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Anatomy of the Patient Exam
© 2008–2012, BSM Consulting
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Anatomy of the Patient Exam
Table of Contents
OVERVIEW ................................................................................................................................ 1
PRELIMINARY WORK-UP ......................................................................................................... 1
OTHER DIAGNOSTIC TESTING ............................................................................................... 3
DIAGNOSIS ................................................................................................................................ 4
TREATMENT PLAN ................................................................................................................... 5
CONCLUSION ............................................................................................................................ 6
COURSE EXAMINATION ........................................................................................................... 7
© 2008–2012, BSM Consulting
Anatomy of the Patient Exam
OVERVIEW
Once the check-in process has been completed, the patient is ready to begin the medical eye
examination. This module will describe a basic medical eye examination, which includes the preliminary
work-up, the external exam, dilation, slit lamp exam, and fundus exam. A diagnosis (or physician’s
medical opinion) and a treatment plan are also important components of the exam. While different
practices have unique styles and requirements for the exam, the basic components are similar. Following
the description of the exam components is a listing of common diagnostic testing and common
diagnoses.
PRELIMINARY WORK-UP
The preliminary work-up is most frequently performed by ophthalmic assistants or technicians.
Preliminary work-up components include:
History
The patient will be asked for their chief complaint, or the reason they are visiting the office. A thorough
patient history is essential for the physician to make an accurate diagnosis. Obtaining the HPI (history of
the present illness) includes asking such questions as:

When did the problem start?

How long or how often?

Which eye?

What is your current treatment?
Included in the history are discussions of past eye problems (including previous eye or other surgical
procedures performed) and a review of the patient’s medical history and family medical history. The
patient’s current medications should be reviewed and listed in the chart, as well as any drug allergies.
Most often, the patient has completed a medical history questionnaire during the check-in process, so the
technician may review the information provided and ask for any necessary clarification.
Visual Acuity
Visual acuity is the numerical value associated with the smallest objects the patient can see on specific
eye charts at a specific distance. It is the cornerstone of the medical eye exam and gives documentation
of the patient’s vision before any other test is performed in the office. Distance vision is usually tested
using the familiar Snellen chart (Big “E” on the top of the chart with increasingly smaller rows of letters
below), while near vision is tested by having the patient read standard paragraphs of increasingly small
print at a comfortable reading distance. Measurements are usually taken both with and without glasses,
one eye at a time. 20/20 is considered “normal” visual acuity.
External Exam
The external exam consists of three segments:

Confrontation Visual Field (CVF): Obtains a gross measurement of the patient’s peripheral vision.
It is useful in the detection of damage due to a stroke, glaucoma, and some retinal detachments.

ExtraOcular Motility (EOM): Measures the range of motion and the function of the six extraocular
muscles. This testing helps to detect eyes that are misaligned or not working together properly.

Pupil Evaluation: Evaluates pupils according to their size, shape, and reaction to light.
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Anatomy of the Patient Exam
Lensometry (Automated or Manual)
A lensometer is an instrument that is used to document the patient’s current spectacle prescription. The
readings identify not only the power of the lens but also the type of lens (as noted below):

Single Vision Lens: Is strictly for distance or for near.

Bifocal Lens: Has two different focus points, one for distance and one for near. Usually the top
portion of the lens corrects distance vision while the bottom portion corrects near vision.

Tri-Focal Lens: Has three different focus points – one for distance, one for near, and one for
intermediate distance. The intermediate lens is usually used for computer work or music.

Progressive Lens: A true multi-focal lens. The distance prescription is at the top of the lens, and
the power gets progressively stronger in the bottom segment. This gives the patient a wide range
of focusing points.

Prism: Special formatting of the optical centers of lenses to reduce double vision or imbalance in
vision.
The prescription of the glasses currently worn by the patient and obtained by lensometry is recorded in
the chart.
Refraction
This portion of the examination determines the best lens correction for eyes with refractive errors. An
autorefractor (a computerized instrument) estimates the refractive error of the patient by analyzing the
light reflected from the eye. Using the measurements from both the autorefractor and the lensometer as a
beginning point, more specific and refined measurements are made using the retinoscope and the
phoropter. The final refraction is the prescription given to provide the best corrected visual acuity.
Tonometry
Tonometry is a measurement of intraocular pressure (IOP). The eye’s ability to maintain a proper IOP
allows for proper blood flow throughout the ocular structures. The aqueous (fluid) inflow and outflow
determines the steady pressure within the eye. A certain pressure is necessary to give the eye its shape
and stability; yet too much intraocular fluid may indicate a sight-threatening problem, such as glaucoma.
Testing may be accomplished by:

Applanation tonometry, which measures the force needed to flatten part of the cornea. This type
of procedure requires the administration of anesthetic drop.

