Assessing Eyes

Objective 1: Explain the structure and functions of the eyes, including the concept of visual fields.

Slides 3–8

External structures of the eye

Internal structures

The lecture divides the eye into the following groups:

Eye chambers

• Anterior chamber: Between the cornea and iris.

• Posterior chamber: Between the iris and lens.

Vision and visual perception

Visual perception occurs through the following sequence:

Light rays strike the retina

Light is converted into nerve impulses

Impulses travel through the optic nerve

Brain interprets visual information

Visual fields

Definition: What a person sees with one eye.

Each visual field is divided into four quadrants.

Visual pathways

Slide 7 includes a diagram showing visual field defects associated with lesions along the visual pathway.

Visual reflexes

Pupillary light reflex

• Direct response

• Indirect (consensual) response

Accommodation

- Allows the eyes to focus on near objects.

The lecture introduces accommodation but does not specify the expected observable changes.

Key takeaway: Know the major eye structures, the pathway of visual information, the four visual-field quadrants, and the difference between direct and indirect pupillary responses.

Objective 2: Conduct an interview with a client to obtain a comprehensive eye and vision history.

Slides 9–12

Importance of subjective assessment

• Vision changes may develop gradually and go unrecognized.

• Visual impairment ranges from reduced visual acuity to total blindness.

• Personal and family history help identify risk for vision loss.

The lecture identifies three categories of visual impairment:

• Low vision

• Functional blindness

• Total blindness

History of present health concern

Ask the client:

• Have you noticed any changes in vision?

• Did the changes occur suddenly or gradually?

• Do you see spots or floaters?

• Do you experience blind spots?

• Do you see halos or rings around lights?

• Do you experience double vision?

• Do you have eye pain or itching?

• Have you noticed redness or swelling?

• Do your eyes water or tear excessively?

• Have you experienced eye discharge?

Personal and family history

Lifestyle and health practices

Ask about:

• Exposure to harmful substances or conditions.

• Use of safety glasses.

• Use of sunglasses.

• Vision loss affecting self-care.

• Visual aids.

• Typical diet.

• Smoking history.

Key takeaway: Assess current symptoms, previous eye conditions, family history, and lifestyle factors that could affect eye health.

Objective 3: Inspect the external eye structures, assess visual acuity, visual fields, corneal light reflex, and eye movements.

Slides 13–23

This objective contains several physical assessment techniques.

Preparing for the examination

Purpose: Identify changes in vision or signs of eye disorders.

Equipment:

• Snellen chart

• Penlight

• Gloves

• Ophthalmoscope (advanced practice only)

The lecture states that ophthalmoscope examinations are not routinely performed in acute care settings.

A. Visual acuity

Distant visual acuity: Snellen chart or E chart

• Used to test distance vision.

• Client reads each line until unable to decipher the letters.

• Observe the client's behavior during the examination.

Myopia: Impaired far vision.

Near visual acuity

• Used for middle-aged clients.

• Assesses near vision.

Presbyopia: Impaired near vision.

The slide asks how to perform the near-vision test but does not provide the steps.

B. Visual fields

Test: Confrontation test.

Purpose: Assess gross peripheral vision.

The lecture identifies the confrontation test and includes a demonstration video reference on slide 16.

C. Corneal light reflex

Assessment steps

1. Hold a penlight approximately 12 inches from the client's face.

2. Shine the light toward the bridge of the nose.

3. Ask the client to look straight ahead.

4. Observe the reflection of light on the corneas.

Expected finding: Light is reflected on the corneas.

D. Cover test

Purpose: Detect deviation in eye alignment or strength.

Steps

1. Ask the client to stare straight ahead at a distant object.

2. Cover one eye using a hand or card.

3. Observe the uncovered eye for movement.

4. Remove the cover.

5. Observe the previously covered eye for movement.

6. Repeat with the opposite eye.

Normal finding: The uncovered eye remains fixed straight ahead, and the covered eye remains fixed straight ahead after being uncovered.

