With patient wearing glassestest each eye separately on eye chart/ cardusing an eye cover.
Examine visual fields by confrontation by wiggling fingers 1 foot frompt's earsasking which they see move. • Keep examiner's head level with patient's head.
If poor visual acuitymap fields using fingers and a quadrant-coveringcard.
Shine light in from the side to gauge pupil's light reaction. • Assess both direct and consensual responses. • Assess afferent pupillary defect by moving light in arc from pupil topupil. unne). Optionally: as do arc testhave pt place a flat handextending vertically from his facebetween his eyesto act as a blinder solight can only go into one eye at a time.
"Follow finger with eyes without moving head": test the 6cardinal points in an H pattern. • Look for failure of movementnystagmus [pause to check it during upward/lateral gaze].
Convergence by moving finger towards bridge of pt's nose.
Test accommodation by pt looking into distancethen a hat pin 30cm fromnose.
If MG suspected: pt. gazes upward at Dr's finger to show worsening ptosis.
Corneal reflex: patient looks up and away. • Touch cotton wool to other side. • Look for blink in both eyesask if can sense it. • Repeat other side [tests V sensoryVII motor].
Facial sensation: sterile sharp itemon foreheadcheekjaw. • Repeat with dull object. Ask to report sharp or dull. • If abnormalthen temperature (heated/ water-cooled tuning fork)lighttouch (cotton).
Motor: pt opens mouthclenches teeth (pterygoids). • Palpate temporalmasseter muscles as they clench.
Facial expression muscles: pt looks up and wrinkles forehead. • Examine wrinkling loss. • Feel muscle strength by pushing down on each side [UMNL preserved becauseof bilateral innervation].
Dr's hands arms length by each ear of pt. • Rub one hand's fingers with noise on one sideother hand noiselessly. • Ask pt. which ear they hear you rubbing. • Repeat with louder intensitywatching for abnormality.
Weber's test: Lateralization • 512/ 1024 Hz [256 if deaf] vibrating fork on top of patients head/forehead. • "Where do you hear sound coming from?" • Normal reply is midline.
Rinne's test: Air vs. Bone Conduction • 512/ 1024 Hz [256 if deaf] vibrating fork on mastoid behind ear. Ask whenstop hearing it. • When stop hearing itmove to the patients ear so can hear it. • Normal: air conduction [ear] better than bone conduction [mastoid].
If indicatedlook at external auditory canalseardrums.
