1. History
2. Inspection
3. Visual acuity
4. Visual fields
5. Ophthalmoscopic (fundi)
6. Pupils
7. Corneal reflections
8. Eye movements
9. Corneal reflex

History

• Presenting complaint:
  • Onset: gradual vs. sudden vs. asymptomatic.
  • Duration: brief vs. continuous.
  • Location: focal vs. diffuseunilateral vs. bilateral.
• Eye Hx: squintamblyopiaglassesglaucoma.
• Family Hx: squintlazy eyeglassesglaucomacataract (young person).
• Past medical Hx: especially vascular (diabeteshypertension).
• Medications: current medsHx of drugs affecting eye.
  • Is pt on or been on eye drops.
• Social Hx: relevant post-op (to put eye drops in).

Inspection

In alllooking for asymmetrydeformitiesdiscolorationrednessdischargelesions.

• Diagnostic facies.
• Orbitrim: palpate for lumps.
• Brow: lost sweating (Horner's).
• Eyelids: xanthelasmaectropianentropian.
• Eyelids: pus on lids (blepharitis).
• Ptosis.
• Exophthalmos.
• Iris: colourdefects.
• Cornea: transparent vs. opaquecorneal arcusband keratopthyKayser-Fleischer ringslesionscars.
• Ask the patient to look up and pull down both lower eyelids to inspect theconjuntiva and sclera.
  • Conjunctiva: clear/infected. If conjuntivitiswash hands immediately:viral form contagious.
  • Sclera: jaundicepallorinjection.
• Spread each eye open with Dr's thumbindex finger. Ask pt to look to eachside and downward to expose entire bulbar surface.
  • Eyeball tenderness.

Visual acuity

If  eye paininjuryvisual losscheck visual acuitybefore rest of the exam or inserting medications into eyes [so don't get sued].

• Let pt to use glassescontacts if available.
• Put pt 20 feet from Snellen eye chartor hold Rosenbaum pocket card 14inches away.
• Pt. covers an eye at a time with a cardreading smaller letters tillstop.
• Record smallest line readeg 20/40.

Visual fields

• Stand 2 feet in front of ptwho looks in Dr's eyes at eye-level.
• Dr's hands to side half way between Dr and ptwiggle fingersask which they see move.
• Repeat 2-3 to test both temporal fields.
• If suspect abnormalitytest 4 quadrants of each eye while card coversother.

Ophthalmoscopic (fundi)

• Darken roomadjust scope so light is no brighter than necessary.
• Adjust aperture to a plain white circle.
• Set diopter dial to zerounlesshave a preferred setting.
• Dr. uses left hand and left eye toexamine the patient's left eye.
• Dr's free hand onto the pt'sshoulder or forehead for control.
• Tell pt to stare at wall.
• Look through scopeshine light into pt's eye from 2 feet away at a 45ºangle.
• See the retina as a "red reflex.". Reflex: clear vs. opaque(cataract). Follow red color to move within a few inches from pt's eye.
• Adjust diopter dial to bring the retina into focus. Find a blood vesseland follow it to the optic diskuse this as a point of reference.
• Inspect optic disk:
  • Colour of disc: pink vs. pale.
  • Margins clear.
  • State of cup.
• Inspect vessels: all 4 quadrantsveins are darker than arteries:
  • Bleedingexudate.
  • Pigmentationocclusion.
• Inspect maculaby moving the scope nasally:
  • Foveal light reflex
  • Bleedingexudate.
  • Edemadrusen.

Pupils

• Shaperelative size.
• Light reaction: dim lights if needed.
  • Pt looks in distanceshine light in from side to gauge pupil's lightreaction. Record sizeirregularity.
  • Assess both direct (same eye) and consensual (other eye) responses.
• Assess afferent pupillary defect by moving light in arc from pupil topupiland if left eye light makes right eye dilatenot constrict (MarcusGunne). Optionally: as do arc testhave pt place a flat hand extendingvertically from his facebetween his eyesto act as a blinder so light canonly go into one eye at a time. 
• Accommodation: pt alternates between looking into distanceand a hat pin30from nose.

Corneal reflections

• Shine a light from directly in front of the pt.
• Corneal reflections should be centered over pupils.
• Assess asymmetry (extraocular muscle pathology).

Eye movements

• "Follow finger with eyes without moving head": test the 6cardinal points in an H pattern. Assess:
  • Failure of movement.
  • Nystagmus [pause to check it duringupwardlateral gaze]).
• Convergence by moving finger towards bridge of pt's nose.
• Gaze palsies (supranuclear lesions).
• Fatiguability (myasthenia).

Corneal reflex

• 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].

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