Chapter 14 Eyes PDF

# UNIT 3: Physical Examination ## Chapter 15: Eyes **Dr. Laila A. Hamed** Assistant Professor, College of Nursing University of Hail ## Structure and Function ### I- External Anatomy 1. **Bony orbital cavity** surrounded by a cushion of fat to protect the eye. 2. **Palpebral fissure** is: * Elli...

# UNIT 3: Physical Examination ## Chapter 15: Eyes **Dr. Laila A. Hamed** Assistant Professor, College of Nursing University of Hail ## Structure and Function ### I- External Anatomy 1. **Bony orbital cavity** surrounded by a cushion of fat to protect the eye. 2. **Palpebral fissure** is: * Elliptical open space between eyelids 3. **Lower lid margin** between cornea and sclera. 4. **Tarsal plates** * contain meibomian glands that secrete an oily lubricating material onto lids. 5. **Conjunctiva** * Transparent protective covering of the eye 6. **Cornea** * covers and protects the iris and pupil. 7. **Lacrimal apparatus** * provides irrigation to the eye. - An illustration of the external anatomy of the eye showing the following structures: upper eyelid, palpebral fissure, lateral canthus, lower eyelid, pupil, iris, sclera, medial canthus, caruncle, limbus, orbicularis oculi muscle, palpebral conjunctiva, bulbar conjunctiva, posterior chamber, anterior chamber, cornea, tarsal plate, meibomian glands, and sclera. ## II- Extraocular Muscles (1 of 2) * **Six muscles attach the eyeball to its orbit and direct the eye to points of a person's interest.** * Give the eye both straight and rotary movement. * Their axes always remain parallel, called conjugate movement. * Four straight, or rectus, muscles are superior, inferior, lateral, and medial rectus muscles. * Two obliques, muscles are superior and inferior muscles. * **Parallel axes are important because the human brain has a binocular, single-image visual system.** * **Movement of the extraocular muscles stimulated by three cranial nerves** * **Cranial nerve VI:** abducens nerve, innervates lateral rectus muscle, which abducts the eye * **Cranial nerve IV:** trochlear nerve, innervates the superior oblique muscle * **Cranial nerve III:** oculomotor nerve, innervates all the rest: the superior, inferior, and medial rectus and the inferior oblique muscles - An illustration showing the attachments and direction of movement of the extraocular muscles. ## III- Internal Anatomy **Eye: Symmetric sphere of three concentric coats:** 1. **Outer fibrous layer:** * **Sclera:** tough, protective, white covering. bending incoming light rays so that they will be focused on the inner retina. * **Corneal reflex-contact with a wisp of cotton stimulates a blink in both eyes** * **Trigeminal nerve, cranial nerve V, carries afferent sensation into the brain.** * **Facial nerve, cranial nerve VII** carries an efferent message that stimulates blinking - An illustration of the internal anatomy of the eye showing the following structures: sclera, choroid, retina, vitreous body, superior rectus muscle, conjunctiva, iris and pupil, lens, anterior chamber, posterior chamber, ciliary body, inferior rectus muscle, macula, optic disc, and retinal vessels. 2. **Middle vascular layer of the eye contains:** * **2.a. Choroid:** has dark pigmentation to prevent light from reflecting internally and is heavily vascularized to deliver blood to the retina * **2.b. Iris:** functions as a diaphragm, with varying openings at its center, the pupil of the eye * Muscle fibers of the iris contract the pupil in bright light to accommodate for near vision * Dilate pupil when light is dim and for far vision. * **2.c. Pupil of the eye:** round and regular * Stimulation of the parasympathetic branch, through cranial nerve III, causes constriction of the pupil. * Stimulation of the sympathetic branch dilates the pupil and elevates the eyelid. * **2.d. Lens:** biconvex disc located just posterior to the pupil * **2.e. Transparent:** it serves as a refracting medium, keeping a viewed object in focus on the retina. * Anterior and posterior chambers contain clear, watery aqueous humor produced continually by the ciliary body. * Continuous flow of fluid serves to deliver nutrients to surrounding tissues and to drain metabolic wastes. * Intraocular pressure determined by the balance between the amount of aqueous produced and resistance to outflow 3. **Inner Layer