Print Friendly, PDF & Email

Ready to test your knowledge? Try our ophthalmology questions.

An Approach to Examination of the Eye

A template for examination of the eye for junior doctors, medical students, and membership exams. A systematic approach is useful to ensure a swift and efficient clinical examination.


  • Wash hands
  • Introduce self, confirm patient’s name and date of birth
  • A brief history from the patient if not provided
  • Explain examination, gain permission, check if patient is happy with privacy
  • Check if patient is experiencing any pain or visual disturbance
  • Position patient in chair and sit opposite, move around patient as required (e.g. when assessing red reflex)

General Inspection

  • Begin with general inspection – is the patient in a hospital bed, with any treatments/monitoring/paraphernalia suggestive of systemic disease?
  • Then move to the face – any asymmetry may indicate cranial nerve lesions which can hint that there may be findings on ophthalmic examination
  • Comparison with old clinical photographs or a collateral history from a relative may be helpful in determining the degree and timescale of any positive findings on general inspection

Inspection of the eyes

  • In a structure like the eye, comparison between sides is crucial in differentiating pathology from normal variation
  • Globe
    • Proptosis, enophthalmos
  • Eyelids/lash margins
    • Ptosis, blepharitis, styes, ectropion, entropion, eyelid tumours
  • Sclera, conjunctiva, cornea, iris
    • Injection, opacities, colour change, discharge
  • Pupils
    • Please see below

Visual Acuity, Fields, and Colour Vision (CNII)

  • To be assessed one eye at a time
  • Near vision
    • Best assessed using a near-reading chart, can be assessed more crudely with any small print, e.g. newspaper
    • Ensure patient wear reading glasses if they use these normally
  • Distance vision
    • Typically assessed using a Snellen chart – chart 6 metres from the patient, report the lowest line patient can read
      • Repeat at a lower distance if unable to read top line, then can assess whether they can see hand movements, or perception of light
    • Ensure patient wears glasses if they usually do
    • Repeat with a pinhole to assess whether any change in acuity is related to refractive error
    • Gross visual acuity can be ascertained by requesting them to look for distant objects such as a wall clock, painting or something far in through the window
  • Colour vision
    • Assessed using standard Ishihara plates
    • Red top of bottles or pen can be used to compare both eyes if color plates not available
  • Although traditionally assessed on paper, in busy inpatient settings, electronic versions of all of these tests (e.g. those found on MD Calc) can be useful

Visual Fields

  • Assessed clinically using the confrontation test, and quantitively using e.g. Goldmann visual field testing
    • Ask patient to cover an eye, mirror them (i.e., if they cover their left eye, cover your right eye)
    • Ask them to keep their eye fixed on yours; you do the same
    • Assess all four visual quadrants compared to yours by moving a hatpin, pen, or your fingers from outside your visual field, diagonally towards the centre until the patient can see it
    • Repeat for the other eye
Visual field diagram

Figure 1. Visual Fields to be Assessed by Confrontation.

Visual field defects

Figure 2. Visual Field Defects and their Corresponding Anatomical Lesions. Credit: Uretsky S. Visual field deficits. In: Ettinger AB, Weisbrot DM, eds. Neurologic Differential Diagnosis: A Case-Based Approach. Cambridge: Cambridge University Press; 2014:477-486.

Eye Movements

  • Ask patient to keep their head still and follow a hatpin, pen, or your finger with their eyes, at a distance of approximately 30cm
  • Move your finger in the following shape (Figure 3), to assess each of the extremes of movement
  • Ask whether the patient is experiencing any pain, diplopia (‘double vision’), or visual blurring throughout the assessment
    • Observe for any focal deficits in movement, or nystagmus
    • Note: nystagmus at the extremes of vision can be normal
Assessment of eye movements

Figure 3. Schematic Diagram for Assessment of Eye Movements.


  • The 3 ‘S’s – size, symmetry, shape
    • Anisocoria (different pupil sizes) occurs in at least 20% of people in the absence of any pathology, but may reflect an abnormally large pupil (e.g. CN II or CN III lesion), or an abnormally small one (e.g. in Horner’s syndrome)
      • You may be guided by whether the anisocoria becomes more or less pronounced in light versus dark environments
    • Irregularly shaped pupils are rarely normal, and may reflect inflammation (uveitis, iridocyclitis) or previous surgery/trauma
  • Reflexes (best assessed in dim light)
    • Light reflex
      • Direct – pupil constricts when a pen-torch is shone into ipsilateral eye
      • Consensual – contralateral pupil constricts when a pen torch is shone into the ipsilateral eye
    • Relative Afferent Pupillary Defect (RAPD)
      • Rapidly move pen torch between both eyes (i.e. ‘swinging light test’)
      • If RAPD is present, the affected pupil will appear to dilate when light is shone into it due to lesion of direct pathway but intact consensual constriction
    • Accommodation
      • Ask the patient to focus on the wall behind you
      • Hold a hatpin, pen, or your finger approximately 30cm away from their eyes in the midline
      • Closely observing their pupils, ask them to focus on the close object, looking for bilateral and symmetrical constriction and convergence
Pupillary light reflex

Figure 4. Schematic Diagram of the Pupillary Light Reflex. (1): Light shone into left pupil. (2): Optic nerve (CNII) fibres from the nasal retina cross to the contralateral (right) side at the optic chiasm, while temporal fibres remain uncrossed. (3): fibres from the left eye reach both the ipsilateral and contralateral pretectal nucleus (in red). (4): Interneurons from both pre-tectal nuclei synapse with both Edinger-Westphal nuclei (in orange). (5): EW nuclei each synapse with the ipsilateral ciliary ganglion (CNIII). (6): Each ciliary ganglion delivers nerve fibres via the short ciliary nerve to the ipsilateral pupillary sphincter.


Additional Tests

  • It is pertinent to perform a full cranial nerve examination and consider whether the patient requires onward referral
  • Several additional tests may be carried out if deemed necessary, but are not routinely performed in general medical environments
    • Colour vision – in addition to colour blindness, may detect pathologies such as macular degeneration or certain cataracts
    • Cover test – if any concern about strabismus, either a -phoria (latent squint) or -tropia (manifest squint)
    • Further imaging – slit lamp, ultrasound, OCT, autofluorescence etc.


Author: Dr Archith Kamath BA BMBCh FHEA

Senior Editor: Mr Nachiketa Acharya MB BS, MD, FRCSEd (Ophth)