1 Ophthalmology: History Taking and Physical examination of the Eye |Dr.

Dumapig

o CHIEF COMPLAINT
OPHTHALMOLOGIC • Reason why the patient came in
• Taken from the patient him/herself or
HISTORY & PHYSICAL from relatives/guardians
EXAMINATION
o HISTORY OF PRESENT ILLNESS
Moses Job Dumapig, MD • Get more details from the chief
complaint
• Use open-ended questions
Outline: • Establish good flow of information
• Ophthalmologic History Taking
• Quantify and Qualify (QQ)
• 8-Part Eye Exam • 8 Elements of HPI
✓ Location
✓ Quality
✓ Severity
✓ Duration
HISTORY TAKING ✓ Timing
▪ INTRODUCTION ✓ Context
✓ Modifying factors
“HIS STORY” ✓ Associated signs and symptoms
• Many eye diseases are “silent” while serious • NOTES:
ocular damage is occurring • Location – left or right eye, front or back of
the eye
• Obtaining a thorough history and performing
• Quality – burning pain, heaviness, stabbing
basic eye exam can reveal such conditions
pain
• Severity – glaucoma may be accompanied
o SIGN
by nausea and vomiting
• Objective
• Duration – how long has the problem been
• What you see
occurring
• Timing – when the patient perceives the
o SYMPTOM
problem; every morning, every other day,
• Subjective
etc.
• What the patient relays
• Context – conditions in which the problems
arise
• How to begin:
• Welcome the patient
• Description of symptoms
• Introduce yourself
• Onset-gradual, rapid or asymptomatic
• Ensure comfort and privacy
• Duration-acute, chronic
• Frequency- continuous,
▪ OCULAR HISTORY
constant, intermittent,
• Present Complaint
or episodic
• History of Present Illness
• Degree-mild, moderate,
• Review of Systems
severe
• Past Medical History
• Location-focal, diffuse, unilateral
• Medications
or bilateral
• Allergies
• Family History • Progression-worsening of symptoms
• Social History
2 Ophthalmology: History Taking and Physical examination of the Eye |Dr. Dumapig

• Eye Symptoms o PAST MEDICAL HISTORY

o Abnormalities of Vision • Past Ocular History
o Abnormalities of Ocular Appearance - Ocular trauma, itchiness, spectacle
o Abnormalities of Sensation prescription & use
- Previous vision status
• Past Systemic Medical History
Abnormalities of VISION • Past Surgical History
- Indicate which eye, what kind of
• Visual loss surgery, when the surgery happened,
• Visual Aberration the institution, name of the doctor, if
• Flashing/Flickering Lights possible
• Floaters
• Oscillation o FAMILY HISTORY
• Diplopia • Systemic disease
Abnormalities of APPEARANCE - Diabetes
- Hypertension
• Red eye - Cancer & neoplasms
• Color abnormalities other than redness • Ophthalmologic disorders
• Ptosis - Glaucoma
• Focal growth or mass - Myopia
• Ocular Deviation or misalignment - Retinitis pigmentosa
• Abnormality in size - Colorblindness
- Nyctalopia
- Retinoblastoma
- ARMD
- Strabismus

o SOCIAL HISTORY
• Tobacco consumption
- usually leads to dry eyes and early
cataract formation
• Alcohol use
• Recreational drugs
• Occupation
- use of googles or protective eye
equipment
• Hobbies
- Nature of work of patient (occupation
Abnormalities of OCULAR SENSATION hazards) should be considered in
• Eye pain prescribing eyeglasses E.g. using
- Periocular computer or watching TV would
- Retrobulbar cause dry the eyes
- Ocular
- Non-specific o MEDICATIONS
• Eye irritation • List of current medications
- Itching • Dosage
- Dryness • Frequency
- Tearing - There are medications that are
• Headache contraindicated or contain side
effects
3 Ophthalmology: History Taking and Physical examination of the Eye |Dr. Dumapig

