Physical Assessment: Eyes

Physical Assessment

• Focuses on the structure and function of the eyes, ears, mouth, throat, nose, sinuses, thorax, lungs, breasts, and lymphatic vessels

Assessment of the Eye

• Eyes are the visual system organ
• They detect light and convert it into electrochemical impulses for vision
• Vision is the ability to interpret light information

External Eye Structures

• Eyelids protect the eye
  • Both contain a tarsal plate with Meibomian glands
  • Lids join at medial and lateral canthi
• Sclera: Thick, protective outer coat underlying the conjunctiva
  • Normally white, possibly bluish, and opaque
  • Inflammation is painful, associated with vision loss
• Episclera covers the anterior sclera lacking the bluish discoloration
  • Continuous with the cornea
  • Inflammation is not typically painful or vision-altering
• Limbus: Corneal-scleral junction
• Iris is a pigmented light filter
  • Its muscular aperture controls pupil size
• Pupil: Central hole within the iris
  • Size is controlled by iris constriction (miosis) and relaxation (mydriasis)
  • Pupil size determines light exposure on the retina
• Conjunctiva: Thin, vascular tissue
  • It covers the inner lid lining (palpebral conjunctiva) and sclera (bulbar conjunctiva)
  • It aids in focusing images at 60%
• Cornea: Transparent front refractive window
• Macula is the fine central vision area at the posterior pole
  • Contains the fovea: oval depression at the macula's center

Extraocular Muscles

• Innervated by cranial nerves III, IV, and VI
• Medial range of motion: Medial rectus (cranial nerve III)
• Lateral range of motion: Lateral rectus (cranial nerve VI)
• Upward range of motion: Superior rectus and inferior oblique (cranial nerve III)
• Downward range of motion: Inferior rectus (cranial nerve III) and superior oblique (cranial nerve IV)

Internal Eye Structures

• Anterior chamber is between the cornea and iris
  • Contains aqueous humor
• Posterior chamber is between the iris and zonulae (very small space)
• Ciliary body produces aqueous humor and suspends the lens via zonulae
• Aqueous humor: Clear fluid
  • Fills anterior and posterior chambers
  • Produced by the ciliary body
  • Passes through pupil
  • Drains via trabecular meshwork at the aqueous outflow angle
    • Intersection of cornea, iris, and ciliary body
    • Blockage results in glaucoma
• Vitreous cavity
  • Large space (4.5cc) between lens and retina
  • Contains transparent gel (vitreous humor)

Anatomy: Vascular

• Choroid: Vascular pigmented tissue between sclera and retina
  • Vascular supply for outer retina
• Avascular structures: Lens, anterior vitreous, corneal endothelium

Eye Muscles

• Ciliary muscle innervated by CN III constricts to relax lens tension for accommodation
• Sphincter pupillae innervated by CN III constricts the pupil
• Dilator pupillae innervated by sympathetic nerves dilates the pupil

Eye Muscle Deficits

• CN3 palsy: Lateral & downward deviation with ptosis
• CN4 palsy: Upward deviation
• CN6 palsy: Medial deviation

Visual Acuity Test

• Measures sharpness or clarity to assess vision at various distances
• Those who cannot see the top line (20/200) are tested via:
  • Light perception
  • Hand movement test
  • Counting fingers
• Normal Findings: Denominator of 40+ on Snellen chart utilizing corrective lenses or 20/20 vision without
• Emmetropia indicates normal vision
• Myopia causes difficulty seeing distant objects clearly
• Hyperopia causes difficulty seeing close objects clearly
• Presbyopia is age-related loss of focusing on nearby objects
• Glaucoma means increased eye pressure damages the optic nerve, causing vision loss
• Retinal detachment means that the retina pulls away, causing vision loss
• Astigmatism means that irregular cornea shape causes blurred vision
• Papilledema: Swelling of optic disc due to increased intracranial pressure
• Optic atrophy means damage to optic nerve leading to vision loss
• Diabetic retinopathy: Damage caused by diabetes to retina blood vessels
• AMD: Age-related macular degeneration causing central vision loss

Visual Field Test

• Measures the overall area someone can see
• Helps evaluate peripheral vision and detect blind spots or vision loss
• Normal findings:
  • Peripheral field - 90° angle, temporally
  • Upward field vision - 50°, orbital ridge
  • Downward field vision - 70°, cheekbone
  • Nasal field vision - 50°, nose

Abnormal findings

• Smaller than normal visual field, possible glaucoma
• Loss in specific fields (e.g., left superior quadrant anopia)
• Unilateral/bilateral blindness: Loss of vision in one or both eyes
• Anopsia/anopia: General vision loss or blindness
• Bitemporal hemianopia: Loss in the outer half of both visual fields.

