Ophthalmic Exam

A comprehensive examination of the eyes and their functions is important for all individuals with ocular symptoms, and to screen for visual acuity, glaucoma Glaucoma Glaucoma is an optic neuropathy characterized by typical visual field defects and optic nerve atrophy seen as optic disc cupping on examination. The acute form of glaucoma is a medical emergency. Glaucoma is often, but not always, caused by increased intraocular pressure (IOP). Glaucoma, and retinal pathology. A routine examination includes testing for visual acuity, peripheral vision, and color vision, plus an examination of the external eye, conjunctiva, sclera, iris, pupil Pupil The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. Physiology and Abnormalities of the Pupil, and extraocular movements. Primary care clinicians evaluate and refer for visual acuity issues, and treat minor eye conditions such as infections, hordeola (styes), and corneal abrasions. Slit-lamp exams are performed by eye specialists or emergency providers to examine the cornea, anterior chamber, lens, and fundus. Dilated exams help examine the retina. Annual examinations are recommended for individuals with diabetes for early detection and treatment of retinopathy.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Introduction

Overview

  • Vision testing:
    • Visual acuity
    • Peripheral vision
    • Color vision
  • Office exam:
    • Examination of the external eye
    • Conjunctiva
    • Sclera
    • Iris
    • Pupil
    • Extraocular movements
    • Ophthalmoscopic exam of the fundus
  • Detailed exam by slit lamp:
    • Cornea
    • Anterior chamber
    • Lens
    • Dilated exam of the retina

Eye examination recommendations

Recommended frequency of eye exams is not standard, but in general:

  • Children:
    • At birth
    • At 6–12 months
    • At 3 years of age
    • Early teens
    • Annually, if vision correction is needed
    • As needed for symptoms or injuries
  • Adults:
    • Once in the 20s and 30s
    • Every 2 years after 40–50 years of age including screening for glaucoma Glaucoma Glaucoma is an optic neuropathy characterized by typical visual field defects and optic nerve atrophy seen as optic disc cupping on examination. The acute form of glaucoma is a medical emergency. Glaucoma is often, but not always, caused by increased intraocular pressure (IOP). Glaucoma
    • Annually, if vision correction is needed
    • Annually for individuals with diabetes
    • As needed for symptoms or injuries

A dilated exam helps diagnose:

  • Diabetic retinopathy
  • Hypertensive retinopathy Hypertensive retinopathy Hypertension has many adverse effects on the eye, of which retinopathy is the most common presentation. Hypertensive retinopathy consists of retinal vascular changes that develop as a direct effect of elevated blood pressure. In acute increases of blood pressure, autoregulation results in retinal arteriolar narrowing. Hypertensive Retinopathy
  • Macular degeneration Macular degeneration Age-related macular degeneration (AMD) is visual impairment due to changes in the macula, the area responsible for high-acuity vision. It is marked by central vision loss with peripheral vision relatively spared. Risk factors include advanced age, smoking, family history, and cardiovascular disease. Macular Degeneration
  • Retinal detachment Retinal detachment Retinal detachment is the separation of the neurosensory retina from the retinal pigmented epithelium and choroid. Rhegmatogenous retinal detachment, the most common type, stems from a break in the retina, allowing fluid to accumulate in the subretinal space. Retinal Detachment

History

  • Wellness exam or visual complaints
  • History of glasses or contact lens use
  • Family history:
    • Glaucoma
    • Color blindness
    • Other eye diseases
  • Chronic medical conditions
  • Surgical history
  • Medications

Anatomy

The eye and its appendages are situated in the orbit Orbit The orbit is the cavity of the skull in which the eye and its appendages are situated. The orbit is composed of 7 bones and has a pyramidal shape, with its apex pointed posteromedially. The orbital contents comprise the eye, extraocular muscles, 5 cranial nerves, blood vessels, fat, the lacrimal apparatus, among others. The Orbit and Extraocular Muscles. The eyeball is spheroidal and attached to the extraocular muscles.

  • The front of the eye:
    • Cornea: the transparent anterior ⅙th of the outer eyeball
    • Sclera:
      • “White part” of the eye
      • Fibrous, protective, outer layer
      • Made up mainly of collagen and some crucial elastic fibers
    • Limbus: the junction of the cornea and sclera
    • Conjunctiva: the transparent mucus membrane that attaches to the limbus
    • Iris:
      • The “colored part” of the eye
      • Connected to the anterior part of the ciliary body
      • Covers the top of the lens and acts as a shutter for the eye
    • Ciliary body: holds the lens in place
  • Uvea (middle vascular coat of the eye):
    • Anterior uvea: iris and ciliary body
    • Choroid: Posterior portion of the uvea
      • Contains blood vessels that provide nutrients to the eye
      • Located between the retina and sclera
      • Extends to the optic nerve posteriorly
  • The back of the eye:
    • Retina:
      • The nerve coat of the eye
      • Responsible for the perception of vision
      • Contains several photoreceptor cells
      • Connected to the optic nerve
    • Macula (area in the center of the retina):
      • Responsible for clearly seeing objects in detail
      • Required for activities such as driving and reading
    • Fovea centralis: a small depression in the macula where vision is the sharpest
  • Extraocular muscles:
    • 6 muscles that control eye movements
    • 4 rectus muscles:
      • Superior
      • Inferior
      • Lateral
      • Medial
    • 2 oblique muscles:
      • Superior
      • Inferior
Eye anatomy

Anatomy of the human eye

Image by Lecturio.