-Use of steroids like in chronic asthma • removing obstacles and clutter from
– develop cataract or glaucoma floors
- Drugs containing phenylamine are • anchoring loose rugs and eliminating
contraindicated to patients with uneven surfaces
glaucoma because it exacerbates the • installing well-designed hand rails
condition by increasing intraocular and other safety features, such as
pressure nonskid flooring
• Allergies • using appropriate aids for walking
- Drug allergies (walkers and canes)
- Asthma (some drugs are • avoiding footwear such as high
contraindicated like drugs which heels
exacerbate asthma) ✓ Visual and hearing impairment can
coexist
o REVIEW of SYSTEMS ✓ Associated with depression
• Relates to the condition of the body ✓ Can worsen dementia
- Blurring of vision associated with high ✓ ADLs are affected
cholesterol
- Think of this as a review of symptoms ❖ APPROACH to PATIENT
- Most complete ROS involves ✓ Compassionate and professional
asking symptoms-related ✓ Create an atmosphere of trust, respect,
questions. and openness encouraging patient to be
Ex: In cataract patient “Is your blood honest
sugar elevated?” ✓ LISTEN to patients concern with
undivided attention
SUMMARY Ophthalmologic History
✓ After everything, ASK if are there any
questions or concerns to be addressed

OCULAR EYE EXAMINATION

❖ CONFIDENTIALITY
✓ Most important part of the history taking

❖ Approach to PEDIATRIC patients ▪ Ocular Physical Examination

✓ Parent or caretaker is the primary source • Snellen Chart
of information • Rosenbaum Pocket vision screener
✓ Older children should be involved in or Jaegger chart
discussions • Occluder/ Pinhole
❖ Approach to ELDERLY patients (effects of • Penlight
visual loss) • Ophthalmoscope
✓ Increases incidence severity of falls • Stethoscope
and fractures • Amsler grid
• increasing lighting and decreasing
glare
• increasing contrast at dangerous
areas such as steps and corners
4 Ophthalmology: History Taking and Physical examination of the Eye |Dr. Dumapig

▪ Eight-Part Eye Examination 5. Note the corresponding acuity measurement

• Visual Acuity shown on that line of the chart. Record the
• External eye examination acuity value separately with correction
• Ocular motility and without correction. If the patient
• Pupillary examination misses half or fewer than half the letters on
• Visual Field examination the smallest readable line, record how many
• Slit lamp Biomicroscopy (not your letters were missed. (E.g. 20/40 -2)
competency as medical students) Conversely, if the patient reads the next line
• Tonometry but does not reach half the letters, record
• Ophthalmoscopy how many letters were read in excess. (E.g.
VISUAL ACUITY 20/40 +2)

• Measurement of smallest object a person 6. If the patient could not read the biggest
can identify at a given distance from the optotype line, have the patent come nearer
eye until the patient can see the biggest optotype
• Common abbreviations: line. Record the acuity value, reducing the
• VA- Visual Acuity numerator by the distance the patient went
• OD (oculus dexter): Right eye nearer with (E.g. 15/200 if using a Snellen
• OS (oculus sinister): Left eye chart). Continue doing so until the patient is
• OU (oculus uterque): Both eyes 5 feet away from the Snellen chart.
• ph: pinhole
• Measure both distance and near vision
• It should be performed prior to any 7. If the patient still could not read the
manipulation of the eye to avoid any largest optotype line 5 feet away, begin
medico legal issues that may arise. having the patient count the examiners
fingers 5 feet away from the patient.

8. f the patient still could not see and count the

examiner's fingers, occlude the eye not
being examined with cotton or cloth to
• Notes:
ensure that the eye not being examined is
1. Ask the patient to stand or sit at a
fully and properly occluded. Have the
designated testng distance (20 feet from a
examiner wave his or her hand and ask if
well illuminated Snellen chart or 4 meters
the patient could see the examiner's hand
from a ETDRS wall chart)
movement. Vary the examination,
alternating moving the hand and keeping it
2. Examine the poorer eye. If there is no
still. Make sure that the examining hand that
poorer eye, the right eye is examined first.
is waving is not too close as for the patient to
feel its presence.

3. Ask the patient to make sure that the

occluder is not touching or pressing against
9. If the patient still could not see the
the eye. Observe the patient to make sure
examiner's hand, test the patient for Light
there is no conscious or inadvertent peeking.
Projection. To do this, use a penlight and
illuminate the eye being examined and
4. Ask the patient to say aloud each letter or
illuminate it from four different quadrants
number or name the picture object on the
namely superiorly, temporally, inferiorly, and
lines of successively smaller optotypes, from
nasally. Ask the patient if he or she can
left to right until the patient correctly
identify the direction where the light is
identifies only half the optotypes on a line.
coming from and record it accordingly. If the
patient can identify all four quadrants, record
5 Ophthalmology: History Taking and Physical examination of the Eye |Dr. Dumapig

it as "good light projection". If the patient ➢ What if patient came in and you checked
could not identify all quadrants, record the or the visual acuity yet upon assessment
identified quadrants accordingly. patient cannot even read the biggest
letter. What will you do?
10. If the patient still could not identify the
Reduce distance between patient and chart
direction where the illuminating penlight is
and record new distance
coming from, illuminate the light directly on
the patient's eye and ask the patient if he or VA
she can identify is there is presence of light. OD – 5/200
If the patient can identify if there is presence
of light, record it as "Light perception".
Otherwise, record it as "no light
perception".

