Austin College

Access Provided by:

Current Medical Diagnosis & Treatment 2025

7­02: Ocular Examination

Jacque L. Duncan; Neeti B. Parikh; Gerami D. Seitzman

Abbreviations and symbols commonly used in ophthalmology are listed in the accompanying box.

Abbreviations & Symbols Used in Ophthalmology

A or Acc Accommodation

Ax or x Axis of cylindric lens

BI or BO Base­in or base­out (prism)

CF Counting fingers

Cyl Cylindric lens or cylinder

D Diopter (lens strength)

E Esophoria (latent convergent squint)

EOG Electro­oculography

EOM Extraocular muscles or movements

ERG Electroretinography

ET Esotropia (manifest convergent squint)

H Hyperphoria (latent vertical squint)

HM Hand movements

HT Hypertropia (manifest vertical squint)

IOP Intraocular pressure

IPD Interpupillary distance

J1–J20 Test types (Jaeger) for testing near vision

KP Keratic precipitate

LogMAR Logarithm of minimum angle of resolution (scale for testing visual acuity)

LP
Downloaded 2024­9­16 6:14LightPperception
Your IP is 72.24.242.248
7­02: Ocular Examination, Jacque L. Duncan; Neeti B. Parikh; Gerami D. Seitzman Page 1 / 8
©2024L McGraw
Proj Hill. All Rights Reserved. Terms of Use • Privacy Policy • Notice • Accessibility
Light projection

N5­N48 Test types (Faculty of Ophthalmologists) for testing near vision, equivalent to printer's points
 J1–J20 Test types (Jaeger) for testing near vision

Austin College
KP Keratic precipitate
Access Provided by:

LogMAR Logarithm of minimum angle of resolution (scale for testing visual acuity)

LP Light perception

L Proj Light projection

N5­N48 Test types (Faculty of Ophthalmologists) for testing near vision, equivalent to printer's points

NLP No light perception

NPC Near point of convergence

OD (R, or RE) Oculus dexter (right eye)

OS (L, or LE) Oculus sinister (left eye)

OU Oculi unitas (both eyes)

PD Prism diopter (strength)

PH Pinhole

PRRE Pupils round, regular, and equal

S or Sph Spherical lens

VA Visual acuity

VER Visual evoked response

X Exophoria (latent divergent squint)

XT Exotropia (manifest divergent squint)

+ Plus (convex) lens

− Minus (concave) lens

∞ Infinity (6 meters [20 feet] or more distance)

° Degree (measurement of strabismus angle)

Δ Prism diopter (PD)

1. VISUAL ACUITY (VA)

Corrected (with glasses, contact lens, or pinhole) distance visual acuity should be tested for each eye in turn, using a Snellen or logMAR (EDTRS) chart.
Snellen visual acuity is traditionally measured at 20 feet (6 meters in Europe) or nearer if vision is poor. LogMAR acuity is tested at 13 feet (4 meters), 10
feet (3 meters), or 3 feet (1 meter) when accuracy of test distance and provision of (1 D) refractive correction for presbyopic patients become important.
Snellen visual acuity is expressed as a fraction—the test distance over the figure, determined by the distance at which the respective line can be read by
a normal individual, assigned to the lowest line the patient can read. If the patient is unable to read the top line even when standing close to the chart,
acuity is categorized as counting fingers (CF), hand movements (HM), perception of light (LP), or no light perception (NLP). In general, corrected acuity
less than 20/30
Downloaded (6/9, 0.67)6:14
2024­9­16 is abnormal
P Your but
IP is20/20 (6/6, 1.0) may be abnormal, especially if reduced in comparison to the other eye. LogMAR acuity, which
72.24.242.248
increases
7­02: as vision
Ocular deteriorates,
Examination, is recorded
Jacque L. Duncan;as the total
Neeti B.of the values,
Parikh; Geramidetermined
D. Seitzman by their size, of all the letters correctly identified with 0.00Page
being2 / 8
©2024 McGraw
equivalent Hill.(6/6,
to 20/20 All Rights Reserved.
1.0) and 1.00 being Terms of Use
equivalent • Privacy
to 20/200 Policy
(6/60, 0.1).• For
Notice • Accessibility
the Visual Acuity Rating (VAR), which decreases as vision deteriorates,
each letter identified correctly scores 1, from a baseline of 20/2000 (6/600, 0.01) such that 50 is equivalent to 20/200 (6/60, 0.1) and 100 is equivalent to
20/20 (6/6, 1.0).
Snellen visual acuity is traditionally measured at 20 feet (6 meters in Europe) or nearer if vision is poor. LogMAR acuity is tested at 13 feet (4 meters), 10
feet (3 meters), or 3 feet (1 meter) when accuracy of test distance and provision of (1 D) refractive correction for presbyopic patients becomeAustin College
important.
Snellen visual acuity is expressed as a fraction—the test distance over the figure, determined by the distance at which the respective line Access
can be Provided by:
read by
a normal individual, assigned to the lowest line the patient can read. If the patient is unable to read the top line even when standing close to the chart,
acuity is categorized as counting fingers (CF), hand movements (HM), perception of light (LP), or no light perception (NLP). In general, corrected acuity
less than 20/30 (6/9, 0.67) is abnormal but 20/20 (6/6, 1.0) may be abnormal, especially if reduced in comparison to the other eye. LogMAR acuity, which
increases as vision deteriorates, is recorded as the total of the values, determined by their size, of all the letters correctly identified with 0.00 being
equivalent to 20/20 (6/6, 1.0) and 1.00 being equivalent to 20/200 (6/60, 0.1). For the Visual Acuity Rating (VAR), which decreases as vision deteriorates,
each letter identified correctly scores 1, from a baseline of 20/2000 (6/600, 0.01) such that 50 is equivalent to 20/200 (6/60, 0.1) and 100 is equivalent to
20/20 (6/6, 1.0).

