is on the lateral
▪ Bloodshot eye, fresh blood, like a hematoma portion of the L pupil
● Exodeviations (outward turning)
→ “Nababanlag”
→ Exotropia 📋
▪ Divergent manifest deviation
▪ “Wall eyes”
▪ Example: Left exotropia
− Light reflex is centered on R pupil but is on the medial
Figure 6. Red eye that affects the globe[Lecturer’s PPT] portion of the L pupil
● Hypertropia (upward turning)
COLOR ABNORMALITIES
● Jaundice
● Hyperpigmented lesions
fixating) 📋
→ Eye is upward in a vertical deviation (regardless of which eye is

→ Ocular melanoma
▪ Hyperpigmented lesions that spreads already in the
● Hypotropia (downward turning)
→ Eye is deviated downward relative to the fixing eye 📋
adjacent structures
● Thinned out / bluish sclera (OI)
→ Seen in patients with osteogenesis imperfecta
● White opacity in the cornea (leukocoria)
→ Whitish opacity in a patient with a red eye
→ Keratitis (Note: Be cautious in giving steroids, do not give
steroids because it may induce more harm than good)

Figure 11. Ocular misalignment [Valbuena, 2005]

OPHTHALMOLOGY Eye Symptoms and Eye Examination Page 2 of 14

 ABNORMALITIES IN SIZE ✏️
CONCEPT CHECKPOINT
1. A patient came into the clinic complaining that
✏️
● Disparity in the size either between corneas or globe
● Rhabdomyosarcoma “gumagalaw ang paningin ko" or her field of vision is
→ Proptosis & bigger left eye moving. This is known as:
● Retinoblastoma with a physical eye a. Photophobia
→ Smaller/shrink left eye b. Floaters
→ Post-chemotherapy patient c. Ptosis
→ Right eye with leukocoria because this eye is with d. Oscillopia
retinoblastoma also 2. When one shines a light on the eyes and the light reflex is
● Congenital Glaucoma centered on the left pupil and the light reflex is at the 9 o’
→ Bigger right eye, eyeball is huge, megalocornea/ clock border of the right pupil, the patient has:
megalophthalmos a. Left exotropia
b. Right esotropia
c. Right exotropia
d. Right hypotropia
ANS:
1. D. A. Patient can describe it as “nasisilaw” or “ayaw sa liwanag/araw”. B.
Patient can describe it as “may lumulutang sa harap ng mata” or “may
insekto na sumusunod sa paningin”. C. Drooping of eyelid
2. B. A. Pupil should be located laterally to the corneal light reflex (light reflex
Figure 12. Abnormalities in size[Lecturer’s PPT] at the 9 o’clock border) C. Pupil should be located laterally to the corneal
light reflex (light reflex should be at the 3 o’clock border). D. Pupil should
C. ABNORMALITIES IN SENSATION be located inferior to the corneal light reflex (light reflex at the 12 o’clock
EYE PAIN border).
● Important to ask, “where is the pain coming from?” III. OPHTHALMIC PHYSICAL EXAMINATION
Table 2. Eye Pain Note: Traditionally, the 8 part eye exam is conducted however in Doc’s lecture
Location Possible cause & in the reference book, the visual field exam & anterior segment exam have

Periorbital
Tenderness of the lid, tear sac, sinuses and
temporal arteries
the ophthalmic PE 📣❗️
been removed. The pupillary exam is placed under the external eye exam of

● Traditional 8 Part Eye Exam

Orbital inflammation, orbital myositis, optic 1. Visual Acuity determination
Retro-orbital
neuritis 2. External Eye Examination
Corneal abrasion, corneal foreign body, 3. Ocular Motility
Ocular glaucoma, corneal ulcer, endophthalmitis, 4. Pupillary Examination
photophobia 5. Visual Field Examination
Non-specific Ocular accommodation, binocular fusion 6. Anterior Segment Examination
7. Tonometry
EYE IRRITATION
8. Funduscopic Examination
● Itching ● Lecturer’s Discussion & Ophthalmic PE reference book
● Dryness 1. Visual Acuity determination
● Tearing 2. External Eye Examination
● Ocular secretions a. Pupillary examination
→ Watery 3. Ocular Motility
→ Mucoid 4. Tonometry
→ Ropy or stringy 5. Funduscopic Examination
→ Purulent or copious
→ Bloody A. VISUAL ACUITY TESTING
→ Dried matter/crusting ● Fundamental element of eye examination
→ It’s basically the vital sign of the eye
HEADACHE
● Should be performed prior to manipulation of the eye especially
● Uncorrected EOR and presbyopia in traumatic cases
→ Referred pain to the eyes and brow area → If you don’t test the visual acuity of the patient, they might think
● High or low blood pressure that they lost their vision after you did the physical exam
→ Referred pain around the eyes → Before touching the patient’s eye, you should examine the
● Angle closure glaucoma visual acuity no matter what happens
→ Unilateral headache emanating from the eye

● Ocular History
⚠️
MUST KNOW ⚠️ ● Performed at a far distance and at a near distance
● Visual acuity refers to the angular measurement relating testing
distance to the minimal object size resolvable at that distance
→ Obtain an ocular and systemic history ● Traditionally, visual acuity refers to a visual test in which a target
▪ Determine the optical and health status of the eye, visual subtends a visual angle of 5 minutes of arc when a subject is
system and related structures by history. 20 feet away from the target
▪ Identify risk factors for ocular and systemic diseases.
● Ocular Examination
→ Perform a systemic and complete ocular examination.
▪ Detect and diagnose ocular abnormalities and disease
▪ Establish and document the presence or absence of
ocular signs of systemic diseases.
● Symptom Elucidation: COLDERS
→ Characteristic, Onset, Laterality/location, Degree,
Exacerbating factors, Relieving factors, S/S
● Eye Symptoms Figure 13. Visual Acuity. As the letter goes further from the eye, the
→ Abnormalities in Vision: Visual loss, Visual aberrations letter becomes bigger. However, it maintains the 5 minutes of arc or
→ Abnormalities in Appearance: Red eye, Color abnormalities, angle that is from the eye [Lecturer’s PPT]
Ptosis, Focal growth or mass, Proptosis, Ocular
deviation/misalignment, Abnormalities in size
→ Abnormalities in Ocular Sensation: Eye pain, Eye irritation,
Headache

