Ocular examination and imaging

techniques
 The general order for nonemergency
examination
• 1History. Present complaints, previous eye disorders, family eye
problems, present and past general illnesses, medications, and
allergies.
• 2. Visual acuity. Distant and near without and with glasses, if used,
and with pinhole if less than 20/30 is obtained.
• 3. Extraocular muscle function. Range of action in all fields of gaze,
stereopsis testing, and screening for strabismus and diplopia.
• 4. Color vision testing.
• 5. Anterior segment examination under some magnification if possible
(loupe or slitlamp), with and without fluorescein or rose bengal dyes.
• 6.Intraocular pressures (IOPs).
• 7. Ophthalmoscopy of the fundi.
• 8. Visual field testing.
 The general order for nonemergency
examination
• 9. Other tests as indicated by history and prior examination:
• a. Tear film adequacy and drainage.
• b. Corneal sensation.
• c. Transillumination.
• d. Exophthalmometry.
• e. Keratoscopy.
• f. Keratometry.
• g. Gonioscopy.
• h. Corneal topography.
• i. Corneal pachymetry.
• j. Specular microscopy.
 The general order for nonemergency
examination
• k. Confocal slit-scanning microscopy.
• l. Fluorescein and indocyanine green angiography.
• m. Electroretinography (ERG) and
electrooculography (EOG).
• n. Ultrasonography.
• o. Radiology, tomography, magnetic imaging.
• p. Optical coherence tomography
• q. Scanning laser retinal nerve fiber analysis.
Routine office examination techniques

• Visual acuity - Determination of visual acuity

is a test of macular function and should be
part of any eye examination, regardless of
symptomatology or lack there of.

• https://www.youtube.com/watch?v=ovuyPrffi
qg
 Distant visual acuity
• Visual acuity is examined one eye at a time, the
other eye being occluded. If the patient
normally wears glasses, the test should be
made both with and without corrected lenses
and recorded as “uncorrected” and “corrected”
(sc or cc).
• The chart most commonly used for distance
vision with literate patients The chart most
commonly used for distance vision with
literate patients is the Snellen chart
• Preschool children or patients who are unable to read should be shown
the Illiterate E chart, which is made up entirely of the letter E facing in
different directions.
• Children as young as 3 years of age may be able to cooperate in this
testing. Another form of testing is with Allen cards, which are small cards
with test pictures printed on each one;
• If a patient is unable to identify any letter on the chart at any distance,
visual acuity is recorded as counting fingers (CF) at whatever distance
thepatient is able to perform this function, e.g., CF 3. Vision less than CF is
recorded as hand motion or light perception (LP). If an eye is unable to
perceive light, the examiner should record no light perception rather than
the misleading term blind.
• If a patient is unable to identify any letter on the chart at any distance,
visual acuity is recorded as counting fingers (CF) at whatever distance
thepatient is able to perform this function, e.g., CF 3. Vision less than CF is
recorded as hand motion or light perception (LP). If an eye is unable to
perceive light, the examiner should record no light perception rather than
the misleading term blind.
 Color vision testing
• Purpose. Demonstration of adequate color vision is mandatory
for certain jobs in a number of states and for obtaining a driver's
license. Jobs affected are armed services trainees, transportation
workers, and others whose occupations require accurate color
perception. Color vision, particularly red perception, may be
disturbed in early macular disease, whether toxic or idiopathic
• degenerative, and in optic nerve, chiasmal, or bilateral occipital
lobe disease. Some of the earliest and reversible drug toxicities,
such as that from chloroquine and avitaminosis A are detected by
repeated color vision testing; regression and progression may
also be documented.
• Tests: polychromatic plates of Ishihara, Stilling, or Hardy-Rand-
Ritter …….
 Anterior segment examination

• Magnifying loupes. The external examination of

the eye itself is greatly facilitated by the use of a
bright light source, such as a flashlight or
transilluminator, and a magnifying loupe.
• Slitlamp biomicroscopy of anterior segment and
fundus. Biomicroscopy involves examination of
the external ocular structures and the front of
the eye to a depth ofthe anterior vitreous using a
specially designed microscope and light source.
 Biomicroscopy
The general order of examination is to start with the lids and then
progress to the conjunctiva, cornea, anterior chamber, iris and
pupil, lens, and anterior vitreous. The fundi are seen by use of
double ashperic 60, 78, or 90 D lenses handheld before the eye.
The examiner shines the slit beamstraight through the (usually)
dilated pupil to focus on the retina, thus obtaining astereoscopic
but inverted view. This is useful for evaluating macular edema,
optic nerve lesions, or other posterior pole lesions. It is less
useful for the peripheral retina beyond the equator. Other
techniques for views of the deeper vitreous, retina.
https://www.youtube.com/watch?v=ZD5vzrOIm5c
https://www.youtube.com/watch?v=gHW5OYj1Gf8
 IOP measurements for glaucoma or hypotony

