Eyes

Equipment

• Snellen chart or Lea cards, Landolt C or HOTV chart

• Eye cover, gauze, or opaque card

• Rosenbaum or Jaeger near-vision card

• Penlight

• Cotton wisp

• Ophthalmoscope

EXAMINATION
Ask patient to sit or stand.

Technique	Findings
Visual Testing
Measure visual acuity in each eye separately
• Distance vision Use Snellen chart, Landolt C, or HOTV chart. If testing with and without corrective lenses, test without lenses first and record readings separately.	EXPECTED: Vision 20/20 with or without lenses with near and far vision in each eye.
	UNEXPECTED: Myopia, amblyopia, or presbyopia.
• Near vision Use near-vision card.	EXPECTED: Vision 20/20.
• Near vision Use near-vision card.	UNEXPECTED: Limited fields of vision temporally, 50 degrees superiorly, 70 degrees inferiorly.
• Peripheral vision Test nasal, temporal, superior, inferior fields by moving your finger into field from outside.
External Examination
Inspect eyebrows
• Size/extension	EXPECTED: Unusually thin if plucked.
• Size/extension	UNEXPECTED: Ending short of temporal canthus.
• Hair texture	UNEXPECTED: Coarse.
Inspect orbital area
	UNEXPECTED: Edema, puffiness not related to aging, or sagging tissue below orbit. Xanthelasma.
Inspect eyelids
• Eyelid position	UNEXPECTED: Ectropion or entropion.
• Ability to open wide and close completely Examine with eyes lightly closed, closed tightly, open wide.	EXPECTED: Superior eyelid covering a portion of iris when open.
	UNEXPECTED: Fasciculations when lightly closed. Ptosis. Lagophthalmos.
• Eyelid margin	UNEXPECTED: Flakiness, redness, or swelling. Hordeola.
• Eyelashes	EXPECTED: Present on both lids. Turned outward.
Palpate eyelids
	UNEXPECTED: Nodules.
Palpate eye
	EXPECTED: Can be gently pushed into orbit without discomfort.
	UNEXPECTED: Firm and resists palpation.
Pull down lower lids and inspect conjunctivae and sclerae
• Color Inspect upper tarsal conjunctivae only if presence of foreign body is suspected.	EXPECTED: Conjunctivae clear and inapparent. Sclerae white and visible above irides only when eyelids are wide open.
	UNEXPECTED: Conjunctivae with erythema. Sclerae yellow or green. Sclerae with dark, rust-colored pigment anterior to insertion of medial rectus muscle.
• Appearance	UNEXPECTED: Exudate. Pterygium. Corneal arcus senilis or opacities.
Inspect lacrimal gland region
• Lacrimal gland puncta Palpate lower orbital rim near inner canthus. If temporal aspect of upper lid feels full, evert lid and inspect gland.	EXPECTED: Slight elevations with central depression on both upper and lower lid margins.
	UNEXPECTED: Enlarged glands. Dry eyes.
Test corneal sensitivity
Touch wisp of cotton to cornea.	EXPECTED: Bilateral blink reflex.
Inspect external eyes
• Corneal clarity Shine light tangentially on cornea.	UNEXPECTED: Blood vessels present.
• Irides	EXPECTED: Clearly visible pattern. Similar color.
• Pupillary size/shape	EXPECTED: Round, regular, equal in size.
• Pupillary size/shape	UNEXPECTED: Miosis, mydriasis, anisocoria, or coloboma.
• Pupillary response to light	EXPECTED: Constricting with consensual response of opposite pupil.
• Pupillary accommodation	EXPECTED: Constricting when pupils focus on near object or dilating when focus changes from near to distant object.
• Afferent pupillary testing	EXPECTED: The pupil toward which the light is moving dilates and then constricts as the light shines onto it.
• Afferent pupillary testing	UNEXPECTED: The pupil continues to dilate when the light shines into it.
Extraocular Eye Muscles
Evaluate muscle balance and movement of eyes
• Six cardinal fields of gaze Hold patient’s chin and ask patient to watch finger or penlight.	EXPECTED: A few horizontal nystagmic beats. Smooth, full, coordinated movement of eyes.
	UNEXPECTED: Sustained or jerking nystagmus. Exposure of sclera from lid lag. Inability of eye to move in all directions.