• Counting fingers
11. Repeat steps 3 to 10 on the opposite eye • Hand movement
• Light projection (GLP vs LP)
• Light Perception
• No light perception

➢ If patient still unable to see at 3 feet, hold

up 1 hand and extend 2 or more fingers
and ask the patient to count number of
fingers. Record the distance patient is able
to count. (e.g CF 5 D)
➢ If still cannot, determine whether he/she
VA: OD – 20/50 + 2
can detect movement of your hand (HM)
➢ If patient cannot detect hand motion, use
penlight
✓ Check for direction of Light
perception: Light projection (4/4)
✓ Light perception
✓ No Light perception

Near Visual Acuity

VA: OS – 20/50 - 1
6 Ophthalmology: History Taking and Physical examination of the Eye |Dr. Dumapig

• Notes: ▪ INSPECTION
• Inspect the eyebrows, noting their
Near acuity testing assesses the ability of a
fullness, hair distribution, and any
patient to see clearly at a normal reading
scaliness of the underlying skin.
distance.
• Note the position of the lids in relation to
1. Check near vision with and without correction. the eyeballs.
• Inspect for the following:
2. With the patient wearing the habitual corrective - Width of the palpebral fissures
lens for near and the near card evenly - Edema of the lids
illuminated, instruct the patient to hold the test - Color of the lids
card at the distance specified on the card (usually - Lesions
14 inches). - Adequacy of eyelid closure. Look for
3. Examine the poorer eye or the eye in this especially when the eyes are
complaint. unusually prominent, when there is
facial paralysis, or when the patient is
4. Ask the patient to say each letter or read each unconscious.
word on the line of smallest characters that are
legible on the card. CLINICAL APPLICATION (brow and lid
abnormalities)
5. Ask the patient to say each letter or read each
❖ SEBORRHEIC DERMATITIS
word on the line of smallest characters that are
- Scaliness of
legible on the card.
eyebrows occurs in
6. Record the acuity value for each eye seborrheic
separately in the patient's chart. Repeat the dermatitis
procedure with the other eye
❖ Sparse eyebrow may suggest
7. Repeat the procedure with both eyes viewing
hypothyroidism or a rare genetic disease
the test card

8. Record the binocular acuity achieved.

9. If the patient could not read the largest

optotype, place "unable to read Jaeger chart" ❖ TRISOMY 21/DOWN SYNDROME
- Upslanting of the palpebral fissure -
imaginary line that connects the
lateral canthus and the medial
➢ If patient has reading glasses, should be
canthus of each eye
worn when testing
➢ Distance at 14 inches or 35 cm

EXTERNAL EYE EXAM

o Inspection
o Palpation
o Auscultation

❖ BLEPHARITIS
- Blepharitis (red and inflamed eyelids)
- Red, inflamed with matting (clumping
of the eyelashes)
7 Ophthalmology: History Taking and Physical examination of the Eye |Dr. Dumapig

❖ LAGOPHTHALMOS vascular pattern against the white scleral

- Failure of the eyelids to close background. The slight vascularity of the
exposes the corneas to serious sclera is normal and present in most
damage. people.
- Case of complete right facial ➢ Look for any nodules or swelling
paralysis ➢ If you need a fuller view of the eye, rest
your thumb and finger on the bones of the
cheek and brow, respectively, and spread
the lids.
➢ Ask the patient to look to each side and
down. This technique gives you a good
view of the sclera and bulbar conjunctiva,
but not of the palpebral conjunctiva of the
❖ PTOSIS upper lid. For this, you need to evert the
- Lid drooping lid.

