Assessing eyes & ears

Eyelid function

Protect eye and distribute tears

Inner canthus function

Drainage of tears

Conjunctiva description and function

Thin, transparent membrane protecting the eye. Palpebral conjunctiva covers eyelids, bulbar conjunctiva covers anterior eye.

Lacrimal apparatus

Series of glands and ducts forming tear system. Lacrimal glands secrete tears.

Sclera

Dense covering supporting the inner eye

Cornea

Allows for entry of light to eye. Sensitive to pain → corneal reflex

Eye lens

Transparent, encapsulated structure. Reflects light to retina. Bulges to focus close, flattens to focus far.

Choroid layer of eye

Provides nourishment to eye

Rods and cones

Found in the retina. Rods = black and white, dim light. Cones = color.

Visual fields

What a person sees with one eye, divided into 4 quadrants. Some overlap between eyes.

Visual perception

Occurs as light rays strike the retina and change into nerve impulses that are sent to the brain and interpreted.

Visual pathways

Visual information from right half of visual field is conveyed to left side of brain and vice versa.

Pupillary light reflex - direct and indirect

Direct: constriction of pupil at light exposure

Indirect: other eye constricts when eye exposed to light does, even without being directly stimulated

Accommodation

Constriction of pupils and convergence as eyes focus on nearing object.

Seeing halos or rings around lights

Associated with glaucoma

Eye pain/itching

Irritant, allergy, foreign object, infection

Watering, tearing, or discharge from eye

Indicates infection

Snellen chart/E chart

Have pt stand 20 ft from chart and cover one eye. Have pt read each line until they can’t. Note pts behavior during exam like squinting. 20/20 vision is normal.

Test near vision.

Have pt hold Jaeger eye chart or something like a newspaper 14 in from face and have them read it.

Myopia vs presbyopia

Myopia = impaired far vision

Presbyopia = impaired near vision, common in pts 45+

Corneal light reflex test

Hold penlight 12 in from pt face. Shine light towards bridge of nose while pt looks straight ahead. Should see light reflected on the corneas in same spot on both eyes.

Cover test

Cover one eye while focus on distant object. Upon removal of cover to eye, it should remain fixed straight ahead same as uncovered eye. Any difference indicated muscle weakness.

Cardinal fields of gaze

Have pt move eyes through 6 fields of gaze, testing CN II, IV, VI

Nystagmus

Shaking movement of the eye

Normal/abnormal eyelid findings

No redness, swelling or lesions. Drooping indicates neuromuscular damage.

Inspection of bulbar conjunctiva and sclera

White and may have yellow flecks, clear, smooth

Inspection and palpation of lacrimal apparatus

Should have no swelling or tenderness → of present, indicates blockage

Inspection of cornea and lens

Should be transparent

Pupil assessment

PERRLA - pupils are equal, round, reactive to light, with accommodation. Also note size before and after light.

Newborn special considerations for eye assessment

Eyes not fully developed, poor pupillary response, peripheral vision intact, central vision not intact, farsighted, don’t see color until ~8 months

Children special considerations for eye assessment

Achieve full visual acuity by 6-7

Older adults special considerations for eye assessment

Skin around eyes becomes thin. Assess for cataracts and muscular degeneration. Presbyopia common.

Pseudostrabismus

Pupils appear to not be straight. Common in young children and will likely resolve. May be associated with prominent epicanthic folds.

Strabismus - esotropia

Eye turns inward toward bridge of nose

Strabismus - exotropia

Eye turns outward

Phoria

Fails cover test. Weaker eye moves when covered.

Paralytic strabismus

Eye movements impaired by interrupted nerve innervation

Ptosis

Drooping eye, due to oculomotor nerve damage or congenital

Ectropion

Lower lid turned outward. Causes increased risk of infection and dryness.

Conjunctivitis

Inflammation of conjunctiva. Called “pink eye”.

Stye

Red, painful lump near the edge of eyelid due to clogged gland

Entropion

Lower lid is turned inward, causing eyelashes to irritate or injure cornea.

Exophthalmos

Protruding of eyes. Associated with Cushing’s and hyperthyroidism

Chalazion

Swelling of eyelid

Subconjunctival hemorrhage

Red patch of blood in eye. Usually harmless and resolves self. Can be from sneezing, aggressive vomiting, etc.

Scleral jaundice

Yellowing of eye

Cataracts

Clouding of lens of eye, leading cause of preventable blindness, common in older adults. Impossible to perform pupil assessment on affected eye - document.

Miosis

Pinpoint pupils. May be caused by brain damage or narcotics. Can’t do pupil assessment as pupils are already constricted all the way.

Anisocoria

Unequal pupils. Can be normal for the pt or d/t tumor or nerve paralysis.

Mydriasis

Dilated, fixed pupils. Don’t constrict upon pupil assessment. If pt has had anesthesia drugs, this may be normal. If the pt has not, these are “blown pupils” and are BAD.

Cerumen

Ear wax. Keeps tympanic membrane soft.

Auditory ossicles

Small bones that transmit sound waves

Eustachian tube

Connects middle ear to nasopharynx, helps equalize air pressure.

Inner ear

Fluid filled, contains cochlea (sensory organ for hearing) and CN VIII

Conductive hearing

When something blocks/impairs soundwaves causing muffled/faint sounds. Issue with transmission of sound waves through external and middle ear.

Sensorineural hearing

Soundwaves occur but can’t be translated to sound by brain. Issue with transmission of sound waves through inner ear.

Causes for hearing loss at or before birth

Prematurity, hypoxia, mother’s infection, mother’s use of certain drugs, jaundice

Causes of hearing loss after birth

Infectious disease, ototoxic drugs, head/ear injury, wax, excessive noise, age.

Signs of hearing loss during interview

Asking to repeat questions, inappropriate answers to questions, no response to questions.

Inspection of ears

Size, shape, and position should be equal bilaterally. Skin should be smooth and painless with no lesions, discoloration, or discharge.

Newborn special considerations for ear assessment

React to loud noises with startle reflex. Auditory canal curves upward and is short and straight (increased risk for ear infection).

Children and adolescents special considerations for ear assessment

Auditory canal curves upward and is short and straight (increased risk for ear infection) until inner ear matures

Older adults special considerations for ear assessment

Presbycusis (hearing loss, common in pts 50+)

Otitis externa

“Swimmer’s ear”, pain when pulling on earlobe + yellow discharge

Polyp

Growth in inner ear

Tophi

Uric acid crystal build up in outer ear causing mass on outer ear

Acute otitis media

Ear infection. Ear drum is bulging red. Pt will experience pain and fever.

Serous otitis media

Fluid in ear, may bubble

Blue/dark red tympanic membrane

Blood in area, from trauma

Scarred tympanic membrane

Recurrent, frequent ear infections leading to white spots of scar tissue.

Perforated tympanic membrane

Hole in the tympanic membrane from too much pressure

Retracted tympanic membrane

Eardrum pulled inward, due to pressure or dysfunction