Expansion
Acuity, fields, pupils, movements, then the fundus
Expansion
- Acuity: Snellen chart at 6 metres, each eye separately, with correction or through a pinhole. Record as 6/6, 6/12 and so on. If under 6/60, count fingers, then hand movements, then light perception
- Visual fields: by confrontation, quadrant by quadrant, then the blind spot and inattention with both hands
- Pupils: size, shape, symmetry, direct and consensual responses, the swinging light test for a relative afferent pupillary defect, and accommodation
- Eye movements: the H pattern, looking for restriction, nystagmus and diplopia. Ask at which point the images are furthest apart
- Anterior segment: lids, conjunctiva, cornea, anterior chamber, with fluorescein if indicated
- Fundoscopy, in a darkened room, dilated if possible: red reflex, optic disc (colour, contour, cup), vessels, macula, periphery
Field defect localisation
| Defect | Lesion |
|---|---|
| Monocular loss | Optic nerve or eye |
| Bitemporal hemianopia | Optic chiasm, classically pituitary |
| Homonymous hemianopia | Contralateral optic tract or radiation |
| Homonymous quadrantanopia, upper | Temporal radiation (Meyer’s loop) |
| Homonymous quadrantanopia, lower | Parietal radiation |
| Hemianopia with macular sparing | Occipital cortex |
A relative afferent pupillary defect indicates optic nerve disease and is one of the most objective signs in medicine, since it cannot be feigned.