Eyes - Exam 4

Eyelids

• distribute tears that lubricate the surface of the eye

Conjunctiva

• is a thin, transparent membrane allows for inspection of underlying tissue and protects the eye from foreign bodies.

Lacrimal gland

• located in the upper outer corner of the orbital cavity just above the eye, produces tears

Sclera

• is a dense, protective, white covering that physically supports the internal structures of the eye

Cornea

• permits the entrance of light, which passes through the lens to the retina. It is well supplied with nerve endings, making it responsive to pain and touch

Iris

• is a circular disc of muscle containing pigments that determine eye color. 

• Lens functions to refract (bend) light rays onto the retina

Retina

• consists of numerous layers of nerve cells, including the cells commonly called rods and cones

Aqueous humor

• helps to cleanse and nourish the cornea and lens as well as maintain intraocular pressure

Visual Field

• refers to what a person sees with one eye. The visual field of each eye can be divided into four quadrants: upper temporal, lower temporal, upper nasal, and lower nasal

Cornea and Lens

• the main eye components that refract (bend) light rays on the retina. The image projected on the retina is upside down and reversed right to left from the actual image. The left side of the brain views the right side of the world

Visual pathway

• the anatomical structures responsible for the conversion of light energy into electrical action potentials that can be interpreted by the brain

Pupillary light

• reflex causes pupils immediately to constrict when exposed to bright light. These protective reflexes, mediated by the oculomotor nerve, prevent damage to the delicate photoreceptors by excessive light

Accommondation

• a functional reflex allowing the eyes to focus on near objects.  Pupil constricts to increase the depth of focus of the eye. Use pen eyes follow 

Collecting subjective data

Any Vision Difficulties? Pain / Headaches, Redness, swelling, Discharge, Allergies, PMH, Surgery / Cataract, Diabetes / Retina, Glasses or Contact Lenses, Last Eye Exax, Effectiveness, Problems, Contact Use / Make-up, Occupation, Work environment, School, Nutrition, Exercise, Medications, Eye gtts/ointments, Systemic or topical - Digoxin

Collective objective data

• Hand-held Snellen card or near-vision screener

• Jaeger test

• Penlight

• Opaque cards

• Ophthalmoscope

Snellen chart

• Used to test distant visual acuity, the Snellen chart consists of lines of different letters stacked one above the other. The letters are large at the top and decrease in size from top to bottom. The chart is placed on a wall or door at eye level in a well-lighted area. The client stands 20 ft from the chart and covers one eye with an opaque card (which prevents the client from peeking through the fingers). Then the client reads each line of letters until he or she can no longer distinguish them.

E chart

• If the client cannot read or has a handicap that prevents verbal communication, the E chart is used. The E chart is configured just like the Snellen chart but the characters on it are only Es, which face in all directions. The client is asked to indicate by pointing which way the open side of the E faces. If the client wears glasses, they should be left on, unless they are reading glasses (reading glasses blur distance vision).

Jaeger test

• Near vision is assessed in clients over 40 years of age by holding the pocket screener (Jaeger test) or newspaper print 14 in from the eye. Clients who have decreased accommodation to view closer print will have to move the card or newspaper further away to see it.

• normal is 14/14 in each eye

Myopia

• nearsightedness

• makes it difficult to see things far away

Hyperopia

• farsightedness

• makes it hard to see things that are close

Corneal light reflex test

• Use penlight to observe parallel alignment of light reflection on corneas

• This test assesses parallel alignment of the eyes. Hold a penlight approximately 12 in from the client’s face. Shine the light toward the bridge of the nose while the client stares straight ahead. Note the light reflected on the corneas.

Asymmetric position of the light reflex

• indicates deviated alignment of the eyes. This may be due to muscle weakness or paralysis

Cover test

• The cover test detects deviation in alignment or strength and slight deviations in eye movement by interrupting the fusion reflex that normally keeps the eyes parallel.

