Eye methods by Asad
Sources used:
1. Kanski
2. Arsalan notes
3. Umar notes
4. Usama’s videos
5. Selfless medicos videos.
6. Ophthalmology ward book.
7. Net.
Steps common to all examinations.
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient
3. Say Thank you.
Hirschberg corneal reflex test:
4. Approach from right side, greeting, introduction, informed consent.
5. Explain to the patient
6. Check gross VA by showing 2 or 3 (etc) fingers and asking how many fingers did you see.
7. Ask patient to focus on a distant object (Samne dekhna ha apny), Shine the light on the glabella
from an arm’s length, & observe corneal reflex in both eyes.
8. Say Thank you.
Interpretation:
Center of pupil = Normal
At pupil margin = 15 degrees = 30 prism diopters
Middle of iris (between pupil margin limbus) = 30 degrees = 60 prism diopters
At limbus = 45 degrees = 90 prism diopters
EOM Movement Assessment:
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient
3. Check gross VA by showing 2 or 3 (etc) fingers and asking how many fingers did you see.
4. Give definite target for near fixation.
5. Check diplopia by asking whether the patient sees the target as double.
6. Give instruction to – not move the head while looking at the target, -to inform if he/she notes
any pain or double vision during eye movement.
7. Use one hand to fixate as patients tend to move head despite the instructions against it. (not
necessary, if done, it may necessitate hand switching to make complete H properly during
examination)
8. Check pursuit eye movement in right and left gaze. (Central part of H)
9. Check pursuit eye movement in 6 cardinal positions. (Limbs of H)
10. Check midline elevation and depression for fatigability and lid lag.
11. Check vergences (convergence and divergence), by first giving a distant target and then using
finger as near target and moving it near.
12. Check saccadic movements by using 2 targets, e.g spoon and pen torch and asking patient to
switch gaze between them as directed by examiners words.
13. Say thank you.
Ptosis Examination:
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient
3. Start with Inspection and check the following.
4. Head posture
5. Rule out pseudoptosis.
6. Ask patient to close eyes and check eyelid creases, is at higher level in involutional/aponeurotic
type of ptosis & is absent in congenital type
7. Normally, upper eyelid margin covers 2mm and lower one covers 1mm of cornea. Check
palpebral fissure height with scale, ask patient to look ahead (samny dekhen) and put 0 of scale
at upper eyelid margin and note the distance to the lower eyelid margin in mm, do the same in
the other eye.
Normal in males is 7-10 mm and females 8 to 12 mm.
Used to quantify degree of ptosis by the difference between the 2 as:
Mild= 1-2mm Moderate=3-4mm Severe=4mm or more.
In bilateral cases, it can be determined by using following formula:
MRD1 normal (4mm) – MRD1 observed
8. Check Marginal Reflex distances 1 & 2 (MRD1 & 2)
MRD1=Distance in mm from light reflex on patients cornea to the level of the center of
the upper eyelid margin, with the gaze in primary position. Used to indicate degree of
ptosis. Normal is 4-5mm.
MRD2=Distance in mm from the light reflex on patients cornea to the level of the center
of the lower eyelid margin, with the gaze in primary position. Used to indicate degree of
ptosis.
MRD3= It is the distance in mm from the ocular, not corneal, light reflex to the central
upper-eyelid margin when the patient looks in extreme up gaze.
i. -Ask the patient to look ahead (samny dekhen), shine light into eyes using right hand and
measure distances using left hand.
ii. -Do the same in the other eye (Switch hands?)
9. Check levator function.
i. -Ask the patient to look as far down as possible (Without moving head).
ii. -Put the edge of the ruler on the lower margin of middle of the upper lid. (not necessary
to keep the edge, can measure the difference between two points, such as 2 mm and 0.5
mm for convenience)
iii. -Press firmly against the frontalis muscle on the eyebrow using the thumb.
iv. -Ask the patient to look maximally upwards without moving his/her head.
v. -Measure the amount of lid excursion in mm.
vi. -This is the levator function.
vii. -Do the same in the other eye.
10. Check Bells phenomenon. (palpebral oculogyric reflex)
i. Ask the patient to try to close their eye (check each side separately) against pressure
applied by the examiners thumb on the lid.
ii. An upward and outward movement of the eye when the patient tries to close the lids is
+ve bells phenomenon.
Checked to prevent risk of exposure keratitis following ptosis surgery, which may occur if
it is absent.