E. Cardinal fields of gaze

• Assess eye movements.

• The lecture asks which cranial nerves are involved but does not provide their numbers.

• The test is also referenced when discussing paralytic strabismus.

Nystagmus: Shaking movement of the eye.

F. External eye inspection

Inspect:

• Eyelids and eyelashes

• Position and alignment of eyeballs

• Bulbar conjunctiva and sclera

• Cornea and lens

• Iris and pupils

Inspect and palpate the lacrimal apparatus.

G. Pupillary assessment

Pupillary reaction to light

1. Darken the room.

2. Ask the client to focus on a distant object.

3. Shine a light obliquely into one eye.

4. Observe the pupillary reaction.

5. Assess the consensual response.

Also assess accommodation of the pupils.

Advanced assessments

Slide 23 identifies the following as not a focus for this class:

• Optic disc

• Retinal vessels

• Retinal background

• Fovea and macula

• Anterior chamber

Physical assessment comparison

Objective 4: Examine the unique findings related to eye health in special populations.

Slides 24–25

Newborns

• Eyes are not fully developed at birth.

• Poor pupillary response.

• Peripheral vision is intact, but central vision is not.

• Farsighted at birth.

• Begin seeing color around 8 months.

Children and adolescents

- Achieve visual acuity by approximately 6 or 7 years of age.

Older adults

• Skin around the eyes becomes thin.

• Assess the cornea and lens.

• Assess for cataracts and macular degeneration.

• Presbyopia is common.

Comparison chart

Objective 5: Differentiate between normal and abnormal findings of the eye.

Slides 18, 20, 26–28, 31–32

Normal findings

The documentation example on slide 32 identifies:

• Visual acuity of 20/20 without correction.

• Intact peripheral vision.

• Symmetric corneal light reflex.

• Smooth, symmetric extraocular movements.

• No nystagmus.

• Eyelids without erythema or swelling.

• Pink, smooth, moist conjunctiva.

• White sclera.

• Round pupils.

• PERRLA.

Extraocular muscle abnormalities

External eye abnormalities

Abnormal pupillary findings

Key takeaway: Be able to recognize the named abnormalities and distinguish normal eye alignment, movement, and appearance from abnormal findings.

Objective 6: Define cataracts, identify associated risk factors, and recognize key assessment findings.

Slides 29–30

Cataracts

Definition: Clouding of the lens of the eye.

According to the lecture:

• Cataracts are often preventable.

• They are identified as the leading cause of blindness.

• More than 24 million Americans are affected.

Risk factors

• Diabetes

• Medications

• Age greater than 65

• Smoking

• Alcohol

• Family history

Assessment findings

Screening

The lecture recommends screening every 1–2 years in clients older than 65.

Important exam distinction: Cataracts involve clouding of the lens, with vision described as foggy or frosty.

Objective 7: Analyze interview and physical assessment data related to the eye to make clinical judgments.

Slides 32–33

Clinical judgment process

After collecting subjective and objective data:

1. Identify abnormal findings.

2. Identify client strengths.

3. Cluster the data.

4. Identify possible client concerns.

Examples of client concerns

Documentation example

Slide 32 describes a 14-year-old client presenting with right eye redness.

Subjective findings

• Right eye redness for one day.

• Itching without pain.

• Thick green discharge.

• Eye crusted shut upon waking.

• Blurry vision.

• No floaters, blind spots, double vision, or photophobia.

• No glasses or contacts.

• Last eye examination one year ago.

Objective findings

• Visual acuity 20/20 without correction.

• Peripheral vision intact.

• Symmetric corneal light reflex.

• Smooth, symmetric eye movements.

• No nystagmus.

• Crusting on right upper eyelid.

• Right conjunctival erythema and edema.

• White, moist sclera.

• Left conjunctiva pink, smooth, and moist.

• Pupils round, 4 mm bilaterally, PERRLA.

Clinical judgment focus: Identify the abnormal findings, distinguish them from normal findings, and cluster the data to identify client concerns.

Eyes: Final Exam Review