1. Visual acuity
- Make sure that the patient is wearing his or her correction, if possible, and use pinhole to determine the best acuity.
- If checking vision at near, make sure patient uses +2.75 or +3.00 readers.
- Observe pupil size and shape with an indirect light source in the dark.
- Check the reactivity of each pupil separately using a muscle light or pen light, then perform the swinging-flashlight test to evaluate for an afferent pupillary defect.
3. Extraocular motility and alignment
- If an anisocoria exists in dark lighting, check pupil shape and size in the light as well.
- Check corneal light reflexes to assess alignment; if not centered in pupils, perform cover testing.
- Have patient follow an object in the six cardinal directions to assess versions (ductions are tested monocularly).
- Document muscle under action with a (-) and over action with (+) on scale of 1-4, with 0 being normal motility.
- Try to record applanation tonometry if possible; however, a Tonopen may be easier to use in ED.
- Record time of pressure measurement.
5. Visual field
- Document visual-field defects from patient’s perspective.
- Make sure you assess all four visual field quadrants.
- Use a small object, like a cotton tip applicator or eyedrop bottle, to more accurately document a scotoma.
- If patient has poor acuity (i.e., worse than count fingers), you can assess field with hand motion or light.
6. External examination
- Assess structures like lymph nodes and temporal arteries as indicated by the history.
- Assess lid position by measuring marginal reflex distance from pupillary light reflex and edge of upper or lower lid.
- Assess skin for any suspicious lesions that may need biopsy.
- Use an exophthalmometer to measure degree of proptosis in millimeters.
- Test CNII-VIII if patient has sudden onset of diplopia or other neurologic symptoms.
7. Slit-lamp examination
- The exam should document lids/lashes/lacrimal system, conjunctiva/sclera, cornea, anterior chamber, iris and lens.
- Any infiltrates, scars or epithelial defects should by measured in both length and width so they can be followed.
- Perform slit-lamp biomicroscopy to evaluate the optic nerve, macula and vessels.
- Make note of the cup-to-disc ratio, asymmetry between the optic nerves and any focal thinning.
- Use indirect ophthalmoscope to assess retina periphery for tears/defects.
- The slit lamp can be used to visualize the anterior vitreous to look for heme, pigmented or white cells.
- Any fundus pathology should be accurately drawn and size documented in units such as disc diameters or disc areas.
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About the author: David E. Vollman, MD, is a clinical instructor in the department of ophthalmology and visual sciences at the Washington University School of Medicine and a staff ophthalmologist at the John Cochran VA Medical Center in St. Louis, Mo.