11. Check Marcus Gunn Jaw-Winking ptosis.
i. Ask the patient to move jaw as if chewing something.
ii. Lack of eyelid movement on chewing excludes winking ptosis.
12. Check EOM as above. (Check 6 cardinal positions of gaze)
13. Check corneal sensations. (corneal esthesiometry)
i. Ask the patient to look forward
ii. Touch wisp of cotton to the cornea from the side
iii. Eyelid closure upon touching indicates normal function.
14. Rule out myasthenia gravis by:
i. History of worsening lid movement as the day passes (Fatigability).
ii. Ice test.
Placing cold ice over the lid improves lid function.
iii. Tensilon test.
Improvement of lid function upon edrophonium injection.
iv. Cogans lid twitch:
The patient is instructed to look straight ahead, up, down, and straight ahead again. The
upper eyelids were carefully evaluated immediately following this movement for the
presence of a brief upward twitch of the upper eyelid, which would indicate a positive CLT
test.
v. Ask the patient to look at elevated target for 30s. (fatigability test)
15. Thank the patient.
Visual field by confrontation method:
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient
3. Give instructions to:-follow the target given
-not to move the head while doing so
-fixate vision on examiner’s nose or eye (meri khuli ankh myn dekhen) and to not look at thetarget while it is
being moved, just to inform when he/she notes it moving into his/her visualfield.
4. Ask patient to occlude the eye not being tested by placing palm (hatheli) of the hand on the same side over
it. (don’t ask to put fingers over it), occluder can also be used.
5. Check gross VA in all 4 quadrants. (superior temporal, inferior temporal, superior nasal, inferior nasal)
6. Examiner occludes his eye (if testing patients left eye, he occludes his right eye and vice versa).
7. Bring a pen or other target (can also use moving finger) from outside to inside the visual field in
4 quadrants (superior temporal, inferior temporal, superior nasal, inferior nasal), examiner should change the
hand occluding his own eye when testing the opposite side as the eye being tested without obstructing his
own visual field. Target should be in the middle of the patient and the examiner(half arms length).
8. Ask the patient to tell when he sees it, and compare whether you see it before, at the same time or after the
patient.
9. Check blind spot by:
-positioning the target centrally, and then moved temporally (outwards) to locate blind spot 15
degrees temporal to center, by asking the patient to report when the target disappears and
then reappears
10. Say Thank you.
Digital Tonometry:
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient
3. Ask about tenderness in eyes.
4. Ask the patient to look downwards (without closing his/her eyes)
5. Place middle fingers of both hands on forehead to stabilize hands.
6. Palpate eyelid by pulp of index fingers.
7. Apply gentle pressure with pulp of one finger and feel it by pulp of other finger and vice versa.
8. Repeat in other eye.
9. Say thanks.
Eyeball can be =
Firm, like tip of the nose (normal)
Soft, like lips (abnormal)
Hard, like glabella, bone (abnormal)
Pupillary reflexes:
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient.
3. Ask examiner for mid illuminated room.
4. Check gross VA.
5. Give distant fixation target to relax accommodation.
6. Observe shape, size, location, symmetry and number of pupils.
7. Shine the light in one eye (move it onto the eye from the temporal side), and observe light reflex
in same eye.
8. Shine the light in one eye (move it onto the eye from the temporal side), and observe the light
reflex in the opposite eye.
9. Do the same for the opposite eye.
10. Perform swinging flash light test by shining in one eye for 1-2 seconds, moving to other eye via U
shaped motion (swing), shining it in that eye for 1-2 seconds, perform a few swings & observe
both pupils while doing so.
11. Thank the patient.
Cover Uncover tests:
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient
Cover Test (detects manifest squint)
3. Note the eye which is suspected to be deviated by asking the patient to focus ahead (Distant
target)
4. Cover normal (undeviated eye) via occluder.
5. If suspected deviated eye moves and take up fixation, indicates heterotropia.
6. No movement indicates one of 2 things:
-Either orthophoria
-Or heterotropia in the opposite eye.
-If deviation is grossly visible and still no movement is seen on cover test, it can be paralytic
deviation, eccentric fixation or blind deviated eye.
7. Repeat for near target. (use torch or finger)
8. Repeat on opposite eye. (depends on command)
Uncover test (detects latent squint)
9. The patient fixates on a distant target.
10. Cover the normal eye with occluder and uncover it after 2-3 seconds. (can be perfomed in
tandem with cover test)
11. No movement indicates orthophoria
12. If the covered eye was deviated while under the cover, a refixation movement is seen on being
uncovered, indicating heterophoria of that eye. E.g nasal movement (Adduction) at recovery
indicating exophoria of right eye.
