Introduction à l’examen physique de l’œil Copy

Introduction to the physical examination of the eye

A physical examination of the eye is a critical element of vision screening. The environment for the physical examination should be arranged to be as private as possible. Lighting should be adequate, and equipment should be arranged on a clean surface. The worker should be prepared for the physical examination with a clear description of what will be done. In addition, all required tools need to be readily available.

The physical examination of the eye starts before the worker enters the vision testing room. When the worker is collected from reception, watch the worker respond to instructions, how he / she walks and navigates through the clinic, and orientates to the facilities in the vision testing room, this is all part of the “meet – seat – and – greet”. The technician and the worker must be seated comfortably, at the same level, and privacy must be maintained. This is followed by the history which has been discussed above. Explain each step of any procedure or examination and ensure that the worker understands and gives verbal consent, (as there is no invasive procedures a written consent is not required).  An examination of the eye includes an external examination, examination by ophthalmoscope, and an assessment of the various functions of the eye. After completion of the physical examination the vision is tested. When recording the findings of an eye examination comment if the person wears spectacles, has blindness or any visual impairment including photosensitivity, pain, or itchiness.


Discreetly observe the patient for facial symmetry and profile. This can be done during the history taking. Observe the patient’s face from the front and the side. Obvious asymmetry may indicate underlying conditions such as neoplastic growths, muscle atrophy or hypertrophy, and neurological problems.

Inspect the overall appearance of the face – are the eyes and ears at the same level?
Use a pencil and measure from the tip of the outer eye to the tip of the ear lobe, this should be at the same level and then from the edge of the nose to the edge of the inner eye.
Is the head an appropriate size for the body?
Is the face symmetrical – no drooping of the face on one side (eyes or lips)? This can happen in Bell’s palsy, Guillain-bar or after a stroke. See Figure 7.9 below for examples.
Are the facial expressions symmetrical – no involuntary movements, twitches, or ticks?
Any lesions?
Test cranial nerve VII – facial nerve by asking the patient to close their eyes tightly, smile, frown, puff out the cheeks and assess whether they can do this with ease?

Figure 7.9: Examples of Asymmetry22

Figure 7.10: Comparison between Symmetrical and Asymmetrical23

During the inspection of the eyes, observe the eyebrows, eyelids, eyelashes, lachrymal apparatus and around the eyes for any abnormalities before looking at the eye itself. Always conduct an eye inspection after the worker has removed his / her glasses.

Conditions of the external structures of the eye and what to assess during inspection:

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When recording the findings of an eye inspection comment if the person wears spectacles, is blind (which eye) and describe the abnormality, duration of the problem and treatment used.

Table 7.1 Common Abnormalities of the Eye which can be identified during the examination

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Conditions of the eye and what to look for in the inspection focusing on the eye itself:

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Figure 7.11 below: A normal sclera43

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Figure 7.12 below: A normal conjunctiva20

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Figure 7.13: A cataract on the lens44

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Figure 7.14: Different abnormalities Identified during inspection47

Palpation of the Eye

The only palpation done of the eye is when measuring intraocular pressure (IOP). Whilst this is usually measured by an optometrist at a diagnostic assessment, this method can assist in assessing IOP initially. It is possible to detect very high IOP using your fingertips. The accuracy is better if the examiner is familiar with this examination method, practice it first on yourself and then on your colleagues (with their permission) before assessing workers.

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Ask the person being assessed to close their eyes and look down.
Place the tips of both index fingers on the closed upper eyelid. Keeping both fingertips in contact with the upper eyelid, apply gentle pressure through the closed eyelid, first gently pressing on the eye with the right index finger, then with the left, and then with the right again (Figure 7.5).
Repeat on the other eye.
A normal eye should feel a bit like a tomato that is just ripe: not solid, nor very soft
It is important to compare the two eyes with one another. An eye with very high IOP will feel abnormally hard and solid.37

Assessment of the various functions of the eye

The next set of assessments is usually done after inspection and palpation. These assessments require basic tools or equipment and patient co-operation. The assessments test whether the various parts of the eyes are functioning normally.

The pupils – dilate, constrict, and accommodate
Convergence and divergence
Light reflex
Blink reflex
Cardinal fields of gaze or cardinal muscle assessment and cranial nerves

Assessing the pupils

The pupil’s function is assessed in various ways. Testing whether the pupils react to light and accommodate is one of the first assessments done on the eyes. Accommodation is the ability of the eye (lens) to change its focus from distant to near objects and vice versa. This process is achieved by the lens changing its shape. Explained another way, accommodation is the adjustment lens of the eye to keep an object in focus on the retina as its distance from the eye varies. It is the process of adjusting the focal length of a lens.


This is an acronym that means “Pupils equal and round and reactive to light and accommodation”.