Intraocular pressure can be measured by indenting the cornea or sclera. Since the eye has an
internal pressure, any attempt to indent it will provide an equal and opposite pressure. The
indentation tonometer uses this principle for measuring.

Non-contact tonometry, which measures intraocular pressure by blowing a puff of compressed air
at the cornea and measuring the amount of deflection produced. No anesthetic drop is needed for
this procedure (indentation tonometry).
Dilation
Patient’s eyes are dilated with the use of dilating (mydriatic) drops. These drops are most often
administered by the technician and require at least 15 minutes to effect dilation. The dilation of pupils
allows the physician to see more clearly the details of the back of the eye (retina). For a few hours after
the eye exam, the dilation may blur a patient’s vision, cause sensitivity to light, and impair near vision. For
these reasons, patients who have been dilated may be given sunglasses to wear upon completion of the
exam and may wish to have someone accompany them to the office to drive them home. The amount of
© 2008–2012, BSM Consulting
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Anatomy of the Patient Exam
temporary impairment varies from person to person. Some practices provide an eye drop that reverses
the effects of dilation more quickly than the natural abating process.
Slit Lamp Examination
This portion of the examination is most frequently performed by the physician, but portions may be done
by the ophthalmic technician. The slit lamp (a biomicroscope) focuses a narrow beam of light into the eye,
and through magnification and light allows the physician to examine the lids and eyelashes, the
conjunctiva, the cornea, iris, lens, vitreous, and fundus. During this part of the examination, the doctor
may detect such conditions as an eye infection, cataracts, damage to the cornea or retina, etc.
Fundus Examination
The physician examines the retina (back of the eye) to determine the appearance of the optic nerve/disc,
the macula, and the periphery. Diseases identified by the appearance of the retinal structure include
macular degeneration, retinal detachments, glaucoma, optic nerve disease, etc. Special instruments used
to give a clearer detail of the retina include the direct and indirect ophthalmoscope and a wide variety of
fundus lenses
OTHER DIAGNOSTIC TESTING
Previous discussions of the medical eye examination included the basic workup; however, as a result of
findings from the basic workup, additional testing may be needed for the physician to make an accurate
diagnosis. Listed below are additional tests that might be requested by the physician.

Amsler Grid: Helps diagnose macular problems and is performed on patients with complaints of
distortion, letters “jumping” when reading, or anyone with unexplained decrease in near vision.
Patients describe the normal or abnormal appearance of gridlines on a chart. Distortions in the
gridlines on the chart are recorded by the technician.

Color Vision: Using a book of color vision plates or pages, this test screens for acquired and/or
hereditary color visual defects.

Corneal Topography: Using a computerized and digital instrument, this test maps the curvature
of the cornea and is useful in diagnosing corneal diseases such as keratoconus and astigmatism.
This testing is often performed for contact lens fittings and preliminary evaluations for refractive
surgery such as LASIK.

Binocularity (Cover Test, Worth 4 Dot): Tests binocularity (parallelism) and alignment of the
eyes.

Dry Eye Test: Measures the quantity of tear secretion using a special strip of paper placed under
the lower lid for a specified time (often called a Schirmer test).

Extended Ophthalmoscopy: Test in which the physician uses special magnification to see
retinal detail. Testing includes a color drawing of the detail seen, as well as interpretation by the
physician.

Fluorescein Angiography: A technique for viewing the detail of the blood vessels of the retina.
Fluorescein dye is injected into the patient’s arm after which time-lapse photos are taken to
document the appearance of the retinal blood vessels as the dye passes through. This is
important in the diagnosis of retinal disorders such as diabetic retinopathy, macular edema, etc.

Fundus Photography: Photographs the appearance of the optic discs, the macula, and
anomalies of the retina

Glare Test - Brightness Acuity Testing (B.A.T.): Determines the effects of glare on visual
acuity, which is often needed to document medical necessity for cataract surgery.
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Anatomy of the Patient Exam

Gonioscopy: A mirrored contact lens evaluation by the physician to examine the angle structures
in the front portion of eye that allow for fluid outflow (primarily a screening test for glaucoma).

Keratometry: Measures the curvature of a cornea. These measurements are frequently taken on
patients who are being fitted for contact lenses, measured for intraocular lenses for cataract
surgery, or who may have corneal problems. The results are called “K” readings.

Nerve Fiber Analyzer (HRT, GDX): This computerized, digital instrument captures the
appearance of the nerve fibers of the optic nerve. This test is useful in the diagnosis and
maintenance of glaucoma.

Optical Coherence Tomography (OCT): Takes transpupillary images of the retina to assist in
diagnosis and treatment of retinal diseases.

