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Doap ophthalmology……..and related viva questions. ….. determine the anterior chamber depth , elicit iris shadow, blink reflex , me nance reflex, hirschberg test ,cover and uncover test,pupillary reaction,upper lid eversion,foreign body eversion,irrigation of eye,giving pad and bandage , spherical lens and cylindrical lens, lig lag demonstrate

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Here is a complete, exam-ready guide for all your Ophthalmology DOAP stations with viva questions and answers.

OPHTHALMOLOGY DOAP - Complete Guide with Viva Q&A

1. DETERMINATION OF ANTERIOR CHAMBER DEPTH

Procedure (Penlight/Torch Method - DOAP)

Equipment: Pen torch, dark room
Steps:
  1. Seat the patient comfortably with the eye at your level
  2. Hold the pen torch at the temporal side of the eye, shining light tangentially across the anterior chamber (oblique illumination)
  3. Observe the illumination pattern on the nasal half of the iris
Interpretation:
FindingMeaning
Entire iris uniformly illuminatedNormal/Deep anterior chamber
Shadow (crescent) on nasal half of irisShallow anterior chamber (iris bowed forward)
Van Herick Grading (Slit Lamp):
  • Grade 1: Chamber depth < 1/4 corneal thickness - high risk of angle closure
  • Grade 2: 1/4 corneal thickness - angle closure possible
  • Grade 3: 1/4 to 1/2 corneal thickness - low probability of closure
  • Grade 4: ≥ corneal thickness - open angle, no risk

Viva Q&A

Q: Why do we assess anterior chamber depth before dilating the pupil? A: To rule out narrow angle. Dilation is contraindicated in narrow anterior chamber angles as it can precipitate acute angle closure glaucoma by increasing pupillary block.
Q: What is the gold standard for assessing anterior chamber angle? A: Gonioscopy - direct visualization of the angle using a mirrored contact lens and slit lamp.
Q: Name the structures that form the anterior chamber angle (angle of drainage)? A: Schwalbe's line, trabecular meshwork, scleral spur, ciliary body band, and iris root.
Q: What is physiological depth of anterior chamber? A: Approximately 2.5-3 mm centrally.

2. ELICITING IRIS SHADOW

Procedure

Equipment: Pen torch, dark room
Steps:
  1. Stand in front of and slightly to the temporal side of the patient
  2. Direct the torch from the temporal side tangentially across the cornea/anterior chamber
  3. Observe whether the nasal part of the iris is in shadow
Interpretation:
  • No shadow (entire iris lit): Normal/deep anterior chamber, mature cataract (no shadow seen at pupillary margin with oblique illumination)
  • Positive iris shadow (crescent shadow on nasal iris): Shallow anterior chamber - suspect narrow angle or immature cataract
  • No iris shadow at pupillary margin: Mature/hypermature cataract (lens fully opaque, no graduation of density from cortex to nucleus)

Viva Q&A

Q: What is an iris shadow / oblique illumination test? A: A penlight is directed from the temporal side across the iris. In a shallow anterior chamber (where the iris bows forward due to iris-lens diaphragm convexity), a crescentic shadow falls on the nasal iris. In a normal deep chamber, the entire iris is uniformly illuminated.
Q: In which type of cataract is iris shadow ABSENT? A: In a mature cataract - the cortex is completely opaque and the lens is uniformly dense, so no differential illumination occurs, and no shadow is cast.
Q: In which cataract is iris shadow PRESENT? A: In an immature cataract - part of the cortex is still transparent, and because the lens substance projects forward, a shadow is cast on the nasal iris by the opaque part.
Q: What does a positive iris shadow suggest regarding surgery? A: It suggests the cataract may still be immature and that the shallow anterior chamber increases the risk of angle closure glaucoma.

