Performing Physical Performing Physical Assessment of the EyeAssessment of the Eye

It involves assessing the functions, such as vision (distant, near, color, and peripheral), eye muscle functioning, and pupils

reflexes, as well as inspecting the external and

internal eye structures.

EquipmentsEquipments

• Snellen’s Chart• Color vision chart • Ophthalmoscopes• Penlight• Cotton swab/ball• Gloves if indicated

HISTORYHISTORY • Remember to look at each history

component as it relates to the eyes.• Ask the patient the following:• Do you have…

– Vision loss?– Eye pan?– Double vision– Eye tearing?– Dry eyes?– Eye drainage?– Eye appearance changes?– Blurred vision?

HISTORYHISTORY• Have you noticed any changes in your vision• Do you wear glasses or lenses?• Have you ever had surgery? Injury?• Have you ever seen spots or floaters, flashes

of light, or halos around the lights?• Do you a history of recurrent eye infection?• When was your last eye exam?• Do you have a history of HTN or diabetes?• What medications are currently taking?• Do you take any prescribed or OTC eye

drops?

TESTING VISUAL ACUITYTESTING VISUAL ACUITY

1. Distance1. Distance– Have patient stand 20 ft from chart.– Test each eye separately, having patient cover

opposite eye being tested, then together with and without corrective lenses.

– Alternate method using pocket vision screener: Have patient hold pocket vision screener about 14inches from eye and proceed testing as above.

• - (Myopia) nearsightedness 2. Near Vision2. Near Vision

– have patient hold newsprint about 14 inches away and read.

– Hyperopia ( farsightedness)

3. Color VisionColor Vision– have patient identify color bars on Snellen eye

chart– have patient identify figure embedded in the

Ishihara chart.– Colorblindness

4. Visual Fields. Visual Fields– stand in front of patient, face to face about 1-

1/2 ft apart.– Ask patient to fix gaze straight ahead and cover

one eye.– Bring a pen or wiggle your finger in from four

different fields (superior, inferior, temporal, and nasal).

– Have patient say “now” once fingers or object are seen.

– Measure degree of peripheral vision using patient’s fixed gaze as a base.

– Diminished visual fields: Chronic glaucoma or stroke.

– Peripheral vision intact in both eyes and all fields.

ASSESSING THE EXTRAOCULAR ASSESSING THE EXTRAOCULAR MUSCLESMUSCLES

1. Corneal Light Reflex Test1. Corneal Light Reflex Test– Shine light directly in patient’s eyes; note position of

the light reflection off the cornea in each eye.– Light should be seen symmetrically on each cornea. – Exotopia (divergent strabismus)– Congenital exotropia

2. Cover/ Uncover Test2. Cover/ Uncover Test– Cover patient’s eye and have patient focus on object

afar.– Uncover eye and note any drifting.– Gaze should be steady when eye is covered and

uncovered. No drifting. – Weakness of extraocular muscles

3. Cardinal Fields of Gaze Test3. Cardinal Fields of Gaze Test– Stand in front of patient and instruct to fix gaze

straight ahead.– Allow him to follow your finger or an object such as a

pen through the six cardinal fields.– Note for any nystagmus.

INSPECTING THE INSPECTING THE EXTERNAL STRUCTURESEXTERNAL STRUCTURES

1. 1. General AppearanceGeneral Appearance– Note clarity and parallel alignment.– Eyes clear and bright, in parallel alignment.– Glazed eyes: febrile state

2. Eyelashes2. Eyelashes– Note distribution, inversion or eversion.– Present and curving outward.– No crusting or infestation.– Absence of eyelashes: Alopecia universalis– Lice or ticks at base of eyelashes; infestation – Inverted eyelashes: Entropion– Everted eyelashes: Extropion

3. Eyelids3. Eyelids– Note edema, lesions– Upper eyelid normally covers one-half of upper

iris– palpebral fissures symmetrical eyelids in contact– Asymmetrical of lids: CN III damage, stroke– Ptosis of both eyelids: Myasthenia Gravis– Lesions f eyelids: Basal cell carcinoma, squamous

cell carcinoma, xanthelasma, chalazion, hordeolum.

4. Eyeball4. Eyeball– note for protrusion.– Exopthalmus

5. Lacrimal gland and Nasolacriminal Duct5. Lacrimal gland and Nasolacriminal Duct– lacriminal glands located below eyebrow,

nasolacriminal ducts located on inner canthus or eyes.

– Note for swelling, redness or drainage.- swelling, redness, drainage, tenderness – inflammation

6. Conjunctiva6. Conjunctiva– To examine bulbar conjunctiva, gently

pull lower lids down.– To examine the palpebral conjunctiva,

use a q-tip and gently roll eyelid up.– Note color, foreign objects.– Acute allergic conjunctivitis– Pterygium– Pinguecula – Benign growth: Papilloma

7. Sclera7. Sclera– Note color of sclera.– Reddish sclera diffuse episcleritis– Icteric (yellow) sclera at the limbus:

elevated bilirubin (jaundice)

8. Cornea and lenses8. Cornea and lenses– Shine a light on the cornea from an

oblique angle.– Note clarity and abrasions.– Corneal reflex: to test the corneal reflex

take a wisp of rolled cotton and gently touch the cornea, or take a needle less syringe filled with air and shoot a ff of air over the cornea, note blinking and tearing.

– Blinking reflex: brush your index finger across patient’s eyelashes and note blinking.

– Cloudy cornea; Vitamin A deficiency– Lens Opacities: cataract

9. Iris9. Iris– note for color and shape

• bloodshot appearance or vessels; Iritis

10. Pupils10. Pupils – note pupil size and equality– test papillary reaction to light; have patient look

straight ahead while you bring light in from the side over the eyes.

– Note reaction and speech in both eyes.– Small, pinpoint pupils (miosis): brain injury to the

pons.– Larger, dilated pupils (mydriasis): use of marijuana,

mydriatic eye drops. 11. Accommodation11. Accommodation

– hold your finger or an object in font of patient from a distance of about 1 inches from patient.

– Instruct patient to focus on finger or object while you move finger or object closure to patient.

– Note convergence of eyes and constriction of pupils as object gets closer.

– Poor convergence – exophthalmus 12. Anterior chamber12. Anterior chamber

– have patient look straight ahead as you shine a light from the side across the eye.

– Note clarity and shadowing from iris.– Hypopyon – pus

PALPATING THE EXTERNAL PALPATING THE EXTERNAL STRUCTURESSTRUCTURES

1. Eyeball1. Eyeball– gently palpate below eyebrow and note

firmness or eyeball.– Excessively firm or tender globe:

Glaucoma2. Lacrimal Glands and Nasolacriminal Duct2. Lacrimal Glands and Nasolacriminal Duct– to palpate glands, gently palpate below

eyebrows on brows.– To palpate ducts, glands, gently palpate

inner canthus of eyes.– Swelling and tenderness; inflammation

PERFORMING AN OPTHALMIC EXAMINATION

1. Red Reflex1. Red Reflex– Stand about ft from patient at a 15-degree angle

from patient’s line of vision.– Place index finger on lens wheel and turn wheel

as needed to focus.– Keep free hands on patient’s forehead to

determine distance/ closeness to patient. 2. Optic Disc. Optic Disc

– Move closer within inches from patient, turning the lens wheel to focus as needed.

– Identify structures.3. Blood Vessels. Blood Vessels• - Arteries and veins originate from disc in

pairs, so make sure to note size, color and crossings.