Table of Contents

Visual Acuity 2
Pupils 9
Intraocular Pressure (IOP) 12
Motility and Strabismus 15
Refraction 27
External Exam 54
Dilation and Gonioscopy 56
Slit Lamp Exam 61
Indirect Ophthalmoscopy 77
Summary 80
Proofread, fact-checked, and edited by Rachel Conlee and
Ariess Gharabagi.

Disclaimer: This writing is my own and based on knowledge I’ve

accumulated through various resources thus far in my
ophthalmology training. I encourage every reader to consult the
relevant literature/texts for their program and/or training level.
Don’t take my word for it. The purpose of this work is to provide
a concise summary of critical topics. This work contains no
medical advice and is in no way a substitute for formal medical
training. I use examples of one way to perform or document
these exams and they are by no means universal or
comprehensive. I also don’t cover every component of the exam
in total detail either but attempted to summarize what would
be reasonable for a new resident to know and would be
applicable the majority of the time. Please submit errors to
[email protected]. All figures/photographs are original.

1
 Visual Acuity
The physical exam for ophthalmology is rarely taught to
any degree of detail in medical school. If anything, students may
be shown a direct ophthalmoscope which is rarely used in an
ophthalmology practice. This means it’s difficult for students or
new residents to fully participate in the physical exam.
Hopefully, this short guide will help explain the method behind
a typical exam in ophthalmology. To keep the scope concise, my
goal is to focus on how to perform a physical exam and the
reasoning/science behind it without getting too deep into the
pathology behind specific exam findings. Some discussion of
specific pathology will be inevitable.
Most of the work-up for a patient is done by ophthalmic
technicians although every ophthalmologist knows how to work
patients up and must be proficient at it themselves. The work-
up usually involves the ophthalmology equivalent of “vital signs”
which are vision, pupils, and pressure. Some clinics (e.g.,
pediatrics) have a more involved or unique workup. Many
components of the workup are typically obtained before the
ophthalmologist/optometrist walks in the room.
Visual Acuity (VA)
Visual Acuity (VA) is essentially a
measure of visual clarity. It is tested one
eye at a time. There are different ways to
measure visual acuity and the most
common way in clinic is with a chart such
as the Snellen (pictured here). There are
different types of visual acuity tests, and
minimum legible threshold is the most
common. Minimum legible threshold
describes the point at which a patient
cannot distinguish progressively smaller
optotypes (letters or numbers) from one another. Reading a
chart like the Snellen is a form of minimum legible threshold.
There are other types of visual acuity tests, but these are rarer
compared to minimum legible threshold testing.
2
 Minimum separable threshold measures the smallest
distinguishable separation between two objects.
Vernier acuity measures the smallest perceivable break
between in a line (the space between line segments).
There are also more modern analogs to the Snellen chart
including the Sloan or Tumbling “E” chart. Chart preference
varies substantially by clinic.
Minimum legible threshold is reported as the distance a
patient could read a line of optotypes divided by the distance a
person with normal vision could read the same line. Patients are
asked (one eye at a time) to read smaller and smaller lines until
they’re unable to read the optotypes.
So, 20/60 means the patient can see at 20 feet what a
“normal” eye can see at 60. 20/15 means the patient can see at
20 feet what a normal eye can see at 15. Vision can be more
specifically reported as well. For example, if there are 5
optotypes on the 20/20 line and a patient reads 3 of them, it
can be reported as 20/20-2. If they read 2, it’s 20/25+2.
The technical definition of 20/20 vision is the ability to
resolve a separation of one minute of arc on the retina which is
the spatial resolution of the human eye. An arcminute is 1/60th
of a degree. The angle refers to the angle formed as it relates to
the “nodal point” of the (model) eye.

The optotypes are designed carefully with this in mind.

On the 20/20 line, the letter “E” is constructed such that the
spaces between the arms are 1’ of arc. To distinguish the letter
as “E” vs. “P”, the eye must be able to resolve to 1’ – the spatial
resolution of the retina. The entire letter is 5’ of arc tall.
3
 20/20 is “normal” vision, around 20/60 driving becomes
difficult and 20/200 is legal blindness. 20/800 (aka 5/200) makes
ambulating a challenge. Once a patient can’t identify the largest
optotypes on the charts, we move to counting fingers (CF). This
reports the patient’s ability to count fingers and how far away
from the eye. For example, CF 3’ means the patient can
accurately count fingers 3 feet from the eye. Beyond the ability
to count to fingers is “Hand Motions” (HM). This is assessed by
moving the hand back and forth and up and down over the eye.
If the patient can accurately report which direction the hand is
moving, the vision can be reported as HM in that eye. If the
patient cannot accurately report which
direction a hand is moving, the eye is
checked for its ability to perceive light (LP
for “light perception”). This is typically
accomplished by shining a bright light (like a
muscle light pictured here) in the patient’s
eye while asking the patient if the light is on
or not. If they can accurately tell when the
light is shining in their eye and when it is not
their vision can be reported as LP for that
eye. Sometimes BLP is recorded for “bare
light perception”. If they definitely cannot
detect the light, their vision is reported as
“NLP” for “no light perception”. Always
report vision for each eye separately.
While on the topic of “20/20” and visual acuity, why 20
feet? 20 feet (or 6 meters) is close to "optical infinity" where
light rays entering the eye are parallel and the eye doesn’t need
to accommodate. The eye in an unaccommodated state allows
for an accurate refraction. Remember, a diopter (D) is an
inverse meter so 1/6 m = 0.167 D. That is less than can be
ground into glasses.

4
 20-foot rooms are expensive, so most eye clinics use
mirrors to simulate this distance.

Visual acuity can be recorded with or without corrective

lenses or contacts. With corrective glasses is recorded as “cc”
for con correction. Without glasses is “sc” for sans correction.
“Sans” means “without”. Contact lenses are abbreviated as CL
so “cCL” means “with contact lenses”.

5
Pinhole
A pinhole is a small (1.2 mm) hole in an occluder that can
screen for uncorrected refractive error. They use the stenopeic
principle and eliminate diverging rays from entering the optical
system. This makes the blur circle of the light much smaller on
the retina by only allowing light to pass through the very center
of the cornea and lens, eliminating any refractive errors of the
eye. This is why patients shouldn’t squint when testing visual
acuity. Pinhole visual acuity can be recorded separately. It is a
good measure of visual potential with corrective lenses. This is a
very similar principle to pinhole cameras.
Pinhole is abbreviated “ph” in the exam. “NI” is the
abbreviation for “no improvement” with pinhole occlusion.

LogMAR
For purposes of research or tracking visual acuity over
time, logMAR visual acuity is commonly used. This measures the
minimum angle of resolution using a base-10 logarithm. Specific
logMAR charts include the Bailey-Lovie chart or ETDRS which
was designed for the famous “Early Treatment Diabetic
Retinopathy Study” study. Here are some quick conversions:

Feet (Snellen) logMAR Meters

20/200 1.00 6/60
20/20 0.00 6/6
20/15 -0.12 6/4.5

While Snellen or Sloan charts dominate the adult world,

other types of minimum legible threshold are used for different
age groups. The “HOTV” chart consists of just those four letters
and is used for children 2-5 who might not know every letter yet
and can come with a key card of the four letters so children can
match by pointing. “LEA” symbols are also popular in this age
group. They consist of a simple image of a house, an apple, and
a square and can also come with a key.

6
Pediatric Visual Acuity
What about children (or anyone) who can’t talk? Under
two years of age, vision is assessed on if it is “central”, “steady”,
and “maintained”. This is abbreviated CSM.
Central: Tested monocularly (covering one eye). The
corneal reflex from a muscle light should be in the center of
each pupil; documented “C”. If it is not, this might suggest
strabismus and would be documented as “UC”.
Steady: Tested monocularly. When moving the muscle
light around, the eyes should be able to easily follow it. “S”
represents “steady” and “US” represents “unsteady”.
Maintained: This is a binocular test. Fixation should be
maintained when each eye is intermittently covered. An eye
that doesn’t maintain fixation might have a lower VA than the
other eye. “M” represents “maintained” and “UM” represents
“unmainatained”.
This can be reported as any combination. For example, if
vision is central and steady but not maintained in the right eye:
OD: CSUM
OS: CSM
Young infants (around 3 months) should have ability to
fixate on and follow a target (in each eye separately) which can
be documented as “Fixes and Follows”.

Crowding
Something that comes up often in the pediatric clinic is
the idea of crowding. Visual acuity
can be overestimated when using a
single optotype on a big white
screen, especially in amblyopia.
There are competing theories about
the exact mechanism. This is
overcome by using “boxed” letters
in “crowding bars”. They’re officially
called contour interaction bars and
can improve the accuracy of visual acuity.

7
Color Vision
Color vision testing can be a sensitive screening tool for
optic nerve pathology. There are
many types of color vision tools
including color plate tests (like
Ishihara) or more complicated
hue tests. The exact test is scored
based on the patient correctly
identifying the number (or
squiggly line). Each test has its
own criteria and interpretation
system.

Normal Visual Acuity Exam

Some other important terminology for ophthalmology in
general is the names used for the eyes.
• OD – “Oculus Dexter” or “Right Eye”; note this does not
apply to lids (i.e., Say “Right Upper Lid” not “Upper Lid OD”.
• OS – “Oculus Sinister” or “Left Eye”
• OU – “Oculus Uterque” or “Both Eyes”

I will provide examples for a “normal” exam at the end

of each section. There are many ways to perform and document
these exams so you will see many variations. Here is an example
of a normal adult visual acuity exam:

sc cc cCL Ph
OD 20/30-2 20/20 NI
OS 20/30+1 20/20 NI

Color Vision: 14/14 OU (Ishihara)

8
 Pupils
The Pupillary Reflex
You may recall the pupillary reflex from
medical school. Shining light in one
pupil should cause approximately
equal constriction of both
pupils at the same time.
Additionally, both pupils should
constrict when viewing things at
near as part of the near
triad: miosis, convergence,
and accommodation.

