Key Takeaways for Eye Physical Examination
1. The comprehensive eye examination must systematically evaluate both anterior and posterior structures, with pupillary dilation essential for optimal visualization of posterior segment pathology 1
The examination follows a structured anterior-to-posterior approach:
Anterior Segment Assessment:
- Visual acuity with current correction at distance and near, with refraction when indicated 1
- External examination including eyelid position and character, lashes, lacrimal apparatus and tear function, globe position, and pertinent facial features 1
- Pupillary function assessing size and response to light, including evaluation for relative afferent pupillary defect 1
- Ocular alignment and motility using cover/uncover test, alternate cover test, and assessment of ductions and versions 1
- Slit-lamp biomicroscopy examining eyelid margins and lashes, tear film, conjunctiva, sclera, cornea, anterior chamber depth (central and peripheral), iris, lens, and anterior vitreous 1
- Intraocular pressure measurement preferably with contact applanation (Goldmann tonometer), though contact tonometry should be deferred with suspected ocular infection or corneal trauma 1
Posterior Segment Assessment:
- Fundus examination requires evaluation of mid and posterior vitreous, retina (including posterior pole and periphery), vasculature, and optic nerve 1
- Dilation is mandatory for optimal examination—evaluation of structures posterior to the iris is best performed through a dilated pupil 1
- Indirect ophthalmoscopy or slit-lamp fundus biomicroscopy with appropriate accessory diagnostic lenses is required for optimal examination of optic nerve, macula, and peripheral retina 1
Critical Pitfall: Attempting to adequately examine the posterior segment without dilation will miss significant pathology. The guidelines explicitly state that examination of anterior segment structures involves evaluation both before and after dilation 1.
2. Visual field testing by confrontation and red reflex examination are non-negotiable screening components that detect vision-threatening pathology often missed by visual acuity alone 1
Visual Fields by Confrontation:
- This is a required element of every comprehensive eye examination 1
- Detects neurological pathology affecting the visual pathway that may present with normal visual acuity 1
Red Reflex Examination:
- Must be performed before pupillary dilation because subtle differences in the red reflex are difficult to detect once pupils are dilated 1
- A symmetric red reflex from both eyes is required for normal 1
- Abnormal findings include opacities within the red reflex, markedly diminished reflex, white or dull reflex, or asymmetry between eyes 1
- The appearance varies by race/ethnicity based on retinal pigmentation—emphasis is on symmetry rather than color 1
- Refractive error patterns: Significant hyperopia presents as an inferiorly placed brighter crescent; significant myopia presents as a superiorly placed brighter crescent 1
- Critical for detecting retinoblastoma: A white pupil/reflex indicates possible retinoblastoma and requires immediate referral 1
Pupillary Examination Technique:
- Assess size, shape, symmetry, and response to light 1
- Swinging-light test is mandatory to detect relative afferent pupillary defect (RAPD) 1
- Perform in darkened room with patient fixing on distant target 1
- Shine light in each eye for less than 5 seconds, then swing quickly to opposite eye 1
- Normal response: pupillary constriction or no change 1
- Abnormal response: pupillary dilation when light shined on that eye indicates afferent pupil defect, usually signifying unilateral optic nerve or anterior visual pathway pathology 1
Common Pitfall: Relying solely on visual acuity testing misses significant pathology. Visual acuity alone may underestimate functional impact of disease; glare testing and contrast sensitivity provide additional critical information 2.
3. Specialized testing beyond the standard examination is indicated based on history and initial findings, not performed routinely, and must be selected strategically to evaluate specific structures or functions 1
The guidelines explicitly distinguish between routine comprehensive examination elements and specialized testing that is not routinely part of the comprehensive medical eye clinical evaluation 1.
Specialized Clinical Evaluations (performed selectively):
- Monocular near-vision testing 1
- Potential acuity testing 1
- Glare testing 1
- Contrast sensitivity testing 1
- Color-vision testing 1
- Testing of stereoacuity and fusion 1
- Testing of accommodation and convergence amplitudes 1
- Central visual field testing (Amsler grid) 1
- Expanded evaluation of ocular motility and alignment in multiple fields of gaze 1
- Exophthalmometry (Hertel) 1
- Tear breakup time 1
- Ocular surface vital dye staining 1
- Corneal sensation 1
- Gonioscopy 1
- Functional evaluation of nasolacrimal system 1
- Indirect ophthalmoscopy with scleral indentation 1
- Contact lens stereoscopic biomicroscopy (Goldmann three-mirror lens) 1
Additional Diagnostic Testing (when indicated):
- Keratometry to assess surface quality and power 1
- Corneal topography/tomography with analysis 1, 2
- Corneal thickness measurement (pachymetry) 1
- Corneal endothelial cell analysis 1
- Optical coherence tomography of anterior and posterior segments 1, 2
- Visual fields by automated/manual perimetry 1
- Ophthalmic ultrasonography 1
- Fluorescein or indocyanine green angiography 1
Strategic Selection Principles:
- Base selection on patient history and initial examination findings 1
- For cataract evaluation, corneal topography/tomography assesses corneal irregularities affecting surgical planning, and macular OCT rules out concurrent retinal pathology 2
- For dry eye evaluation, tear breakup time, ocular surface vital dye staining, and assessment of meibomian gland function are indicated 1
- For strabismus evaluation, binocular field testing maps the region of single binocular vision, and forced duction testing confirms mechanical restriction 1
Critical Pitfall: Ordering extensive testing routinely without clinical indication wastes resources and may generate false-positive results requiring unnecessary follow-up. Testing must be targeted based on specific clinical findings 1.