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    The 8-Point Eye Exam

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    The foundation of an informative ophthalmic exam is to be systematic, organized and thorough.

    But how do you make sure you cover your bases, while adopting time-tested techniques and tools? Here are eight tips to make sure you perform the best exam and provide patients with a positive experience.

    1. Check Visual Acuity

    • In the clinic, visual acuity is measured monocularly using a distance chart. In a consult setting, near vision is assessed using a near card. Ensure good illumination on the vision chart.
    • Before starting, ask the patient to wear the appropriate correction. Always have a pinhole occluder because it may improve vision impacted by uncorrected refractive
    • Ask the patient to read the smallest line possible. If they are unable to read the largest optotype, then check if the patient can count fingers (CF), see hand motion (HM) or perceive light (LP). If you’re working with a small child who can’t talk, assess vision by describing whether the eye is central, steady or maintained (CSM).

    Central: The corneal light reflex is in the center of the pupil.

    Steady: Test fixation on a moving light source.

    Maintained: Test if fixation is maintained with the viewing eye when a previously occluded eye is uncovered.

    2. Examine Pupils

    • Evaluate both pupils in ambient light to check for
    • Have the patient fixate on a distant target to minimize
    • Check if both eyes react equally to bright light by constricting and dim light by dilating.
    • Check for a relative afferent pupillary defect with a swinging flashlight test.

    3. Assess Extraocular Motility and Alignment

    • Ask the patient to look in the six cardinal positions of gaze and note any differences between the two eyes (see Figure 1). Test binocularly to assess versions and monocularly to assess ductions.
    • Use the cover/uncover test to assess for heterotropia and alternate the cover test to assess for the total amount of deviation. This amount minus any heterotropia is the amount of heterophoria.
    Figure 1.
    Figure 2.

    4. Measure Intraocular Pressure

    • Goldmann applanation tonometry is the gold standard and should be used whenever possible. If unavailable, Tono-Pen tonometry may be used. A rebound tonometer (e.g., iCare) is the best option for examining children.
    • Avoid placing pressure on the globe when holding the patient’s eyelids open to avoid falsely elevating the
    • If a ruptured globe is suspected, avoid checking intraocular pressure.

    5. Check Confrontation Visual Fields

    • Assess each quadrant monocularly by having the patient count the number of fingers that you hold up. If acuity is particularly poor, have the patient note the presence of light.

    6. Do an External Exam

    • Start by assessing the eyelids, eyebrows and midface. Note any facial asymmetry. The position of the brows is assessed relative to the superior orbital rim. Midface is evaluated by presence of prominence or
    • Check for globe dystopia, exophthalmos or
    • Examine the periorbital region for lesions that may require a Check the eyelid position by measuring the margin-to-reflex distance. Assess for lagophthalmos. Perform a complete cranial nerve exam for patients with neurological symptoms.

    7. Do a Slit-Lamp Exam

    • Start anterior to posterior with the lids, lashes and lacrimal system.
    • Next, evaluate the conjunctiva and sclera for injection, chemosis and unusual lesions.
    • Then evaluate the anterior and posterior chambers for depth and presence of cell, flare or heme. Lastly, evaluate the lens.

    8. Perform a Fundoscopic Exam

    • Assess the optic nerve’s cup-to-disc ratio. Check for thinning, pallor or elevation (see Figure 2).
    • Evaluate the macula for a foveal light reflex, drusen, edema or exudates.
    • Next evaluate the vessels’ course and
    • Finally, evaluate the peripheral retina for tears, holes, lesions or pigmentary changes. At the slit lamp, variations of a 90D or 78D lens can provide a magnified view to assess subtle changes of the nerve, vessels and macula. 20D or 28D lenses are used to assess peripheral retinal pathology and provide a larger dynamic field of view.

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    Duaa Sharfi, MDDuaa Sharfi, MD, is a comprehensive ophthalmologist and completed her fellowship in global ophthalmology at the Emory University School of Medicine in Atlanta. She joined the YO International subcommittee in 2023.