Unit 5A.5: EYES Assessment | Eyes, Ears, Nose & Sinuses, Mouth & Pharynx, Neck

Credit to original flashcards made by @maledine

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. Position and alignment of eyeball in eye socket

2. Inspect eyelids and eyelashes

3. Assess ability of eyelids to close

4. Note position of eyelids compared to eyeballs

5. Observe redness, swelling, discharge, or lesions

6. Inspect bulbar conjunctiva and sclera

7. Inspect palpebral conjunctiva

8. Inspect lacrimal apparatus

9. Palpate lacrimal apparatus

10. Inspect cornea and lens

11. Inspect iris and pupil

12. Pupillary reaction to light

13. Accommodation of pupils

14. Corneal light reflex test

15. Cover test

16. Positions tes/Cardinal gaze test

17. Color vision

18. Distant visual acuity

19. Near visual acuity

20. Gross peripheral vision

20 Steps for the Eye Assessment

1. Position and alignment of the eyeball in the eye socket

First Step of the Eye Assessment

Eyeballs are symmetrically aligned in sockets s̅ protruding or sinking

Normal sample documentation for 1. Position and alignment of the eyeball in the eye socket

1. Difference of more than 2 cm

2. Exophthalmos

3. Sunken eyeballs

Abnormal findings for 1. Position and alignment of the eyeball in the eye socket

2 cm

Abnormal findings for 1. Position and alignment of the eyeball in the eye socket

• A difference in distance greater than ___ is abnormal

Exophthalmos

Abnormal findings for 1. Position and alignment of the eyeball in the eye socket

• 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

• Protrusion of eyeballs accompanied by retracted eyelid margins

• Characteristic of Grave's’ disease (type of hyperthyroidism)

Sunken Eyeballs/Enopthalmos

Abnormal findings for 1. Position and alignment of the eyeball in the eye socket

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

• usual to severely dehydrated px

• Seen with severe dehydration or chronic wasting illness

1. Ptosis

2. Ectoprion

3. Conjunctivitis

4. Exophthalmos

5. Chalazion

6. Hordeolum (Stye)

7. Entropion

8. Blepharitis

9. Diffuse Episcleritis

Abnormalities of the External Eye

Ptosis

Abnormalities of the External Eye

• Drooping eye

Ectropion

Abnormalities of the External Eye

• Outwardly turned lower lid

Conjunctivitis

Abnormalities of the External Eye

• Generalized inflammation of the conjunctiva

• Commonly known as pink eye

Exophthalmos

Abnormalities of the External Eye

• Protruding eyeballs and retracted eyelids

Chalazion

Abnormalities of the External Eye

• Infected meibomian gland

Hordeolum

Abnormalities of the External Eye

• Stye

Entropion

Abnormalities of the External Eye

• Inwardly turned lower lid

Blepharitis

Abnormalities of the External Eye

• Staphylococcal infection of the eyelid

Diffuse Episcleritis

Abnormalities of the External Eye

• Inflammation of the sclera

2. Inspect Eyelids & Eyelashes

Second Step of the Eye Assessment

• Upper lid margin should be between the upper margin of the iris and upper margin of the pupil

• Lower lid margin rests on the lower border of the iris. No white sclera is seen above or below the iris. Palpebral fissures may be horizontal.

Normal documentation for 2. Inspect Eyelids & Eyelashes

Width & position of palpebral fissures

What to note in 2. Inspect Eyelids & Eyelashes

1. Ptosis

2. Exophthalmos

Abnormal findings of 2. Inspect Eyelids & Eyelashes

Ptosis

Abnormal findings of 2. Inspect Eyelids & Eyelashes

• Drooping of the upper lid

• Attributed to oculomotor nerve damage, myasthenia gravis, weakened muscle or tissue, or a congenital disorder

Exophthalmos

Abnormal findings of 2. Inspect Eyelids & Eyelashes

• Retracted lid margins

• Viewing of sclera when eyes are open

• Suggest hyperthyroidism

3. Assess ability of eyelids to close

Third Step of Eye Assessment

Upper and lower lids close easily and meet completely when closed.

Normal finding for 3. Assess Ability of Eyelids to Close

Failure of lids to close completely puts client at risk for corneal damage

Abnormal finding for 3. Assess Ability of Eyelids to Close

4. Position of the eyelids in comparison with the eyeballs

Fourth Step of Eye Assessment

• Lower eyelid is upright with no inward or outward turning

• Eyelashes are evenly distributed and curve outward along the lid margins

• Xanthelasma

Normal Findings in 4. Position of the eyelids in comparison with the eyeballs

Xanthelasma

One of the normal findings in 4. Position of the eyelids in comparison with the eyeballs

• Raised yellow plaques located most often near the inner canthus

• Normal variation associated with increasing age and high lipid levels

1. Entropion

2. Ectropion

Abnormal Findings in 4. Position of the eyelids in comparison with the eyeballs

Entropion

Abnormal Findings in 4. Position of the eyelids in comparison with the eyeballs

• Inverted lower lid

• May cause pain and injure the cornea as the eyelash brushes against the conjunctiva and cornea