3. BLINK REFLEX

Procedure

Steps:
  1. Ask the patient to keep their eyes open and look straight ahead
  2. Suddenly bring your finger or hand quickly toward the eye without touching (threat stimulus)
  3. Observe for blinking (orbicularis closure)
OR: Touch the eyelashes or periorbital skin lightly - observe blink
Interpretation:
  • Normal: Immediate bilateral blink
  • Absent: Lesion of CN VII (efferent - no blink despite sensation) or CN V (afferent - no sensation of touch)

Viva Q&A

Q: What are the afferent and efferent limbs of the blink reflex? A: Afferent - CN V (trigeminal, ophthalmic division V1); Efferent - CN VII (facial nerve, orbicularis oculi).
Q: What is the difference between the blink reflex and the corneal reflex? A: The corneal reflex is elicited by lightly touching the cornea with a wisp of cotton; the afferent is V1 (nasociliary branch), efferent is CN VII. The blink reflex is the same arc but elicited by visual threat or sudden light stimulus (also involves visual cortex for the visual threat/menace component).
Q: In a patient with CN VII palsy, what happens when you touch the cornea? A: The patient feels the touch (afferent intact via V1) but cannot blink (efferent absent). This leads to exposure keratopathy if the eye cannot close.

4. MENACE REFLEX (Menace Response)

Procedure

Steps:
  1. Make a sudden threatening gesture (e.g., thrust your hand rapidly toward the eye) from a distance of >30 cm, without creating air current
  2. Observe for blinking and/or head withdrawal
  3. Test each eye separately (cover the fellow eye)
Interpretation:
  • Present: Visual pathway (retina → optic nerve → visual cortex) and CN VII are intact
  • Absent: Could indicate blindness, severe optic nerve disease, or CN VII palsy

Viva Q&A

Q: What is the menace reflex pathway? A: Visual stimulus → Retina → Optic nerve (CN II) → Lateral geniculate nucleus → Visual cortex (V1, occipital lobe) → Motor pathway → CN VII → Orbicularis oculi → Blink. (It is a learned/cortical reflex, NOT a brainstem reflex.)
Q: At what age does the menace reflex develop in children? A: Around 2-3 months of age (some sources say 3-6 months). It is NOT present at birth (unlike the blink reflex to light which is a brainstem reflex present from birth).
Q: What differentiates menace reflex from corneal reflex? A: Menace reflex requires an intact visual pathway (cortical); corneal reflex is a brainstem (trigeminal) reflex. A blind patient will have absent menace but intact corneal reflex.

5. HIRSCHBERG TEST (Corneal Light Reflex Test)

Procedure

Equipment: Pen torch
Steps:
  1. Seat the patient at eye level, in a dimly lit room
  2. Hold the pen torch at arm's length (~33 cm) from the patient's eyes, directed straight ahead
  3. Ask the patient to look at the light
  4. Observe the position of the light reflex on both corneas simultaneously
Interpretation:
Reflex positionDeviationAngle
Center of pupil (both eyes)Orthotropia (no squint)0°
At pupil margin~15° deviation~30 PD
Midway pupil to limbus~30°~60 PD
At limbus~45°~90 PD
  • Reflex displaced nasally on the deviating eye = Exotropia (outward turn)
  • Reflex displaced temporally on the deviating eye = Esotropia (inward turn)
  • Reflex displaced inferiorly = Hypertropia of that eye
  • 1 mm of displacement ≈ 7°, and 1° ≈ 2 prism dioptres

Viva Q&A

Q: What does the Hirschberg test detect? A: It detects the presence and magnitude of manifest strabismus (heterotropia) by observing the position of the corneal light reflex.
Q: What is pseudostrabismus and how does Hirschberg help? A: Pseudostrabismus is the appearance of a squint without true misalignment, usually due to a wide nasal bridge and epicanthal folds. The Hirschberg test shows symmetric corneal reflexes, confirming no true deviation.
Q: What is the Krimsky modification of Hirschberg? A: Prisms are placed in front of the fixating eye until both corneal reflexes appear centered. The prismatic power needed indicates the angle of deviation. It is more accurate than Hirschberg alone.
Q: What is the difference between Hirschberg test and cover test? A: Hirschberg detects manifest squint roughly by observing reflex position. The cover test is more accurate and also detects latent squint (heterophoria).

