11/13/24, 7\:04 PM Guide | Eye examination

Eye examination

Table of contents
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Gather equipment

Gather the appropriate equipment\:
Snellen chart
Ishihara chart
Fine print reading chart
Pinhole
Hatpin
Ophthalmoscope
Pen torch
Mydriatic eye drops

Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Position the patient sitting on a chair.
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Ask if the patient has any pain before proceeding.

Visual acuity

Assessment of visual acuity (distance)

Begin by assessing the patient's visual acuity using a Snellen chart. If the patient normally uses distance glasses, ensure
these are worn for the assessment.
1. Stand the patient at 6 metres from the Snellen chart.
2. Ask the patient to cover one eye and read the lowest line they are able to.
3. Record the lowest line the patient was able to read (e.g. 6/6 [metric] which is equivalent to 20/20 [imperial]).
4. You can have the patient read through a pinhole to see if this improves vision (if vision is improved with a pinhole, it suggests
there is a refractive component to the patient's poor vision).
5. Repeat the above steps with the other eye.
Recording visual acuity
Visual acuity is recorded as chart distance (numerator) over the number of the lowest line read (denominator)\:
If the patient reads the 6/6 line but gets 2 letters incorrect, you would record this as 6/6 (-2).
If the patient gets more than 2 letters wrong, then the previous line should be recorded as their acuity.
When recording the vision it should state whether this vision was unaided (UA), with glasses or with a pinhole (PH).

Further steps for patients with poor vision

If the patient is unable to read the top line of the Snellen chart at 6 metres (even with pinhole) move through the following
steps as necessary\:
1. Reduce the distance to 3 metres from the Snellen chart (the acuity would then be recorded as 3/denominator).
2. Reduce the distance to 1 metre from the Snellen chart (1/denominator).
3. Assess if they can count the number of
4. Assess if they can see gross hand movements (recorded as “Hand Movements” or “HM”).
5. Assess if they can detect light from a pen torch shone into each eye (“Perception of Light”/”PL” or “No Perception of
Light”/”NPL”).
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Assess visual acuity using a Snellen chart

Assessment of near vision

Assess the patient's near vision using a near vision chart. If the patient normally uses reading glasses, ensure these are worn
for the assessment.
Fine print reading
1. Ask the patient to cover one eye.
2. Then ask the patient to read a paragraph of small print in a book or newspaper.
3. Repeat the assessment on the other eye.
Assess near vision with
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Causes of decreased visual acuity
Decreased visual acuity has many potential causes including\:
Refractive errors
Amblyopia
Ocular media opacities such as cataract or corneal scarring
Retinal diseases such as age-related macular degeneration
Optic nerve (CN II) pathology such as optic neuritis
Lesions higher in the visual pathways
Optic nerve (CN II) pathology usually causes a decrease in acuity in the a
disc swelling from raised intracranial pressure), does not usually a

Colour vision assessment

Colour vision can be assessed using Ishihara plates, each of which contains a coloured circle of dots. Within the pattern of
each circle are dots which form a number or shape that is clearly visible to those with normal colour vision and di
impossible to see for those with a red-green colour vision defect.

How to use Ishihara plates

If the patient normally wears glasses for reading, ensure these are worn for the assessment.
1. Ask the patient to cover one of their eyes.
2. Then ask the patient to read the numbers on the Ishihara plates. The
colour vision and instead assesses contrast sensitivity. If the patient is unable to read the test plate, you should document this.
3. If the patient is able to read the test plate, you should move through all of the Ishihara plates, asking the patient to identify
the number on each. Once the test is complete, you should document the number of plates the patient identi
including the test plate (e.g. 13/13).
4. Repeat the assessment on the other eye.
Assess colour vision using an Ishihara chart at arms length
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Visual

This method of visual
work\:
you need to position yourself, the patient and the target correctly (see details below)
you need to have normal visual