OPHTHALMOLOGY Eye Symptoms and Eye Examination Page 3 of 14

 Figure 16. Testing visual acuity[Lecturer’s PPT]
Figure 14. Visual acuity. A 5x5 square with a letter “E”
superimposed. Each box = 1 min of arc. To be able to resolve this, ● What if the patient cannot see the biggest letters from the VA
will help us determine if you can actually see the letter or not [Lecture] chart?
→ Reduce testing distance
TEST OF VISUAL FUNCTION → Have the patient count your fingers at 2 feet
● Visual acuity tests: → Ask the patient if they can see your hand movement
→ Distance acuity examination ▪ Done if the patient cannot count your fingers
→ Pinhole examination ▪ Ask patient to identify your hand movement, either in vertical
→ Near acuity examination or horizontal direction
● Other tests of visual function → Light projection
→ Contrast sensitivity and glare ▪ Flash a light on all quadrants (up, right, left, down)
→ Color vision → Light perception
→ Stereopsis
Note: At our level, we only need to focus on visual acuity tests.
▪ Can they perceive light?
▪ Should be performed at a dimly-lit room 📣
DISTANCE VISUAL ACUITY
● Ability to identify objects or shapes at a given distance from the
eye
● Testing is usually done by using an age- or literacy-appropriate
visual acuity chart
● Distance visual acuity is expressed in a ratio or fraction that:
20 𝐷𝑖𝑠𝑡𝑎𝑛𝑐𝑒 𝑎𝑡 𝑤ℎ𝑖𝑐ℎ 𝑡ℎ𝑒 𝑡𝑒𝑠𝑡 𝑖𝑠 𝑝𝑒𝑟𝑓𝑜𝑟𝑚𝑒𝑑
20
= 𝐷𝑖𝑠𝑡𝑎𝑛𝑐𝑒 𝑟𝑒𝑎𝑑 𝑏𝑦 𝑎 𝑝𝑒𝑟𝑠𝑜𝑛 𝑤𝑖𝑡ℎ 𝑛𝑜𝑟𝑚𝑎𝑙 𝑎𝑐𝑢𝑖𝑡𝑦
● For a patient with 20/400, the patient can read it at 20 ft, wherein a Figure 17. Modifications that can be done if patient cannot read from
normal person can read at 400 ft. the VA chart [Lecturer’s PPT]

Figure 15. Some charts used to test distance VA [Lecturer’s PPT]

● Different charts may be used to test for distance visual acuity
→ Early Treatment for Diabetic Retinopathy Study (ETDRS) Figure 18. Visual acuity notations[Lecturer’s PPT]
Chart
● After taking the VA, various visual acuity notations can be used
▪ Mostly used in research due to standardized/standard
optotype letters and number of letters per line
→ Snellen Chart - most common
📣 ● The traditional notation is the Snellen US notation like from 20/200
down to the best 20/20
● Snellen Metric notation from 6/60 to 6/6
→ Tumbling E Chart
● Decimal notation
▪ For patients who are unable to read
● LogMar Notation is also used in research studies dealing with
▪ Tested by asking if the legs of the letter E are pointing to the
vision
right, left, upwards, or downwards
→ Lea Symbols Chart TESTING PINHOLE VISUAL ACUITY
▪ Used among preschool children ● Used when a patient is not able to read the 20/20 line in the
→ Allen Chart distance vision chart
▪ For pediatric patients through identification of images ● Determines whether blurring of vision is due to an error of
→ Bailey-Lovie Chart refraction or a problem in the visual axis.
▪ Current chart used for research and in the clinics → If the vision improves when using the pinhole, blurring of the
▪ Position the patient 4-6 meters from the chart vision is due to an error of refraction
TESTING DISTANCE VISUAL ACUITY → If the vision does not improve when using the pinhole, there
may be an organic problem in the visual axis
● Position patient 20 feet or 6 meters away from a well-illuminated
wall chart
● Cover: Occlude one eye
→ Occlude the better eye first. Better eye is identified because
history taking of the eye is already done
→ Ask the patient to read the chart, from the top line to the bottom
line from the left to the right letter or figure
→ If patient has corrective glasses, have them read using the
glasses as well
● Pinhole: If VA is <20/20
→ Done to identify whether the patient has error of refraction or Figure 19. Pinhole occluder [Lecturer’s PPT]
other serious conditions

OPHTHALMOLOGY Eye Symptoms and Eye Examination Page 4 of 14

 ● Ask the patient to look at the distance vision chart through a single B. EXTERNAL EYE EXAMINATION
pinhole FOUR PART EXAMINATION
● Ask the patient to read, similar to testing distance visual acuity. ● Now consists of a four-part examination:
→ Inspection
→ Palpation
→ Auscultation
→ Pupillary Examination
▪ Part that was included
● Percussion on the eye is not done because you may injure eye
Figure 20. Pinhole visual acuity [Lecturer’s PPT] structures
● One side of the implement is occluded and the other side has the INSPECTION
pinhole, so that the patient does not have to hold two different ● Look for symmetry in the following structures:
implements → Head and Face
▪ Bones (e.g. bony protuberances), muscles, nerves
TESTING NEAR VISUAL ACUITY ▪ Skin (e.g. skin lesions) and lymph nodes
● Test performed using near vision charts ▪ Mouth, nose, and paranasal sinuses
→ Contains numbers/ figures in varying size corresponding to a → Orbit
particular point size → Eyelids (including eyelashes) and lacrimal system
→ Globe

Figure 23. General examination[Lecturer’s PPT]

● A general examination of the eyes, adnexa, and the face,
particularly the orbital region is being done by the examiner

Figure 21. Near vision chart[Lecturer’s PPT]

● Testing distance: 14 inches (35 cm)
→ Remind the patient to keep it at this distance because patients
with presbyopia tend to move it farther
Figure 24. Flipped eyelid[Lecturer’s PPT]
● Maneuvers may also be done in examining the eyelid.
● After examining externally, the eyelid may be flipped to look at the
upper palpebral conjunctiva
→ Foreign bodies that cannot be removed by usual means are
sometimes lodged in the furrow
→ Foreign bodies are usually taken out using cotton pledget