Turn the lights off or dim them.
Ask the worker to look at an object or picture directly behind you keeping the eyes open. This dilates the pupils. Normal pupil size should be 3 to 5 mm and equal.
The pupils should be round and equal in size.
Using an examination / pupil torch shine a light coming in from the side in each eye near each ear bringing the light towards the centre of the eye.
Test each eye separately.
The pupil being assessed is the one with the light shining in it, it should constrict, note the dilated size and constricted size (for example: pupil size reduced from 3 mm to 1 mm and back to 3mm).
At the same time assess the pupil not being tested as it should constrict and dilate at the same time.
Repeat the test on the 2nd eye.
If both eyes react the same by dilating and constricting and dilating again, they are reactive to light and accommodate.

Video 7.1: PEARRLA Exam1

Convergence and Divergence

Convergence is the ability to turn the two eyes inward toward each other to look at a close object. We depend on this visual skill for near-work activities such as desk work, working on a smartphone type device, and for sports when catching a ball. When the eyes converge, they start focusing and the pupils get slightly smaller. This set of three processes – technically termed convergence, accommodation, and miosis – is known as the near triad. Divergence is the opposite of convergence and is the ability to turn the two eyes outwards to look at a distant object and the pupils dilate. This skill is required for any distance activities such as reading, driving, and watching TV. If the eyes are unable to converge effectively this may cause double vision when looking at close objects. Convergence can be affected by the functioning of the muscles and varies with age.

The room should be well illuminated so examiner can notice minimal changes in eye movements.
The worker should be seated in front of the technician and look directly at an object, called the fixation object, in the mid-sagittal plane.
The technician should sit infront of the worker so that the eyes of both (technician and worker) are at the same level.
Hold the fixation object at approximately 50 cm away from the worker in the mid-sagittal line.
The technician should move the fixation object slowly and smoothly in the mid-sagittal plane closer to the workers’ nose. Move slowly at approximately 40cm in 10 seconds.
Ask the worker to follow the fixation object with the eyes.
The technician should watch both eyes of the worker to ensure both eyes move smoothly and symmetrically inwards and back to 50cm. The pupils should start dilating and constricting as the fixation object gets closer to the nose, this is convergence and once the eyes have followed the fixation object back to the 50cm position is divergence.
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Corneal Light Reflex / Hirschberg Test

A corneal light reflex test, also known as the Hirschberg test, is a simple test that checks eye alignment. This is done by observing how light is reflected from the cornea of the eyes. This assessment is particularly useful for testing for strabismus (misalignment of the eyes).

Ask the worker to stare at an imaginary picture of an object behind you, the technician.
From a distance of 60cm in the mid-sagittal line, shine a light source (from a small examination torch) equally into the worker’s eyes.
Observe the reflection of light off the cornea, in both eyes, they should be in the same position in each eye and should appear as a pin-point white (dot) light near the centre of the pupil in each eye see figure 7.17 below.
If the light reflects in a different position, this is a misalignment of the eyes and an abnormal finding. The location of the corneal reflex will appear asymmetrical or “off centre” of the pupil in the deviating eye.

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Figure 7.16: Normal alignment and corneal light reflex52

Figure 7.17: Abnormal eye alignment and corneal light reflex53

Video 7.2: Corneal Reflex Exam2

Video 7.3: Examination of the Pupils3

Figure 7.18: Anisocoria. Top picture are normal pupils42

Testing the Cardinal Muscles and Cranial Nerves

As discussed in Chapters 1 and 2 (the anatomy and physiology of the eye), eye movement is controlled by 3 cranial nerves and 6 cardinal muscles / extraocular muscles. Therefore, the technician is required to test the cranial nerve and muscles to assess normal function.

The room should be well illuminated so the examiner can notice minimal changes in eye movements.
The worker should be seated in front of the technician and look directly at an object, called the fixation object, in the mid-sagittal plane.
The technician should sit in front of the worker so that the eyes of both (technician and worker) are at the same level.
Hold the fixation object at approximately 50 – 60cm away from the worker in the mid-sagittal line.
Ask the worker to follow the fixation object without moving the head – follow the direction of the object with the eyes
The technician always starts and ends in the midline position. Move the fixation object slowly from the middle of the eye and to each of the 8 positions indicated in Figure’s 7.21 and 7.22 returning back to the midline – there are 9 positions to be tested however 8 are physically tested as the neutral position is held to start with. The order does not matter.
  1. Front middle – looking straight ahead (neutral position)
  2. Superior (straight up)
  3. Inferior (straight down)
  4. Superior and oblique (to the side of the nose and up)
  5. Superior and oblique (to the side of the ear and up)
  6. lateral (straight to the side of the ear)
  7. Medial (straight to the side of the nose)
  8. Lateral and inferior (down and to the side of the ear)
  9. Medial and inferior (down and to the side of the ear)
The eyes both left and right should move smoothly, together without any uncontrolled, and involuntary movements and be able to follow the fixation object easily.
Uncontrolled or involuntary movements of the eye is called a nystagmus. These movements often result in reduced vision and depth perception and can affect balance and coordination. These involuntary eye movements can occur from side to side, up and down, or in a circular pattern.
By assessing the cardinal fields of gaze all the cranial nerves – III (oculomotor), IV (trochlear), VI (abducens) have been tested