Visual

1. Sit directly opposite the patient, at a distance of around 1 metre.
2. Ask the patient to cover one eye with their hand.
3. If the patient covers their right eye, you should cover your left eye (mirroring the patient).
4. Ask the patient to focus on part of your face (e.g. nose) and not move their head or eyes during the assessment. You should
do the same and focus your gaze on the patient's face.
5. As a screen for central visual
assessment can be completed with an Amsler chart.
6. Position the hatpin (or another visual target) at an equal distance between you and the patient (this is essential for the
assessment to work).
7. Assess the patient's peripheral visual
and slowly move the target towards the centre, asking the patient to report when they
target but the patient cannot, this would suggest the patient has a reduced visual
8. Repeat this process for each visual
9. Document your
Assess the patient's peripheral visual
Types of visual
Bitemporal hemianopia\: loss of the temporal visual
hemianopia typically occurs as a result of optic chiasm compression by a tumour (e.g. pituitary adenoma,
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craniopharyngioma).
Homonymous
tumour, abscess (i.e. pathology a
hemianopias if half the vision is a
Scotoma\: an area of absent or reduced vision surrounded by areas of normal vision. There is a wide range of possible
aetiologies including demyelinating disease (e.g. multiple sclerosis) and diabetic maculopathy.
Monocular vision loss\: total loss of vision in one eye secondary to optic nerve pathology (e.g. anterior ischaemic optic
neuropathy) or ocular diseases (e.g. central retinal artery occlusion, total retinal detachment).

Blind spot

A physiological blind spot exists in all healthy individuals as a result of the lack of photoreceptor cells in the area where the
optic nerve passes through the optic disc. In day to day life, the brain does an excellent job of reducing our awareness of the
blind spot by using information from other areas of the retina and the other eye to mask the defect.

Blind spot assessment

1. Sit directly opposite the patient, at a distance of around 1 metre.
2. Ask the patient to cover one eye with their hand.
3. If the patient covers their right eye, you should cover your left eye (mirroring the patient).
4. Ask the patient to focus on part of your face (e.g. nose) and not move their head or eyes during the assessment. You should
do the same and focus your gaze on the patient's face.
5. Using a red hatpin (or alternatively, a cotton bud stained with
assessing the patient’s blind spot in comparison to the size of your own. The red hatpin needs to be positioned at an equal
distance between you and the patient for this to work.
6. Ask the patient to say when the red part of the hatpin disappears, whilst continuing to focus on the same point on your face.
7. With the red hatpin positioned equidistant between you and the patient, slowly move it laterally until the patient reports the
disappearance of the top of the hatpin. The blind spot is normally found just temporal to central vision at eye level. The
disappearance of the hatpin should occur at a similar point for you and the patient.
8. After the hatpin has disappeared for the patient, continue to move it laterally and ask the patient to let you know when they
can see it again. The point at which the patient reports the hatpin re-appearing should be similar to the point at which it re-
appears for you (presuming the patient and you have a normal blind spot).
9. You can further assess the superior and inferior borders of the blind spot using the same process.
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Assess the patient's blind spot
Causes of an enlarged blind spot
An enlarged blind spot is typically associated with a swollen optic disc (papilloedema) which is most often caused by
raised intracranial pressure (e.g. brain tumour, hypertensive crisis, intracranial haemorrhage).

Inspect the external eye

Inspection of the external eyes including the anterior segment can provide a lot of valuable clinical information.
See our anterior segment examination guide for a more detailed approach.

General inspection

Ask the patient to look straight ahead and inspect both of the eyes assessing the following\:
Peri-orbital regions
Eyelids
Eyes (including pupils)
Note any abnormalities such as\:
Swelling
Redness
Discharge
Prominence of the eyes
Abnormal eyelid position\: ptosis can be a sign of Horner’s syndrome (often very subtle ptosis with miosis) and oculomotor
nerve palsy (can vary from partial to complete ptosis and usually with a 'down and out' eye position and an enlarged pupil)
Abnormal pupillary shape, size and/or asymmetry

