1. Eyes Inspection Visual Acuity Visual Fields Pupillary Response
Fundoscopic Exam
Physical Examination: Eyes
Inspection
Visual acuity
Visual Fields
Pupillary Response
Fundoscopic Exam

2. Eye Examination Inspection
11._____ Inspects external ocular (eye) structures (lids, conjunctiva, iris, cornea, pupils)
12._____ Gently moves eyelids up and down to obtain a better view
11.Inspects external ocular (eye) structures (lids, conjunctiva, iris, cornea, pupils)
12.Gently moves eyelids up and down to obtain a better view

3. Important landmarks of the external eye

4. Inspection 11. Structures to Inspect Position and alignment of eyes
Eye: Inspection
11. Structures to Inspect
Position and alignment of eyes
Eyebrows
Eyelids
Lacrimal Apparatus
Conjunctiva and sclera
Cornea and lens
Iris
Pupils
12. Facilitate visualization
Move lower lid down ask pt to look up
Move upper lid up ask pt to look down
11. Structures to Inspect
Position and alignment of eyes
Eyebrows
Eyelids
Lacrimal Apparatus

5. Eyes
Visual Acuity
13.Checks acuity with Snellen and from proper distance
14.Checks acuity both eyes separately
13._____ Checks acuity with Snellen and from proper distance
14._____ Checks acuity both eyes separately

6. Hand held eye chart Snelling Eye Chart Snelling Eye Chart

7. 13, 14. Visual Acuity
Hold card approx 14” from pt’s nose  Ask pt to cover one eye
 Read smallest line  Cover other eye and repeat
13, 14. Visual Acuity
Hold card approx 14” from pt’s nose
Ask pt to cover one eye
Read smallest line
Cover other eye and repeat

8. Extraocular Movements
Eyes
Extraocular Movements
Extraocular Movements
15. Evaluates extraocular movement (big H)
16. Checks convergence and accommodation (follows finger from far to near)
Extraocular Movements
15. Evaluates extraocular movement (big H)
16. Checks convergence and accommodation (follows finger from far to near)

9. Extraocular Muscles and Direction of Movement
Extraocular Movements
The extraocular movements of each are controlled by the 4 rectus and 2 oblique muscles
The extraocular movements may be tested by having the patient move the eye in the direction controlled by each muscle.
This may be accomplished by having the patient move their eyes in the six cardinal direction depicted on this diagram.
The extraocular movements of each are controlled by the 4 rectus and 2 oblique muscles
The extraocular movements may be tested by having the patient move the eye in the
direction controlled by each muscle.
This may be accomplished by having the patient move their eyes in the
six cardinal direction depicted on this diagram.

10. 15. Extraocular Movements
Ask the pt to hold his/her head still and to follow your finger with their eyes
15. Extraocular Movements
Ask the pt to hold his/her head still and to follow your finger with their eyes

11. Six Cardinal Positions of Gaze
Extraocular Movements
In order to test all of the extraocular muscles ask the pt to follow your finger through the 6 cardinal direction of gaze
Right
Right and up
Right and down
Left
Left and up
Left and down
This is accomplished by moving your finger in a large H
Need our picture

12. Convergence and Accommodation
Ask pt to focus on your finger held approx 12” away from his/her nose
Move your finger towards the pt’s nose
The eyes should converge and the pupils constrict (accommodation)
Needs illustration

13. Eyes Visual Fields Visual Fields
1.        Visual fields - both eyes independently
2.        Visual fields - eight cardinal directions for each eye (N,NE, E, SE, S, SW, W NW)
3.        Visual fields - simultaneous stimulation (each eye should only be able to see on hand – the one on that side)
4.        Visual Fields – Examiners hands or object to view introduced in the plane half-way between patient and examiner

14. Ask the pt to cover one eye Cover your opposite eye
17 –20: Visual Fields
Ask the pt to cover one eye
Cover your opposite eye
Ask the pt to look straight ahead
Place one hand in the plane between the patient and the examiner out of your vision
Move the hand and ask the patient when he/she can see your hand
17 –20: Visual Fields
Ask the pt to cover one eye
Cover your opposite eye
Ask the pt to look straight ahead
Place one hand in the plane between the patient and the examiner out of your vision
Move the hand and ask the patient when he/she can see your hand
This is to be completed in all 8 cardinal directions
Repeat for the other eye

