General examination of the eye

Ptosis is common and is often missed (Table 1). Partial ptosis is usually associated with unilateral overactivity of the frontalis. Ptosis is not a feature of facial nerve palsy (with a facial nerve palsy the eye does not close).

Table 1 Ptosis

Exophthalmos is usually a feature of hyperthyroidism but may indicate orbital disease. Enophthalmos is a feature of Horner’s syndrome. Lid retraction is seen in hyperthyroidism and in rare upper brain stem lesions.

Remember false eyes can be cosmetically effective – a pitfall in exams.

Examination of the pupils

First look at the pupils. Are they the same size? Examination then aims to assess the afferent (optic nerve) and the efferent (parasympathetic via 3rd nerve constricting and sympathetic dilating) elements of the pupillary reflexes.

Ask the patient to look into the distance and shine a light twice in each eye in turn. First, look at the response in the eye into which you are shining the torch (the direct response), and then at the response in the other eye (the consensual response). Then ask the patient to look at your finger held 15 cm from the patient’s face and look at the pupils for brisk constriction – the accommodation response. If no response is obtained from shining a light into the eye, but there is a normal response on accommodation, this is called an afferent pupillary defect and indicates significant optic nerve disease. Other abnormalities are summarized in Table 2.

Table 2 Abnormal pupillary responses

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