I don’t know about you but I personally don’t like being this close to a random person. Also, this examination reminds me of holding my breath near the optician incase I had bad breathe, even though nine times out of ten they had bad breathe anyway. Regardless, we all need to know how to do this examination, so even if you don’t like it, you’re going to have to power on through and do it.
- Wash your hands, tell the patient what will happen, check that they are okay with this and check that you have everything you need. (pro tip: it’s an ISCE, you will do)
- Start by asking them to remove glasses or contact lenses if they normally wear them.
- Then, inspect the eyes, look for
- Proptosis, bulging of the eye balls (tends to happen in thyrotoxicosis).
- Ptosis, drooping eyelids, can be caused by neuromuscular issues or conditions such as hypothyroidism.
- Look at their conjunctiva, is it red or inflamed? Filled with yellow gunk like in conjunctivitis?
- Look at their pupils, inspect for any differences in size, again this can have a neuromuscular cause such as a lesion to the occulomotor nerve.
- Test pupillary reflexes, shine the ophthalmoscope at the patient’s pupil and watch that one contract then do it again with a hand between their eyes blocking the light and watch the other pupil contract. Repeat on the other side.
- Test their visual acuity using the snellen chart, their acuity is measured by the lowest level that they can read perfectly. The snellen chart works by the definition that at 6 metres they should be able to read the line down that has a 6 attached to it, they should be able to read the line with 12 attached to it at 12m as it is twice the size. I wouldn’t worry too much about it though, it’s the type of thing you tend to send people to their optician about. Say you would test visual acuity but you don’t need to do it for year two ISCE’s
- Now you need to test their visual fields. Grab a white hat pin and do the double H movement to test their visual field, its covered in more detail in the cranial nerves examination.
- Then test their blind spot using a red hat pin, again this is talked about more in the cranial nerves examination post.
- Next, we move onto ophthalmoscopy. Make sure the patient is facing away from any light and draw the blinds if you can. Then put the ophthalmoscope on its lowest setting, the white zero, and adjust to what your visual acuity needs numbers wise (this is something you need to figure out when you practice). Use your right hand and right eye to look at the patients right eye. It tends to help to place your other hand on their forehead so you don’t go too close and warn them that you will be invading their personal space.
- Ask them to look at a distant object over your shoulder and assess their red reflex. Do this by holding the ophthalmoscope about 10cm away from their eye and move it around until you find the reflex. Normally your ophthalmoscope will be on the temporal side just above the horizontal midline. Then staying at this angle, gradually move closer to the patient.
- Examine the retinal vessels, optic disk, and macula in turn. You may need to practice this a lot as its sometimes hard to keep focus. A pale disk could be due to ischaemia of the optic blood vessels. Flame haemorrhages can be due to high blood pressure. Diabetic patients can have multiple blot haemorrhages showing lots of vascular breakdown and new vessel formation. My point is that a lot can be wrong so either learn it all or get good at describing what you are seeing.
- You should slowly move away from the eye now. Then repeat with the other eye. Finally, turn the ophthalmoscope off and thank your patient before washing your hands. Jump on over to your skill.
Well Done and Good Luck!!
Macleod, J., Douglas, G., Nicol, E. and Robertson, C. (2009). Macleod’s clinical examination. Edinburgh: Elsevier Churchill Livingstone.
Testing the Brain: What Neurological Exams Can Tell Us About Ourselves – Brain Connection [Internet]. Brain Connection. 2018 [cited 29 March 2018]. Available from: https://brainconnection.brainhq.com/2008/08/06/testing-the-brain-what-neurological-exams-can-tell-us-about-ourselves/
Eye Movements – Cranial Nerves [Internet]. Cranial Nerves. 2018 [cited 11 March 2018]. Available from: https://bmc.med.utoronto.ca/cranialnerves/illustrations-by-chapter/eye-movements
Figure 11.1 Anatomy of the human eye. Box 11A(1) Myopia and Other Refractive Errors. – ppt download [Internet]. Slideplayer.com. 2018 [cited 29 March 2018]. Available from: http://slideplayer.com/slide/7698549/