6. COVER AND UNCOVER TEST

Procedure

Equipment: Occluder/cover card, accommodative target (near), distant target
PART A - Cover Test (detects HETEROTROPIA = manifest squint):
  1. Ask the patient to fix on a target (first near, then distant)
  2. Observe the corneal reflexes
  3. Cover the suspected fixing eye (usually the better eye)
  4. Watch the uncovered (deviating) eye for any movement to take up fixation:
    • No movement → Orthotropia or the covered eye was the deviating one
    • Inward movement (adduction) → Exotropia of that eye
    • Outward movement (abduction) → Esotropia of that eye
    • Downward movement → Hypertropia
    • Upward movement → Hypotropia
  5. Repeat on the other eye
PART B - Uncover Test (detects HETEROPHORIA = latent squint):
  1. After covering one eye for 2-3 seconds, quickly remove the cover
  2. Watch the uncovered eye for a recovery movement
    • No movement → Orthophoria
    • Outward movement (to re-fixate after drift inward) → Esophoria
    • Inward movement (to re-fixate after drift outward) → Exophoria

Viva Q&A

Q: What is the difference between heterotropia and heterophoria? A: Heterotropia is a manifest (constant) squint - present even when both eyes are open. Heterophoria is latent - the deviation is controlled by fusion and only becomes apparent when fusion is disrupted (e.g., by covering one eye).
Q: What is the cover test detecting mechanistically? A: When you cover the fixing eye, the deviating eye must take up fixation. The corrective movement reveals the direction and type of squint.
Q: What is the alternate cover test (prism cover test)? A: The cover is alternated rapidly between the two eyes to dissociate fusion completely. Combined with prisms, it gives the total deviation (manifest + latent), which is used for surgical planning.
Q: Name conditions associated with esotropia in children. A: Infantile (congenital) esotropia, accommodative esotropia (hypermetropia), partially accommodative esotropia, and microtropia.

7. PUPILLARY REACTIONS

Procedure

Equipment: Pen torch, semi-dark room
Steps:
A. Direct Light Reflex:
  1. Ask patient to look at a distant target (to relax accommodation)
  2. Shine torch into one eye from the side
  3. Observe the SAME eye - normal pupil constricts promptly (direct response)
B. Consensual (Indirect) Light Reflex:
  1. Shine torch into one eye
  2. Observe the OTHER eye - it should also constrict simultaneously (consensual response)
C. Near Reflex (Accommodation-Convergence-Miosis triad):
  1. Ask the patient to look at a distant object, then suddenly at your finger held ~15 cm away
  2. Observe: both pupils constrict (miosis), eyes converge, and accommodate
D. Swinging Flashlight Test (for RAPD):
  1. In a semi-dark room, swing the light between the two eyes at ~2-3 second intervals
  2. Normal: both pupils remain constricted as you swing
  3. RAPD (Marcus Gunn pupil): The eye with the optic nerve lesion - both pupils paradoxically DILATE when light is swung to the affected side (because less light input from that side)

Viva Q&A

Q: What is RAPD and what causes it? A: Relative Afferent Pupillary Defect - asymmetric optic nerve or severe retinal disease where light input from one eye is less than the other. Both pupils dilate when the torch swings to the affected eye. Causes: optic neuritis, severe glaucoma, optic nerve compression, large retinal detachment.
Q: What is the Argyll Robertson pupil? A: Irregular, small pupils that accommodate (constrict for near) but do NOT react to light. Classic for neurosyphilis. Also seen in diabetic autonomic neuropathy.
Q: What is a Holmes-Adie (tonic) pupil? A: A large pupil with very slow/tonic reaction to light, brisk response to near (light-near dissociation). Due to postganglionic parasympathetic damage (ciliary ganglion). Associated with absent deep tendon reflexes (Holmes-Adie syndrome).
Q: Efferent pathway of pupillary light reflex? A: Edinger-Westphal nucleus → preganglionic parasympathetic fibers in CN III → ciliary ganglion → short ciliary nerves → sphincter pupillae (constriction).
Q: What is Horner's syndrome? A: Sympathetic pathway disruption causing: miosis (small pupil), ptosis, anhidrosis, and enophthalmos (apparent). Due to lesion of the oculosympathetic pathway at any level (hypothalamus → spinal cord → superior cervical ganglion → eye).

