clinical pract, chapter 6 eyes and ears

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Visual acuity test

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Visual acuity test

  • screening test to detect deficiencies in vision

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Color vision assessment

  • Requires specially prepared colored plates

  • Color blindness: inability to distinguish certain colors

  • Red and green are most common

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Hearing tests

  • use of tuning fork or audiometer

  • Audiometer

  • MA should be alert to signs that indicate the patient might be having difficulty hearing

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  • Audiometer:

  • instrument that emits sound waves at various frequencies

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  • Irrigation:

  • washing a body canal with a flowing solution

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  • Instillation:

  • dropping a liquid into a body cavity

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Layers of the Eye

  • Sclera:

  • Choroid:

  • Lens:

  • Retina:

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  • Sclera:

  • outer layer

  • Composed of tough, white, fibrous connective tissue

  • Front of sclera is modified to form cornea

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  • Cornea

  • : transparent covering over the colored part of the eye (iris)

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  • Choroid

  • middle layer

    • Composed of many blood vessels and is highly pigmented

    • Blood vessels:

    • Pigment:

    • Front part of choroid has specialized structures

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  • Blood vessels

  • nourish the eye

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  • Pigment

  • absorbs stray light rays

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  • Lens:

  • focuses light rays on the retina

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  • Retina

  • inner layer

    • Light rays come to a focus on it

    • Transmitted to brain by optic nerve to be interpreted

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Front part of choroid has specialized structures

  • Ciliary body

  • Suspensory ligaments:

  • Iris:

  • *Pupil

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  • Ciliary body

  • : muscles that control the shape of the lens

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  • Suspensory ligaments

  • suspend the lens in place

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  • Iris:

  • colored part of the eye that controls the size of the pupil

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  • *Pupil:

  • : opening in the eye that permits entrance of light rays

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Chambers of the Eye

  • Anterior chamber:

  • Posterior chamber:

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  • Anterior chamber:

  • Area between the cornea and iris

  • glaucoma

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  • Posterior chamber:

  • Area between the iris and lens

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Substance of the eye

  • Aqueous humor:

  • Vitreous humor:

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  • Aqueous humor:

  • Fills anterior and posterior chambers

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  • Vitreous humor:

  • Transparent jelly-like material

  • Fills eyeball between the lens and retina

  • Function: maintains shape of the eyeball

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Conjunctiva

  • Membrane that lines eyelids and covers front of the eye except for the cornea

  • Conjunctiva covering the sclera: transparent

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  • Conjunctivitis:

  • inflammation of the conjunctiva

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cones

detect blue, green and red

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rods

detect black and white

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special cells

cones and rods connect to neurons and form the optic nerve

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  • glaucoma

increase IO pressure due to failure to properly drain the aqueous humor

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Normal visual acuity:

  • Can see clearly and able to distinguish fine details at a close and long distance

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visual acuity:

  • Acuteness or sharpness of vision

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  • Most common cause of defects in visual acuity

Errors of refraction

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Refraction

bending of the parallel light rays coming into the eye so that they can be focused on the retina

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Error of refraction:

light rays are not being bent properly

  • Are not focused on retina adequately

  • Caused by defect in the shape of the eyeball

  • Can be improved with corrective lenses

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Myopia

(nearsighted):

  • eyeball is too long from front to back

  • Causes light rays to be brought to a focus in front of retina

    • Difficulty seeing objects at a distance

    • May squint and have headache from eyestrain

    • Corrective lenses (eyeglasses, contact lenses) or laser eye surgery can correct the condition

      • Allows light rays to come to a focus on retina

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Hyperopia

(farsighted):

  • eyeball is too short from front to back

  • Causes light rays to be brought to a focus behind the retina

    • Difficulty viewing objects at a reading or working distance

    • May have blurring, headache, and eyestrain while performing close-up tasks

    • Corrective lenses can correct the condition

      • Cause light rays to come to a focus on the retina

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Astigmatism:

  • Causes distorted and blurred vision for both near and far objects

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Normal cornea

  • Round or spherical shape

  • Smooth

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With astigmatism cornea

  • is curved into an oval shape

  • Causes light rays to focus on two different points on the retina (instead of one point)