15. 19. Both eyes should be checked for stimulation simultaneously.
Place hands in the lateral field of both eyes ask the pt to note which hand is moving and at some point move both hands.
Each of the examiners hands should be visible by only one of the pt’s eyes.
If the pt can only see one hand moving when both handsare moving, this may indicate a small defect in the occipital cortex.
19. Both eyes should be checked for stimulation simultaneously.
Place hands in the lateral field of both are moving, this may indicate a small defect in the occipital cortex.
eyes ask the pt to note which hand is moving and at some point move both hands.
Each of the examiners hands should be visible by only one of the pt’s eyes.
If the pt can only see one hand moving when both hands

16. Eyes Pupillary Response
21.Pupillary response to light – direct (same eye the light is directed into)
22.Pupillary response – indirect (eye light is not directed into) (watch examiner’s eyes closely, can watch eye dilate)
23.Swinging flashlight test (start in one eye, quickly move to other eye, wait then fast back to original eye and wait)
Pupillary Response
21. Pupillary response to light – direct (same eye the light is directed into)
22. Pupillary response – indirect (eye light is not directed into) (watch examiner’s eyes closely, can watch eye dilate)
23. Swinging flashlight test (start in one eye, quickly move to other eye, wait then fast back to original eye and wait)
Pupillary Response

17. 21, 22. Pupillary Light Response
Observe reflection of pen light in both pupils. Is it symmetrical?
Test the papillary response to light
Direct response – pupil constricts in examined eye
Consensual (Indirect) response – pupil constricts in the opposite eye
21, 22. Pupillary Light Response
Observe reflection of pen light in both pupils. Is it symmetrical?
Test the papillary response to light
Direct response – pupil constricts in examined eye
Consensual (Indirect) response – pupil constricts in the opposite eye

18. Swinging Flashlight Test
Detects optic nerve disease vs occular disease
A bright light is placed in front of one eye and moved quickly to the other eye, then one or two seconds later moved quickly back to the first eye.
The pupils should remain constricted when the light is taken from one eye quickly to the other
Note in the example shown on the right, the patient’s L pupil dilates when the light is shown into it after the light has been “swung” from the R eye.
This indicates damage to the optic nerve on the L. The sensory (afferent) stimulus sent to the midbrain is reduced. The affected pupil responds less vigorously to the light dilates from its prior constricted state (from the efferent output from the consensual reaction). This finding is know as a Marcus Gunn pupil and is an afferent defect.
Detects optic nerve disease vs occular disease
A bright light is placed in front of one eye and moved quickly to the other eye, then one or two seconds later moved quickly back to the first eye.
The pupils should remain constricted when the light is taken from one eye quickly to the other

19. Fundoscopic Exam of the EYE
Optic disc
Disc outline
Color
Physiologic cup
Fundoscopic Exam
Optic disc
Disc outline
Color
Physiologic cup
Retina
Vessels
4 quadrants
Fovea and macula
Anterior structures
Retina
Vessels
4 quadrants
Fovea and macula
Anterior structures

20. Eye Fundoscopic Exam 24. Lights are dimmed
25. Holds and positions ophthalmoscope properly and uses index finger to switch lens
26. Examiner uses R hand R eye to look in R eye
27. Inspects anterior structure with ophthalmoscope - R eye(Start to see anterior structures and move toward 0)
28. Inspects optic nerve - R eye (comes in at 15 with lens at 0 or moving from the positive toward 0)
29. Traces vessels to all four quadrants - R eye
30. Observes macula - R eye (Credit to be given if #28 and look laterally)
31. Examiner uses L hand L eye to look in L eye
32. Inspects anterior structure with ophthalmoscope - L eye (Start at to see anterior structures and move toward 0)
33. Inspects optic nerve - L eye (Comes in at 15 with lens at 0 or moving from the positive towards 0
34. Traces vessels to all four quadrants - L eye
35. Observes macula - L eye (credit to be given if #33 and look laterally)
Fundoscopic Exam
24. Lights are dimmed
25. Holds and positions ophthalmoscope properly and uses index finger to switch lens
26. Examiner uses R hand R eye to look in R eye
27. Inspects anterior structure with ophthalmoscope - R eye(Start to see anterior structures and move toward 0)
28. Inspects optic nerve - R eye (comes in at 15 with lens at 0 or moving from the positive toward 0)
29. Traces vessels to all four quadrants - R eye
30. Observes macula - R eye (Credit to be given if #28 and look laterally)
31. Examiner uses L hand L eye to look in L eye
32. Inspects anterior structure with ophthalmoscope - L eye (Start at to see anterior structures and move toward 0)
33. Inspects optic nerve - L eye (Comes in at 15 with lens at 0 or moving from the positive towards 0
34. Traces vessels to all four quadrants - L eye
35. Observes macula - L eye (credit to be given if #33 and look laterally)

