- Opthalmology Physical Exam (PhysEx)
Vitals
Visual Acuity
- Snellen chart
- Ask patient to wear their glasses or contact required to see distance
- Ensure adequate lighting and contrast of the chart
- Ask the patient to cover one eye (usually the left eye first by convention)
- Record the best visual acuity where more than half of the letters are identified correctly
- Next record the best visual acuity with pinhole
- Remind the patient to look in the top portion of their glasses if they are wearing bifocals
- Use Tumbling E chart for illiterate patients and Allen chart for infants 2-5
- For infants under 2, you can only test visual function by passing an interesting object (e.g. keys, toy, etc.) and watch how infant follows the object
- Pocket chart
- Used to access near vision or glasses for distance vision is inaccessible
- Ask patient to wear their glasses required for reading
- Ensure adequate lighting and contrast of the chart
- Most charts are held 35 centimetres (14 inches) away
- Ask the patient to cover one eye (usually the left eye first by convention)
- Record the best visual acuity where more than half of the letters are identified correctly
- Remind the patient to look in the top portion of their glasses if they are wearing bifocals
- Low vision
- Ensure patient cannot identify the lowest visual acuity level on a Snellen chart; which is usually 6/60 (i.e. 20/200)
- Ensure adequate lighting
- Hold up your fingersat varying distances of less than 1 metre and check whether the patient can count them
- Record vision as counting fingers (CF) is patient is able to do so
- If patient is unable to count fingers, wave your hand at varying distances of less than 1 metre and check if patient is able to see this
- Record vision as hand motion (HM) if patient is able to do so
- If the patient is unable to see hand movements, shine a flashlight toward his/her eye and check if patient is able to see this
- Record vision as hand motion (LP - Light Perception) if patient is able to do so
- Record vision as no light perception (NLP) if patient is unable to perceive light
Visual Fields
- Ensure adequate lighting
- Sit 1 metre in front of the patient
- Ask patient to cover their left eye with their left hand while the you cover your right eye with your right hand
- Static: ask patient to count the fingers of the examiner in each of the 4 quadrants
- Moving: target should start outside the usual visual field, then move slowly to a more central position until the patient confirms visualization of the target
Extraocular Muscles
- Ensure adequate lighting
- Sit 1 metre in front of the patient
- Sit at the patient's eye level and ask patient to follow your fingers with their eyes while not moving their head
- Assess for lagopthalmos (inability to close the eyelids completely) when having the patient looking down
- Move your fingers along each cardinal directions of gaze and note any deficits in ocular movement in each eye
- Ask the patient if they experience any diplopia, especially at the outer limits of extraocular movement
- Ask the patient if there's pain on extraocular movement at this time
- Note any Nystagmus by pausing during upward and lateral gaze
- Test for Developmental dysconjugate gaze with cover-uncover test
Eye Pressure (Tono-pen)
- Ensure the patient does not have allergies to latex or anaesthetic before putting on a new sterile cover on the tono-pen transducer and apply anaesthetic drops
- For the first measurement of the day you should calibrate the tono-pen
- Turn on the tono-pen, then press the user button twice rapidly to enter calibration mode (Many models will have an LED display reading "CAL")
- Then point the transducer straight down
- After 15 second you will hear a audible beep, at which you point the transducer straight up
- A functional tono-pen will then beep once more (Many models will have an LED display reading "GOOD")
- Press the operator button once if you are ready to take measurements
- Once the tono-pen is calibrated or if this is a repeat measurement, you are ready to begin
- Press the user button once, the tono-pen should beep and the first measurement is ready to be taken
- Brace the patients eyelids open with one hand, telling the patient to look straight ahead
- Hold the pen with your other hand like a pencil and brace this hand against the patient's maxillar region for stability
- Tap the corneal surface lightly four time to get a reading with the statistical reliability (two beeps will be heard after a statistical reading is made)
- Indentation of the cornea is not required and may lead to inaccurate readings.
Pupil Size
- Document bilateral pupil reaction to accommodation
- Instruct patient to focus on your finger and sit on equal level as patient
- Start by having finger 1 metre away from patient, then move finger towards patient until it is at the tip of the patient's nose
- Test for Relative afferent pupillary defect with the swinging light test.
Inspection
- From a distance, note the patient's eye alignment and symmetry of eye position and pupil size
- Note any lesions or deformities around the eyes, such as:
- Traumatic wounds and entry sites of infection (e.g. cuts, ecchymosis, etc.)
- Erythema
- Rashes
- Exudates
- Previous surgical sites
- Lesions (e.g. skin cancers, papillomas, etc.)