• Corneal light reflex Direct light at nasal bridge from 30 cm (12 inches). Have patient look at nearby object.	EXPECTED: Light reflected symmetrically from both eyes.
• Cover-uncover test Perform if imbalance found with corneal light reflex test. Have patient stare ahead at near, fixed object. Cover one eye and observe other; remove cover and observe uncovered eye. Repeat with other eye.	UNEXPECTED: Movement of covered or uncovered eye.
Ophthalmoscopic Examination
Inspect internal eye
• Lens clarity	UNEXPECTED: Cloudiness or opacity. Shallow chamber. If observed, avoid mydriatics.
• Anterior chamber Shine focused light tangentially at limbus. Note illumination of iris nasally.
• Use ophthalmoscope With patient looking at distant object, direct light at pupil from about 30 cm (12 inches). Move toward patient, observing:
• Red reflex	UNEXPECTED: Opacities.
• Fundus	EXPECTED: Yellow or pink background, depending on race. Possible crescents or dots of pigment at disc margin, usually temporally.
• Fundus	UNEXPECTED: Discrete areas of pigmentation away from disc. Lesions. Drusen bodies. Hemorrhages.
• Blood vessel characteristics Follow blood vessels distally in each quadrant, noting crossings of arterioles and venules.	EXPECTED: Possible venous pulsations (should be documented). Arteriole/venule ratio 3:5 or 2:3.
	UNEXPECTED: Nicking, tortuosity.

• Disc characteristics	EXPECTED: Yellow to creamy pink, varying by race. Sharp, well-defined margin, especially in temporal region; 1.5-mm diameter.
• Disc characteristics	UNEXPECTED: Myelinated nerve fibers. Papilledema. Glaucomatous cupping.
• Macula densa characteristics Ask patient to look directly at light.	EXPECTED: Yellow dot surrounded by deep pink.

AIDS TO DIFFERENTIAL DIAGNOSIS

Subjective Data	Objective Data
Strabismus (paralytic and nonparalytic)
Eyes cannot focus simultaneously. Can focus separately in nonparalytic type.	Eye movement on the cover-uncover test, strabismic eye will fixate on the object after the “straight” eye is covered.
Episcleritis
Acute onset of mild to moderate discomfort or photophobia. Painless injection and/or watery discharge.	Injection of the bulbar conjunctiva purplish elevation of a few millimeters.
Cataracts
Cloudy or blurry vision, faded colors; halo may appear around lights.	Opacity of lens, generally central, occasionally peripheral.
Diabetic Retinopathy (background or nonproliferative)
Initially asymptomatic. Blurred vision, distortion, or visual acuity loss in more advanced stages.	Dot hemorrhages, microaneurysms, hard exudates.
Diabetic Retinopathy (proliferative)
Generally asymptomatic, floaters, blurred vision, or progressive visual acuity loss in advanced stages.	New vessel formation; extension out of the retina, hemorrhage.

PEDIATRIC VARIATIONS
EXAMINATION

Technique	Findings
Visual Testing
Measure visual acuity
• Distance vision	EXPECTED: Infants should be able to focus on and track a face or light through 60 degrees. Age 3-5 years: 20/40 or better. Age 6: 20/30 or better.
Visual acuity is tested, when child is cooperative, with Lea cards, Landolt C, or HOTV chart, usually at about 3 years of age.
Extraocular Eye Muscles
Evaluate muscle balance and movement of eyes
Evaluation of six cardinal fields of gaze is performed as with adults. You may, however, need to hold child’s head still.

Sample Documentation

Eyes

Near vision 20/40 in each eye uncorrected, corrected to 20/20 with glasses. Distant vision 20/20 by Snellen. Visual fields full by confrontation. Extraocular movements intact and full, no nystagmus. Corneal light reflex equal.

Lids and globes symmetric. No ptosis. Eyebrows full, no edema or lesions evident.

Conjunctivae pink, sclerae white. No discharge evident. Cornea clear, corneal reflex intact. Irides brown; pupils equal, round, reactive to light and accommodation.

Ophthalmoscopic examination reveals red reflex. Discs cream colored, borders well defined with temporal pigmentation in both eyes. No venous pulsations evident at disc. Arteriole/venule ratio 3:5; no nicking or crossing changes, hemorrhages, or exudates noted. Maculae are yellow in each eye.