Eye Exam

POM – March 18, 2020

Charlie Goldberg, M.D.

Professor of Medicine, UCSD SOM
cggoldberg@health.ucsd.edu
Eye ROS
• Any known eye disorders?
• Change in vision or blurriness?
• Eye discharge?
• Eye redness?
• Eye pain?
• Double vision?
• Change in appearance of eye/surrounding structures?
Eye Exam
FunctionalAnatomy

Posterior
Anterior Chamber
Chamber

Image courtesy Dr. Karl

Bodendorfer, Univ of Florida
More Detailed Internal Anatomy
Functional Assessment – Acuity (Cranial
Nerve 2 – Optic) –Vital Sign of the Eye

• Using hand held card (held @ 14

inches) or Snellen wall chart,
assess each eye separately.
• Allow patient to wear glasses.
• Direct patient to read aloud line
w/smallest lettering that they’re
able to see. Hand Held Acuity Card
Functional Assessment – Acuity (cont)

• 20/20 =s patient can read at

20` w/same accuracy as
person with normal vision.
• 20/400 =s patient can read @
20` what normal person can
read from 400` (i.e. very poor
acuity).
• If patient can’t identify all
items correctly, number
missed is listed after a ‘-’ sign
(e.g. 20/80 -2, for 2 missed on
20/80 line). Snellen Chart For Acuity Testing
Functional Assessment - Visual Fields (Cranial
Nerve 2 - Optic)

Lesion #1 Lesion #3
Images Courtesy of Wash Univ.
School of Medicine, Dept
Neuroscience
http://thalamus.wustl.edu/course
/basvis.html
NEJM Interactive case – w/demo of visual
field losses:
http://www.nejm.org/doi/full/10.1056/NEJ
Mimc1306176?query=featured_home
CN 2 - Checking Visual Fields By
Confrontation
• Face patient, roughly 1-2 ft apart,
noses @ same level.
• Close your R eye, while patient
closes their L. Keep other eye
open & look directly @ one
another.
• Move your L arm out & away,
keeping it ~ equidistant from the 2
of you.
• A raised index finger should be
just outside your field of vision.
CN 2 - Checking Visual Fields By
Confrontation (cont)
• Wiggle finger & bring it in towards your
noses. You should both be able to
detect it @ same time.
• Repeat, moving finger in from each of
the 4 quadrants
• Use other hand to check medial field
(i.e. starting in front of the closed eye).
• Then repeat for other eye.
 CNs 3, 4 & 6
Extra Ocular Movements

• Eye movement dependent on Cranial

Nerves 3, 4, and 6 & muscles they
innervate.
• Allows smooth, coordinated movement
in all directions of both eyes
simultaneously
• There’s some overlap between actions
of muscles/nerves

Image Courtesty of Leo D Bores,

M.D. Occular Anatomy: http://www.e-
sunbear.com/anatomy_01.html
Cranial Nerves (CNs) 3, 4 & 6
Extra Ocular Movements (cont)

• CN 6 (Abducens)
• Lateral rectus muscle → moves eye laterally
• CN 4 (Trochlear)
• Superior oblique muscle → moves eye down (depression)
when looking towards nose; also rotates internally.
• CN 3 (Oculomotor)
• All other muscles of eye movement – also raises eye lid &
mediates pupilary constriction.
 CNs & Muscles That Control Extra
Occular Movements
LR- Lateral Rectus
MR-Medial Rectus
SR-Superior Rectus
IR-Inferior Rectus
SO-Superior Oblique
SR IO SR
IO-Inferior Oblique
MR CN 6-LR
CN 6-LR

IR
IR CN 4-SO

6 “Cardinal” Directions
Movement
SO ‘4’, LR ‘6’, All The Rest ‘3’
Technique For Testing Extra-Ocular
Movements

• To Test:
• Patient keeps head immobile, following your finger w/their eyes as you trace
letter “H”
• Eyes should move in all directions, in coordinated, smooth, symmetric
fashion.
• Hold the eyes in lateral gaze for a second to look for nystagmus
 National MS Society Video
Examples of Impaired Extra Ocular Movement https://www.youtube.com/watch?v=0cGJiqBn2DM

L CN 6 Palsy – L eye cannot Trapped L Inferior Rectus

move laterally Muscle – L eye cannot look
downward

• Binocular Diplopia: Resolves when close one eye (more serious)

