A temporal defect in the visual field of one eye suggests a nasal defect in the other eye. To test this hypothesis, examine the other eye in a similar way, again moving from the anticipated defect toward the better vision.
Small visual field defects and enlarged blind spots require a finer stimulus. Using a small red object such as a red-headed matchstick or the red eraser on a pencil, test one eye at a time. As the patient looks into your eye directly opposite, move the object about in the visual field. The normal blind spot can be found 15° temporal to the line of gaze. (Find your own blind spots for practice.)
A left homonymous hemianopsia may thus be established.
An enlarged blind spot occurs in conditions affecting the optic nerve, e.g., glaucoma, optic neuritis, and papilledema.
Position and Alignment of the Eyes. Stand in front of the patient and survey the eyes for position and alignment with each other. If one or both eyes seem to protrude, assess them from above (see p. 167).
Eyebrows. Inspect the eyebrows, noting their quantity and distribution and any scaliness of the underlying skin.
Eyelids. Note the position of the lids in relation to the eyeballs. Inspect for the following:
■ Width of the palpebral fissures
■ Condition and direction of the eyelashes
■ Adequacy with which the eyelids close. Look for this especially when the eyes are unusually prominent, when there is facial paralysis, or when the patient is unconscious.
Lacrimal Apparatus. Briefly inspect the regions of the lacrimal gland and lacrimal sac for swelling.
Look for excessive tearing or dryness of the eyes. Assessment of dryness may require special testing by an ophthalmologist. To test for nasolacrimal duct obstruction, see pp. 167-168.
Conjunctiva and Sclera. Ask the patient to look up as you depress both lower lids with your thumbs, exposing the sclera and conjunctiva. Inspect the sclera and palpebral conjunctiva for color, and note the vascular pattern against the white scleral background. Look for any nodules or swelling.
Inward or outward deviation of the eyes; abnormal protrusion in Graves' disease or ocular tumors
Scaliness in seborrheic dermatitis; lateral sparseness in hypothyroidism
See Table 5-5, Variations and Abnormalities of the Eyelids (p. 177). Blepharitis is an inflammation of the eyelids along the lid margins, often with crusting or scales.
Failure of the eyelids to close exposes the corneas to serious damage.
See Table 5-6, Lumps and Swellings In and Around the Eyes (p. 178).
Excessive tearing may be due to increased production or impaired drainage of tears. In the first group, causes include conjunctival inflammation and corneal irritation; in the second, ectropion (p. 177) and nasolacrimal duct obstruction.
A yellow sclera indicates jaundice.
If you need a fuller view of the eye, rest your thumb and finger on the bones of the cheek and brow, respectively, and spread the lids.
Ask the patient to look to each side and down. This technique gives you a good view of the sclera and bulbar conjunctiva, but not of the palpebral conjunctiva of the upper lid. For this purpose, you need to evert the lid (see p. 168).
The local redness below is due to nodular episcleritis:
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