Visual inspection

• Detects abnormalities on the eye
• Eyes should be aligned and symmetrical, with no squinting, tilting, or asymmetry.
• Eyelids blink involuntarily 15-20 times per minute
• Ptosis: Drooping eyelids, can be due to nerve damage
• Entropion: Eyelid turns inward, lashes irritate eye
• Ectropion: Eyelid turns outward, causes dryness
• Trichiasis: Eyelashes grow inwards, cause discomfort

Lacrimal Gland/Sac

• Dacryocystitis: Swelling, redness, or tenderness, may indicate blocked tear ducts

Bulbar Conjunctiva

• Allergic conjunctivitis is caused by allergens and results in itchy, red, watery eyes
• Viral conjunctivitis is caused by a virus and is often associated with other cold symptoms, watery discharge, red eyes
• Bacterial conjunctivitis is caused by bacteria, resulting in yellow/green discharge, red eyes
• Episcleritis involves inflammation of the episclera, causes localized mild discomfort
• Jaundiced sclera indicates liver issues
• Pale sclera indicates anemia
• Reddened sclera indicates inflammation

Cornea and Lens

• Arcus senilis: A gray ring around the cornea, possibly high cholesterol
• Keratoconus: Bulging cornea causing distortion
• Normal pupils: Black, equal size (3-7 mm), round, smooth border
• Cloudiness is a sign of cataracts
• Mydriasis: Dilated pupils
• Miosis: Constricted pupils
• Anisocoria: Unequal pupil sizes
• Bulging iris associated with glaucoma

Pupillary Reaction Test

• Assesses the neural pathways for pupillary light reflexes
• Direct response: Pupil constriction when directly exposed to light
• Consensual response: Non-illuminated pupil constricts when light shines on the other pupil.
• Normal: Both pupils constrict to light.
• Abnormal: Unequal or sluggish responses, no response
• Horner syndrome: Smaller pupil, drooping eyelid, lack of sweating from nerve damage
• Unilateral dilated pupil: Potential brain injury/increased pressure

Accommodation Test

• Tests the ability of the eye to change focus
• Normal: Pupils constrict for near objects, dilate for distant objects, and converge as objects move toward the nose

Corneal Light Reflex

• Assess the alignment of the eyes and detect strabismus (misalignment of the eyes)
• Strabismus is an asymmetry misalignment or involuntary eye movements.
• Esotropia: One or both eyes turn inward
• Exotropia: One or both eyes turn outward
• Hypertropia: One eye turns upward
• Hypotropia: One eye turns downward

Cardinal Gaze

• Tests the movement and coordination of the extraocular muscles
• Normal: Eyes move in unison with coordinated, parallel movements
• Abnormal: Eyes fail to follow the finger in certain directions or one eye fails to follow
• Strabismus indicates a cross eye
• Nystagmus indicates rapid involuntary rhythmic eye movement suggesting neurologic impairment

Convergence

• To assess the eye's ability to work together, when focusing on a close object, which is important for binocular vision

Refraction

• Measured in Diopters
• Refers to the bending of light rays by the eyes
• Cornea is responsible for 66% of the eye's fixed focusing power
• Crystalline lens: 33% of the eye's focusing power, changes shape to focus on objects (accommodation)
• Refractive power of the lens is the reciprocal of focal length measured in meters
• 1-diopter lens has 1 meter focal length, 2-diopter lens has 0.5 meters focal length

Emmetropia (Normal Vision)

• The eye's focusing power is perfectly matched to the globe length
• The image is focused perfectly on the retina
• Causes are: Autosomal dominant inheritance or environmental

Myopia (Nearsightedness)

• Mild Myopia appears between 5-8 years (-0.5 to -2.0D)
• Moderate Myopia appears between 8-14 years (-2.0 to -5.0 D)
• Severe occurs between 20-28 years (<-6.0 D)
• Light rays focus in front of the cornea
• Causes blurry distance
• Treated with concave (divergent, minus power) lenses

Hyperopia (Farsightedness)

• Normal in infants (+0.50 to +2.50 Diopters)
• Light rays focus behind the cornea
• Causes blurry near vision
• Treated with convex (convergent, plus power) lenses

Astigmatism

• Results from non-spherical corneal surface
• Causes blurry vision at any distance.