Equipment for examination

  • Snellen chart or handheld pocket card for testing visual acuity
  • Ishihara chart for testing color blindness
  • Penlight for examining the pupils
  • Ophthalmoscope for examining the retina/fundus
  • Special equipment used primarily by eye specialists or emergency physicians:
    • Slit lamp to examine the cornea
    • Tonometer to measure intraocular pressure
    • Eye drops for pupillary dilation:
      • Phenylephrine
      • Atropine
      • Tropicamide
      • Cyclopentolate
    • Fluorescein and UV lamp to detect corneal abrasions
    • Amsler grid
    • Perimeter-testing machines

Vision Testing

Visual acuity testing

Snellen chart:

  • Shows a series of 11 lines of block letters on a white background, each progressively diminishing in size:
    • The smallest row that can be read accurately indicates the visual acuity in that specific eye.
    • Line 8 is 20/20 vision, indicating a person with normal visual acuity can read this line accurately from 20 feet away (6.1 m).
  • The “Tumbling E” eye chart can detect nearsightedness in young children or in individuals who cannot read.
  • Procedure:
    • The subject sits or stands 20 feet (6.1 m) from the Snellen chart.
    • The subject is asked to cover an eye, read the chart with each eye separately, and then with both eyes. Visual acuity for each is recorded as a fraction (e.g., 20/30).
    • Counting fingers test: tested if the subject is unable to read the top line even from 3 feet (0.91 m). The subject is asked to count the number of fingers held up by the examiner. Results are recorded as CF–1, 2, or 3 based on the number of fingers accurately visualized and counted. 
    • Hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand movement (HM): tested if the subject is unable to count fingers; recorded as HM positive or HM negative
    • Light-perception test: for subjects unable to count fingers or appreciate hand movements; recorded as PL positive or PL negative 

Near-vision chart:

  • Used to test near vision at a distance of 35 cm (14 inches)
  • Jaeger eye chart (with 10 lines of progressively smaller print) is commonly used:
    • Text sizes increasing from 0.37–2.5 mm
    • Acuity is recorded at the smallest line that can be accurately read by the subject.

Clinical relevance:

  • Refractive disorders can be treated with refractive devices (glasses or contact lenses):
    • Myopia: nearsightedness
    • Hyperopia: farsightedness
    • Astigmatism: Blurred vision due to a warped corneal surface causes light rays entering the eye along different planes to be focused unevenly.
  • Presbyopia:
    • Nonrefractive error in older adults
    • Affects visual acuity due to loss of normal lens accommodation

Visual field testing

The field of vision is the total area in which objects can be visualized while looking straight ahead; it includes central vision and peripheral vision.

  • Exam for peripheral vision = confrontation test
    • Procedure:
      • The examiner sits facing the subject at the same head level but at a distance of about 60 cm (2 feet).
      • The individual is asked to cover their left eye with the palm of their hand and is told to look straight into the examiner’s left eye.
      • The examiner closes their right eye and moves their hand in from the periphery toward the common line of vision.
      • The examiner announces that they can see hand movement when it enters their field of vision.
      • The movement of the hand is repeated in various parts of the field of vision, that is above, below, to the right, to the left.
      • The process is repeated for the other eye.
    • Results: The subject should confirm the movement of the hand in their field of vision, which is compared with that of the examiner (assuming it is normal).
  • Other tests used by eye specialists:
    • Perimetry:
      • Manual or automated perimeter machines are used to examine and quantify the visual field of individuals using targets of various sizes and colors.
      • Clinical relevance: Decreased peripheral vision may be due to damage to the optic nerve, retina, or areas of the brain that process vision (e.g., after a stroke).
    • Amsler grid:
      • A test for central vision loss occurring due to macular degeneration
      • Horizontal and vertical lines in a grid with a single dot in the center
      • 1 eye is tested at a time from 30 cm away.
      • The subject is asked to fix their vision on the central dot and describe any patterns they see in their vision.
      • Amsler grid is used to detect defects in the central 20 degrees of the visual field.
  • Clinical relevance
    • Testing of visual fields helps diagnose:
      • Optic nerve damage
      • Glaucoma
      • Hemianopsia
      • Cataracts
    • Amsler grid can be used to evaluate an individual’s central visual field, particularly for macular degeneration.
Testing visual fields

Testing visual fields:
The examiner’s left eye is closed, so he can compare the field of his right eye with the field of the subject’s left eye.

Image: “Testing visual fields” by Consultant ophthalmic surgeon, Department of Ophthalmology, Norfolk & Norwich University Hospital, and Honorary Reader, University of East Anglia, Norwich, UK. License: Cc BY 2.0

Color vision

  • Delineates red/green and total color perception deficiency
  • Can be performed in the office to diagnose color blindness
  • Ishihara color test: 14 colorful, numbered plates for mass screening and classroom use
Ishihara chart

Ishihara chart used for examining color vision

Image: “Ishihara chart” by Wellcome Trust. License: CC BY 4.0

Eye Examination

General exam of the face

  • Head posture:
    • May be abnormal in individuals with squinting
    • The head may be turned in the direction of action of the paralyzed muscle (e.g., stroke).
    • With ptosis, the chin is elevated to uncover the pupillary area.
  • Forehead:
    • Complete loss of wrinkling on 1 side of the forehead is seen in individuals with lower motor neuron facial palsy (e.g., Bell’s palsy).
    • Facial asymmetry may also be noted in individuals with sequelae of stroke, but only the lower half of the face is affected (not the forehead).
    • Mnemonic:
      • B as in Bell’s palsy: Both upper and lower face are affected.
      • S as in Stroke: Only the Smile is affected.