Figure 22. Near visual acuity test. Test one eye at a time 📣
● If the patient is wearing progressives, you need to check whether
the progressives are still working or not
RECORDING OF FINDINGS
Figure 25. Globe inspection[Lecturer’s PPT]
Table 3. Abbreviations for recording of finadings
Abbreviations Features ● After examining the adnexa, the globe of the patient is examined
VA Visual Acuity by asking them to look up, down, right, and left
OD Oculus Dexter (Right Eye)
OS Oculus Sinister (Left Eye)
OU Oculus Utirique (Both Eyes)
sc Without correction
cc With correction
ph Pinhole Figure 26. Mass on the lateral area of the lower lid [Lecturer’s PPT]
NV Near vision
⚠️MUST KNOW⚠️
VISUAL ACUITY TESTING
● In inspection, lesions may be seen such as this mass on the
lateral area of the lower lid with associated redness of the other
structures of the lid.
● Fundamental element of eye examination ● The lesion is more likely infected because of the redness of the
● Should be performed prior to manipulation of the eye surrounding structures.
especially in traumatic cases
● Performed at a far distance and at a near distance
→ Testing distance acuity
▪ Position patient 20 feet or 6 meters away from a
well-illuminated wall chart.
▪ Cover: Occlude one eye
▪ Pinhole: If VA is <20/20 Figure 27. Mass on the lateral area of the lower lid [Lecturer’s PPT]
→ Testing near distance acuity
▪ Test performed using near vision charts ● In inspection, the lesions in the eye are described using this clock
▪ Testing distance: 14 inches (35 cm) image
● When there is a lesion in the 2 o’clock position, we can say that
we see a lesion in the 2 o’clock position of the limbus, or at the 3
o’clock position of the border of the iris

OPHTHALMOLOGY Eye Symptoms and Eye Examination Page 5 of 14

 ● Entropion
PALPATION
→ Inward turning of the eyelid margin
● Involves tactile, proprioceptive and temperature senses
● Avoid sudden, unexpected touches around the eyes, especially in
patients with poor vision
eye 📣
→ Eye lashes are directed vertically to the point it's poking the

→ If you are a male and your patient is female, you need to ask
permission when you are going to touch the eyes
● Palpate preauricular lymph nodes, eyelids, and periorbital area
● Record any mass according to its size, shape, composition,
tenderness, and movability
→ Like any other mass seen in physical exam systemically Figure 30. Ptosis (L) and Entropion (R)
● Tender, palpable preauricular nodes are common in viral
conjunctivitis ● Ectropion
→ Lower lid margin turns outward
● Exophthalmos
→ Protrusion of the eyeball

Figure 28. The examiner is palpating the pre-auricular nodes

(L) and the submandibular nodes (R) of the patient because Figure 31. Ectropion (L) and Exophthalmos (R)
the eyes drain to these particular places [Lecturer’s PPT] ● Periorbital contusion hematoma in a patient with trauma
AUSCULTATION
● Auscultate for an orbital bruit by placing the bell of a stethoscope
→ Laceration can be drawn when recording findings
→ Commonly seen in cases of assault or violence 📣
over the closed eyelids.
● Presence of a bruit may indicate the presence of a
● Capillary hemangioma
→ Found among with neurofibromatosis 📣
→ Measure the size using a ruler and note whether patient has
carotid-cavernous fistula or an AV malformation.
adequate palpebral fissure opening
B. GROSS EXAMINATION OF THE EYE AND ADNEXA ● Lymphangioma
Table 4. What and how to examine → Everting the lower eyelid is needed to see the mass
→ Measure and document properly
What to examine How to examine
● Preseptal cellulitis
Position of the eye Examine the eye position from different → Draw and document the extent of inflammation
(global protrusion) angles (front view, side view, top view)
Lids & palpebral ● Inspect the lids with a penlight
fissure ● Examine palpebral fissure height (use
ruler), asymmetry
● Examine for presence of redness,
masses, pigmentation
● Examine the lid margin and lashes
Sclera and ● Ask the patient to look up as you depress Figure 32. Examining the lids and palpebral fissure[PPT]
Conjunctivae the lower lid SCLERA AND CONJUNCTIVA
● Inspect for color and vascular pattern ● Pinguecula
against the white scleral background → Harmless yellowish triangular nodule in the bulbar conjunctiva
● Look for any nodules, swelling, or foreign ● Episcleritis
bodies → Benign, usually painless localized ocular inflammation of the
● Ask the patient to look to each side and episcleral vessels
down
Cornea & Lens ● With oblique lighting, inspect the cornea
of each eye for opacities
● Note any opacities in the lens that may be
visible through the pupil

Pupils
● Ideally, you’ll need to have a slit lamp to
have a better view of the structures
● Assessment of pupil size and shape
📣 Figure 33. Pinguecula (L) and Episcleritis (R)
● Assessment of pupil reaction to light ● Stye (Hordeolum)
● Swinging flashlight test → A painful, tender, red infection at the inner or outer margin of
the eyelid
POSITION OF THE EYE ▪ Inner margin: obstructed meibomian gland

→ Usually caused by Staphylococcus aureus

● Chalazion
📣
▪ Outer margin: obstructed eyelash or tear gland

→ A subacute, nontender, usually painless nodule caused by a

blocked meibomian gland

Figure 29. Examining globe protrusion [Lecturer’s PPT]

LIDS AND PALPEBRAL FISSURE
● Ptosis
→ Drooping of the upper eyelid
→ Commonly seen among the old age or in patients with other Figure 34. Stye/Hordeolum (L) Chalazion (R)
systemic autoimmune diseases (e.g. Myasthenia Gravis,

📣
damage to Cranial Nerve III / Oculomotor nerve, or in Horner
Syndrome)

OPHTHALMOLOGY Eye Symptoms and Eye Examination Page 6 of 14

 CORNEA AND LENS PUPILS
● Corneal Arcus
→ A thing grayish-white arc or circle not quite at the edge of the
cornea
→ Common among
African-Americans 📣 the elderly, especially among

📣
→ If seen among young adults, it is usually suggestive of Benign
Hypolipoproteinemia

Figure 41. Examining the pupils[Lecturer’s PPT]

