3. Eyes - Tagged.pdf

Eyes Dr. Laura Graafland, DNP, MS, AGPCNP- BC, CBCN 6.2023 Frank Rodrigues 1 Subjective - History Frank Rodrigues PMH PMH: – Hx of ocular problems –...

Eyes Dr. Laura Graafland, DNP, MS, AGPCNP- BC, CBCN 6.2023 Frank Rodrigues 1 Subjective - History Frank Rodrigues PMH PMH: – Hx of ocular problems – Hx of strabismus – Glaucoma – Cataracts If so were they removed surgically? – Eye trauma – Macular degeneration – Any medications for your eyes/eyedrops – Diabetes – Hypertension PSH: – Prior surgery involving the eyes (lasik, cataract removal etc.) FMH: – Family history of genetic eye conditions Macular degeneration, retinitis pigmentosa, retinoblastoma, glaucoma, night blindness, etc. Frank Rodrigues 3 ROS Ask about: Recent changes in vision Use of contacts/glasses Eye pain Blurred vision* Double vision Photophobia – light intolerance Floaters Flashing lights Redness/swelling of eyes Watering/discharge Date of last eye exam Frank Rodrigues Self care behaviors 4 Objective – Physical Exam Frank Rodrigues Physical Exam Assess visual acuity Inspect lids and lashes, conjunctiva, sclera, iris, cornea Shape and size of pupils Corneal light reflex Direct and consensual reflex Accommodation: convergence Extraocular movements Visual fields Funduscopic Frank Rodrigues  6 Testing Visual Acuity – Snellen Test Position the patient 20 feet from the chart Leave glasses on/contacts in Shield one eye and have them read the smallest line possible Encourage reading the next line down as well Record fraction noted at last line read with more than half correct answers Record for each eye separately (OD = pts right eye, OS = pts left eye) Ex: 20/50 = at 20 ft, pt can read what a healthy eye could have read at 50ft Frank Rodrigues 20/200= legal blindness (in best eye) 7 Abnormal – Impaired Vision Myopia Hyperopia (Farsighted) (Nearsighted) Impaired close vision Impaired far vision Frank Rodrigues Inspect Eyebrows Ptosis Note fullness, hair distribution and any scaliness of underlying skin Eyelids Width of palpebral fissures Edema Exophthalmos Lid color Lesions Condition and direction of the eyelashes Adequacy of eyelid closure Eyeball Frank Rodrigues Aligned normally in the socket Note protrusion or  Inspect Conjunctiva and sclera Ask pt to look up while using thumbs to lower bottom lid Should appear moist and glossy Small blood vessels show through transparent conjunctivae against white sclera Note any swelling or nodules Jaundice of sclera/conjunctiva Lacrimal Apparatus Note swelling around lacrimal gland and lacrimal sec. Note excessive tearing or dryness Cornea and Lens Use oblique lighting to look Frank Rodrigues for opacities and abrasions Iris Iris marking should be clearly Inspect – Pupils Pupils Inspect size, shape and symmetry of both pupils Should be 3-5mm in size Miosis – abnormal constriction Mydriasis – abnormal dilation Anisocoria – unequal pupils Frank Rodrigues Tests for Eye Function Corneal Light Reflex Direct and Consensual (Pupillary Light Reflex) Accommodation Extraocular Muscles Visual Fields Frank Rodrigues  12 Test Corneal Light Reflex Shine a light towards eyes Light should hit both eyes in the same spot – slightly nasal to center of pupils If abnormal, there is a problem with EOMs and you can do a cover test to confirm strabismus Normal corneal light reflex  Frank Rodrigues 13 Abnormal - Strabismus A weakness or paralysis of one or more of the extraocular muscles, due to a congenital defect, an orbital fracture, trauma, or CVA-related palsy. Frank Rodrigues 14 sess for Direct and Consensual Reaction to Lig Pupillary Light Reflex Have the patient gaze into the distance Shine pen light onto the eye from the side Direct Reaction: normally pupil exposed to bright light will constrict Consensual Reaction: normally opposite pupil will ALSO constrict Frank Rodrigues 15 Assess for Near Reaction: Convergence & Accommodation Hold finger in front of pt nose, in the distance – Have pt focus on your finger Pupils will normally dilate here (when focusing on far object) Have pt continue focusing on finger as you move closer (3 inches from face) Pupils will normally constrict and converge as finger moves closer Frank Rodrigues 16 Testing Extraocular Muscles Hold finger about 12 inches from patient’s face and have them follow finger through the six cardinal positions of gaze Should have parallel tracking of eyes Frank Rodrigues Check for nystagmus (fine oscillating movement) Check for lid lag Testing Extraocular Muscles Cranial nerve VI (abducens)- innervates the lateral rectus muscles Cranial nerve IV (trochlear) - innervates the superior oblique muscles Cranial nerve III (oculomotor) innervates all the rest – Superior inferior medial rectus Frank Rodrigues inferior oblique Abnormal - Paralysis Looking Right Looking Left Frank Rodrigues Assess Range of Peripheral Visual Fields Frank Rodrigues 20 Review of Visual Pathways – Key to Understanding CN II Frank Rodrigues 21 Visual Fields and Visual Pathways Visual Fields Visual Pathways Projected upside down and reversed right to left Nerve impulses are conducted through the retina, optic nerve, optic chiasm and optic tract on each side, and then on though a curving tract called the optic radiation. Frank Rodrigues Optic Nerve Cut X Frank Rodrigues 23  Optic Chiasm Cut Bitemporal