8. UPPER LID EVERSION

Procedure

Equipment: Cotton bud applicator, topical anesthetic (proparacaine/oxybuprocaine)
Steps:
  1. Instill one drop of topical anesthetic in the eye
  2. Ask the patient to look downward (this relaxes the levator muscle)
  3. Grasp the eyelashes of the upper lid between thumb and index finger of your right hand
  4. Place a cotton bud stick (horizontally) against the upper border of the tarsal plate (about 8-10 mm above the lid margin)
  5. Pull the lashes gently downward, outward, and then UPWARD over the cotton bud - the lid flips over (everts)
  6. Hold the everted lid in position by pressing the lashes against the superior orbital rim
  7. Inspect the palpebral (tarsal) conjunctiva under good illumination
What to look for:
  • Foreign bodies
  • Follicles (viral conjunctivitis, trachoma)
  • Papillae (allergic conjunctivitis)
  • Scars/symblepharon
  • Concretions
To restore: Ask the patient to look up - the lid returns to normal position.

Viva Q&A

Q: Why does the patient look downward during lid eversion? A: Looking down relaxes the levator palpebrae superioris muscle, allowing easy eversion of the lid.
Q: What is the landmark used for placing the cotton bud? A: The superior tarsal border - approximately 8-10 mm above the lid margin, at the upper edge of the tarsal plate.
Q: What is double eversion and when is it needed? A: Double eversion exposes the superior conjunctival fornix (the space between the palpebral and bulbar conjunctiva superiorly). A lid retractor or Desmarres retractor is used. Indicated when a foreign body is suspected in the upper fornix but not seen on simple eversion.
Q: What are follicles vs papillae on the everted tarsal conjunctiva? A: Follicles are small, avascular, smooth elevations with blood vessels going around them (seen in viral conjunctivitis, trachoma). Papillae have a central vascular core and are seen in allergic/bacterial conjunctivitis - they give a "cobblestone" appearance in giant papillary conjunctivitis (GPC).

9. FOREIGN BODY REMOVAL FROM EYE

Procedure

Equipment: Topical anesthetic, cotton bud, irrigation syringe, loupes/slit lamp, spud/needle (for corneal FB)
Steps:
A. Conjunctival FB:
  1. Instill topical anesthetic
  2. Evert the upper lid (as above); also pull down lower lid to inspect lower fornix
  3. Ask the patient to look in all directions to expose bulbar conjunctiva
  4. Locate the FB using pen torch + loupes or slit lamp
  5. Remove with a moistened cotton bud (gently touch and lift)
  6. Alternatively, irrigate with sterile saline from a syringe to wash it onto the bulbar conjunctiva, then remove
B. Corneal FB:
  1. Topical anesthetic, slit lamp for visualization
  2. Use a spud, 25-gauge needle on syringe, or bur drill tangentially to dislodge the FB
  3. Apply fluorescein after removal to check for residual rust ring (if metallic) - remove with bur drill
  4. Prescribe topical antibiotic after removal
  5. Cycloplegic if significant corneal abrasion/uveitis
Vertical corneal abrasions = FB under upper lid (pathognomonic finding guiding eversion).

Viva Q&A

Q: What are the signs of a corneal FB? A: Foreign body sensation, photophobia, lacrimation, blepharospasm, reduced vision, visible opacity on cornea, fluorescein staining around the FB.
Q: What is a rust ring and how is it treated? A: When a metallic FB embeds in the cornea, iron oxidizes and forms a rust ring in the surrounding tissue. It must be removed as it impairs healing; removed with an ophthalmic bur drill (Alger brush) under slit lamp.
Q: What history feature suggests an intraocular FB? A: High-speed injury (e.g., hammering metal on metal, grinding), explosion. Examine for wound, check IOP, fundus. Investigate with CT orbit (preferred over MRI if magnetic FB suspected).