The Pupil Exam

The pupils are constricted by the iris sphincter which is
innervated by the parasympathetic nervous system in the
oculomotor nerve (cranial nerve III). The pupils are dilated by
the iris dilator which is innervated by the sympathetic nervous
system. Using standardized cards or rulers, measure the pupils
in light and dark. They should be equal to each other in both the
light and dark. A penlight/muscle light is then shone in each
pupil individual to evaluate appropriate constriction.
The light is then swung
back and forth (swinging
flashlight test, pictured here)
to ensure both the illuminated
and fellow pupil constrict
which is referred to as the
consensual light reflex. If
shining light in one eye
produces no constriction in
either pupil, this can be a sign
of unilateral/ asymmetrical
retina or optic nerve disease.

9
 Optic neuritis, severe retinal disease, or even advanced
glaucoma can feature a relative afferent pupillary defect
(RAPD). Some conditions like posterior synechiae (adherence of
the iris to the lens capsule), traumatic mydriasis, or certain iris
pathology can make the pupils irregular by nature of the disease
and thus complicate the pupillary exam.
Patients can be asked to look at a near target (finger or
light) to ensure miosis with the near triad.

Anisocoria
Pupil sizes can differ between eyes (called anisocoria) by
1 mm physiologically (i.e., physiologic anisocoria). Anything
more than this must be evaluated in both light and dark.
Anisocoria worst in the dark implies one pupil is not
dilating appropriately, and there may be pathology in the
sympathetic pathway, like Horner Syndrome. This is typically
evaluated using the apraclonidine test. Apraclonidine is a
nonselective α adrenergic receptor agonist. In addition to
inhibiting aqueous production in glaucoma, it’s also a
sympathomimetic. Horner Syndrome can cause hypersensitivity
of the sympathetic pathway due to denervation and
apraclonidine can reverse anisocoria in these cases. Reversal of
the anisocoria and resolution of the ptosis after administration
of apraclonidine is a sensitive test for Horner’s Syndrome.
Traditionally, Horner syndrome was tested using a
combination of cocaine and hydroxyamphetamine, but
obviously these are now difficult to obtain and store.
Anisocoria that is worst in the light implies one pupil is
not constricting appropriately and there may be pathology in
the parasympathetic pathway. Common causes of dilated pupils
include Adie’s Tonic Pupil and pharmacologic dilation. Dilute
pilocarpine (0.1%) can be used to distinguish these. If the pupil
does not constrict, 1% pilocarpine can be instilled. If either of
these solutions constrict the pupil, Adie’s is likely. If the eye
does not dilate to even full-strength pilocarpine, pharmacologic
dilation must be considered.

10
 Pharmacologic dilation can come from sources other
than eyedrops. Scopolamine patches are used for seasickness or
nausea associated with anesthesia. If a patient touches the
patch and then touches their eye this can induce pharmacologic
dilation.
Here is a flow chart that summarizes anisocoria. This is
NOT comprehensive and is extremely simplified. Additional
findings like ocular motility deficits could be suggestive of CNIII
palsies. This is just a summary of common anisocoria clinic drop
testing.

Again, the slit lamp exam is a good time to determine if

the anisocoria is due to something like posterior synechiae.

Normal Pupil Exam

Here is an example of a normal pupillary exam:

Pupils:
Round, equal, and reactive to light; no RAPD
Light: 2.0 mm OU
Dark: 4.0 mm OU

11
 Intraocular Pressure (IOP)
IOP is measured in millimeters of mercury (mmHg).
Normal IOP is between 10-21 mmHg with a right skew (so the
average is closer to 15 mmHg). IOP is one of the most important
modifiable risk factors for glaucoma.
Types of Tonometry
There are several ways to measure intraocular pressure.
The most common ways in routine clinic work-up include the
Tono-Pen® and iCare. The eye is typically numbed with
Proparacaine (which lasts around 20 minutes) for the Tono-
Pen® and it takes ~10 readings to make an average. Patients
should look to the distance and the Tono-Pen®
should be gently tapped perpendicular to the
cornea in the very center. Avoid scraping
motions since it can be easy to cause epithelial
defects. Both of these handheld methods have
limited accuracy and are not sufficient for
monitoring IOP in conditions such as glaucoma.
Some examples of handheld tonometry devices are pictured.
The gold standard for measuring IOP is Goldmann
Applanation. This is a device, usually connected to the slit lamp,
with a 3.06 mm disc. They utilize the Imbert-Fick law: P=F/A.
That is, pressure is equal to the force required to flatten an area
of cornea divided by the area of cornea flattened.
The 3.06 mm diameter was chosen very intentionally.
The Imbert-Fick law assumes the cornea is infinitely thin and
dry. It’s neither and IOP is influenced by the fact that corneal
tissue is pushing back on the applanator and artificially
increasing IOP, and the capillary action of the tear film pulls the
applanator forward and artificially lowers IOP. In Dr.
Goldmann’s time, the central cornea was thought to be an
average of 520 μm so 3.06 mm was chosen because that is the
diameter that a 520 μm cornea pushes with equal force that the
capillary action is pulling so those two variables are essentially
cancelled. An average cornea is actually closer to 550 μm. There
are tables for correction (but their use is variable).
12
 Fluorescein must be applied to the eye first to make the
mires of the applanator visible. You may recall fluorescein from
biochemistry. Fluorescein is an orange dye that… fluoresces. It
absorbs light of one wavelength (the 475-490 nm Cobalt Blue
light of the slit lamp) and emits a different color wavelength
(510-520 nm green).
A summary of Goldmann Applanation Tonometry is
below. In cases of high astigmatism, the applanator can be used
once at 90° and once at 180° and subsequently averaged.

If IOP needs careful monitoring (e.g., as in glaucoma), it’s

common to see tables of IOP so trends can be observed over
time. It’s also a good idea to record the time the IOP was
obtained as there are diurnal fluctuations in IOP. Some
glaucoma specialists will also record which drops patients are
on in this same location.
For workflow purposes, it’s important to avoid actually
touching the eye too much before the patient has any cornea
imaging. For example, if the patient is going to have their
surface measured (e.g., tomography/topography) or biometry
for cataract surgery, it’s better to wait until after these
measurements for things like Goldmann applanation because it
can distort the cornea and reduce accuracy of the cornea
measurements.

13
 This is what a typical Goldmann tonometer looks like.
Notice the dial on the bottom for adjusting IOP. These can vary
in appearance.
Illuminating it with the Cobalt blue light from the side
allows visualization of the Fluorescein tear film mires.
Lastly, things like refractive surgery, corneal

transplants, or scars can influence tonometry. Be very cautious

with tonometry (pushing the globe) in the setting of trauma.
Air-puffs or the iCare may be preferred for corneal transplants.
Pushing anything on the eye can cause an abrasion so always be
gentle.

Normal IOP Exam

Here is an example of a normal IOP portion of an exam.

IOP: 15/15 (tp)

“tp” for “Tono-Pen®”; also can use “GA” for “Goldmann
Applanation

OR

Date OD OS Drops
10/05/2021; 1034 24 22 latanoprost
11/12/2021; 0934 19 18 latanoprost, timolol
01/14/2022; 1332 17 16 latanoprost, timolol

14
 Motility and Strabismus
Extraocular Motility
Recall that there are 6 extraocular muscles responsible
for movement of the globe. They each control a cardinal field of
gaze. That is, a direction of eye movement where only one
muscle is controlling the movement. Because of this, the muscle
functions can be isolated. It’s important to realize that “up” and
“down” are not cardinal positions. The extraocular muscles can
be best assessed by moving a target (finger or light) in an “H”
pattern. See how this isolates each muscle. At the end of the
“H”, move in towards the nose to ensure convergence is normal.

Here is an example of how that translates clinically:

Check “up” and “down” too even though these motions

are due to two muscles.

15
 If any of the motions are incomplete (including up and
down), they can be graded and scored in accordance with the
table below based on the “H” plus “up” and “down”:

RSR “UP” RIO LIO “UP” LSR

RLR RMR LML LLR
RIR “DOWN” RSO LSO “DOWN” LIR

Numbers are assigned to reflect the relative ability of the

eye to complete a gaze in that position. A normal exam looks
like this:
0 0 0 0 0 0
0 0 0 0
0 0 0 0 0 0

The grading is based on the ability of the eye to normally

gaze in that position by quarters:
No limitation: 0
75% of movement: -1
50% of movement: -2
25% of movement: -3
No movement past midline: -4

Stereo Vision
When the eyes are working together (including moving
normally together) the subtle difference in perspective between
eyes creates stereo (3D) vision. Stereo vision can be tested in a
variety of ways. They usually involve
wearing polarized 3D glasses (like in a
movie theatre). These allow each eye to
see a different image and create the
illusion of 3D. Children might be asked to
grab a fly or identify 3D animals. Adults
might be asked to identify 3D circles. Lack
of stereo vision may be an indicator of
strabismus.
16
Strabismus
Strabismus refers to misalignment between the eyes. It
can also be called “cross-eye” or “lazy-eye”. In England,
strabismus is also called “squint”. Symptoms of strabismus can
be obvious based on appearance (e.g., parents noticing eye
misalignment in their children) or based on symptoms including
diplopia (double vision) or reduced stereo vision. The types of
strabismus are beyond the scope of this reference guide, so
we’ll focus on the general evaluation of strabismus.
Strabismus can present as exotropia (eyes out),
esotropia (eyes in), hypertropia (vertical eye misalignment,
usually just represented as one eye above the other), or
cyclotropia (torsional strabismus). Strabismus can also be
constant or intermittent.
A tropia describes strabismus, but a phoria is a deviation
when the eyes are not under binocular vision. For example,
when one eye is covered, the other may deviate slightly without
a fixation target but binocular function will resume when the
eyes are both uncovered and allowed to fixate. A phoria is
generally normal and nondisruptive.
Strabismus can be evaluated at near, distance, and in all
fields of gaze with head turn and tilt. The strabismus exam can
become quite complicated.
Frist, recall the optical principles of prisms. Light bends
towards the base of a prism and the image actually moves
towards the apex. Prisms are used to determine the amount of
misalignment between the eyes with the unit of prism diopter
(PD, or Δ). The definition of a prism diopter is a prism that
would displace light by 1 cm at the distance of 1 m.

