External Examination of the Face and Eyes

Start by examining the face for skin lesions and rashes, particularly if in a dermatomal distribution suggesting varicella zoster infection.

Lymphatic drainage of the eyelid and conjunctiva is to the pre-auricular and submandibular lymph nodes, which should be palpated for lymphadenopathy.

The temporal arteries should be felt for tenderness and the trigeminal and facial nerves examined for intact function.

A general external examination of the eye must include:

Orbit

The bony orbit and zygomatic complex should be palpated for swelling, tenderness, palpable fractures and subcutaneous emphysema.

Check for intact sensation in the supra- and infra-orbital nerve distributions (the forehead above the eye, and the cheek and upper gum, respectively).

These cutaneous nerves are particularly susceptible to injury from assault, as they emerge through foramina immediately above and below the eye.

Eyelids/globe position

Any generalised or local swelling should be identified.

Note the position and symmetry of the eyelids:

• Ptosis (e.g. third nerve palsy) or
• Retraction (e.g. exophthalmos)
• Entropion or ectropion

Any wounds must be examined carefully to identify depth and extension to the lid margin and possible involvement of the lacrimal apparatus.

The globe may appear to be:

• Protruding, e.g. retrobulbar haemorrhage or
• Sunken, e.g. Horners syndrome

Conjunctiva/cornea

An initial examination of the visible conjunctiva and cornea (palpebral fissure) should identify:

• General or localised swelling
• Colour
• Bleeding
• Clarity of the cornea

Note the distribution of any redness or prominent blood vessels of the conjunctiva (conjunctival injection):

• Generalised injection suggests conjunctivitis
• Localised injection is a sign of scleritis and episcleritis (image shows localised conjunctival injection in episcleritis)
• Perilimbal injection (surrounding the cornea, also known as ciliary flush) is seen in keratitis, acute glaucoma and other significant intraocular disorders

Pupil/iris

Examine the iris and pupil and ensure the anterior chamber is clear.

Blood (hyphaema) or pus (hypopyon) may appear as either a horizontal fluid level or generalised cloudiness of the anterior chamber.

Note the shape of the pupil and, if irregular, check if this is new, or due to previous trauma or surgery.