UNIT TWO

BASIC EXAMINATION OF THE EYE

2.1. HISTORY TAKING 2.2. TESTING VISION
2.3. EXAMINING THE EYE
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1. To give a clear idea about the approach to ophthalmic patients

and specific examination techniques.
2. Tofamiliarizethestudentswithcertainophthalmicinstruments.
3. At the end of the course the students are expected to know how
to examine ophthalmic patients and use of certain ophthalmic
instruments

2.1. HISTORY TAKING: History taking should follow this out line
1. Personaldetails Name
Address
Age
Occupation
2. Historyofthepresentcomplaint
3. Generalhealthandanymedicationthepatientmaybetaking
4. Pastophthalmicmedicalandsurgicalhistory
5. Familyhistory
The main purpose of the history is to find out what exactly the patient
is complaining. However it is always helpful to find out some
background information about the patient e.g. age, sex, occupation,
and literacy. Such information will indicate what vision the patient
needs for work and for personal satisfaction.

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In History taking one has to consider the following
Particular environmental or occupational factors
Patients diet, drinking and smoking habits
General health of the patient like diabetes, hypertension &
neurological disease affecting the eye.
Previous eye disease, injuries or treatment
Use of traditional medicine or uses of other treatment.
Family history of similar complaint e.g. myopia and glaucoma.
Major symptom of eye disease given

Disturbances of vision

Discomfort or pain in the eye

Eye discharge
A. Disturbances of vision

The most common visual symptom

Can be sudden or gradual

Blurring or reduction of vision

Dazzling/glare/ difficulty of seeing in bright light, may be caused
by opacities in the cornea or lens
Diplopia/ double vision/
Decreased peripheral vision may be caused by various
disorders
in the retina, optic nerve or visual pathway pathology up to the
visual cortex.
Photophobia is a fear of light

It is usually a sign of inflammatory eye disease, especially a corneal

ulcer and uveitis.
Distortion of shapes usually indicates a disorder of the retina
around the macular.
Haloes (rainbow) colored rings around the light e.g. Corneal
edema, Glaucoma.
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B. Discomfort or pain in the eye.

Usually a symptom of inflammation of the eye or of the structure

surrounding the eye.

Discomfort, irritation or grittiness conjunctival problems

Pain related to corneal disease, Glaucoma

Eyestrain and tiredness of the eyes are common complaint
usually associated with extra ocular muscles abnormalities and
refractive errors.
C. Eye discharge

type (mucoid, purulent, watery) amount

2.2. TESTING THE VISION

A. Visual acuity B. Visual field C. Color vision
A. Visual Acuity
Test the visual acuity in each eye separately.
Measured with a Snellen chart, showing letters, E chart or
pictures for patient who cannot read.
Patient should sit at 6 meters

Start with the right eye by closing the left eye with palm of the
hand.
Use commonly E chart and ask the patient to show the
direction
of the E (right, left, up or down) and then record the last line that
the patient sees.
Repeat for the left eye.
The human finger is about the same size as the top letter on the
chart, so counting fingers at 6 meters is about equal to 6/60
vision, and abbreviated as CF
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If vision is below 1/60, use the patient to detect motion of hand
in front of the eye; hand motion (HM)
If the patient cant see HM, the final test is to shine a light into
his eye
- If he can perceive light LP
- If he cant perceive light NLP
Projection of the light from four quadrants of the eyes should be
examined to test the peripheral retina and optic nerve function.
Test for red and/or green color discrimination, macular function
test
Pin hole test If V/A improves with this test, it usually indicates
an error of refraction; But if not corrected, then loss of visual
acuity is from other eye diseases.

Interpretation of V/A
The WHO classification of Visual impairment and blindness
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6/6
<6/18 <6/60 <3/60
-6/18 -6/60 - 3/60 - NPL
: Normal
: Visual impairment
: severe Visual impairment : blindness
Blindness is defined as visual acuity of less than 3/60 in the better eye
with the best possible correction.
B. Visual field
Visual field is that portion of ones surroundings that is visible at one
time during central vision
Not a routine test in all patients
Important to do in any patients with suspected glaucoma,
diseases of the optic nerves in visual pathways, and certain
retinal diseases Confrontation test
-Simple and no need of special equipment
Will detect serious visual field defects.
Works by comparing the patients visual field with the
examiners
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Steps

Sit facing the patient at one meter distance

If the patients left eye is being tested, he should cover his right
eye
and you should cover your left eye.
Patient looks straight into your eye and you look straight into his
to
make sure he is fixing your eye.
Then hold your fingers at an angle equidistant between you and
the
patient and ask him to say visible or not as your fingers move.
If you can see them and the patient cannot, then he has a
defect.
Move in different quadrant
- Do the same with the other eye.
Perimetery
Difficult to test in children, old or non comprehending
people.
In all visual field test, each eye is tested separately
The patient must fix his gaze on a target or spot in front of
him.
The examiner then sees at what angle objects come into
the
patients range of vision
A calibrated black screen / Bjerrum screen/
Give a more accurate result
C. Color vision
Done by using a chart called Ishihara chart.