External eye

Preliminary examination for any gross anomalies in the eye and the surrounding structures is conducted in diffuse light. The clinically relevant findings are:

Eyebrow: 

  • Level of the eyebrows may be changed in individuals with ptosis.
  • Madarosis (absence of hair in the lateral ⅓rd of the eyebrows) is seen in:
    • Leprosy Leprosy Leprosy, also known as Hansen's disease, is a chronic bacterial infection caused by Mycobacterium leprae complex bacteria. Symptoms primarily affect the skin and peripheral nerves, resulting in cutaneous manifestations (e.g., hypopigmented macules) and neurologic manifestations (e.g., loss of sensation). Leprosy
    • Hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto's disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism

Eyelids:

  • Position:
    • Normally, the lower eyelid covers the nimbus and the upper eyelid covers 2 mm of the cornea with the eyes open.
    • In cases of ptosis, the eyelid covers more than one-sixth of the cornea.
    • Upper limbus may be seen due to lid retraction in:
      • Thyrotoxicosis Thyrotoxicosis Thyrotoxicosis refers to the classic physiologic manifestations of excess thyroid hormones and is not synonymous with hyperthyroidism, which is caused by sustained overproduction and release of T3 and/or T4. Graves' disease is the most common cause of primary hyperthyroidism, followed by toxic multinodular goiter and toxic adenoma. Thyrotoxicosis and Hyperthyroidism
      • Sympathetic overactivity
  • Movement:
    • Normally, the upper lid follows the eyeball with downward movement.
    • With thyroid ophthalmopathy, the upper-lid movement lags behind the downward gaze.
    • Lagophthalmos (inability to close the eyes completely) seen with:
      • Facial nerve palsy
      • Extreme proptosis
    • Normal blinking rate is 12–16 per minute:
      • Increased with local irritation
      • Reduced with 7th nerve palsy
  • Lid margin:
    • Entropion: inward turning of the lid margin
    • Ectropion:
      • Outward turning of the lid margin
      • The common causes include trachoma, blepharitis Blepharitis Blepharitis is an ocular condition characterized by eyelid inflammation. Anterior blepharitis involves the eyelid skin and eyelashes, while the posterior type affects the meibomian glands. Often, these conditions overlap. Blepharitis, stye Stye A hordeolum is an acute infection affecting the meibomian, Zeiss, or Moll glands of the eyelid. Stasis of the gland secretions predisposes to bacterial infection. Staphylococcus aureus is the most common pathogen. Hordeolum (Stye), and lid trauma.
    • Distichiasis: an abnormal extra row of eyelashes
    • Madarosis (absence of eyelashes) can be seen in:
      • Chronic blepharitis Blepharitis Blepharitis is an ocular condition characterized by eyelid inflammation. Anterior blepharitis involves the eyelid skin and eyelashes, while the posterior type affects the meibomian glands. Often, these conditions overlap. Blepharitis
      • Leprosy Leprosy Leprosy, also known as Hansen's disease, is a chronic bacterial infection caused by Mycobacterium leprae complex bacteria. Symptoms primarily affect the skin and peripheral nerves, resulting in cutaneous manifestations (e.g., hypopigmented macules) and neurologic manifestations (e.g., loss of sensation). Leprosy
      • Hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto's disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism
    • Swelling at lid margin may be due to:
      • Hordeolum Hordeolum A hordeolum is an acute infection affecting the meibomian, Zeiss, or Moll glands of the eyelid. Stasis of the gland secretions predisposes to bacterial infection. Staphylococcus aureus is the most common pathogen. Hordeolum (Stye) ( stye Stye A hordeolum is an acute infection affecting the meibomian, Zeiss, or Moll glands of the eyelid. Stasis of the gland secretions predisposes to bacterial infection. Staphylococcus aureus is the most common pathogen. Hordeolum (Stye))
      • Papilloma
      • Marginal chalazion Chalazion A chalazion is one of the most common inflammatory lesions of the eyelid. It is caused by obstruction of the Meibomian or Zeis glands, leading to granulomatous inflammation and resulting in a firm, rubbery, slow-growing nodule that is typically non-tender. Chalazion
    • Ankyloblepharon (horizontally narrow palpebral fissure) seen at angles of the eye after:
      • Adhesions of the lids after ulcerative blepharitis Blepharitis Blepharitis is an ocular condition characterized by eyelid inflammation. Anterior blepharitis involves the eyelid skin and eyelashes, while the posterior type affects the meibomian glands. Often, these conditions overlap. Blepharitis
      • Adhesions of the lids after burns Burns A burn is a type of injury to the skin and deeper tissues caused by exposure to heat, electricity, chemicals, friction, or radiation. Burns are classified according to their depth as superficial (1st-degree), partial-thickness (2nd-degree), full-thickness (3rd-degree), and 4th-degree burns. Burns
    • Blepharophimosis (narrow palpebral fissure): usually a congenital anomaly
    • Vertically narrow palpebral fissure seen in:
      • Inflammatory conditions of the conjunctiva
      • Inflammatory conditions of the cornea and uvea
      • Ptosis
      • Enophthalmos and anophthalmos
      • Atrophic bulbi
    • Vertically wide palpebral fissure seen in:
      • Proptosis
      • Retraction of the upper lid
      • Facial nerve palsy
  • Lacrimal apparatus:
    • Inspection of lacrimal sac area for:
      • Redness
      • Swelling
      • Fistula
    • Inspection of the lacrimal puncta for defects such as:
      • Eversion
      • Stenosis
      • Absence
      • Discharge
    • Regurgitation test for dacryocystitis Dacryocystitis Dacryocystitis is inflammation of the lacrimal sac due to nasolacrimal duct obstruction and the subsequent stasis of tears. The condition can have an acute or chronic onset. Acute dacryocystitis presents within hours or days with redness, swelling, tenderness, and excessive tearing. Dacryocystitis: Press over the lacrimal sac area just medial to the medial canthus and observe for regurgitation of any discharge from the puncta.
Papillae on the everted upper eyelid in vernal keraconjunctivitis