● Direct pupil reaction
→ Shine a light on the eye being examined
Figure 35. Corneal Arcus → Check whether the reaction is sluggish or brisk
● Corneal Scar ● Consensual pupil reaction
→ A superficial, grayish-white opacity in the cornea, secondary to → Observe the reaction on the opposite eye
an old injury or to inflammation
interval with each swing 📣
● The process can be repeated for several times with about 1 sec

● Normal response: constriction of both eyes every time the light is

directly in front of the eye
● If dilation is observed instead of constriction, an optic nerve
problem on the eye where the light is being shone exists
SWINGING FLASHLIGHT TEST
● Steps:
Figure 36. Corneal Scar → Shine a light first on the RIGHT eye then swing it to the LEFT
● Kayser-Fleischer ring and vice-versa.
→ A golden to red-brown ring, sometimes shading to green or → When light is on the RIGHT eye
blue; copper deposition in the periphery of the cornea (Wilson ▪ Look at direct reflex of right eye and the consensual reflex of
Disease) the left eye
→ When light is on the LEFT eye
▪ Look at direct reflex of the left eye and the consensual reflex
of the right eye
● The process can be repeated for several times with about 1 sec
interval with each swing
● Normal response: constriction of both eyes every time the light is
directly in front of the eye

● Pterygium
Figure 37. Kayser-Fleischer ring
→ A triangular thickening of the bulbar conjunctiva that grows
slowly across the outer surface of the cornea
→ Called Surfer’s eye in the US; Pugita in the PH
● If dilation is observed instead of constriction, an optic nerve
problem on the eye where the light is being shone exists
→ This is called Relative Afferent Pupillary Defect (RAPD) aka
📣
a Marcus Gunn Pupil
📣 → Indicates a disorder of the optic nerve or a severe retinal
pathology
▪ So the swinging flashlight test is a good test for CN II

Figure 38. Pterygium

● Cataract
→ Opacity of the lenses visible through the pupil
→ Not only seen among elderly but also among those with Figure 42. Marcus Gunn Pupil[Lecturer’s PPT]
congenital cataracts
NEAR REACTION

Figure 43. Near Reaction

● Steps
Figure 39. Cataract 1. Test the near reaction in both dim and normal light
● Ocular Trauma 2. Testing one eye at a time
→ Get visual acuity 3. Hold your finger or pencil about 10cm from the patient’s eye
→ NEVER palpate an eye with suspected open globe injury 4. Ask the patient to look alternately at it and into the distance
directly behind it
PUPILLARY REFLEX PATHWAY
Note: The following section was lifted from last semester’s lecture.
● The pupil is the window of the inner eye through which light
passes to reach the retinal photoreceptors.
● Pupillary examination has the potential to reveal serious ocular,
neurologic, and other diseases.
Figure 40. Ocular Trauma

OPHTHALMOLOGY Eye Symptoms and Eye Examination Page 7 of 14


Figure 45. Pupillary Reflex Pathway[Lecturer’s PPT]
● Pupillary Reflex Pathway
→ Shine a light to the eye → received by photoreceptors →
passes through optic nerve → optic chiasm → one goes
ipsilateral then another goes contralateral → midbrain →
comes out of the third nerve nucleus → causes constriction of
the pupil
▪ Ipsilateral side: constricts, direct pupillary reflex
▪ Contralateral side: consensual reflex
● Anisocoria 📣
CONDITIONS ASSOCIATED WITH PUPILLARY REACTION
▪ Periorbital contusion hematoma: Seen in cases of
assault or violence
▪ Capillary hemangioma: Found among with
neurofibromatosis
▪ Lymphangioma: Everting lower eyelid to see the mass
▪ Preseptal cellulitis: document extent of inflammation
→ Sclera and Conjunctivae
▪ Pinguecula: Harmless yellowish triangular nodule in the
bulbar conjunctiva
▪ Episcleritis: Benign, usually painless localized ocular
inflammation of the episcleral vessels
▪ Stye (Hordeolum): A painful, tender, red infection at the
inner or outer margin of the eyelid
▪ Chalazion: A subacute, nontender, usually painless
nodule caused by a blocked meibomian gland
→ Cornea and Lens
▪ Corneal Arcus: A thing grayish-white arc or circle not
quite at the edge of the cornea
▪ Corneal Scar: A superficial, grayish-white opacity in the
cornea, secondary to an old injury or to inflammation
▪ Kayser-Fleischer ring: A golden to red-brown ring,
sometimes shading to green or blue; copper deposition in
the periphery of the cornea (Wilson Disease)
▪ Pterygium: A triangular thickening of the bulbar
conjunctiva that grows slowly across the outer surface of
the cornea; Surfer’s eye/Pugita
▪ Cataract: Opacity of the lenses visible through the pupil
▪ Ocular Trauma: NEVER palpate an eye with suspected
open globe injury
→ Pupils
▪ Direct pupil reaction

→ Represents a defect in the constriction or dilation of the pupil

▪ Consensual pupil reaction
▪ Swinging flashlight test
− Normal: constriction of both eyes
→ Unequal; one is dilated, one is constricted
− If dilation is observed instead of constriction, an optic
Table 5. Conditions associated with Pupillary Reaction nerve problem (RAPD)
Condition Description ▪ Near Reaction
Tonic Pupil (Adie ● Pupil is large (dilated), regular, and ▪ Associated conditions
Pupil) usually unilateral − Tonic Pupil (Adie Pupil)
● Reaction to light: severely reduced and − Oculomotor Nerve (CN III) Paralysis
slowed, or even absent − Horner Syndrome
● Near: constriction is present, although − Small, Irregular Pupils (Argyll Robertson Pupil)
very slow (tonic)
C. OCULAR MOTILITY TESTING
Oculomotor ● Pupil is large & fixed to light and near
EXTRAOCULAR MUSCLES
Nerve (CN III) effort
Table 6. Actions of extraocular muscles
Paralysis ● (+) Ptosis of the upper eyelid
● (+) Downward & outward eye deviation PRIMARY SECONDARY TERTIARY
MUSCLE
ACTION ACTION ACTION
Medial Rectus Adduction -
Lateral Rectus Abduction -
Inferior Rectus Depression Extorsion Adduction
Horner ● Affected pupil: small, unilateral, reacts
Superior Rectus Elevation Intorsion Adduction
Syndrome briskly to light and near effort, but dilates
slowly, especially in dim light Inferior Oblique Extorsion Elevation Abduction
● Ipsilateral ptosis of the eyelid and often Superior Oblique Intorsion Depression Abduction
loss of sweating on the forehead ● Mnemonics:

