OCANZ SKILLS EXAMINATION PROCEDURES

STATION 1
PART A: BINOCULAR VISION STATUS

COVER TEST – Distance and Near

SET-UP:
• Ensure that the patient is in a primary viewing position
• Patient should wear full distance Rx at the correct distance IPD for distance testing
and the near add should be incorporated with the near IPD for near testing
• Distance target: Isolate a 6/9 letter on the distance visual acuity chart OR a 6/12
letter if the patient’s BCVA is 6/9. Alternatively, if the BCVA is 6/12 or worse – opt for
a spot of light on the VA screen as the fixation target
• Near target: Preferably Gulden fixation stick but a near VA chart with a vertically
arranged column of letters should be sufficient – at a 40cm viewing distance – direct
patient’s attention to one letter in the column

PROCEDURE:
UNILATERAL COVER TEST:
1) Patient instruction: I am going to perform a test to assess your eye muscle strength. I
need you to focus on this letter and try to “keep it clear” throughout the test. I will
be moving this occluder between your eyes – are you okay with this or do you have
any questions? Okay great, from here onwards, I will be addressing the examiner as I
am performing the test.
2) Cover the RE and observe the LE for movement
3) After 1 – 2 seconds, remove the cover for 1 – 2 seconds to allow the patient to
regain fixation
4) Cover the LE and observe the RE for movement
a. To the examiner: I am performing the unilateral cover test to assess for the
presence of heterotropia. I’ve covered the right eye to break fusion and am
observing the left eye for any compensatory movements. No movement.
Now covering the left eye and observing the right eye for movement – again,
there isn’t any movement. This indicates that fixation is maintained under
both monocular and binocular conditions and there is no tropia present.
b. Esotropia → Outward movement of the uncovered eye
c. Exotropia → Inward movement of the uncovered eye
d. Hypertropia → Downward movement of the uncovered eye
e. Hypotropia → Upward movement of the uncovered eye
ALTERNATE + PRISM COVER TEST:
1) To the examiner:
a. I am now performing the alternating cover test to assess for the presence of
a heterophoria which is a latent/hidden deviation which only manifests upon
dissociation. I am moving this occluder to alternate between the eyes and
each time, I am observing the “just uncovered” eye for movement. I am
noting an inward pursuit movement of the eyes, in that they are moving
inwards in the same direction of the occluder movement – this indicates that
the eyes were deviated outwards beneath the occluder and have to move
inwards when the occluder is removed in order to regain fixation. This means
that the patient has an exophoria.
2) Move the occluder to alternate between the RE and LE every second to observe the
movement of the “just-uncovered”eye
a. Exophoria → Inward pursuit movement
b. Esophoria → Outward pursuit movement
c. Hyperphoria → Downward pursuit movement
d. Hypophoria → Upward pursuit movement
3) To the examiner:
a. I am now going to quantify the heterophoria with the prism cover test. As
noted, this patient has an exophoria and this will be neutralized with BI
prism. I’ve introduced BI prism over the right eye and will continue to move
the occluder between the eyes to observe the movement. The BI prism will
be progressively increased each time until there’s no longer any movement. I
am observing no movement at this point and will stop here.
4) Place a prism in front of the deviated eye and cover with the occluder
a. XOP/XOT → Neutralize with BI prism
b. SOP/SOT → Neutralize with BO prism
c. Hyperphoria/tropia → Neutralize with BD prism
d. Hypophoria/tropia → Neutralize with BU prism
5) Alternate the occluder between the eyes whilst observing the movement behind the
prism. Increase prism until the movement is neutralized.
6) Record whether the patient has a heterophoria/tropia and the amount and base
direction of the prism required to neutralize this as well as the test distance and
comment on the recovery, e.g. Cover Test: Exophoria – 10 prism BI with a
Smooth/Jerky/Slow recovery → Distance/Near (40cm)
7) Should the patient be strabismic – be sure to record further details, e.g. is it
constant, intermittent, unilateral or alternating?
8) Repeat the procedure at 40cm using a single 6/9 letter on a vertical row of letters on
a near fixation chart. Don’t forget to implement the near add if indicated and shift to
the near IPD!!
9) Norms: 2 SOP – 4 XOP at dx and 0 – 6 XOP at nx
MADDOX ROD – H and V at Distance and Near
SET-UP:
• Ensure that the patient is in a primary viewing position
• Patient should wear full distance Rx at the correct distance IPD for distance testing
and the near add should be incorporated with the near IPD for near testing
• The Maddox rod can be placed in front of the right eye with the lines running
horizontally – this will create a vertical red line and can be used to assess for
horizontal deviations
• Distance target: Examiner holds pen torch at 6 meters or stands behind the patient
in a 3 metre room – shining it at the mirror ahead
• Near target: Pen torch light at 40cm

PROCEDURE:
1) Patient Instruction:
a. I am now going to perform a different test to assess your eye muscle
strength. This involves having you wear this frame/sit behind this device (trial
frame/phoropter) whilst I introduce different lenses. I will also be relying on
your responses but I will explain along the way so are you okay with me
proceeding? Okay great, I’d like you to close your eyes for now while I set up
the frame/device. You can now open your eyes and blink a few times.
b. When I cover this eye (RE), what do you see? (Px: A vertical red line).
c. When I cover this eye (LE), what do you see? (Px: A spot of light).
d. Now that both eyes are open, what do you see? (Px: Both the red line and the
spot of light – if px only reports one target – indicates suppression)
e. Perfect, now I need you to tell me, does it appear as though the white spot is
on the red line? (Show px an illustrated image of what you expect them to
see – if they are superimposed – no further testing required. If they are apart,
ask patient to point to which illustration depicts what they are seeing (see
below: i.e. is the spot of light displaced towards the right or left of the vertical
red line)? Also ask them to comment on how far apart they are.
f. I am now going to place some lenses in front of your eyes to help bring the
line and spot closer together like in this image (show them the illustration
again). You have to stop me when they are fused like this, do you
understand?
2) Introduce prism over the right eye until patient reports fusion
a. Orthophoria: Spot is on the line
b. Exophoria: Spot is to the right of the line (crossed) → Neutralize with BI
c. Esophoria: Spot is to the left of the line (uncrossed) → Neutralize with BO
3) Rotate the Maddox rod by 90 degrees and repeat the procedure to detect vertical
phoria at distance – Patient will report seeing a horizontal line this time.
 a. Orthophoria: Spot is on the line
b. Right hypophoria: Spot below the line → Neutralize with BU
c. Right hyperphoria: Spot above the line → Neutralize with BD
4) Repeat the entire procedure at near to test for both horizontal and vertical phorias.
5) Record the phoria testing method used, the distance as well as the type of phoria
that the patient has and the amount and base direction that was required to
neutralize this. e.g. Exophoria → 6 prism BI → Maddox Rod at Distance/Near (40cm)
6) Norms: Children and Young Adults: 2 SOP – 4 XOP at dx and 0 – 6 XOP at nx ;
Presbyopes: 0 – 2 SOP at dx and 5 – 11 XOP at nx

OR:

VON GRAEFE – H and V at Distance and Near

SET-UP:
• Ensure that the patient is in a primary viewing position
• Patient should wear full distance Rx at the correct distance IPD for distance testing
and the near add should be incorporated with the near IPD for near testing
• Distance target: Isolated 6/9 letter or vertical row of letters
• Near target: Isolated 6/9 letter or vertical row of letters at 40cm
• Ask patient to close their eyes and place Risley prisms before both eyes (RE: 12 prism
BI (measuring prism) LE: 6 prism BD (dissociating prism))

