UNIT 6: cephalocaudal (EYES)

orbicularis oculi

• muscle that allows you to close your eyes, squint, blink and wink

• the lens bulges to focus on close objects and flattens to focus on far objects, possible due to the refractive ability of the lens.

1. snellen or snellen E chart

2. hand-held snellen card or near vision screener (eg Rosenbaum)

3. ishihara plates

4. penlight, opaque cards, ophthalmoscope

5. cotton pedget, disposable gloves

equipment for eye and vision assessment:

1. eyeballs

2. eyebrows

3. eyelids

4. bulbar conjunctivae & sclerae

5. palpebral conjunctivae

6. lacrimal apparatus

7. cornea & lens

8. iris

9. pupils

10. corneal light reflex

11. cover test

12. cardinal gaze

13. color vision

14. visual acuity (distant vision)

15. visual acuity (near vision)

16. peripheral vision

what to assess for eye and vision assessment:

note symmetry of eyeballs & for any protrusion or sinking

what to note for eyeball symmetry

symmetrically aligned in sockets s̅ protruding or sinking

sample documentation for eyeball symmetry

1. exophthalmos

2. sunken eyeballs

abnormal findings for eyeball symmetry:

exophthalmos

(abnormal findings for eyeball symmetry)

• bulging eyes

• could be a sign of thyroid gland problems; it can be treated but it needs to be checked quickly as your vision can be affected

sunken eyeballs

(abnormal findings for eyeball symmetry)

• “eyebags” or enopthalmos, sunk in your face. Family history, dehydration and lack of sleep.

• usual to severely dehydrated px

note color, symmetry and distribution

what to note for eyebrows

same c̅ hair color; symmetric; evenly distributed

sample documentation for eyebrows

note position and appearance of eyelids and eyelashes, color changes and blinking

what to note for eyelids

let patient open and close eyes

how to assess the eyelids

• lashes short, evenly spaced and curled outward;

• lower lid margins at the bottom edge of iris;

• upper lid margins cover approximately 2 mm of iris;

• lid margins pink and moist without swelling or lesions;

• upper and lower lids close easily and meet with each other

sample documentation for eyelids

1. ectropion

2. entropion

3. chalazion

4. hordeolum (stye)

5. blepharitis

6. ptosis

7. lagophthalmos

8. eye trauma

abnormal findings for eyelids:

ectropion

(abnormal findings for eyelids)

• where the lower eyelids droops away from the eye and turns outward

• everted lower eyelid

entropion

(abnormal findings for eyelids)

• an inward turning of the eyelid margin and appendages such that the pilosebaceous unit and mucocutaneous junction are directed posteriorly towards the cornea and ocular surface.

chalazion

(abnormal findings for eyelids)

• a red bump on your eyelid (upper lid)

hordeolum (stye)

(abnormal findings for eyelids)

• an infection of an oil gland at the edge of the eyelid. (lower lid)

blepharitis

(abnormal findings for eyelids)

• a common eye condition that makes your eyelids red, swollen, irritated, and itchy

ptosis

(abnormal findings for eyelids)

• drooping of the upper eyelids

lagophthalmos

(abnormal findings for eyelids)

• incomplete or abnormal closure of the eyelids

eye trauma

(abnormal findings for eyelids)

• bruises, punctures, and scratches. They can result from accidents, exposure to chemicals, or foreign objects in the eye.

note for clarity, color & texture

what to note for bulbar conjunctivae

let patient look above, using object

how to assess bulbar conjunctivae

clear, moist, smooth and c̅ tiny vessels visible; sclerae are white

sample documentation for bulbar conjunctivae

1. conjunctivitis

2. pinguecula

3. subconjunctival hemorrhage

4. episcleritis

abnormal findings for bulbar conjunctivae:

conjunctivitis

(abnormal findings for bulbar conjunctivae)

• pink eye or piskat

pinguecula

(abnormal findings for bulbar conjunctivae)

• common type of conjunctival stromal degeneration in the eye. It appears as an elevated yellow-white plaque in their bulbar conjunctiva near the limbus

subconjunctival hemorrhage

(abnormal findings for bulbar conjunctivae)

• occurs when a tiny blood vessel breaks just underneath the clear surface of your eye (conjunctiva); hypertension (HPN)

episcleritis

(abnormal findings for bulbar conjunctivae)

• common, benign, self-limited cause of red eye, due to inflammation of the episcleral tissue

note for swelling, lesions, foreign bodies, trauma or discharges) / membranous membrane

what to note for palpebral conjunctivae

pull lower palpebrae down and let patient look above; use ear buds fold upper palpebrae with eyelash and pull up look down

how to assess palpebral conjunctivae

1. pallor

abnormal findings for palpebral conjunctivae:

pallor

(abnormal findings for palpebral conjunctivae)

• pale palpebral conjunctivae;

• signifies anemia, low blood count, low blood pressure

note appearance

what to note for cornea and lens

transparent, moist, and s̅ opacities; lens are clear

sample documentation for cornea and lens

1. arcus senilis

normal variation for cornea and lens:

arcus senilis

(normal variation for cornea and lens)

• depositing of phospholipids and cholesterol in peripheral cornea

• whitish ring surrounding the cornea around the iris; normal in aging, young high cholesterol level or lipids

1. corneal scar

2. pterygium

3. cataract

abnormal findings for cornea and lens:

corneal scar

(abnormal findings for cornea and lens)

• opacity of the cornea

pterygium

(abnormal findings for cornea and lens)

• pinkish triangular tissue growth in cornea treated with scraping

• bulbar conjunctiva moves toward the cornea

cataract

(abnormal findings for cornea and lens)

