Eye examination

Definition

An eye examination is a series of tests that measure a person's ocular health and visual status, to detect abnormalities in the components of the visual system, and to determine how well the person can see.

Purpose

An eye examination is performed by an ophthalmologist, (M.D. or D.O. -doctor of osteopathy), or an optometrist (O.D.) to determine if there are any pre-existing or potential vision problems. Eye exams may also reveal the presence of many non-eye diseases. Many systemic diseases can affect the eyes, and since the blood vessels on the retina are observed during the exam, certain problems may be uncovered (e.g., high blood pressure or diabetes).

Infants should be examined by a physician to detect any physical abnormalities. Frequency of eye exams then generally differs with age and the health of the person. Eye exams can be performed in infants, and if a problem is noted the infant can be seen, generally by a pediatric ophthalmologist. A child with no symptoms should have an eye exam at age three. Early exams are important because permanent decreases in vision (e.g., amblyopia, also called lazy eye) can occur if not treated early (usually by ages 6-9). Again, with no other symptoms, the second exam should take place before first grade. After first grade, the American Optometric Association recommends an eye exam every two years; ages 19-40, every two to three years; ages 41-60, every two years; and annually after that. However, these are recommendations for healthy people with no risk factors. Patients should ask their doctors how often they should come for exams. Some patients have risk factors for eye disease (e.g., people with diabetes or a family history of eye disease; African Americans, who are at higher risk for glaucoma) and may need more frequent checkups. Also, if children seem to be having trouble in school, problems with reading, rubbing their eyes when reading, etc., an eye exam may be necessary sooner.

Precautions

The examiner needs to know if the patient is taking any medications or has any existing health conditions. Some medications, even over-the-counter (OTC) medications can affect vision or even interfere with the eyedrops the doctor may use during the exam. Certain eyedrops would not be used if the patient has asthma, heart problems, or other conditions.

The patient may need someone to drive them home in case the eyes were dilated. Bringing sunglasses to the exam may also help decrease the glare from light until the dilating drops wear off.

Description

An eye examination, given by an ophthalmologist or optometrist, costs about $100. It may or may not be covered by insurance. It begins with information from the patient (case history) and continues with a set of primary tests, plus additional specialized tests given as needed, dictated by the outcomes of initial testing and the patient's age. The primary tests can be divided into two groups, those that evaluate the physical state of the eyes and surrounding areas, and those that measure the ability to see.

The order of the tests for the exam may differ from doctor to doctor, however, most exams will include the following procedures:

Information gathering and initial observations

The examiner will take eye and medical histories that include the patient's chief complaint, any past eye disorders, all medications being taken (e.g., OTC medications, antibiotics, and birth control pills), any blood relatives with eye disorders, and any systemic disorders the patient may have. The patient should also tell the doctor about hobbies and work conditions. This information helps in modifying prescriptions and lets the doctor know how the patient uses his or her eyes. For example, using a computer screen vs. construction work, the working distance of a computer screen may affect the prescription; the construction worker needs protective eyewear.

The patient should bring their current pair of glasses to the exam. The doctor can get the prescription from the glasses by using an instrument called a lensometer.

Visual acuity examination

Visual acuity measures how clearly the patient can see. It is measured for each eye separately, with and without the current prescription. It is usually measured with a Snellen eye chart, a poster with lines of different-sized letters, each line with a number at the side denoting the distance from which a person with normal vision can read that line. Other kinds of eye charts with identifiable figures are available for children or anyone unfamiliar with the Roman alphabet. These charts are made to be placed at a certain distance (usually 20 ft) from the person being tested. At this distance, people with normal vision can read a certain line (usually the lowest), marked the 20/20 line; these people are said to have 20/20 vision. For people who can't read the smallest line, the examiner assigns a ratio based on the smallest line they can read. The first number (numerator) of the ratio is the distance between the chart and the patient, and the second number (denominator) is the distance where a person with normal vision would be able to read that line. The ratio 20/40 means the patient can see at 20 ft. what people with normal vision can see at 40 ft. away.

When a patient is unable to read any lines on the chart, they are moved closer until they can read the line with the largest letters. The acuity is still measured the same way. A ratio of 5/200 means the person being tested can see at 5 ft what a normal person can see 200 ft.