Ectropion

Abnormal Findings in 4. Position of the eyelids in comparison with the eyeballs

• Everted lower eyelid

• Results in exposure and drying of the conjunctiva

5. Redness, swelling, discharge, or lesions

Fifth Step of Eye Assessment

Skin on both eyelids is without redness, swelling, or lesions

Normal Finding for 5. Redness, swelling, discharge, or lesions

1. Seborrhea or Blepharitis

2. Hordeolum (Stye)

3. Chalazion

Abnormal Findings for 5. Redness, swelling, discharge, or lesions

Seborrhea or Blepharitis

Abnormal Findings for 5. Redness, swelling, discharge, or lesions

• Redness and crusting along the lid margins

• Infection caused by Staphylococcus Aureus

Hordeolum (Stye)

Abnormal Findings for 5. Redness, swelling, discharge, or lesions

• Hair follicle infection, causes local redness, swelling, and pain

Chalazion

Abnormal Findings for 5. Redness, swelling, discharge, or lesions

• Infection of the meibomian gland (located in the eyelid)

• May produce extreme swelling of the lid, moderate redness, but minimal pain

6. Inspect bulbar conjunctiva and sclera

Sixth Step for Eye Assessment

• Bulbar conjunctiva is clear, moist and smooth

• Sclera is white

• Pinguecula

Normal Findings for 6. Inspect bulbar conjunctiva and sclera

Pinguecula

One of the Normal Findings for 6. Inspect bulbar conjunctiva and sclera

• Yellowish nodules on the bulbar conjunctiva

• Harmless nodules common in older clients

• Appear first on the medial side of the iris and then on the lateral side

1. Conjunctivitis

2. Episcleritis

Abnormal Findings of 6. Inspect bulbar conjunctiva and sclera

7. Inspect palpebral conjunctiva

Seventh Step for Eye Assessment

Lower and upper palpebral conjunctivae are clear and free of swelling or lesions

Normal Finding for 7. Inspect palpebral conjunctiva

1. Cyanosis

2. Foreign body or lesion

Abnormal Findings for 7. Inspect palpebral conjunctiva

Cyanosis

Abnormal Finding for 7. Inspect palpebral conjunctiva

• Heart or lung disorder

8. Inspect lacrimal apparatus

Eighth Step of Eye Assessment

1. Lacrimal Glands

2. Puncta

What is assessed in 8. Inspect lacrimal apparatus?

• No swelling or redness should appear over areas of the lacrimal gland

• Puncta is visible without swelling or redness and is turned slightly toward the eye

Normal Finding for 8. Inspect lacrimal apparatus

1. Swelling of lacrimal gland

2. Redness or swelling around puncta

3. Excessive tearing

Abnormal Findings for 8. Inspect lacrimal apparatus

Swelling of the lacrimal gland

Abnormal Finding for 8. Inspect lacrimal apparatus

• May be visible in the lateral aspect of the upper eyelid

• Caused by blockage, infection, or an inflammatory condition

Redness or swelling around the puncta

Abnormal Finding for 8. Inspect lacrimal apparatus

• Indicate infectious or inflammatory condition

Excessive tearing

Abnormal Finding for 8. Inspect lacrimal apparatus

• Indicate nasolacrimal sac obstruction

9. Palpate the lacrimal apparatus

Ninth Step of the Eye Assessment

No drainage should be noted from the puncta when palpating the nasolacrimal duct

Normal finding for 9. Palpate the lacrimal apparatus

Expressed drainage from the puncta on palpation occurs with duct blockage

Abnormal finding for 9. Palpate the lacrimal apparatus

10. Inspect the cornea and lens

Tenth Step of the Eye Assessment

1. Shine a light side of the eye for an oblique view

2. Look through the pupil to inspect the lens

How do you 10. Inspect the cornea and lens?

• Cornea is transparent, with no opacities

• Oblique view shows a smooth and overall moist surface

• Lens is free of opacities

• Areus senilis

Normal Findings for 10. Inspect the cornea and lens

Areus Senilis

One of the Normal Findings for 10. Inspect the cornea and lens

• Normal condition in older clients

• White arc around the limbus

• Has no effect on vision

1. Roughness or dryness of cornea

2. Cataracts

Abnormal Finding for 10. Inspect the cornea and lens

Roughness or dryness on cornea

Abnormal Finding for 10. Inspect the cornea and lens

• Often associated with injury or allergic responses

Cataracts

Abnormal Finding for 10. Inspect the cornea and lens

• Opacities of the lens

1. Corneal Scar

2. Early Pterygium

3. Keratitis

4. Corneal Ulcer

5. Keratoconus

6. Corneal Dystrophies

6 Corneal Abnormalities

Corneal Scar

One of the 6 Corneal Abnormalities

• Appears grayish white

• Usually due to an old injury or inflammation

Early Pterygium

One of the 6 Corneal Abnormalities

• Thickening of the bulbar conjunctiva that extends across the nasal side

Keratitis

One of the 6 Corneal Abnormalities

• Inflammation of the cornea, which can be infectious (bacterial, viral, fungal) or non-infectious (due to trauma, dry eyes, or improper use of contact lenses)