Papillae on the everted upper eyelid in vernal keratoconjunctivitis

Image: “Papillae on the everted upper eyelid in vernal keraconjunctivitis” by Millicent Bore. License: CC BY 2.0

Conjunctiva

Examination:

  • Bulbar part of the conjunctiva can be examined by retracting the eyelid with the fingers.
  • Lower palpebral conjunctiva: Pull down the lower eyelid while the subject looks upward.
  • Upper palpebral conjunctiva: Retract the upper eyelid gently with the fingers.

Clinical relevance:

  • Discoloration:
    • Primary acquired melanosis: Unilateral, painless, brown macule can transform to malignant melanoma Melanoma Melanoma is a malignant tumor arising from melanocytes, the melanin-producing cells of the epidermis. These tumors are most common in fair-skinned individuals with a history of excessive sun exposure and sunburns. Melanoma.
    • Pale conjunctiva: seen with anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview
    • Bright red patches: indicative of subconjunctival hemorrhage
  • Congestion:
    • Superficial: conjunctivitis Conjunctivitis Conjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis
    • Deep: iridocyclitis or keratitis
    • Mixed: glaucoma Glaucoma Glaucoma is an optic neuropathy characterized by typical visual field defects and optic nerve atrophy seen as optic disc cupping on examination. The acute form of glaucoma is a medical emergency. Glaucoma is often, but not always, caused by increased intraocular pressure (IOP). Glaucoma
  • Edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema:
    • Inflammatory conditions
    • Infection
    • Allergic reactions
  • Follicles:
    • Grayish-white raised areas (aggregation of lymphocytes Lymphocytes Lymphocytes are heterogeneous WBCs involved in immune response. Lymphocytes develop from the bone marrow, starting from hematopoietic stem cells (HSCs) and progressing to common lymphoid progenitors (CLPs). B and T lymphocytes and natural killer (NK) cells arise from the lineage. Lymphocytes) seen in:
      • Trachoma
      • Acute follicular conjunctivitis Conjunctivitis Conjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis
  • Papillae (see photo):
    • Red, raised areas with flat tops
    • Seen in:
      • Trachoma
      • Allergic conjunctivitis Conjunctivitis Conjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis
      • Giant papillary conjunctivitis Conjunctivitis Conjunctivitis is a common inflammation of the bulbar and/or palpebral conjunctiva. It can be classified into infectious (mostly viral) and noninfectious conjunctivitis, which includes allergic causes. Patients commonly present with red eyes, increased tearing, burning, foreign body sensation, and photophobia. Conjunctivitis (GPC)
  • Concretions:
    • Yellowish-white raised areas varying in size
    • Represent thickened mucous and dead epithelial cells in the glands of Henle
    • Seen in:
      • Trachoma
      • Conjunctival degeneration
      • Can be idiopathic
  • Pinguecula:
    • Yellowish, triangular, avascular nodule resembling a fat drop
    • Fatty/proteinaceous deposits on the conjunctiva (does not involve the cornea)
    • Develops on the bulbar conjunctiva in response to:
      • UV light exposure
      • Wind irritation
      • Dust irritation
    • May progress to pterygium
    • May or may not obscure field of vision
  • Pterygium (see photo):
    • Yellowish, triangular, vascular nodule resembling a fat drop
    • Fatty/proteinaceous deposits on the conjunctiva (involves the cornea)
    • Develops on the bulbar conjunctiva in response to:
      • UV light exposure
      • Wind irritation
      • Dust irritation
    • May be preceded by pinguecula
    • Generally affects the field of vision
  • Cysts: seen on the conjunctiva
  • Malignancies of the conjunctiva:
    • Dermoids
    • Papillomas
    • Squamous cell carcinoma Squamous cell carcinoma Cutaneous squamous cell carcinoma (cSCC) is caused by malignant proliferation of atypical keratinocytes. This condition is the 2nd most common skin malignancy and usually affects sun-exposed areas of fair-skinned patients. The cancer presents as a firm, erythematous, keratotic plaque or papule. Squamous Cell Carcinoma
Pterygium

Severe pterygium reaching the pupil Pupil The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. Physiology and Abnormalities of the Pupil

Image: “Pterygium” by José Miguel Varas, MD. License: CC BY 3.0

Sclera

  • Examined at the same time as the conjunctiva
  • Clinical relevance:
    • Yellow sclera: jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice due to liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver disease
    • Bluish discoloration: osteitis deformans, Marfan’s syndrome
    • Inflammation: A pink or purple circumscribed flat nodule is seen with scleritis.
    • Episcleritis: deep, dusky patch associated with marked inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation and ciliary congestion
    • Traumatic perforations can be seen in conditions of trauma.
    • Perforating trauma may communicate with the anterior chamber.