When a patient can't read the chart at all, the examiner may hold up some fingers and ask the patient to count them at various distances, and records the result as "counting fingers" at the distance of recognition. If the patient cannot count the examiner's fingers at any distance, the examiner determines if the patient can see hand movements. If so, the result is recorded as "hand movements." If not, the examiner determines if the patient can detect light from a penlight. If the patient can detect the light but not its direction, the result is recorded at "light perception." If the patient can recognize its direction, the result is recorded as "light projection." If the patient cannot detect the light at all, the result is recorded as "no light perception."

Eye movement examination and cover tests

The examiner asks the patient to look up and down, and to the right and left to see if the patient can move the eyes to their full extent. The examiner asks the patient to stare at an object, then quickly covers one eye and notes any movement in the eye that remains uncovered. This procedure is repeated with the other eye. This, and another similar cover test, helps to determine if there is an undetected eye turn or problem with fixation. The doctor may also have the patient look at a pen and follow it as it is moved close to the eyes. This checks convergence.

Iris and pupil examination

The doctor checks the pupil's response to light (if it dilates and constricts appropriately). The iris is viewed for symmetry and physical appearance. The iris is checked more thoroughly later using a slit lamp.

Refractive error determination-Refraction

The examiner will determine the refractive error and obtain a prescription for corrective lenses for people whose visual acuity is less than 20/20. An instrument called a phoropter, which the patient sits behind, is generally used (sometimes the refraction can be done with a trial frame that the patient wears). The phoropter is equipped with many lenses that allow the examiner to test many combinations of corrections to learn which correction allows the patient to see the eye chart most clearly. This is the part of the exam when the doctor usually says, "Which is better, one or two?" The phoropter also contains prisms, and sometimes the doctor will intentionally make the patient see double. This may help in determining a slight eye turn. The exam will check vision at distance and near (reading).

A prescription for corrective lenses can also be supplied by automated refracting devices, which measure the necessary refraction by shining a light into the eye and observing the reflected light. Another objective way to obtain a prescription is using a hand-held retinoscope. As in the automated method just mentioned, the doctor shines a light in the patient's eyes and can determine an objective prescription. This is helpful in young children or infants.

Sometimes drops will be instilled in the patient's eyes before this part of the exam. The drops may relax accommodation so that the refraction will be more accurate. This is helpful in children and people who are farsighted.

After the refraction and other visual status tests, for example color tests or binocularity tests (can the patient see 3-D, or have depth perception), the doctor will check the health of the eyes and surrounding areas. The main instruments used are the ophthalmoscope and the slit lamp.

Ophthalmoscopic examination

These observations are best accomplished after dilating the pupils and require an ophthalmoscope. The ophthalmoscope most frequently used is a called a direct ophthalmoscope. It is a hand-held illuminated 15X multi-lens magnifier that lets the examiner view the inside back area of the eye (fundus). The retina, blood vessels, optic nerve, and other structures are examined.

Slit lamp examination

The slit lamp is a microscope with a light source that can be adjusted. This magnifies the external and some internal structures of the eyes. The lid and lid margin, cornea, iris, pupil, conjunctiva, sclera, and lens are examined. The slit lamp is also used in contact lens evaluations. A little probe called a tonometer may be used at this time to check the pressure of the eyes. A colored eyedrop may be instilled immediately prior to this test. The drop has a local anesthetic so the patient won't feel the probe touch the eye. It is a quick procedure.

Visual field measurement

A perimeter, the instrument for measuring visual fields, is a hollow hemisphere, equipped with a light source that projects dots of light over the inside surface. The patient's head is positioned so that the eye being tested is at the center of the sphere and (about 13 in. 33 cm) from all points on the inside surface of the hemisphere. The patient stares straight ahead at an image on the center of the surface and signals whenever he or she detects a flash of light. The perimeter records which flashes are seen and which are missed and maps the patient's field of vision and blindspots.

Intraocular pressure (IOP) measurement

Tonometers are used to measure IOP. Some tonometers measure pressure by expelling a puff of air (noncontact tonometer) towards the eyeball from a very short distance. Other tonometers are placed directly on the cornea. The noncontact tonometers are not as accurate as the contact tonometers and are sometimes used for screenings.