Pachymetry: Measures the thickness of the cornea. This is used commonly in the diagnosis of
glaucoma and corneal disease.

Potential Acuity Measure (PAM): Tests a patient’s potential for improvement in visual acuity
following cataract surgery.

Stereopsis Test: Screens for normal or abnormal depth perception in both eyes.

Ultrasonography (Biometry): Uses the reflection or echo of sound waves to measure the length
of the eye or to detect abnormalities in the eye. Two types of tests are performed:

o
A-Scan – An ultrasound biometry test used to measure the length of the eye to assist in
the calculation of the power of an intraocular lens to be used in cataract surgery.
o
B-Scan – An ultrasound test that provides two-dimensional reconstruction of the ocular
and orbital tissues. It is also used to detect ocular tumors.
Visual Field (Perimetry): Used to test and document abnormal defects in a patient’s central and
peripheral vision. This test is most commonly used to diagnose and monitor glaucoma and other
neurological eye problems.
DIAGNOSIS
After completing the examination and reviewing any additional testing that has been performed, the
physician makes a diagnosis of the patient’s ocular condition.
Descriptions of the most common ocular diagnoses follow.

Age-Related Macular Degeneration (ARMD): Degeneration of the macula, resulting in loss of
central and reading vision. It affects older people.

Astigmatism: Irregular curvature of the cornea causing blurred vision that normally can be
corrected using a cylindrical lens.

Blepharitis: Infection and inflammation of the eyelid margins, usually causing scaling and
crustiness of the upper and lower lid margins.

Cataract: Clouding of the crystalline lens in the eye. When the cataract gets to the point that a
person’s declining vision interferes with their activities of daily living (i.e., they can not see to
drive, to sew, to read, to see television, etc.), surgical removal of the cloudy lens may be
recommended.

Chalazion: Swelling in the eyelid caused by an inflammation of one of the oil producing glands in
the upper and/or lower eyelid.
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Anatomy of the Patient Exam

Conjunctivitis: Inflammation of the conjunctiva (white of the eye), often called “pink eye.”

Corneal Abrasion: Scratched surface of the cornea.

Corneal Ulcer: A potentially sight-threatening lesion on the surface of the cornea, usually caused
by infection or injury.

Dermatochalasis: Excessive eyelid skin that may impair a person’s field of vision.

Diabetic Retinopathy: A sight-threatening disease that results in the abnormal growth and
leaking of retinal blood vessels due to diabetes.

Dry Eye Syndrome: Dryness of the eye due to insufficient tear production causing scratchy,
burning eyes.

Emmetropia: Refractive condition of the eye that requires no lens correction.

Floaters: Small particles or debris suspended in the vitreous, causing shadows or shapes seen
by the patient. When accompanied by flashes of light and loss of vision, floaters may be
symptoms of a sight-threatening problem like retinal detachment.

Glaucoma: Progressive vision loss due to damage of the optic nerve, caused by higher than
normal intraocular pressure. Treatment may include eye drops, laser, or surgical intervention.

Hyperopia: Farsightedness.

Keratitis: Inflammation of the cornea.

Myopia: Nearsightedness.

Presbyopia: A condition most commonly seen in people over age 40 who have lost the ability to
focus at near and who need reading glasses (magnification).

Pseudophakia: Diagnosis resulting from the removal of a cataract and the implantation of an
intraocular lens (IOL).

Pterygium: A growth of fleshy tissue on the conjunctiva that may extend onto the cornea.

Ptosis: Droopy upper lid due to age, gravity, or a weak eye muscle.

Retinal Detachment: Separation of the retina from the back of the eye; a potentially sightthreatening disorder.

Secondary Membrane: Clouding of the membrane (lens capsule) of the lens after cataract
surgery. This condition may be surgically treated with a laser.

