3. EXTERNAL EXAMINATION:
⢠Look for any ptosis.
⢠Look for lagophthalmos
⢠Note any unusual growths or lesions that may require a biopsy.
⢠Measure proptosis or enophthalmos with an exophthalmometer.
⢠Perform a full cranial nerve exam for patients with diplopia or other
neurologic symptoms.
4. VISUAL ACUITY
(VA)
⢠Monocularly
⢠Un-aided VA
⢠VA with glasses
⢠BCVA (Best Corrected VA)
⢠Binocularly VA
⢠Pinhole VA (if BCVA is worse)
If patient is unable to see the biggest
optotype, the progression is:
⢠CF (Counting Fingers)
⢠HM (Hand Movement)
⢠Perception of Light (PL) with projection
⢠PL without projection
⢠No Light Perception (NPL)
VA is measured first for the
distance then for near. Most
commonly carried out using
a Snellen chart, with the
subject reading the chart
from the standard distance.
Steps for evaluating VA:
5. ⢠Children who are too young to
use âAllen picturesâ employ the
Central Steady Maintain (CSM)
approach.
Near VA:
⢠Near VA is a sensitive indicator
for the macular disease.
⢠Near chart held at comfortable
reading distance.
⢠Patient wear necessary distance
correction together with a
presbyopia correction.
TOOLS:
⢠Snellen chart
⢠Log MAR chart
⢠ETDRS chart
⢠Computer chart
⢠Jaeger chart
6. COLOR VISION TESTING:
⢠It is useful in the evaluation of optic nerve disease and
in determining the presence of a congenitally
anomalous color defect.
⢠Color vision depends on 3-populations of retinal cones
with specific peak sensitivity:
ďąBlue (tritan): 414-424nm
ďąGreen (deuteron): 522-539
ďąRed (protan): 549-570nm
⢠If any cone pigment may be deficient (e.g.;
protanomaly-red weakness) or entirely absent
(protanopia- red blindness)
⢠Acquired macular disease tends to produce blue-yellow
defects, and optic nerve lesions red-green defects.
TOOLS:
⢠Ishihara test
⢠City University test
⢠Hardy-Rand-Rittler test
⢠Farnsworth-Munsell
100-hue test
7. PUPILLARY EXAM:
⢠Look for anisocoria, if present check for the pupil size
⢠Check the reactivity of each pupil with a pen light or Finoff trans-illuminator.
⢠Use the swinging flash light test to look for a relative afferent pupillary
defect.
8. EXTRAOCULAR MOTILITY AND
ALIGNMENT:
⢠Test with both eyes open to test versions in six cardinal positions of gaze.
⢠Repeat monocularly to test ductions.
⢠Use cover/uncover tests to assess for heterotropias.
⢠Use the alternate cover test to assess the total amount of deviation.
9. BINOCULAR VISION TESTING:
⢠Evaluating the sensory status of children is an essential part of the
pediatric eye examination
⢠Testing stereo acuity is an excellent way of screening for various
conditions that may interfere with the development of binocular
depth perception.
There are two different types of stereo tests:
⢠Contour stereopsis tests like Titmus test
⢠Random dot tests like Randot or Lang tests.
10. AMSLER GRID:
⢠Evaluates 20ď° of the visual field
centered on fixation.
⢠Useful for screening and
monitoring macular disease. It
measures between 5 and 6 mm
in diameter.
⢠Patients with risk of
CNV(Choroidal
Neovascularization) should
provided with an Amsler grid
for regular use at home.
⢠Relative scotoma
⢠Absolute scotoma
⢠Metamorphopsia
⢠Micropsia
⢠Macropsia
11. SLIT-LAMP BI-MICROSCOPY:
Anterior Segment:
⢠Direct illumination: use to detect
gross abnormalities
⢠Scleral scatter: to detect stomal
haze, cellular or lipid infiltration.
⢠Retro-illumination: use after pupil
dilation to detect fine epithelial and
endothelial changes.
⢠Specular reflection: shows
abnormalities of the endothelium
Posterior Segment:
Different dioptric power lenses are
used to view fundus and optic nerve.
ďą60D
ďą90D
ďą78D
12. INDIRECT OPHTHALMOSCOPE:
⢠Used to refer to the head mounted technique.
⢠It allows retinal visualization through a greater degree of media
opacity than slit lamp bi-microscopy.
⢠Lens of various powers are available:
ďą20D
ďą28D
ďą40D
13. TONOMETRY:
Goldmann Tonometry:
⢠It states that for an ideal, dry, thin-walled sphere, the pressure inside the
sphere (P) equals the force necessary to flatten its surface (F) divided by the
area of flattening (A) i.e. P=F/A
⢠It is an accurate variable-force tonometer consisting of a double prism.
Other forms of Tonometry:
⢠Pneumo-tonometry
⢠Portable applanation tonometry
⢠Dynamic contour tonometry
⢠Electronic indentation/applanation tonometry
14. GONIOSCOPY:
⢠It is a method of evaluating the anterior chamber angle (ACA) and
can be used therapeutically for procedures such as laser
trabeculoplasty and goniotomy.
Other means of angle assessment:
⢠Anterior Segment Optical Coherence Tomography (AS-OCT)
⢠High frequency ultrasound biomicroscopy (UBM)
15. CENTRAL CORNEAL THICKNESS
(CCT):
⢠It can be measured using pachymetry or by Orbscan,
⢠The normal distribution is 540 ¹ 30 microns.
⢠Eyes with a thin cornea have a true IOP that is greater than the
measured IOP.
⢠Eyes with a thick cornea have a true IOP that is lower than the
measured IOP.
⢠Patients with NTG tends to have thin CCT measurement.
⢠It is a vital element when determining the risk of conversion to
glaucoma in individuals with raised IOP.