Eye exam

Question 1

What do you inspect for in the external eye?

Answer 1

Eyes - Ptosis
Lids - Redness, swelling, lacerations, lumps, rashes, ulcerations, ill-defined thickening, check eyelashes
Puncta - size, shape, if there is swelling medial to it?
Conjunctiva - colour (redness?), cysts? ulceration? laceration?
Cornea - Hazy? (generalised or localised?), white dots?
Pupils - size? (dilated or constricted), shape? (round or abnormal)

Question 2

What tests do we perform to assess vision?

Answer 2

Visual acuity
Colour vision
Visual fields
Blind spot (in raised ICP/papilloedema)

Question 3

How do you test visual acuity?

Answer 3

Use a snellens chart at 6 metres - record as 6/(lowest line they can read)
If unable to see top line, move patient forward to 3 metres
If still unable to see, move to 1 metre
If still unable to see, then see if patient can: count fingers, see hand movements, or perceive light

Then assess patients near vision by covering one eye and reading from a fine print chart. Swap for other eye

Question 4

How do you test colour vision?

Answer 4

Ask patient to look at something red with one eye and then the other - is there any difference?

Use Ishihara plate and ask patient to cover eye and read all numbers from an arms length away

Question 5

How to test visual fields?

Answer 5

Ask patient to look at your nose - can they see your whole face?
Then cover one eye and say when finger wiggles into view. Repeat on there eye

Question 6

When is blind spot test used? And how do you test for it?

Answer 6

Test used in cases of raised ICP and papilloedema
Test by patient covering an eye and keep head straight forward, then moving red hat-pin along horizontal plane from midline to lateral side until hat-pin vanishes (should vanish at 15 degrees in each eye)

Question 7

What tests do we perform to assess the pupils?

Answer 7

Direct and consensual reflex
Swinging light test
Accommodation

Question 8

How do you test direct and consensual reflex?

Answer 8

Ask the patient to concentrate on a spot

Bring light in from side and look at direct reflex on ipsilateral eye and consensual reflex on contralateral eye

Question 9

How do you perform swinging light test?

Answer 9

Ask patient to concentrate on a spot
Swing light back and further between the 2 pupils (each eye for 2 seconds)
Both pupils should constrict then relax a little each time

Question 10

How do you perform accommodation test?

Answer 10

Ask patient to concentrate on a spot
Then hold an object close in front of them and focus on that
Pupils should constrict and eyes converge

Question 11

How do you test eye movements?

Answer 11

Keep head still
Move finger in 6-lined star shape
Observe for nystagmus and ophthalmoplegia
Ask patient if experienced any diplopia and where it was? - then repeat direction but with one eye covered up and ask if diplopia corrected?

Question 12

How do you perform fundoscopy?

Answer 12

Dilate pupils with tropicamide (advise patient they will have blurred vision for 1 hour)
Dim room lights
Place thumb on patient forehead and observe for RED REFLEX at one arms length away
Come close to focus on vessel and follow nasally to find the OPTIC DISC
Examine the disc for CUP, COLOUR and CONTOUR
Follow the 4 vascular arcades
Check for peripheral changes by asking the patient to look up, down, left and right
Check macula by asking patient to look directly into the light

Question 13

What is the colour of the optic disc

Answer 13

Orange-pink rim with a pale centre

Orange-pink represents healthy, well perfused neuro-retinal tissue

Question 14

What is the cup?

Answer 14

It is the pale centre of the optic disc that is devoid of neuro-retinal tissue

Question 15

What is a normal cup to disc ratio?

Answer 15

0.3 (cup occupies 1/3 of the height of the entire disc)

Question 16

What does an increased cup to disc ratio suggest? and what disease can this occur in?

Answer 16

A reduced volume of healthy neuro-retinal tissue

This can occur in glaucoma

Question 17

What pathology may a pale disc suggest?

Answer 17

Suggests the presence of optic atrophy. This can occur as a result of optic neuritis, advanced glaucoma and ischaemic vascular events

Question 18

What is contour?

Answer 18

This is the borders of the optic disc. It should be clear and well defined

Question 19

What may blurred contour suggest?

Answer 19

Presence of papilloedema (optic disc swelling) secondary to raised ICP

Question 20

Name the 4 vascular arcades

Answer 20

Superior temporal
Superior nasal
Inferior temporal
Inferior nasal

Question 21

Why might red reflex be absent in adults?

Answer 21

Due to cataracts in lens blocking light

Other causes include vitreous haemorrhage and retinal detachment

Question 22

Why might red reflex be absent in children?

Answer 22

Due to congenital cataracts, vitreous haemorrhage, retinal detachment and retinoblastoma

Question 23

What does the presence of leukocoria (white reflex) suggest?

Answer 23

Retinopathy of prematurity
Retinoblastoma
Congenital cataract
Retinal detachment
Intraocular infection 
Retinal vascular abnormality

Question 24

What causes RAPD?

Answer 24

Damage to afferent limb of optic nerve

Due to retinal damage in affected eye secondary to central retinal artery/vein occlusion and large retinal detachment

OR

Due to optic neuropathy e.g. optic neuritis, unilateral advanced glaucoma, compression secondary to tumour or abscess and ischaemic optic neuropathy

Question 25

Further assessment and investigations

Answer 25

Asmler chart - to assess central visual loss and distortion associated with macular degeneration

Cranial nerve examination

BP - if concerned about hypertensive retinopathy

Blood sugars and HbA1c - if concerned about diabetic retinopathy