Physical examination maneuver

Physical Exam

Extraocular Movements

🎬
Video coming September 2026

How to Perform

Hold your fingertip about an arm's length away from the patient and ask the patient to follow it with their eyes while keeping the head still. Move it through the six cardinal directions of gaze in an 'H' pattern, pausing at the extremes. Ask the patient to report any double vision experienced during the examination. Watch both eyes for full, smooth, conjugate movement and for any nystagmus or lag.

How to Interpret

Showing 6 of 21 findings

Hyperthyroidism

Eyelid lag
Rule in
Very helpfulDerived CI
Rule out
Not helpfulDerived CI
Evidence:Limited

Myasthenia Gravis

Improvement of ptosis with the ice-pack test
Rule in
Somewhat helpfulNo CI
Rule out
Very helpfulNo CI
Evidence:LimitedResearch in progress

Orbital Fracture

Diplopia after facial trauma
Rule in
Somewhat helpful
Rule out
Not helpful
Evidence:Limited

Stroke

Ophthalmoparesis in a patient with acute dizziness
Rule in
Very helpfulDerived CI
Rule out
Not helpfulDerived CI
Evidence:Limited
Conjugate gaze palsy in a patient with confirmed acute ischemic stroke
Rule in
Somewhat helpfulDerived CI
Rule out
Not helpfulDerived CI
Evidence:Limited
Diplopia in a patient with confirmed acute ischemic stroke
Rule in
Very helpfulDerived CI
Rule out
Not helpfulDerived CI
Evidence:Limited

References

Research in progress on one or more findings above; ratings may change.

  • Fakiri MO, Tavy DLJ, Hama-Amin AD, Wirtz PW. Accuracy of the ice test in the diagnosis of myasthenia gravis in patients with ptosis. Muscle Nerve. 2013;48(6):902-904. doi:10.1002/mus.23857. PMID: 23536427.
  • Kim HJ, Kim HJ, Choi JY, Yang HK, Hwang JM, Kim JS. Diplopia: characteristics and etiologic distribution in a referral-based university hospital. J Neurol. 2023;270(2):1067-1075. PMID: 36355187.
  • Kee HJ, Yang HK, Hwang JM, Park KS. Evaluation and validation of sustained upgaze combined with the ice-pack test for ocular myasthenia gravis in Asians. Neuromuscul Disord. 2019;29(4):296-301. PMID: 30704861.
  • Tao WD, Liu M, Fisher M, et al. Posterior versus anterior circulation infarction: how different are the neurologic deficits? Stroke. 2012;43(8):2060-2065. doi:10.1161/STROKEAHA.112.652420. PMID: 22678088.
  • Nordyke RA, Gilbert FI Jr, Harada ASM. Graves' disease: influence of age on clinical findings. Arch Intern Med. 1988;148(3):626-631. PMID: 3341864. doi:10.1001/archinte.148.3.626.
  • Rozema R, Doff MHJ, Delli K, Spijkervet FKL, van Minnen B. Diagnostic accuracy of physical examination findings for midfacial fractures: a systematic review and meta-analysis. Clin Oral Investig. 2022;26(4):3405-3427. doi:10.1007/s00784-022-04423-y. PMID: 35298710. PMCID: PMC8979892.
  • Hörner R, Kassubek J, Dreyhaupt J, Ludolph AC. The spectrum and differential diagnosis of acquired ocular motor nerve palsies: a clinical study of 502 patients. J Neurol. 2022;269(4):2140-2148. PMID: 34537871.
  • Runchey S, McGee S. Does this patient have a hemorrhagic stroke? Clinical findings distinguishing hemorrhagic stroke from ischemic stroke. JAMA. 2010;303(22):2280-2286. PMID: 20530782
  • Green WR, Hackett ER, Schlezinger NS. Neuro-ophthalmologic evaluation of oculomotor nerve paralysis. Arch Ophthalmol. 1964;72:154-167. PMID: 14162937.
  • Keane JR. Vertical diplopia. Semin Neurol. 1986;6(2):147-154. PMID: 3332419.
  • Litvan I, Agid Y, Jankovic J, et al. Accuracy of clinical criteria for the diagnosis of progressive supranuclear palsy (Steele-Richardson-Olszewski syndrome). Neurology. 1996;46(4):922-930. doi:10.1212/wnl.46.4.922. PMID: 8780065.
  • Cnyrim CD, Newman-Toker D, Karch C, Brandt T, Strupp M. Bedside differentiation of vestibular neuritis from central 'vestibular pseudoneuritis'. J Neurol Neurosurg Psychiatry. 2008;79(4):458-460. PMID: 18344397.
  • Navi BB, Kamel H, Shah MP, et al. Rate and predictors of serious neurologic causes of dizziness in the emergency department. Mayo Clin Proc. 2012;87(11):1080-1088. PMID: 23063099.
  • Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504-3510. PMID: 19762709.
  • Bickley LS, Szilagyi PG, Hoffman RM, Soriano RP. Bates' Guide to Physical Examination and History Taking. 13th ed. Philadelphia, PA: Wolters Kluwer; 2021.
  • Swartz MH. Textbook of Physical Diagnosis: History and Examination. 9th ed. Philadelphia, PA: Elsevier; 2025.

Research last updated September 10, 2026.

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