• Finger tension. A rough estimate of IOP may be made by palpation

of the eyeball
• through closed lids
• Tonometry. Accurate IOP may be determined by use of tonometers.
If the IOP is between 22 and 25 mm Hg or more, ocular hypertension
or glaucoma must be considered. Visual field and ophthalmoscopic
study of the nerve head should be performed
• A. Schiötz tonometry;
• B. Applanation tonometry
• C. The pneumotonometer
• Tonography is an electronic Schiötz measurement over 4 minutes to
determine the rate of aqueous outflow from the anterior chamber. It
is currently used infrequently. A coefficient of outflow factor less than
0 is suspicious of glaucoma.
 Gonioscopy

The visually inaccessible anterior chamber angle

may be viewed directly with gonioscopic
techniques that involve the use of a contact lens,
focal illumination, and magnification. The contact
lens eliminates the corneal curve and allows light
to be reflected from the angle so that its
structures may be seen in detail.This procedure
may be performed with topical anesthetic drops
at the slitlamp and such lenses as the Alan-
Thorpe, Goldmann, or Zeiss lenses, all of which
have periscopic mirrors by which the angle is
examined with reflected light. This technique is
most useful in determining various forms of
glaucoma, iris tumors , cysts as well as in the
evaluation of trauma to the tissues in the area of
the angle.
 Direct ophthalmoscopy

Examination of the posterior segment of the

eye (vitreous, optic nerve head or disk,
vessels, retina, choroid) is performed with
the aid of an ophthalmoscope. A satisfactory
examination of the posterior pole can usually
be made through an undilated pupil,
provided that the media (aqueous, lens,
vitreous) are clear. However, a greater extent
of the peripheral posterior segment can be
examined through a dilated pupil.
Ophthalmoscopy is best done in a darkened
room.
https://www.youtube.com/watch?v=5LvUm
OFOsGA
 Indirect ophthalmoscopy
Indirect ophthalmoscopy is a technique
generally used by specialists and involves the
use of a head-mounted, prism-directed light
source coupled with use of double aspheric (+14,
+20, or +28) diopter condensing lenses to see the
retinal image. The image covers approximately
ten times the area usually seen in the field of
the direct ophthalmoscope, but is smaller than a
direct ophthalmoscope (3×), although the larger
field of view gives great perspective to the entire
fundus and is helpful in locating multiple lesions
or in evaluating retinal detachment. Another
advantage is stronger illumination, which allows
light to pass through opacities of the vitreous
obstructive to a direct ophthalmoscope.
 Visual field testing
• The purpose of visual field testing is to determine both the outer limits of
visual perception by the peripheral retina and the varying qualities of vision
within that area. Visual field interpretation is important for diagnosing disease,
localizing it in the visual pathway between the retina and the occipital cortex in
the brain, and noting its progress, stability, or remission. As a result, repeated
tests of the visual field are important both diagnostically and in ascertaining the
effects of therapy. Each eye is tested separately. With one eye fixing on a given
distant test object, the sensitivity of various areas of the visual field may be
tested with varying size and color of test objects moved throughout that field.
The greatest sensitivity, of course, is at the fovea and represents the highest
visual acuity of central fixation. This visual acuity decreases rapidly as the test
objects are moved away from central fixation. Colored objects offer less stimulus
to the retina than white objects of similar size.Therefore, an object may be too
small to be detected by peripheral retinal receptors,but quite effective in
mapping out central visual field within 10 to 15 degrees offoveal fixation.
 Techniques for Visual fields
examination
• Amsler grid
https
://www.aao.org/eye-health/tips-prevention/fact
s-about-amsler-grid-daily-vision-test
• Confrontation
• perimetry
• tangent screen.
 Perimetry
• Perimetry is the systematic measurement of visual field function. The two
most commonly used types of perimetry are Goldmann kinetic perimetry
and threshold static automated perimetry. With Goldmann or "kinetic"
perimetry, a trained perimetrist moves the stimulus; stimulus brightness is
held constant. The limits of the visual field are mapped to lights of different
sizes and brightness.
• With threshold static automated perimetry, a computer program is selected.
The most commonly used one tests the central 30° of the visual field using a
six degree spaced grid. This is accomplished by keeping the size and location
of a target constant and varying the brightness until the dimmest target the
patient can see at each of the test locations is found. These maps of visual
sensitivity, made by either of these methods, are very important in
diagnosing diseases of the visual system. Different patterns of visual loss are
found with diseases of the eye, optic nerve central nervous system.
 Tear film adequacy: clinical tests