❖ ENTROPION
- Inward turning of lid

❖ ECTROPION
- Outward turning
of lid
❖ ECOPHTHALMOS
- Eyeball protrusion

Lumps and Swelling Around the Eye

• Notes
✓ ICTERUS yellowish conj and sclera due to
liver disease causing jaundice
✓ PTERYGIUM fleshy material crossing on
your cornea causing BOV. Common among
farmers and fishermen that are exposed to
➢ Briefly inspect the regions of the lacrimal sun for long periods of time.
gland and lacrimal sac for swelling. ✓ EPISCLERITIS - A localized ocular
inflammation of the episcleral vessels.
❖ DACRYOCYSTITIS Vessels appear movable over the scleral
- obstruction of the nasolacrimal duct surface. May be nodular or show only
causing obstruction causing redness and dilated vessels. Seen in
inflammation rheumatoid arthritis, Sjögren syndrome, and
herpes zoster.
✓ PINGUECULA - A harmless yellowish
➢ Inspect and compare the palpebral triangular nodule in the bulbar conjunctiva
fissures and bulbar conjunctiva of both on either side of the iris. Appears frequently
eyes. with aging, first on the nasal and then on the
➢ Conjunctiva and Sclera. Ask the patient temporal side.
to look up as you depress both lower lids
with your thumbs, exposing the sclera and
conjunctiva. Inspect the sclera and
palpebral conjunctiva for color. Note the
8 Ophthalmology: History Taking and Physical examination of the Eye |Dr. Dumapig

o Anterior Chamber Depth Estimation

• Shine a light from temporal side of
the head across front of eye parallel
to plane of iris
• Look at nasal aspect of iris
Subconjunctival • If 2/3 or more of nasal iris is in the
Conjunctivitis
Hemorrhage shadow, probably shallow and angle
Conjunctival Leakage of blood
narrow
injection: diffuse outside of the vessels,
dilatation of producing a • Repeat test on the other eye
Pattern of
conjunctival vessels homogenous, sharply
Redness
with redness that demarcated, red area
tends to be maximal that resolves over 2
peripherally weeks
Pain Mild discomfort Absent
Not affected except Not affected
for temporary mild
Vision
blurring due to
discharges
Ocular Watery, mucoid, or Absent • Notes
Discharge mucopurulent ✓ Ask the patient to fixate at a far point. Using a
Pupil Not affected Not affected
penlight, illuminate the eye being examined
Cornea Clear Clear
Bacterial, viral, and Often none. May result on or near the level of the lateral canthus and
other infections; from trauma, bleeding observe the iris. At the nasal side of the iris,
Significance highly contagious, disorders, or sudden
note the amount of shadow created. A
allergy, irritation increase in venous
pressure, as from cough crescent shadow nearer the limbal area on
the nasal side denotes a deep chamber, while
a shadow that's nearer the pupil at the nasal
side denotes a shallow chamber.

▪ PALPATION
• Feel for abnormalities
• Avoid sudden unexpected touches
Ciliary injection: The deeper vessels radiating from the limbus are specially in patients with poor vision
dilated, creating a reddish violet flush. Ciliary injection is an • Use index finger and thumbs to open
important sign of these three conditions but is not always visible.
The eye may be diffusely red instead. Other signs of these
eyelids wide apart
serious disorders are pain, decreased vision, unequal pupil, and • Ask patient to gaze in different
a clouded cornea. directions to expose globe
Moderate to Moderate, aching, Severe, aching,
severe, superficial deep deep
• Judge and record and masses, size,
Usually decreased Decreased; Decreased shape, composition, movability,
photophobia tenderness
Watery or purulent Absent Absent
Not affected unless Small and irregular Dilated, fixed
• Check for preauricular lymph nodes
iritis develops
Changes Clear or slightly Steamy, cloudy
depending on clouded; injection
cause confined to corneal ➢ NEVER PALPATE IF CONSIDERING AN
limbus OPEN GLOBE INJURY
Abrasion, and other Associated with Acute increase in
injuries; viral and systemic infection, intraocular
bacterial infection Herpes zoster, TB, pressure
or autoimmune constitutes an
emergency
9 Ophthalmology: History Taking and Physical examination of the Eye |Dr. Dumapig