📣
● Horner’s Triad: Ptosis, Miosis, → All SUPERIORS are INTORTERS
Anhidrosis → All RECTUS ms. are ADDUCTORS
Small, Irregular ● Pupils are small, irregular, and usually CARDINAL DIRECTIONS OF GAZE
Pupils (Argyll bilateral ● Cardinal gazes
Robertson Pupil) ● A normal near reaction → Position at which you can examine the specific eye muscle
● Do not react to light

EXTERNAL EYE EXAMINATION

⚠️
MUST KNOW ⚠️
● Four-part examination: Inspection, Palpation, Auscultation,
Pupillary Examination Figure 46. Cardinal gazes[Lecturer’s PPT]

📣
● Examine: Table 7. Muscles examined when patient is asked to look at a
→ Position of the eye (global protrusion) specific direction
→ Lids and palpebral fissure Direction Muscle Examined
▪ Ptosis: Drooping of the upper eyelid Up and Outward Superior Rectus
▪ Entropion: inward turning of the eyelid margin
Outward Lateral Rectus
▪ Ectropion: Lower lid margin turns outward
▪ Exophthalmos: Protrusion of the eyeball Down and Out Inferior Rectus
Up and In Inferior Oblique

OPHTHALMOLOGY Eye Symptoms and Eye Examination Page 8 of 14

 Medially Medial Rectus
Down and In Superior Oblique
Table 8. Cardinal Fields of Gaze 📖
Right and Up Left and Up
R superior rectus L superior rectus Figure 51. Outward deviation with decentered light reflex [Lecture]
L inferior oblique R inferior oblique
Right Left
R lateral rectus L lateral rectus
L medial rectus R medial rectus
Right and down Left and Down
R inferior rectus L inferior rectus
L superior oblique R superior oblique

Figure 52. Inferior oblique of the eye is overacting. Hence, gaze

becomes asymmetric as compared to other gazes) [Lecturer’s PPT]

Figure 47. Cardinal positions of gaze [Lecturer’s PPT]

POSSIBLE CAUSES OF IMPAIRED EYE MOVEMENTS
● Neurologic problems
📖
OCULAR ALIGNMENT EVALUATION → E.g., Cranial nerve palsy
● Checked before assessing ocular motility ● Primary extraocular muscular weakness
● Begins by examining the ocular alignment in primary position → E.g., Myasthenia gravis
● Observe the corneal light reflex ● Mechanical constraints within the orbit limiting rotation of the
→ Shine pen light/ophthalmoscope in front of the patient’s eyes globe
▪ Examine the first Purkinje reflex → E.g., Orbital floor fracture with entrapment of the inferior rectus
▪ When eyes are aligned: reflection of light is centered on muscle
both eyes
● Decentered corneal reflex: ocular misalignment
● OCULAR MOTILITY TESTING
⚠️
MUST KNOW ⚠️
→ Before doing ocular motility testing, first test for the ocular
alignment of the movement of the eye
→ EOMs can be tested by using the asterisk method or the H
method
▪ Fixate: 14 inches (35 cm) at all cardinal gazes
▪ Ductions: monocular testing, one eye at a time
▪ Versions: binocular testing, two eyes at a time
− Note for jerky or pendular movements, diplopia, and
Figure 48. Normal ocular alignment[Lecturer’s PPT]
frozen eyeball
✏️
CONCEPT CHECKPOINT ✏️
1. T/F. Vergence are binocular eye movements and are tested
one eye at a time
a. True

📣
Figure 49. Comparison before and after surgery: (L) Inward b. False
deviation, pre-op. (R) Orthophoria, post-op ANS:
1. B. False. Vergence: Routine evaluation of convergence & divergence.
EYE MOVEMENT EXAMINATION Version is the one that tests both eyes, tests for jerky movements &
● With both eyes open, instruct the patient to follow your finger, diplopia
penlight, or a small target through the six cardinal positions of
gaze (H configuration) D. VISUAL FIELD EXAM 📖
Note: This part was not included in the lecture. Information under this heading
→ Move the target SLOWLY through each position of gaze
was taken from the book.
● Fixate: 14 inches (35 cm) at all cardinal gazes
● Ductions and versions CONFRONTATION TESTING
→ Monocular testing (ductions) ● Patient is seated facing the examiner with one eye covered while
→ Binocular testing (versions) the examiner closes the opposite eye.
● Eyes only: Avoid unnecessary head movement → Each eye is tested separately since the visual fields of the two
→ Extraocular muscles cannot be fully assessed if the patient’s eyes overlap.
head is also moving ● Targets are presented at a distance halfway between the patient
and the examiner
→ Allows direct comparison of the field of vision of each eye of
the patient and the examiner
● Examiner briefly shows a number of fingers of one hand (usually
one/two/four fingers) peripherally in each of the four quadrants
● The patient must identify the number of fingers flashed while
maintaining straight-ahead fixation.
● The upper and lower temporal and the upper and lower nasal
quadrants are all tested in this fashion for each eye
Figure 50. Ocular motility testing[Lecturer’s PPT]
● Things to take note of the ff:
→ Double vision
📖 ● 5-mm-diameter red sphere or disk
→ Attached to the handle of the target for detection and
quantification of more subtle visual field defects
→ Limitation of movement ▪ If areas of abnormal reduction in color (desaturation) are
→ Nystagmus sought
→ Smoothness of movement

