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This videotape demonstrates a series of basic 

techniques for ocular examination and management.

The techniques have been taken from the following series of 

self instructional slide tape units.

Since this videotape is intended to supplement the 

slide tape units.

We recommend that you study them first,

then view the videotape to refine your 

techniques or to answer questions about a particular 

technique.

The videotape is meant primarily to demonstrate 

performance the slide tape units 

present examples of normal and abnormal patients 

and go into more detail about indications 

background knowledge and conditions for referral.

The techniques presented our confrontation 

visual field testing,

corneal examination,

examination of the pupil,

checking the anterior chamber,

depth 

motility,

basic screening 

installation of eye drops,

version,

patching 

superficial foreign body 

removal,

irrigation 

and ocular massager.

When a patient complains of blind spots,

bumping into things or other symptoms 

suggestive of a visual field defect.

A confrontation visual field test should be 

performed.

It is also an important part of a complete neurologic 

examination 

confrontation.

Visual field testing can only rule out gross 

visual field defects.

Each eye is tested separately.

The visual field is divided into quadrants with the 

center at the point of fixation.

First each of the quadrants is tested 

separately 

to detect more subtle defects.

The left and right quadrants are tested 

simultaneously.

Finally the nasal and temporal 

halves of the visual field are compared for 

their relative clarity 

in this procedure,

the patient's visual field is compared with the examiners,

The patient and examiners should be seated facing each other 

about one m apart.

The patient should cover one eye and the examiner 

should close his own opposite I the 

patient should maintain fixation on the examiners 

open eyes in a plane 

midway between patient and examiner,

the examiner presents his closed hands in 

each of the upper quadrants of his own visual field,

so that he can clearly see one hand in each of his 

own upper quadrants.

To test the upper nasal and temporal quadrants.

The examiner should display 12 or 

five fingers on one hand,

then on the other hand ask the patient how many 

fingers are seen randomly alternate 

hands.

Two,

one,

two,

two.

Next 1.

The examiner shows fingers of both hands 

simultaneously and ask the patient how many 

total fingers are shown?

Four,

two,

four.

This so called double simultaneous 

presentation may identify a subtle field 

defect that wasn't evident when testing the 

individual quadrants.

Similarly the lower temporal and nasal 

quadrants are tested singly one,

one and simultaneously 

two.

Be sure that the patient maintains fixation on your open 

eye and keeps the other I completely covered.

You should be able to count your own fingers at all times.

Any difficulty in counting fingers suggests a 

visual field defect.

Finally,

with the patients I still covered the examiner 

presents the palms of both hands,

left and right of center and the patient is asked 

if both hands are equally clear both hands 

equally clear 

blueness of any part of one hand compared to the 

other suggests the defect.

Next the opposite.

I is tested.

Have the patient cover the other eye and repeat the 

procedure.

First the upper quadrants are tested singly.

Okay,

one and 

simultaneously two.

Then the lower quadrants are tested 

when two.

One true,

two.

Two.

Finally have the patient compare the palms for 

clarity,

arms equally clear.

Yes,

the results of your testing should be described or 

sketched,

since this is only a gross test by 

confrontation should be included in the 

patient's record.

A defect demonstrated by the confrontation 

method requires referral for more 

precise visual field testing.

There are four tests used to examine the Cornea,

corneal clarity,

corneal light reflection,

fluorescent staining and corneal 

sensitivity 

as the window of the eye.

The cornea must be perfectly clear.

You should be able to see the irish details clearly 

as your pen light illuminates the eye 

haziness of irish details may indicate that the 

cornea is not entirely clear.

The cornea should not only be clear,

but its surface must also be perfectly smooth.

This is most easily checked by examining the 

corneal light reflection.

A good light source should be large,

such as a fluorescent fixture or a window.

A normal corneal surface reflects the light source 

clearly and sharply mirror like as 

demonstrated with this mirror 

and on an actual cornea,

as seen here,

any distortion of the reflected image suggests an 

irregularity of the corneal surface.

