see also:

• ophthalmology
• chemical injuries and burns to the eyes
• welder flash burns - UV keratopathy (photo keratitis)
• Eye injuries
• the eye

• the ability to perform a good eye examination is an important skill for most doctors

• wash hands BEFORE and AFTER touching patient's skin and consider wearing gloves
• detailed relevant history
• brief initial examination of face and the eye to ascertain any obvious pathologies
  • eg. trauma, zoster, HSV skin rash, conjunctivitis, etc.
  • a zoster lesion on tip of nose indicates naso-ciliary nerve involvement and probable ocular involvement
• visual acuity in both eyes
  • usually with patient's usual glasses if they have them
  • patient ideally should be 6m from a reference chart and cover one eye and read out the smallest symbols and that line becomes their acuity score for that eye
    • repeat with other eye
    • record eg. if can read only down to 9m symbols with right eye but could not read two of them with their usual glasses on then this would be R: 6/9-2 (with glasses)
    • if poor performance, consider a pinhole test to exclude refractive errors as the cause
• examine eye under normal light using a slit lamp if available
  • if severely photophobic then apply local anaesthetic drops and try again when settled
  • adjust size of the slit and its orientation to your needs
  • is there chemosis of the sclera, if so is there a pattern to it or is it generalised
  • is the pupil reactive
  • is the pupil distorted
  • does the lens appear clear
    • it may have cataracts or it may have been injured in a penetrating injury
  • is the anterior chamber normal
    • is there a hyphaema from blunt trauma
    • is there a cloudiness to it suggesting possible uveitis
  • now examine the cornea carefully
    • is there a corneal foreign body or a residual rust ring / ulcer from a foreign body that is no longer there
    • are there any obvious pathologies
• if no significant pathology found, consider using flourescein staining and examine with the cobalt-blue light in a darkened room:
  • this will be very sensitive for detecting corneal pathology such as:
    • vertical scratches - these generally indicate a subtarsal foreign body which may still be there
    • corneal foreign body
    • ulcer from a corneal body or superficial trauma
    • other corneal ulcers such as dendritic herpetic ulcers
    • a single linear ulcer suggests a scratch such as from a fingernail or a tree branch
    • evidence of a punctate keratitis
      • if the upper third and lower third are spared, this suggests an exposure keratitis from welding, other UV, or inadequate blinking
      • a more generalised keratitis could indicate other causes such as viral, chemical, contact lens issue, etc
• evert upper eyelid if Hx or exam suggests a subtarsal foreign body
  • most common technique:
    • stand behind patient with a good light source above you and directed onto patient's eye
    • ensure you are wearing the correct glasses for this distance if you need glasses
    • ask patient to look down
    • grab the patient's eye lashes and with a horizontal cotton bud pressed firmly against the upper part of the upper eyelid (above the tarsal plate), lift the eyelashes upwards and hopefully the eyelid and its tarsal plate will evert over the cotton bud
  • the Gary AYTON technique for patients with minimal eyelashes which are impossible to grab onto:
    • apply a small length of 5-10mm wide Transpore tape across the bottom half of patient's upper eyelid then use this to hopefully lift the eyelid over the cotton bud as above
  • sweep with a moist cotton bud and inspect with a magnifying glass
• perform tonometry if available to help exclude penetrating eye injury (pressure may be low) or glaucoma (pressure will be high)
• assess extra-ocular muscle movements
  • painful movements may suggest a retro-orbital condition such as orbital cellulitis, etc
• further specific examinations pending suspected pathology
  • ocular pH if suspect chemical burn - this will need immediate and prolonged eye irrigation until pH normalises
  • visual fields if concern is of visual impairment and possible neurologic cause
  • fundoscopy or retinal camera
  • CT orbits if concern for retro-orbital pathology or blow-out fracture entrapping an extra-ocular muscle
• urgent referral to ophthalmology if red flags such as
  • acute vision loss not explained by tears, corneal pathology or visual cortex stroke
  • penetrating eye injury
  • acute glaucoma
  • intra-ocular haemorrhage (except subconjunctival haemorrhage alone which is usually benign)
  • papilloedema
  • concern of retro-orbital pathology
  • history suggestive of retinal detachment
  • unexplained unilateral red eye
  • possible HSV or zoster involvement of the eye