10. IRRIGATION OF THE EYE

Procedure

Indication: Chemical burns (acid/alkali), removal of particulate matter
Equipment: Topical anesthetic, isotonic saline/Ringer lactate, 20 mL syringe + IV cannula tubing or irrigating lens (Morgan lens), pH paper, lid speculum
Steps:
  1. Immediately instill topical anesthetic (proparacaine 0.5%)
  2. Place a lid speculum to keep the eye open
  3. Hold the patient's head comfortably, with a bowl/towel to catch fluid
  4. Irrigate with copious sterile normal saline or Ringer lactate at room temperature
  5. Direct the stream over the cornea, conjunctival fornices, and beneath both lids (evert lids to irrigate under them)
  6. Irrigate for minimum 15-30 minutes (continue until pH is neutral)
  7. Check conjunctival sac pH with litmus paper 10 minutes after stopping (to allow equilibration)
  8. Target pH: 7.2-7.4
  9. If alkali (worse prognosis) - irrigate even longer; sweep fornices to remove any particulate alkali
  10. After irrigation, check vision, corneal clarity, and refer to ophthalmologist

Viva Q&A

Q: Why are alkali burns worse than acid burns? A: Alkalis cause liquefactive necrosis - they penetrate deeply and rapidly through the cornea, destroying stromal collagen and entering the anterior chamber. Acids cause coagulative (protein) necrosis, which forms a barrier limiting penetration. pH > 11 or < 3 = high risk.
Q: What is the endpoint of irrigation? A: Conjunctival sac pH of 7.2-7.4, measured 10 minutes after stopping irrigation to allow equilibration between the corneal tissue and irrigating fluid.
Q: What is the Roper-Hall classification of chemical burns? A: Grades 1-4 based on corneal clarity and limbal ischaemia:
  • Grade 1: Clear cornea, no limbal ischaemia - excellent prognosis
  • Grade 2: Hazy cornea (iris visible), <1/3 limbal ischaemia - good prognosis
  • Grade 3: Total epithelial loss, 1/3-1/2 limbal ischaemia - guarded
  • Grade 4: Opaque cornea, >1/2 limbal ischaemia - poor prognosis
Q: If both acid and alkali splashed into the eye simultaneously, which do you irrigate first? A: Alkali, as it penetrates more rapidly and causes more damage. However, in practice, immediate copious irrigation with whatever is available takes priority over choosing the agent.

11. GIVING PAD AND BANDAGE (Eye Pad Application)

Procedure

Indications: Corneal abrasion, post-procedure, protecting an eye post-surgery, chemical burn (temporary), traumatic eye
Equipment: Eye pad (oval cotton/gauze pad), micropore/adhesive tape (3-4 strips), antibiotic ointment (if indicated)
Steps:
  1. Clean the closed eyelid with a swab if needed
  2. Apply antibiotic ointment if indicated (e.g., for corneal abrasion)
  3. Ask the patient to close both eyes (this ensures the eye beneath remains firmly closed)
  4. Place the oval eye pad over the closed eyelid - it should sit in the orbital hollow
  5. Apply the first piece of tape diagonally from the middle of the forehead toward the cheek (upper to lower)
  6. Apply a second tape parallel and just below the first, from lateral forehead to the medial cheek
  7. Apply a third tape horizontally or as needed to secure the lower edge of the pad
  8. The pad should be firm (pressure pad for corneal abrasion) but not excessively tight
Pressure Pad (for corneal abrasion): Extra padding to prevent blinking and aid epithelial healing; ensure the eye is closed beneath.
Note: Eye pads are NOT recommended for infectious conjunctivitis (traps bacteria) or alkali burns (delays re-examination).

Viva Q&A

Q: Why must the eye be properly closed before applying the pad? A: To prevent corneal drying and abrasion from the pad rubbing on an open cornea. If the eye blinks beneath the pad, the pad movement damages the corneal epithelium further.
Q: When is an eye pad contraindicated? A: Chemical burns (needs repeated pH checking), infective conjunctivitis (traps organisms, worsens infection), contact lens-related corneal ulcer (risk of Pseudomonas), and perforating eye injuries (pad pressure may extrude intraocular contents).
Q: What is the purpose of a pressure pad? A: Traditionally used for corneal abrasions to reduce blinking-related epithelial shear forces and promote healing. However, modern evidence suggests patching may not significantly speed healing in traumatic abrasions and can be omitted in favor of topical antibiotics.