21. Internal Anatomy of the Eye
During the Fundoscopic Exam the ophthalmoscope may be used to visualize the following strutures of the eye:
•Optic disc
•Disc outline
•Color
•Physiologic cup
•Retina
•Vessels
•4 quadrants
•Fovea and macula
•Anterior structures
During the Fundoscopic Exam the ophthalmoscope may be used to visualize the following strutures of the eye:
•Optic disc
•Disc outline
•Color
•Physiologic cup
•Retina
•Vessels
•4 quadrants
•Fovea and macula
•Anterior structures

22. Need our picture or permission from Welsh Allen
Ophthalmoscope
Lenses (magnification power of lens = diopters)
Controlled by diopter dial
Black or green numbers - positive numbers - counterclockwise – plus lenses
Red numbers – negative numbers –clockwise- minus lenses
Light source
Brightness controlled by rheostat
Various apertures
Large – usually use this one
Small - small pupils
Red free filter - green beam, optic disc pallor and minute vessels changes
Slit - Anterior eye, elevation of lesions
Grid - size of fundal lesions
Ophthalmoscope
Lenses (magnification power of lens = diopters)
Controlled by diopter dial
Black or green numbers - positive numbers - counterclockwise – plus lenses
Red numbers – negative numbers –clockwise- minus lenses
Light source
Brightness controlled by rheostat
Various apertures
Large – usually use this one
Small - small pupils
Red free filter - green beam, optic disc pallor and minute vessels changes
Slit - Anterior eye, elevation of lesions
Grid - size of fundal lesions
Need our picture or permission from Welsh Allen

23. Need our picture or permission from Welsh Allen
Holding the Opthalmoscope
Use the index finger to change lenses (diopters)
Holding the Opthalmoscope
Use the index finger to change lenses (diopters)
Need our picture or permission from Welsh Allen

24. 24-35. Fundoscopic Examination Darken the room
Place the opthalmoscope to 0 diopters and the large round beam
Keep index finger on lens disc
Use R hand for pt’s R eye and L hand for pt’s L eye
Ask pt to fix gaze on a spot on the wall
From about 15” away and about 15o lateral look into pt’s eye
Observe the red reflex and then move in closer
You may rest your opposite hand on the pt’s forehead above the eye to help guide
Move the opthalmoscope very close to the pt’s eye
If you initially see blood vessels, you can follow the blood vessels toward the disc.
They flow like rivers toward the disc.
Diopters may need to be adjusted to obtain a good focus
Fundoscopic Examination
Darken the room
Place the opthalmoscope to 0 diopters and the large round beam
Keep index finger on lens disc
Use R hand for pt’s R eye and L hand for pt’s L eye
Ask pt to fix gaze on a spot on the wall
From about 15” away and about 15o lateral look into pt’s eye
Observe the red reflex and then move in closer
You may rest your opposite hand on the pt’s forehead above the eye to help guide
Move the opthalmoscope very close to the pt’s eye
If you initially see blood vessels, you can follow the blood vessels toward the disc.
They flow like rivers toward the disc.
Diopters may need to be adjusted to obtain a good focus

25. Once you see the disc, you should note its color and note what percent of the physiologic cup involves the disc.
The cup-to-disc ratio should be less than 0.6.
You should note the size of the arterioles as compared to the veins. They should be 2/3 to 4/5 the size of veins.
Next look in all 4 quadrants of the retina
Finally, look at the fovea and macula. This may be accomplished by asking the pt to look at the light
Once you see the disc, you should note its color and note what percent of the physiologic cup involves the disc.
The cup-to-disc ratio should be less than 0.6.
You should note the size of the arterioles as compared to the veins. They should be 2/3 to 4/5 the size of veins.
Next look in all 4 quadrants of the retina
Finally, look at the fovea and macula. This may be accomplished by asking the pt to look at the light
/ this site shows a movie of the retinal exam
Need illustration

26. Inspecting the Anterior Structures
Rotate the lens progressivly towards the positive diopters to around +10 to +12 visualize the anterior aspects of the eye
Inspecting the Anterior Structures
Rotate the lens progressivly towards the positive diopters to around +10 to +12 visualize the anterior aspects of the eye

27. Panoptic Ophthalmoscope
Focus the scope on an object about 10 to 15 feet away
Put the aperture on the “home position” (green line)
Start about 6 inches away at a 15o angle
Visualize the fundus and move in until the cup is compressed against the pt’s face
Panoptic Ophthalmoscope
Focus the scope on an object about 10 to 15 feet away
Put the aperture on the “home position” (green line)
Start about 6 inches away at a 15o angle
Visualize the fundus and move in until the cup is compressed against the pt’s face
--Used with permission of Welch Allyn