- Allergic shiner in the adnexal region
- Eye protruding from the orbit (exophthalmos)
- Enopthalmos (eye sunken into the orbit)
- Palpate for preauricular lymphadenopathy
- Palpate for scalp tenderness when giant cell arteritis is in the differntial
- N.B. Any lesion larger than 1mm should be measured
- Preform either cover-uncover test or Hirschberg test for strabismus
- Test for Colour vision defects using the Ishihara test
Lids and Lashes (L/L)
- From a distance, note the patient's lid function and symmetry
- Note any ptosis (eye lid drop) or lagopthalmos (inability to close the eyelids completely)
- Assess the eyelid position in relation to the globe, look for:
- Ectropion - condition where the lower eyelid turns outwards
- Entropion - condition where the eyelid (usually the lower lid) folds inward
- Proceed to the slit lamp exam and look for lesions on the eyelid and lid margins; look for:
- Deformities
- Erythema
- Masses
- Foreign bodies
- Previous surgical sites
- Uleceration
- Inspect the glands of Moll and Zeis along the lid margin
- Look for prominent glands and blocked glands
- Inspect the lacrimal puncta at the nasal end of the lid margin
- Evert the eyelids and look for
- Papules (cobblestone arrangement of flattened nodules with central vascular cores)
- Follicles (small, dome-shaped nodules without a prominent central vessel)
- Masses
- Lesions
- Foreign bodies
- To evert the upper eyelids
- Applying a drop of anaesthetic to the eye may be necessary to ensure patient comfort
- Ask patient to look down
- Push down on the tarsal plate with the blunt end of a cotton swab, as you grasp the lashes and pull up
- Have patient look up once you are done inspecting the tarsal conjunctiva
- Inspect the lashes and look for
- Eyelash loss
- Inverted eyelashes
- Signs of blepharitis
- N.B. Any lesion larger than 1mm should be measured with the lamp slit beam
Conjunctiva and Sclera (C/S)
- To fully expose the conjunctiva/sclera for inspection, you must instruct the patient to look in the opposite direction you wish to exam (e.g. ask patient to look down to examine the superior bulbar conjunctiva)
- Using the slit lamp assess the following:
- Scleral colour
- Note any scleral or conjunctival lesions
- Observe the contour and thickness of the conjunctiva
- Chemosis is edema of the conjunctiva and will cause an uneven thickness
- Note any injection of the conjunctiva or sclera
- Note if injection is mobile when manipulated with a cotton swab
- Conjunctival vessels are mobile when manipulated
- Scleral vessels are deeper and remain in place when manipulated
- Note any ciliary flush which presents as circumferential injection surrounding the limbis
- Document any subconjunctival hemorrhage
- Note any previous surgical sites (e.g. bleb from trabeculectomy)
- N.B. Any lesion larger than 1mm should be measured with the lamp slit beam
- Test for Keratoconjunctivitis sicca (dry eye syndrome) with Schirmer test
Cornea (K)
- Using the slit lamp assess the following
- Corneal thickness
- Using a narrow slit beam at an angle, pass through the entire corneal surface, any local areas of corneal thinning will be noted by a change in the beam's thickness
- Corneal shape
- Using a narrow slit beam at an angle, pass through the entire corneal surface, any change in corneal shape will be noted by a change in the beam's contour
- Note any corneal foreign bodies
- Assess the limbis for pannus
- Assess the colour of the peripheral cornea and limbis (e.g. Kayser-Fleischer ring, arcus senilis)
- Corneal clarity
- Note the shape and size of any corneal opacity and look for corresponding epithelial defects
- Note any corneal haze
- Assess corneal reflex before applying anesthetic if viral keratitis is in the differential
- Apply pressure to the suspected corneal opacity with the tip of a tissue
- Assess the patient's blink reflex, a decreased or absent response signifies decreased corneal sensitivity
- Note any epithelial defect using fluorescein and anaesthetic drops
- Option 1: apply fluorescein drops to eyes
- Option 2: wet the tip of a fluorescein strip with anesthetic drops, apply fluorescein strip to lower tarsal or bulbar conjunctiva
- Turn on cobalt blue filter for slit lamp
- Note any focal fluorescein uptake which is immobile with blinking
- Note any folds in Descemet's membrane
- Note any lesions on the endothelium such as:
- Guttata
- Keratic precipitates
- Krukenberg's spindle
- Note any previous surgical sites (e.g. corneal transplant, corneal incisions)
- To look for leakage from anterior chamber, preform the Seidel test
- N.B. Any lesions, foreign bodies, opacities larger than 1mm should be measure with the lamp slit beam
Anterior Chamber (AC)
- Using the slit lamp, assess chamber depth using the Van Herick's test.