Pupillary assessment

The pupil is the hole in the centre of the iris that allows light to enter the eye and reach the retina.
Inspect the patient's pupils for abnormalities.
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Pupil size
Normal pupil size varies between individuals and depends on lighting conditions (i.e. smaller in bright light, larger in the dark).
Pupils can be smaller in infancy and larger in adolescence, then often smaller again in the elderly.
Pupil symmetry
Note any asymmetry in pupil size (anisocoria). This may be longstanding and physiological or be due to acquired pathology. If
the di
the larger pupil is the pathological one. This is because the normal pupil will constrict in brighter light accentuating the
di
larger pupil would then dilate while the pathologically small pupil remains the same size.
Examples of asymmetry include a larger pupil in oculomotor nerve palsy and a smaller one in Horner’s syndrome.
Pupil shape
Pupils should be round. Abnormal shapes can be congenital or due to pathology (e.g. posterior synechiae associated with
uveitis) or previous trauma and surgery.
Peaked pupils in the context of trauma are suggestive of globe rupture (the peaked appearance is caused by the iris plugging
the leak).
Pupil colour
Asymmetry in pupillary colour is most commonly due to congenital disease.
In rare cases, asymmetry of colour can suggest Horner's syndrome, with the paler washed-out iris being pathological.
Inspect the external eye
Pathology which may be noted during general inspection
Examples of pathology you may note during general inspection of the eye include\:
Periorbital erythema and swelling\: a feature of preseptal cellulitis (anterior to the orbital septum) or orbital cellulitis
(posterior to the orbital septum)
Eyelids\: lumps (benign or malignant), oedema, ptosis and entropion/ectropion
Eyelashes\: loss of eyelashes (can be associated with malignant lesions), trichiasis (eye lashes rubbing on the cornea)
and blepharitis collarettes
Pupils\: abnormal size, shape, colour and symmetry (see above)
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Conjunctival injection (redness)\: this can be di
infection, allergy, trauma and in
Cornea\: di
of the cornea with
Anterior chamber\: a
yellow in colour).
Discharge\: watery discharge is typically associated with allergic or viral conjunctivitis or reactive physiological
production (e.g. corneal abrasion/foreign body). Purulent discharge is more likely to be associated with bacterial
conjunctivitis. Very sticky, stringy discharge can suggest chlamydial conjunctivitis while blood staining can be seen
with gonococcus.
Causes of red eye
Below is a non-exhaustive list of causes of red eye, with their associated clinical features.
Painless red eye\:
Conjunctivitis\: di
debris. Bacterial conjunctivitis typically has more purulent discharge than viral or allergic conjunctivitis.
Subconjunctival haemorrhage\: a
conjunctiva surrounding it.
Episcleritis\: sectoral area of subconjunctival injection (unilateral). The subconjunctival injection in episcleritis is
super
Dry eye\: caused by de
(obstruction of meibomian glands). Clinical features include di
in
Painful red eye\:
Scleritis\: deep pinkish localised conjunctival injection (unilateral), visual acuity may be reduced, minimal watery
discharge, photophobia and a tender globe (causing the patient to wake at night). Symptoms tend to progressively
worsen and individuals commonly have other connective tissue diseases.
Uveitis\: circumciliary conjunctival injection (unilateral), hazy cornea, distorted pupil, hypopyon, reduced visual acuity,
watery discharge, photophobia and pain are common clinical features.
Corneal abrasion\: eye redness, pain, watering and photophobia are common clinical features. Epithelial defects can be
very hard to see with the naked eye but stain brightly with
Corneal ulcer\: typical clinical features include pain, watering, photophobia and a staining epithelial defect with
associated haziness (in
Acute angle-closure glaucoma (AACG)\: typical clinical features include signi
circumciliary conjunctival injection (unilateral), reduced visual acuity, photophobia, haloes in vision, hazy cornea and a
mid-dilated unreactive pupil.
Foreign bodies\: may be visible on the surface of the eye or embedded within the cornea or sclera. Associated clinical
features include redness, pain, watering and a ‘foreign body sensation’
. Foreign bodies may be hidden under the top
and bottom of the eyelid.

Pupillary re

With the patient seated, dim the lights in the assessment room to allow you to assess pupillary re

Direct pupillary re

Assess the direct pupillary re
Shine the light from your pen torch into the patient's pupil and observe for pupillary restriction in the ipsilateral eye.
A normal direct pupillary re
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Consensual pupillary re

Assess the consensual pupillary re
Once again shine the light from your pen torch into the same pupil, but this time observe for pupillary restriction in the
contralateral eye.
A normal consensual pupillary re
being tested.
Assess direct and consensual pupillary light re

Swinging light test

Move the pen torch rapidly between the two pupils to check for a relative a
Perform the swinging light test
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Accommodation re

