Please make sure that you have learned these clinical skills and

have practiced them while examining the patients, your

Assessment of Visual acuity with and without correction and

Guidelines for visual acuity assessment:

• Far vision
1. Make the patient familiar with optotypes (0.25 marks)

2. Let the patient sit at a proper distance; 6m or 3m plus a mirror (0.25 marks)

3. Illuminate the chart.

4. Occlude the left eye (0.5 marks)

5. Ask the patient to localize the missing part of C, on the lines of successively

smaller optotypes, until he correctly identifies only half the optotypes on a

line (0.5 marks)

6. When the patient can read only half the letters correctly in any given line, the

visual acuity will be expressed in the form of a fraction where the size of the
optotype

(which is usually written beside or below each line on the chart) will be
denominator, while the distance at which the patient is placed will be the
numerator.

e.g. 6/60 (0.5 marks)

7. Test with and without glasses (0.5 marks)

8. Do the same with the other eye (0.5 marks)

9. Do the same with both eyes open (0.5 marks)

• Near vision
1. With the patient wearing his near glasses (if he has), and the card evenly

illuminated, instruct the patient to hold the card at the distance specified

on the card (0.5 marks)

Examination of the ocular adnexa (eyelids and lacrimal apparatus).

Guidelines for lacrimal system examination

Lacrimal gland palpation:

• Orbital part
- The examiner is standing at the patient's side (0.5 marks)

- Ask the patient to look down & and nasally (0.5 marks)

- Try to palpate the lacrimal gland by introducing your little finger (with its
anterior surface upwards) between the globe & and the upper outer part of the

orbital margin (0.5 marks)

- Use the right little finger for the right gland & and the reverse (0.5 marks)

- Results: (0.5 marks)

*If palpable: enlargement of the lacrimal gland

*If not palpable: Normal lacrimal gland

• Palpebral part:
Ask the patient to look downwards and you elevate the upper lid (0.5 marks)

• Drainage system:
- Punctum (the eyelid margin should be everted slightly) and lid margin and tear
meniscus observed (0.5 marks)

- Swellings at the site of the lacrimal sac and regurge test:

By index or a Q-tip at the site of lacrimal sac pressure up, backward and medially

(Below Medial Palpebral Ligament at the lacrimal fossa in the inferomedial part of
inferior orbital margin) (0.5 marks)

Guidelines for eyelids examination and eyelid eversion

1- Proper illumination

2- Eyelid examination is divided into:

Inspection for

Dermatochalasis

Swellings: diffuse (edema, blepharochalasis) or localized: chalazions, styes,

or cysts.

Signs of trauma: cut wounds or marginal wounds or scars.

Inflammation: blepharitis

Lid margin abnormalities: trichiasis, entropion, ectropion.

Punctum

Eyelid position: using corneal reflex and comparing both eyes (if ptosis or
retraction

proceed with specific tests)

Palpation for

Swellings consistency, tenderness, temp., mobility

Special tests:

For ptosis: palpebral fissure height, marginal reflex distance, and levator
excursion

Retraction: other thyroid lid signs

Lid eversion:

lower lid simple lower lid skin traction will reveal the conjunctival side of the
lower eyelid.

Upper lid: the patient is instructed to look downwards pressure is applied by a Q-

Assessment of the ocular motility and muscle balance.

Guidelines for extraocular muscle examination:

[Muscle balance/ EOM motility: each 4 marks separately]

1-Muscle Balance (4 marks):

- Ask the patient to sit or stand with the head in the primary position (0.5
marks)

Hold a penlight at about 40 cm from the patient (0.5 marks)

- Ask the patient to look at a distant target (0.5 marks)

- Patient and doctor should be at the same level (0.5 marks)

2-Do the cover test: 2 types

a- Cover- uncover test: (0.5 marks)

Cover the fixing eye (normal eye)

Look at the uncovered eye and check for fixation and movement, if the
uncovered eye moves to

pick up fixation then the diagnosis of manifest squint can be made (0.25 marks)

b- Alternate cover test (0.5 marks)

Cover each eye for a few seconds

Test for eye movements for the eye under the cover

The presence of eye movement diagnoses the presence of a latent squint (0.25
marks)

2-EOM motility (4 marks):

Ask the patient to sit or stand with the head in the primary position/ or fix the
head (0.5 marks)

Hold a penlight at about 40 cm from the patient (0.5 marks)

Ask the patient to move his eyes to follow the object without moving his head
(0.5 marks)
Test binocular eye movements in the 6 directions of gaze (version movements) (1
mark)

Test uniocular eye movements (ductions) (1 mark)

Test for vergence (convergence and divergence) (0.5 marks)

Assessment of the pupils.

1- Have a bright torch (0.5 marks)

2- Reduce illumination in the room (0.5 marks)

3- The patient should focus on a distant target (0.5 marks)

4- Direct your light towards the pupil to be examined (0.5 marks)

5- Observe the brisk constriction of the pupil in response to direct light as well as
the simultaneous constriction of the pupil of the other eye (1 mark)

6- Perform the swinging flashlight test by shining the light (2-4 seconds) in one
eye and rapidly moving it to the other, and switching between eyes (1 mark)

Examination of the anterior segment of the eye by penlight.

Assessment of the visual field by confrontation.

- Approach to the patient.

- Patient and doctor at the same level (0.5 marks)

- Patient and doctor wearing their glasses (0.5 marks)

- Patient and doctor should cover facing eye (right eye of patient and left eye of
doctor) (0.5 marks)

- Instruct the patient to look into the doctor's eyes (0.5 marks)

- Place Finger Or Target midway between patient and doctor (0.5 marks)

- Test upper, lower, temporal, and nasal fields (0.5 marks)

- Shift your hand while testing the nasal field (0.5 marks)

- Test the Other eye (0.5 marks)

GOOD LUCK