Assessment and examination

Ophthalmic history and examination

Overview and approach

A basic eye assessment documents acuity, pupils, fields and movement before assigning a diagnosis.

  • Every patient with an eye complaint needs an eye examination. The minimum kit is a Snellen chart, an ophthalmoscope and 1% fluorescein (1).
  • Features of a sight-threatening problem: severe pain, photophobia, reduced acuity, or a history of possible penetrating trauma (2).
Assessment and clinical features

Ask onset, pain, photophobia, diplopia, trauma, contact lenses, surgery, medicines and systemic symptoms. Test each eye separately with correction/pinhole.

  • History checklist (RACGP): visual deterioration, trauma, discharge (type), photophobia, contact lens wear, previous eye surgery (1). Add flashes/floaters, diplopia, headache and systemic symptoms.
  • Children: observe first (red or white eye, lid swelling, ptosis, proptosis, eye movements). Test acuity early, before the child is distressed (2).
Differentials and investigations

Check colour vision where relevant, confrontation fields, pupils/RAPD, eye movements, external eye and fundus; use slit lamp/fluorescein/tonometry when trained and safe.

  • Order of examination (RCH): visual acuity (and fields if vision is lost or changed) → general inspection → pupils → red reflex → slit lamp/ophthalmoscope → cranial nerves (2).
  • Acuity: each eye separately, with usual glasses or a pinhole, Snellen at 6 m (1). Children: Snellen from 5 years, Tumbling E at 3-5 years, picture/target tests at 2-3 years, fix-and-follow if younger. A difference of more than 2 lines between eyes is likely significant (2).
  • Pupils: direct and consensual response, shape and size; the swinging flashlight test detects a relative afferent pupillary defect (RAPD) (1)(2). A missing red reflex suggests a detached retina or an opacity in the cornea, anterior chamber, lens or vitreous (2).
  • Cornea: instil 1% fluorescein and view with cobalt blue light in a dim room for abrasions or ulcers (1). Evert both upper lids to look for subtarsal foreign bodies, and palpate pre-auricular nodes (viral conjunctivitis) (1).
  • Fields: four-quadrant confrontation in each eye in older children when vision is lost or changed (2).
  • Eye movements: both eyes together, then each eye; ask about diplopia or pain on movement and exclude entrapment after orbital fracture (2).
Management and follow-up

Document actual acuity and findings and arrange escalation according to risk. Confrontation fields are not the H-pattern eye-movement test.

  • Topical anaesthetic drops help the examination but must never be prescribed for home use (1). Repeated use is toxic to the corneal epithelium and delays healing (2).
  • OSCE sequence: introduction/general inspection (eyebrows, periorbital skin, eyelids, cornea, conjunctiva, pupil and lens); visual acuity (Snellen at distance, then closer, count fingers, hand movements, perception of light); colour vision (Ishihara plates); visual fields (H-pattern movement); inspect the external eye including pupils and lids; pupillary reflexes (direct, consensual, swinging light test, accommodation); eye movements through all axes; fundoscopy (explain, mydriatic drops, red reflex, optic disc, retina, macula, repeat in the other eye); conclude (thank the patient, wash hands, summarise, suggest further assessments such as cranial nerve exam, Amsler chart, blood pressure, capillary glucose, retinal photography, slit lamp, tonometry, lid inversion).
  • Basic ophthalmic skills: assessment of ocular adnexae; ocular position and movement; anterior and posterior segment; intraocular pressure; lid eversion and corneal staining; confrontation visual fields.
  • Fluorescein is the only eye drop that does not sting; amethocaine (tetracaine) 0.5% or 1% in children gives about 10-20 minutes of anaesthesia (2).
  • Document the actual acuity for each eye (with correction/pinhole) and the findings before referring.
Red flags and clinical pearls

Do not perform tonometry or pressure on suspected open globe. Dilating drops need an appropriate clinical indication and safety assessment.

  • Warning features needing prompt specialist review (RACGP): contact lens wearer, previous eye or refractive surgery, decreased vision, severe pain, nausea/vomiting, cloudy cornea, dendritic ulcer, hypopyon, non-reactive pupil or RAPD, trauma, persisting or worsening symptoms (1).
  • Dilation is usually not needed in an emergency assessment of a child, and should not be done after head injury or trauma (2).
  • In suspected open globe do not press on the eye, and do not measure pressure (see Eye and orbital injuries).
  • Viva: how do you test for RAPD? Why must you check acuity before putting drops in? (1)(2)
References
  1. Sharma, Ooi, Li. A painful red eye. Aust Fam Physician 2009 (RACGP)
  2. RCH Clinical Practice Guidelines: Eye examination

Last updated from Sen’s notes on 9 October 2026.