PROCEDURE:
1) Patient Instruction:
a. I am now going to perform a different test to assess your eye muscle
strength. This involves having you wear this frame/sit behind this device (trial
frame/phoropter) whilst I introduce different lenses. I will also be relying on
your responses but I will explain along the way so are you okay with me
proceeding? Okay great, I’d like you to close your eyes for now while I set up
the frame/device. You can now open your eyes and blink a few times.
b. How many targets can you see? (Px: 2)
c. I will be moving the upper target from side to side until it is directly above the
lower target, like buttons on a shirt. I’d like you to look at the lower target
(seen by the LE) and try to keep it clear all the time. You need to stop me
when the targets are one above the other.
d. The bottom target is seen by the LE and the upper target is seen by the RE.
e. If the upper target is seen to the right of the lower target → uncrossed
diplopia and the measuring prism must be reduced.
 f. If the upper target is seen to the left of the lower target → crossed diplopia
and the measuring prism must be increased.
g. Increase/decrease the RE 12 prism BI at a rate of about 2 prism per second
2) Record the phoria testing method used, the distance as well as the type of phoria
that the patient has and the amount and base direction that was required to
neutralize this. e.g. Exophoria → 6 prism BI → von Graefe at Distance/Near (40cm)
3) Ask patient to close their eyes and Reset the prism to 12 BI RE and 6 BD LE
4) Patient instruction:
a. You can now open your eyes. How many targets can you see? (Px: 2)
b. I will be moving the lower target from side to side until it is directly next to
the upper target, like headlights on a car. I’d like you to look at the upper
target (seen by the RE) and try to keep it clear all the time. You need to stop
me when the targets are next to each other.
c. Start to decrease the 6 BD over the LE and ask the patient if the targets are
moving closer together or further apart. If they are moving closer together,
continue decreasing until patient reports alignment. If they are moving
further apart, increase the prism instead until patient reports alignment.
5) Record the phoria testing method used, the distance as well as the type of phoria
that the patient has and the amount and base direction that was required to
neutralize this. e.g. 2 prism R/L = 2 prism Right hyper and 2 prism Left Hypo → von
Graefe at Distance/Near (40cm); OR 3 prism L/R = 3 prism Left hyper and 3 Left hypo
6) Repeat the above process for both Horizontal and Vertical phoria testing at 40cm
HORIZONTAL VERGENCE TESTING AT NEAR
SET-UP:
• Ensure that the patient is in a primary viewing position
• Patient should be seated comfortably behind the phoropter, wearing their full
distance Rx and the near add should be incorporated + near IPD for near testing
• Near target: Vertical row of 6/9 letters on the near VA chart at 40cm
• Ask them to keep their eyes closed as you set up the phoropter
• Place the Risley prisms before both eyes and set them at zero. Position them with
the zeros pointing upwards (this enables you to introduce horizontal prism)

PROCEDURE:
1) Patient instruction:
a. This test is used to assess how well your eyes work together as a team. Again, I
would be relying on your responses for this test. Are you happy to begin? Lovely,
I’d like you to close your eyes whilst I set up the device. You can open your eyes
now.
b. Tell me, how many rows of letters can you see? (Patient should report seeing one
target – if the patient reports diplopia, introduce either BI or BO prism until
fusion occurs – this is your starting point)
c. I will be changing the lenses in front of your eyes. I need you to focus on this line
of letters and try to keep them single and clear for as long as you can. But tell me
as soon as they become blurry or double – do not look away or move away when
this happens.
d. Measuring reserves:
- Introduce BI prism at a rate of 2 prism per second simultaneously and equally
over both eyes
- Record the amount of prism when the patient reports blur (Blur)
- “Good, now continue staring at the target and tell me when they break up
into two lines of letters or when they are doubled.” Continue to add BI prism
and record the amount of prism when the patient reports diplopia (Break)
- “Great, now tell me when they become single again” Continue 2 – 4 prism
past the break point and then begin reducing BI prism until the patient
reports single vision again (Recovery)
- Perfect, you can sit back whilst I record these findings
- Come forward and keep your eyes closed whilst I reset the device
f. Repeat the above with BO prism at nx
g. You may sit back again whilst I record these findings
VERTICAL VERGENCE TESTING AT NEAR
SET UP:
• Ensure that the patient is in a primary viewing position
• Patient should be seated comfortably behind the phoropter, wearing their full
distance Rx and the near add should be incorporated + near IPD for near testing
• Near target: Horizontal row of 6/9 letters on the near VA chart at 40cm
• Ask them to keep their eyes closed as you set up the phoropter
• Place the Risley prisms before both eyes and set them at zero. Position them with
the zeros pointing inwards (this enables you to introduce vertical prism)

PROCEDURE:
2) Patient instruction:
e. Come forward again and keep your eyes closed whilst I reset the device. I’d like
you to open your eyes and tell me how many rows of letters you can see?
(Patient should report seeing one target – if the patient reports diplopia,
introduce either BI or BO prism until fusion occurs – this is your starting point)
f. I will be changing the lenses in front of your eyes. I need you to focus on this row
of letters and try to keep them single and clear for as long as you can. But tell me
as soon as they become blurry or double – do not look away or move away when
this happens.
g. Measuring reserves:
- Introduce BU prism at a rate of 2 prism per second over the RE only
- Record the amount of prism when the patient reports blur (Blur)
- “Good, now continue staring at the target and tell me when they break up
into two rows of letters or when they are doubled.” Continue to add BU
prism + record the amount of prism when the patient reports diplopia (Break)
- “Great, now tell me when they become single again” Continue 1 - 2 prism
past the break point and then begin reducing BI prism until the patient
reports single vision again (Recovery)
- Perfect, you can sit back whilst I record these findings
- Come forward once more and keep your eyes closed whilst I reset the device
h. Repeat the above with BD prism over the RE only at nx
i. Excellent, we’re all done, you can sit back now
5) Finally, record the reserves as BI/BO/BU/BD reserves: blur/break/recovery at 40cm
6) Norms:
a. BO (dx): 9/19/10
b. BI (dx): -/7/4
c. BO (nx): 17/21/11
d. BI (nx): 13/21/13
PART B: DISTANCE RETINOSCOPY – BOTH EYES
SET UP:
• Should a phoropter be used, the fitted Retinoscopy (R) fogging lenses are 1.50D
which indicates that you should maintain a 67cm working distance.
• Alternatively, a trial frame could be used with either +1.50D or +2.00D fogging lenses
at a 67cm/50cm working distance respectively.
• Both eyes should be adequately fogged throughout the procedure.
• It is possible to not use the working distance lenses but to ensure that this value is
subtracted from your final finding & that a large non-accommodative target is used.
This would give you the advantage of avoiding excessive reflections coming off
superimposed lenses on the trial frame – but not advisable on patients < 60yo.
• Patient Instruction: “For this test, I would have to shine some light into your eyes to
help give me an indication of the strength of glasses that you may need. The lights
would have to be switched off though, are you okay with this? Great, I’d like you to
look straight ahead at the red and green targets and let me know if I am blocking you
during this procedure. (IF you have used fogging lenses – It’s okay if they appear a bit
blurry as I need them to be this way for this test.)”
• Clean (alcohol swab or lens cloth) and adjust the trial frame or phoropter head and
put in the correct distance IPD. Switch the lights off and stand at the correct working
distance. Begin scoping with a wide thick ret beam (sleeve down).

PROCEDURE:
• Right Eye → Sit on patient’s right side and use your right eye
• Left Eye → Sit on the patient’s left side and use your left eye
• Ensure that you are looking through the patient’s visual axis by maintaining eye-
level. Adjust the patient’s chair or yours to set this up
• Scope the horizontal, vertical and oblique (45 & 135) meridians:
o All meridians moving at the same speed = Spherical
o One meridian moves faster than the other = Astigmatic
o Take note of the reflex speed, brightness and thickness along each meridian
• If astigmatic – determine the principal meridians by rotating the ret streak until it is
parallel to the patient’s ret reflex. If this is difficult to see, move the sleeve upwards
slightly to thin out the beam.
• Always begin by neutralizing the “more with/least against” movement → This will be
your sphere (The meridian with the slowest, dullest “with” OR fastest, brightest
“against” movement)
• Once the sphere is neutralized, rotate the beam by 90 degrees and scope a few
times, taking note of the axis of the ret reflex in relation to the retinoscope beam.
Align the cylinder axis to the ret reflex – when scoping, you should see an “against”
movement, then begin introducing minus cylinder to neutralize the astigmatism.
 • If you aren’t sure of which is the more with/least against meridian – just begin
neutralizing one meridian. When you rotate to the other meridian and see a “with”
movement, it means that this was supposed to be the spherical meridian. Continue
neutralizing this meridian with plus lenses, then rotate by 90 degrees and you should
now observe an against movement which you may neutralize with minus cylinder.
• To confirm the cylinder axis, assess the width and speed of the reflex at 45 degrees
on either side of the axis. If they appear equal, your axis is correct. If they are not the
same, change the axis by 5 degrees and check again. Once the reflexes appear
aligned on either side of the axis, lift up the sleeve to narrow your beam and read
the axis directly off the trial frame
• Record the final prescription in minus cylinder form taking care to subtract the
working distance lens and repeat the process for the other eye

STATION 2
PART A: SOFT CONTACT LENS FITTING – ONE EYE
SET-UP:
• Patient instruction: “I am going to be fitting your eye with a soft contact lens. In
order to do this, I would have to take a quick measurement of the size of your eye to
help me select the best size of contact lens. Is this okay? (Place ruler against
patient’s nose for stability) I’d like you to look into my open eye”

