Eye examination

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Eye examination
Snellen chart.svg
Traditional Snellen chart used for visual acuity testing
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An eye examination is a series of tests performed by an ophthalmologist (medical doctor), optometrist, or orthoptist, optician, assessing vision and ability to focus on and discern objects, as well as other tests and examinations pertaining to the eyes. Health care professionals often recommend that all people should have periodic and thorough eye examinations as part of routine primary care, especially since many eye diseases are asymptomatic.

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Eye examinations may detect potentially treatable blinding eye diseases, ocular manifestations of systemic disease, or signs of tumours or other anomalies of the brain.

A full eye examination consists of an external examination, followed by specific tests for visual acuity, pupil function, extraocular muscle motility, visual fields, intraocular pressure and ophthalmoscopy through a dilated pupil.

A minimal eye examination consists of tests for visual acuity, pupil function, and extraocular muscle motility, as well as direct ophthalmoscopy through an undilated pupil.

Basic examination

Visual acuity

Visual acuity is the eyes ability to detect fine details and is the quantitative measure of the eye's ability to see an in-focus image at a certain distance. The standard definition of normal visual acuity (20/20 or 6/6 vision) is the ability to resolve a spatial pattern separated by a visual angle of one minute of arc. The terms 20/20 and 6/6 are derived from standardized sized objects that can be seen by a "person of normal vision" at the specified distance. For example, if one can see at a distance of 20 ft an object that normally can be seen at 20 ft, then one has 20/20 vision. If one can see at 20 ft what a normal person can see at 40 ft, then one has 20/40 vision. Put another way, suppose you have trouble seeing objects at a distance and you can only see out to 20 ft what a person with normal vision can see out to 200 feet, then you have 20/200 vision. The 6/6 terminology is more commonly used in Europe and Australia, and represents the distance in metres.

This is often measured with a Snellen chart or with a logMAR base Velorum Visual Acuity System.

Refraction

In physics, "refraction" is the mechanism that bends the path of light as it passes from one medium to another, as when it passes from the air through the parts of the eye. In an eye exam, the term refraction is the determination of the ideal correction of refractive error. Refractive error is an optical abnormality in which the shape of the eye fails to bring light into sharp focus on the retina, resulting in blurred or distorted vision. Examples of refractive error are myopia, hyperopia, presbyopia and astigmatism. A refraction procedure consists of two parts: objective and subjective.

Objective refraction

An objective refraction is a refraction obtained without receiving any feedback from the patient, using a retinoscope or auto-refractor.

To perform a retinoscopy, the doctor projects a streak of light into a pupil. A series of lenses are flashed in front of the eye. By looking through the retinoscope, the doctor can study the light reflex of the pupil. Based on the movement and orientation of this retinal reflection, the refractive state of the eye is measured.

An auto-refractor is a computerized instrument that shines light into an eye. The light travels through the front of the eye, to the back and then forward through the front again. The information bounced back to the instrument gives an objective measurement of refractive error without asking the patients any questions.

Subjective refraction

A subjective refraction requires responses from the patient. Typically, the patient will sit behind a phoropter or wear a trial frame and look at an eye chart. The eye care professional will change lenses and other settings while asking the patient for feedback on which set of lenses give the best vision.

Cycloplegic refraction

Sometimes, eye care professionals prefer to obtain a cycloplegic refraction, especially when trying to obtain an accurate refraction in young children who may skew refraction measurements by adjusting their eyes with accommodation. Cycloplegic eye drops are applied to the eye to temporarily paralyze the ciliary muscle of the eye.

Pupil function

Medical student giving eye exam at ITESM-Campus Ciudad de Mexico. CCMDonation11.JPG
Medical student giving eye exam at ITESM-Campus Ciudad de México.

An examination of pupilary function includes inspecting the pupils for equal size (1 mm or less of difference may be normal), regular shape, reactivity to light, and direct and consensual accommodation. These steps can be easily remembered with the mnemonic PERRLA (D+C): Pupils Equal and Round; Reactive to Light and Accommodation (Direct and Consensual).

A swinging-flashlight test may also be desirable if neurologic damage is suspected. The swinging-flashlight test is the most useful clinical test available to a general physician for the assessment of optic nerve anomalies. This test detects the afferent pupil defect, also referred to as the Marcus Gunn pupil. It is conducted in a semidarkened room. In a normal reaction to the swinging-flashlight test, both pupils constrict when one is exposed to light. As the light is being moved from one eye to another, both eyes begin to dilate, but constrict again when light has reached the other eye.