12. SPHERICAL LENS AND CYLINDRICAL LENS

Spherical Lens

Definition: A lens that has the same power in all meridians. It corrects spherical refractive errors.
Types:
  • Convex (plus/converging): Corrects hypermetropia (far-sightedness). Light converges through it. Cross-section: thicker in the center.
  • Concave (minus/diverging): Corrects myopia (near-sightedness). Light diverges. Cross-section: thicker at the edges.
Identification of a spherical lens:
  1. Hold the lens in front of a line of text
  2. Slowly move the lens up/down and side to side
  3. Convex (plus): Print moves in the opposite direction (against movement)
  4. Concave (minus): Print moves in the same direction (with movement)
  5. On rotation, the image does NOT change direction (no "scissors movement")

Cylindrical Lens

Definition: A lens that has power only in one meridian (the axis of the cylinder) and no power in the meridian perpendicular to it. Corrects astigmatism.
Identification:
  1. Hold the lens before text and rotate it
  2. A cylindrical lens produces a "scissors" or "break" movement of the image when rotated
  3. In one position the text magnifies/minifies (power meridian), in another there is no effect (axis meridian)
  4. Moves in one direction but not the other when moved side to side vs up/down
Prescription example:
  • Spherocylindrical: -2.00 DS / +1.00 DC × 90°
  • "DS" = dioptre sphere, "DC" = dioptre cylinder, "×" = axis

Viva Q&A

Q: What is the difference between a spherical and cylindrical lens? A: A spherical lens has the same power in all meridians and corrects pure myopia or hypermetropia. A cylindrical lens has power in only one meridian and corrects astigmatism.
Q: What refractive error is corrected by a cylindrical lens? A: Astigmatism - a condition where the corneal (or lenticular) surface is not spherical but toric, resulting in two different focal points in two meridians.
Q: What is "with-the-rule" astigmatism? A: The steeper corneal meridian is vertical (90°), corrected with a plus cylinder at 90° or minus cylinder at 180°. Most common in young individuals.
Q: What is "against-the-rule" astigmatism? A: The steeper corneal meridian is horizontal (180°). Common in older individuals.
Q: How do you neutralize a spherical lens? A: Use a trial lens of equal and opposite power until no movement of the image is seen - this is the neutralization point. Neutralization confirms the power.

13. LID LAG - DEMONSTRATION

Procedure

Definition: Lid lag (von Graefe's sign) - the upper eyelid fails to follow the downward movement of the eyeball during downward gaze. There is a white strip of sclera visible between the upper lid and the corneal limbus in downgaze.
Steps:
  1. Seat the patient comfortably at eye level
  2. Hold your finger/pen at the patient's eye level, in front of them
  3. Ask the patient to follow your finger with their eyes only (without moving their head)
  4. Move your finger slowly downward from the patient's eye level to below
  5. Observe the upper eyelid position relative to the cornea during downward gaze
  6. Normally, the upper lid smoothly follows the globe downward
Positive Lid Lag: The upper eyelid remains elevated (lags behind) while the eye moves down - a strip of sclera is visible superiorly in downgaze.
Lid Retraction (different): Sclera visible above the cornea in PRIMARY gaze = lid retraction (Dalrymple sign).

Viva Q&A

Q: What is the sign of lid lag called? A: Von Graefe's sign - the upper lid lags behind the downward movement of the globe.
Q: What is the most common cause of lid lag? A: Thyroid eye disease (Graves' ophthalmopathy) - due to infiltration of the levator palpebrae superioris muscle by inflammatory cells and glycosaminoglycans, causing fibrosis and reduced flexibility.
Q: What other eye signs are seen in thyroid eye disease (Graves')? A: Dalrymple's sign (lid retraction, stare appearance), von Graefe's sign (lid lag), Möbius sign (convergence weakness), Stellwag's sign (reduced blinking), Joffroy's sign (no wrinkling of forehead on upward gaze), exophthalmos/proptosis, conjunctival injection and chemosis, optic nerve compression.
Q: What is the mechanism of lid lag in thyroid eye disease? A: The superior tarsal muscle (Müller's muscle) and the levator palpebrae have increased sympathetic tone and/or infiltrative fibrosis, preventing normal relaxation during downgaze.
Q: What is lagophthalmos (differentiate from lid lag)? A: Lagophthalmos is the inability to fully close the eye (due to CN VII palsy, proptosis, cicatricial disease). Lid lag is failure of the lid to follow the globe in downgaze. They are different signs.
Q: How do you assess proptosis clinically? A: From above the patient (bird's eye view), looking down from behind the patient's head - if the cornea projects beyond the superior orbital rim, proptosis is present. Formal measurement with a Hertel exophthalmometer (normal: <20 mm; asymmetry >2 mm is significant).