• The testing of tear film

adequacy can be divided into
three separate areas: (a) tear
quantity, (b) tear quality, and (c)
tear film stability. Each is of
importance in determining the
role of the tear film in the
symptomatology and pathologic
changes noted in dry eye (https
://www.tearfilm.org/dettconferences-diagnostic_videos/5582_5581/eng/)

• https
://flei.com/portfolio-items/dry-eye-testing-tear-bre
akup-time/
 Corneal sensation

• Corneal sensation is tested prior to topical anesthetics by

gently touching the cornea with a wisp of cotton (drawn out
from the end of a cotton-tip applicator) and comparing each
eye against the other on a 0 to 10 scale of increasing
sensitivity.
Transillumination
• Intense light, such as that from a small handheld flashlight,
placed on the sclera in successive quadrants behind the ciliary
body will be transmitted inside the eye, where it produces a
red reflex in the pupil. Intraocular masses, such as malignant
melanoma containing pigment, will block the light when it is
placed over the tumor, thus diminishing or preventing the red
reflex. Atrophy of the iris pigment layer or ciliary body may
also be revealed by transillumination.
 Extraocular muscle function
• In the primary position of gaze (i.e., straight ahead) the straightness, or
orthophoria, of the eyes may be ascertained by observing the reflection of
light on the central corneas. The patient is asked to look directly at a
flashlight held 30 cm in front of the eye. Normally, the light reflection is
symmetric and central in both corneas. The asymmetric positioning of a
light reflex in one eye indicates deviation of that eye.
• Cardinal positions of gaze. The patient is asked to look in the six cardinal
positions of gaze, i.e., left, right, up and right, up and left, down and right,
and down and left.
• The near point of conversion (NPC) is the point closest to the patient at
which both eyes converge on an object as it is brought toward the eyes.
This point is normally50 to 70 mm in front of the eye. The moment one eye
begins to deviate outward, the limit of conversion has been reached. An
NPC greater than 10 cm is considered abnormal and may result in excessive
tiring of the eyes on close work such as reading or sewing.
• https://www.youtube.com/watch?v=zkFlXjC8eEY
 Exophthalmometry
• The exophthalmometer (Hertel) is used to determine the degree of anterior
projection or prominence of the eyes. This instrument is helpful in
diagnosing and in following the course of exophthalmos.
• 1. Technique. The patient holds the head straight and looks directly at the
examiner's eyes. Two small concave attachments of the exophthalmometer
are placed against the lateral orbital margins, and the distance between
these two points is recorded from the central bar. This distance must be
constant for all successive examinations in order to judge accurately the
status of ocular protrusion. The examiner views the cornea of the patient's
right eye in the mirror while the patient fixes the right eye on the examiner's
left eye. Simultaneously, the cornea is lined up in the mirror with the cale,
which reads directly in millimeters. A similar reading is then taken from the
left eye with the patient fixing on the examiner's right eye. The bar reading
and the degree of exophthalmos are then recorded in millimeters; e.g., a bar
reading of 100 might have right eye 17 mm, left eye 18 mm.
 Keratometry

• The keratometer is an instrument generally used for

measuring corneal astigmatism in two main meridians. It
is particularly useful in the fitting of corneal contact
lenses, but may also be used to detect irregular
astigmatism and early pathologic states such as
keratoconus. Successive readings several months apart
will indicate progression or stability of corneal disease.
The device is similar to a slitlamp in use. The corneal
reflex is evaluated for regularity and measured at 90-
degree axes in the two meridians of greatest difference,
i.e., the flattest and steepest planes.
 Corneal topography
• Corneal topography is done with
computerized machines which use
video capture of concentric circle
Placido disk images to produce
videokeratographs in the form of colorcoded
dioptric contour maps which show even subtle
variations in power distribution plots, and can calculate the
power and location of the steepest and flattest meridians,
similar to values given by a keratometer. Corneal diagnosis
and changes may be monitored by sequential topography
and include disorders such as keratoconus, contact lens
warping of the cornea, postoperative healing patterns
(keratoplasty, cataract, tight sutures, radial keratotomy,
excimer laser photorefractive keratectomy), marginal
degenerations, and keratoglobus.
 Corneal pachymetry