1. Ask the patient to focus on a distant object (clock on the wall/light switch).
2. Place your
3. Ask the patient to switch from looking at the distant object to the nearby
4. Observe the pupils, you should see constriction and convergence bilaterally.
Assess the accomodation re
Pupillary light re
Each a
The a
Sensory input (e.g. light being shone into the eye) is transmitted from the retina, along the optic nerve to the ipsilateral
pretectal nucleus in the midbrain.
The two e
Motor output is transmitted from the pretectal nucleus to the Edinger-Westphal nuclei on both sides of the brain
(ipsilateral and contralateral).
Each Edinger-Westphal nucleus gives rise to e
ciliary sphincter and enable pupillary constriction.
Normal pupillary light re
provide an indirect way of assessing their function\:
The direct pupillary re
The consensual pupillary re
The swinging light test is used to detect relative a
Abnormal pupillary responses
Relative a
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Normally light shone into either eye should constrict both pupils equally (due to the dual e
above). When the a
less when light is shone into the a
dilate when swinging the torch from the healthy to the a
This can be due to signi
large retinal detachment; or due to signi
compression secondary to tumour or abscess and ischaemic optic neuropathy.
Unilateral e
Commonly caused by extrinsic compression of the oculomotor nerve, resulting in the loss of the e
ipsilateral pupillary re
to loss of ciliary sphincter function). The consensual light re
pathway (i.e. optic nerve) of the a
intact.

Assessment of strabismus

Light re

1. Ask the patient to focus on a target approximately half a metre away whilst you shine a pen torch towards both eyes.
2. Inspect the corneal re
If the ocular alignment is normal, the light re
De

Cover test

The cover test is used to determine if a heterotropia (i.e. manifest strabismus) is present.
1. Ask the patient to
2. Occlude one of the patient's eyes and observe the contralateral eye for a shift in
If there is no shift in
alignment).
If there is a shift in
3. Repeat the cover test on the other eye.
The direction of the shift in
Interpretation of the cover test
Direction of eye at rest
The direction of shift in
opposite eye is occluded
Type of tropia
present
Temporally (i.e. laterally or
outwards)
Nasally (i.e. medially or inwards) Nasally (i.e. medially or
inwards)
Temporally (i.e. laterally or outwards) Superiorly (i.e. upwards) Inferiorly (i.e. downwards) Inferiorly (i.e. downwards) Superiorly (i.e. upwards) Exotropia
Esotropia
Hypertropia
Hypotropia
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Cover test interpretation

Eye movements

Brie
trochlear, abducens, vestibular nerve pathology).
1. Hold your
the primary position for any deviation or abnormal movements.
2. Ask the patient to keep their head still whilst following your
any double vision or pain.
3.Move your
4. Observe for any restriction of eye movement and note any nystagmus (which may suggest vestibular nerve pathology or
stroke).
Actions of the extraocular muscles
Superior rectus\: primary action is elevation, secondary actions include adduction and medial rotation of the eyeball.
Inferior rectus\: primary action is depression, secondary actions include adduction and lateral rotation of the eyeball.
Medial rectus\: adduction of the eyeball.
Lateral rectus\: abduction of the eyeball.
Superior oblique\: depresses, abducts and medially rotates the eyeball.
Inferior oblique\: elevates, abducts and laterally rotates the eyeball.
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Assess eye movements

Fundoscopy

Ophthalmoscope overview

Parts
Parts of the ophthalmoscope include\:
Viewing window\: this is where you look through to observe the eye
Filter switch\: allows you to select a light
Aperture dial\: adjust the size of the light beam
Diopter dial\: adjusts the lens used to view the eye
Diopter power display\: shows the current lens being used
Rheostat\: adjusts the intensity of the light beam
On/o
Aperture size (beam size)
Ophthalmoscopes typically allow you to select from a range of di
Micro aperture\: used for viewing the fundus through very small undilated pupils
Small aperture\: used for viewing the fundus through an undilated pupil
Large aperture\: used for viewing the fundus through a dilated pupil and for the general examination of the eye
Slit aperture\: can be helpful in assessing contour abnormalities of the cornea, lens and retina as it makes elevation easier to
see
Filter
Filters can be used to highlight speci
Cobalt blue
guide for more details)
Red-free
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Practitioner side of the ophthalmoscope