PROCEDURE:
• Measure HVID
• Compare HVID with given Corneal Curvature to help you choose the correct LOFC
• Total Diameter: 1-2mm larger than HVID
• Base curve:
o Smaller lenses → 0.4 – 0.6mm flatter than K
o Larger lenses → 0.6 – 1.0mm flatter than K [This is the norm]
• Wash and dry your hands
• Choose the correct lens and hold up to eye level to inspect for any tears and to
ensure that it’s the correct side up. To the examiner: “Since this is a sealed blister
pack, there is no need to clean the lens.”
• Left eye → Stand on patient’s left + Place the lens at the tip of your left index finger
→ Use right hand to hold upper eyelid + left middle finger to hold lower eyelid
• Right eye → Stand on px’s right + Place the lens at the tip of your right index finger
• → Use left hand to hold upper eyelid + right middle finger to hold lower eyelid
• Patient instruction: “It’s time to fit the lens on to your eye – it would feel a bit cold
and you might experience a little bit of reflex tearing or discomfort (maybe like an
eyelash in the eye kind of sensation) but it won’t be unbearable. If, however, it feels
quite pokey and sore, I need you to let me know. Hold on to this tissue, just in case
you have some reflex tearing. Are you ready? I’d like you to look all the way down
(grip the lashes and hold the upper eyelid firmly against the brow bone). Now look
all the way up (use your middle finger to hold the lower eyelid down). Now look up
and towards your nose (place lens on to the exposed sclera). Now look slowly
towards the lens. I’m going to gently release your eyelids and I need you to close
your eyes very slowly and blink very slowly thereafter.”
• To the examiner: Ideally, we would wait about 20minutes for the lens to adapt on
the eye before checking fit and vision but I will be doing it now for exam purposes.
• Clean the slit lamp chin rest and forehead rest
• Position the patient comfortably – ensure that chin is on the chin rest and forehead
on the forehead rest
• Patient instruction: “Okay, the next step is to assess the fit of the lens. I need you to
place your chin on this little rest here and your forehead should be touching this bar
to help keep you stable. There will be some light shone into your eye so I can get a
better look at the contact lens and make sure it isn’t too tight/too loose. I need you
to look at my ear (direct patient’s non-fitted eye towards your ear on the same
side).”
• Centration with/without lid interaction: Check centration on primary gaze, then ask
the patient to look down, lift the upper eyelid, look up, hold down the lower eyelid
and then straight ahead to observe centration without lid interaction.
• Sag on primary gaze: “I’d like you to blink whilst still looking straight ahead at my
ear. Blink again. One more time please.” Norm → 0.2 – 0.4mm
• Sag on upgaze: “Now look upwards and blink. I’d like you to continue looking
upwards the entire time between blinks.” Norm → 0.4 – 0.6mm
• Lag on lateral gaze: “Now look at my ear, and to your right, back at my ear, and to
your right. Back at my ear, and to your left, ear, left.” Norm → 0.5 – 1mm
• Push up test: “I’d like you to look up slightly at the upper part of my ear. I’m going to
push on your lower eyelid gently, to check the lens movement.” Norm → Smooth
movement with swift recovery
• Patient instruction: “Okay, you can sit back now. I’m just going to record my findings
and we will get that lens out afterwards.”
• Record the following:
o Centration with/without lid interaction – comment on high/low-riding; lid
attachment, estimate the decentration in mm, if any etc.
o Sag on primary gaze – comment on movement in mm and in brackets
(steep/flat/ideal)
o Sag on upgaze – comment on movement in mm and in brackets
(steep/flat/ideal)
 o Lag on lateral gaze – comment on movement in mm and in brackets
(steep/flat/ideal)
o Push up test – comment on generalized ease, speed and recovery of
movement and in brackets (steep/flat/ideal)
o Overall lens fit – Steep/Flat/Ideal – comment on using a smaller lens diameter
if lens appears too large and lid-attached. Comment on using a larger lens
diameter if lens appears too small or decentred. Comment on using a
steeper/flatter base curve if necessary.
• Wash and dry hands
• Patient instruction: “I need you to sit back here (at the slit lamp – position
comfortably as per above). I will be instilling a temporary dye into your eyes. This will
help highlight the surface of your eye and make it easier for me to check and make
sure that it is healthy and there aren’t any surface scratches from the fitting and
removal of the contact lens. It shouldn’t burn or sting but will feel cold like eye
drops. Are you okay with this? You may hold on to this piece of tissue, just in case it
drips down your cheek. I’m just preparing the dye now and will tell you when to
come forward.”
• Wet the fluorescein strip with saline
• “You can come forward now with your chin on the rest and forehead against the bar
and look all the way up.” Touch the lower bulbar conjunctiva with the strip and ask
the patient to blink a few times.
• Analyze the cornea for any abrasions
• Record: Intact cornea, no significant staining. OR Significant central or inferior
staining – Recommended tear supplements and advised patient to return if any
symptoms of pain/photophobia/redness.

PART B:
SKILL 1: AMSLER GRID – ONE EYE
SET-UP:
• Patient instruction: This is an Amsler Grid. It is a tool that can be used to detect
vision problems resulting from damage to the central part of the back of the eye,
called the macula as well as to the optic nerve itself. This damage could be due to
macular degeneration or other eye diseases. Any changes picked up on this grid will
help us with an early diagnosis and early treatment to prevent further progression. I
want you to hold on to this pen so that if you pick up on any irregularities to your
vision, you would be able to mark them for me on this grid. You should wear your
reading glasses and use this occluder to cover the left/right eye. Do you have any
questions? Are you ready to begin?
 • Ensure that the patient is wearing their near Rx at the near PD if using a trial frame.
Also make sure that the eye that isn’t being tested is fully occluded.
• Hold the Amsler Grid at eye-level at a 30cm distance
• Questions:
o Are you able to see the central dot? (Yes – Continue; No – Central scotoma →
Turn to Chart Two and ask patient to look centrally at the point where the
diagonal lines appear to meet)
o I need you to focus on the dot at the centre of the grid and do not look
anywhere else
o Whilst focusing on the central dot, do any of the lines in the grid appear
wavy, blurred or distorted? (No – Continue; Yes – Metamorphopsia)
o Still looking at the central dot, do all the boxes in the grid look square and the
same size? (Yes – Continue; No – Micropsia/Macropsia)
o Again, focus on the central dot, are there any holes, missing areas or dark
areas on the grid? (Absolute or Relative Scotomas)
o Are you able to see the four corners and sides of the grid while keeping your
eye on the central dot? (Arcuate, Altitudinal, Quadrantic, Hemianopic VF loss,
Overall VF Constriction)
• Ask patient to draw and plot/mark any missing areas, darker areas or waviness –
they should plot it after responding to each question if applicable
• Record the medical terms of what the patient has depicted on your record card, i.e.
Metamorphopsia, Relative scotoma, Absolute scotoma, Micropsia, Macropsia,
Within Normal Limits (WNL)
o Always include the Patient Name, Date and the Eye that was tested.

SKILL 2: AUTOMATED PERIMETRY – ONE EYE

SET-UP:
• At the main menu screen, select Central 24-2
• Select Right/Left eye
• Enter Patient Data (ID, Name, DOB, Gender)
• Enter Patient Refraction to calculate the trial lens
• Move the lens holder into an upright position – place the sphere in the slot furthest
away from the patient and then the cylinder in the slot closest to the patient and
align the axis
• Click on Proceed
• Patient Instruction:
o I’m going to be performing a visual field test on you that helps to map out the
areas that you can or cannot see. During the test, I need you to look at the
central orange light. A second white light will randomly appear and when you
see this, I need you to press this button (hand the trigger to the patient).
 o For this test, the lights need to be turned off, are you okay with that? The
test will take approximately 10 minutes. It’s okay to blink, however, I need
you to keep looking at that central orange light even when the second white
light appears.
o You can click on the button whenever you are aware of the white lights whilst
maintaining central focus the entire time.
o It’s also important to keep your head and your body still, otherwise we might
need to repeat the test. Do you have any questions before we start?
o We are going to be testing your right/left eye first, so we have to cover the
right/left eye with this patch
o If patient is wearing glasses → I’d like you to remove your glasses please
o Fit the patch over the eye that is not being tested – is that comfortable?
o Clean the chin and forehead rest using an alcohol swab and cloth
o RE → I need you to place your chin on this left chin rest and your forehead
against the left bit of the forehead rest so you’re well aligned (and vice versa)
o Adjust the table height for patient comfort – You can come forward now, is
that comfortable or would you like me to bring the table up higher/lower?
o Adjust the chin rest to align patient central fixation – the white cross should
be at the centre of the pupil → I’m going to adjust the chin rest now so
please keep looking at the central orange light
• Initial gaze tracking gives the patient an opportunity to get familiar with the test
o So this is a demo for you to get familiar with the test. Each time you notice a
white light in the periphery, you will have to press the button.
• Once this is completed, the test may begin
o That’s great, the actual test will begin now
• Pause the test after three minutes/wait for the examiner to signal you
o The test is now over, you may sit back and take off the patch. Thank you.