If there is an efferent defect in the left eye, the left pupil will remain dilated regardless of where the light is shining, while the right pupil will respond normally. If there is an afferent defect in the left eye, both pupils will dilate when the light is shining on the left eye, but both will constrict when it is shining on the right eye. This is because the left eye will not respond to external stimulus (afferent pathway), but can still receive neural signals from the brain (efferent pathway) to constrict.

If there is a unilateral small pupil with normal reactivity to light, it is unlikely that a neuropathy is present. However, if accompanied by ptosis of the upper eyelid, this may indicate Horner's syndrome.

If there is a small, irregular pupil that constricts poorly to light, but normally to accommodation, this is an Argyll Robertson pupil.

Ocular motility

Ocular motility should always be tested, especially when patients complain of double vision or physicians suspect neurologic disease. First, the doctor should visually assess the eyes for deviations that could result from strabismus, extraocular muscle dysfunction, or palsy of the cranial nerves innervating the extraocular muscles. Saccades are assessed by having the patient move his or her eye quickly to a target at the far right, left, top and bottom. This tests for saccadic dysfunction whereupon poor ability of the eyes to "jump" from one place to another may impinge on reading ability and other skills, whereby the eyes are required to fixate and follow a desired object.

The patient is asked to follow a target with both eyes as it is moved in each of the nine cardinal directions of gaze. The examiner notes the speed, smoothness, range and symmetry of movements and observes for unsteadiness of fixation. These nine fields of gaze test the extraocular muscles: inferior, superior, lateral and medial rectus muscles, as well as the superior and inferior oblique muscles.

Visual field (confrontation) testing

Testing the visual fields consists of confrontation field testing in which each eye is tested separately to assess the extent of the peripheral field.

To perform the test, the individual occludes one eye while fixated on the examiner's eye with the non-occluded eye. The patient is then asked to count the number of fingers that are briefly flashed in each of the four quadrants. This method is preferred to the wiggly finger test that was historically used because it represents a rapid and efficient way of answering the same question: is the peripheral visual field affected?

Common problems of the visual field include scotoma (area of reduced vision), hemianopia (half of visual field lost), homonymous hemianopsia and bitemporal hemianopia.

External examination

External examination of eyes consists of inspection of the eyelids, surrounding tissues and palpebral fissure. Palpation of the orbital rim may also be desirable, depending on the presenting signs and symptoms. The conjunctiva and sclera can be inspected by having the individual look up, and shining a light while retracting the upper or lower eyelid. The position of the eyelids are checked for abnormalities such as ptosis which is an asymmetry between eyelid positions. [1]

Slit-lamp

Slit lamp examination of the eyes in an ophthalmology clinic Slit lamp Eye examination by Ophthalmologist.jpg
Slit lamp examination of the eyes in an ophthalmology clinic

Close inspection of the anterior eye structures and ocular adnexa are often done with a slit lamp which is a table mounted microscope with a special adjustable illumination source attached. A small beam of light that can be varied in width, height, incident angle, orientation and colour, is passed over the eye. Often, this light beam is narrowed into a vertical "slit", during slit-lamp examination. The examiner views the illuminated ocular structures, through an optical system that magnifies the image of the eye and the patient is seated while being examined, and the head stabilized by an adjustable chin rest.

This allows inspection of all the ocular media, from cornea to vitreous, plus magnified view of eyelids, and other external ocular related structures. Fluorescein staining before slit lamp examination may reveal corneal abrasions or herpes simplex infection.

The binocular slit-lamp examination provides stereoscopic magnified view of the eye structures in striking detail, enabling exact anatomical diagnoses to be made for a variety of eye conditions.

Also ophthalmoscopy and gonioscopy examinations can also be performed through the slit lamp when combined with special lenses. These lenses include the Goldmann 3-mirror lens, gonioscopy single-mirror/ Zeiss 4-mirror lens for (ocular) anterior chamber angle structures and +90D lens, +78D lens, +66D lens & Hruby (-56D) lens, the examination of retinal structures is accomplished.

Intraocular pressure

Intraocular pressure (IOP) can be measured by Tonometry devices. The eye can be thought of as an enclosed compartment through which there is a constant circulation of fluid that maintains its shape and internal pressure. Tonometry is a method of measuring this pressure using various instruments. The normal range is 10-21 mmHg.

Retinal examination

Fully dilated pupil prior to ophthalmoscopic examination Fully dilated eye during eye exam.jpg
Fully dilated pupil prior to ophthalmoscopic examination

Examination of retina (fundus examination) is an important part of the general eye examination. Dilating the pupil using special eye drops greatly enhances the view and permits an extensive examination of peripheral retina. A limited view can be obtained through an undilated pupil, in which case best results are obtained with the room darkened and the patient looking towards the far corner. The appearance of the optic disc and retinal vasculature are also recorded during fundus examination.

