Sandra Fortenberry, OD, FAAO, ABO Diplomate
Sphygmomanometry/Pupils/CVF/EOM Workshop Handout – AOA 2016
Sphygmomanometry
BLOOD PRESSURE EVALUATION
Blood pressure measurements provide important information about a patient’s hemodynamic status and
overall health condition. Blood pressure should be performed on all patients.
Procedure Guidelines
Patients should be seated with their legs uncrossed, with their arm bare, free of constrictive clothing, and
supported and positioned at approximately heart level. Patients should not have smoked or ingested
caffeine within 30 minutes prior to test. Patients should rest for five minutes prior to the test. The proper
size cuff should be used. The rubber bladder should encircle at least 80 percent of the arm circumference.
A cuff that is too wide causes falsely low results; a narrow cuff causes falsely high results. At a patient’s
first assessment, measure blood pressure in both arms; thereafter, take measurements in the arm with the
higher pressure (a difference of 5 to 10 mmHg is normal; a greater difference may indicate a condition
such as aortic stenosis or arterial occlusion).
Definition of Korotkoff Sounds – these sounds are auscultary sounds heard over the artery as pressure in
the cuff is changed.
First sound – clear rhythmic tapping that gradually increases in intensity. Systolic pressure is the reading
at the point the sound first appears.
Second Sound – murmur or swishing as the vessel distends and blood creates vibrations in the vessel
wall.
Third sound – movement of blood in the vessel sounds crisper and more intense, as the vessel remains
open in systole but is obliterated in diastole.
Fourth sound – sound is muffled, as the cuff pressure falls below the blood pressure.
Fifth sound – disappearance of sounds. Diastolic pressure is the reading at the point the sounds
disappear.
Procedure
1. Determine proper cuff size; Wash hands; Inform patient that you are taking his/her blood pressure;
Patient seated comfortably with arm slightly flexed, forearm supported at heart level and palm turned
up.
2. Fully expose upper arm; Palpate brachial artery; Position cuff 1 inch above site of brachial artery
pulsation (antecubital space); Center the arrows marked on the cuff over the brachial artery.
3. Be sure that the cuff is fully deflated. Wrap the cuff evenly and snugly around the upper arm; Be sure
that the manometer is positioned where it can be easily read.
4. Place stethoscope earpieces in the ears and be sure sounds are clear, not muffled.
5. Relocate brachial artery and place bell (diaphragm may also be used) of stethoscope over it.
6. Close valve of pressure bulb clockwise until tight.
7. Inflate cuff to pressure 30 mmHg above patient’s normal systolic level.
8. Slowly release valve, allowing mercury to fall at rate of 2 to 3 mmHg per second.
9. Note point on manometer when first clear sound is heard.
10. Continue to gradually deflate cuff, noting the point when sound disappears.
11. Deflate cuff rapidly and remove from patient’s arm unless there is a need to repeat measurement.
12. Wait 30 seconds before repeating procedure.
13. Record systolic / diastolic pressure
Record the following:
1. Systolic Pressure / Diastolic Pressure
2. Right arm or left arm (RAS = right arm sitting)
3. Posture: sitting, standing, or lying down
4. Time of day
5. Cuff size (if other than regular)
Example: 110/70 mmHg, Right arm, sitting, 11:15am
Pupil Testing
Pupil Size
1. Have patient fixate a distance target
2. Measure in dim illumination using a pupil gauge. It is best to hold your gauge along the temporal
aspect of the eye to completely eliminate accommodation. If anisocoria is present, re-measure pupil
sizes in bright illumination.
3.
4. Anisocoria:
a. Greater in dim light – Sympathetic defect or dilator muscle problem.
b. Greater in bright light – Parasympathetic defect or sphincter muscle problem.
c. Equal in dim and bright light – Physiologic Anisocoria.
5. Corectopia – A pupil that is not round in shape
Direct and Consensual Response
1. Maintain distance fixation
2. Shine your transilluminator in the OD observing the amount and speed of the pupillary constriction of
the OD (Direct response). Shine the light for at least 1 second.
3. Shine your transilluminator again in the OD, but now observe the constriction of the left eye
(Consensual response). Shine the light for at least 1 second.
4. Repeat above on OS
5. Reactivity can be graded on a scale of 0 - 4+ (0=no response, 4+ large, rapid response). Numerical
values are usually only assigned when the eyes have unequal responses.
Example: OD 2+ response, OD 4+ response
6. Expected findings: Direct response should equal consensual response.
APD Testing (Swinging Flashlight)
1. Dim room lights as much as possible
2. Shine the brightest light possible on the pupil (transilluminator or BIO light)
3. Patient maintains distance fixation
4. Shine the transilluminator into the OD. Stimulate right eye for three seconds, then move the
transilluminator light quickly to the left eye. Hold light in front of OS for three seconds, and then
move the light quickly back to the right eye. Perform three cycles.