INTERPRETATION
See Visual Fields Notes

SKILL 3: CONFRONTATIONS – BOTH EYES

SET-UP:
• You should be seated in front of the patient at eye level with knees almost touching
• Patient should not be wearing their glasses
• Patient Instruction: So this is a more general type of visual field test which helps us
to get a gross idea of what you can or cannot see around you. I’m going to be using
this stick with the red target and will move it closer to you from a point where you’re
unable to see it. As soon as you’re aware of the red bead, I need you to tell me that
 you can see it. The entire time, you would be focusing on my eye and not looking
anywhere else. Do you have any questions? Are you ready to begin? Alright, I’d like
you to use this occluder to cover your LE. I will also be closing my RE so that I can
compare what you are seeing to what I am able to see. You need to focus on my
open eye and remember to tell me as soon as you’re aware of the red target coming
into focus in the periphery.

PROCEDURE:
• Bring the red target from an area of unseen to the visual axis/pupil in all 8 directions
(Superior, Superonasal, Nasal, Inferonasal, Inferior, Inferotemporal, Temporal,
Superotemporal)
• Once completed, repeat the procedure for the patient’s LE
• Record:
o Method: Flat Field to Confrontation
o Red Bead – 15mm diameter

STATION 3
PART A – DISPENSING – BOTH LENSES
SET-UP:
• To the examiner: I am aware that I need to complete this dispensing station first but
is it okay for me to quickly disinfect the tonometer probe with an alcohol swab so
that it would be adequately dry by the time I need to use it? Thank you
• Disinfect the tonometer probe with an alcohol swab and return to dispensing
• Adjust the position locking lever for your height and comfort
• Focus the lensmeter for individual use:
o Instrument must be switched off first
o Rest a sheet of white paper against the lens stop
o Wind the individual focus ring/knob fully counter-clockwise until it stops
o Look into the device through the Eye-cup and rotate the focusing ring
clockwise until the reticle inside is crisp and clear
o Remove the sheet of white paper
• Turn on the lensmeter – switch should be located on the side of the device
• Set the PCD (Prism Compensating Device) at 0 and 90 degrees
• Rotate the power drum into high plus (+7.00 or higher)
• Look into the device and move the power drum away from you until the sphere and
cylinder lines/mires are crisp and clear
 • Check the power drum index at this point – if it is at zero, it means that the
instrument is correctly calibrated for your eyesight
• If the power drum index is sitting at +0.25 or -0.25 – try it again. Try focusing it
without your glasses as well to see if that helps
• If you find that no matter what you do, you’re always either at -0.25 or +0.25 – then
you must take this into account when checking prescriptions

PROCEDURE:
• Position the glasses on the lensometer by placing the back surface of the right lens
against the lens stop (temples pointing away from you). Since the patient PD would
already be marked on the lenses – centralize this marked centre against the lens stop
and release the lens holder to keep it in place
• Rotate the axis wheel to zero
• Look into the device and move the power drum away from you and then towards
you until the mires come into focus
• The three thinner lines are the sphere lines
• The three thicker lines are the cylinder lines
• If it’s a sphere → Both sets of mires will be in focus at once
• If it’s a spherocylinder → Rotate the power drum until the three thinner lines are
crisp and clear – take note of the number on the power drum - this is your sphere
• If you find that the cylinder lines are coming into focus BEFORE the sphere lines –
rotate the axis by 90 degrees and refocus the sphere from scratch
• Continue turning the lens away from you (if minus cylinder form) and bring the three
thicker cylinder lines into focus
• Take note of the power on the power drum – this is NOT your cylinder power - the
distance that the drum has travelled from the sphere to this new power is the
amount of cylinder
• For example: Sphere lines are focused at -1.50D and cylinder lines come into focus at
-3.00D. The power drum has travelled a distance of 1.50D to get to -3.00 and the
cylinder power is therefore -1.50DC
• For example: Sphere lines are focused at +1.00D and cylinder lines come into focus
at -1.50D. The power drum has travelled a distance of 2.50D to get to -1.50 and the
cylinder power is therefore -2.50DC
• If you’re struggling to get clear cylinder lines – rotate the axis wheel back and forth
until they appear crisp and clear and read the axis off the wheel
• Record your final prescription and repeat for the other lens
MEASURING PRISM
• If the mires are not centralized within the target at the given marked points – this
indicates induced prism
• Measurement of Vertical Prism:
o First, you must measure the lens powers. Then, determine which lens has the
higher power (higher absolute value) in its vertical (90 degree) meridian.
Place this lens on the lens stop. (Note: if the lens powers are almost the
same, it doesn’t matter which lens is placed first on the lens stop.)

o Examples:
▪ 0.D. +3.00 D.S. (+3.00 at 090)
▪ 0.S. +3.00 -2.00 X 180 (+1.00 at 090)
▪ So, you would start by placing the right lens on the lens stop

▪ 0.D. +3.00 -2.00 X 090 (+3.00 at 090)

▪ 0.S. -5.00 D.S. (-5.00 at 090)
▪ Start with the left lens

▪ 0.D. +3.00 -2.00 x 045 (approximately +2.00 at 090)

▪ 0.S. +0.75 D.S
▪ Start with the right lens

o Center the target lines on the center of the reticle

o Move the lens table up against the bottom of the frame
o Move the other lens onto the lens stop, without moving the lens table
vertically
o IMPORTANT: Move the lens laterally to eliminate any horizontal prism (any
horizontal deflection of the target)
o Any remaining vertical deflection of the target from the center of the reticle
is the amount of vertical prism in the glasses. The amount, base direction,
and eye must all be specified, but note that base-up prism in one lens is the
same as base-down in the other
o Note: this method provides only the total prism in the glasses. However,
when ordering prism, the amount is usually split equally between the two
eyes
o For example, the target has first been centered on the reticle for the right
lens. The left lens is then moved into position on the stop, without moving
the glasses vertically. Since a vertical target deviation is present, vertical
prism is present in the glasses, 1Δ BU OS or equivalently, 1Δ BD OD
 • Measurement of Horizontal Prism:
• Center the given marked point for the right lens on the lens stop
• Now, move the lens up or down to eliminate any vertical prism
• Any remaining sideways deflection of the target is the amount of horizontal prism in
the right lens
• Record the amount, eye, and direction
• Repeat steps 3 and 4 for the left lens
• The total horizontal prism in the glasses can be calculated as follows:
o BO and BO → Add
o BI and BI → Add
o BO and BI → Subtract
o For example, 2Δ BI OD combined with 1Δ BO OS = 1Δ BI

MEASURING OPTICAL CENTRES

• Use a PD ruler to measure the monocular PD’s as per the marked points on the
lenses (distance from the marked point to the middle of the nose bridge on each
lens)

MEASURING BASE CURVES

• Use the Geneva lens measure – place the central leg against the distance centre
marking of the lens and press down until all three legs are at the same height – read
the radius of curvature off the dial

MEASURING LENS CENTRE THICKNESS

• Use the lens thickness gauge – place the calipers centrally at the distance centre
markings and read off the measurement in mm for the lens thickness

IDENTIFY LENS MATERIALS

• Polycarbonate goes “plink” – sounds like a poker chip – slightly grey sheen when
held against a white background
• Trivex goes “thud” – dull sound – very flexible! Can almost fold over with pressure –
slightly grey sheen against a white background
• CR39 goes “plunk” – clear against a white background
• Glass goes “clink” - high pitched sound and is cold to the touch – clear against a
white background
 • High-index lenses – clear against a white background – thinner than usual especially
if it’s a higher prescription and usually comes standard with an AR Coating – has a
distinctive garlic smell when heated

IDENTIFY TINTS/COATINGS
• Use the UV torch to identify if the lens has any photochromic tint
• Hold the lens beneath overhead lighting – if the reflections are white – the lens is
either uncoated/hard coated. If the reflections are a bit colourful – green/yellow – it
could be either a hard multi-coat/anti-reflective coating
• If the lens appears slightly yellow against a white background and has purple/blue
reflections on the surface – blue blocker/blue light filtering anti-reflective coating

LENS EDGING AND FRAME FIT

• Comment on the quality of the lens edge:
o Translucent satin polish edge
o Crystal clear edge
o Frosted smooth edge
o No chips/cracks
• Comment on the fit of the lens within the frame:
o Asymmetrically fit
o Well-fitted, symmetrical
o No gaps between the lens and the frame