17
Prism Cover Test
When the eyes are aligned, it is reported in the physical
exam as “alignment: ortho”. When they’re not, it’s important to
determine the amount of deviation. This is commonly
accomplished by covering one eye with an occluder and then
moving the occluder between the eyes. Alternating which eye is
covered will cause the image to “jump” from the perspective of
the patient and the eyes to move as the misaligned eye re-
fixates on the object (usually a dot on the wall or projector).
Prisms are then introduced (with the apex in the direction of the
deviation, so apex OUT for EXOtropia and apex IN for ESOtropia)
until the image doesn’t appear to jump anymore from the
patient’s perspective. At this point, the eyes won’t appear to
move anymore from the examiner’s perspective. There are 3
main variations of this test:
The Monocular Cover-Uncover test involves viewing a
fixation target and covering one eye while observing the fellow
eye for movement. Once the eye is uncovered, it is again
observed for movement. If the covered eye re-aligns, this can
indicate a phoria. Again, phorias typically are harmless and the
eyes will appear ortho before and after the test, only “breaking
down” when one is occluded. In a patient with a tropia, the eyes
will start and end deviated.
The Alternate Cover Test involves moving an occluder
between eyes to detect latent phoria and manifest tropias.
“Latent” means the misalignment is only present when fixation
is interrupted while “manifest” deviations is present under
binocular conditions.
The Prism Alternate Cover Test (PACT) is the same as the
alternate cover test except prisms are held over one eye until
the deviation is neutralized and movement is no longer seen
when the occluder is moved back and forth. This is the
magnitude of the deviation. This can be used for both horizontal
and vertical deviations. The test measures total deviation which
is the tropia plus phoria (i.e., manifest plus latent deviation).

18
 The Simultaneous Prism Cover Test (SPCT) measures
manifest deviation under binocular conditions (so only the
tropia is measured; remember, a phoria is only present when
fixation is interrupted). In this test, a prism is placed in front of
the deviating eye at the same time the fixating eye is covered.
Like before, the strength of the prism is increased until the eye
movement is neutralized. This is mostly used for monofixation
syndrome which we’ll talk about in a moment.
As mentioned previously, strabismus can be measured in
all fields of gaze and with head turn or tilt.
Remember that measuring strabismus these ways
requires fixating on a target (finding a target when the occluder
is moved). What about cases where the vision is too poor to
fixate on a target?
The amount of deviation can still be measured using the
pupillary light reflex (Hirschberg). The pupillary light reflex can
even be neutralized to the center of the pupil using prisms while
the other eye fixates on a target to precisely measure deviation
(Krimsky). These are outlined below:

19
 There is a special circumstance where an eye
experiences a deviation when it is not being used and the fellow
eye is fixating but when both eyes are fixating again (when the
deviating eye is uncovered) the deviated eye returns to primary
position without associated motion in the fellow eye.
Remember, strabismus typically features the eyes moving
together so this situation is unique. This is called dissociated
strabismus complex and is unique from hypertropia, exotropia,
or esotropia. “Dissociated” because the movement is in one
eye. When the motion is vertical, it’s called Dissociated Vertical
Deviation (DVD). When it’s horizontal, it’s called Dissociated
Horizontal Deviation (DHD). It can also be torsional (DTD).

Parks-Bielschowsky
Another special maneuver worth mentioning is the “Parks-
Bielschowsky three-step test” for determining the paretic
muscle in hypertropia. It boils down to these three questions:
1. Which eye is hypertropic in primary gaze?
2. Is the hypertropia worse in right or left gaze?
3. Is the hypertropia worse in right or left head tilt?

Just try to remember if everything is worse in the same

direction it’s the opposite inferior oblique that is paretic. For
example, if the RIGHT hypertopia is worst in RIGHT gaze and
RIGHT head tilt then the paretic muscle is the LEFT inferior
oblique. That gets you a third of the way there.
You can also remember if the tilt is the only thing that’s
different it’s the opposite inferior recuts from the worse tilt. For
example, RIGHT hypertropia that is worse in RIGHT gaze and
LEFT head tilt is a RIGHT inferior rectus palsy. If it doesn’t fit one
of those two scenarios, it’s an opposite side superior rectus
palsy.

20
 I know, that’s complicated and a lot. Here is a summary.

Inferior Oblique Palsy Inferior Rectus Muscle Palsy

• Opposite side HT • Same side HT
• Opposite gaze worst • Same side gaze worst
• Opposite tilt worst • Opposite tilt worst

Superior Rectus Muscle Palsy

• Opposite side HT
• Same side worse gaze
• Opposite side tilt worst

The Maddox Rod

A Maddox rod is a lens with parallel cylinders that
convert a point light source into a streak/line perpendicular to
the cylinders. They are helpful for strabismus screening and
especially evaluating the torsional component of strabismus.
They can come either free or in
trial frames so the axis can be
carefully determined.
Always remember eXo deviations result in X’d (crossed)
diplopia (OD image to the left of OS image and vice versa).

21
Strabismus Notation
After obtaining these measurements, it’s important to
record them correctly. Like most things in ophthalmology,
strabismus has special notation. Here are some of the symbols
and phrases used:

O Orthophoria/Orthotropia
E Esophoria (distance)
E’ Esophoria at near (the ‘ symbol indicates “near”)
X Exophoria (distance)
X’ Exophoria at near
RH/LH Right/Left Hyperphoria
ET Exotropia (constant), ET’ for near
XT Exotropia (constant) XT’ for near
RHT/LHT Right/Left Hypertropia (constant), RHT’/LHT’ for near
E(T) Intermittent Esotropia, E(T)’ for near
X(T) Intermittent Exotropia, X(T)’ for near
R/LHoT The addition of “o” can indicate hypOtropia
OEAd Overelevation in adduction
IOOA Inferior Oblqiue Overactivation
ODAd Overdepression in adduction
SOOA Superior oblique overactivation
UDAd Underdepression in adduction
SOUA Superior obluqe underactivation
UEAd Underelevation in adduction
IOUA Inferior oblique underaction
DVD Dissociated vertical deviation
DHD Dissociated horizontal deviation

For example; 5 ET’, means there is 5 prism diopters of

constant esotropia at near.
Strabismus can be recorded along with the extraocular
muscle exam in all the fields of gaze if necessary. See the
example at the end of the chapter.

22
Worth Four Dot Test
Either hanging in the back of every exam room, sitting in
the drawers, or some combination thereof is the Worth Four-
Dot Test. This is useful for examining fusion, strabismus,
suppression, and monofixation syndrome. It is composed of a
diamond shape with a red dot on top, two green dots on the
sides, and a white dot on the bottom. The patient wears red-
green glasses, Red lens over Right eye. The right eye then
should see two dots (the top red one and the bottom white one
seen as red) and the left eye should see three green dots (the
two green and the bottom white one seen as green).
Monofixation syndrome describes a small-angle
strabismus resulting in a small (< 3°) unilateral scotoma.
Essentially, for some reason (small angle strabismus,
anisometropia, macular pathology, etc.) a small central scotoma
develops but binocular fusion is maintained through the
peripheral fields which have a larger tolerance for image
discrepancy than the high acuity fovea. The eyes will usually not
look grossly misaligned. Picture the four dots up close, they are
occupying a large portion of the visual field and it is likely the
dots will all fall outside of the small central scotoma. Now
picture the four dots far away. They are occupying a small
central portion of the visual field and now they will fall within
the central scotoma so there will be a discrepancy in what the
patient sees with the four dots at near and at a distance.

23
 The following is a more concise summary than can be
conveyed in words of Worth dot test interpretation.

Nystagmus and Optokinetic Drum

Nystagmus is a repetitive and involuntary motion of the
eye characterized by a “slow” phase that takes the eye off
fixation with a fast phase to bring it back. It is often described as
“jerk” or “pendular” and is usually worsened or improved by
certain directions of gaze (see the following graphic on
Alexander’s Law). Nystagmus can also be torsional (the eyes
appear to rotate). Nystagmus is distinct from saccadic intrusions
which are rapid eye movement off and then back on the target.
Physiologic (end-gaze) nystagmus can occur at the
extremes of lateral gaze and is a normal finding.
An exam for nystagmus involves closely observing the
eyes in all fields of gaze for any sign of nystagmus. If present, it’s
important to determine where it’s most and least prominent.

24
 A “charismatic” instrument in the ophthalmology clinic is
the optokinetric drum. It’s a striped cylinder that spins and looks
like a Halloween Decoration. The spinning motion induces
nystagmus. They specifically can evaluate optokinetic
nystagmus (tracking objects in motion with a stationary head).
The eyes will follow the spinning target and then saccade back.
Its most practical use is to evaluate the afferent and efferent
visual pathway. If a patient claims to be NLP (and denies the
ability to see light at all) then their eyes
shouldn’t move when looking at the drum. It
can also be used in children to get a sense of
visual acuity (their eyes should follow the
drum). For the efferent pathway it essentially
evaluates the ability to form symmetric eye
movements and can inform the examiner on
the overall health of the pursuit system in the
parietal lobe. Lastly, spinning downward (and
causing an upward saccade), it can bring out
convergence retraction nystagmus
characteristic of Parinaud’s Syndrome.

25
 Head position is also important to record due to
posturing patients may prefer if they have strabismus or
nystagmus. Based on Alexander’s law above, nystagmus can
have a “null point” or a direction of gaze where the nystagmus
is minimized or eliminated. Obviously, patients will prefer this
gaze and adjust their posture accordingly. For example, if their
nystagmus is minimized in right gaze, they may turn their head
to the left so they’re always looking to the right.

Normal Exam
Here is an example of a normal extraocular muscle and
strabismus exam.