• Accompanied by eye redness, pain, decreased vision, discharge, and photophobia

Corneal Ulcer

One of the 6 Corneal Abnormalities

• An open sore on the cornea, often resulting from untreated keratitis or corneal abrasions

• Can lead to permanent scarring and vision loss if not promptly treated

Keratoconus

One of the 6 Corneal Abnormalities

• A progressive, degenerative disorder where the cornea thins and bulges into a cone shape, leading to distorted vision

Corneal Dystrophies

One of the 6 Corneal Abnormalities

• Group of inherited disorders that cause abnormal deposits or growths in the corneal tissue

• Examples include Fuchs’ dystrophy and lattice dystrophy

1. Nuclear Cataract

2. Peripheral Cataract

3. Ectopia Lentis

4. Spherophakia

4 Lens Abnormalities

Nuclear Cataract

One of the 4 Lens Abnormalities

• Appear gray when seen with a flashlight

• Appear as a black spot against the red reflex when seen through an opthalmoscope

Peripheral Cataract

One of the 4 Lens Abnormalities

• Looks like gray spokes that point inward when seen with a flashlight

• Look like black spokes that point inward against the red reflex when seen through an opthalmoscope

Ectopia Lentis

One of the 4 Lens Abnormalities

• Condition where the lens becomes displaced from its normal position due to trauma, genetic disorders (like Marfan syndrome), or conditions like homocystinuria

Spherophakia

One of the 4 Lens Abnormalities

• Rare congenital lens abnormality where the lens is abnormally small and spherical, leading to refractive errors susch as myopia or lens dislocation

11. Inspect iris and pupil

Eleventh Step of Eye Assessment

1. Inpect shape and color of iris and size and shape of pupil

2. If pupil is larger, smaller, or different sizes, measure pupils against a gauge

How to conduct 11. Inspect iris and pupil?

• Iris is round, flat, and evenly colored

• Pupil is round with a regular border, and is centered in the iris

• Pupils are normally equal in size (3-5 mm)

Normal finding for 11. Inspect iris and pupil

Inequality in pupil size less than 0.5 mm

Normal variation for 11. Inspect iris and pupil

1. Irregularly shaped irises

2. Miosis

3. Mydriasis

4. Anisocoria

4 Abnormal Findings for 11. Inspect iris and pupil

Irregularly Shaped Iris

4 Abnormal Findings for 11. Inspect iris and pupil

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

Miosis

4 Abnormal Findings for 11. Inspect iris and pupil

• Aka pinpoint pupils

• Characterized by constricted and fixed pupils

• Possibly a result of narcotic drugs or brain damage

Anisocoria

4 Abnormal Findings for 11. Inspect iris and pupil

• Pupils of unequal size

• If greater in bright light compared with dim light, the caused may be trauma, tonic pupil (caused by impaired parasympathetic nerve supply to iris), and oculomotor nerve paralysis

• If greater in dim light compared with bright light, the cause may be Horner’s syndrome (caused by paralysis of the cervical sympathetic nerves and characterized by ptosis, sunken eyeball, flushing of the affected side off the face, and narrowing of the palpebral fissure)

Mydriasis

4 Abnormal Findings for 11. Inspect iris and pupil

• Dilated and fixed pupils, typically resulting from CNS injury, circulatory collapse, or deep anesthesia

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

• 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.

1. P-E-R-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

12. Pupillary reaction to light

Twelfth Step of Eye Assessment

1. Darken the room and ask client to focus on a distant object

2. Shine a light obliquely into one eye and observe the pupillary reaction

How to test 12. Pupillary reaction to light?

Left Eye (Oculus Sinister)

3 - Pupil’s eye at rest

2 - Constricted size

How to interpret result of O.S. 3/2 in 12. Pupillary reaction to light?

Constriction of the pupils

Normal Finding for 12. Pupillary reaction to light

1. Monocular Blindness

2. Both pupils constrict

Abnormal Findings for 12. Pupillary reaction to light

Monocular Blindness

Abnormal Findings for 12. Pupillary reaction to light

• Light directed to the blind eye results in no response in either pupil

13. Accommodation of pupils

Thirteenth Step of the Eye Assessment

1. Hold finger 12-15 in from client

2. Ask client to focus on finger and to remain focused on it as it is moved closer

How to test 13. Accommodation of pupils?

Constriction of the pupils and convergence of the eyes when focusing on a near object (accommodation and convergence)

Normal finding for 13. Accommodation of pupils