Visual Acuity: Opthalmology CEX Steps

Opthalmology CEX Steps
1. VISUAL ACUITY
1 Inspection My patient is a elderly Chinese gentleman. On inspection, I do not note

obvious pathology such as pthiasis bulbi, occular deviation, or ptosis. He is
not wearing spectacles.
2 Snellen Chart I will first test distance vision with a Snellen chart at 6m
Sir, please cover your right eye and read out the letters
His visual acuity without pinhole is ----
3 Pinhole Sir, please look through this pinhole and read out the letters
His visual acuity with pinhole is ---, which is an improvement over the vision
without pinhole, suggesting a refractive error.
(Repeat for contralateral eye)
4 Near vision Sir, please look at this near-vision chart and read out the letters
5 If poor vision Count fingers at 1m, then
Hand movement, then
Perception of light.
6 Summary Offer additional tests as appropriate
2. VISUAL FIELDS
1 Inspection Sir, please cover your right eye.

Gross visual field Can you see my face? How many fingers do you see?
2 Central field Count fingers in 4 quadrants centrally:
Sir, please look straight at my nose. Tell me how many fingers you see.
Repeat for contralateral eye
3 Peripheral field Sir, I will wriggle my finger and move it in from the side. Look straight at my
nose. When you see my finger appear, say “yes” and point to the finger.
Wriggle finger in from 4 peripheral quadrants
4 Red hat pin Sir, this is a red object. I will move it in from the side. Look straight at my
nose. When you can see the object AND the object is red, say “yes” and
point to where the object is.
Move red hat pin in 8 planes: 30°, 60°, 120°, 150°, 210°, 240°, 300°, 330°
5 Presentation My patient is a elderly Chinese gentleman.
On confrontation visual field testing, he shows a (e.g.)
 Bitemporal hemianopia suggesting an optic chiasmal lesion e.g. a
pituitary adenoma
 Congruent right homonymous hemianopia with macular sparing
suggesting a lesion posteriorly in the left occipital lobe
 Right superior quadrantanopia suggesting a lesion in the left
temporal lobe
 Right inferior quadrantanopia suggesting a lesion in the left parietal
lobe
 Inferior altitudinal defect suggesting ischemic optic neuropathy
 Restricted peripheral vision, e.g. due to glaucomatous changes
 Monocular blindness suggesting a right optic nerve / eye lesion.
I will like to
 Verify my findings using static automated perimetry
 Examine cranial nerves / colour vision (optic neuropathy) /
fundoscopy (glaucoma) / IOP (glaucoma)
3. RED REFLEX AND DIRECT FUNDOSCOPY
1 Inspection Sir, I am going to look in your eyes. The light may be a little bright but it will
not hurt you. I will come quite close, please let me know if you feel
uncomfortable.
2 Red reflex [Opthalmoscope 1m in front of patient, look for bilateral red reflexes]. E.g.
 Bilateral red reflexes are present and symmetrical
 There is decreased red reflex on the left, which may be due to a
pathology e.g. cataract
3 Fundoscopy Describe
 Demography
 Optic disk: margin (sharp vs blur), colour (pink vs pale), cup-disk
ratio (<0.6), neovascularization
 Vessels: tortuosity, microaneurysms, AV nipping)
 Additional features: cotton wool spots (peripheral, fluffy), exudates
(central, more defined, in DM eye), drusen (in non-DM eye)
 Macula: neovascularization, etc
I will like to (offer as relevant)
 Test visual acuity / IOP / visual fields / check for RAPD
Yellow spots may be

 Cotton wool spots: fluffy edge, outside macula
 Hard exudates: in DM eyes, harder edges, harder to trace edge as
may clump together
 Drusen: in non DM eyes, individual lesions
Red colour may be

 Microaneurysm, dot/blot haemorrhage
 Subretina bleed (vessels on top – from choroid vessels in wet AMD)
 Retinal bleed
 CRVO type bleed
 Subhyaloid bleed (the precursor to vitreous haemorrhage
 Vitreous haemorrhage (will have hazy view)
4. PUPIL EXAM
Either (i) RAPD type, or (ii) anisocoria type.
1 Inspection My patient is an elderly Chinese gentleman. On inspection, I do not note