Alignment: Ortho
Method: Cover-Uncover
Correction: sc
Fixing Eye: N/A (the fixing eye would go here if
applicable)
Distance: Ortho
Near: Ortho
0 0 0 0 0 0
Ortho
0 0 0 0
Ortho’
0 0 0 0 0 0
Head posture: Straight
Nystagmus: None

The empty boxes can be filled with strabismus measurements in

the different gazes. For example, strabismus might be worst in
upgaze (the middle upper box) and least in downgaze (the
middle lower box) which would be called “V-Pattern strabismus.
If the strabismus was worst in downgaze and best in upgaze it is
called “A-Pattern strabismus”.

26
 Refraction
Overview
The art of refraction measures the refractive error of the
eye for purposes of prescribing glasses. Whether it’s for a
pediatric strabismus exam or for a cataract evaluation, knowing
the refractive state of the eye is extremely important.
Before discussing how to refract, it’s important to
understand how glasses correct vision and the basics of a
glasses prescription. Some of this discussion will be familiar
from The Eye Guide: Anatomy and Optics.

Lens Basics
If you can remember what a prism does to light, you will
never forget PLUS, CONVEX, CONVERGING or MINUS,
CONCAVE, DIVERGING lenses ever again. Remember from the
strabismus discussion, due to Snell’s law light bends towards the
base of a prism. The dotted lines on the following illustrated
prism represent the normal, the imaginary line perpendicular to
the optical surface. When light enters a substance with a
greater refractive index (n) it bends towards the normal. When
light enters a substance with a lesser refractive index it bends
away from the normal. The n of air is 1.00. Other important ns
include the cornea (1.376), aqueous (1.336), vitreous (1.337),
water (1.333), and crown glass (1.517).
Spherical lenses can be thought of as two prisms either
apex to apex or base to base. Light has 3 options, it can either
converge, diverge, or have zero vergence (be parallel). PLUS,
CONVEX, CONVERGING lenses (two prisms base to base) are
converging lenses and MINUS, CONCAVE, DIVERGING lenses
(two prisms apex to apex) are diverging lenses.
PLUS, CONVEX, CONVERGING lenses are denoted by
BLACK numbers. MINUS, CONCAVE, DIVERGING lenses are
denoted by NEGATIVE numbers.

27
Far and Focal Points
The eye must take light with no vergence (remember,
parallel light from infinity) and focus it to a single point on the
retina over a distance of ~24 mm (the average length of an eye).
This requires quite a bit of refracting power and the average eye
is ~ +60 D. The eye must be PLUS, CONVEX, CONVERGING
naturally because natural light must be focused onto the retina.
The cornea (especially the air-tear interface where the biggest
refractive index change occurs) contributes ~74% of this
refractive power and the lens does the rest.
Eyes have a Far Point. This is the point conjugate to the
retina when the eye is not accommodating. Put another way,
this is the point where an object could be placed and the
emitted/reflected light rays would focus onto the fovea after
passing through the eye’s optical system. For myopes, either the
lens is “too powerful”, or the axial length is too long and light
rays with no vergence will focus in the vitreous. For hyperopes,
the lens is either “too weak” or the eye is too short, and the
incoming light would focus behind the retina but strikes the
retina as a blurry circle.

28
 Lenses have Focal Points. A primary focal point (f1) is a
point where an object could be placed and the light rays coming
from that object would exit the lens with zero vergence. A
secondary focal point (f2) is where light with zero vergence
would focus on a single point after passing through the lens. For
minus, concave lenses, the focal points are the locations where
the light rays “appear” to be going or coming from because the
light rays in a concave system may never actually cross to form a
single point. This is indicated with dotted lines below.
The goal of corrective lenses in a pair of glasses then is
to take the light coming from a distance with zero vergence and
focus it to the conjugate point of the unaccommodated eye, the
Far Point. Remember, the far point is where light will focus on
the retina after passing through the unaccommodated optical
system of the eye. You can think of a corrective lens then as
taking light from infinity and focusing it to the point where the
eye sees most clearly. As far as the eye is concerned, it is seeing
that “image” of infinity since all the light is focused there and
the result is clear distance vision.

29
Refractive Error
Emmetropia describes an eye without refractive error.
Light with zero vergence from a distance will pass through the
optical system of the unaccommodated eye and focus on the
retina. Unaccommodated is an important modifier because the
lens can accommodate and become more PLUS.
Myopia, or “nearsightedness”, is a refractive error of the
eye characterized by light focusing IN FRONT OF the retina after
passing through the optical system of the unaccommodated
eye. Uncorrected myopes can see at near but not at a distance.
• Correction: Concave lenses that diverge the light (denoted
by a -, MINUS prescription)
o One way to think of it is that a concave lens will
“spread” the light rays or “push” the image back, so
it comes to a point on the retina.
o Another way to think about it is that the concave
lens will focus light with zero vergence to f2 which is
powered to align with the far point of the eye (close
in front of the eye in myopes).
Hyperopia, or “farsightedness”, is a refractive error of the
eye characterized by light focusing BEHIND the retina after
passing through the optical system of the unaccommodated
eye. Technically for the unaccommodated hyperopic eye, no
distance (near or far) will result in clear vision but (especially
young) hyperopes can simply accommodate, make their lens
more CONVEX (PLUS), and see well at distance.
• Correction: Convex lenses that converge the light (denoted
by a +, PLUS prescription)
o One way to think of it is that a convex lens will more
“sharply” focus the light rays or “pull” the image
forward, so it comes to a point on the retina.
o Another way to think about it is that the convex lens
will focus light with zero vergence to f2 which is
powered to align with the far point of the eye
(behind the eye in hyperopes).

30
 Recall from earlier that accommodation is necessary
because as objects become nearer to the eye, more divergent
rays are allowed to enter the eye. The eye must accommodate
to allow the light to keep focus on the retina. The result of this
process is the lens bulging and becoming more convex (positive)
to increase the refractive power of the lens and increase its
converging power. The process (according to the Hemholtz
theory) is:
o The ciliary muscles contract
o This loosens the zonular fibers supporting the lens
o The lens bulges becoming more CONVEX (+) and
increases converging power

This becomes particularly important when refracting

children as we’ll discuss later.
The Goldberg theory of accommodation postulates that
coordinated ciliary body, zonule, and anterior hyaloid
movements changes the posterior lens curvature. During ciliary
contraction in accommodation, the ciliary muscle annular ring
moves forward and relaxes tension on the zonules which rounds
the lens and increases refractive power.

31
Astigmatism
Before discussing the basics of a spectacle prescription,
it’s important to have a solid understanding of astigmatism
(which can be confusing at first so let’s really break it down).
First, consider two shapes. A sphere and a torus. A torus
is the geometry term for a donut shape. This might sound
familiar because toric intraocular lenses are derived from
toruses.

Now imagine taking a sharp blade and cutting a slice off

of each of these shapes.

32
 We’re left with these two lenticular endcaps.

Now, let’s turn them so the round part is facing you (and
enlarge them for clarity).

The spherical lens has the same radius of curvature no

matter which direction light enters it. I.e., a pair of light rays
entering the top and bottom of the lens will focus in the same
area as a pair of light rays entering the horizontal sides of the
lens. These are also called the meridians of power.

33
 So, the horizontal vertical meridian and horizontal
meridian have the same refracting power (two black lines)

The toric lens has TWO radii of curvature. In the following

example, the vertical meridian (blue) is less steep with less
refracting power while the horizonal (red) meridian is more
steep with more refracting power. When people liken
astigmatism to having a football shaped cornea this is exactly
what they mean.

34
 The final consequence of this is that light entering a
spherical lens (or cornea) will (essentially) focus to a single
point.

For the toric lens (or cornea) though, the steeper meridian
(again, red) will will focus its rays in front of the less steep (blue)
meridian.

Therefore, if corneas (or crystalline lenses) are shaped this

way with astigmatism, it means we need to be able to correct
both meridians separately. We accomplish this with cylindrical
lenses.

35
 Lastly, you’ve probably seen the topography of a state
park. The red areas are higher than the flat green or blue areas.
We can image the cornea this way too, either through
tomography or topography.
If the previous astigmatic cornea was a state park, it’s
topography would probably look like this. Notice that vertical
meridian stays essentially blue the whole time because it’s not
very steep while the horizontal meridian goes from green to
yellow to orange very quickly because it is steep.

Now, let’s think about a cylinder. A cylinder has a curved

surface that is capable of refracting light. We already know this
is called the meridian of power. A cylinder also has a long
portion, along which there is technically no refracting power
because it’s flat. This is called the axis of power. Immediately
notice the meridian and axis are 90° away from each other.
We can think of using cylinders to correct astigmatic vision
by imagining “catching up” the power of the weak meridian
using a cylinder so the light rays from each meridian land on the
same spot. In the 3D example from before, we said the
horizontal meridian (red) was weaker than the vertical meridian
(blue) so we essentially need to place a cylinder so it exerts its
refracting power of the weaker (blue) meridian. To accomplish
this, we’d need a cylinder “on its side” so the power is exerted
over that weak 90° meridian. That means the axis would be at
180° because remember, an axis of power has no refracting
power itself but dictates the orientation of the cylinder and will
contribute nothing to that meridian.

36
 Here is a review of cylindrical lenses and astigmatism.

One last complicating factor is that fact that

ophthalmologists work in PLUS CYLINDER. That means, we
essentially imagine literal glass cylinders that exert PLUS
refracting power (for many reasons including that toric
intraocular lenses are labeled in plus cylinder). Optometry
typically works in MINUS CYLINDER. This imagines a long
concave, MINUS lens that only exerts power on one meridian.
The MINUS cylinder system is probably better because this is
how the lenses for glasses are actually made. This can create
confusion though because the axes are different depending on
PLUS or MINUS cylinder. It’s easy to see because instead of
“strengthening the weak meridian” optometry thinks of
“weakening the strong meridian”. To facilitate communication,
we use “WITH THE RULE” (WTR) and “AGAINST THE RULE” (ATR)
terminology.
To an ophthalmologist, WTR astigmatism requires
correction (with a PLUS cylinder) at 90°. To our optometry
friends though, WTR astigmatism requires correction (with a
MINUS cylinder) at 180°. Either way, we know what refractive
state the eye is in based on common WTR/ATR terminology.

