Physical Exam

Extraocular Movements

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Video coming September 2026

How to Perform

Hold a target (your fingertip or a pen) about an arm's length away 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, and watch both eyes for full, smooth, conjugate movement and for any nystagmus or lag. Ask about double vision in each position.

How to Interpret

Ocular Myasthenia Gravis

Improvement of ptosis with the ice-pack test

Rule in

Somewhat helpful

Rule out

Very helpful

Evidence:Limited

References

Proudman W, Kleinig O, Lam L, Collins L, Bagster M, Gupta A, Kovoor J, Bacchi S, Slee M, Chan WO. The Icepack Test in the Diagnosis of Myasthenia Gravis with Ocular Features: A Systematic Review of Diagnostic Accuracy, Technique, and Economic Utility. Semin Ophthalmol. 2023 Oct;38(7):679-685. doi:10.1080/08820538.2023.2194984. PMID: 36967601. [Systematic review (range, not pooled): sensitivity 38.5-100%, specificity >95% in six studies. Displayed sens/spec are from the bias-controlled cohort Fakiri 2013, Muscle Nerve, PMID 23536427: sensitivity 0.92, specificity 0.79.]
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.