Physical Examination
1. Check for visual acuity using a Snellen eye chart or eye chart in the exam room
2. assess visual fields
- Ask the patient to look with both eyes into your eyes
- While you return the patient gaze, place your hand about 2 feet apart, lateral to the patient’s ears
- Instruct the patient to point to your fingers as soon as they are seen
- Then slowly move the wiggling fingers of both your hand along the imaginary bowl and towards the line of gaze until the patient identifies them
- Repeat this pattern in the upper and lower temporal quadrants
3. Inspect external eye
- Stand in front of the patient and survey the eyes for position and alignment with each other
- Inspect the eyebrows – quantity and distribution
- Inspect the eyelids
- Inspect the region of the lacrimal gland
- Inspect the conjunctiva and sclera
• Ask the patient to look up as you depress both lower lids with your thumbs, exposing sclera and conjunctiva
- Inspect the cornea and lens, using a penlight shined oblique across the eye
- Inspect each iris
- Inspect the pupil for size, shape and symmetry
4. Assess papillary reflexes
- To light – ask the patient to look into the distance and shine a bright light obliquely into each pupil in turn
• Note direct reaction – pupillary constriction in the same eye
• Note indirect reaction – pupillary constriction in the opposite eye
- Assess accommodation – ask the patient to look alternately at a pencil held 10 cm. from his eye and into the distance directly behind it. Observe for pupillary constriction with near effort
5. Assess extraocular movements
- From 2 feet in front of the patient, shine a light into the patient’s eyes and ask the patient to look at it. Inspect the reflections in the corneas, which should be visible slightly nasal to the center of the pupils
- Ask the patient to follow your finger or pencil as you sweep through the 6 cardinal directions of gaze
• To the patient’s extreme right
• To the right and upwards
• To the right and downwards
• Without pausing in the middle to the extreme left
• To the left and upwards
• To the left and downwards
6. Ophthalmoscopic exam