OPHTHALMOLOGY Eye Symptoms and Eye Examination Page 9 of 14

 VISUAL NEGLECT Note: Not discussed in the synchronous lecture by Dr. Aclan, but discussed in
the posted asynchronous lecture by Dr. Pedro
● Disease of the parietal lobe
● Patient functions as if there is a left homonymous hemianopia ● Might be used in the clinic, and can also be used in bedside; used
→ When each eye is tested separately: no comparable visual field for bedridden patients and children
loss ● Consists of a scale & a foot plate that you put at the eye of the
→ When the right hemifield of both eyes are simultaneously patient
tested: objects are not identified in the left hemifield of either ● Steps:
eye → Anesthetize the eye of the patient
● Detected by simultaneous confrontation testing → Put the foot plate on the eye
→ The examiner holds both hands out peripherally, one on each → Scales will move, so one can interpret eye pressure of patient
side.
→ The patient, with both eyes open, is asked to signify on which
side (right, left, or both) the examiner is intermittently wiggling
his or her fingers.
→ The patient will still be able to detect the fingers in the left
hemifield when wiggled alone but not when the fingers in the
right hemifield are wiggled simultaneously.
E. INTRAOCULAR PRESSURE DETERMINATION
INTRAOCULAR PRESSURE (IOP)
● Pressure that is created within the closed environment of the eye
●
●
●
IOP varies and fluctuates
Normal IOP: 10-21 mmHg
❗️
Balance between aqueous production and drainage

Figure 55. Schiotz Tonometry Instrument [Lecturer’s PPT]

● Tonometry - Indicates measurement of intraocular pressure
→ The maneuver that helps detect ocular hypertension, glaucoma
and hypotony

●
hypertension, it is not
Methods:
📋
▪ In glaucoma, the optic nerve is damaged while in ocular

→ Finger palpation/ Tension tonometry/ Digital tonometry

→ Indentation tonometry
→ Applanation tonometry
→ Non-contact tonometer
●
standard of IOP measurements
Goldmann Applanation tonometry: Remains to be the Gold
Figure 56. Schiotz Tonometry Procedure [Lecture]
GOLDMAN APPLANATION TONOMETRY
● Method of measurement:
❗️
→ Contact-based
→ Flattening of the cornea area
● Advantage: Gold standard for IOP determination
● Disadvantage:
📣
Requires a skilled operator and slit
lamp/biomicroscopy is usually needed

measurement 📣
● Commonly used in: Ophthalmology clinics, for detailed IOP

→ Considered an office procedure

● Steps
→ Anesthetize the eye of the patient by an eye drop
→ Sit the patient
Figure 53. Circulation of Aqueous Humor. The pressure of the eye is → Put instrument to the eye of the patient
due to the aqueous humor production and drainage [Lecturer’s PPT]
FINGER PALPATION/TENSION TONOMETRY/ DIGITAL
TONOMETRY
Note: This part was not discussed in the lecture. Information under this heading
was taken from last sem’s posted asynchronous and synchronous lecture
● Ask the patient to look down, and gently palpate the globe of the

● Gives IOP estimates 📣

patient using index fingers.

→ If palpated globe is as soft as your lips = hypotonic

→ If as soft as your nose = normal

❗️
→ If it is as hard as your forehead = hypertension
● Findings:
📣 Figure 57. Applanation Tonometry with blue light and contact
between cornea and tonometer. Mounted on a slit lamp.
→ Normal - “Soft” upon palpation
▪ Considered to be normotensive or of normal IOP
▪ Paralleled to palpating the tip of nose

📋
→ Hypotensive or hypotonic upon palpation (softer than “soft”) is
considered a low IOP
▪ Paralleled to palpating the lips
→ “Hard” upon palpation is considered as a high IOP 📋
▪ “Firm” 📖
▪ Paralleled to palpating glabella Figure 58. Applanation Tonometry Procedure
NON-CONTACT/ AIR PUFF TONOMETER
● Method of measurement: Air puff to measure corneal response
● Advantage: Quick and non-invasive

irregularities📣
● Disadvantage: Less accurate in certain cases, corneal

● Commonly used in: Initial screenings, general IOP assessment

📋
Figure 54. Finger Tonometry. Do not ask the patient to fully close It blows air and the reflection of air back into the machine is
their eyes because you want to palpate the sclerae measured
● Non-contact procedure in getting the pressure of the eye
SCHIOTZ TONOMETRY