of the eye** * **3.a. Retina:** the visual receptive layer of the eye where light waves change into nerve impulses * with ophthalmoscope: optic disc, retinal vessels, general background, and macula. * **3.b. Optic disc:** area in which fibers from the retina converge to form the optic nerve * Located toward the nasal side of the retina, it has characteristics specific to color, shape, and margins * **Retinal vessels:** normally include a paired artery and vein extending to each quadrant * **3.c. Macula:** located on the temporal side of the fundus * Slightly darker pigmented. * Receives and transduces light from the center of the visual field - An Illustration of the optic disc and retinal vessels showing the various types of normal optic discs, as well as the macula. ## Visual Pathways and Visual Fields * **ight rays are refracted through transparent media, the cornea, aqueous humor, lens, and vitreous body, striking the retina.** * **Retina transforms light stimulus into nerve impulses conducted to visual cortex.** * Image formed on retina is upside down and reversed. * All retinal fibers collect to form optic nerve, but maintain same spatial arrangement. * At optic chiasm, fibers from both visual fields cross over. * Left optic tract now has fibers from left half of each retina, and right optic tract contains fibers only from right; thus, right side of brain looks at left side of the world. - An illustration of the visual pathways and visual fields showing the left visual field, right visual field, temporal, nasal, optic nerve, optic chasm, optic tract,. and occipital cortex. ## Visual Reflexes * **The pupillary light reflex** is the normal constriction of the pupils when bright light shines on the retina. * **Fixation** is a reflex direction of the eye toward an object attracting our attention. * **Accommodation** is the adaptation of the eye for near vision. ## Developmental Competence * Infants, Children, and aging adult ## Culture and Genetics * Culture and Genetics could affect the eye. ## Subjective Data 1. Vision difficulty (decreased acuity, blurring, blind spots) 2. Pain 3. Strabismus, diplopia 4. Redness, swelling 5. Watering, discharge 6. History of ocular problems 7. Glaucoma 8. Use of glasses or contact lenses 9. Patient-centered care ## Vision Difficulty Questions * Any difficulty seeing or any blurring? Blind spots? * Come on suddenly or slowly? One eye or both? * Constant, or does it come and go? * Do objects appear out of focus or clouding of objects? * Do spots move in front of your eyes? One or many? * In one or both eyes? * Any halos, rainbows, rings around objects? * Any blind spot? Does it move as you shift your gaze? * Any loss of peripheral vision? * Any night blindness? ## Pain Questions * Any eye pain? Please describe. * Come on suddenly? * Quality: burning or itching? Or sharp, stabbing pain; pain with bright light? * A foreign body sensation? Or deep aching? Or headache in brow area? ## Strabismus, Diplopia, Redness, and Swelling * **Strabismus, diplopia**: Any history of crossed eyes? Now or in the past? Does this occur with eye fatigue? * Ever see double? Constant, or does it come and go? In one eye or both? * **Redness, swelling** * Any redness or swelling in eyes? * Any infections? Now or in past? When do these occur? In a particular time of year? ## Discharge and Past History * **Watering, discharge** * Any watering or excessive tearing? * Any discharge? Any matter in the eyes? Is it hard to open your eyes in the morning? What color is the discharge? * How do you remove matter from eyes? * **Past history of ocular problems** * Any history of injury or surgery to eye? Any history of allergies? ## Glaucoma, Eyeglasses, and Contact Lenses * **Glaucoma** * Have you ever been tested for glaucoma? What were the results? * Do you have any family history of glaucoma? * **Use of glasses or contact lenses** * Do you wear glasses or contact lenses? How do they work for you? * Last time your prescription was checked? Was it changed? * If you wear contact lenses, are there any problems such as pain, photophobia, watering, or swelling? * How do you care for contacts? How long do you wear them? How do you clean them? Do you remove them for certain activities? ## Patient-Centered Care * Last vision test? Ever tested for color? * Any environmental