▪ AUSCULTATION ▪ Extra Ocular Muscles

• Orbital Bruit assessment
- performed by placing the bell of the
stethoscope over the closed eyelids
as the patient briefly holds his or her
breath.
• The noise of eyeball movement can
be eliminated by instructing the
patient to open the opposite eyelid.
• An optical bruit can signify the
presence of carotid-cavernous
fistula or an arteriovenous
malformation
• Adduction - movement of the eye nasally
• A faint rumbling noise heard over the
• Abduction - movement of the eye
globe is considered normal
temporally
• Elevation - movement of the eye upward
OCULAR MOTILITY EXAMINATION • Depression - movement of the eye
downward
1. Sit facing the patient. • Intorsion - nasal rotation of the superior
2. Hold fixation target at eye level 10-14 inches in vertical corneal meridian
front of the patient with the patient looking at the • Extorsion - temporal rotation of the
primary position (straight ahead). superior vertical corneal meridian

3. Ask the patient to follow target as you move in

the different field of gaze. Elevate the upper lid to
observe down gaze.

4. Note if the amplitude of eye movements is

normal or abnormal in both eyes.
• Ductions – examine one eye at a time,
covering the eye not being examined.
• Versions – test for extraocular function
with both eyes open.
• Vergence – routinely evaluated
• Convergence (the movement of both
eyes nasally)
• Divergence (the movement of both eyes
▪ HIRSCHBERG TEST (Corneal Light temporally).
Reflex)
• Instruct patient to look straight and fixate ➢ All Extra Ocular Muscles of the Eye are
at a distant object while light is shone innervated by CN 3, except LATERAL
towards both eyes RECTUS (CN 6) and SUPERIOR
OBLIQUE (CN 4)
• Misalignment: appearance of corneal
reflection outside of center of the pupil LR6 SO4

Left Esotropia

Left Exotropia

Left Hypertropia

Left Hypotropia
10 Ophthalmology: History Taking and Physical examination of the Eye |Dr. Dumapig

normally be equivalent to that seen in the direct

light reaction and is graded on the same numeric
scale.

▪ Swinging Flashlight Test

➢ RADSIN
• Rectus muscles are Adductors
• Superior muscles are INtorters

1. Under dim room illumination, ask the patient to

fixate a target a few degrees above midline to
view the brown pupil better.

2. Shine a bright hand-held light directly into the

Pupillary Examination right eye by approaching it from the side or from
below. Do not stand in front of the patient or allow
• Pupils can be seen in dim light by shining a the patient to look directly at the light, which
handheld light on the patient’s face from would stimulate the near reflex and preclude
below while the patient looks into the accurate light-reflex testing.
darkness
3. Swing the flashlight below the nose (for
1. Under dim room illumination, ask the patient to uniformity of movement) towards the other eye
fixate a target a few degrees above midline to and observe the pupillary response of the left eye.
view the brown pupil better.
4. Repeat steps 1-3 for the left eye.
2. Shine a bright hand-held light directly into the
right eye by approaching it from the side or from 5. Swing the flashlight every three seconds
below. Do not stand in front of the patient or allow several times to observe pupillary response to
the patient to look directly at the light, which direct light stimulation. A dilating pupil with
would stimulate the near reflex and preclude direct stimulation may indicate an optic nerve
accurate light-reflex testing. pathology, or severe macular problem.

3. Record the direct pupillary response to light in

the right eye in terms of the briskness of the Anisocoria -unequal pupil
response, graded from 0, indicating no • CONSTRICTION – Parasympathetic
response, to 4+, indicating a brisk response. • DILATION - Sympathetic
4. Repeat steps 1-3 for the left eye. • Anisocoria in DIM – Sympathetic
• Anisocoria in BRIGHT – Parasympathetic
5. When checking for consensual reflex, shine the
light on the unobserved eye to check for the
reaction of the non-illuminated eye. The rapidity
of the response and change in pupil size should
11 Ophthalmology: History Taking and Physical examination of the Eye |Dr. Dumapig

