Lecture. 1

Ophthalmology
Ophthalmic Examination
Dr. Mohamed Abdullahi

Equipment
• The basic equipment for the ophthalmic examination
includes the following instruments:
Direct ophthalmoscope for examining the fundus (Fig. 1.1).
Focused light (Fig. 1.1) for examining the reaction of the
pupil and the anterior chamber.
Aspheric lens (Fig. 1.1) for examining the anterior chamber.
Eye chart for testing visual acuity at a distance of 5 meters
Binocular loupes for removing corneal and conjunctival foreign
bodies.
Desmarres eyelid retractor and glass rod or sterile cotton swab for
eyelid eversion (Fig. 1.3).
Foreign-body needle for removing superficial corneal foreign bodies

(Fig. 1.3).
Fig. 1.2 From left to right: Snellen letter chart,
Arabic number chart, E game, Landolt broken
rings, children’spictograph.
Recommended medications:
Topical anesthetic (such as oxybuprocaine 0.4% eyedrops) to provide
local anesthesia during removal of conjunctival and corneal foreign
bodies and superficial anesthesia prior to flushing the conjunctival sac
in chemical injuries.
Sterile buffer solution for primary treatment of chemical injuries.
Antibiotic eyedrops for first aid treatment of injuries, sterile eye
compresses, and a 1 cm adhesive bandage for protective bandaging
Fig. 1.3 From left to right: Foreign
body needle, glass spatula, and
Desmarres
eyelid retractor.
History
• A complete history includes four aspects:
1. Family history. Many eye disorders are hereditary or of higher
incidence in members of the same family.
Examples include
Refractive errors
Strabismus
Cataract
Glaucoma
Retinal detachment
Retinal dystrophy.
2. Medical history. As ocular changes may be related to
systemic disorders, this possibility must be explored.
Conditions affecting the eyes include
diabetes mellitus
Hypertension
infectious diseases,
rheumatic disorders
skin diseases, and
surgery.
• Eye disorders such as
corticosteroid-induced glaucoma,
corticosteroid-induced cataract, and
chloroquine-induced maculopathy can occur as a result of treatment
with medications such as steroids, chloroquine, Amiodarone,
Myambutol, or chlorpromazine
3. Ophthalmic history. The examiner should inquire about
corrective lenses, strabismus or amblyopia, posttraumatic
conditions, and surgery or eye inflammation.
4. Current history. What symptoms does the patient present
with? Does the patient have impaired vision, pain, redness of
the eye, or double vision? When did these symptoms occur?
Are injuries or associated generalized symptoms present?
Visual Acuity
• Visual acuity, the sharpness of near and distance vision, is tested separately for
each eye.
• One eye is covered with a piece of paper or the palm of the hand placed lightly
over the eye. The fingers should not be used to cover the eye because the
patient will be able to see between them (Fig. 1.4). The general practitioner or
student can perform an approximate test of visual acuity.
• The patient is first asked to identify certain visual symbols referred to as
optotypes (see Fig. 1.2) at a distance of 5 meters (test of distance vision). These
visual symbols are designed so that optotypes of a certain size can barely be
resolved by the normal eye at a specified distance (this standard distance is
specified in meters next to the respective symbol). The eye charts must be clean
and well illuminated for the examination. The sharpness of vision measured is
expressed as a fraction actual distance/standard distance = visual acuity.
• Normal visual acuity is 5/5 (20/20).
• An example of diminished visual acuity (see Fig. 1.2):
• The patient sees only the “4” and none of the smaller symbols on the
left eye chart at a distance of 5 meters (20 feet)(actual distance).
• A normal-sighted person would be able to discern the “4” at a
distance of 50 meters or 200 feet (standard distance). Accordingly, the
patient has a visual acuity of 5/50 (20/200).
Ocular Motility
• With the patient’s head immobilized, the examiner asks the patient to
look in each of the nine diagnostic positions of gaze: 1, straight ahead;
2, right; 3, upper right; 4, up; 5, upper left; 6, left; 7, lower left; 8,
down; and 9, lower right (Fig. 1.5).
• This allows the examiner to diagnose strabismus, paralysis of ocular
muscles, and gaze paresis.
• Evaluating the six cardinal directions of gaze (right, left, upper right,
lower right, upper left, lower left) is sufficient when examining
paralysis of the one of the six extraocular muscles.
• The motion impairment of the eye resulting from paralysis of an
ocular muscle will be most evident in these positions.
• Only one of the rectus muscles is involved in each of the left and right
positions of gaze (lateral or medial rectus muscle).
• All other directions of gaze involve several muscles.
Binocular Alignment
• Binocular alignment is evaluated with a cover test.
• The examiner holds a point light source beneath his or her own eyes and
observes the light reflections in the patient’s corneas in the near field (40 cm)
and at a distance (5 m).
• The reflections are normally in the center of each pupil. If the corneal reflection
is not in the center of the pupil in one eye, then a tropia is present in that eye.
• Then the examiner covers one eye with a hand or an occluder (Fig. 1.6) and
tests whether the uncovered eye makes a compensatory movement.
• Compensatory movement of the eye indicates the presence of tropia. However,
there will also be a lack of compensatory movement if the eye is blind. The
cover test is then repeated with the other eye.
• If tropia is present in a newborn with extremely poor vision, the baby will not
tolerate the good eye being covered.
Examination of the Eyelids and
Nasolacrimal Duct
• The upper eyelid covers the superior margin of the cornea.
• A few millimeters of the sclera will be visible above the lower eyelid.
• The eyelids are in direct contact with the eyeball.
• Stenosis of the nasolacrimal duct produces a pool of tears in the medial
angle of the eye with lacrimation (epiphora).
• In inflammation of the lacrimal sac, pressure on the nasolacrimal sac
frequently causes a reflux of mucus or pus from the inferior punctum.
• Patency of the nasolacrimal duct is tested by instilling a 10% fluorescein
solution in the conjunctival sac of the eye. If the dye is present in nasal
mucus expelled into paper tissue after two minutes, the lacrimal duct is
open.
Examination of the Conjunctiva
• The conjunctiva is examined by direct inspection. The bulbar

