How do you examine the eyes?

Comprehensive Eye Examination Procedure

A comprehensive eye examination should include a systematic assessment of visual function and ocular structures, beginning with visual acuity testing and concluding with a dilated fundus examination to evaluate the posterior segment of the eye. 1

Initial Assessment

Visual Acuity Testing

• Measure distance visual acuity with current correction (record power of present correction)
• Test at standardized distance (typically 20 feet/6 meters for Snellen charts)
• Test each eye separately (monocular testing) using appropriate occlusion technique
• For children under 3 years: assess fixation and following ability
• For children 3-5 years: use age-appropriate charts (Snellen letters, HOTV, LEA symbols) 1

Refraction

• Perform objective and/or subjective refraction when indicated
• Document spherical and cylindrical components with axis

Visual Field Assessment

• Perform confrontation visual fields as a screening tool
• Test each eye separately in all four quadrants
• Consider automated perimetry when indicated

External Examination

• Evaluate eyelid position and function
• Assess lacrimal apparatus and tear function
• Examine conjunctiva, sclera, and cornea
• Note globe position and pertinent facial features
• Document any abnormalities of external structures 1

Pupillary Assessment

• Evaluate pupil size and shape
• Test pupillary light response (direct and consensual)
• Check for relative afferent pupillary defect (RAPD) using swinging flashlight test
• Document any abnormalities in pupillary function 1

Ocular Alignment and Motility

• Perform cover/uncover test and alternate cover test
• Assess ocular ductions and versions in all fields of gaze
• For children: perform cross cover test at 10 feet (3 meters) and consider random dot E stereo test at 40 cm
• Document any eye movement abnormalities 1

Slit-Lamp Biomicroscopy

• Examine systematically from anterior to posterior:
  • Eyelid margins and lashes
  • Tear film
  • Conjunctiva and sclera
  • Cornea
  • Anterior chamber (depth and clarity)
  • Iris
  • Lens
  • Anterior vitreous 1

Intraocular Pressure Measurement

• Measure using contact applanation method (typically Goldmann tonometer)
• May defer contact tonometry if ocular infection or corneal trauma is suspected
• Document pressure readings for each eye 1

Red Reflex Testing

• Perform in a darkened room using direct ophthalmoscope
• View eyes separately at 12-18 inches
• Normal reflex should be bright reddish-yellow (light gray in darkly pigmented eyes)
• Document any asymmetry in color, brightness, or size
• White pupil, dark spots, or absent reflex requires immediate referral 1

Dilated Fundus Examination

• Dilate pupils unless contraindicated
• Examine mid and posterior vitreous, retina (posterior pole and periphery), vasculature, and optic nerve
• Use indirect ophthalmoscope or slit-lamp biomicroscopy with appropriate diagnostic lenses
• Document any abnormalities of posterior segment structures 1

Special Considerations

For Children

• Adapt examination techniques based on age and cooperation level
• For newborns to 3 years: focus on fixation patterns, external examination, pupillary response, and red reflex
• For children over 3 years: add age-appropriate visual acuity testing and attempt ophthalmoscopy 1

For Specific Conditions

• Consider specialized testing based on findings:
  • Gonioscopy for angle assessment
  • Corneal topography for corneal disorders
  • Optical coherence tomography for retinal or optic nerve evaluation
  • Visual field testing for glaucoma or neurological disorders 1

Common Pitfalls to Avoid

1. Inadequate pupillary dilation: Failure to dilate pupils may result in missed peripheral retinal pathology.
2. Improper visual acuity testing: Ensure proper occlusion technique and appropriate testing distance.
3. Overlooking subtle signs: Pay attention to small changes in the optic nerve, macula, or peripheral retina.
4. Incomplete documentation: Record all findings systematically for future comparison.
5. Failure to correlate findings: Consider how different examination elements relate to each other and to the patient's symptoms.

By following this systematic approach to eye examination, clinicians can effectively detect ocular abnormalities that may impact visual function and overall health, allowing for timely intervention to preserve vision and quality of life.