– Misaligned eyes from impaired extra-ocular movement →causes patient to see two images (i.e.
double vision) when look in direction that’s affected – Secondary to: CN, Muscle or NMJ disorder
• Monocular: Double vision even with one eye closed (usually local eye process)
Impaired Movement With CN Palsys

BMJ 2015; 351: h5385

https://doi.org/10.1136/bmj.h5385
Observation External Structures
• Pupil, iris and eyelids & lashes should appear symmetric
• Sclera should be white
• Conjunctiva clear
Examples of Asymmetry, Scleral & Conjunctival
Abnormalities

Yellow Sclera
Asymmetric Lids and Pupils

Subconjunctival
Conjunctivitis Hemorrhage
Pupillary Response
• Pupils modulate light entering eye (like shutter on camera)
• Dark → dilate; Bright → constrict
• Light impulses travel away (afferents) from pupil
via CN 2 & back (efferents) to cilliary muscles
controlling dilatation & constriction
• Parasympathetics along CN3 (constrict)
• Sympathetics (dilate)
• Pupils respond symmetrically to light in either eye
• Direct =s constriction in response to direct light
• Consensual =s constriction in response to light shined in opposite eye
What’s Abnormal Here?

Endophthalmitis: Infection within the eye. Acute pain, redness and loss of vision.
Profound chemosis (redness and edema of the conjunctiva).
Easily visible hypoyon, a white layer of inflammatory cells in the anterior chamber (in front of the iris).
Describing Pupillary Response

• Normal recorded as: PERRLA (Pupils Equal, Round,

Reactive to Light and Accomodation)
• accommodation = constriction occurring when eyes follow
finger towards nose (looking “cross eyed”).
Abnormal Appearing Pupils
• Asymmetric pupils (anisocoria) secondary to:
• Parasympathetic nervous system dysfunction → e.g. tumor
compressing CN3 → pupil dilated (also ptosis, eye down/out)
• Sympathetic nervous system dysfunction (e.g. Horner’s
Syndrome) → pupil smaller at baseline (also ptosis)
• Prior surgery, trauma to pupils, other
• Systemic Meds affect both pupils
• sympathomimetics (cocaine)→ dilate
• narcotics (heroin)→ constrict
• Local meds (e.g. eye drops) can affect just one pupil
Which Eye Has Abnormal Pupil, Lid and Eye
Position?

Right Eye Left Eye

Right CN3 Palsy: Right eye deviated laterally, has ptosis,

and the pupil is more dilated than the left eye (loss of parasympathetic input).
Which Eye Has Abnormal Pupil and Lid
Position?

Right Sided Horner’s Syndrome: Disruption of sympathetic chain (in this case
due to right apical lung tumor)→ ptosis, miosis (and anhidrosis).
Note right pupil smaller than left
and right eyelid covers more of eye compared with left
Pupillary Response Testing
Technique
• Make sure room is dark → pupils dilated – but not so
dark that can’t observe response
• Shine light in R eye:
• R pupil → constricts
• Again shine light in R eye, but this time watch L pupil
(should also constrict)
• Shine light in L eye:
• L pupil → constricts
• Again shine light in L eye, but this time watch R pupil
(should also constrict)
Pupillary Response Testing: Relative
Afferent Pupillary Defect (RAPD)
• Swinging Flashlight Test
• Looks for afferent pupil defect (CN
II)
• Baseline appear normal
• Move flashlight between left &
right eye at steady rate
• With right afferent defect, pupil
appears to dilate when swing light
repeatedly from left (normal
afferents) → right (abnormal
afferents)
• RAPD indicates process affecting
Optic nerve (e.g. optic neuritis,
stroke, Temporal arteritis)
Demonstration of Swinging Flashlight Test:
http://www.neuroexam.com/neuroexam/content.php?p=19
Corneal Reflex
Sensory CN 5, Motor CN 7
• Pull out wisp of cotton.
• W/patient looking straight ahead, gently brush wisp against the
cornea (area in front of the pupil)
• Should cause the patient to blink.
• You don’t have to do this on one another.
 Making The Most of Ophthalmoscopy

• Why bother?
• Exam reveals evidence disease localized to eye
• Retinal exam gives insight into systemic vascular Dz, CNS Dz
• Difficult skill – particularly in non-dilated eye – Expect to be
frustrated!
• Take time, have patient @ comfortable height, lights low (so
pupils dilate).
• Closer you get, the more you’ll see (like looking through a key
hole)
Using Your Opthalmoscope
Standard Panoptic
Pros: widespread, less $s Pros: easy to use, magnified view
Cons: harder to see things Cons: $s, less widely available

Focus
Wheel

Aperture
Dial

Power Dial

When using either scope, make sure your

battery is charged!
Dr. Campbell Purchased his Oto-Ophthalmoscope 52
Years Ago In Med School - And Still uses It!

