Eyes

palpebral fissure

opening between eyelids

conjunctiva

transparent protective covering of the eye

Cornea

covers and protects iris and pupil

Retina

Visual receptive layer of the the eye in which light waves are changed into nerve impulses

Ocular fundus

area of the retina visible through the ophthalmoscope

cataract

clouding of the lens of the eye

Cataracts are caused by

aging

exposure to UV light

Smoking

Diabetes

Obesity

Is cataracts curable?

Yes, with len replacement surgery

Glaucoma

Optic nerve compression caused by increased intraocular pressure

How does glaucoma affect vision?

*Glaucoma will often lead to a loss of peripheral vision before central vision is affected.

Risk factors for glaucoma

Age

African American race

Positive family history

Women (b/c they have longer life expectancy)

pupillary light reflex

normal constriction of pupils when bright light shines on retina

Fixation

a reflex direction of eye toward an object attracting person's attention

accomadation

adaption of the eye to near vision

Age-related macular degeneration (AMD)

A loss of vision of unknown cause, possibly oxidative stress and inflammation

AMD is characterized by

Yellow deposits called drusen and neovascularity in macula

AMD risk factors

Age around 50 more common in women

By 80 1 & 10 Americans suffer

How does AMD effect ADLs?

Unable to read, sew, or fine work.

Cannot distinguish faces

With AMD do you lose peripheral vision?

No only central vision. So for awhile they can manage.

What is visual impairment?

not being able to see letters on the line 20/50 or below on the eye chart

Infants and Children eyes general facts

Limited vision at birth only see black and white and gray shades

2-3 months able to recognize faces and start tracking

4 months use both eyes and work on depth perception

By age 8 what happens to eye?

They reach adult size

Aging adult pupil size

decreases

presbyopia

Lens loses elasticity, becoming hard and glasslike, which decreases ability to change shape to accommodate for near vision

(RESULTS FROM AGING)

By age 70 transparent fibers of lens begin to thicken and yellow, beginning

Cataracts

visual acuity

sharpness of vision

As you age what happens to visual acuity?

Diminishes

diabetic retinopathy

damage to the retina as a complication of uncontrolled diabetes

What is the leading cause of blindness in aging adults

diabetic retinopathy

(Present 10-15 yrs after diagnosis of DM)

Subjective questions to ask for eyes

Vision difficulty (decreased acuity, blurring, blind spots)

Pain

Strabismus, diplopia

Redness and swelling

Watering, discharge

Past history of ocular problems

Glaucoma

Use of glasses or contacts

Pt-centered care (vision last tested, method of care for contacts or glasses, efforts to protect eyes)

Prednisone medication and eyes

May cause cataracts or increased intraocular pressure

Cigarette smoking is related to

AMD, cataract, diabetic retinopathy, and eye inflammation

Sudden vision loss

emergency go to doctor

List some eye emergencies (all can cause vision loss)

Trauma

Herpes Zoster (shingles to face)

Corneal damage

Sudden distorted pupils

Reasons pupils are pinpoints substance abuse

Benzos, PCP, opioids, tobacco

Reasons for pinpoint pupils prescriptions

Alzheimer's med, antihypertensives, glaucoma eye drops, antipsychotics, some antidepressants

reason for pinpoint pupils diseases

Rheumatic disease, skin disease, GI problems, lung disease, mumps, rubella, neurosyphilis

Horner syndrome is caused by and what can it cause

Caused by stroke or tumor, accompanied by drooping eyelid and inability to sweat on effected side.

Causes pinpoint pupils

Reasons for dilated pupils

Uppers (SSRI, amphetamine, mdma, lsd, cocaine, meth, adderall or Ritalin)

If you have one eye that's pinpoint and one eye that is dilated what could be the problem

Head trauma

Ishihara Color Testing

Test for color blindness

Say the shape or number you see

Enchroma

Color blindness

Snellen eye chart

most commonly used and accurate measure of visual acuity

Snellen eye chart cranial nerve

2

How to conduct a Snellen eye test

20 feet away

Hand person obaque card to shield one eye

Leave contact or glasses on

Read through chart to smallest line possible; encourage trying next smallest also

Abnormal findings snellen eye chart

Hesitancy, squinting, leaning forward, misreading letters

Report pt to eye specialist if vision is poorer than

20/30

If patient cannot read top line from 20 ft away do what

Move them 10 ft away and chart appropriately 10/__

Impaired vision occurs with

Refractive error, opacity in media, or disorders of retina or optic pathway

near vision test

Jaeger chart

Normal score for jaeger chart

14/14

Abnormal finding for near vision test

Presbyopia, decrease in power of accommodation with aging, suggested when person moves card farther away