QUICK SUMMARY TABLE

DOAPKey TechniqueKey SignViva Buzzword
Anterior chamber depthOblique penlight from temporal sideShadow on nasal iris = shallowVan Herick grading
Iris shadowOblique illuminationAbsent in mature cataractPenlight tangential
Blink reflexTouch lashes/visual threatCN V afferent, CN VII efferentCorneal reflex arc
Menace reflexHand threat toward eyeCortical - absent if blindVisual cortex pathway
HirschbergPen torch at arm's lengthReflex decentered = squint1 mm = 7°, 1° = 2 PD
Cover testCover fixing eyeMovement = heterotropiaManifest vs latent
Uncover testRemove cover, watch eyeRecovery movement = phoriaFusion disruption
Pupillary reactionTorch, dark roomRAPD = optic nerve lesionSwinging flashlight
Lid eversionPatient looks down, cotton budEvert over tarsal borderDouble eversion for fornix
FB removalTopical anesthetic, evert lidVertical abrasions = upper lid FBRust ring = bur drill
Eye irrigationSaline 15-30 minpH target 7.2-7.4Alkali > acid damage
Pad and bandageEye closed, diagonal tapesEye must be shut under padContraindicated in perforation
Spherical lensMove lens over textAgainst = convex, with = concaveNo scissors movement
Cylindrical lensRotate lensScissors movement = cylindricalCorrects astigmatism
Lid lagSlow downward gazeSclera visible in downgazeVon Graefe's sign, thyroid
*Sources: Kanski's Clinical Ophthalmology 10th Ed; The Wills Eye Manual; Roberts & Hedges' Clinical Procedures in Emergency Medicine; Tintinalli's Emergency Medicine; Harrison's Principles of Internal Medicine 22e; Textbook of Family Medicine 9e.*That's your complete Ophthalmology DOAP guide. Here's a quick orientation to what's covered:
All 13 stations covered:
  1. Anterior Chamber Depth - penlight oblique technique + Van Herick grading (slit lamp)
  2. Iris Shadow - oblique illumination; absent in mature cataract, present in immature
  3. Blink Reflex - CN V afferent / CN VII efferent arc
  4. Menace Reflex - cortical reflex, absent in blindness, develops at 3-6 months age
  5. Hirschberg Test - corneal reflex position; 1 mm = 7°; nasal displacement = exotropia
  6. Cover & Uncover Test - cover test finds heterotropia (manifest); uncover test finds heterophoria (latent)
  7. Pupillary Reactions - direct, consensual, near reflex, swinging flashlight (RAPD)
  8. Upper Lid Eversion - patient looks DOWN, cotton bud at tarsal plate superior border
  9. Foreign Body Removal - conjunctival vs corneal; rust ring requires bur drill
  10. Eye Irrigation - 15-30 min saline, pH target 7.2-7.4; alkali burns worse than acid
  11. Pad and Bandage - eye MUST be closed, diagonal tapes; contraindicated in perforation
  12. Spherical vs Cylindrical Lens - with/against movement; scissors movement = cylindrical
  13. Lid Lag - Von Graefe's sign, thyroid eye disease; differentiate from lagophthalmos
Key exam tips:
  • Always mention topical anesthetic before any lid/corneal manipulation
  • Lid eversion: patient looks DOWN (relaxes levator)
  • Lid lag: move finger DOWN slowly, eye must follow without head movement
  • Cylindrical lens = "scissors/break" movement on rotation - this is the hallmark identifier
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