Iris

  • The “colored part” of the eye, examined in regular light
  • Anterior coloboma: a fissure or cleft of the iris:
    • Uveal coloboma lends a “keyhole” or “cat-eye” appearance to the iris:
      • May be benign
      • May be associated with serious lens and optic nerve defects
  • Synechiae: adhesions between the iris and other pupillary structures
    • Anterior synechiae are seen in:
      • Adherent leucoma
      • Leprosy Leprosy Leprosy, also known as Hansen's disease, is a chronic bacterial infection caused by Mycobacterium leprae complex bacteria. Symptoms primarily affect the skin and peripheral nerves, resulting in cutaneous manifestations (e.g., hypopigmented macules) and neurologic manifestations (e.g., loss of sensation). Leprosy
      • Perforating corneal injury
    • Posterior synechiae: seen with iridocyclitis
  • Congenital heterochromia iridis (different colored irides in the same individual) may warrant further evaluation for:
    • Waardenburg syndrome
    • Sturge-Weber syndrome Sturge-Weber Syndrome Sturge-Weber syndrome (SWS) is a congenital neurocutaneous disorder presenting with a facial birthmark called a port-wine stain (PWS), neurological abnormalities such as seizures, and eye abnormalities such as glaucoma. Sturge-Weber Syndrome (SWS)
    • Horner’s syndrome
  • Iritis: leukocytes in the anterior chamber of the eye
  • Anterior uveitis Uveitis Uveitis is the inflammation of the uvea, the pigmented middle layer of the eye, which comprises the iris, ciliary body, and choroid. The condition is categorized based on the site of disease; anterior uveitis is the most common. Diseases of the Uvea: inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the iris and anterior ciliary body
  • Iridocyclitis: inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of iris and adjacent ciliary body
    • Most common type of uveitis Uveitis Uveitis is the inflammation of the uvea, the pigmented middle layer of the eye, which comprises the iris, ciliary body, and choroid. The condition is categorized based on the site of disease; anterior uveitis is the most common. Diseases of the Uvea
    • May be limited to the eye or may signify systemic disease
    • Associated with rheumatological conditions:
      • HLA-B27-related ankylosing spondylitis Ankylosing spondylitis Ankylosing spondylitis (also known as Bechterew's disease or Marie-Strümpell disease) is a seronegative spondyloarthropathy characterized by chronic and indolent inflammation of the axial skeleton. Severe disease can lead to fusion and rigidity of the spine. Ankylosing Spondylitis
      • Psoriatic arthritis
      • Systemic lupus erythematosus Systemic lupus erythematosus Systemic lupus erythematosus (SLE) is a chronic autoimmune, inflammatory condition that causes immune-complex deposition in organs, resulting in systemic manifestations. Women, particularly those of African American descent, are more commonly affected. Systemic Lupus Erythematosus
    • Associated with infectious diseases:
      • Herpes zoster Herpes Zoster Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Shingles (also known as herpes zoster) is more common in adults and occurs due to the reactivation of VZV. Varicella-Zoster Virus/Chickenpox
      • Cytomegalovirus Cytomegalovirus CMV is a ubiquitous double-stranded DNA virus belonging to the Herpesviridae family. CMV infections can be transmitted in bodily fluids, such as blood, saliva, urine, semen, and breast milk. The initial infection is usually asymptomatic in the immunocompetent host, or it can present with symptoms of mononucleosis. Cytomegalovirus
      • Toxoplasmosis Toxoplasmosis Toxoplasmosis is an infectious disease caused by Toxoplasma gondii, an obligate intracellular protozoan parasite. Felines are the definitive host, but transmission to humans can occur through contact with cat feces or the consumption of contaminated foods. The clinical presentation and complications depend on the host's immune status. Toxoplasma/Toxoplasmosis
      • Syphilis Syphilis Syphilis is a bacterial infection caused by the spirochete Treponema pallidum pallidum (T. p. pallidum), which is usually spread through sexual contact. Syphilis has 4 clinical stages: primary, secondary, latent, and tertiary. Syphilis
      • TB TB Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis complex bacteria. The bacteria usually attack the lungs but can also damage other parts of the body. Approximately 30% of people around the world are infected with this pathogen, with the majority harboring a latent infection. Tuberculosis spreads through the air when a person with active pulmonary infection coughs or sneezes. Tuberculosis
    • Leukemia or lymphoma: may produce a leukocyte response that can be mistaken for inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation

Pupil

  • Both eyes should have round, symmetric pupils.
  • Examine in dim light or in the dark with a flashlight to inspect:
    • Size
    • Shape
    • Color
    • Reactions
  • Size:
    • Normal: 3–4 mm
    • Unequal size of pupils: anisocoria
      • May be a benign physiologic condition that is longstanding (simple anisocoria)
      • May indicate an efferent pupillary defect seen in:
        • Cranial nerve III palsy
        • Pharmacologic mydriasis
        • Disorders of the iris
        • Horner syndrome Horner syndrome Horner syndrome is a condition resulting from an interruption of the sympathetic innervation of the eyes. The syndrome is usually idiopathic but can be directly caused by head and neck trauma, cerebrovascular disease, or a tumor of the CNS. Horner Syndrome/disturbance in the sympathetic pathway
    • Decreased size of the pupil Pupil The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. Physiology and Abnormalities of the Pupil (miosis) seen with:
      • Effect of local miotic drugs
      • Iridocyclitis
      • Horner’s syndrome
      • Head injury
      • Opioid use
    • Increased size of the pupil Pupil The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. Physiology and Abnormalities of the Pupil (mydriasis) seen with:
      • Effect of local mydriatic drugs
      • Acute congestive glaucoma Glaucoma Glaucoma is an optic neuropathy characterized by typical visual field defects and optic nerve atrophy seen as optic disc cupping on examination. The acute form of glaucoma is a medical emergency. Glaucoma is often, but not always, caused by increased intraocular pressure (IOP). Glaucoma
      • Optic atrophy
      • Retinal detachment Retinal detachment Retinal detachment is the separation of the neurosensory retina from the retinal pigmented epithelium and choroid. Rhegmatogenous retinal detachment, the most common type, stems from a break in the retina, allowing fluid to accumulate in the subretinal space. Retinal Detachment
      • Cocaine and stimulant use
  • Shape (abnormal shape usually indicates prior surgery)
  • Color (depends on the structures located behind the pupil Pupil The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. Physiology and Abnormalities of the Pupil):
    • Jet black in aphakia
    • Grayish white in immature senile cortical cataract
    • Pearly white in mature cortical cataract
    • Leukocoria (white reflex in pupil Pupil The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. Physiology and Abnormalities of the Pupil (see photo)) seen in:
      • Congenital cataract
      • Retinoblastoma Retinoblastoma Retinoblastoma is a rare tumor but the most common primary intraocular malignancy of childhood. It is believed that the condition arises from a neuronal progenitor cell. Retinoblastoma can be heritable or non-heritable. Retinoblastoma
      • Retrolental fibroplasia
    • Dirty white exudates are seen in iridocyclitis.
  • Pupillary exam for reactions:
    • Direct light reflex:
      • To elicit this reflex, the subject is seated in a dark room and a flashlight is used to elicit constriction. Repeat in the other eye.
      • A normal pupil Pupil The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. Physiology and Abnormalities of the Pupil reacts to light by constricting briskly.
    • Consensual light reflex:
      • A pupil Pupil The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. Physiology and Abnormalities of the Pupil is exposed to light and the response is noted in the other eye. The procedure is repeated for the other eye.
      • Normally, the contralateral pupil Pupil The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. Physiology and Abnormalities of the Pupil will constrict when bright light is directed at the ipsilateral pupil Pupil The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. Physiology and Abnormalities of the Pupil.
    • Swinging flashlight test:
      • To evaluate for an afferent pathway defect
      • Shine a flashlight on 1 pupil Pupil The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. Physiology and Abnormalities of the Pupil and note the constriction. The flashlight is then moved to the other eye and the pupil Pupil The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. Physiology and Abnormalities of the Pupil response is noted.
      • The to-and-fro swinging motion is repeated several times while observing the response of the pupils.
      • Normal response: Both pupils constrict equally. In an afferent pathway defect, the affected pupil Pupil The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. Physiology and Abnormalities of the Pupil will dilate when the flashlight is moved from the normal eye to the abnormal eye.
      • Known as Marcus Gunn pupil Pupil The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. Physiology and Abnormalities of the Pupil (relative afferent pupillary defect)
    • Near reflex:
      • The subject is asked to focus on a distant object and then instructed to suddenly focus on an object held at about 15 cm from their eye.
      • Normal response: Constriction of the pupil Pupil The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. Physiology and Abnormalities of the Pupil is observed when the subject tries to focus on the nearby object.
Child with retinoblastoma

Child with retinoblastoma of the right eye presenting with leukocoria

Image: “Pathology: Patient: Retinoblastoma Retinoblastoma Retinoblastoma is a rare tumor but the most common primary intraocular malignancy of childhood. It is believed that the condition arises from a neuronal progenitor cell. Retinoblastoma can be heritable or non-heritable. Retinoblastoma” by National Cancer Institute. License: Public Domain

Cornea

The cornea is examined with a slit lamp or after corneal staining.

  • To examine for a corneal abrasion Corneal abrasion Corneal abrasions are classified as corneal epithelial defects. These defects are differentiated from other corneal lesions according to their depth: abrasions are into the corneal surface epithelium.. Corneal Abrasions, Erosion, and Ulcers:
    • A drop of fluorescein dye is applied to the conjunctiva at the inside corner of the eye.
    • Corneal abrasions or ulcers stain bright green with fluorescein when viewed under UV light.
  • Clinical relevance
    • Size (abnormalities diagnosed in infants):
      • Microcornea: horizontal diameter < 10 mm
      • Megalocornea: horizontal diameter > 13 mm
    • Shape:
      • Normally, the cornea is a watch glass-like structure with a uniform posterior surface.
      • Keratometry and corneal topography tests are performed to analyze the curvature of the cornea.
      • Keratoconus: conical shaping of the cornea
      • Cornea plana: Flattening of the cornea may occur in individuals as a congenital anomaly.
      • Astigmatism:
        • Refractive condition
        • Warped corneal surface causes uneven focusing of light rays.
    • Sheen:
      • Normal cornea has a sheen.
      • Lost with “dry eye” conditions such as Sjögren syndrome
    • Sensation:
      • Blink reflex:
        • Examiner touches the corneal surface with a cotton wick.
        • Normal response is to blink.
        • May be impaired with neurologic conditions
      • Sensitivity of cornea is diminished in:
        • Herpetic keratitis
        • Neuroparalytic keratitis
        • Leprosy Leprosy Leprosy, also known as Hansen's disease, is a chronic bacterial infection caused by Mycobacterium leprae complex bacteria. Symptoms primarily affect the skin and peripheral nerves, resulting in cutaneous manifestations (e.g., hypopigmented macules) and neurologic manifestations (e.g., loss of sensation). Leprosy
        • Diabetes mellitus Diabetes mellitus Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus
        • End-stage glaucoma Glaucoma Glaucoma is an optic neuropathy characterized by typical visual field defects and optic nerve atrophy seen as optic disc cupping on examination. The acute form of glaucoma is a medical emergency. Glaucoma is often, but not always, caused by increased intraocular pressure (IOP). Glaucoma
        • After trigeminal block for postherpetic neuralgia
Old keratic precipitates