• Ask the client to stare straight ahead and focus on a distant object. Cover one of the client’s eyes with an opaque card. As you cover the eye, observe the uncovered eye for movement. Now remove the opaque card and observe the previously covered eye for any movement. Repeat test on the opposite eye.  

Positions test

• Observe for eye movement

Corneal Light Reflection

• Assess alignment of eyes

• Patient looks straight ahead

• Reflection of light on corneas

• NORMAL = symmetric

• If ABNORMAL then do the cover/uncover test

Phoria

• term used to describe misalignment that occurs only when fusion reflex is blocked

Strabismus

• is constant malalignment of the eyes. Eyes don’t look in exactly the same direction at the same time

Tropia

• is a specific type of misalignment: esotropia is an inward turn of the eye, and exotropia is an outward turn of the eye

Cardinal fields of gaze test

• assesses eye muscle strength and cranial nerve function. Instruct the client to focus on an object you are holding (approximately 12 in from the client’s face). Move the object through the six cardinal positions of gaze in a clockwise direction (H), and observe the client’s eye movements.

• Failure of eyes to follow movement symmetrically in any or all directions indicates a weakness in one or more extraocular muscles or dysfunction of the cranial nerve that innervates the particular muscle. 

Lateral gaze

• looking to the right or to the left in the horizontal plane

Nystagmus

• an oscillating (shaking) movement of the eye—may be associated with an inner ear disorder, multiple sclerosis, brain lesions, or narcotics use.  An involuntary eye movement which may cause the eye to rapidly move from side to side, up and down.

PERRLA

• pupils equal round reactive to light and accomidation

PERRLA test

• Test pupillary reaction to light. Test for direct response by darkening the room and asking the client to focus on a distant object. To test direct pupil reaction, shine a light obliquely into one eye and observe the pupillary reaction. Shining the light obliquely into the pupil and asking the client to focus on an object in the distance ensures that pupillary constriction is a reaction to light and not a near reaction.

Accommodation

• Shifting gaze from far to near

• Normally, pupils constrict 

• Have patient look distant (Pupils will Dilate with Distance)

• Have patient look at object 3 inches from eyes (Pupils will Constrict with Closeness)

Opthalmoscope Dos:

• Begin about 10 to 15 in from the client at a 15-degree angle to the client’s side.

• Pretend that the ophthalmoscope is an extension of your eye. 

• Stay focused on the red reflex as you move in closer, then rotate the diopter setting to see the optic disc.

Opthalmoscope Donts

• Do not use your right eye to examine the client’s left eye or your left eye to examine the client’s right eye (your noses will bump).

• Do not move the ophthalmoscope around; ask the client to look into the light to view the fovea and macula.

• Do not get frustrated—the ophthalmologic examination requires practice.

Cataract

• Opacity or clouding of the eye’s lens

• Leading cause of blindness worldwide

Cataract risk factors

• Increasing age 

• Diabetes mellitus

• Excessive alcohol use

• Exposure to sunlight (ultraviolet B light)

• Exposure to ionizing radiation, such as that used in X-rays and cancer radiation therapy

• High blood pressure

• Obesity

• Previous eye injury, inflammation, surgery

• Prolonged steroid use

• Cigarette smoking

Reducing risk of Cataracts

• Wear sunglasses that block UVB rays.

• Avoid smoking or quit smoking.

• Avoid excessive alcohol intake.

• Avoid eye injuries.

• Maintain healthy weight.

• Use eye protectant equipment if necessary.

• Seek medication treatment for prolonged or unusual eye inflammation or any eye injury.

• Regular eye examination.

Glaucoma

• Glaucoma is a group of eye diseases that damage the optic nerve, often caused by abnormally high pressure (intraocular pressure) within the eye. There are no warning signs and its effects are so gradual that no change in vision may be noted until the condition is advanced. Vision loss caused by glaucoma is not reversible. Glaucoma is the second leading cause of blindness after cataracts. Vision loss due to glaucoma cannot be recovered, and there are no warning signs that glaucoma is developing. If found early, vision loss can be prevented or slowed.