37
Anatomy of a Glasses Prescription
Now that we have a solid foundation in astigmatism, we
can talk about how a glasses prescription is written. A typical
prescription has 3 numbers. The amount of spherical correction
in diopters, the amount of cylindrical correction in diopters, and
the axis of the cylinder in degrees. The sphere number can be
thought of as the correction necessary to put the light rays from
the strongest meridian on the retina. The cylindrical component
can be thought of as the power required to then independently
“pull” the weakest meridian onto the retina also. Again, keep in
mind this is fiction because glasses are actually ground with
MINUS cylinder but it’s still helpful to conceptualize.

38
 Remember that optometry typically works in MINUS
cylinder, so you will see many refractions in this notation. Here
is how to convert between PLUS and MINUS cylinder:
1. ADD sphere and cylinder
2. REVERSE the sign of the cylinder
3. FLIP the axis by 90°
For example, a prescription of -4.00 + 2.00 x 090° is
equivalent to -2.00 - 2.00 x 180°. We only use 0° - 180° for
simplicity. 270° is the same as 90°.
Even though it is entirely fictitious, it is helpful to think
of glasses as a base spherical lens with a positive cylinder on top
of it. Again, this is the opposite of reality but it’s how
ophthalmology refracts and conceptualizes cylinder. The
following example considers a cornea with astigmatism
belonging to a hyperope. This astigmatic cornea has two
different radii of curvature that require two different powers to
place an image on the retina because one is “further back” than
the other. Picture using a normal convex, PLUS, spherical lens to
put the farther forward picture on the retina. We’re halfway
there but we need to individually move the other axis to put it
on the retina as well. We need a little more converging power
only on that axis so we can use a cylindrical lens to “help out”
where the cornea is flatter and contributing less converging
power.

39
 Not all eyes have astigmatism though. The notation for
only sphere is “DS” for “diopters sphere”. This is usually written
in place of astigmatism for additional clarity. So, “-2.00 DS”
represents a prescription of -2.00 spherical lens without any
astigmatism correction. Axis should also have 3 numbers to
eliminate confusion. Instead of writing “90” it’s better to write
“090”.
Not all eyes even have refractive error. Emmetropic eyes
with no astigmatism have no prescription and this is denoted by
“Plano”, which simply means a prescription of +0.00 DS.

Spherical Equivalent
A final important consideration for prescriptions is the
idea of “spherical equivalent” (SE). The technical definition of SE
is the point where the “Circle of Least Confusion” lies between
the two focal planes in an astigmatic optical system. The
practical definition is SE represents the spherical lens that would
provide the best possible vision in an eye with astigmatism. It is
calculated by the following formula:
SE = SPHERE + ½ CYLIDNER
In our example of -4.00 + 2.00 x 090°, the spherical
equivalent would be:
-4.00 + ½ (+2.00) = -3.00
A -3.00 spherical lens would give the best vision when
using spherical lenses alone. Pay attention to the minus sign in
minus cylinder. Remember that same prescription in minus
sylinder is -2.00 - 2.00. The SE is:
-2.00 + ½ (-2.00) = -3.00
The spherical equivalent is the same because the minus
sign from the cylinder led to a subtraction from sphere.
This is a good time to discuss the concept of the Jackson
Cross. A Jackson Cross is a lens that has cylinder but an SE of 0.
Examples include -1.00 + 2.00 x 090, -0.50 + 1.00 x 180, and
-1.50 + 3.00 x 045. Calculate the SE of those lenses and see how
they’re all Plano. They’re useful because they can help guide the
prescription of cylinder as we’ll see shortly.

40
Refracting
Now we can finally talk about how to refract. There are
autorefractors that can give a pretty good estimate of the
refractive status of the eye, and these can be a good place to
start.
Manifest Refraction is the classic “Better one? Better
two?” exam in the phoropter (pictured below). It’s always easier
to start from an autorefractor reading or from a previous pair of
glasses. Put this in the phoropter. Sphere is adjusted by the
large dials on the side and cylinder by the small dials
surrounded by the axis markings. It’s also important to know
what kind of phoropter your clinic uses. They can be plus or
minus cylinder. How do you think you can tell? The color of the
cylinder window will tell you. If it’s BLACK text, it’s PLUS
cylinder. If it’s RED text, it’s MINUS cylinder.

41
 Here is an overview of how to perform a very routine
refraction starting from an autorefraction or previous glasses
prescription. You will find many ways to refract and many
different preferences. This is just one method. I want to give
special thanks to Kelli Shaon OD for teaching me refraction.
Summary of Refraction
1. Put the autorefraction or current glasses
prescription in the phoropter.
2. Occlude one eye by turning it to “OC”,
keep the other eye open on the “O”
setting as in the diagram.
3. Have the patient read down the chart
until they reach the smallest legible line. Go up by 1 line.
4. Blur their vision by adding +0.75 D of sphere (3 clicks on the
big dial). This should make the line illegible.
5. Start progressively adding minus back in by asking “Better 1?
Better 2?”. Patients need to “earn” minus. You’ll hear
phrases like “eating minus” because it’s preferable for
patients to be a little more minus than they need. Think
about it, if you push the focal point behind the retina, you
still can accommodate and pull the image forward with the
natural crystalline lens. This means a constant state of
accommodation and eye strain though, so it’s not preferable
for eye doctors. “Push plus” is the rally cry. Another way to
tell is to ask if the image is clearer or just darker and smaller.
The Duochrome test (discussed later) also helps with this.
6. After landing in a good
place with sphere, rotate
the Jackson cross in front of
the ocular. In the image, the
right eye has the Jackson
Cross engaged and the left
eye doesn’t. The Jackson
Cross also has two dots, a
white dot and a red dot.

42
7. Twist the Jackson Cross over the ocular such that a red and
white dot straddle the axis. For example, if the axis is set to
90°, the red and white dots should be sitting around 45° and
135°. This will help us find the axis of cylinder.

8. Flip the axis of the Jackson Cross back and forth using the
little spin dial while asking “Better 1? Better 2?”. The red
and white dots will switch places. What you’re doing is
changing the axis that the cylinder is exerting its refracting
effect. Whichever orientation patients prefer, turn the axis
(outer dial) of the astigmatism knob in the direction of the
dot. In PLUS CYLINDER notation, you’ll hear about
“chasing the dot”. Turn it by 5°-15°. Once they start
going back and forth or saying they look the same you’ve
found the axis of power for the cylinder.
Better 1? Better 2?

43
9. Next, twist the Jackson cross such that a red/white dot (and
“P”) are ALIGNED with the axis. Now we’re looking for
power.

10. Flip the axis of the Jackson Cross back and forth using the
little spin dial while asking “Better 1? Better 2?”. The dots
will change between red and white. What you’re doing now
with the Cross in this orientation is changing the amount of
cylinder exerted on that axis. If the patient says the option
with the dot aligned with the axis is better, increase
the power. Again, chase the dot. If they prefer the
red dot, decrease cylinder. Once they start going back and
forth or saying they look the same you’ve found the amount
of cylinder correction.
a. For every +0.50 D (2 clicks) that astigmatism
increases, decrease the sphere (large dial) by -0.25 D
(1 click). This is to preserve the spherical equivalent.

44
11. Lastly, fine tune the cylinder with one more round of “Better
1? Better 2?” keeping in mind to go as PLUS with the
prescription as possible where they can still read 20/20 (or
as good as they can).
12. Repeat for the fellow eye.
Lastly, “ADD” power for bifocals or transition lenses can
be carefully determined using a prince rule (a small reading
chart on a stick) but in reality, most patients do well with +2.50
D and this is the go-to for many clinicians.
Prism can also be prescribed to be built into lenses. The
orientation of prism is set by base: up, down, in, or out.

The Duochrome Test

We mentioned earlier than the Duochrome Test can be
used to ensure patients are not over minused. This is the Red
and Green split background for the acuity charts. The basis is
chromatic aberration. Not all light is refracted through a lens by
the same amount. Shorter wavelengths are slowed more by
optically dense substances. The visible color spectrum ranges
from ~400-700 nm and there is about a 1.25 D difference
between the blue (~400 nm) and red (~700 nm) range of the
spectrum. If you look at the BLUE/RED image below, even with
one eye closed it will look 3D because the blue is focusing
slightly anterior relative to the red so the red appears closer.

45
 If you had to pick one color to precisely fall on your
retina, which would you choose? During the day, yellow light
dominates the ambient spectrum, so this is the color for which
we try to optimize vision. How positive are we, though, that the
yellow spectrum is the one falling on the retina? Remember
earlier we said that people will generally prefer a little more
MINUS than PLUS because (especially young) eyes can dial in
their own accommodation and pull the image forward onto the
retina. To avoid allowing someone to “eat minus” we can
perform the Duochrome Test. This involves overlaying the
Snellen (or other) chart on a red and green background. Why
red and green though? Well, we just said yellow light dominates
the daytime atmosphere and red and green tend to straddle the
yellow spectrum by about 0.25 D on either side.
The mnemonic RAM GAP can help us remember what to
do depending on what the patient reports seeing. If the red side
is clear but the green side is blurry then this means the red part
of the spectrum is falling on the retina and there is too much
converging power (PLUS) so we need to “add MINUS.” In the
opposite circumstance where the green side is clearer than the
red side then there is too much diverging power (MINUS) so we
need to “add PLUS.” Hence, RAM GAP = Red Add Minus, Green
Add Plus. Visual acuity needs to be at least 20/30 in each eye for
this test to be effective.

46
Lensometers/Lensmeters
We mentioned one way to start an MRx is to see what a
patient’s current prescription is. There are automated ways to
read a glasses prescription, but the TOP-CON Lensmeter is one
of the most common ways to do this manually.

