OSCE Eye Examination

Related Subjects: | Retinoblastoma | Leukocoria (White Pupillary Reflex) |OSCE Eye Exam

👁️ The eye examination is a high-yield OSCE station that tests systematic approach, communication, and interpretation of common pathology. Key principle: Always do **visual acuity first** — it is the “vital sign” of the eye. Verbalise every step aloud and reassure the patient continuously. Time goal: 6–8 minutes. Finish by stating how you’d complete the exam: “To complete, I would perform colour vision testing (Ishihara), assess intraocular pressure (if tonometry available), check for relative afferent pupillary defect (RAPD) again, and arrange slit-lamp examination, visual fields (formal perimetry), and fundus photography / OCT as indicated.”

🛠️ Preparation & Introduction (30–45 s)

• 🧼 Wash hands, introduce yourself, confirm name & DOB.
• 💬 Explain clearly: “I’m going to check your vision, eye movements, pupils, and the back of your eyes with a light. It involves reading a chart, shining a torch, and looking into your eyes. It shouldn’t hurt, but tell me if anything is uncomfortable.”
• ✅ Gain informed consent, offer chaperone if needed, ensure good lighting and 6-metre distance for Snellen.
• 🧰 Equipment: Snellen chart (6 m), near vision chart (Jaeger/Reading chart at 33 cm), pen torch, ophthalmoscope, occluder, mydriatic drops (if allowed), Ishihara plates (optional), red hat pin (confrontation fields).
• Verbalise: “I’m ensuring the room is well-lit and the Snellen chart is at 6 metres.”

👀 Step 1: General Inspection (30–45 s)

• Patient: facial asymmetry, head posture (torticollis in IV/VI palsy), ptosis, proptosis, enophthalmos.
• Eyelids: swelling (allergy, cellulitis), xanthelasma (hyperlipidaemia), lid lag/retraction (thyrotoxicosis).
• Conjunctiva: injection (conjunctivitis, scleritis), chemosis, discharge (purulent – bacterial; watery – viral/allergic).
• Sclera: jaundice, episcleritis/scleritis (rheumatoid), blue sclera (osteogenesis imperfecta).
• Cornea: scars, opacities, arcus senilis (hyperlipidaemia), fluorescein staining (if available for ulcers/abrasions).
• Clinical pearl: Painful red eye + halos + fixed pupil = **acute angle-closure glaucoma** 🚨 (emergency).

📊 Step 2: Visual Acuity (1–2 min – always first!)

• Snellen chart at 6 m (or mirror equivalent).
• Test one eye at a time (occlude gently, not press), then binocular if needed.
• Record as 6/X (e.g., 6/6 = normal, 6/60 = can only read top line at 6 m).
• If <6/60: move chart closer → count fingers (CF) at 1 m → hand movements (HM) → light perception (LP) vs no light perception (NLP).
• Near vision (optional): Jaeger/Reading chart at 33 cm (useful for presbyopia, macular disease).
• Pearl: Always test VA **before** shining lights or using drops — glare or mydriasis affects acuity.
• Verbalise: “I’m testing the right eye first with the left occluded. Can you read the smallest line you can see clearly?”

🔦 Step 3: Pupils (45–60 s)

• Inspection: size (normal 2–5 mm), shape (irregular = synechiae), symmetry (anisocoria).
• Light reflexes:
  • Direct: shine pen torch → constriction in same eye.
  • Consensual: constriction in opposite eye.
  • Swinging flashlight test: RAPD (Marcus Gunn pupil) → optic nerve/retinal pathology (e.g., optic neuritis, central retinal artery occlusion).
• Accommodation reflex: Ask to look at distant object → near target → constriction + convergence (absent in Argyll Robertson pupil – neurosyphilis).
• Clinical pearl: RAPD + reduced VA + colour desaturation → optic nerve lesion until proven otherwise.

👁️ Step 4: Extraocular Movements & Cranial Nerves III, IV, VI (1 min)

• H-pattern: follow finger in H shape (check all 6 cardinal positions).
• Look for restriction, nystagmus, diplopia (ask patient: “Do you see double?”).
• Key palsies:
  • CN III: ptosis, down-and-out eye, dilated pupil, inability to adduct/elevate/depress.
  • CN IV: vertical diplopia, head tilt away from affected side.
  • CN VI: inability to abduct → esotropia, horizontal diplopia worse on distance.
• Pearl: CN VI palsy = commonest isolated palsy (long intracranial course); patient turns head towards lesion to compensate.

