Eye: History, Examination
- History
- Inspection
- Visual acuity
- Visual fields
- Ophthalmoscopic (fundi)
- Pupils
- Corneal reflections
- Eye movements
- Corneal reflex
- Presenting complaint:
• Onset: gradual vs. sudden vs. asymptomatic.
• Duration: brief vs. continuous.
• Location: focal vs. diffuse, unilateral vs. bilateral.
- Eye Hx: squint, amblyopia, glasses, glaucoma.
- Family Hx: squint, lazy eye, glasses, glaucoma, cataract (young person).
- Past medical Hx: especially vascular (diabetes, hypertension).
- Medications: current meds, Hx of drugs affecting eye.
• Is pt on or been on eye drops.
- Social Hx: relevant post-op (to put eye drops in).
In all, looking for asymmetry, deformities, discoloration, redness,
discharge, lesions.
- Diagnostic facies.
- Orbit, rim: palpate for lumps.
- Brow: lost sweating (Horner's).
- Eyelids: xanthelasma, ectropian, entropian.
- Eyelids: pus on lids (blepharitis).
- Ptosis.
- Exophthalmos.
- Iris: colour, defects.
- Cornea: transparent vs. opaque, corneal arcus, band keratopthy,
Kayser-Fleischer rings, lesion, scars.
- Ask the patient to look up and pull down both lower eyelids to inspect the
conjuntiva and sclera.
• Conjunctiva: clear/infected. If conjuntivitis, wash hands immediately:
viral form contagious.
• Sclera: jaundice, pallor, injection.
- Spread each eye open with Dr's thumb, index finger. Ask pt to look to each
side and downward to expose entire bulbar surface.
• Eyeball tenderness.
If eye pain, injury, visual loss, check visual acuity
before rest of the exam or inserting medications into eyes [so don't get sued].
- Let pt to use glasses, contacts if available.
- Put pt 20 feet from Snellen eye chart, or hold Rosenbaum pocket card 14
inches away.
- Pt. covers an eye at a time with a card, reading smaller letters till
stop.
- Record smallest line read, eg 20/40.
- Stand 2 feet in front of pt, who looks in Dr's eyes at eye-level.
- Dr's hands to side half way between Dr and pt, wiggle fingers,
ask which they see move.
- Repeat 2-3 to test both temporal fields.
- If suspect abnormality, test 4 quadrants of each eye while card covers
other.
- Darken room, adjust scope so light is no brighter than necessary.
- Adjust aperture to a plain white circle.
- Set diopter dial to zero, unless
have a preferred setting.
- Dr. uses left hand and left eye to
examine the patient's left eye.
- Dr's free hand onto the pt's
shoulder or forehead for control.
- Tell pt to stare at wall.
- Look through scope, shine light into pt's eye from 2 feet away at a 45º
angle.
- See the retina as a "red reflex.". Reflex: clear vs. opaque
(cataract). Follow red color to move within a few inches from pt's eye.
- Adjust diopter dial to bring the retina into focus. Find a blood vessel
and follow it to the optic disk, use this as a point of reference.
- Inspect optic disk:
• Colour of disc: pink vs. pale.
• Margins clear.
• State of cup.
- Inspect vessels: all 4 quadrants, veins are darker than arteries:
• Bleeding, exudate.
• Pigmentation, occlusion.
- Inspect macula, by moving the scope nasally:
• Foveal light reflex
• Bleeding, exudate.
• Edema, drusen.
- Shape, relative size.
- Light reaction: dim lights if needed.
• Pt looks in distance, shine light in from side to gauge pupil's light
reaction. Record size, irregularity.
• Assess both direct (same eye) and consensual (other eye) responses.
- Assess afferent pupillary defect by moving light in arc from pupil to
pupil, and if left eye light makes right eye dilate, not constrict (Marcus
Gunne). Optionally: as do arc test, have pt place a flat hand extending
vertically from his face, between his eyes, to act as a blinder so light can
only go into one eye at a time.
- Accommodation: pt alternates between looking into distance, and a hat pin
30cm from nose.
- Shine a light from directly in front of the pt.
- Corneal reflections should be centered over pupils.
- Assess asymmetry (extraocular muscle pathology).
- "Follow finger with eyes without moving head": test the 6
cardinal points in an H pattern. Assess:
• Failure of movement.
• Nystagmus [pause to check it during
upward, lateral gaze]).
- Convergence by moving finger towards bridge of pt's nose.
- Gaze palsies (supranuclear lesions).
- Fatiguability (myasthenia).
- Corneal reflex: patient looks up and away.
- Touch cotton wool to other side.
- Look for blink in both eyes, ask if can sense it.
- Repeat other side. [Tests V sensory, VII motor].