Anterior uveitis Uveitis Uveitis is the inflammation of the uvea, the pigmented middle layer of the eye, which comprises the iris, ciliary body, and choroid. The condition is categorized based on the site of disease; anterior uveitis is the most common. Diseases of the Uvea: slit-lamp photograph showing large, old keratic precipitates

Image: “Anterior uveitis Uveitis Uveitis is the inflammation of the uvea, the pigmented middle layer of the eye, which comprises the iris, ciliary body, and choroid. The condition is categorized based on the site of disease; anterior uveitis is the most common. Diseases of the Uvea” by L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, India. License: CC BY 2.0

Anterior chamber

  • Depth:
    • Measured using a slit lamp
    • Normal depth is 2.5 mm.
    • Shallow anterior chamber is seen with:
      • Primary narrow-angle glaucoma Glaucoma Glaucoma is an optic neuropathy characterized by typical visual field defects and optic nerve atrophy seen as optic disc cupping on examination. The acute form of glaucoma is a medical emergency. Glaucoma is often, but not always, caused by increased intraocular pressure (IOP). Glaucoma
      • Anterior subluxation of the lens
    • Deep anterior chamber is seen with:
      • Congenital aphakia (lack of lens)
      • Myopia
      • Keratoglobus
      • Keratoconus
  • Clinical relevance:
    • Hyphema (blood in the anterior chamber) seen in:
      • Ocular trauma
      • Ocular surgery
      • Iridocyclitis
    • Hypopyon (pus in the anterior chamber) seen in:
      • Corneal ulcer Corneal ulcer Corneal ulcers are classified as corneal epithelial defects. These defects are differentiated from other corneal lesions according to their depth: ulcers extend into the underlying stroma. Corneal Abrasions, Erosion, and Ulcers
      • Iridocyclitis
      • Endophthalmitis Endophthalmitis Endophthalmitis is an inflammatory process of the inner layers of the eye, which may be either infectious or sterile. Infectious endophthalmitis can lead to irreversible vision loss if not treated quickly. Based on the entry mode of the infectious source, endophthalmitis is divided into endogenous and exogenous types. Endophthalmitis
    • Aqueous flare (inflammatory cells in the anterior chamber): seen as fine moving particles in cases of iridocyclitis
    • Foreign bodies may be found after traumatic injury (e.g., wood, iron, glass particles, stone particles, eyelashes).

Lens

Examination of the lens is done using a slit lamp after fully dilating the pupils.

  • Position:
    • Dislocation:
      • Anteriorly into the anterior chamber
      • Posteriorly into the vitreous chamber
    • Subluxation:
      • Partial displacement of the lens from its position
      • Observed as a shining golden crescent on focal illumination
      • Observed as a dark line on distant direct ophthalmoscopy
    • Clinical relevance: may have dislocation or subluxation with trauma
  • Transparency:
    • Opacity is indicative of a cataract.
    • Grayish or yellowish white
    • Clinical relevance of cataracts seen on ophthalmoscopy:
      • Congenital
      • Develop with aging and sun exposure
      • Side effect of corticosteroids
      • Diabetic cataract: “snowflake opacities”
      • Wilson disease: “sunflower cataract”
      • Concussion injury of the lens: “rosette-shaped cataracts”

Testing the intraocular pressure

  • Normal intraocular pressure: 10–21 mm Hg
  • Equipment used in screening for glaucoma Glaucoma Glaucoma is an optic neuropathy characterized by typical visual field defects and optic nerve atrophy seen as optic disc cupping on examination. The acute form of glaucoma is a medical emergency. Glaucoma is often, but not always, caused by increased intraocular pressure (IOP). Glaucoma:
    • Indentation tonometer (Schiotz tonometer)
    • Applanation tonometer (Goldman tonometer)
  • Clinical relevance
    • Ocular hypertension:
      • Increased intraocular pressure
      • No damage to optic structures and normal visual fields
      • Risk factor for glaucoma Glaucoma Glaucoma is an optic neuropathy characterized by typical visual field defects and optic nerve atrophy seen as optic disc cupping on examination. The acute form of glaucoma is a medical emergency. Glaucoma is often, but not always, caused by increased intraocular pressure (IOP). Glaucoma
    • Glaucoma:
      • Elevated intraocular pressure with optic nerve damage
      • Symptoms:
        • Blurred vision
        • Blindness
        • Pain in the eye
      • Requires immediate treatment to prevent vision loss
Tonometer

Tonometer used for measuring intraocular pressure

Image: “Tonometer” by University of California, Irvine School of Medicine, Emergency Department, Irvine, California. License: CC BY 4.0

Examination of the Fundus

Examination of the fundus is important to diagnose disorders of the vitreous humor Vitreous humor The transparent, semigelatinous substance that fills the cavity behind the crystalline lens of the eye and in front of the retina. It is contained in a thin hyaloid membrane and forms about four fifths of the optic globe. Anatomy of the Eye, optic nerve, choroid, and retina.

