Nurs 5220: Eyes

The eye A&P

-transmit visual stimuli to the brain for interpretation

-occupies orbital cavity/anterior aspect exposed

-attached by four rectus muscles/two oblique muscles

-innervated by CN III, IV, and VI

-connected to brain by CN II

HPI

-eyelids: recurrent hordeola, ptosis

-vision correction

-vision difficulties: color vision, halos, floaters, diplopia

-cataracts

-pain

-secretions

-medications

PMI

-trauma

-eye surgery

-chronic illness that affect vision (hypertension, diabetes, glaucoma)

Family history

-diabetes

-retinal detachment

-nearsightedness

-farsightedness

-strabismus (lack of coordination of EOM)

-amblyopia (loss of vision d/y lazy eye)

-retinoblastoma

-glaucoma

-macular degeneration

-retinitis pigmentosa (loss of night vision)

-color blindness

-cataract formation

Personal and social history

-employment exposure

-activities

-allergies

-corrective lenses

-protective eyewear

Testing CNII optic nerve

-function is tested via visual acuity

-also, via peripheral vision

Visual acuity

-always start with this

-tips: wear corrective lenses, snellen 20 ft, Rosenbaum 14 inches, OD(right eye) ,OS (left eye), OU (both eyes), read left to right then left to right, age, culturally appropriate

Testing peripheral vision

Confirmation test

-comparing you vision to your patients

-recorded in degrees from line of vision

-most suggesting-colored wiggling object

-eye to eye level is most important

Corneal light reflex

-light shone on bridge of nose

-Corneal reflections should be symmetrical

-asymmetry suggests that extraocular muscles are not intact

Fields of gaze

Nerve muscle weakness

-causes divergent gaze

External exam

-eyelid external covering

-conjunctiva clear lining

-lacrimal gland (provides lubrication)

-eye muscles (discussed with cranial nerves)

-bony skull orbit- container

Hordeolum

Red painful lump near edge of eyelid may look like pimple or boil

Sty

Conjunctivitis

Allergic: clear watery discharge, itching, mild redness, swollen eyelids

Bacterial: minimal pain, moderate-profound redness, yellow/green discharge

Viral: red burning eyes with watery discharge, may be unilateral or bilateral

Irritant: chemical, foreign body, or pollutants

Orbital fracture

One or more of the bones around the eye break

Symptoms: blurry vision, double vision, swelling, bruising, numbness, or blood in white part of the eye, might have pain with moving eye

Periorbital cellulitis

-involves skin of eyelid to bone of the eye

-very painful, usually swelling is involved

-need antibiotics

Internal structures of the eye

-sclera

-cornea

-iris

-lens

-retina

Sclera

-white, outer coating of the eye

-from the Greek meaning hard

-covering is quite tough

-should remain white

-blue: numerous conditions including Marian’s, turners, minocycline exposure

-yellow: (icterus) jaundice, build up of bilirubin in blood-liver dz

Cultural variation

Muddy sclera

Confirm by asking patient looking up and examine it, should be white

Sclera icterus

Neonatal jaundice

Liver disease

Pupillary reactions

-dim the lights, especially for neonates

-pt looks into the distance

-responses are: direct (same eye) or consensual (opposite eye)

Anisocoria

Unequal pupils

About 1/5 of the population has this

To be normal: no more than 1 mm difference

-Pearl: if acute in patient over 50m consider temporal arteritis

Cornea

-clear

-covers front of the eye

-must be transparent to correctly refract light

-contains thousands of tiny nerve endings (that’s why it hurts!)

-astigmatism is more common problem- an abnormal shape causes blurring

-wood lamp evaluation

Iris

-divides anterior and posterior chambers

-color is determined by melanin deposits

-muscle regulates pupil size

-melanoma: is this acute? (Pigmentation)

Lens

-transparent in younger patients

-provides for accommodation-adjustment from far to near

-presbyopia: stiffening of lens after 40

-cataracts: clumped proteins usually due to aging

Retina

-converts images to electrical impulses which travel to the brain via the optic nerve

-allows direct exam of CNS via the retina optic nerve

-should be reddened in appearance due to vascularity

Fundoscopic exam

-allows direct exam of vessels

-allows direct exam of CNS via the retina

TIPS:

-right eye to right eye

-dark room

-you are going to get close

-lighter eyes typically easier

-glasses off if you are nearsighted

-have patients stare at a spot on the wall

-move in towards ptient’s eye, following the red reflex

-find a blood vessel and follow it to the optic disc

-move from the disc to try to visualize macula

Red reflex

-darkened room

-1 foot away from eye

-initial step in fundoscopy

-included in all well child exams

Retinoblastoma

Eye cancer that begins in back of eye (retina)

-abnormal red light reflex, will be white

More common in infants and kids

Pediatric eye exam

-infants 20/200

-red reflex from birth on up

-around 6, attains 20/20

-blocked tear ducts

-blepharitis

-conjunctivitis

-vision screening

-cover/uncover test

Blepharitis

Infection of the eyelid affects the eye lashes

-commonly curs when tiny oil glands become inflamed

Eye exam during pregnancy

-corneal edema may cause discomfort

-and inability to wear contact lenses

-hormones can lead to dryness and sensation of grittiness

-Scotoma (blind spot) is a sign of pre-eclampsia

Eye exam in the elder

-aging

-macular degeneration

-vascular disease

-loss of dexterity and eye medications

-acrus senility: should not be seen under 40, check for hyperlipidemia

Macular degeneration

Yellow/white deposits on retina

Drussen spots

Loss of central vision

Heath promotion

-sports protection

-Sun protection

-Correcting lenses

-Screening