A window or a fluorescent fixture is a good 

light source because any distortion of a large 

rectangular image is detected much more 

easily than distortion of a small source,

such as your pen.

Light with the patient 

seated opposite the light source 

tilt the patient's head is needed 

so that the reflection is clearly visible on the 

patient's cornea.

Then have the patient's eyes follow your finger 

so that the reflection moves systematically 

over all parts of the cornea in 

succession 

by having the patient follow your finger up,

down,

left and right.

The entire cornea can be systematically scanned for 

irregularities.

Common causes of an irregular surface are 

abrasion,

foreign body corneal ulcer or 

corneal scar.

If a defect in the corneal surface is suspected 

from the history or from your examination,

fluorescent staining should be performed.

Floor scene will stain any area of the cornea 

where the epithelium has been disturbed.

It is used to confirm suspected interruptions of the 

corneal epithelium and to detect subtle 

defects which might not be found in any other 

way.

You will need some sterile floor seen strips 

in a squeeze bottle of sterile irrigating solution,

remove a floor seen strip,

taking care not to contaminate it.

Place a drop of sterile irrigating solution on the 

tip,

Retract the eyelids gently and instruct the 

patient to look down or up 

briefly touched the floor seen.

Strip to the con Gentiva,

above or below the cornea.

Do not touch the cornea as an abrasion could 

result,

have the patient blink a few times so that the flow racine 

is spread over the cornea 

flush out any excess floor scene with some 

drops of sterile irrigating solution,

Check the cornea for any areas where the dye is 

retained.

Any green staining that adheres to the cornea 

denotes an area of damaged epithelium 

Corneal sensitivity testing is indicated 

when you wish to test the integrity of the 5th 

cranial nerve or to determine 

if a herpes simplex infection has 

compromised the superficial nerve endings.

If indicated,

corneal sensitivity should be checked after fluorescent 

staining since the sensitivity test may 

cause an ia tra genetically positive fluorescent 

stain.

The examiner first teases out some strands from a 

cotton swab.

Then the patients should be instructed to look to the side 

opposite the eye.

Being tested,

the examiner retracts the eyelids 

and brings the swab in laterally.

To avoid a visually evoked blink response.

Then the peripheral cornea is lightly touched with the teased 

out strands.

When normal sensation is present,

a light touch applied to the cornea evokes a blink 

reflex and slight discomfort.

Repeat the test on the other eye.

Using a new cotton swab to avoid any 

possibility of cross contamination.

You should ask the patient if the touch felt the same in each 

eye.

Reviewing the four tests used to examine the Cornea 

first make sure the cornea is perfectly 

clear and that the irish details are easily 

seen.

Then check the surface of the cornea.

Using a large,

rectangular light source 

fluorescent staining will confirm suspected 

interruptions of the corneal epithelium.

Finally,

to check the integrity of the fifth cranial nerve or 

to determine if a herpes simplex infection has 

compromised the superficial nerve endings,

corneal sensitivity is tested.

When examining the pupils,

you should check them for shape,

size and reaction to light 

pupils should be tested in a semi dark room,

since inequality has become more obvious when the pupils are 

wide instruct the patient to look 

at an object at least 10 ft away to prevent 

the constriction of the pupil due to the near reflex,

the pupil should be round and in the center of the 

iris.

The pupil should be approximately equal in diameter.

A difference in diameter of greater than one millimeter 

may indicate a significant abnormality.

To check the pupils reaction to light first 

illicit the direct pupil.

Every reaction 

Shine your penlight into one I the 

pupil of this I should constrict quickly and 

smoothly 

Shining a light into one pupil should also 

bring about symmetrical constriction of the opposite pupil.

This is the consensual pupil.

Every reaction 

as you shine your hand light into one,

I observe the pupil of the other eye for 

consensual constriction.