Open angle glaucoma

• Patchy blind spots in your side (peripheral) or central vision, frequently in both eyes

• Tunnel vision in the advanced stages

Acute angle closure glaucoma

• Severe headache

• Eye pain

• Nausea and vomiting

• Blurred vision

• Halos around lights

• Eye redness

Glaucoma risk factors

• High eye pressure

• Family history of glaucoma

• Age 40 and older for African Americans

• Age 60 and older for the general population, especially Mexican Americans

• Thin cornea

• Suspicious optic nerve appearance with increased cupping (size of cup, the space at the center of optic nerve, is larger than normal)

Risk factors for open angle glaucoma

• High myopia (very severe nearsightedness)

• Diabetes

• Eye surgery or injury

• High blood pressure

• Use of corticosteroids (e.g., eye drops, pills, inhalers, and creams)

Educating about glaucoma

• Get regular eye examinations and treat any elevated IOP promptly.

• Wear protective eye gear if involved in activities that risk eye injury.

• Maintain optimum body weight and blood pressure to avoid diabetes, or control diabetes if present.

• Eat a varied, well-rounded, and healthy diet. Carotenoids (especially lutein and zeaxanthin), antioxidants (such as vitamins C and E), vitamins A and D, zinc and omega-3 fatty acids may all contribute to better vision overall.”

Macular degreneration

• Damage to the macula –loss in center field

  • blind spots 

  • blurred vision

• can be Dry or Wet

Age related macular degeneration (AMD)

• a major cause of visual impairment that affects the macula portion of the retina. AMD causes deterioration of the macula, the central area of the retina. Damage to the macula results in blind spots and blurred or distorted vision. People affected by AMD find many daily activities, such as driving and reading, increasingly difficult.

Dry macular degeneration

• most common

• may advance and cause loss of vision without turning into the wet form, or the dry form in early stages or in late stages may change into the wet form of AMD.

Wet macular degeneration

• abnormal new blood vessels form deep in the sensory retina, which can leak or bleed and result in marked loss of central vision in one or both eyes.

Macular degeneration risk factors

• Advancing age 

• Smoking (increases risk 2- to 5-fold; affects blood vessels in retina)

• Family history of AMD

• Gender (females more likely to be affected)

• Obesity (BMI >30)

• Race (Caucasians more affected than any other group)

• Light eye color

• Prolonged sun exposure (UV light directly damages retinal tissue)

• High fat, high cholesterol, high sugar/low antioxidant diet that is low in antioxidants and green leafy vegetables

• Hypertension (narrows blood vessels in retina) or blood pressure above 120/80 mm Hg

• Cardiovascular disease

• Inactivity (probably related to vascular oxygen levels)

• AMD in one eye

• Genetic predisposition (several genes associated with AMD)

Ptosis

• drooping of the upper lid

Exophthalmos

• protrusion of the eyeballs accompanied by retracted eyelid margins

Entropin

• inverted lower lid

Ectropin

• an everted lower eyelid, results in exposure and drying of the conjunctiva.

Chalazion

• an infection of the meibomian gland (located in the eyelid), may produce extreme swelling of the lid, moderate redness, but minimal pain

Blepharitis

•  redness and crusting along the lid margins suggest seborrhea or blepharitis, an infection caused by Staphylococcus aureus. 

Conjunctivitis

• generalized redness of the conjunctiva suggests conjunctivitis (pink eye).

Hordeolum (stye)

• a hair follicle infection, causes local redness, swelling, and pain.

Diffuse episcleritis

• inflammation of the sclera.