• opacity of the lens, blurring of vision

note shape and color

what to note for iris

round; uniform color

sample documentation for iris

1. hyphema

2. hypopyon

abnormal findings for iris:

hyphema

(abnormal findings for iris)

• collection of blood inside anterior chamber of eye (space between cornea and iris)

• pooling or collection of blood inside the anterior chamber of the eye (the space between the cornea and the iris); trauma

hypopyon

(abnormal findings for iris)

• condition involving inflammatory cells in anterior chamber of eyes

• the accumulation of white blood cells that form a whitish layer of fluid in the lower portion of the eye’s anterior chamber (front part); infection of internal eye.

note shape, size, direct and consensual reaction to light and accommodation; 3 or 4 is normal

what to note for pupil:

1. P-E-R-L-A (Pupils Equally Round, Reactive to Light Accommodation)

2. testing pupillary reaction to light (direct and consensual)

3. testing accommodation of pupils

3 procedures for assessing the pupil:

in checking the pupils - the pupils will constrict when there is light, the pupil will dilate when it is dark

(3 procedures for assessing the pupil)

• testing pupillary reaction to light (direct and consensual)

equally round about 3 mm in size; illuminated pupil constricts and pupil opposite the one illuminated constricts simultaneously; pupils converge and constricts as object moves in toward nose; pupil responses uniform

(3 procedures for assessing the pupil)

• sample documentation for testing accommodation of pupils

1. miosis

2. anisocoria

3. mydriasis

abnormal findings for pupil:

miosis

(abnormal findings for pupil)

• small or constricted and fixed pupils; shrinking of pupils

• drug addicts

anisocoria

(abnormal findings for pupil)

• pupil of one eye differs in size from the other

• brain lesions.

mydriasis

(abnormal findings for pupil)

• unusual dilation or widening of pupil

• when the black center of your eyes are larger than normal (dilated pupils); high on drugs, coffee, or stimulants

note for swelling, redness, drainage & tenderness); gland and nasolacrimal duct

what to note for lacrimal apparatus

1. palpating lacrimal glands

2. palpating nasolacrimal duct

procedures in assessing lacrimal apparatus:

puncta visible s̅ without swelling or redness; no tenderness or drainage noted; minimal lacrimation

sample documentation for lacrimal apparatus

1. dacryocystitis

abnormal findings for lacrimal apparatus:

dacryocystitis

(abnormal findings for lacrimal apparatus)

• characterized as an inflammatory state of the nasolacrimal sac/ lacrimal apparatus

• infection in lacrimal duct due to blockage

1. corneal light reflex test

2. cover test

3. cardinal gaze

tests used in the assessment of extraocular muscle function inspection:

12 inches away from the client on the bridge of nose

procedure for the corneal light reflex

reflections of light noted at same location on both eyes.

sample documentation for corneal light reflex

cover other eye and remove, repeat with other eye

procedure for the cover test

uncovered eye remains fixed; covered eye does not move as cover is removed

sample documentation for cover test

let client stare at object in 6-9 directions. Laevoeversion, Laevoelevation, and Laevodepression may not be necessary. But the other 6 are required

procedure for the cardinal gaze

both eyes move in a smooth, coordinated manner in all 6 directions

sample documentation for cardinal gaze

1. strabismus (tropia)

2. esotropia

3. exotropia

4. nystagmus

abnormal findings for extraocular muscle function:

strabismus (tropia)

(abnormal findings for extraocular muscle function)

• a disorder in which both eyes do not line up in the same direction; crossed eye.

• constant malalignment of the eyes

esotropia

(abnormal findings for extraocular muscle function)

• an eye misalignment in which one eye is deviated inwards, or nasally

exotropia

(abnormal findings for extraocular muscle function)

• a type of eye misalignment , where one eye deviates outwards

nystagmus

(abnormal findings for extraocular muscle function)

• a vision condition in which the eye makes repetitive, uncontrolled movements; inner ear problem

six screening ishihara plates; write on the table the corresponding number seen on each plate; if a number could not determined, indicate “spots”

procedure in assessing color vision

able to identify primary colors in snellen chart & in exam room; identifies all six screening ishihara plates correctly

sample documentation for color vision

interpretation of ishihara test (sample)

snellen chart / snellen e-chart away 20 feet or 6 meters

procedure in assessing visual acuity: distant vision

20/20 OD & OS s̅ hesitation, frowning or squinting

sample documentation for visual acuity: distant vision

1. astigmatism

2. myopia

3. amblyopia

abnormal findings for visual acuity: distant vision:

astigmatism

(abnormal findings for visual acuity: distant vision)

• happens when your cornea (the clear front layer of your eye) or lens (an inner part of your eye that helps the eye focus) has a different shape than normal; irregular cornea

myopia

(abnormal findings for visual acuity: distant vision)

• a common vision condition in which near objects appear clear, but objects farther away look blurry (nearsighted)

amblyopia

(abnormal findings for visual acuity: distant vision)

• also called lazy eye. a type of poor vision that usually happens in just 1 eye but less common in both eyes; legally blind. The lazy eye cannot see

cover other eye and read rosenbaum 14 inches away

procedure in assessing visual acuity: near vision

pocket snellen chart, rosebaum card, jaeger test card

variations used in assessing visual acuity: near vision

reads print at 14 inches s̅ difficulty

sample documentation for visual acuity: near vision

1. hyperopia

2. presbyopia

abnormal findings for visual acuity: near vision:

hyperopia

(abnormal findings for visual acuity: near vision)

• far sighted

presbyopia

(abnormal findings for visual acuity: near vision)

• aging

cover other eye and let client signal if object can be seen in their peripheral vision

procedure in assessing peripheral vision (confrontation test)

client sees examiner’s finger at the same time the examiner sees it (visual fields full by confrontation)

sample documentation for peripheral vision (confrontation test)