conditions at home or at work that may affect your eyes? If so, do you wear goggles to protect your eyes? * What medications are you taking? Systemic or topical? Any specifically for eyes? * Do you smoke? * If you have experienced a vision loss, how do you cope? Do you have books with large print, books on audio tape, braille? * Do you maintain living environment the same? * Do you sometimes fear complete loss of vision? ## Objective Data **Preparation** * Position a person standing for vision screening; then sit up with your head at your eye level. **Equipment needed:** * Snellen eye chart * Handheld visual screener * Opaque card or occluder * Penlight * Applicator stick * Ophthalmoscope ## Normal Range of Findings/Abnormal Findings ### 1. Test Central Visual Acuity * **The Snellen alphabet chart is the most commonly used and accurate measure of visual acuity.** * It has lines of letters arranged in decreasing size. * If the person wears glasses or contact lenses, leave them on. * **If the person cannot see even the large letters, shorten the distance to the chart until the person sees it.** * **If visual acuity is even lower, assess whether the person can count your fingers when they are spread in front of your eyes or distinguish light perception from your penlight.** - An Illustration of a person using a Snellen eye chart to test visual acuity. ### 2. Test Near Vision * **Used** For those who report increasing difficulty reading * **Test** near vision with a handheld vision screener with various print sizes. (e.g., a Jaeger card). * Hold the card in good light about 35 cm (14 inches) from the eye. * Test each eye separately, with glasses on. * When no vision screening card is available, ask the person to read from a magazine or newspaper. - An Illustration of a person using the Jaeger chart to test Near Vision. ### 3. Confrontation Test * **Gross measure of peripheral vision; compares the person's peripheral vision with yours** * Position yourself at eye level with the person about 2 feet away. * Direct the person to cover one eye with an opaque card and with the other eye to look straight at you. * Hold a pencil or your finger as the target midline between you and the person, and slowly advance it in from the periphery in several directions. * Ask the person to say "now" as the target is first seen; this should also be just as you see the object. * Estimate the angle between the anteroposterior axis of the eye and the peripheral axis where the object is first seen. * Normal results are about 50 degrees upward, 90 degrees temporal, 70 degrees down, and 60 degrees nasal. * Sensitivity can be increased by combining a wiggling finger with a moving red target. - An Illustration of the confrontation test showing how to administer the test. ### 4. Corneal Light Reflex (Hirschberg Test * Assess the parallel alignment of eye axes by shining a light toward the person's eyes. * Direct the person to stare straight ahead as you hold the light about 30 cm (12 inches) away. * Note the reflection of light on the corneas; should be in the exact same spot on each eye. - An Illustration of a doctor using a penlight to examine the Corneal Light Reflex (Hirschberg Test). ### 5. Diagnostic Positions Test * **☑eading eyes through six cardinal positions of gaze elicits any muscle weakness during movement:** * Follow the movement of the penlight or object proceeding clockwise. * Hold the target back about 30 cm (12 inches) so the person can focus on it comfortably, move it to each of the six positions, hold it momentarily, then back to center. Progress clockwise. A normal response is parallel tracking of the object with both eyes. * Assess for potential EOM muscle weakness, nystagmus, or lid lag. - An Illustration of a Doctor examining the Diagnostic Positions Test. ### 6. General Inspection * **Eyebrows** * Look for symmetry between the two eyes. * Normally eyebrows are present bilaterally * move symmetrically as expression changes, and have no scaling or lesions. * **Eyelids and lashes** * Upper lids normally overlap the superior part of iris and approximate completely with lower lids when closed. * Palpebral fissures are horizontal in non-Asians; Asians normally have an upward slant. * Eyelashes are evenly distributed along lid margins and curve outward. * **Eyeballs:** aligned normally in their sockets with no protrusion or sunken appearance. * African Americans normally may have slight protrusion of the eyeball beyond the supraorbital ridge. ### 7. Conjunctiva and Sclera: * Ask the person to look up; using your thumbs, slide lower lids down along the orbital rim, being careful not to push against the eyeball. * Inspect the exposed area; the eyeball should look moist and glossy. * Numerous small blood vessels normally show through transparent conjunctiva. * **Otherwise, conjunctivae clear and show the normal color of structure below; pink over lower lids and white over the sclera.