ptosis, head tilt, or obvious occular deviation which I will like to confirm on
Hirschburg testing
2 Anisocoria [Lights on then off for rest of steps]
 There is no anisocoria in light or in dark
 There is anisocoria, worse in the dark. The constricted left pupil is
abnormal. Possible etiologies include Horner’s syndrome, and
drugs e.g. opiates
 There is anisocoria, worse in the light. The dilated right pupil is
abnormal. Possible etiologies include a surgical CN III palsy, drugs
e.g. mydriatic eyedrops
3 Direct light reflex [One eye, pause, other eye]
4 Consensual [Need 2nd diffuse light]
 On illuminating the right eye, the left pupil constricts normally
5 RAPD [Swing rapidly from one eye to the next]
 There is no RAPD
 On illuminating the right pupil, the left pupil paradoxically dilates.
This is a right RAPD suggesting a lesion of the right optic nerve (e.g.
optic neuropathy, advanced glaucoma) or a large retinal lesion.
** Do not confuse Hippus (pupil constricts then dilates) for RAPD. Hippus is
normal.
6 Accomodation
7 Complete exam I will like to complete my examination by
 Horner’s case: testing extraocular eye movements, confirming
Horner’s using cocaine eyedrops, localizing the lesion using
hydroxyamphetamine eye drops, examining the lung apex, the T1
muscles, and the neck
 RAPD case: performing fundoscopy for signs of optic nerve
pathology or large retinal disease.
5. HIRSCHBURG & COVER TESTS
1 Inspection My patient is an young Malay boy. On inspection, I do not note any head tilt.
The patient is bespectacled.
2 Hirschberg There is visible exotropia which I will like to confirm on Hirschberg testing.
There is unequal corneal light reflex, deviating is abt 1mm, corresponding to
7° of squint
3 Cover test [Cover right, look at left eye. Uncover right, look at right eye]
 Occlusion of the right eye causes the left eye to turn out to fixate.
On uncovering, I notice that the right eye had turned in (may or
may not turn out to take up fixation). This confirms a esotropia
 Occlusion of the right eye causes the left eye to turn in to fixate
On uncovering, I notice that the right eye had turned out (may or
may not turn in to take up fixation again). This is a exotropia
4 Alternate cover [Cover right, cover left, cover right, cover left]
test  With both eyes open, there is no exotropia.
On occluding the right eye, the left eye takes up fixation
When the left eye is rapidly occluded, the right eye turns in.
When the right eye is rapidly occluded, the left eye turns in
This is a exophoria
 With both eyes open, there is no esotropia.
On occluding the right eye, the left eye takes up fixation
When the left eye is rapidly occluded, the right eye turns out.
When the right eye is rapidly occluded, the left eye turns out
This is a esophoria
5 Extraocular See EOM testing.
muscles  There is no EOM deficit. The strabismus is concomitant
 There is an EOM deficit. The strabismus is likely incomitant
6 Complete I will like to complete my examination by using prisms to identify the degree
of misalignment
6. EOM
1 Inspection My patient is an elderly Chinese gentleman. On inspection, I do not note

ptosis or head tilt. However the right eye is adducted and there is esotropia
which I will like to confirm on Hirschburg testing
2 Versions Sir, can you see my red ball? Do you see one or two? Please look at my red
ball, don’t move your head, only move your eyes. If you see one, say “one”,
if you see double, see “two”
Test movements in 9 positions
3 Ductions If there is any deficit, cover the “normal” eye and test movement again. If
movement is now normal, it was not due to a nerve palsy
4 Complete Based on identified pathology, e.g.
 CN3: check pupils, vertical gaze
 CN6: fundoscopy for papilloedema for raised ICP
 CN4: Parks-Bielchowsky 3-step test
 Cerebellar signs, other CN, long tract signs
 Fatigability for MG
7. Anterior segment
1 Inspection My patient is an elderly Chinese gentleman. On inspection, I note that his

eyes are not erythematous and there is no discharge.
2 Pentorch exam Sir, I will look into your eyes. I will use a cotton bud to lift your eyelid, it may
be slightly uncomfortable but will not be painful.
In his left eye, there is a 5mm x 5mm opacity at the 2 o’clock position of the
cornea, 5mm away from the centre of the cornea.
3 Fluorescein I will like to stain his eyes with fluorescein and examine under cobalt blue
light.
The left eye corneal opacity does not light up under fluorescein stain
suggesting that the epithelial defect has healed.
4 Summary Given the lack of erythema, discharge, and epithelial defect, the most likely
pathology is a healed scar due to an old cornea ulcer

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Opthalmology CEX Steps

1 Inspection My patient is a elderly Chinese gentleman. On inspection, I do not note

1 Inspection Sir, please cover your right eye.

Yellow spots may be

Red colour may be

Either (i) RAPD type, or (ii) anisocoria type.

1 Inspection My patient is an elderly Chinese gentleman. On inspection, I do not note

5. HIRSCHBURG & COVER TESTS

1 Inspection My patient is an elderly Chinese gentleman. On inspection, I do not note

1 Inspection My patient is an elderly Chinese gentleman. On inspection, I note that his

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