SEE LENS TOLERANCES PDF

PROGRESSIVE SPECTACLES – FITTING
SET-UP:
• The frame has already been adjusted to fit the patient:
o To the examiner: This frame has already been adjusted to fit my patient and I
will therefore move on to the next step

PROCEDURE:
• Patient Instruction: I’m going to be taking some measurements that are essential for
making sure that your pair of progressive lenses are tailored to your eyes and as a
result, you would have clear, comfortable vision at all distances. I’ll be talking you
through each step. Let me know if you’re happy to begin.
• Measure the patient’s interpupillary distance:
o To the patient: this device helps me to get an accurate measurement of the
distance between your eyes. I’m going to ask you to hold on to this and rest
the brow bar flush against your forehead so that you can look through them
like a pair of binoculars.
o Set the pupillometer to Infinity
o Set the brow bar against the patient’s forehead – making sure that the
pupillometer is centred before the patient’s face
o Look into the pupillometer and adjust the vertical bars so that the line is
bisecting the corneal reflex on each eye
o Set the pupillometer to a near setting and repeat the process
o To the patient: Thank you
o Look at the bottom of the device and record the binocular + monocular PDs
• Measure the fitting heights:
o Position yourself directly in front of the patient at eye-level
o Mark each lens at the centre of the pupil using a felt-tip pen
o If the patient has dark irides – you could shine a pen torch at your lateral
canthus and alternate this torch between your eyes so that you can mark
against the corneal reflex
o Draw a horizontal line along each lens making sure that the lines cross at the
centre of each pupil
o Measure from the pupil centre till the lowest point of the bevel
• Verify against the provided centration chart
o Position the marked pupil centre at the fitting cross on the chart and verify
that the appropriate lens diameter is larger than the lens in the frame the
patient has selected
o Centre the glasses face down over the inverted V and draw a small vertical
line running through the pupil centre of each lens to represent the fitting
cross on the horizontal scale
 o You could now read off the fitting height using the centration device – keep
the glasses in the same position as above and then read the fitting height off
in mm along the vertical scale – alternatively a PD ruler can be used

PART B – CONTACT APPLANATION TONOMETRY – ONE EYE

SET-UP:
• Wash and dry hands
• To the examiner: Just a reminder that the probe was disinfected at the beginning of
this station and should now be adequately dry for testing
• Patient Instruction: I am going to be measuring the pressure in your right/left eye. To
do this, I would need to put two drops into the eye. One drop helps to numb the
eyes and the other drop highlights the front of your eye so that I can get a more
detailed view. The drop that numbs your eye does sting a little bit and the numbing
effect will last for about 10-15 minutes afterwards so just be sure to not rub your
eyes. Are you ready to begin? Great, I’d like you to hold on to this tissue, just in case
some of the drops leak down your cheek or you experience some reflex tearing. Now
you could rest your head backwards and look up towards the ceiling for me.
• Instil 1 drop of anaesthetic into the lateral part of the lower fornix
• Record the name of drops, concentration, dosage and time instilled
• Patient Instruction: I need you to place your chin on this little rest here and your
forehead should be touching this bar to help keep you stable.
• Position the patient comfortably at the slit lamp and adjust the chin rest so that the
patient’s lateral canthus aligns with the marker. “Are you comfortable? I need to
turn off the room lights to increase the contrast of what I’m able to see. There will
be some light shone into your eye and I will also be instilling the second drop that I
spoke to you about – it’s a temporary dye that gives me a brighter view. You can
keep your eyes closed for now.
• Wet the fluorescein strip with saline. “You can open your eyes and look upwards for
me.” Instil fluorescein into the lower fornix. “Blink a few times now. Lovely, I need
you to look at my ear (direct the eye that is not being tested towards your ear on the
same side).””

PROCEDURE:
• Pre-corneal assessment – document any signs of significant corneal staining – “You
may sit back for now while I write down my findings and quickly set this up.”
• Set the slit lamp at low magnification and mid-high light intensity
• Use a wide diffuse beam with a cobalt blue filter at maximum width and height and
set the angle between the illumination and observation systems at 60 degrees
• Set the measuring drum at 1, which is equivalent to 10mmHg
• Place the tonometer into position
• To the patient: This device is going to be coming closer to your eye. You will not be
able to feel it against your eye so don’t be afraid. I’ll need to hold on to your upper
lid to prevent blinking but there is a chance that you may feel the presence of the
probe if I lose grip of your eyelid since your eyelashes may blink against it – there
shouldn’t be any pain though. Are you ready? You can come forward again – chin on
the chin rest and forehead flush against the bar. Look all the way down (grip
patient’s eyelashes and hold them against the brow bone) Now look back at my ear.
• Move the tonometer forward in a swift motion whilst observing the corneal
reflection from outside of the slit lamp
• Once a green halo is obtained and you are close to the cornea, look back into the slit
lamp and make small movements until the mires are visible
• Chase the mires → If a full circle is visible in an upward location – move upwards so
that the circle splits into two semi-circles and vice versa if it were located
downwards
• Once the mires are centralized as two semi-circles – increase the pressure until the
inner portion of each semi-circle are touching
• Pull the probe backwards, release the patient’s eyelid – “You can sit back for now.”
• Record the pressure – record the eye, the amount of pressure in mmHg and the time
of the test
• ‘’I’d like you to come forward one last time. Let’s just make sure that everything is
still looking good.” Perform post-corneal assessment – document any significant
corneal staining – if significant – ask the patient to obtain some antibiotic eye
ointment from the clinic and use lubrication for about a week to promote re-
epithelialization and prevent infection
STATION 4
PART A: PUPIL REFLEXES – BOTH EYES
SET-UP:
• No spectacles on
• Lights on for pupil measurements and observation
• Lights dimmed sufficiently for pupil measurements and observation
• Non-accommodative target – 6/120 Letter on the VA screen
• Pen torch and near VA card

PROCEDURE:
• Patient Instruction: “I am going to be measuring the size of your pupils which are the
little black dots on the centre of the front of your eyes. I will also be assessing how
well the pupils respond to light and near targets as well. For this procedure, I will
have to be eventually dimming the lights and will be shining a bright light into your
eyes for a few seconds at a time. Are you okay with this? Great, let’s begin.”
• If patient is wearing spectacles, “I’d like you to take your glasses off please?”
• “I need you to look ahead at the big letter and just keep your eyes nice and relaxed,
it’s perfectly fine if that letter appears to be a bit fuzzy. I will be addressing the
examiner as I’m performing the test.”
• Room lights on → Measure and record photopic pupil diameters, comment on pupil
shape (round, keyhole, iris coloboma, pupil trauma, posterior synechiae, etc.),
comment on pupil symmetry (are they located at the same spot on each eye or is
there pupil dislocation)
• Narration: Photopic pupil diameters are 3mm on each eye – they are equally round
and symmetrical in shape, size and location.
• Room lights off → “I have to dim the lights now.”
• Perform direct response: Move pen torch in from the temporal side about 5cm away
from the eye → “I am going to be checking that each eye has a direct response to
light – this involves shining a bright light directly into the eye and observing the pupil
response of that same eye. Each eye is displaying a positive direct response and this
indicates that there is an intact afferent pathway from the eye to the brain.”
• Perform consensual response: “I am now checking the opposite eye to observe the
consensual response – this involves shining the light into one eye whilst observing
the other eye for a pupil response. Each eye is displaying a positive consensual
response and this indicates that there is an intact efferent pathway from the brain to
the eye.”
• Perform swinging flashlight test: “I am now performing the swinging flashlight test
which is a comparative test of the two optic nerves and may detect conditions such
as optic neuritis or optic nerve compression where the nerve is functioning but
 poorly when compared to the other side. It is used to assess for the presence of a
Relative Afferent Pupillary Defect or RAPD. I am looking for a sustained pupil dilation
as the light is swung into the eye from the other eye – this would indicate an RAPD.
In this case, each eye constricts well as the light is introduced and are normal.”
• Room lights on → “Clinically, if the eyes are responsive to light, there isn’t really a
need to assess the near reflex. Usually, if there’s no light reflex, then the near pupil
miosis is assessed as in cases of Argyll Robertson pupils with light-near dissociation,
but I will be doing it for exam purposes.”
• To the patient: “I am going to be assessing how your pupils react to a near target. I
need you to hold on to this near card – it should be relatively close to you and held
slightly higher up so that it’s easier for me to observe your eyes. I want you to focus
on this letter on the near card. When I say “distance”, I need you to look up at the
big letter on the screen. When I say “near”, I need you to look back at the small
letter on the near card. Do you understand? Okay, near, distance, near, distance,
near. Great, thank you.”
• To the examiner: “Both pupils displayed miosis when looking at the near target
indicating an intact accommodation reflex and parasympathetic nervous system. I
will just record my final findings now.”
PART B: SUBJECTIVE REFRACTION – BOTH EYES
SET-UP:
• Patient Instruction: I am going to check how far down you’re able to see on this
chart. We have to test one eye at a time. I’d like you to use this occluder to cover
your left eye and read out the letters as I point to them. Try not to squint your eyes
to help you focus – just keep them relaxed and it’s perfectly okay if you aren’t able
to see some letters.
• Record the patient’s unaided VA monocularly
• Request for the patient distance IPD
• Disinfect and set up the trial frame/phoropter with an occluder lens on the left and
the IPD split equally between the eyes
• Ask the patient to fixate on a target that is one line above best VA