** * **Note any color change, swelling, or lesions.** * **The sclera is china white, although blacks occasionally have a gray-blue or "muddy" color to the sclera. Also in dark-skinned people normally** * may see small brown macules on the sclera, which should not be confused with foreign bodies or petechiae. * Finally, blacks may have yellowish fatty deposits beneath the lids away from the cornea. Do not confuse these yellow spots with the overall scleral yellowing that accompanies jaundice - An Illustration of a doctor examining the conjunctiva and sclera. ### 8. Lacrimal Apparatus * Ask the person to look down; with thumbs, slide outer part of upper lid up along bony orbit to expose under lid; inspect for any redness or swelling. * Normally puncta drain tears into the lacrimal sac. * Presence of excessive tearing may indicate blockage of nasolacrimal duct. * **Check by pressing index finger against sac, just inside lower orbital rim, not against side of the nose.** * Pressure will slightly evert lower lid, but there should be no other response to pressure. - An Illustration of a doctor examining the lacrimal apparatus showing how to administer the test. ### 9. Inspect Anterior Eyeball Structures #### 1. Cornea and Lens: * Shine light from the side across the cornea, and check for smoothness and clarity. * Oblique view highlights any abnormal irregularities in the corneal surface. * **There should be no opacities (cloudiness) in the cornea, anterior chamber, or lens behind the pupil.** * Do not confuse an arcus senilis with an opacity; arcus senilis is a normal finding in aging persons. - An Illustration of a doctor examining the cornea and lens with a penlight. #### 2. Iris and Pupil (1 of 2) * **Iris normally appears flat, with a round regular shape and even coloration.** * Note size, shape, and equality of pupils; normally pupils appear round, regular, and of equal size in both eyes * **To test pupillary light reflex** * Darken the room and ask person to gaze into the distance; this dilates pupils; advance a light in from side and note the response. * Normally you will see constriction of same-sided pupil (a direct light reflex) and simultaneous constriction of other pupil (a consensual light reflex). * In acute care setting, pupil size is measured in millimeters before and after the light reflex. #### 3. Iris and Pupil * **Record normal response to all these maneuvers as PERRLA, or Pupils Equal, Round, React to Light, and Accommodation.** * **Test for accommodation by asking the person to focus on a distant object.** - An illustration of a pupil gauge showing the size of the pupil in millimeters. ## Advanced Practice Techniques * **●Inspection of Ocular Fundus by:** * Ophthalmoscope enlarges the view of the eye so that you can * inspect media (anterior chamber, lens, vitreous) and the ocular fundus (internal surface of retina). * **Lenses control focus with a unit of strength measurement known as a diopter.** * **Black numbers indicate positive diopter; they focus on nearer objects.** * **Red numbers show negative diopter and focus on objects farther away.** - An illustration of an ophthalmoscope, showing the viewing aperture, lens selector dial, and diopter indicator. ## Ocular Fundus Examination (1 of 3) * **To examine a person** * Darken the room to help dilate pupils; dilating eye drops are not needed during a screening examination. * Select a large round aperture with white light for routine examination. * If pupils are small, use smaller white light. * Ask a person to please keep looking at the mark on a wall across the room. * Staring at distant fixed objects helps to dilate pupils and to hold retinal structures still. * Begin about 25 cm (10 inches) away from a person at angle of 15 degrees to the person's line of vision. * **Observe for presence of red reflex and steadily move closer to eye.