• Pachymeters measure corneal thickness (normal

0.50 to 0.65 mm, thicker peripherally) and are good
indicators of endothelial function as well as being
useful in calculating blade set for radial keratotomy.
Optical pachymeters attach to the slitlamp and are
quite reliable, but are subject to reader variation.
Ultrasonic pachymeters can record readings at
multiple corneal sites with a vertical applanating tip,
thus minimizing errors caused by tilting, but also
making peripheral readings more difficult.
 Fluorescein and indocyanine green (ICG) angiography
of the fundus
• Fluorescein angiography (FA) has proved to be a valuable tool in the diagnosis and
management of a large number of retinal disorders that affect either the retinal vascular
system or the choriocapillaris, Bruch m embrane.
• After the patient's pupils have been dilated, he or she is seated at a slitlamp mounted with
a fundus camera and equipped with both exciter and barrier interference filters. These
filters will allow only green light from the fluorescent dye passing through the vessels to be
recorded on the film, thus exclusively outlining the vascular pattern and pathologic
structures contained therein. Five milliliters of sodium fluorescein 10%, a harmless and
painless dye, is injected into the antecubital vein. Photographs of one eye are taken at 5
seconds and then every second thereafter for 15 more seconds. Photographs will then be
taken for up to 1 minute at 3- to 5-second intervals and then repeated at 20 minutes in
both eyes. Occasionally, in patients with sensory epithelial detachments or diffuse retinal
edema, photographs embrane, or the pigment epithelial layers.
• ERG - ERG is a technique of placing an ocular fitted
contact lens electrode on the patient's eye so that
recordings of electrical responses from various parts
of the retina to external stimulation by light of varying
intensity may be made. The A and B waves originate
in the outer retinal layers, the A wave being produced
by the photoreceptor cells and the B wave by the
interconnecting Müller cells. The ERG is an important
instrument in the detection and evaluation of
hereditary and constitutional disorders of the retina.
• EOG is an electrical recording based on the standing
potential of the eye. The EOG is useful in situations in
which the ERG is not sufficiently sensitive to detect
macular degeneration. This includes Best's disease
(vitelliform macular degeneration), in which the ERG is
abnormal even in carriers, and early toxic retinopathies
such as those caused by chloroquine or other antimalarial
drugs. Supranormal EOGs have been found in albinism
and aniridia, in which chronic excessive light exposure
appears to have resulted in attendant peripheral retinal
damage. The EOG records metabolic changes in RPE as
well as in the neuroretina. Therefore, it serves as a test
that is supplemental and complementary to the ERG and,
in certain disease states, more sensitive than the ERG.
 Ultrasonography
• commonly used are A-mode, B-mode, high-
frequency ultrasound; optical coherence
tomography (OCT); and confocal scanning
laser ophthalmoscopy.

• A-mode is a one-dimensional time-

amplitude representation of echoes received
along the beam path. The distance between
the echo spikes recorded on the oscilloscope
screen provides an indirect measurement of
tissue such as globe length or lens thickness.
• Routine B-scan ultrasound is performed
using 10 MHz or less and is useful in
detecting retinal detachments, swollen
cataracts, hyphemas, and ciliary body
detachment in hypotonous eyes.
• High-frequency ultrasound is a newer, more
sensitive technique using up to 50 to 60 MHz
and detecting anterior segment pathology in
great detail. high frequency scans are being
developed, up to 150 MHz, particularly
• for corneal evaluation, e.g., for use with
excimer laser surgery.
OCT complements all of the ultrasound
techniques described in this section in
posterior segment evaluation. It is a
noncontact, noninvasive cross-sectional
imaging technique that does not
require immersion of the eye and can
detect and measure changes in tissue
thickness with micron-scale sensitivity
to produce high-resolution
measurements and images of the eye.
Imaging of the anatomic layers within
the retina and quantitation of the optic
nerve fiber layer is quite accurate and
correlates well with glaucoma status.
 Radiologic studies of the eye and orbit

Radiologic examination of the eye and orbit is useful

in evaluating trauma, foreign bodies, and tumors.
• X- ray
• CT scan -
• M RI - MRI is the procedure of choice for soft
tissue anatomy and pathology and vascularized
lesions of global, orbital, and neuroophthalmic
structures from the orbit through the brain