Near acuity is tested with a reduced Snellen chart or standardized near vision test types, eg, Jaeger (J) or Faculty of Ophthalmologists (N—equivalent to
printer's points and computer fonts). The patient must be wearing appropriate near vision correction.

2. VISUAL FIELDS
Confrontation testing, preferably using a small (5­mm) red target, is valuable for rapid assessment of field defects but it has low sensitivity, ie, subtle
defects are easily missed. Amsler charts are the easiest method of detecting central field abnormalities due to macular disease. Automated and manual
perimeters are the standard instruments for visual field tests.

3. PUPILS
The pupils are examined for absolute and relative size and reactions to both light and accommodation (eFigure 7–3). A large, poorly reacting pupil may
be due to third nerve palsy, acute tonic pupil, iris damage caused by acute glaucoma, or pharmacologic mydriasis. A small pupil occurs in Horner
syndrome, inflammatory adhesions between iris and lens (posterior synechiae), long­standing tonic pupil, or neurosyphilis (Argyll Robertson pupils).
Physiologic anisocoria is a common cause of slightly unequal (less than 0.5 mm difference in diameter) pupils that react normally.

eFigure 7–3.

Anatomic basis of the pupillary light reflex. The afferent visual pathways from the retina to the pretectal nuclei of the midbrain are represented by
dashed lines, the efferent pupilloconstrictor pathways from the midbrain to the retinas by solid lines. Note that illumination of one eye results in
bilateral papillary constriction. (Reproduced, with permission, from Simon RP, Greenberg DA, Aminoff MJ. Clinical Neurology, 10th ed. McGraw­Hill,
2018.)

Downloaded 2024­9­16 6:14 P Your IP is 72.24.242.248

7­02: Ocular Examination, Jacque L. Duncan; Neeti B. Parikh; Gerami D. Seitzman Page 3 / 8
©2024 McGraw Hill. All Rights Reserved. Terms of Use • Privacy Policy • Notice • Accessibility

A relative afferent pupillary defect, in which the pupillary light reaction is reduced when light is shined into the affected eye compared with the normal
Anatomic basis of the pupillary light reflex. The afferent visual pathways from the retina to the pretectal nuclei of the midbrain are represented by
Austin College
dashed lines, the efferent pupilloconstrictor pathways from the midbrain to the retinas by solid lines. Note that illumination of one eye results in
Access Provided by:
bilateral papillary constriction. (Reproduced, with permission, from Simon RP, Greenberg DA, Aminoff MJ. Clinical Neurology, 10th ed. McGraw­Hill,
2018.)

A relative afferent pupillary defect, in which the pupillary light reaction is reduced when light is shined into the affected eye compared with the normal
eye, generally indicates optic nerve disease. It is detected with the “swinging light test,” in which the pupillary light reactions are compared as a bright
light is moved from one eye to the other (eFigure 7–4).

eFigure 7–4.