OPHTHALMOLOGY Eye Symptoms and Eye Examination Page 10 of 14


Figure 59. Air Puff Tonometry Procedure
REBOUND TONOMETER
● Method of measurement:
→ Probe rebound off of the cornea
▪ A ball comes out and slowly moves towards the cornea of
the eye of the patient
▪ Ball rebounds when it touches the cornea,
− “Rebound” is measured; equals to the IOP
● Advantage: Portable, no anesthesia required
● Disadvantage: Variable accuracy, calibration needed 📣 b. Tono-pen
in the pediatric age group 📣
● Commonly used in: Mobile clinics, more comfortable in patients
● Contact form in getting the pressure of the eye
● Can be done when the patient is in supine or any position 📣 of IOP determination, with increased accuracy.
Figure 60. Rebound Tonometry with needle-like refill that you need to
put in the tonometer which bounces & measured (not as visible)
TONO-PEN
● Method of measurement: Contact-based measurement using a
handheld device
● Advantage: Portable, useful in various settings
● Disadvantage: Calibration needed, operator variability 📣
● Commonly used in: Emergency situations, non-hospital settings
you need to put an anesthetic” 📣
● “Parang rebound tonometer lang din, but it is contact-based and
● Not as accurate as the Goldmann Tonometer 📣
Figure 61. Tonopen Procedure. Press it gently at the cornea
PERKINS HANDHELD TONOMETER
● Method of measurement: Contact-based, handheld device
●
● Disadvantage: Less common, requires proper alignment 📣
Advantage: Portable, suitable when slit lamp is unavailable
● Commonly used in: Field clinics, limited resources
● “Steeper learning curve when it comes to ophthalmologists”
● Like a Goldman tonometer, so it needs at anesthetic
Figure 62. Perkins Tonometer 📣
⚠️
MUST KNOW
INTRAOCULAR PRESSURE DETERMINATION
⚠️
● Finger Tonometry: estimated pressure using both index
fingers
→ Hypotonous (soft as lips), Normal (tip of your nose), Firm
(glabella)
● Schiotz Tonometry: can be used in bedside; uses foot plate
and scale
● Goldmann Applanation Tonometry: Office procedure done
with a slit lamp
OPHTHALMOLOGY Eye Symptoms and Eye Examination
● Air Puff Tonometry: Non-contact procedure using reflection of
air to estimate pressure
● Rebound Tonometry: Contact procedure using a ball that
rebounds from the corner of the eye
● Tonopen: Used for emergency situations, similar to rebound
tonometer
● Perkins Tonometer: Used for field clinics, when limited
resources are available
1.
✏️
CONCEPT CHECKPOINT
What are the most common ways to determine IOP?
✏️
a. Finger tonometry, Goldman tonometry, Air puff tonometry
b. Finger tonometry, Goldman tonometry, Rebound tonometry
c. Perkins tonometry, Goldman tonometry, Air puff tonometry
2. What technique is used for pediatric age group
a. Applanation tonometry
c. Rebound tonometry
ANS:
1. A. According to Doc Aclan’s lecture, these 3 are the most standard ways
2. C. Recall. Tono-pen (b) is useful for emergency situations as it is
portable.
D. FUNDOSCOPIC EXAMINATION
● The last component of ophthalmic physical examination
● Examination of the ocular fundus is an integral part of assessing
ocular health
● Performed with an instrument called the ophthalmoscope
→ Two types: Direct or Indirect
▪ If Direct, you will see the image as is
− Disadvantage: Image that is seen is limited
▪ If Indirect, you will be needing condensing lenses
− Most commonly the 20 diopter condensing lens
− Wider view of the patient’s retina
○ Used in patients with retinal pathology
− “Tricky, because image you see is inverted”
Figure 63. (L) Direct and (R) Indirect Ophthalmoscope
● Can also be done either dilated or non-dilated 📣
→ However, it is performed best with a pharmacologically dilated
pupil
▪ For patients who have certain retinal conditions, you need to
📣 📣
have a dilated fundus examination using an indirect
ophthalmoscope
▪ (From asynchronous): There may be contraindications to
these mydriatic medications: like narrow angle glaucomas
where inducing dilation of pupils may precipitate an acute
attack.
📣 ▪ Recall: mydriatics are drugs like Atropine, Phenylephrine
❗
● Perform fundoscopic exam after visual acuity (VA)
measurement
→ Bright light may affect the VA measurement if fundoscopy is
done earlier
DIRECT STRUCTURES TO BE OBSERVED
Figure 64. Fundus and parts usually seen
● Ocular media
→ Check for the red-orange reflex
▪ Normal ROR: No ocular media opacity
▪ Dull ROR: Retinal pathology (eg. Vitreous hemorrhage)
▪ Absent ROR: Very large retinal detachment or cataract
Page 11 of 14
 Figure 65. Red Orange Reflex
● Optic disc
→ Take note of optic cup which is a depression on your optic
nerve
Table 8. Optic Disc Evaluation Figure 66. Diabetic retinopathy. With (a) Soft exudates that appear
Condition Process Appearance feathery. (b) Hard exudates that are yellowish. (c) Flame shaped
Normal Tiny disc vessels ● Color yellowish hemorrhage (due to superficial capillary rupture). (d)
give normal color to orange to creamy Neovascularization, abnormal retinal vessels found in Proliferative
the disc pink Diabetic Neuropathy. (e) Dot hemorrhage (due to capillary rupture
● Tiny disc vessels deep to the cornea already). (f) Vitreous hemorrhage seen just
● Sharp disc margins floating in the vitreous
⚠️
MUST KNOW
● FUNDUSCOPIC EXAMINATION
⚠️
Papilledema Elevated ICP ● Disc swollen with → Usually performed with pharmacological dilated pupils
causes intra-axonal margins blurred → May either be done via
edema along the ● Loss of venous ▪ Direct ophthalmoscopy
optic nerve → pulsations ▪ Indirect ophthalmoscopy
engorgement & ● Disc vessels more
swelling of the optic numerous & visible ✏️
CONCEPT CHECKPOINT
1. Important structures to examine in performing
✏️ direct
disc
ophthalmoscopy include:
Glaucoma Increased IOP → ● Color yellowish a. Macula
Increased cupping orange to creamy b. Retinal vessels & background
and atrophy pink c. Optic disc
● Tiny Disc vessels d. Ocular media
● Sharp Disc margins e. All of the above
● Really big cup with a ANS:
thin rim & dull color 1. E. All are part of the examination
Note: the following parts on Direct and Indirect Ophthalmoscopy are not part of
Optic Atrophy Physiologic cup is ● Color white the synchronous lecture by Dr. Aclan but taken from the asynchronous lecture
enlarged, ● Absent tiny disc of the late Dr. Pedro
occupying more vessels DIRECT OPHTHALMOSCOPY
than half of the
disc’s diameter
● Direct ophthalmoscope can only see around 25% of your fundus
→ Periphery is not seen with direct ophthalmoscopy 📋
📋
● One needs to move ophthalmoscope a bit to examine other
portions of the retina

● Retinal vasculature
→ Retinal vein is thicker in caliber and more pigmented
Table 9. Retinal vasculature
Condition Appearance Image
● Arterial wall is
Normal transparent
Retinal Artery ● Normal light reflex is
narrow

Retinal
Arteries in
● Focal or generalized
narrowing of the lumen
Figure 67. Cross section of the right eye from above showing a
portion of the fundus commonly seen with the ophthalmoscope 📋
Hypertension and the light reflex

● Sometimes the arteries

become full & somewhat
Copper wiring tortuous
● Increased light reflex
with a bright coppery
luster
● Wall of a narrowed
Figure 68. Ocular Fundus. Notice the optic nerve pointed by arrow.
artery becomes opaque
Optic
Atrophy
so there is no visible
blood
● Steps in Direct Ophthalmoscopy
→ Dim the lights
📣
Areas usually seen: the cupping, veins, arteries, macular area[Lecturer]

→ Turn the focusing wheel to zero diopters

● Retinal background → Right to right: Use your right eye to examine patient’s right eye
→ Observe whether this is pale: → Position yourself 15 inches away from the patient and at a 15o
▪ Retinal artery occlusion may be possible angle
→ Changes in color may also hint at other retinal conditions. → Shine the light towards the eye of the patient
● Macular area → Look for the Red Orange Reflex