Basic Steps of Using a Manual Lensmeter

1. Place the pair of spectacles on
the table (arms back) and
secure them with the holder.
The device should look through
the optical center of the lens.
2. Turn the light on (usually a
button).
3. Look through the ocular. The
power knob is rotated until the cross (both large and small
focusing bars) are clear (as pictured; it’s really difficult to
photograph this by the way). The large and small focusing
bars will only be in focus at the same time if the lens is
purely spherical.
4. The power knob indicates the prescription of the lens.

47
5. If there is any astigmatism, remember Focus Fat First. That
means (for PLUS cylinder), focus the large bars first and the
small bars second. The axis w
6. Once the large bars are in focus (and thin bars are out of
focus), take note of the power, this is the sphere. The axis
wheel will need to be rotated until the center circles
appears aligned with the large bars for maximum focus.

Not aligned Adjust Axis Aligned

7. Lastly increase power until the small bars are in focus. The
difference in power between the large bars being in focus
and the thin bars being in focus is the amount of
astigmatism. The axis of astigmatism is the lower power in
which the large bars were in focus and circles aligned.

This is a good picture of

what alignment of the
axis circles looks like.
For example, if the large bars were in focus and the
circles aligned at -2.50 x 170° and the thin bars in focus at -1.50,
then the prescription is -2.50 +1.00 x 170°.
48
 Add power can also be measured by a lensmeter. It is
possible to discern prism as well but that is beyond this this
scope.
To determine the add power on progressive lenses, a special
machine with green lights and a magnifier is used. The add
power stamped on the lens becomes illuminated by the green
light.

For completeness, here is an image of an autorefractor

and an automatic lensmeter. The autorefractor is a great way to
to get pupillary distance (PD) which helps lensmakers craft
glasses.

Autorefractor Automatic Lensmeter

49
Streak Retinoscopy
Lastly, we have to consider cases where the patient can’t
answer “Better 1? Better 2?”. This is especially useful in
pediatric clinic using free lenses (or paddles with lenses on
them) but can also be done using the phoropter.
The essence of streak retinoscopy is to sweep a light
back and forth from a retinoscope until the reflex is neutralized.
A big pupil makes this easier on anyone, but children especially
should be cyclopleged (have their ciliary body paralyzed) so they
can’t accommodate. Children can accommodate a lot, as in over
10 diopters. If they’re increasing the prescription of their eye
during refraction by accommodating, then the refraction will be
more minus to cancel the accommodation as a result. Over
minusing children is especially bad as it can lead to myopia
progression. A cycloplegic refraction is sometimes called a “wet
refraction.”
Here is the retinoscope. It emits a beam shape of light.
There is a plastic collar underneath the head that is adjustable
by both rotating it (which changes the axis of the beam) and
moving it up and down. The collar should always be kept at the
bottom of its range.

50
 Basic Steps of Streak Retinoscopy
1. Make sure you have “with” motion or try minus lenses
until you have with motion of the streak in the eye.

2. Go more “plus” until the streak is totally neutralized.

3. The reflex is neutralized when there is no apparent

motion with movement of the streak.

51
 4. Too much plus results in “against” motion of the streak.

5. Check 90° away, if the streak isn’t neutralized then there

is astigmatism.

6. Once this axis is neutralized also, the difference is the

astigmatism.

7. Subtract the working distance (1.50D for a 67cm arm)

from the first axis, this is sphere. The difference in the
two axes is the cylinder.

The prescription for this example is: +1.50 + 1.50 x 180.

52
 Remember, streak retinoscopy can be done using the
phoropter as well for patients who have no glasses to base a
prescription off of or if an autorefractor is not available.

Contact Lenses
Fitting contact lenses is a complex topic. Contact lenses
have a diameter and base curve that must be carefully fit to
each patient. Additionally, there isn’t a one-to-one relationship
between the spectacle prescription and contact prescription.
Contact lenses have a smaller vertex distance than glasses. That
is the location of the refracting element with respect to the
nodal point. Contact lenses sit much closer to the eye, so a
correction is necessary. There are also many types of contact
lenses including soft, daily, rigid, scleral, and even toric contacts
that are weighted to maintain their orientation on the eye.

Normal Exam
Here is an example of normal prescription.
Eye Sphere Cylinder Axis ADD Prism Base
OD -2.25 +1.25 095 +2.50
OS -2.00 +1.50 080 +2.50
PD 62

53
 External Exam
Ptosis
The ptosis exam involves taking several eyelid
measurements, many with respect to the pupillary light reflex.
Time to get the muscle light out again.
Palpebral Fissure (PF) is a measure between eyelids at
the axis of the pupil. A normal measurement is 9 to 12 mm.
Margin to Reflex Distance 1 (MRD1) is the distance
between the upper eyelid and the pupillary light reflex.
Margin to Reflex Distance 2 (MRD2) is the distance
between the lower eyelid and the pupillary light reflex. MRD1 +
MRD2 should equal palpebral fissure height.
Levator Function (LF)
is the distance the upper
eyelid travels from
downgaze to upgaze. It’s
sometimes necessary to
hold the brow down while
measuring this to prevent
the patient from using the frontalis muscle. > 10 mm is normal.
Bell’s Phenomenon refers to the upward movement of
the globe when the eyelids are forcefully closed. It’s important
to record if this reflex is intact since it can be a protective
mechanism for the cornea.
Another crucial piece of a ptosis evaluation is
photographs before and after administering phenylephrine. A
picture is always worth a thousand words.
Cogan's lid twitch refers to the overshooting of the
upper lid when a patient goes from downgaze to upgaze and
can be suggestive of myasthenia gravis.

Hertel
The most common cause of unilateral or bilateral
proptosis (bulging eyes) is thyroid eye disease (TED). Proptosis
can be measured by use of a Hertel Exophthalmometer.

54
 Overview of Hertel Exophthalmometry
1. The notches are set against the patient’s orbial rim.
2. The base measurement is taken.
3. The examiner should look with the same eye (examiner’s
right eye to patient’s right eye) through the portion with the
mirrors, aligning the red lines. The patient looks into the
examiner’s open eye.
4. Measure the most
anterior portion of the
cornea.
5. Repeat for the fellow eye.
Von Graefe’s Sign
refers to lagging of the upper
eyelid on downgaze (i.e., when looking down it takes a second
for the upper lid to cover the globe) and can be a sign of TED.
Normal Exam
Here is an example of a normal external eye exam.
Eyelid Measurements
Right Left
PF 10 mm 10 mm
MRD1 4 mm 4 mm
MRD2 6 mm 6 mm
LF 15 mm 15 mm
Bell’s Present Present

Hertel Exam
Base: 97 mm
OD: 18 mm
OS: 18 mm

55
 Dilation and Gonioscopy
Dilation
Before dilating, we need to be confident that this won't
induce angle closure. Recall the anatomy of the angle below.

If the angle is too narrow, a dilated iris could obstruct

the trabecular meshwork and cause an abrupt rise in IOP.
Two quick screening tools for anterior chamber depth
are the Van Herick and Oblique flashlight test. The Van Herick
Technique involves shining a slit beam from the slit lamp at an
angle of 60° near the limbus. The distance between the corneal
endothelium and iris is compared to the limbal corneal
thickness (based on the slit beam passing through it). If there is
a full “limbal corneal thickness” or more of space near the
angle, then the anterior chamber is usually sufficiently deep.
An even simpler screening test is the oblique flashlight
test. A light source (hello again muscle light) is held temporally
parallel to the iris. There should be no obstruction and the light
should easily illuminate the entire iris/anterior chamber. If the
iris is casting a shadow, this could indicate a shallow anterior
chamber.

56
 When it comes to dilating, this varies by clinic but
typically Proparicaine (a sodium channel blocker) is
administered first to provide anesthesia for both tonometry and
subsequent drops that can sting or burn.
Tropicamide (a non-selective muscarinic antagonist) is
an anti-cholinergic drop that inhibits parasympathetic drive to
the pupillary sphincter. The result is pupillary dilation. It also
binds to muscarinic receptors of the ciliary body to prevent
accommodation. On average, onset begins in 20 minutes and
effect last for 6 hours. Other medications in this class are
cyclopentolate and atropine. Cyclopentolate has a stronger
cycloplegic affect in children which is essential for obtaining an
accurate refraction. For this reason, cyclopentoalate is often
used to dilate children. On average, onset begins in 30 minutes
and the effects last for 24 hours. Atropine is much longer acting
and is more common in other applications (like dilation to
prevent synechiae in uveitis) than routine dilated exams. On
average, onset begins in 1 hour and effect lasts 7 days.
Phenylephrine (an alpha-1 receptor agonist) acts as a
sympathomimetic to directly contract the pupillary dilator
muscle. A common formulation is 1%. Higher concentrations
like 10% may affect blood pressure.
It’s important to remind consultants that the effects of
even tropicamide may cause pupil irregularities for 24 hours.

57
Gonioscopy
There is NO substitute for gonioscopy when evaluating
the angle. Neither van Herick, the oblique flashlight test,
anterior segment ocular coherence tomography, or ultrasound
biomicroscopy are adequate substitutes for visualizing the
angle. A question that comes up frequently is why we can’t
simply see the angle by moving the slit lamp in the right place.
The answer is because of total internal reflection of the air-tear
film interface. Gonioscopy involves using a lens or prism to
visualize the angle. The lens is called a gonioprism. There are
different types of gonioprisms including Koeppe, Barkman,
Zeiss, Possner, and Sussman. Koppe and Barkman lenses allow
direct visualization of the angle while the rest use mirrors.
Dynamic gonioscopy (aka compression gonioscopy or
indentation gonioscopy) involves applying pressure with the
gonio lens to see if the angle can deepen. If applying pressure
doesn’t deepen the anterior chamber and allow more angle
structures to be visualized then there may be peripheral
anterior synechia (PAS). PAS are adherences of the iris to the
angle structures. Only Zeiss, Possner, and Sussman style lenses
can perform dynamic gonioscopy.

