Video

http://geekymedics.com/2013/08/28/eye-examination-osce-guide/

Exam Summary


1. Introduction

  • Introduce yourself and the exam
  • Ask if the patient if they normally wear glasses or contact lenses
  • Hand hygiene

2. General Inspection

Look for:
  • Ptosis (drooping eyelid or eyelids)
  • Horner's Syndrome - Compression of sympathetic nerves may cause ipsilateral pupil constriction, partial ptosis, possible anhydrosis and possible iris discoloration.
  • Sclera colour:
    • Yellow - jaundice
    • Blue - osteogenesis imperfecta
    • Blue-grey - ochronosis
    • Red - iritis scleritis or subconjunctival haemorrhage
  • Conjunctival Pallor - anaemia
  • Exopthalmos - stand from behind the patient and look down. May be due to Grave's Disease.
  • Corneal Ulceration
  • Cataracts
Ptosis.jpg
Ptosis
Horner's.jpg
Horner's Syndrome
Cataracts.jpg
Cataracts in a baby with congenital rubella syndrome

3. Visual Acuity

  • To test the optic nerve assess the patient's Visual Acuity using a Snellen Chart. Assess each eye individually.
  • Assess:
    • Without Visual aid
    • With Visual Aid
    • Using a pinhole to correct for refractive errors.


4. Visual Fields

  • To test Visual Fields using a red pin.
  • Assess each eye individually
  • Move pin in from four corners to centre vision
  • Loss of visual fields may be due to:
  • Glaucoma
    • Optic nerve lesion
    • Pituitary Tumour (Bitemporal Hemianopia)
    • Optic tract lesion (eg stroke)

5. Eye Movements

  • Test the movements of the eye by getting the patient to follow your finger and making an H-shape.
  • Ask the patient if they ever experience eye pain or double vision while doing so. Look for any movement the patient can't do as well as nystagmus (involuntary eye movements)
Eye2.png
Isolating the different eye muscles. Superior Oblique (CNIV), Lateral Rectus (CNVI). All others CNIII

6. Pupils

  • Check shape and symmetry
  • Assess each eye with a torch for direct and consensual response (ie constriction of the ipsilateral and contralateral eye). Failure to do so indicates an optic (CNII) or oculomotor problem.
  • Perform a swinging torch test. Each eye should constrict

7. Corneal Reflex

  • Test the corneal reflex by lightly touching the cornea from the side with cotton wool. This should illicit a blink reflex in both eyes simultaneously.
  • Failure for this to happen may be due to a trigeminal (CNV) or facial (CNVII) nerve problem. (See cranial nerves)

8. Fundoscopy

a. Cornea

  • Look for corneal ulceration

b. Retina

  • Assess red reflex is the red reflection of the retina when light is shone on it. If there is no red reflex it may be due to cataracts or retinoblastoma
  • Haemorrhage
  • Non-proliferative changes
    • Dot or blot haemorrhages
    • Microaneurysms
    • Hard or soft exudates
  • Proliferative changes
    • New vessel formation
  • Hypertensive changes
    • Silver wiring of arteries
    • Arteriovenous nipping
    • Haemorrhage and exudate
    • Papilloedema
  • Central retinal artery occlusion - milky white fundus
  • Central retinal vein thrombosis - tortuous veins and haemorrhage
  • Retinitis pigmentosa - scattered black pigment
  • Retinal detachment - retina appears elevated or folded
  • Choroiditis - white spots with fluffy edges which can occur in toxoplasmosis or sarcoidosis
Redeyeeffect.JPG
Red reflex

c. Macula

  • Drussen formation - small deposits seen under the epithelium in macula degeneration

9. Palpation

  • Palpate the orbits for tenderness
  • Palpate the pre-auricular lymph nodes which may be enlarged in adenoviral conjunctivitis.

10. Conclude

Thank the patient and offer assistance.

See Also

Geeky Medics - Examination of the eyes & vision – OSCE Guide

Reference

Talley and O'Connor Clinical Examination - 7th edition pp507-16

Citation

Cataracts image: "Cataracts due to Congenital Rubella Syndrome (CRS) PHIL 4284 lores" by http://phil.cdc.gov/phil_images/20030724/28/PHIL_4284_lores.jpg. Licensed under Public Domain via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Cataracts_due_to_Congenital_Rubella_Syndrome_(CRS)_PHIL_4284_lores.jpg#/media/File:Cataracts_due_to_Congenital_Rubella_Syndrome_(CRS)_PHIL_4284_lores.jpg
Eye movements image: By Alex Miles, author's own
Horner's Syndrome Image: "Miosis" by Waster - Nautiyal A, Singh S, DiSalle M, O'Sullivan J (2005) Painful Horner Syndrome as a Harbinger of Silent Carotid Dissection. PLoS Med 2(1): e19 doi:10.1371/journal.pmed.0020019 Copyright: © 2005 Nautiyal et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.. Licensed under CC BY 2.5 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Miosis.jpg#/media/File:Miosis.jpg
Ptosis image: By Andrewya (Own work) [Public domain], via Wikimedia Commons
Red Eye Effect: "BoldRedEye" by User:PeterPan23. Original uploader was PeterPan23 at en.wikipedia - Transferred from en.wikipedia; transferred to Commons by User:Liftarn using CommonsHelper.(Original text : self-made). Licensed under Public Domain via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:BoldRedEye.JPG#/media/File:BoldRedEye.JPG

"Cataracts due to Congenital Rubella Syndrome (CRS) PHIL 4284 lores" by http://phil.cdc.gov/phil_images/20030724/28/PHIL_4284_lores.jpg. Licensed under Public Domain via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Cataracts_due_to_Congenital_Rubella_Syndrome_(CRS)_PHIL_4284_lores.jpg#/media/File:Cataracts_due_to_Congenital_Rubella_Syndrome_(CRS)_PHIL_4284_lores.jpg