5. Observe the response of the pupil of the eye receiving light during the swinging flashlight test.
6. Expected finding: The rate and amount of constriction should be the same for both pupils. Therefore,
both pupils will stay equally constricted throughout the test.
a. Graded on a scale of 1 - 4+ (grade 4+ being severe).
b. The eye must be specified.
Accommodative/Near Response
1. Turn up room illumination so the patient will have adequate light to view the near target. One
of the patient’s own fingers will be the target used for testing the near response.
2. Tell the patient to first look at a distant target (e.g., 20/400 “E”). Then, tell the patient to look
at their finger (which will be about 20-40cm away from their eyes). At this point, observe the
pupillary reactions. The patient’s pupils will constrict as soon as they look at their finger.
3. Repeat this cycle at least two times (Distant target, then near target; Distant target, then, near
target)
4. Expected finding: Pupillary constriction should occur during near viewing and dilation
should be observed when changing to a distant target.
a. There is NO condition in which the light reflex is present, but the near is absent.
b. Light-near dissociation occurs when there is a near response but not a light response.
This can occur from several etiologies, but the most well-known is the ArgyllRobertson pupil, sequelae of syphilis.
Recording the Pupils
1. All of the above pupil tests are usually grouped together for recording purposes.
2. Normal results example: 4/4m, PERRLA (-) APD
3. PERRLA stands for pupils equal, round, responsive to light and accommodation
4. Anisocoria example: P (7/6, 5/4mm) RRLA (-) APD ; OR: 7/6 5/4 mm PERRLA (-)APD
5. APD example: 5/5mm, PERRLA (+) 3+ RAPD OD
EOM Procedure
1. Have patient remove spectacles, use transilluminator for target at 40cm.
2. Versions
a. Instruct patient, “Follow this lighted target without moving your head. Let me know if you
ever see double or feel any pain.”
b. Move the light smoothly in the physiological H pattern and observe the patient’s eyes or
corneal reflexes. The patient’s eyes are taken to endpoint or “bury the sclera.” It is normal to
observe a low amplitude nystagmus (fast, uncontrollable eye movements) at the extreme
limits of gaze. If a restriction is seen or the patient reports diplopia, perform ductions.
3. For testing the horizontal recti (medial and lateral muscles), the patient will need to look all
the way to the right and then all the way to the left.
4. For testing the superior and inferior recti and the superior and inferior oblique muscles:
Remember that the superior and inferior recti insert with an angle of approx. 20degrees with the
visual axis, whereas the superior and inferior oblique muscles insert with an angle of approx.
50degrees with the visual axis. Move your transilluminator about 20 degrees temporal to the patient’s
primary gaze (on the right side) and ask the patient to follow your transilluminator. At this moment,
move the transilluminator up (this will generate upward eye movement in both eyes). At this point,
you have isolated the right superior rectus and left inferior oblique muscles. While keeping the
20degree position, now move the transilluminator downwards (generating downward eye movements
in both eyes). At this point, you have isolated the right inferior rectus and left superior oblique
muscles. Repeat these for the left side now.
5. Recording examples:
a. If no restrictions are found, record as SFROM OU (smooth, full range of motion);
(-) pain (-) diplopia. Do not record as OD, OS unless you tested ductions.
b. If a restriction or overaction is found, record the eye and the field of gaze that it occurred
in. Example: Versions: OS restriction in up and right gaze, Ductions: OS underaction of IO
Confrontation Visual Fields
1. Even illumination (bright setting). Patient and examiner should sit directly opposite each other at
the same height and about 67 cms apart. Have patient remove spectacles.
2. Ask the patient to occlude OS. You close / cover your OD, so that your open eye and your
patient’s open eye are aligned and level.
3. Ask the patient to look directly into the center of your open eye. Inform your patient that this
is a test of side vision and that it is important to keep looking at your open eye. They should
not move their eyes or head during the test. Instruct patient, “While still looking at my open
eye, tell me how many fingers I am holding up.” Present your finger showing 1, 2, or 5 fingers.
4. Your fingers should be at the farthest extent of your own field of vision (assuming you have a
normal visual field). This will have the effect of placing your fingers close to the limit of the
patient’s visual field. Make sure your hands are halfway between you and your patient. Test all
four quadrants. If your patient gives an incorrect response, make sure that you are able to see the
correct number. If not, bring your hand in closer and recheck.
5. Test the other eye
Recording – If the test is normal, record FTFC OD, OS (FTFC = Full to finger count). DO NOT
WRITE “OU” as this is a monocular test. If the test is abnormal, draw the abnormality. What is the
field loss shown below?
OS
OD