Getting called to the ER in the middle of the night, you will be working in less than ideal environments more times than not. The key is to remember that you are there for the patient and to address their issues efficiently. Here are some pointers for the standard eight-point exam, with tips for when you are on call.
1. Visual acuity
- Make sure that the patient is wearing his or her correction if possible, and use pinhole to determine best acuity.
- If you are checking vision at near, make sure the patient uses +2.75 or +3.00 readers.
Tip: Have a near card, +2.50 loose lens and pinhole occluder with you. More times than not, patients will not have their glasses in the emergent setting.
- Observe pupil size and shape in the dark, using an indirect light source.
- Check the reactivity of each pupil separately with a muscle light or penlight, and then perform the swinging-flashlight test to evaluate for an afferent pupillary defect.
- If an anisocoria exists in dark lighting, check pupil shape and size in the light as well.
Tip: You must check for a relative afferent pupillary defect. Remember that you can check for it by reverse.
3. Extraocular motility and alignment
- Check corneal light reflexes to assess alignment. If not centered in pupils, perform cover testing.
- Have the patient follow an object in the six cardinal directions to assess versions (ductions are tested monocularly).
- Document muscle under action with a minus (–), over action with a plus (+) on a scale of 1 to 4, with 0 being normal motility.
Tip: Make sure to check all nine cardinal positions of gaze. The ER staff’s “blessing” of motility with a four-point exam is not adequate.
- Try to record applanation tonometry if possible; however, a Tono-Pen may be easier to use in ED.
- Remember to record the time of pressure measurements.
Tip: Applanation is ideal, but Tono-Pen is acceptable in most cases. Sometimes palpation is all that you have.
5. Visual field
- Document visual-field defects from the patient’s perspective.
- Make sure you assess all four visual-field quadrants.
- Use a small object, like a cotton tip applicator or eye drop bottle, to more accurately document a scotoma.
- If the patient has poor acuity (i.e., worse than count fingers), you can assess field with hand motion or light.
Tip: Using dilation drop caps or small red balls also allows determination of subtle color desaturation. An Amsler grid can be very helpful when assessing macular issues.
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 refl ex and the edge of the upper or lower lid.
- Assess skin for any suspicious lesions that may need biopsy.
- Use an exophthalmometer to measure the degree of proptosis in millimeters.
- Test CNII-VIII if patient has sudden onset of diplopia or other neurologic symptoms.
Tip: Look for facial asymmetry, ptosis and proptosis.
7. Slit-lamp examination
- The exam should document the lids/lashes/lacrimal system, conjunctiva/sclera, cornea, anterior chamber, iris and lens.
- The length and width of any infiltrates, scars or epithelial defects should by measured so that they can be followed.
Tip: Sometimes a slit lamp is not available or not practical due to trauma. A penlight/muscle light exam is better than nothing in these situations.
- 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 an indirect ophthalmoscope to assess the retina periphery for tears/defects.
- The slit lamp can be used to visualize the anterior vitreous and identify heme and pigmented or white cells.
- Any fundus pathology should be accurately drawn and the size documented in units such as disc diameters or disc areas.
Tip: Always be systematic in your exam.
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|About the author: Edward Hu, MD, PhD, is a cataract specialist practicing in Iowa’s Quad Cities. After graduating from the Massachusetts Institute of Technology, he received both his MD and a PhD in retinal electrophysiology from the New York University School of Medicine. He completed his residency at the University of Iowa Hospitals and Clinics, perennially ranked one of the top three training programs in the country.