Completing the evaluation with additional tests

Depending upon the results other tests may be necessary. These can include, but are not limited to binocular indirect ophthalmoscopy, gonioscopy, color tests, contrast sensitivity testing, ultasonography, and others. The patient may have to return for additional visits.

Results

External observations

INITIAL OBSERVATIONS AND SLIT LAMP EXAM

Some general observations the doctor may be looking for include: head tilt; drooping eyelids (ptosis); eye turns; red eyes (injection); eye movement; size, shape, and color of the iris; clarity of the cornea, anterior chamber, and lens. The anterior chamber lies behind the cornea and in front of the iris. If it appears cloudy or if cells can be seen in it during the slit lamp exam an inflammation may be present. A narrow anterior chamber may put the patient at risk for glaucoma. A clouding of the normally clear lens is called a cataract.

Internal observations

OPHTHALMOSCOPIC EXAM

The observations include, but are not limited to the retina, blood vessels, and optic nerve. The optic nerve enters the back of the eye and can be checked for swelling or other problems. The blood vessels can be viewed as can the retina. The macula is a 3-5 mm area in the back of the eye and is responsible for central vision. The fovea is a small area located within the macula and is responsible for sharp vision. When a person looks at something, they are pointing the fovea at the object. Changes in the macular area can be observed with the ophthalmoscope. Retinal tears or detachments can also be seen.

Visual ability

VISUAL ACUITY

The refraction will determine the refractive status for each eye for distance and for near. A prescription for glasses is made after taking many things into consideration. The eye doctor may alter a prescription based upon many factors. Different materials for glasses may be suggested. For example, polycarbonate may be suggested for children or people active in sports because it is very impact resistant. Bifocals, trifocals, single-vision spectacles, and contact lenses are also options.

VISUAL FIELDS

A normal visual field extends about 60° upward, about 75° downward, about 65° toward the nose, and about 100° toward the ear and has one blind spot close to the center. Defects in the visual field signify damage to the retina, optic nerve, or the neurological visual pathway.

Seeing clearly does not necessarily mean the eyes are healthy or that the eyes are working together as a team. Regular checkups can detect abnormalities, hopefully before a problem arises. The eye doctor can suggest ways to help protect the eyes and vision (e.g., safety goggles, ultraviolet (UV) coatings on lenses). A person should also have an eye exam if they notice a change in vision, eyestrain, blur, flashes of light, a sudden onset of floaters (little dots), distortion of objects, double vision, redness, pain or discharge.

Amblyopia

Decreased visual acuity, usually in one eye, in the absence of any structural abnormality in the eye.

Conjunctiva

The mucous membrane that covers the white part of the eyes (sclera) and lines the eyelids.

Cornea

Clear outer covering of the front of the eye.

Floaters

Translucent specks that float across the visual field, due to small objects floating in the vitreous humor.

Fundus

The inside of an organ. In the eye, refers to the back area that can be seen with the ophthalmoscope.

Glaucoma

There are many types of glaucoma. Glaucoma results in optic nerve damage and a decreased visual field and blindness if not treated. It is usually associated with increased IOP, but that is not always the case. The three factors associated with glaucoma are increased IOP, a change in the optic nerve head, and changes in the visual field.

Gonioscope

An instrument used to inspect the eye (e.g., the anterior chamber). It consists of a magnifier and a lens equipped with mirrors; it's placed on the patient's cornea.

Iris

The colored ring just behind the cornea and in front of the lens that controls the amount of light sent to the retina.

Macula

The central part of the retina where the rods and cones are densest.

Ophthalmoscope

An instrument designed to view structures in the back of the eye.

Optic nerve

The nerve that carries visual messages from the retina to the brain.

Pupil

The circular opening that looks like a black hole in the middle of the iris.

Retina

The inner, light-sensitive layer of the eye containing rods and cones; transforms the image it receives into electrical messages which are then sent to the brain via the optic nerve.

Sclera

The tough, fibrous, white outer protective covering that surrounds the eye.

Slit lamp

A microscope that projects a linear slit beam of light onto the eye; allows viewing of the conjunctiva, cornea, iris, aqueous humor, lens, and eyelid.

Tonometer

An instrument that measures intraocular pressure (IOP).

Ultrasonography

A method of obtaining structural information about internal tissues and organs where an image is produced because different tissues bounce back ultrasonic waves differently.