58
Gonioscopy Grading
The Shaffer System is based on the angular width of the
angle.
Shaffer Gonioscopic Grading System
Grade 4 45°-35°; wide open
Grade 3 35°-20°; wide open
Grade 2 20°; narrow
Grade 1 < 10°; extremely narrow
Slit 0°; slit

The Sheie System is based on the most posterior visible

structure.
Scheie Gonioscopic Grading System
Wide Open All structures visible
Grade 1 Iris Root
Grade 2 Ciliary Body Band
Grade 3 Trabecular Meshwork
Grade 4 Schwalbe’s Line

The Spaeth System is extremely complex and uses

several metrics including iris insertion, peripheral iris
appearance, and trabecular meshwork (TM) appearance.
Spaeth Gonioscopic Grading System
Iris Insertion Angle Peripheral Iris TM Pigment
A: Anterior to 0°-50° r: regular 0 – no pigment
Schwalbe’s s: steep 1+ – minimal
B: Behind q: queer 2+ – mild
Schwalbe’s f: flat 3+ – moderate
C: SCleral Spur b: bowed 4+ – intense
D: Ciliary Body p: plateau
(Deep) c: concave
E: Extremely
Deep
Lastly, the Becker Goniogram is a standardized drawing
of gonioscopic findings.

59
 Immediately notice that some of these systems are the
inverse of each other. For example, a “Grade 4” Shaffer angle is
wide open while a “Grade 4” Scheie angle is very narrow. My
unsolicited opinion on these is that while they may facilitate
quick communication between glaucoma specialists, they’re
complex and confusing and it may be better to just describe
what you’re seeing. For example:
Open to CB 360, 2+ TM
contains essentially the same information as
E45r2+
but is easily understandable to any ophthalmologist.

One of the most common gonio lenses is the G-4 Gonio

(pictured here). A gonio with 4 mirrors makes the most sense
since it’s common to report findings in
quadrants, always remember with
mirror lenses you’re actually looking at
the opposite angle (e.g., the top mirror
visualizes the inferior angle). This is a
Sussman style lens.
Dilation is generally considered safe if two quadrants of
trabecular meshwork are visible.

Normal Exam
Here is an example of a normal gonioscopy exam.

Gonioscopy: With a Sussmann Style 4-mirror lens

OD: Open to CB 360, 2+ TM, no PAS
OS: Open to CB 360, 2+ TM, no PAS
Impression: Open OU

Dilated with Tropicamide 1% and Phenylephrine 1% at

0945 01/22/23

60
 The Slit Lamp Exam
The Slit Lamp
After all that, we’ve finally made it to the quintessential
ophthalmology tool: the Slit Lamp Biomicroscope. It is literally a
microscope for examining the eye and produces a stereoscopic
view and a slit shaped beam (that can be widened to a circle).
Slit lamps date to the early 1900s.

Slit Lamp Optics

The optics of the slit lamp have very little clinical utility
but do appear in board questions.
First, the patient’s eye must be placed at the primary
focal point (f1) of the slit lamp’s objective lens. This means the
light rays will exit the lens with zero vergence (all parallel to
each other) and upright. For a review of focal points, please see
Page 29 or The Eye Guide: Anatomy and Optics.

The magnification portion of the slit lamp uses principles

of a Galilean (terrestrial) telescope. The low plus objective lens
and high minus eyepiece are separated by the difference in their
focal lengths. The light rays again leave with zero vergence and
upright.

61
 The light rays are then inverted using a Porro-Abbe
prism. They exit the prism with zero vergence but inverted
which is equivalent to a 180° rotation.

The ocular (eyepiece of the slit lamp) uses principals of a

Keplerian (astronomical) telescope. The low plus objective lens
and high plus eye piece are separated by the sum of their focal
length. The light rays leave the eyepiece portion inverted but
since the light rays entered inverted they are now upright.

Here is a summary of slit lamp optics.

62
Anatomy of a Slit Lamp
Like everything we’ve discussed so far, slit lamps vary
wildly in appearance and design. I use a Haag-Streit slit lamp in
this example because it’s very common but there are many
different types.
Here is an overview of the entire device.

The light source can either be an incandescent bulb or

LED.

63
 The light source has many levers that control the nature
of the slit beam. You can control the length of the slit beam,
filters, and angle of the beam. The scale for the height of the
beam is in millimeters and combining this with the ability to
rotate the entire beam makes it easy to take measurements of
lesions. The red-free filter is great for visualizing veins, arteries,
and the nerve fibers.

Rotating the length past

14 mm engages the Cobalt Blue
filter for the fluorescein exam.

64
 The oculars should produce a clear stereoscopic view.
Make sure the pupillary distance is comfortable to you. The
little dials at the end of the oculars are for setting the refraction
of the examiner but assuming you wear correction for distance
vision then the light should be set to “0” for both eyes.

The width of the beam is set by the dial. The dial is also
used to swing the arm of the slit beam around. The maximum
with and length is 14 mm.

65
 The slit beam is focused and moved around using the
joystick. Moving the joystick around controls the “X-Axis” and
“Z-Axis”. Twisting it controls the “Y-Axis” (up and down).

Don’t forget to lock and unlock the slit lamp by twisting

the locking screw.

A final helpful tip is to

make sure the patient’s lateral
canthus is in line with this black
mark so the eye is well within
the slit beam’s excursion.

66
Slit Lamp Exam
General
Some of the internal medicine exam still applies. In fact
for billing purposes a general medical exam is often required, so
take note of orientation, breathing, mood/affect, etc.

Adnexa/External
Then, observe around the eye for any lesions or swelling.
Many eye diseases present around the eye such as herpes
zoster ophthalmicus. Even allergic reactions to eyedrops can
cause periorbital dermatitis. Make note of any abnormality on
the face or around the orbits.

Lids/Lashes
Next, carefully examine the eyelids and eyelashes. Make
note of any lesions, edema, ecchymosis, blepharitis, meibomian
gland dysfunction, or any other abnormality.

Conjunctiva/Sclera
The sclera should be white and conjunctiva free of any
follicles and papillae. Note any unusual injection, hemorrhages,
concerning findings, pterygia, etc.

Cornea
This is a good time to carefully examine the tear film.
Take note of Tear Breakup Time (TBUT). This is easier to see
with fluorescein instilled but this is essentially how long it takes
for dry spots on the cornea to develop. Fluorescein can also
reveal punctate epithelial erosions and other surface disease.
There are 4 reflections of the slit beam when examining
the eye: the anterior surface of the cornea, the posterior
surface of the cornea, the anterior surface of the lens, and the
posterior surface of the lens. These are called Purkinje reflexes.
There are several methods for examining the cornea.

67
 Direct (Focal) Illumination involves moving from a broad
to narrow beam (~1 mm). This is helpful for evaluating cornea
edema, thinning, infiltrates, or endothelial pathology (e.g.,
guttae).

Specular Reflection involves using the light reflex on the

corneal surface to detect any abnormalities in the tear film or
underlying cornea. This applies to the posterior cornea and
endothelium as well. The arm of the slit lamp is set to ~60° and
the beam is set to a short, small slit. Next, look for the reflection
of the light source and its Purkinje light reflex on the anterior
and posterior cornea. The endothelial Purkinje reflex is overlaid
on the light source mirror image to produce a glare and then the
endothelial reflex is brought in focus with the joystick.

Sclerotic Scatter is a form of indirect illumination using

total internal reflection (the same reason we can’t directly
visualize the angle by just using the slit lamp). A bright beam is
shone near the limbus, scatters off the sclera, and causes the
cornea to glow. This highlights opacities, edema, and verticillata
among other things. It’s also great for viewing the endothelium.

68
 Retroillumination is commonly used to help visualize the
lens but can also help visualize the cornea (especially opacities).
A tangential beam is directed on the iris while observing the
cornea.

The cornea portion of the exam can be very extensive.

It’s important to note tear film health and any signs of
abnormality or pathology including scars, limbus
neovascularization (especially for contact lens users), pterygia,
edema, or endothelial guttae.

Anterior Chamber (AC)

The anterior chamber should be assessed for overall
architecture (e.g., depth). To evaluate for any cell or flare, make
a very small (1 mm x 1 mm) square with the slit lamp beam. It’s
analogous to looking at dust in the beam of a projector. A
microhyphema presents as red blood cells in the AC.

69
 Flare refers to proteins in the AC which scatters light and
spreads it in multiple directions.

Iris
The iris should be evaluated for overall architecture
(e.g., two humps in the iris can be a sign of plateau iris
syndrome). Make note of any posterior synechia or TIDs
(transillumination defects). Posterior synechia are adhesions
between the iris and anterior lens capsule. Here’s an example in
a surgical setting.

70
 Transillumination defects are best seen by using
retroillumination again. Align the slit beam straight through the
pupil to elicit the red reflex. This makes it easy to see thin spots
in the iris. Here’s an example of TIDs in Essential Iris Atrophy (a
form of iridocorneal epithelial syndrome).

Lens
The lens has the other two Purkinje reflexes. The slit
beam should be visible on the anterior and posterior portion of
the lens. Always note if the patient is phakic (natural lens),
pseudophakic (an IOL), or aphakic (no lens). Describe the lens
and if there is any cataract. Here is a review of the types.

71
 Retroillumination is essential for examining the lens
because it allows any subtle opacities (e.g., cortical vacuoles,
posterior capsular opacification) to become more visible.

Without Retroillumination With Retroillumination

Cataracts and posterior capsular opacifications can be

graded on a scale of 1-4 but this can be quite subjective.
Sometimes it’s better to just describe what you see, e.g.:
Trace NSC with dense cortical spokes to visual axis.

Vitreous
Focusing the slit beam posterior to the posterior capsule
allows visualization of the anterior vitreous. The vitreous should
be clear and visible floaters are typical. Using a similar
technique as visualizing cell in the anterior chamber, evaluate
for the presence of cell in the vitreous. Pigmented cell in the
anterior vitreous is call Shaffer’s Sign (aka tobacco dust) and is
associated with retinal detachment. The vitreous can also
appear hazy if there is a hemorrhage. Make note if the media to
the back of the eye is not clear.