Subconjunctival Hemorrhage: Breaking of a blood vessel under the conjunctiva causing a
“blood red” eye.
TREATMENT PLAN
Once the physician has reviewed the testing and made a diagnosis, a treatment plan is developed.
Recommendations may include a prescription for glasses, prescription for medication, surgical
intervention, referral to sub-specialists, or perhaps, no treatment. Often practices provide educational
counseling and printed materials to enable patients to better understand their condition and treatment.
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Anatomy of the Patient Exam
It is hoped the patient leaves the office feeling their concerns have been addressed and the staff and
physician care about them and are competent to help them with their problem.
CONCLUSION
As noted earlier, different practices have unique styles and requirements for the medical eye exam;
however, the basic components are similar. Having a fundamental understanding of the patient exam,
common diagnostic testing, and common diagnoses will enable staff to be more effective in their
interaction with patients and help ensure a positive experience and quality of care for all patients in the
practice.
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Anatomy of the Patient Exam
COURSE EXAMINATION
1. Which part of the patient examination tests for gross measurement of peripheral vision, range of
motion and function of eye muscles, and evaluates the size, shape, and reaction of the pupils?
a.
b.
c.
d.
e.
History
Visual Acuity
External Exam
Slit Lamp Examination
Fundus Examination
2. A numerical value associated with the smallest objects a patient can see on a specific chart at a
specific distance is called:
a.
b.
c.
d.
e.
History
Visual Acuity
External Exam
Slit Lamp Examination
Fundus Examination
3. The lids and eyelashes, the conjunctiva, the cornea, iris, lens and vitreous are evaluated during
which portion of the eye exam?
a.
b.
c.
d.
e.
History
Visual Acuity
External Exam
Slit Lamp Examination
Fundus Examination
4. A patient will be asked for their chief complaint and symptoms of their current problem during
which portion of the eye exam?
a.
b.
c.
d.
e.
History
Visual Acuity
External Exam
Slit Lamp Examination
Fundus Examination
5. The examination of the back of the eye is called the:
a.
b.
c.
d.
e.
History
Visual Acuity
External Exam
Slit Lamp Examination
Fundus Examination
6. The portion of the examination that determines the best lens correction for the patient, and may
result in a prescription for glasses is called:
a.
b.
c.
d.
Lensometry
Refraction
Tonometry
Dilation
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Anatomy of the Patient Exam
7. In order for the physician to see clearly the details of the back of the eye (retina), patients are
given drops that make the pupil larger. This process is called:
a.
b.
c.
d.
Lensometry
Refraction
Tonometry
Dilation
8. The measurement documenting the patient’s current spectacle prescription is called:
a.
b.
c.
d.
Lensometry
Refraction
Tonometry
Dilation
9. The measurement of intraocular pressure is called:
a.
b.
c.
d.
Lensometry
Refraction
Tonometry
Dilation
Match one of the following diagnostic tests with the description of its purpose:
Diagnostic Tests
a.
b.
c.
d.
e.
f.
Amsler Grid
Corneal Topography
Dry Eye Test (Schirmers)
Extended Ophthalmoscopy
Fluorescein Angiography
Gonioscopy
g.
h.
i.
j.
k.
Nerve Fiber Analyzer
Pachymetry
Potential Acuity Measure (PAM)
Ultrasonography (biometry)
Visual Field
10. ____ Maps the curvature of the cornea.
11. ____ Evaluates the angle structures in the eye that allow for fluid transfer.
12. ____ Allows for viewing the appearance of retinal blood vessels as dye injected into the patient’s
arm flows through the blood vessels.
13. ____ Tests the patient’s peripheral vision.
14. ____ Measures the quantity of tear secretion using a special paper strip.
15. ____ Measures the thickness of the cornea.
16. ____ Measures the length of the eye to assist in calculating the power of an intraocular lens to be
used in cataract surgery.
17. ____ Tests a patient’s potential for improvement in visual acuity with cataract surgery.
18. ____ Uses special magnification to see retinal detail and includes a color drawing of the detail
and interpretation by the physician.
19. ____ Uses a patient’s description of gridlines on a chart to document distortions in near vision.
20. ____ Captures the appearance of the fibers of the optic nerve.
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Anatomy of the Patient Exam
Match one of the following ocular diagnoses with its description:
Ocular Diagnoses
a. Age-related macular degeneration
(ARMD)
b. Astigmatism
c. Blepharitis
d. Cataract
e. Chalazion
f. Conjunctivitis
g. Diabetic Retinopathy
h.
i.
j.
k.
l.
m.
n.
o.
Dry Eye Syndrome
Floaters
Glaucoma
Hyperopia
Myopia
Pseudophakia
Retinal Detachment
Secondary Membrane
21. ____ Inflammation of the conjunctiva, often called “pink eye.”
22. ____ Progressive vision loss due to the damage of the optic nerve, causing peripheral vision
loss.
23. ____ Separation of the retina from the back of the eye.
24. ____ Farsightedness.
25. ____ Nearsigntedness.
26. ____ Irregular curvature of the cornea causing blurred vision.
27. ____ Clouding of the crystalline lens.
28. ____ Diagnosis resulting from removal of cataract with implantation of intraocular lens.
29. ____ Clouding of membrane of the lens after cataract surgery.
30. ____ Inflammation of the eye lid margins.
31. ____ Swelling in the eyelid caused by an inflammation of one of the oil producing glands.
32. ____ Abnormal growth of retinal blood vessels due to diabetes.
33. ____ Degeneration of the macula resulting in loss of central and reading vision.
34. ____ Small particles or debris suspended in the vitreous causing shadows and shapes.
35. ____ Insufficient tear production.
© 2008–2012, BSM Consulting
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