The process of extrocular muscles
If there is an efferent defect in the left eye, the left pupil will remain dilated regardless of where the light is shining, while the right pupil will respond normally. If there is an afferent defect in the left eye, both pupils will dilate when the light is shining on the left eye, but both will constrict when it is shining on the right eye.
If there is a unilateral small pupil with normal reactivity to light, it is unlikely that a neuropathology is present. However, if accompanied by ptosis of the upper eyelid, this may indicate Horner’s syndrome.
If there is a small, irregular pupil that constricts poorly to light, but normally to accommodation, this is an Argyll Robertson pupil, which is a sign of tertiary syphilis.
Ocular motility should always be tested, especially when patients complain of double vision or physicians suspect neurologic disease. First, the doctor should visually assess the eyes for deviations that could result from strabismus, extraocular muscle dysfunction, or palsy of the cranial nerves innervating the extraocular muscles.
Saccades are assessed by having the patient move his or her eye quickly to a target at the far right, left, top and bottom. This tests for saccadic dysfunction whereupon poor ability of the eyes to “jump” from one place to another may impinge on reading ability and other skills.
Slow tracking, or “pursuits” are assessed by the ‘follow my finger’ test, in which the examiner’s finger traces an imaginary “double-H”, which touches upon the eight fields of gaze. These test the inferior, superior, lateral and medial rectus muscles of the eye, as well as the superior and inferior oblique muscles.
Evaluation of the visual fields should never be omitted from the basic eye examination. Testing the visual fields consists of confrontation field testing in which each eye is tested separately to assess the extent of the peripheral field. To perform the test, the individual occludes one eye while fixated on the examiner’s eye with the non-occluded eye. The patient is then asked to count the number of fingers that are briefly flashed in each of the four quadrants. This method is preferred to the wiggly finger test that was historically used because it represents a rapid and efficient way of answering the same question: is the peripheral visual field affected?
Common problems of the visual field include scotoma (area of reduced vision), hemianopia (half of visual field lost), homonymous quadrantanopia (involving both eyes) and bitemporal hemianopia.
Intraocular pressure can be measured by any of a series of devices designed to measure the outflow (and resistance to outflow) of the aqueous humour from the eye.