Eye Examination Component What to do/look for and rationale Sit the patient on the edge of the bed and look for the below. Ptosis: Myasthenia gravis Congenital -> defect in Levator muscle -> difficulty raising the eyelids -> may affect one or both eye lids. Myotonic dystrophy. Nerve paralysis -> CN III Horner’s Syndrome Look for: Iritis Conjunctivitis Conjunctivitis Haemorrhage Scleritis Colour of the sclera: Yellow -> bilirubin deposition -> jaundice. Blue -> osteogenesis imperfecta -> thin sclera -> choroidal pigment shows through General inspection the eye Bluish grey -> ochronosis (inherited condition) -> accumulation of homogentisic acid in connective tissue. Red -> iritis, scleritis, conjunctivitis Pallor -> anaemia, cyanosis (pull the eye lids). Look from behind the patient for exophthalmos. Protrusion of the eyes from the orbits -> proptosis. G ravis Disease If present examine the thyroid gland. Corneal ulcerations. Obvious if severe. Strip coated with sterile fluorescence will stain the corneal ulcers and make them easily visible. A branching (dendritic) ulcer -> herpes complex keratitis. Ophthalmoplegia Weakness of the upward gaze. Look for corneal abnormalities: Stye of the eyelid -> hordeolum: Infection -> usually caused by S. aurus Chalazion: Sterile inflammation of the meibomian glands deep or the sebaceous glands if superficial -> Slowly enlarged non-tender nodule of the eyelid Dacryocystitis: Infection of a lacrimal gland or lacrimal duct. Inspection of the Eyelids Orbital cellulitis: May spread to involve the eyelid. Ectropion: Drooping of the lower lid when it loses its elasticity in old age and falls away from the sclera -> interrupts tear drainage -> eye becomes dry and tears spill over the patient’s check. Entropium: Scarring and thickening of the lower eyelids -> corneal abrasion from inverted lashes. Patient follows the finger as it descends Lid Lag Upper lid lagging behind the pupil Visual acuity: Use Snellen chart and be 20 feet away from the patient. Test for one eye at a time, then both eyes. Colour vision Assess if visual acuity is not poor Use Ishihara plates Visual fields: Assess by confrontation and stand 2 to 3 feet away from the patient. Tell the patient to loo directly at you and tell them to identify when your finger comes into their visual field. Optic Nerve Examination Fundoscopic examination: Use ophthalmoscope to examine the fundus of the eye. Look for red reflex. Assess optic disc, retina, macula size, elevation, lesions or swelling and track the vessels out from the optic noting any vascular abnormalities. Refer to fundoscopy notes in the clinical procedure kills doc for procedure and to tablet notes for guide on interpretation. Pupillary light reflex: Afferent pathway -> CN II Accommodation. Assess direct and consensual response. Extra ocular movements: Oculomotor nerve: Examine the superior, inferior, inferior oblique and medial rectus muscles. Downward and upward movements of the eye. Loss of adduction when moving. Inwards movements of the eye. Trochlear nerve: Examine the superior oblique muscle. Extrusion of the eye -> inability to depress and adduct eye. Diplopia worse when looking down. Causes: cavernous sinus thrombosis or vascular compression of CN IV. Abducens nerve: Examine the lateral rectus muscle of the eye. Medial deviation of the eye at rest. Loss of abduction when moving. Diplopia worse when focusing at distant objects. Causes: cavernous sinus thrombosis or pseudotumor cerebri affecting CN IV. Oculomotor, trochlear and abducens -> CN III, IV and VI. Saccades Abnormal saccades. Frontal eye field lesions. PPRF lesion, vertical gaze centre lesion. Nystagmus Peripheral Usually, horizontal. Inner ear issue. Central Usually, vertical CNS issue. Visual accommodation -> light neat dissociation (Argyll Robertson Pupil). When pupils slushily constrict to light. Pupils do constrict to accommodation: Neurosyphilis. Parinaud syndrome. CN V and VII Assess for corneal reflex Palpate the orbits for tenderness while the tested eye is shut, and the non-tested eye is kept open. Palpate for the periocular node -> adenoviral conjunctivitis. Other Important Tests Auscultate with the bell of the stethoscope while the tested eye is shut, and the nontested eye is kept open. Consider possibility of glass eye -> this should be suspected if visual acuity is 0 in one eye and no papillary reaction is apparent.