** * If you lose red reflex, adjust angle to find it again. * As you advance, adjust lens to #6 and note any opacities in media; these appear as dark shadows or black dots interrupting red reflex; normally, none is present. * Progress toward the person until foreheads almost touch. ## Ocular Fundus Examination * **Adjust the diopter to bring the ocular fundus into sharp focus; if you and a person have normal vision, this should be at 0.** * **Moving diopters compensates for near- or farsightedness.** * Use red lenses for nearsighted eyes. * Use black lenses for farsighted eyes. * **Moving in on a 15-degree lateral line should bring your view just to the optic disc.** * If the disc is not in sight, track a blood vessel as it grows larger and it will lead to a disc. * **Systematically inspect structures in ocular fundus** * Optic disc * Retinal vessels * General background * Macula - An Illustration of a doctor examining the ocular fundus, showing two different perspectives. - An illustration showing a diagram of a normal eye, a myopic eye, and a hyperopic eye. Alongside it is an image of a normal ocular fundus. ### Inspection of Optic Disc (1 of 2) * **most prominent landmark is the optic disc, located on the nasal side of the retina; explore these characteristics:** * Color: creamy yellow-orange to pink * Shape: round or oval * Margins: distinct and sharply demarcated, although nasal edge may be slightly fuzzy * Cup-disc ratio: distinctness varies; when visible, physiologic cup is brighter yellow-white than rest of disc; width not more than one half disc diameter - An Illustration of the normal optic disc and retinal vessels showing the different structures. ### Inspection of Optic Disc (2 of 2) * **Two normal variations may ring disc margins** * Scleral crescent: gray-white new moon shape occurs when the pigment is absent in the choroid layer looking directly at the sclera * Pigment crescent: black due to accumulation of pigment in the choroid * **Diameter of the disc (DD) is the standard measure for other fundus structures.** * **To describe the finding, note its clock-face position and relationship to the disc in size and distance (e.g., at 5:00, 3 DD from disc).** ### Retinal Vessels * **Only place in the body where you can view blood vessels directly.** * **Many systemic diseases that affect the vascular system show signs in retinal vessels.** * **Follow a paired artery and vein out to the periphery in four quadrants, noting these points:** * Number: paired artery and vein pass to each quadrant; vessels look straighter at the nasal side * Color: arteries brighter red than veins; also have arterial light reflex, with thin stripe of light down middle * A:V ratio: ratio comparing artery-to-vein width is 2:3 or 4:5 * Caliber: arteries and veins show a regular decrease in caliber as they extend to the periphery * A-V, arteriovenous crossing: artery and vein may cross paths; not significant if within 2 DD (Diameter of disc) and if no sign of interruption in blood flow is seen; should be no indenting or displacing of vessel * Cortuosity: mild vessel twisting when present in both eyes is usually congenital and not significant * Pulsations: present in veins near the disc as their drainage meets intermittent pressure of arterial systole; often hard to see ### Fundus and Macula * **General background of Fundus:** * Color normally varies from light red to dark brown-red; view of fundus should be clear; no lesions should obstruct retinal structures. * **Macula:** * 1 DD in size, located 2 DD temporal to disc * Inspect last in the funduscopic examination; bright light causes some watering, discomfort, and pupillary constriction. * Normal color somewhat darker than the rest of fundus but even and homogeneous * Clumped pigment may occur with aging. ## Eversion of the Upper Lid * **Used when one suspects foreign body or eye pain** * **Procedure may cause apprehension; therefore use directed, deliberate approach.