Explanation

Explain the process of fundoscopy to the patient to ensure they are aware of what to expect during the assessment.
Example explanation
" I w i l l b e u s i n g a m a g n i f y i n g t o o l c a l l e d a n o p h t h a l m o s c o p e t o l o o k a t t h e b a c k o f y o u r e y e s w i t h t h e l i gh t s o
I' l l n e e d t o g e t q u i t e c l o s e t o y o u r f a c e. I' l l p l a c e a h a n d o n y o u r f o r e h e a d t o p r e v e n t u s f r o m b u m p i n g i n t o e a c h o t h e r .
"
" I' l l a l s o b e u s i n g s o m e e y e d r o p s t o d i l a t e y o u r p u p i l s. T h e d i l a t i n g d r o p s w i l l c a u s e y o u r v i s i o n t o b e t e m p o r a r i l y b l u r r y
a n d y o u' l l b e m o r e s e n s i t i v e t o l i g h t , s o y o u' l l n o t b e a b l e t o d r i v e f o r s e v e r a l h o ur s a f t e r w a r d s .
"

Preparation for fundoscopy

1. It is essential to darken the room for the examination. Make sure the patient is positioned seated prior to turning out the lights
to avoid accidents.
2. Dilate the patient's pupils using short-acting mydriatic eye drops such as tropicamide 1%. You will be unable to monitor pupil
reactions once dilating drops have been applied, furthermore assessing vision, colour vision, double vision and visual
be less accurate once drops are instilled.
3. Ask the patient to look straight ahead for the duration of the examination (asking the patient to
as a light switch can cause confusion if you then obstruct the view of this target).

Assess the fundal re

Correct terminology
The term fundal re
colour.
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In patient's with lighter skin, the re
re
Ophthalmoscope settings
To set up the ophthalmoscope for assessing the fundal re
you can see the patient and their eye clearly from a distance\:
If you have normal visual acuity, you can set the diopter dial to 0.
If you have a refractive error but are planning to wear glasses/contact lenses that correct this when using the
ophthalmoscope you can also set it to 0.
If you have a refractive error and are not going to wear your glasses/contact lenses you should adjust the diopter dial to
match your prescription (e.g.
-2).
How to assess for the fundal re
1. Look through the ophthalmoscope, shining the light towards the patient's eye at a distance of approximately one arm's
length.
2. Observe for a reddish/orange/white/yellow/blue re
vascularised retina.
Causes of an absent fundal re
Absence of the fundal re
include vitreous haemorrhage and retinal detachment.
Absence of the fundal re
and retinoblastoma.
Assess the fundal re