A red reflex can be seen when looking at a patient's pupil through a direct ophthalmoscope. This part of the examination is done from a distance of about 50 cm and is usually symmetrical between the two eyes. An opacity may indicate a cataract.

Using a phoropter to determine a prescription for eyeglasses Man at Phoropter.jpg
Using a phoropter to determine a prescription for eyeglasses

Retinal vessel analysis is a non-invasive method to examine the small arteries and veins in the retina which allows to draw conclusions about the morphology and the function of small vessels elsewhere in the human body and is used in particular by cardiologists as well as ophthalmologists. [2]

Eye exams for children

It is often recommended that children should have their first eye at 6 months old, or earlier if a parent suspects something is wrong with the eyes. Across the world, screening programs are important for identifying children who have a need for spectacles but either don't wear any or have the wrong prescription. [3]

Children need the following basic visual skills for learning:

Conditions diagnosed during eye examinations

Specialized eye examinations

See also

Related Research Articles

Diabetic retinopathy Human disease

Diabetic retinopathy, also known as diabetic eye disease, is a medical condition in which damage occurs to the retina due to diabetes mellitus. It is a leading cause of blindness in developed countries.

Pupil part of an eye

The pupil is a black hole located in the center of the iris of the eye that allows light to strike the retina. It appears black because light rays entering the pupil are either absorbed by the tissues inside the eye directly, or absorbed after diffuse reflections within the eye that mostly miss exiting the narrow pupil. The term “pupil” was created by Gerard of Cremona.

Optic nerve paired nerve that transmits visual information from the retina to the brain

The optic nerve, also known as cranial nerve II, or simply as CN II, is a paired cranial nerve that transmits visual information from the retina to the brain. In humans, the optic nerve is derived from optic stalks during the seventh week of development and is composed of retinal ganglion cell axons and glial cells; it extends from the optic disc to the optic chiasma and continues as the optic tract to the lateral geniculate nucleus, pretectal nuclei, and superior colliculus.

Oculomotor nerve brain nerve

The oculomotor nerve is the third cranial nerve. It enters the orbit via the superior orbital fissure and innervates extrinsic eye muscles that enable most movements of the eye and that raise the eyelid. The nerve also contains fibers that innervate the intrinsic eye muscles that enable pupillary constriction and accommodation. The oculomotor nerve is derived from the basal plate of the embryonic midbrain. Cranial nerves IV and VI also participate in control of eye movement.

Macula of retina Oval-shaped pigmented area near the center of the retina

The macula (/ˈmakjʊlə/) or macula lutea is an oval-shaped pigmented area near the center of the retina of the human eye and some other animalian eyes. The macula in humans has a diameter of around 5.5 mm (0.22 in) and is subdivided into the umbo, foveola, foveal avascular zone, fovea, parafovea, and perifovea areas.

Cycloplegia is paralysis of the ciliary muscle of the eye, resulting in a loss of accommodation. Because of the paralysis of the ciliary muscle, the curvature of the lens can no longer be adjusted to focus on nearby objects. This results in similar problems as those caused by presbyopia, in which the lens has lost elasticity and can also no longer focus on close-by objects. Cycloplegia with accompanying mydriasis is usually due to topical application of muscarinic antagonists such as atropine and cyclopentolate.

Cyclopentolate chemical compound

Cyclopentolate is a muscarinic antagonist. It is commonly used as an eye drop during pediatric eye examinations to dilate the eye (mydriatic) and prevent the eye from focusing/accommodating (cycloplegic). Cyclopentolate or atropine can also be administered to reverse muscarinic and central nervous system effects of indirect cholinomimetic (anti-AChase) administration.

Eye surgery medical specialty

Eye surgery, also known as ocular surgery, is surgery performed on the eye or its adnexa, typically by an ophthalmologist. The eye is a very fragile organ, and requires extreme care before, during, and after a surgical procedure to minimise or prevent further damage. An expert eye surgeon is responsible for selecting the appropriate surgical procedure for the patient, and for taking the necessary safety precautions. Mentions of eye surgery can be found in several ancient texts dating back as early as 1800 BC, with cataract treatment starting in the fifth century BC. Today it continues to be a widely practiced type of surgery, having developed various techniques for treating eye problems.

Visual acuity clarity of vision

Visual acuity (VA) commonly refers to the clarity of vision. Visual acuity is dependent on optical and neural factors, i.e., (i) the sharpness of the retinal focus within the eye, (ii) the health and functioning of the retina, and (iii) the sensitivity of the interpretative faculty of the brain.