- Look for hypopyon (pus in the anterior chamber)
- Look for hyphema (blood in the anterior chamber)
- Look for microscopic white blood cells in the chamber
- Turn slit lamp on high intensity
- Rotate slit beam to 30-45 degrees
- Adjust to 1.6 magnification
- Adjust beam height and width to 1mm x 1mm
- Focus on the iris, and then pull back the slit beam to focus in front of the iris
- Check for floating white cells
- Check for "flare" which is a haze along the slit beam due to high concentration of protein in the anterior chamber
- Look for microscopic red blood cells in the chamber
- Set up slit lamp in the same manner as looking for white cells
- Switch to red free filter on the slit lamp, red blood cells will appear black
- Look for any previous surgical sites (e.g. Shunt or tube in the anterior chamber, anterior chamber lens)
Iris (I)
- Assess iris colour and pupil contour
- Look for congenital defects of the iris
- Look for neovascularization by using high magnification along the papillary border
- Look for lesions of the iris (e.g. nevi, neoplasm)
- Retroilluminate to look for iris defects and iridotomies
- Turn slit lamp to maximum intensity
- Rotate slit beam to 90 degree (i.e. perpendicular to the eye)
- Shine slit beam through the pupil
- Look for light shining through the iris
- Appreciate any anterior or posterior synechiae
- N.B. Any lesions larger than 1mm should be measured with the lamp slit beam
Lens (L)
- Note the patient's lens status
- Natural lens
- Assess lens clarity
- Assess lens position
- Assess lens colour
- Look for Pseudoexfoliation
- Without lens (aphakia)
- Artificial lens (pseudophakic)
- Document the lens position
- Assess the lens clarity by retroillumination
- Turn slit lamp to maximum intensity
- Rotate slit beam to 90 degree (i.e. perpendicular to the eye)
- Shine slit beam through the pupil
- Look for light shining through the iris
Anterior Vitreous (Avit)
- Focus on the anterior vitreous by shining slit beam through pupil
- Have patient look up, down, and then straight ahead in rapid succession
- Appreciate any floaters that have changed position after movement
- Note the colour of the anterior vitreous (e.g. pinkish hue in vitreous due to intravitreal bleed)
Fundus
OnExam will focus on the basic fundus exam with an ophthalmoscope. A full-dilated fundus exam with indirect ophthalmoscopy will not be discussed.
Preparation
- Sit at the patient's eye level, a dim room will help with fundoscopy
- To examine the right eye, hold the ophthalmoscope in your right hand and in front of your right eye (while keeping both eyes open)
- Approach the patient at a 30 degree angle and find the red reflex
- Note the presence or absence of a red reflex
- Note the presence of a white reflex
- Follow the red reflex until you approach to within 5 cm of the patient's eye
- Rotate the diopter wheel until the retina comes into focus
- Use the “0” lens if examiner does not wear glasses or if the examiner if wearing glasses to correct his/her vision during the exam
- Use “minus” (red numbers) lenses if you are myopic and are not wearing glasses for fundoscopy
- Use “plus” (black numbers) lenses if you are hyperopic and are not wearing glasses for fundoscopy
Examination
- Retinal vessels
- Assess for venous pulsations (veins are often wider, darker in colour and have a dimmer reflex then arteries)
- Find a retinal vessel and follow it towards it's branching points until you reach the optic disk, assess the disk by looking at
- Sharpness of the disk margin
- Disk colour
- Cup to disk ratio
- Disk hemorrhages
- Assess for papilledema
- ask patient to look directly into the light to view the macula
- Tilt the ophtalmoscope to view the peripheral retina
- Note the colour of the retina
- Look for microaneurysms by using the red free filter
- Look for lesions and comment on
- Location
- Colour
- Shape
- Size (by disk diameter, if possible)
References
- Bickley LS, Szilagyi PG. Bates' Guide to Physical Examination and History-Taking, 11th ed. Baltimore: Lippincott Williams & Wilkins; 2011.
- Gerstenblith AT, Rabinowitz MP. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease, 6th ed. Baltimore: Lippincott Williams & Wilkins; 2012.
- Harper RA. Basic Ophthalmology, 9th ed. San Francisco: American Academy of Ophthalmology; 2010.
- Stevens S. Test distance vision using a Snellen chart. Community Eye Health 2007; 20(62): 52. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2040251/ (accessed 10 September 2014).
- Knoop KJ. Slit lamp examination. http://www.uptodate.com/contents/slit-lamp-examination (accessed 10 September 2014).
- Goldberg C. The Eye Exam. http://meded.ucsd.edu/clinicalmed/eyes.htm (accessed 10 September 2014).
- Hu E. How to Conduct an Eight-Point Ophthalmology Exam. http://www.aao.org/yo/newsletter/2013-print/article05.cfm (accessed 10 September 2014).