PROCEDURE:
• Patient instruction: During this test, I’ll have to place various lenses in front of your
eyes to find the lenses that give you the best vision. Don’t worry about giving a
wrong answer as everything is double-checked. And if at any point, you feel that
they look almost the same, you can tell me. You don’t have to force yourself to
choose one if you’re uncertain.
• Fit the trial frame on or position the patient comfortably behind the phoropter

BEST SPHERE
• Introduce +0.25DS first – “Does the letter appear clearer with 1 (+0.25DS) or 2
(plano) or do they look the same?
• If improvement or similarity is reported – add on the +0.25DS
o If the patient is a hyperope – always add on the +0.25 BEFORE removing
what’s currently on the trial frame – e.g. If there is a +2.00 fitted and the
patient reports improvement with a +0.25DS, then add in the +2.25 FIRST and
then remove the +2.00 thereafter – this will prevent accommodation
o Continue introducing plus until the patient reports a reduction in clarity –
always prescribe maximum plus for BCVA
• If improvement is reported with plano – probe with a -0.25DS lens
• “Does the letter appear clearer with 3 (plano) or 4 (-0.25DS)?”
• If improvement is reported with the -0.25DS lens – add it on
o Continue introducing minus until the patient reports a reduction or similarity
in clarity – always prescribe minimum minus for BCVA
o If the patient is accepting minus but VA is remaining the same – ask the
patient, “Are the letters really getting clearer or are they just getting a bit
 smaller/darker?” If the patient reports decreased letter size – do not add on
any more minus

DUOCHROME
• To the patient, “I am going to be switching off the room lights now.”
• Put on a duochrome target on the VA chart
• Are the rings/letters/dots clearer and darker on the red side or on the green side? Or
do they appear equally dark and clear?
• Green → Add +0.25DS until patient reports equal clarity
• Red → Add -0.25DS until patient reports equal clarity
• If the patient is accepting more than 0.50DS – this test is unreliable for this patient
and should be ignored
• Switch lights back on → Change back to a standard Snellen chart and repeat best
sphere to see if the patient still prefers what was selected on Duochrome

JACKSON CROSS CYLINDER

• Use a circular letter like an O – one line above BCVA as the target. Alternatively, the
collection of black dots can be used
• To the patient, ‘’I’d like you to focus on this letter O/dots – I am going to show you
two different lenses – both of them may make the O/dots blurry but I need you to
tell me which of the two is clearer or if they both look the same, do you
understand?”
• As we don’t have a retinoscopy result to work with – rotate the cylinder axis to be
set at 180 degrees on the phoropter and then align the JCC such that the red and
white dots align with 90 and 180 degrees. Flip the JCC to bracket and find where the
angle lies. “Does the O/dots appear rounder and darker with lens 1 (at 90 degrees)
or 2 (at 180 degrees)?”
• Rotate the JCC to clock in at the point where the red and white dots are in line with
45 and 135 degrees. Flip the JCC once more. “Does the O appear rounder and darker
with lens 3 (at 45 degrees) or lens 4 (at 135 degrees)?”
• For example: If the patient preferred lens 1 (which was at 90 degrees) and lens 4
(which was 135 degrees) – then clock in a -0.25DC lens and adjust the axis to lie
between 90 and 135 degrees
• Continue to bracket until the patient reports reversal or similarity – this is your
endpoint
• For every 0.50D shift in cylinder – the sphere must be adjusted by 0.25D in the
opposite direction to bring the circle of least confusion back on to the retina
o If the patient accepts -0.50DC → add +0.25DS
o If the patient rejects -0.50DC → remove +0.25DS/add -0.25DS
• Check and record monocular VA
HUMPHRISS IMMEDIATE CONTRAST (HIC)
• Introduce a +1.00D fogging lens over the left eye
• To the patient: “I have put in a lens over your left eye that will purposely blur out
your vision. You will notice that your LE is a bit blurry but the RE should be much
clearer.”
• Switch the occluder between the eyes for the patient to take note of this.
• “Are you able to read this line (6/12 line) or does it appear fuzzy?”
• If the patient is able to read the line without any difficulty – fog by a further +0.50D
• If the patient reports blur, continue
• “I need you to look at the letter in the middle of this line (6/6 line) and tell me which
of the following lenses make it appear clearer but also comfortable to look at.”
• Introduce +0.25, followed by -0.25, followed by +0.25 once more. “Is it any better
with lens 1, 2 or 1?”
• If the patient chooses -0.25 immediately – ensure that the letter is appearing clearer
and NOT smaller.
• If the patient is uncertain of which lens is clearer and after some time, chooses the
-0.25D – do not add on the minus.
• If the patient chooses +0.25D or says that both lenses appear the same, add on the
plus and continue showing the lenses to the patient until reversal
• For every +0.25D accepted by the patient → Add +0.25D over the fogged eye to
maintain accommodative balance
• Shift your fogging lens over to the RE and repeat the procedure over the left eye
• Check and record binocular VA
STATION 5
PART A: SLIT LAMP BIOMICROSCOPY – BOTH EYES
SET-UP:
• Wash and dry hands
• To the examiner: “I’m aware that slit lamp biomicroscopy comes first in this station
but I would like to quickly clean and disinfect the gonioscopy lens now so that it is
dry by the time we get to that skill. Is this okay? Thank you.”
• Clean and disinfect the gonio lens – leave to air dry
• Disinfect chin and forehead rest
• Patient instruction: I am going to use this special microscope to carefully examine
the front of your eyes. I need you to place your chin on this little rest here and your
forehead should be touching this bar to help keep you stable.
• Position the patient comfortably at the slit lamp and adjust the chin rest so that the
patient’s lateral canthus aligns with the marker. “Are you comfortable? I need to
turn off the room lights to increase the contrast of what I’m able to see. There will
be some light being shone into your eyes.”

DIFFUSE/PARALLELEPIPED ILLUMINATION
• Low magnification, Medium light intensity, Wide beam with Diffuser in place, 45
degree angle
o Lids and Lashes → I’d like you to close your eyes please (to the examiner: I
am examining the eyelids and eyelashes using Diffuse Direct Illumination with
Medium intensity at a 45 degree angle) You can open your eyes and look at
my ear on this side.
▪ What to look out for: Blepharitis, trichiasis, distichiasis, poliosis,
madarosis or meibomianitis as well as any cysts/styes of the eyelid
margins or lash follicles
• Remove diffuser and use a parallelepiped beam with low magnification and medium
light intensity at a 45 – 60 degree angle
o Bulbar/Palpebral Conjunctiva and Sclera + Hyperemia Grading → (I’ll now be
examining the bulbar conjunctiva as well as the sclera itself and will be
manipulating the lids to gauge the depth of any hyperemia as per the extent
of blood vessel movement. I have removed the diffuser and will be using a
parallelepiped beam for more accurate examining) Look towards your right…
Left… up… (Hold the lower eyelid down – I am examining the inferior
palpebral conjunctiva and will do the same for the superior now) You could
look down now please? I will be using a soft cotton bud to evert your upper
eyelid and make sure everything is normal and healthy. Are you okay with
this? (pull the upper eyelid forward gently and use an earbud to evert the lid)
 ▪ What to look out for: Hyperemia → episcleritis, scleritis,
conjunctivitis, anterior uveitis; Concretions/Papillae/Follicles or
Hyperemia of the Palpebral Conjunctiva

