Preliminary ocular examination in optometry

2. Purpose of Preliminary examination
 Upon completion of history, the examiner is in a
position to make a tentative diagnosis
 The purpose of the preliminary examination is to
detect any gross anomaly such as a high refractive error,
a binocular vision anomaly, a disturbance of ocular
motility, or an ocular or systemic diseases.

3. Order of ocular examinations
1. Visual Acuity
2. Tests of ocular motility and binocular vision
a. Cover Tests
b. Corneal Reflex Tests
c. NPC Testing
d. NPA Testing
e. Motility Tests
f. Tests of Pupillary function
g. Tests of stereopsis
3. Tests of Color Vision

4. Order of ocular examinations
4. Visual Field screening
a. Confrontations
4. Tonometry
5. Blood Pressure measurement
6. External examination (anterior segment Evaluation)
a. Slit lamp examinations
4. Internal examination (Posterior Segment Evaluation)
a. Fundus Evaluation
i. Direct
ii. Indirect

5. Order of ocular examinations
9. Special Investigations:
a. Keratometry
b. A-scan
c. Ultrasound (B-scan)
d. Perimetry
e. Pachymetry
f. Amsler grid Testing
g. Goniosopy
h. Ocular photodocumentation
i. Fundud Fluorescein Angiography
j. Neurodiagnostic tests
k. Contrast Sensitivity Test
l. Electrodiagnostic tests
m. Exophthalmometry
n. Ophthalmodynamometry-for carotid artery insufficiency; transient loss of vision

6. Visual Acuity
• VA is assessed to obtain visual status of each eye.
• Pin hole test helps differentiating abnormality due to dioptric
apparatus or one due to organic disease.
• Defect in dioptric apparatus is further confirmed by
retinoscopy.
Tested with
Snellen’s test types
E test chart & Landolt’s broken ring test types.
SG chart & kay picture cards
Optokinetic nystagmus test & forced preferential looking charts
LogMAR charts

8. General Observation
It is recommended that you stand back and observe the whole
patient for a few seconds before carrying out the examination.
Sometimes, observation alone is sufficient to give you the
diagnosis and the examination only serves to confirm it.
Observation is conducted for
Head posture, facial asymmetry, Forehead, Eyebrows, ocular
posture, ocular movements

9. Ocular Posture
Determined by the position of the
two visual axes in the primary
position of gaze.
Different occular postures are
esotropia, exotropia, hypotropia,
hypertropia, incyclotropia,
excyclotropia.
It is revealed by cover-uncover test.
Cover test is done by covering one
eye and watching the other eye for a
fixation movement. Uncover test is
done by watching they eye just
uncovered.

12. Cover
Uncover
Alternate
Prism Cover
 ).
Hirchberg test:
position of light reflex is seen by asking the patient to see on
the torch light. Reflex on the temporal side of pupil indicates
the eye is convergent & if it is on the nasal side the eye is
divergent.

13. Ocular motility
ask patient to focus on a near target and follow it as he/
she traces a broad letter "H." This tests the ability of the e
yes to follow the target. It will indicate any problem with th
e nerve supply to the eye muscles or problems with the m
uscles themselves.

16. External ocular examination
Done either in
Diffused light using torch.
Or Focal illumination using slit lamp or loupe.
Procedures go as follows:
Asymmetry in wrinkling of foreheads
Eyebrows
Eye lashes
Eye lids

17. Conjunctiva
Method of examination
Bulbar conjunctiva is examined by
retracting the upper lid & lower lid
by index finger & thumb respectively.
Lower palpebral conjunctiva is seen
by asking the patient to look up &
then pulling the lower lid down.
Upper palpebral conjunctiva &
fornix is seen by asking the patient to
look down and then grasping the lid
margin by thumb & index finger the
lid is everted using index finger as
fulcrum.

18. Points to be noted while examining:
Redness or congestion.
Discharge.
discoloration.
Chemosis.
Changes on the surface.
New formations: papillae, follicles,
concretions, pinguecula, pterygium,
phlycten, tumors, cysts etc.
Ulcers & granulomas.
Membranes & pseudomembranes.
Scar
Foreign bodies.