Irregular shaped iris

• causes a shallow anterior chamber, which may increase the risk for narrow-angle (closed-angle) glaucoma

Miosis

• pinpoint pupils, constricted and fixed pupils—possibly a result of narcotic drugs or brain damage

Anisocoria

• pupils of unequal size. In some cases, the condition is normal; in other cases, it is abnormal

Mydriasis

• dilated and fixed pupils, typically resulting from central nervous system injury, circulatory collapse, or deep anesthesia.

Papilledema

• Swollen optic disc and Blurred margins

• Hyperemic appearance from accumulation of excess blood

• Visible and numerous disc vessels

• Lack of visible physiologic cup

Glaucoma and optic disk abnormalities

• Enlarged physiologic cup occupying more than half of the disc’s diameter

• Pale base of enlarged physiologic cup

• Obscured and/or displaced retinal vessels

Optic atrophy

• White optic disc

• Lack of disc vessels

Presbyopia

• he gradual, age-related loss of your eyes' ability to focus on nearby objects

Pinguercula

• yellowish nodules on the bulbar conjunctiva

• These harmless nodules are common in older clients, appearing first on the medial side of the iris and then on the lateral side.

Arcus senilis

•  normal condition in older clients, appears as a white arc around the limbus

External ear contents

• auricle

• helix

• external ear canal

Middle ear contents

• tympanic membrane and cavity

• Eustachian tube

• auditory ossicles

Inner ear contents

• Bony labyrinth

• Cochlea

• Spiral organ of Corti

Conductive hearing loss

• fluid in middle ear, middle ear infection (otitis media),

• allergies (serous otitis media), eustachian tube dysfunction,

• perforated eardrum, benign tumors, impacted cerumen,

• infection in the ear canal (external otitis) or presence of a foreign body.

Sensorineural hearing loss

• ototoxic drugs, genetic hearing loss, aging, head trauma, malformation of the inner ear, and loud noise exposure. 

• This is the most common type of permanent hearing loss. It decreases one’s ability to hear faint sounds.

• Even loud speech may be muffled. 

Hearing loss signs

• Repeat statements, Straining, Leaning forward, Tilting Head, Shouting in conversation, Raising volume, Avoiding large groups

Risk factors for hearing loss

• Aging, especially due to many years of exposure to sounds that can damage inner ear cells

• Heredity, with genetics that are related to susceptibility to ear damage

• Occupational loud noises as regular part of the working environment 

• Recreational noises and exposure to explosive noises

• Ototoxic medications 

• Illnesses, especially with high fever

• Noise exposure

• Smoking

• Cardiovascular risk factors

• Genetic and family susceptibility 

• Premature birth 

• Hypoxia during birth

• Rubella, syphilis, or other infections in pregnant mother

• Inappropriate use of ototoxic drugs during pregnancy

• Neonatal jaundice, which can damage the otic nerve in a newborn baby

• Infectious diseases such as meningitis, measles, mumps, and chronic ear infections in childhood as well as later in life

• Head injury or injury to the ear

• Wax or foreign bodies blocking the ear canal

Otitis Media

• inflammation or infection located in the middle ear.

• Purulent drainage associated with pain and a popping sensation is characteristic of otitis media with perforation of the tympanic membrane.  

• Age (between 6 months and 2 years especially, due to size and shape of eustachian tubes)

Risk factors for Otitis Media

• Age 

• Group childcare

• Babies fed from a bottle, especially lying down

• Seasons of fall and winter, due to exposure to colds, flu, and increased allergens

• Poor air quality (especially irritants in the air, e.g., cigarette smoke)

• Family history

• Cleft palate

• Down syndrome

• Ethnicity 

• Enlarged adenoids

External ear inspection and palpation

• Inspect the auricle, tragus, and lobule for size, shape, position, lesions/discoloration, and discharge.

• Palpate the auricle and mastoid process for tenderness

Whisper test

• instruct client to gently occlude the ear not being tested and rub the tragus with a finger in a circular motion. Start with testing the better hearing ear and then the poorer one. With your head 2 ft behind the client (so that the client cannot see your lips move), whisper a two-syllable word such as “popcorn” or “football.” Ask the client to repeat it back to you. If the response is incorrect the first time, whisper the word one more time. Identifying three out of six whispered words is considered passing the test.