Simple macular test is to ask the patient for red and green
color
perception

2.3. EXAMINATION OF THE EYE

Nearly all parts of the eye are visible with an
appropriate optical instrument.
Anyone who cares for the patients should know how
to examine the eye.
Some of ophthalmic diagnostic instruments are very
expensive, but a reasonable examination is possible
with available simple
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instruments. There are two important instrument for examination of
the eye
1. To examine the front of the eye, this requires both a good light
illumination with bright light, torch and magnifying lens(loupe).
2. To examine the back of the eye, need ophthalmoscope.
Normal eye

Eye lids should open and close properly

Eye lashes should grow forward and out ward

white part of the eye should be white

Cornea should be clear and transparent

Pupil is black and reactive to light

During Examination of the Eye One Has to

Comment the Following Things

1. Examinationofthefrontaspectoftheeye Eye lids
In growing eye lash, misdirected
Everted eyelid examinations; follicles, papillary reaction, foreign
body,
concretions
Any mass, ulcer, discharge
Characterize it
Opening and closing pattern and defect of eye lid

Lagophthamos eye lid that cant close

Ptosis eye lid drooping Nasolacrimal apparatus

Punctum
Mass, Ulcer or discharge over the Nasolacrimal apparatus
Conjunctiva
Color
Growth

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Bleeding
Foreign body
Spot - white foamy
Follicles, papillae, scarring
Limbus
Cornea
Characterize each findings
Herberts pit
Ciliary /circumcorneal/ injection Arcus

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Color and transparency Size

Ulcer, scar, infiltrates Foreign body Laceration, perforation Blood
vessels growth Sensation to touch
Iris /pupil
Color
Defect
Reaction to light
Relation with adjacent parts
Pupillary margin: shape, adhesion between lens , iris
and cornea
Transparency
Position, sublaxated or dislocated
Lens
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Anterior chamber
look for clarity Depth
2. Examiningthefundusandusingtheophthalmoscope.
Ophthalmoscope is a form of illumination, which allows the examiner
to look down the same axis as the rays of light entering the patients
eye.
To see the fundus

Ocular media must be healthy and transparent

Dilate the pupil with mydriatic drops

With the ophthalmoscope it appears 15 times larger than

its actual size

In myopic patient the magnification is greater, but in

hypermetropic patient it is less. How to use ophthalmoscope
Hold closer both to the examiners and to the patient's eye If the
patient has spectacles, he has to put it off.
If the examiner wears spectacles, he should keep it.
Steps

A. For examination of the right eye, sit or stand at the patients right
side.
B. Select O on the illuminated lens dial of the ophthalmoscope
and start
with small aperture.
C. Take the ophthalmoscope in the right hand and hold it vertically
in front
of your own right eye with the light beam directed toward the
patient and place your right index finger on the edge of the lens
dial so that you will be able to change lenses easily if necessary.
D. Dim room lights. Instruct the patient to look straight ahead at a
distant object.
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E. Position the ophthalmoscope about 6 inches (15cm) in front and
slightly to the right(250) of the patient and direct the light beam into
the pupil. A reflex should appear as you look through the pupil.
F. Rest the left hand on the patients forehead and hold the upper lid
of the eye near the eyelashes with the thumb. While the patient holds
his fixation on the specified object, keep the reflex in view and
slowly move toward the patient. The optic disc should come into view
when you are about 1and1/2 to 2 inches (3-5cm) from the patient. If it

is not focused clearly, rotate lenses into the aperture with your index
finger until the optic disc is clearly visible as possible. The hyperopic,
or far- sighted, eye requires more plus(black numbers)sphere for
clear focus; the myopic, or near-sighted, eye requires minus(red
numbers) sphere for clear focus.
G. Now examine the disc for clarity of outline, color, elevating and
condition of the vessels. Follow each vessel as far to the periphery as
you can. To locate the macula, focus on the disc, then move the light
approximately 2 disc diameters temporally. You may also have the
patient look at the light of the ophthalmoscope, which will
automatically place the macula in full view. Examine for abnormalities
in the macula area. The red-free filter facilitates viewing of the center
of the macula, or the fovea.
H. TO examine the extreme periphery instruct the patient to: a) look
up for examination of the superior retina
b) look down for examination of the inferior retina
c) look temporally for examination of the temporal retina d) look
nasally for examination of the nasal retina.
This routine will reveal almost any abnormality that occurs in the
fundus.
I. To examine the left eye, repeat the procedure outlined above except
that you hold the ophthalmoscope in the left hand, stand at the
patients left side and use your left eye. If you dont get a clear view it
is usually for one or two reason
1. If the patient has a refractive error, try dialing up plus or minus
lenses in the ophthalmoscope to bring the fundus into focus.
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Especially in myopic patient. It is difficult to see the fundus clearly so
use a strong minus lens in the ophthalmoscope.
2. If the patient has some opacity in the transparent part of the eye i.e.

in the cornea, lens or vitreous, this can be detected with plus lens in
the ophthalmoscope when the pupil is dilated.
Options of Examining a Young Child
1. Seat the baby on his mothers lap, so that her hands restrain his
arms and steady his head
2. Wrap the baby in a sheet or blanket, with his head on the
examiners lap, and continue what you are going to do
3. In very difficult cases, it may be necessary to apply a drop of local
anesthetic, and use a speculum to hold open the eyelids. Use
speculum cautiously as it will damage the cornea.
Intra ocular pressure
Should be measured in any patient with suspected glaucoma.
Ideally it should be part of routine eye examination in any one
over 40 years of age.
Measured by tonometry
There are three methods of assessing IOP
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Digital palpation Steps

- Order your patient to look down
- Place two fingers on the upper eye lid and depressing slowly
- Assess the consistency of the globe (whether it is firm or hard) and
compare with the fellow eye.
Schitz tonometry cheap & commonly used Applanation tonometry
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