Notes ❖ HORNER’S SYNDROME

• The affected pupil is small, unilateral,
✓ Anisocoria represents a defect in the
reacts briskly to light and near effort, but
constriction or dilatation of one pupil.
dilates slowly, especially in dim light.
✓ Constriction to light and near effort is
Anisocoria is >1 mm, with ipsilateral
mediated by parasympathetic pathways, and
ptosis of the eyelid and often loss of
pupillary dilatation by sympathetic pathways.
sweating on the forehead.
The light reaction in bright and dim light
• These findings reflect the classic triad of
identifies the abnormal pupil.
Horner syndrome—miosis, ptosis and
✓ When anisocoria is greater in bright light than
anhidrosis, due to a lesion in the
in dim light, the larger pupil cannot constrict
sympathetic pathways anywhere from the
properly. Causes include blunt trauma to the
hypothalamus through the brachial plexus
eye, open-angle glaucoma, and impaired
and cervical ganglia into the
parasympathetic innervation to the iris, as in
oculasympathetic fibers of the eye.
tonic pupil and oculomotor nerve (CN III)
Causes include ipsilateral brainstem
paralysis.
lesions, neck and chest tumors affecting
✓ When anisocoria is greater in dim light, the
the ipsilateral sympathetic ganglia, and
smaller pupil cannot dilate properly, as in
orbital trauma and migraine
Horner syndrome, caused by an interruption
of the sympathetic innervation.
✓ Assessing the near reaction is also important
in determining the cause.

CLINICAL APPLICATION (pupils) ❖ ARGYLL ROBERTSON PUPIL

❖ TONIC (ADIE’s) PUPIL • Prostitute’s Pupil
• Pupil is large (dilated), regular, and • The pupils are small, irregular and usually
usually unilateral. bilateral. They constrict with near vision
Reaction to light is and dilate with far vision (a normal near
severely reduced reaction) but do not react to light, seen in
and slowed, or neurosyphilis and rarely in diabetes.
even absent.
Constriction during
the near vision is
present, although
very slow (tonic).
These changes
reflect parasympathetic denervation. Slow
accommodation causes blurred vision.
❖ CN 3 NERVE PALSY
• The pupil is large and fixed to light and
near effort. Ptosis of the upper eyelid
(due to impaired CN III innervation of the
levator palpebrae muscle) and lateral
deviation of the eye downward and
outward are almost always present.
12 Ophthalmology: History Taking and Physical examination of the Eye |Dr. Dumapig

VISUAL FIELD CONFRONTATION ▪ Recording

• If an abnormality is detected, sketch a 360°
• Confrontation testing of the visual fields is a
visual field chart, labeled for right and left
valuable screening technique for detection of
eye and temporal and nasal field, and plot
lesions in the anterior and posterior visual
the visual field as the patient sees it. Record
pathway.
a failure to detect an abnormality as "no
1. Seat the patient and make sure the eye not defect to finger confrontation"
being tested is occluded.

2. Seat yourself facing the patient at a distance of

about 1 meter. The examiner closes the eye that
mirrors the patient’s eye that is occluded (ex. If
the patient closes his/her left eye, the examiner
closes his right eye)

3. Ask the patient to fixate on your nose.

4. While the patient is fixating on your nose, ask

the patient if there are any missing parts on the
examiner's face to detect any central scotoma.

5. Hold your hands stationary midway between

yourself and the patient in opposite quadrants ▪ Amsler Grid Testing
about 30° from central fixation. Extend your
fingers on one hand on the temporal hemifield of TONOMETRY
the monocular field, asking the patient if they see • Measurement of intraocular pressure (IOP)
movement. Repeat the exam again on the nasal • Performed as part of a thorough ocular
hemifield, testing at least two times per quadrant. examination to help detect ocular
Note if there are any abnormal findings such as hypertension and glaucoma and to detect
the patient not being able to recognize finger ocular hypotony (low IOP) in conditions such
movement. You may test both nasal and temporal as iritis and retinal detachment.
fields simultaneously. Repeat the same steps,
• Normal: 10-21 mmHg
this time testing for 4 quadrants and record the
• Types
findings accordingly.
• Palpation/Digital/Tension tonometry
a) Test patients who have marked visual loss • Indentation tonometry
by waving your hand in each quadrant • Applanation tonometry
individually and asking if the patient - Goldmann Applanation: Gold
perceives the motion. With patients who standard
can only perceive light, test in each
quadrant individually for the ability to
correctly determine the direction of light
projection by pointing a penlight toward
the pupil while keeping the patient's other
eye completely occluded. ▪ Digital Tonometry
b) Test young children with a finger- • Estimating IOP by digital pressure on the
mimicking procedure. First teach the child globe may be used with uncooperative
to hold up the same number of fingers as patients or in the absence of
you do, then conduct the test as usual. instrumentation, but it may be inaccurate
even in very experienced hands. In
general, digital estimation of IOP is only
➢ Check for any visual field deficit useful for detecting large differences
between the patient’s eyes.
13 Ophthalmology: History Taking and Physical examination of the Eye |Dr. Dumapig