OPHTHALMOLOGY Eye Symptoms and Eye Examination Page 12 of 14

 → Follow ROR forward until retina is seen V. REVIEW QUESTIONS
1. Which of the following is/are TRUE of the Pinhole Test
a. All of the choices are true
b. It is used when the vision is less than 20/20
c. Improvement of vision to 20/20 on Pinhole indicates that
visual blurring is more likely an error of refraction and may be
corrected by eyeglasses
d. No improvement may indicate an organic eye problem
Figure 69. Direct Ophthalmoscopy Procedure [Lecture]
📋
2. In a patient diagnosed to have right eye esotropia, the
INDIRECT OPHTHALMOSCOPY patient has:
● Usually binocular, uses both eyes a. Weakness of the right lateral rectus
● Uses condensing lenses to examine retina (refer to Figure 55) b. Weakness of the right medial rectus
● May also use in the slit lamp (refer to Figure 54) where you can c. Multiple rectus muscle weakness
use a condensing lens with binocular view using the slit lamp d. None of the choices are true
3. When one shines a light on the eyes and the light reflex is
centered on the left pupil and the light reflex is at the 12
o’clock border of the right pupil, the patient has:
a. Right hypotropia
b. Right hypertropia
c. Left hypotropia
d. Left hypertropia
Figure 70. Indirect Ophthalmoscopy - binocular [Lecture] 4. The following are part of the 6 cardinal positions of gaze,
EXCEPT:
a. Right and up
b. Left
c. Up
d. Left and up
5. A common related manifestation of disturbance in
appearance is proptosis of the eyes which leads to different
symptoms such as foreign body sensation, dry eyes and
Figure 71. Indirect Ophthalmoscopy (Retinal lens) - condensing lens lagophthalmos. A condition most commonly associated is:
and slit lamp [Lecturer’s PPT] a. Orbital pseudotumor
IV. SUMMARY b. DM neuropathy
c. Retinoblastoma
● Ocular History
d. Grave’s ophthalmopathy
with an impression, plan, and management
→ Three major categories in visual complaints
📣
→ Examines a patient’s ocular complaints and helps you come up
6. All of the following are methods of eye pressure
determination:
a. Air Puff (non-contact)
▪ Abnormalities in Vision
b. Schiotz (indentation)
▪ Abnormalities in Appearance
c. Goldman (applanation)
▪ Abnormalities in Ocular Sensation
D. None of the above
● Ocular Examination
E. All of the above
→ Visual acuity determination
7. Motility testing is important in determining
▪ Distance visual acuity
a. Vision
▪ Near visual acuity
b. Ocular pressure
▪ Pinhole visual acuity
c. Alignment
→ External eye exam
d. Ocular inflammation
▪ Inspection, palpation, and auscultation
8. A patient complains of pain on eye movement. Which of the
▪ Pupillary examination
following is the most likely diagnosis?
− Direct and indirect light reflex test
a. Cataract
− Swinging flashlight test
b. Pterygium
→ Ocular motility
c. Orbital myositis
▪ Ductions
d. Bacterial conjunctivitis
▪ Versions
9. Which of the following is a test of visual acuity?
▪ Vergences
a. Titmus fly test
→ Tonometry
b. Jaeger test
▪ For pressure
c. Amsler grid test
→ Funduscopic examination
d. Duochrome test
● After the history and examination, come up with an impression,
10. Among the following methods to measure intraocular
differential diagnosis
pressure, which if the following is the gold standard?
● Come up with a plan of management whether diagnostically,
a. Air-puff tonometry
general practitioner📣
therapeutically, or when to refer your patient in the case of a

● Summary of steps in performing the basic eye examination 📖

→ Measure the visual acuity of each eye
→ Inspect the lids and surrounding tissues. Palpate the orbit if
necessary
→ Inspect the conjunctive, sclera, cornea, and iris
→ Inspect the pupil and check the pupillary reflexes
→ Assess the chamber for clarity and depth
→ Check the ocular alignment and test the extraocular
movements
→ Perform tonometry
→ Assess the lens for clarity through direct ophthalmoscopy
→ Examine the fundus, disc, vessels, retinal background, and
macula.
b. Schiotz tonometry
c. Goldman applanation tonometry
d. Digital tonometry
ANS:
1. A. It is used when a patient is not able to read the 20/20 line in the distance
vision chart. If the vision improves when using the pinhole, blurring of the
vision is due to an error of refraction. If the vision does not improve when
using the pinhole, there may be an organic problem in the visual axis
2. A. Esotropia is the inward turning of the eye so weakness is on the same
eye (right) lateral rectus; B - for exotropia; C - only right eye is affected
3. A. Light reflection appears displaced superiorly (12 o’clock border) in the
non-fixating eye (right eye) showing downward misalignment.
4. C. The “cardinal positions'' are six positions of gaze which allow
comparisons of the horizontal, vertical, and diagonal ocular movements
produced by the six extraocular muscles when both eyes and multiple
muscles are working together. These are the six cardinal positions: Right
and up, Left and up, Right, Left, Left and down, Right and down

OPHTHALMOLOGY Eye Symptoms and Eye Examination Page 13 of 14

 5. D. A. The ocular manifestations of orbital pseudotumor may include
periorbital edema, erythema, proptosis, ptosis, diplopia and pain with eye
movements.B. Glaucoma C. Leukocoria
6. E. IOP is the tension exerted by the aqueous humor as a result between its
production and outflow from the globe. Methods of eye pressure
determination are air puff, Schiotz, and Goldmann. Goldmann applanation
tonometry (GAT) currently is the gold standard, to which all other tonometers
are compared.
7. C. Evaluates both individually/monocular eye movements (ductions) and in
tandem/ binocular eye movements (versions)
8. C. Retrobulbar pain can be due to orbital inflammation of any kind. Certain
locations of inflammation, such as orbital myositis, may produce pain on eye
movement
9. B. Visual acuity test: distance acuity examination, pinhole examination, and
near acuity examination
10. C. Instrument is more accurate than the Schiotz tonometer in determining
the IOP of patients with altered scleral rigidity
VI. REFERENCES
● Aclan, B. (2023). Eye Symptoms and Eye Examination. Lecture
Video.
● Pedro, B. (2022). Eye Symptoms and Eye Examination.
Asynchronous Lecture Video.
● 2024 Trans
● Synchronous recording

OPHTHALMOLOGY Eye Symptoms and Eye Examination Page 14 of 14