hemianopsia X X Involves the fibers crossing over to the opposite side. Since these fibers originate in the nasal half of each retina, visual loss involves the temporal half of each field Frank Rodrigues 24 Right Optic Tract Cut Left homonymous hemianopsia Lesion in the right optic tract X X interrupts fiber originating on the same side of both eyes. Visual loss in the eyes is therefore similar and involves half of each eye – in this case the left temporal and right nasal Frank Rodrigues 25 Ophthalmoscopic (Funduscopic) Examination Frank Rodrigues Parts of the Ophthalmoscope Frank Rodrigues 27 Using the Ophthalmoscope Frank Rodrigues 28 Ophthalmoscope View Retinal vessels Retinal field or background Optic disc Macula Frank Rodrigues 29  Locate the Optic Disc Normal optic disc: Sharp with distinct outline Round or oval Yellow/orange to creamy pink in color Physiologic cup – yellow/white and less than half the diameter of the overall optic disc Frank Rodrigues 30 Location of Macula in Relation to Disc Frank Rodrigues 31  Retinal Background Normal Retinal Background has color varying from light red to dark brown-red. View of the fundus should be clear with no lesions obstructing the retinal structures. Frank Rodrigues 32  Identifying Retinal Vessels uperior nasal vessels Superior temporal vessels Normal Findings 4 Sets of Retinal Vessels – Paired Vein and Artery in each quadrant Arteries appear bright red than veins, may also note a thin strip of white down the center of the arteries A:V Ratio = 2:3 Vessels get smaller the further away they are from the optic disc Frank Rodrigues Inferior nasal vesselsInferior temporal vessels  Abnormal – Arteriovenous Nicking AV nicking, is the phenomenon where a small artery (arteriole) is seen crossing a small vein (venule), which results in the compression of the vein with bulging on either side of the crossing Frank Rodrigues 34 Abnormal - Papilledema A serious medical condition where the optic nerve at the back of the eye becomes swollen due to a buildup of pressure in or around the brain. Optic Disc will appear fuzzy due to swelling and the physiologic cup will bulge. Pt may report: visual disturbances, headaches, and nausea. Frank Rodrigues Abnormal – Retinal Hemorrhages Retinal Hemorrhage Bleeding in the retina – can be superficial, preretinal, or deep Seen in sudden increases in intracranial pressure, severe hypertension, and diabetes University of Michigan Frank Rodrigues Developmental Considerations - Older Adults Skin loses elasticity causing drooping, fat tissues and muscles atrophy Cornea may show arcus senilis degenerative lipid material around the limbus, pupils decrease in size, lens loses elasticity and cannot change shape to accommodate for near vision (presbyopia), lens discolors and thicken (cataract) Floaters may appear from debris in vitreous humor Frank Rodrigues Normal Age Related Changes - Drusen Drusen Normal in aging adult – does not effect vision Seen in normal aging or age-related macular degeneration Drusen are yellow deposits (made up of lipids and proteins) under the retina. University of Michigan Frank Rodrigues Age Related Macular Degeneration Central vision loss due to degeneration of the macula Leading cause of vision loss and blindness among older adults Dry (Atrophic) Wet (Neovascular) Most common type Develops more rapidly Develops gradually over time Early symptom: straight lines appear wa Early symptom: blurred vision Blind spot may be visible in central visio Blind spot in central vision, stars small and grows larger over time Frank Rodrigues  Glaucoma Abnormal increase in IOP, caused by a blockage preventing outflow of vitreous humor Chronic-open angle Acute Closed Angle Slow increase in IOP Rapid increase in IOP due to Genetic sudden blockage Risk factors: family history, Medical emergency -Immediate diabetes, hypertension, treatment is needed severe myopia, older adults Risk factors: eye trauma, eye Symptoms: surgery Halo effect Symptoms: Reduced night vision Halo effect Report of eye “aching” Photophobia Frank Rodrigues Gradual loss of peripheral Eye Pain vision, moving towards Lack of pupil constriction center of vision Decreased visual acuity Cataracts Gradual clouding of the lens Can be age related, genetic, or as a result of trauma from UV exposure Can occur in newborns with maternal rubella infection Symptoms: – Cloudy/Blurred vision – Colors appear faded or yellowed – Patient may report glares and difficult with night time driving – May also report halo effect Frank Rodrigues Documenting Your Findings Frank Rodrigues Sample Write-up ROS – Eyes: Reading glasses for 5 years, bought at drugstore, no recent eye exams. Denies recent change in vision, double vision, eye pain, inflammation, discharge, lesions floaters, and flashing lights. PE – HEENT: Eyes: Acuity by Snellen chart O.D. 20/20, O.S. 20/20. PERRLA. Lids are normal with no ptosis, lid lag, discharge, or crusting. Conjunctivae clear, sclera white, no lesions or redness. Corneal light reflex symmetric bilaterally, no strabismus noted. Visual fields full by confrontation. EOMs intact, no nystagmus noted. Frank Rodrigues Fundi: discs flat with sharp margins. Vessels present in all 4 quadrants bilaterally with no A-V nicking, retinal background is clear and even in color. Macula normal in color and size.