Lid Function

Ptosis can be quantified using the following methods:

1. Measure the distance between the upper lid margin and the midcorneal reflex when the
globe is in normal primary position. Ptosis is present when this distance is ,2 mm or varies
by more than 2 mm between the eyes.
2. Measure the amount of the superior portion of the cornea covered by the upper lid when
the globe is in primary position; normal is approximately 2 mm. With ptosis, more than 4
mm of cornea is covered.
3. Measure the vertical width of the palpebral fissure; it is normally approximately 915
mm.

Pupil
Assess pupil size and reactivity. If anisocoria is present, it should be observed under varied
illumination; in Horner syndrome, the anisocoria is more apparent in darkness
and a lag in pupillary dilation may be observed, whereas with pupillary constrictor paresis,
the difference is more evident under bright light. A relative afferent pupillary defect,
indicating optic nerve dysfunction, is detected by swinging a bright light source from one
pupil to the other, watching for dilation in the affected eye. Slit lamp examination may
identify sectoral irregularities in the iris, an indication of reinnervation.

Ocular Alignment
Assess ocular alignment by the alternate cover test or Maddox rod testing. A patient with a
phoria prefers to fixate with one eye and will shift eye position only when the preferred eye
is covered; if a tropia is present, fixation will shift when either eye is occluded. The degree
of horizontal or vertical misalignment can be quantified using prisms. The Bielschowsky
three-step test is valuable for identification of trochlear nerve palsies (see “Trochlear Palsy
(CN IV)” section). Information as to whether ocular misalignment is
long-standing may be obtained via stereoacuity tests.

Ductions
Assess ductions by having the patient follow a hand-held target to all cardinal positions of
gaze; observe the range, speed, and smoothness of these movements in each eye, as well as
whether the two eyes move conjugately. The examiner can best observe both eyes
simultaneously by fixating on the patient’s nose. When there is limitation of
movement to a given position of gaze, it may be difficult to distinguish between weakness
of an EOM (e.g. lateral rectus) and restriction or overaction (or both) of its antagonist
(medial rectus). The speed and smoothness of movement may serve as a clue; sudden
slowing toward the end of an excursion suggests restriction of the antagonist. The
definitive tests, however, are those of forced duction and active force generation. Forced
duction testing is performed by grasping the anesthetized extraocular muscle, tendon, or
globe itself, and pulling it through its range of motion; the examiner directly feels any
mechanical restriction. In young children, this procedure often requires general anesthesia.
Active force generation requires the alert patient’s cooperation to attempt eye movements
while the examiner grasps muscle, tendon, or globe and senses muscle force.

Horizontal and Vertical Saccades

Assess horizontal and vertical saccades by asking the patient to rapidly switch fixation
between the examiner’s nose and targets held in each extreme of the visual field. Slow
saccades suggest muscle weakness or, in the case of the medially directed saccades, an
internuclear ophthalmoplegia; saccades that begin rapidly but slow toward the end of their
excursion suggest restriction of the opposing EOM. Repeated saccades may reveal the
fatigability associated with myasthenic syndromes. Hyper- or hypometric saccades suggest
cerebellar disease. Occasionally, disturbances in smooth pursuit suggest a particular
pattern of EOM involvement—for example, the upshoot seen during medial pursuit in
Duane’s syndrome (see below). Both horizontal and vertical head thrusts take advantage of
vestibular input to indicate the true range of motion of the eyes where voluntary maneuvers
fail to do so; in addition, they provide helpful information about central control of eye
movements. Identification of nystagmus indicates central dysfunction but may also
provide an indirect indication of limitation, such as with the abducting nystagmus seen
when medial deviation of the opposite eye is limited. Finally, additional general
ophthalmologic testing assists in identifying visual pathway dysfunction that may affect
ocular motility. This testing may include assessment of visual acuity at far and at near,
color perception, the visual fields, and the funduscopic appearance of the optic nerves and
the central and peripheral retina. The latter also may be particularly helpful to identify
complex neurologic syndromes of which abnormal EOMs are a single component.