Relative afferent pupillary defect. (Reproduced, with permission, from Riordan­Eva P, Augsburger JJ. Vaughan & Asbury's General Ophthalmology,
19th ed. McGraw­Hill, 2018.)

Downloaded 2024­9­16 6:14 P Your IP is 72.24.242.248

7­02: Ocular Examination, Jacque L. Duncan; Neeti B. Parikh; Gerami D. Seitzman Page 4 / 8
©2024 McGraw Hill. All Rights Reserved. Terms of Use • Privacy Policy • Notice • Accessibility
eFigure 7–4.
Austin College
Access Provided by:
Relative afferent pupillary defect. (Reproduced, with permission, from Riordan­Eva P, Augsburger JJ. Vaughan & Asbury's General Ophthalmology,
19th ed. McGraw­Hill, 2018.)

4. EXTRAOCULAR MOVEMENTS
Examination of extraocular movements begins with an assessment of whether the two eyes are aligned. A misalignment of the visual axes under
binocular viewing conditions is known as a manifest deviation (tropia). A deviation only when binocular function is disrupted is known as a latent
deviation (phoria), which is common among normal individuals. A manifest deviation may be apparent by comparing the relative positions of the
corneal light reflections. More reliable is the cover test, in which the deviated eye moves to take up fixation when the other eye is occluded. The
correctional movement is in the direction opposite to that of the original manifest deviation. If there is no manifest deviation, any correctional
movement that occurs to reestablish the normal alignment of the eyes as the occluder is removed (uncover test) indicates a latent deviation.

Horizontal diplopia indicates dysfunction of the medial or lateral rectus muscles, vertical diplopia results from dysfunction of the superior or inferior
recti or the obliques. The false outer image arises from the affected eye. If muscle contraction is impaired, the image separation will be greatest in its
normal direction of action; if a muscle cannot relax, image separation will be greatest in the direction opposite to its normal action. For example, a
paretic lateral rectus or a tethered medial rectus of the right eye will cause maximal image separation on looking to the right.
Downloaded 2024­9­16 6:14 P Your IP is 72.24.242.248
Nystagmus
7­02: OcularonExamination,
straight ahead gaze (primary
Jacque position)
L. Duncan; Neeti is
B.always
Parikh;abnormal.
Gerami D.Minor degrees of nystagmus at the extremes of gaze are normal. Other
Seitzman Pageforms
5/8
©2024
of McGraw
physiologic Hill. All Rights
nystagmus Reserved.
include optokineticTerms of Useand
nystagmus • Privacy Policy
nystagmus • Notice
induced by•rotation
Accessibility
or caloric stimulation. Exaggerated gaze­evoked
nystagmus may be due to drugs or posterior fossa disease.
movement that occurs to reestablish the normal alignment of the eyes as the occluder is removed (uncover test) indicates a latent deviation.
Austin College
Horizontal diplopia indicates dysfunction of the medial or lateral rectus muscles, vertical diplopia results from dysfunction of the superior or Provided
Access inferiorby:
recti or the obliques. The false outer image arises from the affected eye. If muscle contraction is impaired, the image separation will be greatest in its
normal direction of action; if a muscle cannot relax, image separation will be greatest in the direction opposite to its normal action. For example, a
paretic lateral rectus or a tethered medial rectus of the right eye will cause maximal image separation on looking to the right.

Nystagmus on straight ahead gaze (primary position) is always abnormal. Minor degrees of nystagmus at the extremes of gaze are normal. Other forms
of physiologic nystagmus include optokinetic nystagmus and nystagmus induced by rotation or caloric stimulation. Exaggerated gaze­evoked
nystagmus may be due to drugs or posterior fossa disease.

Margolin E et al. Approach to a patient with diplopia in the emergency department. J Emerg Med. 2018;54:799.
[PubMed: 29426788]

5. PROPTOSIS (EXOPHTHALMOS)
Proptosis is suspected when there is widening of the palpebral aperture with exposure of sclera both superiorly and inferiorly. (Eyelid retraction
causes more exposure superiorly than inferiorly.) By viewing from above while the patient is asked to look down and the upper lids are lifted by the
examiner, a further estimate of the degree of proptosis can be made. Exophthalmometry provides quantitative assessment. In nonaxial proptosis,
there is also horizontal or vertical displacement of the globe, indicating the presence of a mass lesion outside the extraocular muscle cone.

The most frequent cause of proptosis in adults is thyroid eye disease (Graves ophthalmopathy). Other causes include orbital cellulitis, tumors, and
idiopathic orbital inflammation (pseudotumor).

