Basic Clinical Skills |
Physical Exam Study Guides
Examination of the Eye
- A Snellen Eye Chart or Pocket Vision Card
- An Ophthalmoscope

In cases of eye pain, injury, or visual loss, always check visual acuity before before proceeding with the rest of the exem or putting medications in your patients eyes.
- Allow the patient to use their glasses or contact lens if available. You are interested in the patient's best corrected vision.
- Position the patient 20 feet in front of the Snellen eye chart (or hold a Rosenbaum pocket card at a 14 inch "reading" distance).
- Have the patient cover one eye at a time with a card.
- Ask the patient to read progressively smaller letters until they can go no further.
- Record the smallest line the patient read successfully (20/20, 20/30, etc.) [1]
- Repeat with the other eye.
- Unexpected/unexplained loss of acuity is a sign of serious ocular pathology.
- Observe the patient for ptosis, exophthalmos, lesions, deformities, or asymmetry.
- Ask the patient to look up and pull down both lower eyelids to inspect the conjuntiva and sclera.
- Next spread each eye open with your thumb and index finger. Ask the patient to look to each side and downward to expose the entire bulbar surface.
- Note any discoloration, redness, discharge, or lesions. Note any deformity of the iris or lesion cornea.
- If you suspect the patient has conjuntivitis, be sure to wash your hands immediately. Viral conjuntivitis is highly contagious - protect yourself!
Screen Visual Fields by Confrontation [2]
- Stand two feet in front of the patient and have them look into your eyes.
- Hold your hands to the side half way between you and the patient.
- Wiggle the fingers on one hand. [3]
- Ask the patient to indicate which side they see your fingers move.
- Repeat two or three times to test both temporal fields.
- If an abnormality is suspected, test the four quadrants of each eye while asking the patient to cover the opposite eye with a card. ++ [4]
- Shine a light from directly in front of the patient.
- The corneal reflections should be centered over the pupils.
- Asymmetry suggests extraocular muscle pathology.

- Stand or sit 3 to 6 feet in front of the patient.
- Ask the patient to follow your finger with their eyes without moving their head.
- Check gaze in the six cardinal directions using a cross or "H" pattern.
- Check convergence by moving your finger toward the bridge of the patient's nose.
- Dim the room lights as necessary.
- Ask the patient to look into the distance.
- Shine a bright light obliquely into each pupil in turn.
- Look for both the direct (same eye) and consensual (other eye) reactions.
- Record pupil size in mm and any asymmetry or irregularity.
If the pupillary reactions to light are diminished or absent, check the reaction to accommodation (near reaction): [5] ++
- Hold your finger about 10cm from the patient's nose.
- Ask them to alternate looking into the distance and at your finger.
- Observe the pupillary response in each eye.

- Darken the room as much as possible. ++
- Adjust the ophthalmoscope so that the light is no brighter than necessary. Adjust the aperture to a plain white circle. Set the diopter dial to zero unless you have determined a better setting for your eyes. [6]
- Use your left hand and left eye to examine the patient's left eye. Use your right hand and right eye to examine the patient's right eye. Place your free hand on the patient's shoulder for better control.
- Ask the patient to stare at a point on the wall or corner of the room.
- Look through the ophthalmoscope and shine the light into the patient's eye from about two feet away. You should see the retina as a "red reflex." Follow the red color to move within a few inches of the patient's eye.
- Adjust the diopter dial to bring the retina into focus. Find a blood vessel and follow it to the optic disk. Use this as a point of reference.
- Inspect outward from the optic disk in at least four quadrants and note any abnormalities. [pictures on p208]
- Move nasally from the disk to observe the macula.
- Repeat for the other eye.

This procedure is performed when a foreign body is suspected. ++
- Ask the patient to look down.
- Gently grasp the patient's upper eyelashes and pull them out and down.
- Place the shaft of an applicator or tongue blade about 1 cm from the lid margin.
- Pull the lid upward using the applicator as a fulcrum to turn the lid "inside out." Do not press down on the eye itself.
- Pin the eyelid in this position by pressing the lashes against the eyebrow while you examine the palpebral conjuntiva.
- Ask the patient to blink several times to return the lid to normal.
- Visual acuity is reported as a pair of numbers (20/20) where the first number is how far the patient is from the chart and the second number is the distance from which the "normal" eye can read a line of letters. For example, 20/40 means that at 20 feet the patient can only read letters a "normal" person can read from twice that distance.
- For more information refer to A Guide to Physical Examination and History Taking, Sixth Edition by Barbara Bates, published by Lippincott in 1995.
- You may, instead of wiggling a finger, raise one or two fingers (unialterally or bilaterally) and have the patient state how many fingers (total, both sides) they see. To test for neglect, on some trials wiggle your right and left fingers simultaneously. The patient should see movement in both hands.
- Additional Testing - Tests marked with (++) may be skipped unless an abnormality is suspected.
- PERRLA is a common abbreviation that stands for "Pupils Equal Round Reactive to Light and Accommodation." The use of this term is so routine that it is often used incorrectly. If you did not specifically check the accommodation reaction use the term PERRL. Pupils with a diminished response to light but a normal response to accommodation (Argyll-Robertson Pupils) are a sign of neurosyphilis.
- Diopters are used to measure the power of a lens. The ophthalmoscope actually has a series of small lens of different strengths on a wheel (positive diopters are labeled in green, negative in red). When you focus on the retina you "dial-in" the correct number of diopters to compensate for both the patient's and your own vision. For example, if both you and your patient wear glasses with -2 diopter correction you should expect to set the dial to -2 with your glasses on or -4 with your glasses off.
Author: Richard Rathe, MD / rrathe@dean.med.ufl.edu
Copyright: 1996-98 by the University of Florida
Location: http://www.medinfo.ufl.edu/year1/bcs/clist/eye.html
Created: December 1, 1998
Modified: December 19, 2000
Basic Clinical Skills |
Physical Exam Study Guides