  • Dilate the pupil Pupil The pupil is the space within the eye that permits light to project onto the retina. Anatomically located in front of the lens, the pupil's size is controlled by the surrounding iris. The pupil provides insight into the function of the central and autonomic nervous systems. Physiology and Abnormalities of the Pupil with a mydriatic agent:
    • Phenylephrine
    • Atropine
    • Tropicamide
    • Cyclopentolate
  • Fundus can be examined using an ophthalmoscope:
    • Ocular media should be transparent.
    • Opacification can be seen with:
      • Corneal opacity (e.g., keratitis)
      • Lenticular opacity (e.g., cataract)
      • Vitreous opacities (e.g., hemorrhage)
  • Clinical relevance:
    • Examination of retinal blood vessels and abnormal findings:
      • Arterioles appear bright red and venules appear purplish.
      • Narrowing of arterioles may be seen in:
        • Hypertensive retinopathy Hypertensive retinopathy Hypertension has many adverse effects on the eye, of which retinopathy is the most common presentation. Hypertensive retinopathy consists of retinal vascular changes that develop as a direct effect of elevated blood pressure. In acute increases of blood pressure, autoregulation results in retinal arteriolar narrowing. Hypertensive Retinopathy
        • Arteriosclerosis
        • Central retinal artery occlusion
      • Tortuosity of veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins may be seen in:
        • Diabetes mellitus Diabetes mellitus Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus
        • Central retinal vein occlusion
        • Blood dyscrasias
      • Drusen (yellow lipid deposits under the retina) seen in:
        • Normal with advancing age
        • Early sign of macular degeneration
    • Optic disc exam and abnormal findings:
      • Connection of the optic nerve to the retina
      • Pinkish white, 1.5-mm circular structure with a central “cup”
      • Hyperemia of the disc seen in:
        • Papilledema
        • Papillitis
      • Pallor of the disc: sign of optic atrophy
      • The normal cup to disc ratio is 0.3 and may be increased in glaucoma Glaucoma Glaucoma is an optic neuropathy characterized by typical visual field defects and optic nerve atrophy seen as optic disc cupping on examination. The acute form of glaucoma is a medical emergency. Glaucoma is often, but not always, caused by increased intraocular pressure (IOP). Glaucoma.
      • Neovascularization of the disc may occur in:
        • Diabetic retinopathy
        • Sickle cell retinopathy
    • Macular exam and abnormal findings (usually requires a slit-lamp exam):
      • Normal macula is slightly darker than the surrounding retina.
      • Center imparts a bright reflex (foveal reflex).
      • Macular hole: a round, full-thickness defect of retinal tissue in the foveal retina leading to the loss of central vision
      • Cherry-red spot seen in:
        • Central retinal artery occlusion
        • Tay-Sachs disease Tay-Sachs disease Tay-Sachs disease is an autosomal recessive lysosomal storage disorder caused by genetic mutations in the hexosaminidase A (HEXA) gene, leading to progressive neurodegeneration. Classic symptoms in infants include rapid degeneration of cognitive and neuromuscular abilities, progressive blindness, and a macular cherry-red spot on physical examination. Tay-Sachs Disease
        • Niemann-Pick disease Niemann-Pick disease Niemann-Pick disease (NPD) is a rare, inherited, lysosomal storage disorder. The disease is classified on the basis of the genetic mutation. Type A and type B result from mutations in the SMPD-1 gene, resulting in acid sphingomyelinase enzyme deficiency. Type C results from NPC1 or NPC2 gene mutations, which are needed for intracellular transport of lipids. Niemann-Pick Disease
        • Gaucher’s disease
      • Macular edema seen in:
        • Trauma
        • Intraocular operations
        • Uveitis
        • Diabetic maculopathy
      • Hard exudates seen in:
        • Diabetic retinopathy
        • Hypertensive retinopathy Hypertensive retinopathy Hypertension has many adverse effects on the eye, of which retinopathy is the most common presentation. Hypertensive retinopathy consists of retinal vascular changes that develop as a direct effect of elevated blood pressure. In acute increases of blood pressure, autoregulation results in retinal arteriolar narrowing. Hypertensive Retinopathy
      • Pale macula: seen with macular degeneration in elderly individuals

References

  1. Khurana, A.K. (2018). Comprehensive Ophthalmology (4th edition, pp. 461-498).
  2. Sihota, R., Tandon. (2019). Parson’s Diseases of the Eye (22nd edition, Chapters 9-13, pp. 87-145).
  3. Jason, D. (2016). The 8-Point Eye Exam. American Academy of Ophthalmology. https://www.aao.org/young-ophthalmologists/yo-info/article/how-to-conduct-eight-point-ophthalmology-exam
  4. Ing, B.E. (2019). Neuro-Ophthalmic Examination. Medscape. Retrieved July 13, 2021, from https://emedicine.medscape.com/article/1820707
  5. Yadav, S., Tandon, R. (2019). Comprehensive eye examination: what does it mean? Community Eye Health, 32, S1-S4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC704181
  6.  Machiele, R., Motlagh, M., Pater, B.C. (2020). Intraocular Pressure. https://www.ncbi.nlm.nih.gov/books/NBK532237/
  7. Golnik, K.C. (2019). Congenital anomalies and acquired abnormalities of the optic nerve. UpToDate. Retrieved July 15, 2021, from https://www.uptodate.com/contents/congenital-anomalies-and-acquired-abnormalities-of-the-optic-nerve
  8. Rosenbaum, J.T. (2020). Uveitis: Etiology, clinical manifestations, and diagnosis. UpToDate. Retrieved July 15, 2021, from https://www.uptodate.com/contents/uveitis-etiology-clinical-manifestations-and-diagnosis

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