The Ear

• Outer ear includes Pinna and External auditory canal
• Middle ear includes the Tympanic membrane(eardrum) and Ossicles(Malleus, Incus, Stapes)
• Inner ear includes Semicircular canals, Cochlea, and Eustachian Tube

Outer (External) Ear

• Fleshy auricle (pinna) of elastic cartilage
• The external auditory canal guides sound waves to the eardrum, also amplifying sound.

Middle Ear

• Thin, cone-shaped tympanic membrane separates from the outer ear
• Ossicles are three small bones that transmit sound vibrations to the inner ear

Inner Ear

• Cochlea has sensory cells turning vibrations into electrical signals
• Vestibular system including semicircular canals and vestibule aids in balance/orientation
• Eustachian tube connects the middle ear to the throat and helps equalize pressure.

Hearing

• Sound vibrations travel through air and the malleus, incus, and stapes
• Movement of fluid stimulates hair cells, initiating nerve impulses to the brain's acoustic nerve.

Types of Hearing Loss

• Conductive hearing loss affects external and middle ear sound transmission
• Involves transmission of sound through the outer ear and middle ear through air/bone conduction.
• Percetive/Sensorineural hearing loss affects sound transmission in the inner ear.
• The cochlea/auditory nerve processes and sends signals to the brain for interpretation.

Abnormal Findings

• Sudden hearing loss can be because of otitis media
• Immediate follow-up for Sudden Sensorineural Hearing Loss (SSHL)
• Earache (otalgia) from blockage or dental
• Tinnitus can be linked to high blood pressure or ototoxic medications
• Vertigo is differentiated as subjective feeling (dizziness) and objective feeling (spinning).

Other considerations

• Indicate purulent or otorrhea is an infection and or blood in the middle infection
• Otitis Externa (Swimmer's Ear) can be avoided by avoiding moist environments.
• After 50, gradual age hearing loss is common(Presbycusis)
• Avoid removing ear wax unless it causes problems, Self-cleaning
• Avoid inserting foreign objects like cotton swabs since it causes further damage

Internal Ear Structures

• Exostoses are considered nonmalignant swellings.

Tympanic Membrane Abnormalities

• Red, Bulging Eardrum is Suggestive of acute otitis media
• Yellowish, Bulging Membrane with Bubbles is suggestive of serous otitis media
• Bluish/Dark Red Color from Blood behind the eardrum due to trauma
• White Spots happen with Scarring from past infections
• Perforations can be due to trauma or infection

Hearing Tests

• Weber's Test assesses sound conducted via bone
• Sound lateralizes to the poorer ear (conductive) or the better ear (sensorineural)
• Rinne Test tests abnormalities in the ear canal and tympanic membrane
• African Americans, more high and low frequency sound heard.
• Adults should be screened once every 10 years until 50 and then every 3 years after.

Mouth

• Salivary glands: aids in digestion including Sublingual, Submandibular, and Parotid

Throat (Pharynx)

• Contains the Nasopharynx, Oropharynxm and Laryngopharynx

Nose

• Composed of bone and cartilage
• A rich supply of blood vessels or is known as the, Kiesselbach's area commonly leads to nasal bleeding
• Four pairs of paranasal sinuses: frontal, maxillary, ethmoidal, and sphenoidal.

Abnormalities

• COLDSPA asses symptoms, sore, or lesions
• Dysphagia increasing aspiration risk, needs consultant by thearapist
• Olr adults can struggle to take care of teeth/dentures due to impairements
• Malocclusion casuses swallow abnormalities

Assessment

• Check that dentures retained, and are removed
• Non-latex gloves, penlight and specuum should be used
• Inspect the lips, coloration is very common depending and varies on each client
• 32 teeth with smooth white serfaces should checked
• Receding gums can depend on older clients due to recession

Abnormal Findings

• Swelling of lips (edema)
• May be caused by smoking or a high fluroide intake
• Can affect speech
• Can be a sign of measels

Throat Abnormalities

• Hard nodules may indicate cancer
• A dim or an light indicates consestion
• Swollen nasal can mean upper resparatory function
• Can occur from strokes