6. PTOSIS
Ptosis is usually due to lid disease. Neurologic causes of ptosis include Horner syndrome, in which the pupil is constricted, and third nerve palsy, in
which there are abnormalities of eye movements and the pupil may be dilated and react poorly to light. In myasthenia gravis, the pupils are normal and
characteristically the ptosis is fatigable.

Bacharach J et al. A review of acquired blepharoptosis: prevalence, diagnosis, and current treatment options. Eye (Lond). 2021;35:2468.
[PubMed: 33927356]

7. ANTERIOR SEGMENT EXAMINATION

Although slit­lamp examination is more sensitive, examination with a flashlight and loupe (magnifying lens) usually provides sufficient information for
initial assessment. Pattern of redness indicates the site of the problem. In conjunctivitis, it extends diffusely across the globe and the inner surface of
the lids. Keratitis, intraocular inflammation, and acute glaucoma cause predominantly circumcorneal injection. Episcleritis and scleritis cause localized
or diffuse deep injection, which in the case of scleritis is associated with blue discoloration.

Focal lesions of the cornea due to infection or trauma can be differentiated from the diffuse corneal haze of acute glaucoma and from the cloudiness
of the anterior chamber and perhaps hypopyon (white cells within the anterior chamber) of iritis. Instillation of fluorescein, if possible supplemented
by examination with a blue light, aids detection of corneal epithelial defect (eFigure 7–5).

eFigure 7–5.

Arrow shows corneal epithelial defect before (top) and after (bottom) instillation of fluorescein.

Downloaded 2024­9­16 6:14 P Your IP is 72.24.242.248

7­02: Ocular Examination, Jacque L. Duncan; Neeti B. Parikh; Gerami D. Seitzman Page 6 / 8
©2024 McGraw Hill. All Rights Reserved. Terms of Use • Privacy Policy • Notice • Accessibility
by examination with a blue light, aids detection of corneal epithelial defect (eFigure 7–5).
Austin College
eFigure 7–5.
Access Provided by:

Arrow shows corneal epithelial defect before (top) and after (bottom) instillation of fluorescein.

8. DIRECT OPHTHALMOSCOPY
Direct ophthalmoscopy, ideally following pupil dilation with tropicamide 0.5–1% that rarely induces angle­closure glaucoma, primarily examines the
fundus (eFigure 7–6) but clarity of the red reflex and fundal details indicates the degree of media opacity. Abnormalities are localized to the cornea,
lens, or vitreous by variations of focus of the ophthalmoscope and use of parallax.

eFigure 7–6.

Ultra­widefield (Optomap) image of normal fundus of left eye showing the optic disk (black arrow), central retina (macula and fovea) (white arrow) and
peripheral retina. (Used, with permission, from Optos plc.)

Downloaded 2024­9­16 6:14 P Your IP is 72.24.242.248

7­02: Ocular Examination, Jacque L. Duncan; Neeti B. Parikh; Gerami D. Seitzman Page 7 / 8
©2024 McGraw Hill. All Rights Reserved. Terms of Use • Privacy Policy • Notice • Accessibility
eFigure 7–6.
Austin College
Access Provided by:
Ultra­widefield (Optomap) image of normal fundus of left eye showing the optic disk (black arrow), central retina (macula and fovea) (white arrow) and
peripheral retina. (Used, with permission, from Optos plc.)

The optic disk is examined for swelling, pallor, and glaucomatous cupping. Macular lesions causing poor central vision are usually apparent. The
retinal vessels are scrutinized for caliber and wall changes. Retinal hemorrhages, hard exudates, and cotton­wool spots are noted. In hospital patients,
dilation should be noted in the record to avoid confusion on neurologic examination.

Fundus photography without pupil dilation (nonmydriatic) and smartphone technology have provided alternative methods of fundus examination that
require less expertise.

Shah D et al. Utility of a smartphone assisted direct ophthalmoscope camera for a general practitioner in screening of diabetic retinopathy at a
primary health care center. Indian J Ophthalmol. 2021;69:3144.
[PubMed: 34708758]

Downloaded 2024­9­16 6:14 P Your IP is 72.24.242.248

7­02: Ocular Examination, Jacque L. Duncan; Neeti B. Parikh; Gerami D. Seitzman Page 8 / 8
©2024 McGraw Hill. All Rights Reserved. Terms of Use • Privacy Policy • Notice • Accessibility