Confrontation test

a gross measure of peripheral vision

How to conduct confrontation test

2 ft away

You and patient cover eye

Wiggle finger

Directions: upward, downward, temporally, nasally

corneal light reflex

assess the parallel alignment of the eye axes by shining a light toward the person's eyes. direct the person to stare straight ahead as you hold the light about 12 inches away. note the reflection of the light on the corneas, it shoudl be in exactly the same spot on each eye

diagnostic positions test how to conduct

lead the eyes through the six cardinal positions of gaze will elicit any muscle weakness during movement. ask person to hold head steady and follow finger. Move finger from midline to all six positions respectively. progress clockwise in each direction.

diagnostic positions test cranial nerves

3,4,6

Normal findings diagnostics positions test

Parallel tracking of object with both eyes

Failure to follow parallelly indicates

Weakness of extraocular muscle (EOM)

Or dysfunction of cranial nerve

In addition to noting parallel movements note what abnormal finding

Nystagmus, a fine oscillating movement best seen around iris

Nystagmus

"Dancing eye" uncontrolled movement

Mild nystagmus at extreme lateral gaze

Normal finding but at any other position it is not

Nystagmus occurs with disease of

Semicircular canals in ears, paretic eye muscle, MS, or brain lesion

Lastly note the upper eyelid overlap during diagnostic position test

Eyelid should overlap superior iris even during downward movement. If it does not and the white sclera is showing this could be "lid lag" and occurs with hyperthyroidism

Lid lag

A white rim of sclera between lid and iris occurs with hyperthyroidism

Inspect external ocular structures

Eyebrows

Eyelids

Eyeball

Conjunctiva and sclera

Lacrimal apparatus

Cornea and lens

Iris and pupils

Exophthalmos

Protrusion of eye could be hyperthyroidism

Enophthalmos

sunken eyes

Palpebral fissure of Asians

Upward slant

Palpebral fissure in non Asians

Horizontal

Eyelid abnormal findings

Lid lag occurs with hyperthyroidism

Incomplete closure creates risk for corneal damage

Ptosis (drooping of upper lid)

Periorbital edema, lesons

Abnormal findings eyelashes

Ectropion (outward eyelid) and entropion (inward eyelid)

Slight Protrusion of eyeball beyond the Supra orbital ridge is normally seen in

Black people

how to assess conjunctiva and sclera

Pt looks up and you pull eyelids down along bony orbital rim

Do not push against eyeball

Normal findings of eyeballs

Moist and glossy

Normal findings of conjunctiva

Small blood vessels

Clear and normal color of structure below

Lower lids pink

Normal findings sclera

China white

Abnormal findings of sclera

Sclera icterus is a yellowing of sclera indicating jaundice

lacrimal apparatus how to inspect

Pt looks down use thumb to expose under upper lid

If you press on the lacrimal sac and excessive tears come out it could indicate

Blockage

Inspect anterior eyeball structures

cornea, lens, iris, pupil

How to inspect Cornea and lens

Shine a light from the side across the cornea and check for smoothness and clarity

Abnormal findings cornea and lens

Opacities

What is Opacities?

Cloudiness and could indicate a cataract

Normal findings of cornea and lens

Smooth and clarity

Pupils of two different sizes is called

anisocoria

Normal resting pupil size

3-5 mm

How to test for pupillary light reflex CN 3

Darken the room and ask person to gaze into distance (this dilates eyes)

advance light in from side

normal finding is constriction

Direct light reflex

constriction of the same-sided pupil as light

consensual light reflex

simultaneous constriction of the other pupil that does not have the direct light

How to test for accommodation

ask the person to focus on a distant object. This process dilates the pupils. Then have the person shift the gaze to a near object such as your finger held about 7 to 8cm (3inches) from the persons nose.

Normal response for accommodation test

1. pupillary constriction

2. convergence of the axes of the eyes

Record normal responses to all eye tests as PERRLA

pupils equal, round, reactive to light and accommodation

We cannot observe the lens directly but we can observe

the convergence and pupillary constriction

Convergence of eye

Medial movement of the eyes to keep both eyes focusing on an object.

Testing for _______ in infants/children is important because if left untreated it can cause permeant vison damage called ______

strabismus. amblyopia ex anopsia.

Sunken eyes older adult

Aging adults eye may seem sunken bc of atrophy of orbital fat which shows a baggy lid

Ptosis

drooping eyelid (not the same as sunken eyelid this is actual drooping of muscle or nerve damage)

What do we use the ophthalmoscope for

look thru pupils at structure of inner eye called ocular fundus including the optic disc, retinal vessels and Macula

Ectropion

lower lid is loose and rolling out, causes tears to not drain