Nervous | Eye History, Examination

Presenting complaint:
• Onset: gradual vs. sudden vs. asymptomatic.
• Duration: brief vs. continuous.
• Location: focal vs. diffuse, unilateral vs. bilateral.
Eye Hx: squint, amblyopia, glasses, glaucoma.
Family Hx: squint, lazy eye, glasses, glaucoma, cataract (young person).
Past medical Hx: especially vascular (diabetes, hypertension).
Medications: current meds, Hx of drugs affecting eye.
• Is pt on or been on eye drops.
Social Hx: relevant post-op (to put eye drops in).

In all, looking for asymmetry, deformities, discoloration, redness, discharge, lesions.

Diagnostic facies.
Orbit, rim: palpate for lumps.
Brow: lost sweating (Horner's).
Eyelids: xanthelasma, ectropian, entropian.
Eyelids: pus on lids (blepharitis).
Ptosis.
Exophthalmos.
Iris: colour, defects.
Cornea: transparent vs. opaque, corneal arcus, band keratopthy, Kayser-Fleischer rings, lesion, scars.
Ask the patient to look up and pull down both lower eyelids to inspect the conjuntiva and sclera.
• Conjunctiva: clear/infected. If conjuntivitis, wash hands immediately: viral form contagious.
• Sclera: jaundice, pallor, injection.
Spread each eye open with Dr's thumb, index finger. Ask pt to look to each side and downward to expose entire bulbar surface.
• Eyeball tenderness.

If eye pain, injury, visual loss, check visual acuity before rest of the exam or inserting medications into eyes [so don't get sued].

Let pt to use glasses, contacts if available.
Put pt 20 feet from Snellen eye chart, or hold Rosenbaum pocket card 14 inches away.
Pt. covers an eye at a time with a card, reading smaller letters till stop.
Record smallest line read, eg 20/40.

Stand 2 feet in front of pt, who looks in Dr's eyes at eye-level.
Dr's hands to side half way between Dr and pt, wiggle fingers, ask which they see move.
Repeat 2-3 to test both temporal fields.
If suspect abnormality, test 4 quadrants of each eye while card covers other.

Darken room, adjust scope so light is no brighter than necessary.
Adjust aperture to a plain white circle.
Set diopter dial to zero, unless have a preferred setting.
Dr. uses left hand and left eye to examine the patient's left eye.
Dr's free hand onto the pt's shoulder or forehead for control.
Tell pt to stare at wall.
Look through scope, shine light into pt's eye from 2 feet away at a 45º angle.
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 vessel and follow it to the optic disk, use this as a point of reference.
Inspect optic disk:
• Colour of disc: pink vs. pale.
• Margins clear.
• State of cup.
Inspect vessels: all 4 quadrants, veins are darker than arteries:
• Bleeding, exudate.
• Pigmentation, occlusion.
Inspect macula, by moving the scope nasally:
• Foveal light reflex
• Bleeding, exudate.
• Edema, drusen.

Shape, relative size.
Light reaction: dim lights if needed.
• Pt looks in distance, shine light in from side to gauge pupil's light reaction. Record size, irregularity.
• Assess both direct (same eye) and consensual (other eye) responses.
Assess afferent pupillary defect by moving light in arc from pupil to pupil, and if L eye light makes R eye dilate, not constrict (Marcus Gunne). Optionally: as do arc test, have pt place a flat hand extending vertically from his face, between his eyes, to act as a blinder so light can only go into one eye at a time.
Accommodation: pt alternates between looking into distance, and a hat pin 30cm from nose.

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