OPTICAL SECTION
• Start with low magnification and then increase, thinnest slit beam, high illumination,
45 – 60 degree angle
o Optic section of the cornea → (I will be assessing the cornea using an optic
section thin slit beam at high illumination placed at a variable angle between
45 – 60 degrees)
▪ I’d like you to continue looking at my ear, please.
▪ Obtain a clear section of the apex of the cornea
▪ Reduce the height of the slit so that all the corneal layers are in view
▪ Once a clear image is obtained, move the angle back and forth
between 45 and 60 degrees to change the corneal section thickness
▪ When you are happy with the thickness, move the beam towards the
temporal cornea and increase magnification whilst maintaining a clear
image – all 5 layers should be visible at this point
▪ What to look out for: Corneal ectasia or edema
o Temporal Van Herrick → (I will be using Van Herrick’s technique to assess the
depth of the anterior chamber angle using an optic section thin slit beam at
high illumination placed at exactly 60 degrees)
▪ I’d like you to continue looking at my ear.
▪ At the temporal cornea, re-check + lock the illum. system at 60 deg
▪ (To the examiner: I am comparing the thickness of the corneal section
(1) to the space between the corneal endothelium and the left-most
light scatter off the iris. This is a grade 4, wide open angle.)
o Optic section of the crystalline lens → (As I am moving nasally, I will examine
the crystalline lens)
▪ Obtain a clear image of the cornea at the temporal pupil margin
▪ Push the slit lamp forward until the anterior lens capsule is in focus
▪ Continue to push it forward to view the nucleus
▪ Lastly, move forward further and simultaneously reduce the angle
slightly to get the posterior lens capsule into focus
▪ What to look out for: Lens opacification/Cataracts
o Sclerotic Scatter (I will be performing the sclerotic scatter technique using a
parallelepiped beam at medium intensity with a variable angle between 45
and 60 degrees)
▪ Obtain a clear optic section of the central cornea – with the anterior
cornea being in focus
▪ Lock down the slit lamp so that the observation system doesn’t move
 ▪Re-direct the illumination system on to the temporal limbus without
moving the microscope
▪ Reduce/Increase the height
▪ What to look out for: Central corneal clouding, foreign bodies, corneal
lesions/scarring
o Nasal Van Herrick → (Due to the placement of the iris often being
asymmetrical, I will also assess the nasal anterior chamber angle) Bring the
section back to the corneal apex – clear it up and move towards the nasal
limbus – there is a chance that the patient’s nose could get in the way of
obtaining the light scatter off the iris
▪ Move the observation and illumination systems together towards the
same side of the eye that you are testing (by 5 – 10 degrees)
▪ I’d like you to look directly into this lens
▪ Compare the thickness once more and quote the estimated grade

Van Herick Corneal Optical/Aqueous Implications

Grade thickness Space Thickness
IV 1 1 or more Wide open, can’t close
III 1 0.5 – 1.0 Open, unlikely to close
II 1 0.25 – 0.5 Suspicious
I 1 0.25 or less Angle closure likely
0 1 0 No aqueous visible, angle is closed

SPECULAR REFLECTION
• Low magnification, medium intensity, parallelepiped beam, 45 – 60 degree angle
o Specular Reflection (I will now be performing the specular reflection
technique using a moderately wide parallelepiped beam at a mid-high
intensity at roughly 45 – 60 degrees)
▪ Form a corneal section at the temporal pupil margin
▪ Adjust brightness + thinness of the slit to clear up the corneal section
▪ Move the corneal section on to the bright corneal reflex
▪ Reduce the height of the slit so that only the area that the corneal
reflex falls over is examined
▪ Observe tear dynamics by asking the patient to blink a few times and
looking at the movement of tear debris across the epithelium
▪ Observe the endothelial cell structure by increasing magnification
▪ What to look out for: Blebs, Guttata, Fuch’s endothelial dystrophy
CONICAL SECTION
• (I will now be using a conical beam to assess the anterior chamber)
• With the illumination and observation systems aligned straight ahead, increase the
light aperture width to obtain a full circle of light – this can be done on the skin
below the patient’s eye to minimize discomfort glare
• Reduce the height of the beam until it generates a disc diameter of 0.2 – 0.5mm
• Raise the beam on to the inferior cornea and move the illumination system
temporally until a conical section of the cornea is formed with the scatter of the iris
to the side of it
• Raise the slit lamp further to place the beam within the pupil – increase light
intensity to the maximum and move back/forth to focus
• The end result should be a blurred conical section of the cornea temporally with a
conical section of the lens nasally
• Observe the optical space between these conical sections discussed above by
increasing magnification if need be
o What to look out for: cells and flare

RETRO ILLUMINATION
• I will be using Retro illumination to get a better view of the iris and lens
• Reduce your angle to 0 degrees, decrease magnification and increase the beam
height to the height of the pupil
• Thereafter focus on the iris and lens
o What to look out for: Iris atrophy, transillumination defects, subcapsular or
cortical cataracts
PART B: GONIOSCOPY – ONE EYE
SET-UP:
• Wash and dry your hands
• “I would like to use a contact lens to examine the hidden part of the front of your
eye. To do this, I would need to put two drops into the eye. One drop helps to numb
the eye and the other drop highlights the front of your eye so that I can get a more
detailed view. The drop that numbs your eye does sting a little bit and the numbing
effect will last for about 10-15 minutes afterwards so just be sure to not rub your
eyes. Are you ready to begin? Great, I’d like you to hold on to this tissue, just in case
some of the drops leak down your cheek or you experience some reflex tearing. Now
you could rest your head backwards and look up towards the ceiling for me.”
• Instil 1 drop of anaesthetic into the lateral part of the lower fornix
• Record the name of drops, concentration, dosage and time instilled
• Patient Instruction: I need you to place your chin on this little rest here and your
forehead should be touching this bar to help keep you stable.
• Position the patient comfortably at the slit lamp and adjust the chin rest so that the
patient’s lateral canthus aligns with the marker. “Are you comfortable? I need to
turn off the room lights to increase the contrast of what I’m able to see. There will
be some light shone into your eye and I will also be instilling the second drop that I
spoke to you about – it’s a temporary dye that gives me a brighter view. You can
keep your eyes closed for now.
• Wet the fluorescein strip with saline. “You can open your eyes and look upwards for
me.” Instil fluorescein into the lower fornix. “Blink a few times now. Lovely, I need
you to look at my ear (direct the eye that is not being tested towards your ear on the
same side).””

PROCEDURE:
• Pre-corneal assessment – document any signs of significant corneal staining – “You
may sit back for now while I write down my findings and quickly set this up.”
• Fill the gonio lens with coupling fluid – ensure that there are no bubbles – begin a
stream of the fluid on to some tissue and then immediately transfer to the lens
• Patient Instruction and Lens Insertion (Two Hand Technique – for beginners):
o “I am now going to insert the contact lens. It is filled with a cold gel so you
may feel some of it dripping down your cheek but it is absolutely harmless so
try to remain still during the test. You might also feel some pressure or a
turning sensation but there shouldn’t be any pain or discomfort.
o Are you okay for us to begin or do you have any questions?
o Alright, you can use the tissue to gently dab the lower eyelid area and close
your eyes and do the same for the upper eyelash area but do not press or rub
when doing so.
 o Now come forward, place your chin on the chin rest and forehead against the
bar. (Hold the gonio lens between your index finger and thumb with the right
hand if testing the RE and vice versa)
• Vertical parallelepiped beam at moderate illumination
o I’d like you to look downwards please. (If testing the RE - Use your left index
finger to grip the lashes and hold them against brow bone)
o Now look all the way upwards. (Use your left thumb to hold down the lower
eyelid. Tilt the gonio lens, which is in your right hand on to the inferior bulbar
conjunctiva and push it forwards till full contact is achieved – now hold on to
the lens with your left index finger and thumb and return to the slit lamp
observation system).
o Lovely, now SLOWLY try to look straight ahead past my shoulder.”
• Use a tissue to wipe up excess fluid that leaks down the patient’s face
• Ensure that you start with the thumbnail mirror oriented at 12 o’ clock – this will be
obtaining a view of the inferior angle which is the deepest and most pigmented
• Describe all the structures that you are able to see in order – from posterior to
anterior: Ciliary body band → Scleral spur → Posterior pigmented Trabecular
meshwork → Anterior non-pigmented Trabecular meshwork → Schwalbe’s
line/Sampaolesi’s line (pigmented Schwalbe’s line)
• If you are having trouble differentiating the brown lines within the angle – use a thin
bright optic section beam at a 20 degree angle to create the corneo-scleral wedge –
this helps to identify the location of Schwalbe’s line – anything beyond this line can
then be identified
• Use one hand to maintain contact on the eye and the other hand to rotate the lens
on the eye until the mirror is now at the 3 o’ clock position, use a horizontal
parallelepiped beam to view the angle structures
• Rotate to 6 o’ clock with a vertical beam + 9 o’ clock with a horizontal beam
• Remove the lens:
o I’m going to remove the lens now. I need you to look towards your nose and
try to blink as hard as you can
• Simultaneously apply pressure through the inferior eyelid on the temporal side of
the globe to break the seal – a popping sound may be heard
• If there are still significant amounts of coupling fluid within the eye – rinse out with
saline remind patient to not rub their eyes for at least another 10 minutes or so
o I need to re-instil the temporary dye to ensure that everything is still healthy.
You can keep your eyes closed for now.
• Wet the fluorescein strip with saline.
o “You can open your eyes and look upwards for me.” Instil fluorescein into the
lower fornix. “Blink a few times now. Lovely, I need you to look at my ear
(direct the eye that is not being tested towards your ear on the same side).””
• Post-corneal assessment – document any signs of significant corneal staining – “You
may sit back, we’re all done, thank you!”
 • Turn the page upside down and record the most posterior structure seen at each
angle as well as the Grade – to the side – take note of which eye was assessed, as
well as the Grading system used and the type of Gonio lens used.