Similarly observe the direct and consensual 

pupil very reactions with the light shining in the 

other eye,

analyzing the direct and consensual reactions 

will help you determine if there is a defect of the different 

sensory pathways.

Notice that the pupils are unequal here and the 

left pupil of this patient does not react to a light 

stimulus shone directly into it,

nor does it react consensually.

The swinging flashlight test is a sensitive screening 

method for detecting defects in the different 

sensory pathways.

The test is based on the fact that an eye with a 

defect of the different sensory pathway 

effectively receives a weaker stimulus 

and thus has a weaker pupil eri response than a 

normal I.

When the hand light shines into the normal I.

A normal direct and consensual 

response is seen 

when the flashlight swings quickly to the abnormal 

I.

The direct reaction is less than the previous consensual 

reaction and thus a 

paradoxical dilatation occurs 

since the stimulus to this I is not adequately 

transmitted centrally.

The direct and consensual reactions are decreased 

or may even be absent.

When the light is quickly swung back to the normal I 

breast constriction is seen again.

This patient has an abnormality of the optic nerve.

Watch as the swinging flashlight test is 

demonstrated,

swing your light back and forth quickly several times 

to make sure that the response is consistent and 

that you did not miss a subtle difference.

It is crucial that the light be swung very quickly between 

the two eyes in order to avoid the normal 

dilation from the relatively low level of 

ambient illumination.

The paradoxical debilitation is called a 

Marcus Gunn pupil 

while you are using your hand light to check the pupil,

you can also use it to check the depth of the anterior 

chamber.

This is an important screening test for possible narrow 

angle glaucoma.

The anterior chamber is the space between the 

cornea and the iris.

In a shallow chamber the iris bulges 

forward,

interrupting a light beam shining across the iris 

and causing a shadow to fall over the part of the iris 

away from the penlight.

In a normal chamber,

the beam will shine across the entire iris 

to check the chamber depth,

shine your pen light from the side of the eye.

Normally,

the light illuminates the entire iris.

As shown here 

in a narrow chamber,

a shadow falls on the nasal side of the iris.

As shown here in patients with a 

shallow chamber dilating,

the pupil may cause a chamber angle block,

triggering an attack of acute glaucoma.

These patients should not be dilated and should be 

referred to an ophthalmologist for appropriate 

care.

Yeah.

In the evaluation of extra ocular muscle function 

there are four aspects range of motion 

smoothness of motion,

stability,

an alignment of the eyes 

to test the patients range of motion.

Have the patient follow your finger into the 

six cardinal positions of gays.

You should note whether there is any limitation in the ability 

of one or both eyes to move into the various 

positions 

when in doubt about whether one eye is limited in movement,

compare its range of movement to that of the other 

eye.

A limitation of movement of one eye.

As demonstrated here may indicate either 

a mechanical constraint or a 

paralysis.

When both eyes cannot move to a given direction 

it indicates a gaze palsy of super 

nuclear origin.

In all cases the patient should be referred for 

ophthalmological evaluation 

while the patient is following your finger.

Also note the smoothness of motion 

and the ability to hold the eyes still.

As the patient fixates on your finger,

inability to hold the eyes still is known as 

nystagmus.

Nystagmus may remain the same in all positions of 

gays or maybe more pronounced in some 

positions and absent in others.

Such differences should be noted if present,

notice the jerk nystagmus evidenced by this 

patient 

and the pendulum nystagmus 

demonstrated by this patient.

Any patient with nystagmus who has not been evaluated 

previously should also be referred.

Finally,

check the alignment of the eyes.

Patient complaints of diplo pia or double 

vision often originate from defects in the alignment 

mechanism of the eyes.

You can determine if the eyes are straight or binocular 

early aligned by noting the relative 

position of the corneal light reflections 

as the patient fixates on a light source.

The corneal reflection should be positioned over the center 

of the two pupils.

In this patient.

The corneal reflection of the left eye is not in the 

center of the pupil If 

you suspect deviation of one I.

A cover test should be performed.

