Physical Examination of the Eye

Visual acuity, Gross examination, Extraocular muscle movement exam, Palpation tonometry, Fundoscopy

What are the five steps of the basic ophthalmologic examination?

Sharpness or clarity of vision

To what does the term visual acuity refer?

Check vision first

What is the general rule regarding when to establish baseline visual acuity during an eye examination?

Examination with bright lights, manipulation of swelling tissues, or eye medications

What three factors can lead to an inaccurate assessment of vision if baseline visual acuity is not established first?

Chemical burns

What is the specific clinical exception where immediate therapeutic intervention takes precedence over checking visual acuity?

One eye at a time

How should eyes be tested to ensure the patient is not using both eyes simultaneously?

An occluder

What is the preferred tool for completely covering the eye not being tested?

Palm of the hand

If an occluder is unavailable, what part of the hand should the patient use to cover their eye?

Spaces between fingers or pressure on the eyeball

Why should patients avoid using their fingers to cover their eye during testing?

Slightly cupped

How should the palm be positioned over the eye to avoid putting pressure on the eyeball?

Hand movements

What serves as an indicator of visual acuity for patients who are non-verbal or mute?

Right eye

Conventionally, with which eye does the distance visual acuity test begin?

Pinhole test

What additional test is performed if a patient's distance visual acuity is measured as less than 20/20?

Worse than 20/20

At what measured visual acuity level is it necessary to perform a pinhole test?

Without correction (without glasses)

Should distance visual acuity be tested first with or without corrective lenses?

With correction (with glasses)

After testing uncorrected vision, how should distance visual acuity be re-tested if the patient has glasses?

Oculus Dextrus (OD)

What is the Latin abbreviation for the right eye?

Oculus Sinister (OS)

What is the Latin abbreviation for the left eye?

Oculus Uterque (OU)

What is the Latin abbreviation for both eyes?

Auris Dextra (AD)

What is the abbreviation for the right ear?

Auris Sinistra (AS)

What is the abbreviation for the left ear?

Auris Utraque (AU)

What is the abbreviation for both ears?

20 feet (6 meters)

How far away from the Snellen chart should the patient be positioned?

Smallest letters

What do the letters on the 20/20 line of a Snellen chart represent?

Largest letters

What do the letters on the 20/200 line of a Snellen chart represent?

Well-lit

What is a critical lighting requirement for using a paper version of the Snellen chart?

Read the smallest line where at least 50% of the letters are correct

How is a patient's visual acuity score determined on a Snellen chart?

The patient read most letters on the 20/40 line but made 2 mistakes

What does a recording of 20/40, -2 signify?

The patient read 3 additional letters on the 20/30 line but not enough to reach 50%

What does a recording of 20/40, +3 signify?

Resolving ability

Distance acuity is typically used as a measure of the eye's what?

5 minutes of arc

Traditional Snellen optotypes subtend a visual angle of how many minutes of arc on the retina?

1 minute of arc

Each smaller part of an optotype, such as the bars of the letter E, subtends how many minutes of arc on the retina?

1 minute of arc

What is the smallest angle that the eye can discriminate?

Test distance

What does the first number (numerator) in a visual acuity recording represent?

The distance from which a normal eye can read that line

What does the second number (denominator) in a visual acuity recording represent?

The patient can read at 20 feet what a normal person sees at 40 feet

What does a result of 20/40 mean?

Bring the patient closer one foot at a time

What should the examiner do if a patient cannot read the largest optotypes on a Snellen chart at 20 feet?

200

If the test distance is less than 20 feet, what should the denominator of the result be?

Counting Fingers

What test is used if the patient cannot read the biggest letters on the Snellen chart even when moved close?

The farthest distance the patient can count fingers

What is recorded when performing a Counting Fingers test?

6 inches

At what distance from the patient does the Counting Fingers test typically begin?

Hand Movement

Which test is used if the patient cannot count fingers at a distance of 6 inches?

Movement of air

What non-visual cue must the examiner avoid during the Hand Movement test?

Small side-to-side movements

What type of hand gestures are used in the Hand Movement test?

Consistency

What must be checked regarding the patient's responses during hand movement and light tests?

Light Projection

Which test determines the quadrant from which light is originating?

Dark room

In what environment should light projection and light perception tests be conducted?