🌐 Step 5: Visual Fields – Confrontation (1 min)

• Sit 1 metre opposite patient, cover opposite eyes.
• Bring red hat pin/target in from periphery in 4 quadrants (compare with your own field as control).
• Patient says “yes” or “now” when target seen.
• Patterns:
  • Bitemporal hemianopia → pituitary macroadenoma/chiasmal lesion.
  • Homonymous hemianopia → stroke, tumour in optic tract/radiation/occipital lobe.
  • Central scotoma → optic neuritis, macular disease.
• Pearl: If field defect suspected, request formal perimetry (Humphrey or Goldmann).

🔍 Step 6: Ophthalmoscopy / Fundoscopy (2–3 min – most marks here)

• Dim room lights, set ophthalmoscope to 0 dioptres initially.
• Approach from ~15° temporal side with your same-side eye (right eye for right fundus).
• Key landmarks:
  • Red reflex: absent → cataract, vitreous haemorrhage, retinal detachment.
  • Optic disc: margins (sharp vs blurred – papilloedema), colour (pink vs pale – atrophy), cup:disc ratio (normal <0.5; raised in glaucoma).
  • Vessels: AV nipping (hypertensive retinopathy), microaneurysms (diabetic), flame haemorrhages, cotton wool spots.
  • Macula: look last (bright light uncomfortable) → drusen (AMD), hard exudates (diabetic maculopathy).
• Verbalise: “I’m now looking at the right fundus. Red reflex is present. Optic disc is pink with sharp margins, cup:disc ratio ~0.3, vessels normal calibre without AV nipping or haemorrhages. Macula appears clear.”

🧪 Step 7: Extras (if time or indicated)

• Near vision (Jaeger/Reading chart at 33 cm) – useful for presbyopia, macular disease.
• Colour vision (Ishihara plates) – red-green deficiency (optic neuritis, inherited).
• Intraocular pressure (tonometry if available – normal 10–21 mmHg; >21 = glaucoma suspect).
• Slit-lamp exam (anterior segment – specialist).

✅ Closure

• Thank patient, ensure comfort, help redress if needed.
• Wash hands 🧼.
• Present findings systematically: “Visual acuity is 6/6 right, 6/9 left. Pupils equal and reactive with no RAPD. Extraocular movements full. Confrontation fields normal. Fundi show healthy discs with no papilloedema or haemorrhages.”
• Suggest further steps: “I would like to complete with colour vision testing, formal visual fields if indicated, intraocular pressure measurement, and arrange refraction, OCT, or ophthalmology referral as appropriate.”

📊 High-Yield Eye Examination Findings Table (OSCE Master Reference)

🚩 Red Flags & Do-Not-Miss OSCE Points

• Acute painful red eye + halos + fixed mid-dilated pupil → **acute angle-closure glaucoma** (emergency – acetazolamide, pilocarpine, laser iridotomy).
• New RAPD + reduced VA + colour desaturation → **optic neuritis** (urgent MRI brain + orbits, consider IV methylprednisolone).
• Sudden painless vision loss + RAPD → **central retinal artery occlusion** (emergency – ocular massage, anterior chamber paracentesis).
• Proptosis + ophthalmoplegia + vision loss → **orbital cellulitis** or **cavernous sinus thrombosis** (emergency CT/MRI + antibiotics).
• New diplopia + headache → **CN III palsy** (posterior communicating artery aneurysm – urgent CTA/MRA).

💡 OSCE Examiner & Candidate Pearls

• Visual acuity first — examiners often deduct marks if you skip it or do it after fundoscopy.
• Verbalise: “I’m testing the right eye first with the left occluded. Can you read the smallest line you can see clearly?”
• Always compare both eyes side-by-side for symmetry.
• Common fail points: forgetting VA, poor ophthalmoscopy technique (not dimming lights, wrong distance), not testing fields properly, no verbalisation.
• Finish strong: “To complete my examination, I would like to perform colour vision testing (Ishihara), assess intraocular pressure (if tonometry available), check for relative afferent pupillary defect again, and arrange refraction, OCT, or ophthalmology referral as appropriate.”

📚 References & Resources (Feb 2026)

• Kanski’s Clinical Ophthalmology (9th ed., 2025 update).
• Geeky Medics Eye Examination OSCE Guide (2026 revision).
• OSCEstop & PassMedicine ophthalmology sections.
• RCOphth Guidelines: Acute Red Eye & Visual Loss (2025).