1. Instruct the patient to look down as the ▪ How to hold your ophthalmoscope
examiner gently rests the forefingers of both • Hold the instrument with your index finger
hands and insinuate both fingers between the resting on the focusing wheel and the
superior orbital rim and superior aspect of the thumb on rheostat that controls
patient‘s globe. Make sure that the patient does brightness.
not close his eyes during the examination to
1. Direct ophthalmoscopy is performed with the
prevent inadvertent trauma to the cornea since
eye that corresponds to the eye being examined,
the patient's eyeballs roll upwards when the
putting the examiner cheek to jowl with the
eyelids are shut.
patient.
2. For added stability, the examiner may rest his
- Instruct the patient to fixate at a distant
other fingers gently on the patient's forehead
point and not on the instrument light.
while the examination is being performed.
- Adjust the light intensity to avoid papillary
3. The examiner gently and alternately depresses constriction at the start of the
both forefingers on the globe while assessing the examination.
tone. [Report the findings as soft, firm, or hard. A
2. Focus the ophthalmoscope by twirling the dial
normotensive eye, or firm eye, roughly
for the millidisc at zero. The optimal focusing lens
approximates the tone of the tip of the nose, an
depends on the patient's refractive error, the
eye with elevated pressure, described as hard,
examiner's refractive error and the examination
approximates the tone of the glabella, and a
distance.
hypotensive eye, described as soft is similar in
tone to that of the lips. 3. Check the patient's red reflex for both eyes and
see if it is homogeneously seen. Report it as
good, dull, or if there is an absence of the red
OPHTHALMOSCOPY orange reflex.

4. Approach the patient slowly. The instrument is

steadied against the patient's face by resting the
ulnar border of the hand holding the instrument
against the patient's cheeks while the thumb of
the free hand raises the upper eyelid.

5. Change the millidisc accordingly once some of

the structures are seen for a clearer view. Note if
the media is clear, hazy, or if the posterior pole
could not be seen. Once the vessel structures are
seen, slowly trace the vessel nasally until the
optic nerve can be seen. Take note and describe
the following:

- The optic nerve cup size, color, and the

disc borders
- The vertical cup-disc ratio and if there is
venous pulsation
- The Neuro-retinal rim thickness and color
- Take note of the arterio-venous ratio
beginning at second branching of the
superior and inferior arcades
- Presence or absence of any hemorrhages
or exudates

7. Examine the macula/fovea last.

14 Ophthalmology: History Taking and Physical examination of the Eye |Dr. Dumapig

Process Process
Increased intraocular The physiologic cup is
pressure within the eye enlarged, occupying more
leads to increased than half of the disc’s
cupping (backward diameter, at times
depression of the disc) extending to the edge of
and atrophy. The base of the disc. Retinal vessels
the enlarged cup is pale sink in and under the cup,
and may be displaced
nasally
Appearance Appearance
Death of the optic nerve Color white
fibers leads to loss of the Tiny disc vessels absent
tiny disc vessels Seen in optic neuritis,
multiple sclerosis,
temporal arteritis
Process Process
Tiny disc vessels give Elevated intracranial
normal color to the disc pressure causes
➢ The cup is the central depression and its
intraaxonal edema along basically the two yellow horizontal lines at
the optic nerve, leading to the edge of the cup and the black lines are
engorgement and swelling the edge of the optic disc so commonly we
of the optic disc talk about the cup-to-disc ratio. That
Appearance Appearance simply would be the ratio of distance
Color yellowish orange to Color pink, hyperemic between the two yellow lines divided by
creaky pink Often with loss of venous the distance between the two black lines.
Disk vessels tiny pulsations
Disc margins sharp Disc vessels more visible.
(except perhaps nasally) More numerous, curve
The physiologic cup is over the borders of the
located centrally or disc
somewhat temporally. It Disc swollen with margins
may be conspicuous or blurred
absent. Its diameter The physiologic cup is not
from side to side is visible
usually less than half of Seen in intracranial mass,
the disc. lesion, or hemorrhage,
meningitis
15 Ophthalmology: History Taking and Physical examination of the Eye |Dr. Dumapig

➢ In hypertension, increased pressure

damages the vascular endothelium,
leading to deposition of plasma
macromolecules and thickening of the
arterial wall, causing focal or generalized
narrowing of the lumen and the light reflex.
➢ The vein appears to stop abruptly on
either side of the artery.

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Reference:

Dr. Dumapig Review Handouts