Penlight or ophthalmoscope light

What are the only permitted light sources for projection and perception tests?

4 quadrants

Light should be projected in how many quadrants to be considered "good" projection?

Identify only the quadrants the patient got correctly

How do you record light projection if the patient misses some quadrants?

Light Perception

What test is performed if a patient is unable to identify where light is coming from?

Positive light perception

If a patient can perceive the presence of light, how is it recorded?

Negative light perception

If a patient cannot perceive light, how is it recorded?

Lights on

Should the room lights be on or off for Counting Fingers and Hand Movement tests?

Lights dimmed or off

Should the room lights be on or off for Light Projection and Light Perception tests?

Landolt C or Landolt Ring Chart

Which chart uses a broken ring and requires the patient to imitate its position?

Illiterate E or Tumbling E Chart

Which chart requires a patient to imitate the position of the "arms" of the letter E?

Illiterate or pre-verbal patients

For what populations are Landolt C and Tumbling E charts primarily used?

Shapes or animals

What optotypes might be used on charts designed specifically for young children?

30–40 and above

At what age range is it necessary to test near visual acuity?

Jaeger chart

What specific chart is used to measure near visual acuity?

J1 to J16

What notations are used to record results on a Jaeger chart?

J1 or J1+

What represents "good" vision on the Jaeger chart notations?

Greater than J16

How should near vision be recorded if a patient can only read the largest Jaeger number (95)?

Omit them (except for J1+)

What is the rule for using plus or minus signs in Jaeger notations?

Estimate distance VA for bedridden patients

What is the purpose of the Snellen equivalents found on a Jaeger chart?

Do not use them

What is the rule for recording near visual acuity using Snellen equivalents?

14 inches

At what distance from the eyes should the Jaeger chart be held?

Anatomical relationship and positions of the globes

What is inspected during the gross examination of the orbits?

Flattened bridge of the nose

What nasal finding should be noted during an orbital exam?

Up to down and out to in

In what direction should the examiner proceed when inspecting eyebrows, eyelids, and eyelashes?

Symmetry, hair distribution, position, masses, edema, and redness

What six characteristics are noted when inspecting the eyebrows and eyelids?

Misdirection

What term describes eyelashes growing inwards towards the eye?

Measure the mass

What should be done if a mass is observed on the eyelid?

Look up and pull down lower lid

What instruction is given to the patient to expose the sclera and bulbar conjunctiva?

Palpebral conjunctiva

Which conjunctival surface is visible upon pulling down the lower lid?

Evert the upper lid

How does the examiner view the palpebral conjunctiva of the upper lid?

Cotton pledget

What tool can be rolled against the upper lid to help evert it?

Icteric sclera

What is the term for a yellowing of the sclera?

Follicles

What might be seen on an inverted eyelid as shown in gross examination findings?

Clear

What is the normal appearance of the cornea?

Corneal opacities

What specific abnormality must be noted during corneal inspection?

Quantify the size

What should an examiner do if a whitish opacity is present on the cornea?

Size, shape, symmetry, and constriction to light

What four features of the pupils are assessed?

Anisocoria

What is the medical term for asymmetry in pupil size?

Quantify size and check reactivity

What two details must be recorded if a patient has anisocoria?

Posterior synechiae

What term describes adhesions where the iris sticks to the lens?

Irregularly sized

How do pupils appear when posterior synechiae are present?

Adhesions prevent movement

Why do pupils with posterior synechiae fail to constrict properly?

Same eye level

At what level should the examiner position themselves relative to the patient for EOM testing?

Capital "H"

What shape should the fixation target move in during the EOM exam?

Cardinal directions

What specific directions of gaze are tested in the ophthalmologic EOM exam?

Without moving the head

How should the patient follow the target during EOM testing?

14 inches

How far away from the patient should the fixation target be held?

Finger or toy

What are two examples of a fixation target?

Test one eye at a time, then both together

What is the sequence for testing extraocular muscle movement?

5 cm from the bridge of the nose

At what distance from the nose is a target held to test for convergence?

Accommodation

Convergence is tested as part of which process?

Slowly

At what speed should EOM exams be performed to prevent patient headaches?

Right side (OD)

In reporting EOM findings, which eye's results are written first by convention?