Human eye Mammalian eye; part of the visual organ of the human body, and move using a system of six muscles

The human eye is an organ that reacts to light and allows vision. Rod and cone cells in the retina allow conscious light perception and vision including color differentiation and the perception of depth. The human eye can differentiate between about 10 million colors and is possibly capable of detecting a single photon. The eye is part of the sensory nervous system.

Accommodation reflex

The accommodation reflex is a reflex action of the eye, in response to focusing on a near object, then looking at a distant object, comprising coordinated changes in vergence, lens shape (accommodation) and pupil size. It is dependent on cranial nerve II, superior centers (interneuron) and cranial nerve III. The change in the shape of the lens is controlled by the ciliary muscles inside the eye. Changes in contraction of the ciliary muscles alter the focal distance of the eye, causing nearer or farther images to come into focus on the retina; this process is known as accommodation. The reflex, controlled by the parasympathetic nervous system, involves three responses: pupil constriction, lens accommodation, and convergence.

Ophthalmoscopy test that allows a health professional to see inside the fundus of the eye and other structures using an ophthalmoscope, crucial in determining the health of the retina, optic disc, and vitreous humor

Ophthalmoscopy, also called funduscopy, is a test that allows a health professional to see inside the fundus of the eye and other structures using an ophthalmoscope. It is done as part of an eye examination and may be done as part of a routine physical examination. It is crucial in determining the health of the retina, optic disc, and vitreous humor.

Eye strain, also known as asthenopia, is an eye condition that manifests through non-specific symptoms such as fatigue, pain in or around the eyes, blurred vision, headache, and occasional double vision. Symptoms often occur after long-term use of computers, digital devices, reading, driving long distances or other activities that involve extended visual tasks.

Ocular myasthenia gravis (MG) is a disease of the neuromuscular junction resulting in hallmark variability in muscle weakness and fatigability. MG is an autoimmune disease where anomalous antibodies are produced against the naturally occurring acetylcholine receptors in voluntary muscles. MG may be limited to the muscles of the eye, leading to abrupt onset of weakness/fatigability of the eyelids or eye movement. MG may also involve other muscle groups.

Polycoria is a pathological condition of the eye characterized by more than one pupillary opening in the iris. It may be congenital or result from a disease affecting the iris. It results in decreased function of iris and pupil, affecting the physical eye and visualization.

The red reflex refers to the reddish-orange reflection of light from the back of the eye, or fundus, observed when using an ophthalmoscope or retinoscope. The reflex relies on the transparency of optical media and reflects off the fundus back through media into the aperture of the ophthalmoscope. The red reflex is considered abnormal if there is any asymmetry between the eyes, dark spots, or white reflex (Leukocoria).

A spasm of accommodation is a condition in which the ciliary muscle of the eye remains in a constant state of contraction. Normal accommodation allows the eye to "accommodate" for near-vision. However, in a state of perpetual contraction, the ciliary muscle cannot relax when viewing distant objects. This causes vision to blur when attempting to view objects from a distance. This may cause pseudomyopia or latent hyperopia.

Mammalian eye eye of a mammal

Mammals normally have a pair of eyes. Although mammalian vision is not so excellent as bird vision, it is at least dichromatic for most of mammalian species, with certain families possessing a trichromatic color perception.

Blast-related ocular trauma comprises a specialized group of penetrating and blunt force injuries to the eye and its structure caused by the detonation of explosive materials. The incidence of ocular trauma due to blast forces has increased dramatically with the introduction of new explosives technology into modern warfare. The availability of these volatile materials, coupled with the tactics of contemporary terrorism, has caused a rise in the number of homemade bombs capable of extreme physical harm.

Glassblowers cataract disorder of lens

Glassblower's cataracts are a form of cataract due to an occupational exposure. They are formed by many years or decades of exposure to infrared radiation while working in the occupation of glass blowing, or working close to hot or molten metals such with metal foundry workers or blacksmiths. Glassblower's cataracts are due to chronic exposure to infrared radiation emitted due to the extreme heating of glass or molten metal. The infrared radiation is absorbed by the iris and lens of the eye. This causes cataracts after decades of exposure. This condition may be prevented by wearing protective glasses while practicing these occupations.

References

  1. "Optometrist Guide". Thursday, April 23, 2020
  2. Nägele MR et al.: Retinal microvascular dysfunction in heart failure. European Heart Journal 2018; 39: 47–56
  3. Evans, Jennifer R; Morjaria, Priya; Powell, Christine (2018-02-15). "Vision screening for correctable visual acuity deficits in school-age children and adolescents". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd005023.pub3. ISSN   1465-1858. PMC   6491194 . PMID   29446439.

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