19. Examination of sclera:
The white sclera is visible through conjunctiva.
The points to be noted are:
Colour
Congestion.
Pain & tenderness.
Traumatic perforations.

20. Examination of cornea
It should be done under slit lamp examination.
The points to be noted are
Size: normal cornea is 11 mm vertically & 11.7 mm
horizontally.
Curvature
Surface is also assessed using placido’s keratoscopic
disc. Other tests for topography are photokeratoscopes.

21. Transparency
Opacity
Foreign bodies
Abrasions
Ulcerations
Vascularization
Corneal sensations
Corneal endothelium examination using specular microscopy.
Corneal thickness (using pachymetry) estimation.

22. Corneal staining is performed when epithelial defect is
suspected.
In this flourescense strip is placed in the inferior
fornix. Patient is asked to blink and then cornea is
inspected under cobalt blue light.
• Cornea is translucent, smooth and avascular.

23. Examination of anterior chamber
• It’s done best under slit lamp.
• Depth and contents are noted.
• Normally anterior chamber is clear with aqueous humor.
• Following contents in the AC are noted:
• Hyphaema
• Hypopyon
• Aqueous flare & cells
• Lens
• Lens particles

24. Examination of Iris
• Normally iris is flat & color varies
• Things to be noted if present
• Adhesions (synaechiae)
• tremulousness (iridodonesis)
• new vessel formation
• pupillary membranes
• Colobomas
• prolapse
• irridodialysis
• nodules
• Cysts

25. Examination of pupil
• Pupil should be examined before any mydriatics is
used.
• Normally pupil varies from 3-4 mm in diameter. Miotic
& midriatic pupils are noted.
• Shape is normally round & regular.
• It’s placed slightly nasal to center.
• It appears greyish black due to lens behind it.

26. • Reaction to light:
• Direct reaction
• Consesual reaction
• Swinging flash reaction
• The reaction to convergence and accomodation.

27. Examination of lens
• Lens is examined by slit lamp and ophthalmoscopy.
• Normally the lens is transparent. Any opacity is called cataract.
• Cataract may be morphologically cortical, polar, subscapular or
nuclear as seen under slit lamp.
• Even under dilatation lens covers the pupillary area.
• Absence, subluxation & dislocation of lens should be noted.
• Normally lens is biconvex & unpigmented.

28. Examination of the posterior segment
• It’s done by slit lamp fundoscopy (using
hruby lens, +90D, +60D lenses), direct &
indirect ophthalmoscopy.
• Normally the media is clear. Any opacity
in the vitreous can be seen as black
shadows against dark glow.
• Disc is 1.5 mm, ellipsoid and pale pink
with discretely demarcated border with
the retina.

29. • Normal cup disc ratio is found to be 0.3:1.
• Depth & shape of cup should be noted.
• Venous pulsation is normal.
• Peripheral retina is pinkish red normally.
• Patency of arterioles & venules and integrity of capillary network
are to be checked.
• Macula is dark area of about 3 mm diameter on the temporal
aspect of the disc. Light reflex is noted, dull reflex indicate
disease.

30. Tests for lacrimal apparatus
• Lacrimaral apparatus is examined in any case of epiphora,
corneal ulcer and before intraocular surgery.
• Regurgitation test is performed to know the patency of
lacrimal apparatus.
• Tear quantity test including schirmer 1 & 2 are done for
dry eyes .
• Tear quality test as well as tear film stability test (TBUT)
is done to assure intact mucin layer secreted by
conjunctival goblet cells.

31. Tonometry
• Normal IOP varies from10 to 21 mm Hg.
• Tonometry is used to measure IOP in all suspected
cases of Glaucoma.
• Different instruments used are SCHIOTZ tonometry,
Goldman applanation tonometry, Perkin’s tonometry,
Tonopen, air puff tonometry etc.

32. If we wouldn’t make simple observations
before examining, we shall be…..
• Mistaking
pseudostrabismus for
manisfest squint
• Mistaking a prosthetic
eye for unreactive pupil
• Mistaking a big eye for
proptosis.