13. Repeat on near target. (use torch or finger)
14. Test is repeated for the opposite eye. (Depends on command)
15. Other uses of uncover test:
-To detect alternating squint, when after covering normal eye, deviated eye takes up fixation,
and after uncovering normal eye, the deviated eye still retains fixation, and the normal eye
becomes the deviated eye.
- To estimate secondary deviation (deviation of normal eye when affected eye takes up fixation
or tries to take up fixation), in this case we will cover normal eye then uncover it after a few secs
which will show us the secondary deviation.
Alternate Cover Test (used to detect phoria in case above tests are unremarkable)
Induces deviation to indicate total deviation (latent + manifest)
16. Patient fixates on a distant target.
17. One eye is covered for 2-3 sec by occluder. Then occluder is shifted to other eye for 2-3 secs and
this is repeated several times.
18. Smoothness of recovery to pre-dissociated stage after dissociation is noted,
- well-compensated heterophoria will have straight eyes before and after the test has been
performed
-patient with poorly controlled heterophoria may decompensate to a manifest deviation
19. Say thank you.
Regurgitation Test:
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient
3. Shine light on punctum with opposite hand as the eye being test (left hand if right eye of patient
is being tested).
4. Press with 3-4 pushes on the area of the lacrimal sac with little finger of the same side hand as
the eye being tested (little finger of right hand).
5. Lack of any regurgitation indicates –ve test and vice versa.
Squint Assessment:
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient
3. Perform Hirschberg test as given above.
4. Perform Cover & uncover test as above.
5. Check EOM as above.
6. Say thank you.
Lid Eversion
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient
Upper lid
3. Ask the patient to look down.
4. Gently evert upper lid by grasping some lashes with thumb and fingers and look for any foreign
body, papilla, scars.
Lower lid
5. Ask the patient to look up.
6. Evert lower lid with thumb
Fluorescein staining:
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient
3. Put one drop of fluorescein in the conjunctival sac.
4. Observe under cobalt blue light under slit lamp.
5. Epithelial defects & corneal ulcers stain bright green with fluorescein.
6. Say thanks.
Ophthalmoscopy:
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient
3. Ask for ambient/dim light.
4. Remove observer/patient glasses.
5. Check pupillary reactions as above.
6. Dilate both pupils.
7. Use red free light.
8. Select large round aperture on ophthalmoscope.
9. Right eye is checked by holding ophthalmoscope in right hand and using your right eye to see
through the peephole. Left eye is seen with ophthalmoscope in left hand using examiner’s left
eye. (triple RRR or LLL)
Distant Direct:
10. Set focusing lens at 0 (for distant direct). (for plus lens move clockwise, for negative
anticlockwise)
11. Ask patient to look as a distant target straight.
12. For distant direct, check patient’s red reflex from 2 feet distance (1 arms length approx. equal to
2 feet)
Direct:
13. Move close to the patient, adjust power of lens to +10D. (clockwise movement on dial)
14. Make appropriate movement to search all 4 quadrants / ask patient to look up down sideways
for each quadrant we are searching.
15. Ask the patient to look into the light for macula.
16. See optic disc, vessels, macula.
17. Thank the patient.
DIFFERENCES BETWEEN DIRECT AND INDIRECT
OPHTHALMOSCOPY
PARAMETER DIRECT INDIRECT
OPHTHALMOSCOPY OPHTHALMOSCOPY
1. Illumination Not as bright and not as useful Useful for hazy media, more
in hazy media bright
2. Accessible View Difficult to see beyond equator Visibility up to ora serrata
3. Stereopsis No Yes
4. Area in field of focus 2-8D 8D
5. Patients position Sitting position Lying down
6. Condensing Lens No Yes
7. Distance Distant or as close to eye as Arm’s length
possible
8. Image Direct (fundoscopy) = virtual, Real, inverted, 2-5x
erect, approximately 15x magnification
magnification
Distant Direct = Real, inverted,
unmagnified.
Retinoscopy:
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient
3. Check pupillary reactions as above.
4. Ask the patient to focus on a distant target.
5. Sit at patient level at a fixed distance.
6. Check the retinal reflex by moving from right to left and from top to bottom.
7. Appreciate with or against movement.
8. Use appropriate lens to neutralize the reflex. (plus lens if there is with movement, minus lens if
there is against movement)
9. Note down readings in form of power cross.
10. Subtract the working distance.
General principle is to subtract working distance from value obtained from retinoscopy
1/ Working distance in meters = value that needs to be subtracted
If we do retinoscopy from 50cm then substract 2D.