Have the patient stare at a distant object 

with your hand Cover one eye and 

watch for any movement of the other eye 

repeat this with the other eye.

Since both eyes are aligned on the same target 

covering either I should normally not 

result in any movement.

If one eye is not aligned with the fixation 

target,

then covering the I will cause the nonaligned 

I to move to take up fixation.

You see in this patient that covering the normal I 

resulted in movement.

Since only the normal I was already fixating on the 

target.

Testing for alignment of the eyes is particularly 

important in young patients,

since an untreated deviation may lead to lifelong 

amblyopia,

mm hmm.

Several ophthalmological examining techniques have been 

demonstrated confrontation,

visual field testing anterior chamber,

depth check examination of the 

pupil corneal,

light,

reflection,

corneal sensitivity,

corneal clarity and 

motility.

Some of these techniques need only be performed as 

indicated.

Others are important to use on every patient 

as part of your routine physical 

examination.

Such a basic screening takes little time 

and will now be demonstrated in patients 

without ocular complaints.

This screening should detect most latent eye 

problems.

There are four basic ocular history screening 

questions.

Ask the patient whether her vision has ever been 

decreased and also whether it is the 

same in both eyes.

Then ask whether the eyes have been red,

painful or otherwise bothersome.

Finally,

ask whether a doctor or anyone else has ever 

told the patient that there was anything abnormal or 

unusual about the eyes.

After taking the ocular history begin the 

examination,

test your eyes.

Now,

would you cover the left eye 

palm of your hand and look down towards 

that chart over there and read 

the line just under the green line.

Okay.

You see those letters.

T.

P E O L F 

DZ.

Good.

Now cover your other eye.

Okay.

Okay.

T P E O L 

F.

D.

Z.

Okay.

Now I'm going to look at your eyes to 

look over there,

look up.

Okay,

fine.

Now look at my finger.

This patient's eyes fixate and moves smoothly 

over the full range of motion and they are well 

aligned.

The next step is op Tomasz Capi 

1 2nd.

I'll turn off the lights.

I'm going to look inside your eye now.

I'd like you to look right at that door knob across the way.

Try not to look directly at my life.

Mhm.

I'm going to look in your other eye.

Look over my other shoulder.

Same place 

your eyes look fine.

The last thing I'm gonna do is check the pressure inside your 

eye.

Would you lie down please?

Thank you.

Has anybody in your family had glaucoma?

Not that I know of.

Have you ever had the pressure in your eyes checked?

I'm going to put some numbing drops in your eyes right now.

Mhm.

So you won't feel the instrument.

Look up for me.

Please Try not to rub or press on your eyes for 

the next 15 minutes.

Otherwise you might scratch them.

Mhm.

Here's a tissue for you.

I want you to take your thumb and hold it up over your head over 

here.

That's good.

Just keep looking right at the thumb.

Try to pay no attention to this instrument.

Just keep looking right at your car.

That's perfect.

Keep looking at your thumb.

Put your thumb down now.

The pressure in your eyes are perfectly normal.

This patient received a basic but comprehensive 

ocular examination in a very short 

time.

The technical details of 10 on the tree and up to Mosca 

P.

Are covered in the other self instructional units.

If the patient had any ocular complaints 

or if you had found any abnormalities in this 

screening examination you might have spent more 

time exploring the specific findings as 

outlined in the tape slide units 

to instill eye drops.

The patient should be seated or lying supine.

The patient's head should be tilted back slightly 

With a tissue in one hand retract the 

patient's upper lid with the 

fourth or fifth finger of the other hand which is 

also holding the dropper.

Retract the lower lid,

instruct the patient to look up 

and instill a drop into the inferior con gente 

Vilsack.

Do not place the drop directly onto the cornea 

to avoid contact with the lashes.

Hold the bottle high enough so that the normal blink 

reflex does not bring the lashes into 

contact with the tip of the dropper.

Blot any excess fluid from around the patients.

II