Exam Techniques & Pearls
Exam Techniques
Step-by-step checklists, OSCE scripts, and the pitfalls that trip up learners on rotations.
Confrontation Visual Field Testing
A fast, equipment-free bedside test for gross visual field defects — the first-line field screen before formal automated perimetry, and often the only field test possible in young children, bedside/inpatient settings, or acutely unwell patients.
Direct Ophthalmoscopy
The core skill of the fundus exam — a systematic, low-tech way to inspect the optic disc, vessels, and macula that every learner needs before touching a slit lamp.
Extraocular Movement Examination
The extraocular movement (EOM) examination is a fundamental component of the neuro-ophthalmic assessment that evaluates the function of the six extraocular muscles and their controlling cranial nerves (III, IV, and VI). This examination identifies motility disturbances that may arise from neurologic conditions, extraocular muscle disorders, or orbital pathology. A systematic approach to testing eye movements in all cardinal positions of gaze enables clinicians to detect subtle movement restrictions, alignment abnormalities, and patterns of diplopia that guide diagnosis and management.
Fluorescein Angiography: Basics
Fundus fluorescein angiography (FFA) uses intravenous sodium fluorescein dye and sequential retinal photography to map retinal and choroidal circulation, remaining a core diagnostic tool for diabetic retinopathy, retinal vascular occlusions, macular degeneration, and inflammatory chorioretinal disease despite the growing role of non-invasive OCT angiography.
Goldmann Applanation Tonometry
Goldmann applanation tonometry (GAT) is the reference standard method for measuring intraocular pressure (IOP) in clinical practice. The technique involves applanating a fixed area of the cornea using a calibrated force while visualizing the tear film meniscus with fluorescein dye and a cobalt blue light. Accurate IOP measurement is essential for glaucoma screening, diagnosis, and monitoring treatment efficacy. GAT readings can be affected by corneal properties including central corneal thickness and curvature, and proper technique is critical to obtain reliable measurements.
Humphrey Visual Field Testing (Automated Static Perimetry)
Automated static threshold perimetry (commonly the Humphrey Field Analyzer) quantifies the visual field point-by-point, forming the standard for detecting, staging, and monitoring glaucomatous and neuro-ophthalmic field loss — far more sensitive and reproducible than confrontation testing, at the cost of longer test time and patient reliability requirements.
Pupillary Examination & the Swinging Flashlight Test (RAPD)
The swinging flashlight test detects a relative afferent pupillary defect (RAPD, or Marcus Gunn pupil) — one of the most important, objective bedside signs of asymmetric optic nerve or severe retinal disease, since it isolates afferent visual pathway dysfunction from any confounding efferent (motor) pupillary abnormality.
Slit Lamp Examination
The slit lamp biomicroscope is a fundamental tool in ophthalmic examination that allows detailed magnified visualization of anterior segment structures and, with accessory lenses, posterior segment evaluation. This examination technique combines focused illumination with binocular magnification to assess the cornea, conjunctiva, sclera, iris, lens, and anterior vitreous. Proper technique includes systematic evaluation using various illumination methods and magnification levels. Understanding normal anatomy and pathologic findings is essential for diagnosis and management of ocular conditions.