11. Formula is:
Rx (refractive error) = Lens power that was needed to neutralize the reflex – 1/working distance
in meters
12. Thank the patient.
Assessment of vision:
Distant Visual Acuity:
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient
3. No need to take off glasses.
4. Ask for well illuminated room.
5. Display Snellen chart 6 meters in front of patient.
6. Occlude one eye (conventionally right eye is tested first)
7. Ask patient to read loudly each letter or number of pictures on the lines of successively smaller
optopypes from left to right. If the patient is unable to read the first line, reduce distance by 1
meter until he reads, if not reading from 1 meter, then check finger counting, if not present then
check hand movement, if hand movements are not appreciated check perception of light.
8. Not the corresponding visual acuity measurements are shown at the bottom of line.
9. Repeat steps from left eye with right eye occluded.
10. Now test each eye separately with spectacle correction.
11. Thank the patient.
Snellen chart:
LOGMAR Chart:
Pinhole visual acuity:
1. Repeat all above mentioned steps using pinhole occluder.
2. Record the Snellen acuity obtained and precede it with abbreviation PH.
Near vision (Near visual acuity):
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient
3. Instruct patient to hold the test card at the distance specified on the card (40cm).
4. Occlude left eye.
5. Ask patient to read upto smallest legible line on the card and document it.
6. Repeat same steps for left eye after occluding right eye.
7. Repeat the procedure with both eyes viewing the card.
8. Record binocular visual acuity.
Near vision chart:
Color vision testing:
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient
3. Display ishihara chart at reading distance to the patient. (40cm).
4. Ask to read the number hidden in the chart.
5. Both eyes are tested simultaneously.
6. Say thank you.
Colour Vision Chart (Ishihara)
Entropion:
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient.
3. Horizontal lid laxity can be demonstrated by pulling the central part of the lid 8 mm or more
from the globe, check whether it goes back before or after first blink, or doesn’t go back.
4. For lateral canthal laxity, pull lower lid medially and note movement of lateral canthus. Ability
to pull lid medially more than 2mm indicates lateral canthal laxity.
5. Medial canthal tendon laxity, demonstrated by pulling the lower lid laterally and observing the
position of the punctum. If the lid is normal the lower punctum should not be displaced more
than 1–2 mm. If laxity is mild the punctum reaches the limbus and if severe it may reach the
pupil.
6. Check facial nerve function.
7. Thank the patient.
Ectropion:
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient.
3. To test for horizontal laxity, place a thumb beneath the lateral canthus and push the eyelid
laterally and superiorly. If the lid margin does not roll back into position, suspect a cicatricial
component. In involutional cases, the ectropion typically disappears with this maneuver.
4. The eyelid distraction test is done by pulling the lid away from the globe. Normal lid
distraction is between 2-3 mm. If it is more than 5mm, there is substantial laxity.
5. In cases of cicatricial ectropion, the eyelid malposition will often become accentuated by
asking the patient to look upwards and to open his or her mouth at the same time; the
maneuver places the anterior lamella on maximum stretch.
6. Check facial nerve.
7. Thank the patient.
-
Cataract Examination:
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient.
3. Visual acuity testing.
4. Pupillary reflexes.
5. Distant direct ophthalmoscopy.
-Ask patient to look right, left, up, down, look whether the black shadow in case of cataract
moves with, against eye movement, or doesn’t move at all.
6. Macular function test (amsler grid test)
7. Thank you.
Proptosis Examination:
1. Approach from right side, greeting, introduction, informed consent.
2. Explain to the patient.
3. Stand behind patient and check.
-presence of proptosis
-palpate thyroid and lymph nodes
4. Inspection with torch.
5. Check for dystopia (malpositioning of the eyes in vertical or horizontal plane, ptosis occurs in
AP plane) with Hirschberg, cover-uncover test.
6. Check pupillary reflexes (for optic nerve involvement).
7. Check retropulsion
-push closed eyes (both) with thumbs backward into the orbit. Normal eye will be pushed back
slightly. This is called retropulsion.
8. Palpate thrill by palm one by one.
9. Auscultate with bell of steth.
10. Measure proptosis with scale.
Place scale at lateral canthus and measure distance to corneal apex at patients level, normally
upto 20mm
11. Corneal esthesiometry via cotton wisp.
12. Thank the patient.