conjunctiva is directly visible between the eyelids; the palpebral
conjunctiva can only be examined by everting the upper or lower
eyelid.
• The normal conjunctiva is smooth, shiny, and moist. The examiner
should be alert to any reddening, secretion, thickening, scars, or
foreign bodies.
• Eversion of the lower eyelid. The patient looks up while the examiner
pulls the eyelid downward close to the anterior margin (Fig. 1.7).
• This exposes the conjunctiva and the posterior surface of the lower
eyelid.
• Eversion of the upper eyelid. Simple eversion (Fig. 1.8). The patient is
asked to look down. The patient should repeatedly be told to relax
and to avoid tightly shutting the opposite eye. This relaxes the levator
palpebrae superioris and orbicularis oculi muscles.
• The examiner grasps the eyelashes of the upper eyelid between the
thumb and forefinger and everts the eyelid against a glass rod or swab
used as a fulcrum.
• Eversion should be performed with a quick levering motion while
applying slight traction. The palpebral conjunctiva can then be
inspected and cleaned if necessary.
• Full eversion with retractor. To expose the superior fornix, the upper
eyelid is fully everted around a Desmarres eyelid retractor.
• This method is used solely by the ophthalmologist and is only
discussed here for the sake of completeness.
• This eversion technique is required to remove foreign bodies or “lost”
contact lenses from the superior fornix or to clean the conjunctiva of
lime particles in a chemical injury with lime.
• Blepharospasm can render simple and full eversion very
difficult especially in the presence of chemical injury.
• In these cases, the spasm should first be eliminated by
instilling a topical anesthetic such as oxybuprocaine
hydrochloride eye drops.
Measurement of Intraocular
Pressure
• With the patient’s eyes closed, the examiner places his or her hands
on the patient’s head and palpates the eye through the upper eyelid
with both index fingers (Fig. 1.15).
• The test is repeated on the contralateral eye for comparison.
• A “rock hard” eyeball only occurs in acute angle closure glaucoma.
• Slight increases in intraocular pressure such as occur in chronic
glaucoma will not be palpable.
Eyedrops, Ointment, and Bandages
• Eyedrops and ointment should be administered posterior to the
everted lower eyelid.
• One drop or strip of ointment approximately 1cm long should be
administered laterally to the inferior conjunctival sac. To avoid injury
to the eye, drops should be administered with the patient supine or
seated with the head tilted back and supported.
• Bottles and tubes must not come in contact with the patient’s
eyelashes as they might otherwise become contaminated. Allow the
drops or strip of ointment to drop into the conjunctival sac.
THANKS

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Ophthalmology

Dr. Mohamed Abdullahi

Foreign-body needle for removing superficial corneal foreign bodies

• The conjunctiva is examined by direct inspection. The bulbar

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