It’s important to establish a routine ophthalmic exam so that you don’t miss anything, especially in an emergency setting. Here are some tips for the standard eight-point eye exam to help you be thorough and stay efficient.
1. Visual acuity
If possible, examine the patient in his or her own corrective lenses.
- To pinhole in a pinch, punch a few holes into a piece of paper with the back of an earring. (You can always borrow one!)
- Bring a near card and +3.00 readers with you to examine the patient’s visual acuity at near.
- Be careful about distinguishing low-vision patients from those with no light perception. Make sure to occlude the contralateral eye well and test light perception with projection in each quadrant. This may be key to determining your management.
- Check the size and shape of both pupils in a dimly lit room.
- Note the reactivity of each pupil separately to light and then with a swinging light to assess for a relative afferent pupillary defect. (You can use your smartphone’s display and flash as ambient and direct light sources, respectively.)
- While you are close to the patient, make note of any gross changes, e.g., lacerations, peaked pupil, flat anterior chamber, etc.
3. Intraocular pressure
- Although applanation is preferable, a handheld tonometer is often sufficient in the emergency setting.
- Resort to digital palpation only if there are no other tools available.
- Avoid this step if there is evidence of a ruptured globe.
4. External exam
- Inspect and palpate the temples, skin and lymph nodes. Look for any lid malposition, lagophthalmos, lacerations, step-off fractures and globe dystopia (include a worm’s-eye view).
- Check for any facial weakness or asymmetry.
- Include globe retropulsion to check for resistance.
5. Extraocular muscles
- Confirm alignment using a corneal light reflex test, with the patient fixating in primary gaze.
- With the patient following an object, check all nine diagnostic positions of gaze.
- If vergences (binocular) are abnormal, ductions (monocular examination) can help distinguish the etiology of overactions or underactions.
6. Visual fields
- With the patient in primary gaze, check his or her monocular confrontational visual fields.
- Use a brightly colored eye drop bottle cap to determine the boundaries of scotomas, especially when paracentral.
- Depending on the case, do a relative red desaturation test and color plates may be relevant as well.
7. Slit-lamp exam
Consider the adnexa, lids, lashes and lacrimal system before moving on to the globe.
- Note irregularities in the sclera and conjunctiva, including the fornices and limbus.
- Examine the cornea, anterior chamber, iris and lens. (Remember to use retroillumination.)
- Note the dimensions and position of epithelial defects, lacerations and opacities.
8. Posterior segment
- Examine the vitreous, optic nerve, macula, vessels and posterior pole via slit-lamp biomicroscopy, if possible.
- Make a note of the cup-to-disc ratio and any asymmetry between both eyes.
- For patients suffering from trauma or limited mobility, indirect ophthalmoscopy may be your only option. (It’s also better for gross and peripheral findings, especially with the aid of scleral depression.)
The extent of your examination may vary depending on the nature of the consult. Nevertheless, developing a reproducible routine early on in your training will allow for quicker comprehensive assessments, even in a chaotic emergency setting.
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About the author: James G. Chelnis, MD, is preparing for his oculoplastics fellowship, which starts in July at Vanderbilt University. He is currently a senior resident at the University at Buffalo, where he graduated from medical school and was the school government president. In this role, he helped renegotiate the university’s health insurance terms with their provider, create a nationwide student–alumnus network, and organize a “Career Day” to place students in direct contact with physicians of all specialties prior to clinical rotations.