  • Often occurs with myopia or hyperopia

  • Can be corrected with corrective lenses

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Presbyopia:

  • decrease in elasticity of the lens

  • Usually begins after age 40 years

  • Results in a decreased ability to focus clearly on close objects

  • Can be corrected with corrective lenses (reading glasses)

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Ophthalmologist:

  • physician specializing in the diagnosis and treatment of diseases and disorders of the eye

  • Prescribes ophthalmic and systemic medications

  • Performs eye surgery

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Optometrist:

  • licensed primary healthcare provider who has expertise in measuring visual acuity and prescribing corrective lenses

  • Can diagnose and treat disorders and diseases of the eye

  • Prescribes ophthalmic medications

  • Not a physician: cannot prescribe systemic medications or perform eye surgery

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Optician:

professional who interprets and fills prescription for eyeglasses and contact lenses

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Assessment of Distance Visual Acuity (DVA)

  • Used to diagnose myopia

  • Snellen eye chart most often used

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Types of charts for DVA

  • Letters

  • Capital letter E

  • Pictures of familiar objects

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  • Letters chart

  • in decreasing sizes

    • Used with school-aged children and adults

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  • Capital letter E chart

  • in decreasing sizes (arranged in different directions)

    • Used for preschool children, non-English-speaking people, nonreaders

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  • Pictures of familiar objects chart

  • Used for preschool children

  • Less accurate because some children may be unable to identify objects

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Conducting a Snellen Test

  • Perform the test in a well-lit room free from distractions

  • Performed at a distance of 20 feet

  • Two numbers next to each row of letters

    • Number above the line:

    • Number below the line:

  • Acuity of each eye is measured separately R-->L

  • Eye occluder:

  • Instruct patient to leave eye not being tested open

    • Closing eye: causes squinting of eye being tested

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  • Number above the line:

  • distance at which the test is conducted (20 feet)

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  • Number below the line:

  • distance from which a person with normal visual acuity can read the row of letters

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  • Normal DVA

  • 20/20

  • Patient can read at 20 feet what a person with normal vision acuity can read at 20 feet

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  • DVA: 20/30

  • Smallest line (30) the individual could read at 20 feet

  • People with normal acuity: can read this line at 30 feet

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  • DVA: 20/15

  • Smallest line (15) the individual could read at 20 feet

  • Indicates above-average DVA

  • People with normal acuity: can read at 15 feet

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  • If patient wears eyeglasses or contact lenses on a Snellen test (except reading glasses)

  • Keep them on during the test

  • Record in chart that corrective lenses were worn

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  • Eye occluder

  • held over eye not being tested

    • Patient’s hand should not be used

      • May encourage peaking through fingers, especially in children

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Assessing Distance Visual Acuity in Preschool Children

  • Snellen Big E chart used

  • Explain procedure completely to child

    • Tell child you will be playing a pointing game

    • Do not force child: results would be inaccurate

  • Draw a capital E on an index card

    • Teach child to point in the direction of the open part of the E by turning the card in different directions

    • Phrases to describe open part of E: “fingers” or “legs of table”

    • Allow child to practice

    • Praise child when correct

  • Parent may need to help child hold occluder in place

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Assessment of Near Visual Acuity (NVA)

  • Assesses patient’s ability to read objects close up

    • At a reading or working distance

  • NVA card

  • Patient is asked to read each line or paragraph

  • Observe patient for unusual symptoms

    • Squinting, tilting of head, watering of eyes

      • Indicates patient is having difficulty reading card

  • Patient continues until reaching smallest line that can be read

  • Record results as smallest type patient could read with each eye

    • Recording based on type of test card used

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(NVA)

  • Used to detect hyperopia and presbyopia

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  • NVA card

  • contains different sizes of type

    • Ranging from size of newspaper headline down to very small print

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  • NVA card: forms

  • Printed paragraphs

  • Printed words

  • Pictures

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  • To perform NVA testing

  • Perform test in a well-lit room free of distractions

  • Patient holds card at a distance of 14 to 16 inches

  • Reading glasses should be worn (if patient uses them)