72
Fundus Exam
The anterior vitreous is the extent of what can normally
be evaluated with the slit lamp alone. Lenses
are needed to see the posterior pole. This
can be accomplished by using high diopter
plus lenses (usually between 60 D - 90 D). An
example of a slit lamp lens is pictured here.
It's important to consider the consequence
of adding this additional, high power plus lens to the slit lamp’s
optical system because it does have an important clinical
correlation. Don’t forget, we’re now looking through the
patient’s optical system as well.

You might immediately notice a major difference with

this optical set up so let’s zoom out.

The image is now inverted from the perspective of the

examiner. The fundus is essentially 180° rotated from reality.

Overview of Fundus Exam

1. Align the slit beam with the pupil.
2. Place the lens between the eye in the path of the slit beam.
3. Move the slit lamp backwards to focus on the retina.
It takes time to master this and to get a feel for “working
distance” which is how close to hold the lens to the eye.

73
 Here is a brief review of the anatomy of the fundus.

Additionally, the measurement of beam length is now

inaccurate. It’s no longer a 1:1 relationship when using a lens.
There are special lenses that maintain the 1:1 ratio but a
conversion factor must be used if taking measurements of the
fundus. It’s common just to measure lesions in “Disc Diameters”
(DD) as this is always ~ 1.5 mm.
Putting it all together, remember if a lesion appears on
the superior arcade, it’s actually on the inferior arcade.

Reality (OD) Examiner’s View

74
Nerve
To examine the nerve, ensure that the margins are sharp
and no vessels are obscured (this could be a sign of disc edema).
Measure the optic cup in relation to the optic disc, it should be ~
0.3 of the optic disc. A larger than normal cup/disc ratio is
characteristic of glaucoma. Examine the rim for notching or thin
spots. Note any hemorrhages or irregularities including
peripapillary atrophy or abnormal disc insertions.

Macula
The macula should be flat. Changes in contour of the slit
beam might indicate elevation from edema. Take note of any
drusen or irregularities. Remember, as you saw in the pictures
on the previous page, younger patients will have a sheen on
their internal limiting membrane (ILM). This ILM sheen is normal
but can trick new examiners. Look for any diabetic changes in
the macula including dot-blot hemorrhages, cotton wool spots,
or exudative changes. Note any irregularities in the retinal
pigment epithelium. Describe what you see that isn’t typical and
where you see it.

Vessels
The vessels should not be too tortuous and there should
be no irregularities when they cross each other (which may
indicate hypertensive changes). It’s hard to see, but diabetes
can appear in the vessels as microaneurysms.

Some lenses (e.g., the Volk Super Field®) allow

visualization of the periphery of the retina by asking the patient
to look up, down, left, and right. To fully visualize the entire
retina out to the ora serrata, binocular indirect ophthalmoscopy
must be used.

75
Normal Exam
Here is an example of a normal slit lamp exam.

General: Patient Alert and Oriented, nonlabored breathing,

mood and affect appropriate.

Slit Lamp Exam: OD OS

Adnexa/External: no edema/lesions no edema/lesions
Lids/Lashes: no lesions no lesions
Conjunctiva/Sclera: white and quiet white and quiet
Cornea: Clear clear
AC: deep and quiet deep and quiet
Iris: Round round
Lens: phakic, clear phakic, clear
Vitreous Clear clear

Fundus Exam: OD OS
Nerve: 0.3, sharp, flat, 0.3, sharp, flat,
Macula: flat, dry flat, dry
Vessels: Normal normal

76
 Indirect Ophthalmoscopy
Overview
Binocular indirect ophthalmoscopy uses a lower power
lens (usually 10 D – 30 d) and a
headlamp. Headlamps can have
many appearances. Some
examples of indirect lenses are
pictured.
Like everything else, this involves sophisticated optics.
The condensing lens forms an image of the retina in the air. This
image is adjusted for pupillary distance by using mirrors and a
low plus lens is used in the ocular portion of the headlamp (like
a pair of reading glasses).
This image is also inverted, so think of everything as
rotated 180°.

77
 The amount of magnification can be simplified to 60
divided by lens power. For example, a 20 D indirect lens has a
magnification of 60/20 = 3X.
Different lenses have different advantages. The 20 D
provides excellent magnification while the 28 D provides an
excellent field of view.
Because of the lack of magnification relative to viewing
the fundus at the slit lamp, determining C/D might be difficult.

Overview of Indirect Ophthalmoscopy

1. First, position the headlamp comfortably. Look at your hand
and adjust the PD so that both eyes are centered on the same
spot.
2. Next, elicit the red reflex by looking into the patient’s eye and
place the lens over the eye at the correct working distance
(distance between the eye and lens).
3. Ask the patient to look up, down, left, and right to visualize
the entire retina.
Here’s an
example. You can tell this
is a left eye so you’d think
the nerve would be
inserting on the left
(nasally) but remember
the image is essentially
flipped 180°. This disc is
edematous.

The indirect exam takes time to master. Remember to

check the published manufacturers’ working distances for their
lenses. There will be a light reflex from the headlamp on the
anterior and posterior surface of the lens. Align these reflexes to
ensure you’re looking through the center of the optic and the
lens isn’t tilted.

78
Scleral Depression
To fully observe the retina out to the ora serrata, scleral
depression is often required. This is the use of a blunt
instrument (usually a metal stick as pictured below) to press the
globe from the outside to bring the far periphery into view.
There are many different methods to accomplish this.
This definitely takes time to learn and probably shouldn’t
be attempted until very comfortable with the rest of the exam.

Normal Exam
The peripheral exam can be lumped in with the rest of
the fundus exam. Again, there’s a lot of ways to do this
depending on preference.

General: Patient Alert and Oriented, nonlabored breathing,

mood and affect appropriate.

Slit Lamp Exam: OD OS

Adnexa/External: no edema/lesions no edema/lesions
Lids/Lashes: no lesions no lesions
Conjunctiva/Sclera: white and quiet white and quiet
Cornea: clear Clear
AC: deep and quiet deep and quiet
Iris: round Round
Lens: phakic, clear phakic, clear
Vitreous clear Clear

Dilated with Tropicamide 1% and Phenylephrine 1% at

0945 01/22/23

Fundus Exam (90D): OD OS

Nerve: 0.3, sharp, flat, 0.3, sharp, flat,
Macula: flat, dry flat, dry
Vessels: normal normal
Periphery (20D): no holes/tears no holes/tears

79
 Summary
As we’ve seen, the eye exam can be quite extensive. It is
usually not necessary to do every exam maneuver on every
single patient every single time. For example, patients rarely
require gonioscopy every single visit. Not every patient requires
the IOP accuracy of Goldmann applanation. A scleral depression
might not always be indicated. The exam ultimately is usually
tailored to the purpose of the visit and symptoms. Just to have
it all together in one place, here is an example of a (very
comprehensive) normal eye exam.

Visual Acuity
sc cc cCL Ph
OD 20/30-2 20/20 NI
OS 20/30+1 20/20 NI
Current Rx:
Eye Sphere Cylinder Axis ADD Prism Base
OD -2.00 +1.0 100
OS -2.25 +1.25 075
Manifest Rx:
Eye Sphere Cylinder Axis ADD Prism Base
OD -2.25 +1.25 095 +2.50
OS -2.00 +1.50 080 +2.50
PD 62
Color Vision: 14/14 OU (Ishihara)
Pupils:
Round, equal, and reactive to light; no RAPD
Light: 2.0 mm OU
Dark: 4.0 mm OU
IOP: 15/15 (tp)
Stereo
Fly: Yes
Circles: 9/9

80
Alignment: Ortho
Method: Cover-Uncover
Correction: sc
0 0 0 0 0 0
Ortho
0 0 0 0
Ortho’
0 0 0 0 0 0
Head posture: Straight
Nystagmus: None

Gonioscopy: With a Sussmann Style 4-mirror lens

OD: Open to CB 360, 2+ TM, no PAS
OS: Open to CB 360, 2+ TM, no PAS
Impression: Open OU

Dilated with Tropicamide 1% and Phenylephrine 1% at

0945 01/22/23

General: Patient Alert and Oriented, nonlabored breathing,

mood and affect appropriate.
Slit Lamp Exam: OD OS
Adnexa/External: no edema/lesions no edema/lesions
Lids/Lashes: no lesions no lesions
Conjunctiva/Sclera: white and quiet white and quiet
Cornea: Clear clear
AC: deep and quiet deep and quiet
Iris: Round round
Lens: phakic, clear phakic, clear
Vitreous Clear clear
Dilated with Tropicamide 1% and Phenylephrine 1% at
0945 01/22/23
Fundus Exam (90D): OD OS
Nerve: 0.3, sharp, flat, 0.3, sharp, flat,
Macula: flat, dry flat, dry
Vessels: normal normal
Periphery (20D): no holes/tears no holes/tears

81
Conclusion
I know what it was like as a student/new resident and
how intimidating the eye exam initially was. It takes time to
learn. It’s much easier to report “lung sounds are coarse” on
Internal Medicine wards than to report “myopic discs with some
lattice at 6 o’clock OS” in the ophthalmology clinic. To even
have the skill set to examine an eye takes time and dedication
to develop. Repetition and practice are critical for anything in
life. Examine a lot of eyes and it gets a lot easier. A thorough
examination is crucial for every ophthalmologist. For example,
corneal scars may interfere with LASIK flaps and certain TID
patterns can be indicative of weak zonules in preparation for
cataract surgery. Dedicate yourself to perfecting the exam and it
will make everything else, including surgery, easier.
If there are any other common exam techniques that I’m
missing here and you feel should be included, please let me
know and I will add them.
I also want to thank everyone who taught me and
continues to teach me the eye exam. I wish I had something like
this when I was a student/new resident so I hope you have
found it helpful.

82
 Notes:
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This book series is dedicated to my first teachers:

Raymond & Helen Holderle

Thank you for reading! Please submit any errors, feedback,

questions, or inquiries to [email protected].

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