STATION 6
PART A: BINOCULAR INDIRECT OPHTHALMOSCOPY – ONE EYE
SET-UP:
• Wash and dry your hands. Adjust the headset to fit you comfortably by using the
knobs at the back and top of the device
• Once a snug fit is achieved, adjust the PD:
o Switch on the light source
o Hold your thumb out in front of you
o Close one eye at a time and adjust the PD slider beneath the eye piece such
that the thumb is in full view within the lower middle portion of the light
source and can be viewed equally by each eye
• Tilt the binocular as close to your eyes as possible to minimize reflections
 • Keep the light source slightly superiorly positioned unless the patient has very deep-
set eyes – in which case it can be brought down
• Positioning:
o If testing the right eye – start by sitting in front of the patient’s right knee
with your knees pointing outwards to your left
o Patient is seated 1 – 1.5 head heights higher than your head position
• Patient Instruction: “I am going to examine the health of the inside of your eyes with
light from this head unit and a lens held close to your eye. I will be asking you to look
at different directions and may hold your lids for you to prevent blinking at certain
points of this test – I will tell you when I’m going to do so, though. Are you ready to
begin?”

PROCEDURE (RIGHT EYE BEING USED AS AN EXAMPLE):

• Testing Acronym: LLRRP
• LIGHT → Place the light source over the patient’s eye that you are testing
• LENS → Place the lens over the eye with the white/silver ring towards the patient
• RED REFLEX → Ensure that you are able to see the red reflex through the lens
• REFLECTIONS → Align the reflections – there will be 2 reflections from the lens and 1
reflection from the pupil – tilt the lens around slightly to align them
• PULL OUT → Slowly and steadily pull the lens outwards towards you

• “I’d like you to look up and to your left please.” → Patient is looking superonasally –
Superior Nasal fundus is being examined
• Move your chair more centrally. “You can look straight up now.” → Superior fundus
is being examined
• Move your chair to be in front of the patient’s left knee with your knees pointing out
towards your right. “Now look up and towards your right.” → Superotemporal
fundus is being examined
• Stand up and ensure that the patient is now positioned 1 – 1.5 head heights lower
than your head position
• Stand in front of the patient’s left knee. “I’d like you to look down and towards your
right. I’ll be holding on to your upper lid now but will blink your eyes for you.” →
Inferotemporal fundus being examined
• Stand directly in front of the patient. “I’d like you to look straight downwards.” →
Inferior fundus is being examined
• Stand in front of the patient’s right knee. “Now look down and to your left.” →
Inferonasal fundus being examined
• Stand directly in front of the patient once more and ensure that you are now both at
eye level. “Look straight ahead past my shoulder.” → Posterior pole being examined
TIPS AND TRICKS:
• As the examiner, you should stand opposite to the area of fundus you wish to view –
position yourself inferonasally if you wish to view the superotemporal fundus
• Ask the patient to look towards the area of fundus that you wish to view, for
example, if the patient is looking superiorly, you will be viewing the superior fundus.
You would have to move yourself and the lens further down if you wish to see more
of the peripheral superior retina extending to the ora serrata
• BIO is vertically and laterally reversed. To avoid confusion when recording:
o Turn the page upside down
o Record the posterior pole as you see it appearing through the lens
o If the patient is looking upwards – the superior retina is being viewed –
therefore record your findings inferiorly exactly the way you see it so that
when the page is turned the right side up, it will be correct
• Narration:
o Which area of fundus you are viewing
o Any landmarks you are able to see:
▪ Posterior pole → ONH and Macula
▪ Mid-periphery → Blood vessels extending outwards from the ONH
▪ Equator → Short ciliary nerves + Vortex veins
▪ Periphery → Vortex ampullae + Long ciliary nerve + Ora serrata
o Any significant findings – retinal lesions, tears, detachment, degeneration
• Record the power and type of condensing lens that was used
 PART B: FUNDUS BIOMICROSCOPY – BOTH EYES
SET-UP:
• Patient instruction: “I am going to examine the health of the inside of your eyes with
a microscope and a lens held close to your eye. The light will be bright, so please let
me know if you would like a break.”
• Wash and dry your hands
• Disinfect chin and forehead rest
• Position the patient comfortably at the slit lamp and adjust the chin rest so that the
patient’s lateral canthus aligns with the marker. “Are you comfortable? I need to
turn off the room lights to increase the contrast of what I’m able to see.”
• Moderate width and height of parallelepiped beam at low magnification with low-
medium light intensity
• “I’d like you to look straight ahead at my ear. You’re welcome to blink but try to keep
your eyes wide open in between the blinks”
• Look through the slit lamp and reduce the height of the slit till it fits within the pupil.

PROCEDURE:
• Hold the lens with your thumb and index finger
• Introduce the lens into the light path, within 5mm of the patient’s cornea – with the
back of the lens facing the patient
• Look on the outside of the slit lamp to ensure that the light is entering the pupil
through the lens
• Once the above is confirmed, look back through the slit lamp and pull the joystick
backwards until an image of the fundus is seen
• Increase the magnification and broaden the illumination
• Reduce reflections by tilting the lens
• If your patient is very photophobic – reduce beam width, height, intensity and use a
yellow filter
• Start off by examining the ONH, followed by the blood vessels – you can chase the
vascular arcades superiorly, inferiorly, nasally and temporally as far as possible whilst
patient is in the primary viewing position and lastly, the macula
• Examine the posterior vitreous by pulling the slit lamp closer to you
DESCRIPTION/NARRATION:
• ONH:
o Large/small disc?
o Crescents (pigmentary/choroidal/scleral at clock positions)
o Shape, colour, clarity of disc margins (distinct/indistinct)?
o Neuroretinal rim tissue – pink and healthy; follows the ISNT rule
o Location and depth of the cup (presence/shape of lamina)?
o Cup-disc ratio
o Abnormalities (notching, disc haemorrhages, peripapillary atrophy etc.)
• Vasculature:
o ONH Vasculature (circumlinear/cilioretinal arteries)
o AV ratio (2:3 in normal eyes; 1:2 in hypertensive eyes d/2 arteriolar
narrowing)
o Abnormalities (bayoneting, nasalization, circumlinear vessel baring,
tortuosity, arteriolar narrowing, atherosclerosis, hollenhorst plaques, AV
nicking/nipping, haemorrhages)
• Macula:
o Flat and healthy?
o Abnormalities (discoloration, edema, hard exudates, drusen, haemorrhage,
detachment)
• Posterior vitreous:
o Clear and intact
o Abnormalities: (vitreous haemorrhage, Shaffer sign/tobacco dusting –
pigment cells, Weiss ring, floaters, detachment)

GAZE MANIPULATION – ONE DIRECTION OF GAZE FOR EACH EYE

• Patient looks up → viewing superior fundus → tilt the bottom of the lens towards
the patient slightly
• Down gaze → inferior fundus → Use middle finger to hold eyelashes up → tilt the
upper portion of the lens towards the patient slightly
• Nasal gaze → nasal fundus → eyelashes may need to be held up → tilt the temporal
portion of the lens towards the patient slightly
• Temporal gaze → temporal fundus → eyelashes may need to be held up → tilt the
nasal portion of the lens towards the patient slightly
TIPS AND TRICKS
• Fundus biomicroscopy is ALSO vertically and laterally reversed. To avoid confusion
when recording:
o Turn the page upside down
o Record the posterior pole as you see it appearing through the lens
o If the patient is looking upwards – the superior retina is being viewed –
therefore record your findings inferiorly exactly the way you see it so that
when the page is turned the right side up, it will be correct
• Narration:
o Which area of fundus you are viewing
o Any landmarks you can see as discussed in the narration above
o Any significant findings – retinal lesions, tears, detachment, degeneration
• Record the power and type of condensing lens that was used