Comprehensive Eye Examination

Why an eye exam is important

Eye examinations are primarily performed by an optometrist or ophthalmologist. Primary care doctors often recommend their patients have periodic and thorough eye examinations, since many eye diseases are asymptomatic. Eye examinations may detect potentially treatable blinding eye diseases, ocular manifestations of systemic disease, or signs of tumors 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.

How well can you see

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) 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.

What glasses prescription do you need

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.

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.

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 optometrist will change lenses and other settings while asking the patient for feedback on which set of lenses give the best vision.

Sometimes, eye doctors 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. Once the drops have taken effect, an objective and subjective refraction are performed.

Check pupil size

An examination of pupillary 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.

Check eye muscles

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 doctor notes the speed, smoothness, range and symmetry of movements and observes for unsteadiness of fixation or any nystagmus. 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.

Check field of vision

Gross visual field testing 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.

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.

Check eye health

Slit lamp examination of the eyes in an optometric office involves close inspection of the anterior eye structures and ocular adnexa 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 color, is passed over the eye. Often, this light beam is narrowed into a vertical "slit", during slit-lamp examination. The doctor 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.

Check eye 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. Tonometry can be measured at the slit lamp with a Goldmann applanation tonometer or using a separate non contact tonometer often referred to as an air puff tonometer.

Check lens and retina

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.  These views are important to asses the eye for glaucoma and to note any retinal tears. The appearance of the optic disc and retinal vasculature are also recorded during fundus examination. An opacity in the lens may indicate a cataract. Many ocular and systemic conditions including macular degeneration are diagnosed by close examination of the retina.

All diabetics should have their eyes dilated annually to screen for diabetic retinopathy, a leading cause of blindness. Examining the retinal blood vessels 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.