Qu ick Ti me™ a nd a
deco mpresso r
Qu ick Ti me ™ an d a are nee ded to see thi s p ic tu re.
deco mpre ssor
are nee ded to s ee th is p icture.
 Using Your Ophthalmoscope – Standard Scope
Medium circle light, medium intensity
Instruct patient to look towards a distant point (avoid roving)
R eye → R eye
Place hand on shoulder or forehead
Grasp handle near top
Start 15 degrees temporal
Move in slowly – click focus wheel until a retinal structure comes
into sharp focus - then eval each quadrant of retina
systematically
Usually start with “green” lens number 0. And rotate counter
clockwise to the red numbers in order to bring things into
focus

Patient usually remove their glasses (contacts ok) to cut down on reflections –
Most examiners find it more comfortable to remove glasses as well
Using Your Ophthalmoscope – Panoptic

Focus sharply on a sign or object 20` away

Set aperture dial to green line
Turn on to max power
Grasp handle near top
Place scope (cushioned side towards patient)
against patients orbit
Look for red reflex – then follow this in to the
retina
With cushion compressed against patient, retina
should be in view
If you lose the pupil, pull back, find the red reflex
and repeat
Using Your Ophthalmoscope – What You
Should See
• Magnified view of surface structures (pupil, iris, sclera, contact
lenses)– using ophthalmoscope like a magnifying glass
• To view retina, must see thru intervening structures –
if no obstruction→ red reflex when look from a distance @
pupil.
Red Reflex
Viewing The Retina
• @ any time, only 15% of retina visible
• Follow vessels (branches of tree→ trunk)→ optic disc
• Be systematic:
• Optic disc
• Vessels (veins & arteries)
• Retina (in quadrants)
• Macula→ ask the patient to look @ your light
 The Retina (fully viewed)
Temporal Optic Disc Optic Cup Nasal
Structures To Note:
1. Color of retina
(orange-ish)
2. Arteries (smaller)
3. Veins (darker)
4. Optic Disc (head of
CN2)
5. Optic Cup (center of
disc)
6. Macula (sharpest
focus) – center =‘s
fovea

Macula Artery Vein

Fovea
You’ll Only Get a Partial View Of the Retina – So,
follow the “braches” towards the “trunk”.. They’ll
point the way to the optic disc..
… heading nose-ward to
reach the optic disc…
… still heading
nose-ward…
.. ‘Til you finally reach
the optic disc - Horray!
Pathology: Intrinsic Retinal Disease

Normal Retina Macular Degeneration

http://eyepathologist.com

Retinal Detachment Retinal Artery Infarct

http://www.kellogg.umich.edu/theeyeshaveit/index.html
 Retinal Pathology – In-Sight Into Disease Elsewhere

Normal Retina
A-V Nicking Arteriolar Copper-Wiring
Chronic Systemic Hypertension
http://www.kellogg.umich.edu/theeyeshaveit/index.html

Diabetic Retinopathy – Marker of Systemic

Microvascular Disease Papilledema – Increased Intracranial Pressure
http://www.diabetesandrelatedhealthissues.com/ http://www.familyoptometry.com
Additional Eye Exam Learning Resource
• New England Journal of Medicine video and text that reviews the
basics of ophthalmoscopy.
• http://www.nejm.org/doi/full/10.1056/NEJMvcm1308125
Summary of Skills
□ Wash hands
□ Visual acuity (hand held card)
□ Visual fields (confrontation)
□ Extra ocular movements
□ Examine external eye structures (lid, sclera, pupil, iris,
conjunctiva)
□ Pupillary response to light – direct and consensual
□ Corneal reflex
□ Red reflex
□ Retinal exam
Time Target: < 10 minutes