** * Multi-step procedure using applicator stick * **Inspect for**: color change, swelling, lesion, or evidence of foreign body. - An illustration of a doctor administering the eversion of the upper lid test. ## Health Promotion and Patient Teaching * **Glaucoma** is a progressive eye disease. * **Risk factors:** older age, diabetes mellitus, and a family history of glaucoma. * **Eye specialist screening uses the measurement of the thickness of the optic nerve fibers, formal visual field testing, measurement of intraocular pressure, and stereoscopic optic nerve examination.** * **Treatment:** eye drop medication, laser trabeculoplasty, and/or surgery. * **Early detection is critical to stop the progress of the disease.** ## Abnormal Findings: ### Extraocular Muscle Dysfunction(EOM) * **Asymmetric corneal light reflex** * Strabismus Esotropia- inward turning of eye * Exotropia-outward turning of eye * **Cover test** Performed on all children * **Diagnostic positions test** * Paralysis indicates cranial nerve dysfunction. ### Eyelid Abnormalities * Periorbital edema: (edema around the eye) * Exophthalmos: (protruding eyes) * Enophthalmos: (sunken eyes) * Ptosis: (drooping upper lid) * Upward palpebral slant * Ectropion * Lower lid rolling out * Entropion * Lower lid rolling in ### Lesions on the Eyelids * Blepharitis: (inflammation of the eyelids) * Chalazion: a red bump on your eyelid * Hordeolum (stye): infection of an oil gland at the edge of the eyelid * Dacryocystitis: (inflammation of the lacrimal sac) * Basal cell carcinoma ### Pupil Abnormalities * Unequal pupil size-Anisocoria * Monocular blindness * Constricted and fixed pupils-Miosis * Dilated and fixed pupils-Mydriasis * Argyll Robertson pupil * Tonic pupil (Adie's pupil) * Cranial nerve III damage * Horner's syndrome ### Visual Field Loss * Retinal damage * Lesion in globe or optic nerve * Lesion at optic chiasm * Lesion of outer uncrossed fibers at optic chiasm * Lesion R optic tract or R optic radiation ### Red Eye-Vascular Disorders * **Conjunctivitis:** inflammation of the conjunctives * Allergic conjunctivitis * **Uritis:** (circumcorneal redness) * **Primary angle-closure glaucoma (PACG)** * Subconjunctival hemorrhage * Herpes simplex virus ### Cornea and Iris * **Pterygium:** growth of the conjunctiva or mucous membrane that covers the white part of your eye over the cornea. * Corneal abrasion * Normal anterior chamber (for contrast) * Shallow anterior chamber * **Hyphema:** pooling or collection of blood inside the anterior chamber of the eye: * **Hypopyon:** An accumulation of pus in the anterior chamber of the eye ### Opacities in the Lens * **Central gray opacity- nuclear cataract.** * **Star-shaped opacity- cortical cataract** - An illustration of a nuclear cataract and a cortical cataract. ### Optic disc abnormalities * Optic atrophy (disc pallor) * Papilledema (choked disc) * Excessive cup-disc ratio ### Retinal vessels and background * Arteriovenous crossing (Nicking) * Narrowed (attenuated) arteries * Diabetic retinopathy * Moderate nonproliferative * Severe nonproliferative * Proliferative ## Summary Checklist: Eye Examination (FR) 1. Test visual acuity * Snellen eye chart * Near vision (those older than 40 years or having difficulty reading) 2. Test visual fields-Confrontation test 3. Inspect extraocular muscle function * Corneal light reflex (Hirschberg test) * Cover test (if indicated) * Diagnostics positions test 4. Inspect external eye structures * General * Eyebrows * Eyelids and lashes * Eyeball alignment * Conjunctiva and sclera * Lacrimal apparatus 5. Inspect anterior eyeball structures * Cornea and lens * Iris and pupil * Size, shape, and equality * Pupillary light reflex * Accommodation 6. Inspect ocular fundus * Optic disc (color, shape, margins, cup-disc ratio) * Retinal vessels (number, color, artery-vein [A : V] ratio, caliber, arteriovenous crossings, tortuosity, pulsations) * General background (color, integrity) * Macula ## References * Bickley L. S. Szilagyi P. G. Hoffman R. M. & Soriano R. P. (2021). Bates' guide to physical examination and history taking 13e (Thirteenth). Wolters Kluwer Health. * Jarvis C. Eckhardt A. & Thomas P. (2020). Physical examination & health assessment (8th ed.). Elsevier. ISSN: 978-0-323-51080-6. * Kirk J. A. Palm M. L. Bickley L. S. & Bates B. (2012). Student laboratory manual for bates' nursing guide to physical examination and history taking. Lippincott Williams & Wilkins. * Maynard K. & Adimando A. (2021). Unfolding health assessment case studies for the student nurse. Sigma.