Assess the fundus

Ophthalmoscope settings
To set up the ophthalmoscope for assessing the fundus, adjust the diopter dial so that it is the net result of yours and the
patient's refractive error\:
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If you and the patient have normal visual acuity, set the dial to 0 (e.g. 0 + 0 = 0).
If you have a refractive error but are planning to wear glasses/contact lenses that correct this, assume you have a refractive
error of 0 and add the patient's refractive error to this (e.g. 0 + -2 = -2).
If the patient has a refractive error and you have normal visual acuity set the dial to the net refractive error. An example of this
would be (your refractive error of 0) + (patient's refractive error of -2) = a setting of -2.
If the patient has a refractive error and you have a refractive error set the dial to the net refractive error. An example of this
would be (your refractive error of +3) + (patient's refractive error of -2) = a setting of +1.
If things appear out of focus during the assessment, simply adjust the diopter dial until things look sharper.
Assess the optic disc
1. If you are assessing the patient's right eye, you should hold the ophthalmoscope in your right hand and vice versa. Place the
hand not holding the ophthalmoscope onto the patient's forehead to prevent accidental collision between yours and the
patient's face.
2. Approaching from a 10-15 degree angle slightly temporal to the patient, move closer whilst maintaining the fundal re
3. Begin by identifying a blood vessel and then follow the branching of this blood vessel towards the optic disc (the branches
point like arrows towards the optic disc).
4. Once you identify the optic disc assess its characteristics including the contour, colour and the cup ("3Cs")\:
Contour\: the borders of the optic disc should be clear and well de
presence of optic disc swelling (papilloedema) secondary to raised intracranial pressure.
Colour\: a healthy optic disc should look like an orange-pink doughnut with a pale centre. The orange-pink colour represents
well-perfused neuro-retinal tissue. A pale optic disc suggests the presence of optic atrophy which can occur as a result of
optic neuritis, advanced glaucoma and ischaemic vascular events.
Cup\: the cup is the pale centre of the orange-pink doughnut mentioned previously. The pale colour of the cup is due to the
absence of neuroretinal tissue. The vertical size of the cup can be estimated in relation to the optic disc as a whole, known as
the "cup-to-disc ratio"
. A cup-to-disc ratio of 0.3 (i.e. the cup occupies one-third of the height of the optic disc) is generally
considered normal. An increased cup-to-disc ratio suggests a reduced volume of healthy neuro-retinal tissue, which can
occur in glaucoma.
Perform fundoscopy
Assess the retina
5. Methodically assess each quadrant of the retina and the associated vascular arcades in a clockwise or anticlockwise fashion
looking for evidence of pathology\:
Superior temporal (ST)
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Superior nasal (SN)
Inferior nasal (IN)
Inferior temporal (IT)
Assess each quadrant of the retina
Types of retinal pathology
Arteriolar narrowing\: subtle, with generalised arteriolar narrowing with typical copper or silver wire appearance. Most
commonly associated with the early stages of hypertensive retinopathy.
Arteriovenous nipping/nicking\: areas of focal narrowing, and compression of venules at sites of arteriovenous
crossing. The typical appearance involves bulging of retinal veins on either side of the area where the retinal artery is
crossing. Most commonly associated with grade 2 hypertensive retinopathy.
Dot and blot haemorrhages\: arise from bleeding capillaries in the middle layers of the retina and may look like
microaneurysms if small enough. They are most commonly associated with diabetic retinopathy.
Flame haemorrhages\: larger haemorrhages with a
or small veins in the retinal nerve
thrombocytopaenia, retinal vein occlusion and trauma.
Cotton wool spots\: appear as small,
They are most commonly associated with diabetic retinopathy and grade 3 hypertensive retinopathy.
Hard exudates\: waxy yellow lesions with relatively distinct margins arranged in clumps or rings, often surrounding
leaking microaneurysms. They are most commonly associated with diabetic retinopathy and grade 3 hypertensive
retinopathy.
Neovascularisation\: formation of new blood vessels that appear as a net of small curly vessels, with or without
associated haemorrhages. They may be located on the optic disc or elsewhere on the retina. They are most commonly
associated with advanced proliferative diabetic retinopathy.
Pan-retinal photocoagulation\: the primary treatment for proliferative diabetic retinopathy. Clinically it is seen as
clusters of pale burn marks on the retina which have been created by the laser used in the treatment process.
Branch retinal vein occlusion\: blockage of one of the four retinal veins, each of which drains about a quarter of the
retina. Typical signs include
oedema, and dilated tortuous veins.
Assess the macula
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6. Finally, inspect the macula by asking the patient to brie
found lateral (temporal) to the optic nerve head and is yellow in colour. The central part of the macula, the “fovea” is about the
same diameter as the optic disc and appears darker than the rest of the macula due to the presence of an additional pigment.
Assess the macula
Types of macula pathology
Hard exudates\: waxy yellow lesions with relatively distinct margins arranged in clumps or rings, often surrounding
leaking microaneurysms. They are most commonly associated with diabetic retinopathy, grade 3 hypertensive
retinopathy and retinal vein occlusions.
Drusen\: yellow-white
epithelium. Most commonly caused by age-related macular degeneration.
Cherry-red spot\: associated with central retinal artery occlusion which typically presents with sudden profound visual
loss.
Assess the other eye
Repeat assessment of the fundal re
opposite side and hold the ophthalmoscope in your other hand.

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
If mydriatic drops were instilled, remind the patient they cannot drive for the next 3-4 hours until their vision has returned to
normal.
Dispose of PPE appropriately and wash your hands.

Suggest further assessment and investigations

All of the following further assessments and investigations are dependent on the patient's presenting complaint and in most
cases, none of them would need to be performed\:
https\://app.geekymedics.com/osce-guides/clinical-examination/eye-examination/ 19/2011/13/24, 7\:04 PM Guide | Eye examination
Amsler chart\: to assess for central visual loss and distortion which is commonly associated with macular degeneration.
Cranial nerve examination\: to further assess for evidence of cranial nerve pathology (e.g oculomotor nerve).
Blood pressure\: if there are concerns about hypertensive retinopathy.
Capillary blood glucose\: if there are concerns about diabetic retinopathy.
Retinal photography\: to better visualise any abnormalities noted on fundoscopy.

Further visual acuity assessment

This video demonstrates how to further assess a patient's visual acuity if they are unable to read the Snellen chart (even at
1m distance).
Source\: geekymedics.com
https\://app.geekymedics.com/osce-guides/clinical-examination/eye-examination/ 20/20