Figure 7.19: The 9 Cardinal Fields of Gaze54

Figure 7.20: 9 Cardinal Positions or Fields of Gaze55

Video 7.4: Cardinal Fields of Gaze4

Blink Reflex

The corneal reflex, also known as the blink reflex or eyelid reflex is an involuntary blinking of the eyelids elicited by stimulation which is controlled by the trigeminal and facial cranial nerves. The reflex occurs at a rapid rate of 0.1 seconds. The purpose of this reflex is to protect the eyes from foreign bodies and bright.

The room should be well illuminated so the examiner can notice minimal eye movements.
Prepare a clean piece of cotton wool, ensuring there is a thin strand.
Approaching the worker’s eye from the side (ear), out of his / her line of sight.
Lightly touch the thin strand of cotton wool on the eyelashes.
Observe for blinking, of the cornea is touch observe tearing in that eye (direct corneal reflex).
At the same time, observe the other eye, it should blink and or tear at the same time (consensual corneal reflex).
Repeat the process with a clean piece of cotton wool in the other eye.

Fundoscopy – not a requirement of the vision screening course

Whilst this assessment is not required for vision screening and will not be assessed for completeness a short segment is included for practitioners who do perform this assessment and are already using this technique as part of the eye examination.
By looking through the various lenses of an ophthalmoscope, the trained examiner can view and assess the internal structures of the eye. Fundoscopy is a test that is used to examine the back of the eye including the optic nerve head (called optic disc), retina and major blood vessels. The fundoscopic examination is typically only performed in certain situations (e.g., suspected intracranial hypertension or stroke). The ophthalmoscope is not difficult to use but it requires some practice. Try to get in the habit of using the ophthalmoscope to perform the examination in every eye examination.

Prepare the equipment, room, and person being assessed:

Check that the ophthalmoscope works—the batteries may be flat, or it may not have been charged. Some ophthalmoscopes have a small cover over their aperture which, if closed, may lead you to think that it is not working.
Switch the room lights off or dim them, but don’t make the room too dark.
Explain to the worker that a bright light is going to be used which can temporarily dazzle them and that the examination is being done to view the internal structures of the eye.
Position the worker so that he or she is comfortable but sitting up
Ask the worker to fixate (stare) at an object behind the examiner (for example, the corner of the room or curtain rail or picture). This spot should be located so that they are looking slightly away from you when they are examined—that is, to the left when you examine the right eye and vice versa.
Ask the worker NOT to blink and to look at the fixation spot no matter what.
It is best to examine the worker’s left eye with your own left eye and right eye with your own right eye—this takes practice. Try to keep your other eye open.
Place your hand on the worker’s forehead so that your fingers are splayed but your thumb is on the upper lid. This is important as you will use your thumb to hold the patient’s lid open and also the joint of your flexed thumb is exactly where your forehead needs to end up.

What is the examiner looking for?

Red reflex: Media opacities obscure the red reflex (corneal scars, cataract, and vitreous haemorrhage, and asteroid hyalosis).
Optic disc: Look for optic disc size, colour (pallor, congestion), cup disc ratio, margins, haemorrhages, new vessels, collaterals. The pale and clearly demarcated disc may be optic atrophy. Pathological cupping is a sign of glaucoma. New vessels on the disc are common in proliferative diabetic retinopathy. Yellow-grey disc with blurred margins with or without haemorrhages may be papilloedema
Vessels: Start at the disc and follow the vessels out to look for hypertensive and arteriosclerotic changes. Look as far as the mid-periphery for scars (inflammatory, laser), haemorrhages, exudates, pigment (white, black), and pigmented lesions. Examine arteries, veins (slightly thicker), and perivascular fundus. Look also for microaneurysms, blot haemorrhages, hard exudates which if there is a history of diabetes could indicate diabetic retinopathy; cotton wool spots (fluffy white patches), vessel changes such as venous beading, and venous loops are pre proliferative changes.
Macula: Find the macula temporal to the disc. The foveal reflex is seen better with a green (red-free) filter and is at two-disc diameters away from the disc and 1.5 degrees below the horizontal (the whole field of view is 8 degrees).

Figure7.21: A Normal Fundoscope59

Video 7.5: How to do a fundoscopy5

Video 7.6: The Assessment of the Eye6