  • Each eye is tested separately

  • Eye occluder held over the eye not being tested

    • Instruct patient to keep covered eye open

      • Closing causes squinting of eye being tested

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Assessment of Color Vision

  • Classification of defects in color vision

    • Congenital defect:

    • Acquired defect:

  • Color vision tests

    • Detect congenital color vision defects

    • Often performed in medical office

  • Basic color vision screening test

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  • Congenital defect

  • most common

    • Inherited (present at birth)

    • Most often affects males

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  • Acquired defect:

  • acquired after birth

    • Eye or brain injury

    • Disease

    • Certain drugs

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  • Basic color vision screening test

  • Ask patient to identify red and green lines on the Snellen chart

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Ishihara Test

  • Detects

    • Total congenital color blindness

    • Red-green color blindness

    • Conduct test in a quiet room

    • Illuminated by natural daylight (if possible)

    • Using bright sunlight: can change shades of color on plates

  • Test consists of 14 color plates

  • Defect in color vision: patient referred to ophthalmologist or optometrist

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  • Ishihara book

  • Series of plates consisting of colored dots

    • Forms a numeral against a background of dots of contrasting colors

  • Patients with normal color vision: read appropriate numeral

  • Patients with defects read dots as

    • Not forming a number at all

    • Forming a different number

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  • First plate

  • can be read correctly by all patients

    • Used to explain test procedure to patient

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  • Plates with winding colored lines

  • For patients unable to identify numbers by name

    • Preschool children

    • Non-English-speaking people

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  • Patient is asked to trace line formed by the colored dots

  • Using a cotton swab or pencil eraser

  • Do not allow patient to use finger

    • Over time: soiled fingers can degrade plates

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  • Test consists of 14 color plates

  • Basic test: plates 1 through 11

  • Further assessment of patients with red-green deficiency: plates 12 through 14

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  • Normal color vision:

  • 10 or more plates read correctly

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  • Color vision deficiency:

  • 7 or fewer plates read correctly

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Eye Irrigation

  • Washing the eye with a flowing solution

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purpose of eye irrigation

  • Cleanse the eye by washing away

    • Foreign particles

      • Ocular discharges

      • Harmful chemicals

  • Relieve inflammation through application of heat

  • Apply an antiseptic solution

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Eye Instillation

  • Dropping of a liquid into the lower conjunctival sac

  • Medications instilled in eye may come in the form of

    • Liquid

    • Ointment

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purpose of eye instillation is

  • Treat eye infections (with medications)

  • Soothe an irritated eye

  • Dilate the pupil

  • Anesthetize the eye during eye examination or treatment

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  • Liquid

  • (ophthalmic drops)

    • Usually dispensed in a flexible plastic container with an attached dropper

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  • Ointment

  • Dispensed in a small metal tube with tip for applying medication

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red and green

most common color blindness

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cornea color

transparent

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sclera outer layer has

no pain receptors

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choroid middle layer color

red

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cataracts surgery

replaces lens

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myopia point of focus

in front of retina

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hyperopia point of focus

behind the retina

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NVA is used to detect

both hyperopia and presbyopia

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Functions of the Ear

  • Hearing

  • Equilibrium

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Structure of the Ear

external

middle

inner

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external ear

auricle

external auditory canal

tympanic membrane

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auricle

pinna

  • Flap of cartilage covered with skin

  • Projects from side of head

  • Receives and collects sound waves and directs them toward the external auditory canal

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middle ear contains

ossicles

eustachian tube

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inner ear

cochlea

semicircular canals

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External auditory canal

  • Extends from the auricle to the tympanic membrane

  • External auditory meatus: opening of the canal

  • Canal is 1 inch long in adults

  • Lined with skin that contains fine hairs, nerve endings, glands

    • Glands secrete cerumen

  • Canal has an S-shaped curve as it leads inward

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  • cerumen

  • lubricates and protects the ear canal

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  • external auditory Canal must be straightened during

  • Otoscopic examination

  • Ear instillation

  • Ear irrigation

  • Aural temperature measurement

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Tympanic membrane

  • Located at the end of the canal

  • Pearly gray semitransparent membrane

  • Receives sound waves causing it to vibrate and produce a frequency of sound waves that are carried further into the middle ear

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