• Unable to repeat the two-syllable word after two tries indicates hearing loss and requires follow-up testing by an audiologist.

Weber test

• This test helps to evaluate the conduction of sound waves through bone to help distinguish between conductive hearing (sound waves transmitted by the external and middle ear) and sensorineural hearing (sound waves transmitted by the inner ear). Strike a tuning fork softly with the back of your hand and place it at the center of the client’s head or forehead. Centering is the important part. Ask whether the client hears the sound better in one ear or the same in both ears.  

Weber test and conductive hearing loss

• he client reports lateralization of sound to the poor ear—that is, the client “hears” the sound in the poor ear. The good ear is distracted by background noise and conducted air, which the poor ear has trouble hearing. Thus the poor ear receives most of the sound conducted by bone vibration.

Weber test and sensorimotor hearing loss

• the client reports lateralization of sound to the good ear. This is because of limited perception of the sound due to nerve damage in the bad ear, making sound seem louder in the unaffected ear.

Rinne test

• The Rinne test compares air and bone conduction sounds. Strike a tuning fork and place the base of the fork on the client’s mastoid process. Ask the client to tell you when the sound is no longer heard.  Move the prongs of the tuning fork to the front of the external auditory canal. Ask the client to tell you if the sound is audible after the fork is moved.  

• Although AC > BC in normal hearing, the Rinne test is used to determine the cause of the hearing loss (conduction or sensorineural) once it is determined that there is a hearing loss. If the cause is sensorineural, the finding will also be AC > BC.

• With conductive hearing loss, bone conduction (BC) sound is heard longer than or equally as long as air conduction (AC) sound (BC ≥ AC).

Romberg test

• this tests the client’s equilibrium. Ask the client to stand with feet together, arms at sides, and eyes open, then with the eyes closed. Client maintains position for 20 seconds without swaying or with minimal swaying.

• When performing this test, put your arms around the client without touching him or her to prevent falls.

• Client moves feet apart to prevent falls or starts to fall from loss of balance. This may indicate a vestibular disorder.  

External canal otoscopic exam

• Note color, drainage, lesions, consistency of cerumen

Tympanic membrane and otoscopic exam

• Note color / position of landmarks / intactness of drum

• Shiny / transparent /opaque pearl gray

• Slightly concave

• Cone of light

• Right – 5 o'clock   Left – 7 o'clock

• Note position of bony landmarks & cone of light

What should you never do if the ear drum is not intact?

• irrigate the canal

Changes with aging ears

• Presbycusis common after 50 years of age

• Negative self-image with hearing aid

• Elongated earlobes with linear wrinkles

• Harder cerumen builds as cilia in ear canal become more rigid

• Coarse, thick wire-like hair may grow at ear canal entrance

• Eardrum appears cloudy

Presbycusis

• a gradual sensorineural hearing loss, is common after the age of 50 years.

• often begins with a loss of high-frequency sounds (a woman’s voice) followed later by the loss of low-frequency sounds.  

Tophi, postauricular cyst

• hard external ear nodules associated with deposits of uric acid crystals in advanced gout

Otitis externa

• infection of the outer ear canal – often caused by water – swimmer’s ear

Polyp exostosis

• thickening and constriction of the ear canal

Acute otitis media

• red, bulging membrane; decreased or absent light reflex.

Serous otitis media

• yellowish, bulging membrane with bubbles behind it

Blue/red tympanic membrane

• indicates blood behind eardrum due to trauma.

Scarred tympanic

• -white spots and streaks indicate scarring from infections

Perforated tympanic membrane

• perforation results from rupture caused by increased pressure, usually from untreated infection or trauma.

Retracted tympanic membrane

• prominent landmarks are caused by negative ear pressure due to obstructed eustachian tube or chronic otitis media.