Eye Examination PDF

- Prof. Wafa Attoof ‫المرحلة الثانية‬ 1 Eye Examination ◼ Introduction: eye transmits visual stimuli the brain for interpretation and doing so function the organ of vision ◼ Anatomy &physiology:- 1-External Structures of the Eyes ◼ 1- Eyelids(palpebra) ◼...

- Prof. Wafa Attoof ‫المرحلة الثانية‬ 1 Eye Examination ◼ Introduction: eye transmits visual stimuli the brain for interpretation and doing so function the organ of vision ◼ Anatomy &physiology:- 1-External Structures of the Eyes ◼ 1- Eyelids(palpebra) ◼ 2-Conjunctiva ◼ 3-Lacrimal glands ◼ 4- Extraocular Muscles 2 External eye & lacrimal apparatus ◼ Extraocular movements ◼ Medial ◼ Lateral ◼ Upward ◼ Downward 3 Extraocular Muscles 2-Internal Structures ◼ 1- Outer layer: sclera ,cornea ◼ 2-Middle layer: choroid , ciliary body , iris ,lens ,pupil , chamber ◼ 3-Inner layer : retina , optic disc 4 Visual Pathway 5 Health History nursing assessment of the eyes Subjective Data: Patient profile ◼ Age - Cataract (congenital, elderly) - Presbyopia(middle age) - Hypertensive retinopathy (middle age to elderly) - Glaucoma (middle age to elderly) - Macular degeneration( elderly) - Entropion , Ectropion( elderly) - Dry eyes( elderly) ◼ Gender - Female: dry eyes , thyroid-related ophthalmopathy ◼ Race - Glaucoma (Amirican ,African) Nursing History Chief Compliant Question Rationale Visual Problems Sudden changes in vision are - Describe any recent changes in your associated with acute problems such vision. Were they sudden as head trauma or increased or gradual? intracranial pressure. Do you see spots or floaters in front Spots or floaters are common among of your eyes? clients with myopia or in clients over age 40. Do you experience blind spots? Are A scotoma is a blind spot that is they constant or intermittent? surrounded by either normal or slightly diminished peripheral vision Do you see halos or rings around Seeing halos around lights is associated lights? with narrow-angle glaucoma. 6  - Do you have trouble seeing at Night blindness is associated with optic night? atrophy, glaucoma, and vitamin A deficiency Do you experience double vision? Double vision (diplopia) may indicate increased intracranial pressure due to injury or a tumor Other Symptoms Burning or itching pain is usually - Do you have any eye pain or associated with allergies or itching? Describe superficial irritation. Throbbing, stabbing, or deep, aching pain suggests a foreign body in the eye or changes within the eye. Do you have any redness or swelling Redness or swelling of the eye is in your eyes? usually related to an inflammatory response caused by allergy, foreign body, or bacterial or viral infection - Do you experience excessive Excessive tearing (epiphora) is caused watering or tearing of the eye? One by exposure to irritants or obstruction eye or both eyes? of the lacrimal apparatus. - Have you had any eye discharge? Discharge other than tears from one or Describe. both eyes suggests a bacterial or viral infection 1- Change in visual acuity: Change in ability to see clearly ▪ Location One eye or both ▪ Quality Dimming of vision ,blurred vision, diplopia, visual field loss 7 ▪ Associated manifestations Headache rhinorrhea, sneezing, vertigo ,floaters ▪ Aggravating factors Allergens ,stress ,lack of sleep ,decreased lighting ,darkness ▪ Alleviating factors Improved lighting ,medication ▪ ,corrective glasses, rest or sleep ▪ Setting Working environment ,increased reading, computer work ▪ Timing With aging ,at night ,after trauma ,with or after a headache 2- Pain ▪ Quality Aching, sharp, throbbing, burning ▪ Associated manifestations Drainage , conjunctival injection, decreased vision, herpes simplex ▪ aggravating factors Foreign body in the eye, sunlight or very bright light, contact lens, allergen ▪ alleviating factors Closing of eyes, removal of cont acts, medication, sunglasses ▪ setting Work environment ▪ timing Sudden onset ,gradual onset ,with reading 3-Drainage ▪ Quality Type, color ▪ Associated manifestations Crusting on the lids ,pain , itching, redness of the eye or lids ▪ Aggravating factors Allergens, eye makeup ,poor hygiene 8 ▪ Alleviating factors Medication ,hypoallergenic or no eye makeup ,good hand washing ▪ Setting Swimming pool ▪ Timing In the morning ,continuous, intermittent, seasonal 4- Itching ▪ Quality Mild , sever ▪ Associated manifestations Rhinitis ,sneezing ,drainage ,burning sensation in the eye ,headache ▪ Aggravating factors Allergens, contact lenses eye makeup ▪ Alleviating factors Medication ,cold compresses to the eye ,avoid allergens & makeup ▪ Setting Indoor, outdoor ▪ Timing Seasonal ,intermittent, continuous 5- Dryness ▪ Associated manifestations With systematic disease ,redness of eye ,itching , ▪ Aggravating factors Decrease humidity, reading ▪ Alleviating factors Artificial tears, humidified air ▪ Setting Indoor, outdoor ▪ Timing With aging ,winter, post menopause 9  Question rational PAST HEALTH HISTORY A history of eye problems or changes in Have you ever had problems with your vision provides clues to the current eyes or vision? health of the eye. Have you ever had eye surgery? Surgery may alter the appearance of Describe any past treatments you have the eye and the results of future received for eye problems examinations. (medication, surgery, laser treatments, Client may not be satisfied with past corrective lenses). treatments for vision problems Were these successful? Were you satisfied? FAMILY HISTORY Many eye disorders have familial -Is there a history of eye problems or tendencies. Examples include vision loss in your family? glaucoma, refraction errors, and allergies. LIFESTYLE AND HEALTH PRACTICES Injuries or diseases may be related to - Are you exposed to conditions or exposure in the workplace or home. substances in the workplace or home that These problems can be minimized or may harm your eyes or vision (e.g. avoided altogether with hazard chemicals, fumes, smoke, dust, or flying identification and implementation of sparks)? to harmful substances? safety measures. - Do you wear sunglasses during exposure -Exposure to ultraviolet radiation puts to the sun? the client at risk for the development of cataracts - What types of medications do you take? -Some medications have ocular side effects such as corticosteroids,lovastatin, - Has your vision loss pyridostigmine, quinidine. affected your ability to care for yourself? - Vision problems may interfere with To work? the client’s ability to perform usual activities of daily living. - When was your last eye examination? -A thorough eye examination is recommended for healthy clients every 2 years. 10 - Do you have a prescription for corrective lenses (glasses or contacts)? Do -The amount of time the client wears you wear them regularly? the corrective lenses provides information on the severity of the visual problem. Equipment ◼ Snellen or E chart ◼ Hand-held Snellen card or near vision screener ◼ Penlight ◼ Opaque cards ◼ Ophthalmoscope ◼ Disposable gloves (wear as needed to prevent spreading infection or coming in contact with exudate) Assessment of the eye(objective) ◼ Determination of Visual Acuity:-CN II 1-Distance Vision- 2-Near Vision 3-Color Vision ◼ Determination of Visual fields:-CN II ◼ Assessment of the external eye & lacrimal apparatus 1-Eyelids, eyelashes , eyebrows 2- lacrimal apparatus ◼ Evaluation of Extraocular muscle function-CN III,IV,VI 1-Corneal light reflex(Hirschberg Test) 2-Cover /uncover Test 3- Cardinal Fields of gaze (Extraocular Muscle Movements) 11  ◼ Assessment of the anterior segment structures: -Conjunctiva ,Sclera, Cornea, Anterior Chamber, Pupil, Lens ◼ Assessment of the posterior segment structures: CN II 1-Retinal structures 2-Macula(ophthalmoscope) Objective Data Test name normal abnormal Distance Vision Normal distant Myopia(nearsightedness 20F from the Snellen or acuity is 20/20 with impaired far vision(20/40) E chart or without Amblyopia: permanent loss of corrective lenses visual acuity resulting from strabismus that was not corrected in early childhood Near Vision Normal near vision Hyperopia (farsightedness) Hold hand held vision chart 14/14with or Presbyopia :impaired near 14 inches from eyes without corrective vision lenses Color Vision Identify colors Color vision defect red/green, correctly blue/yellow, or complete-gray Distance Visual Acuity Testing VA - Visual acuity ◼ OD ………………… oculus dexter (the right eye) OS ………………… oculus sinister (the left eye) OU ………………… oculus uterque (both eyes) ◼ Place patient at 20 ft from Snellen chart ◼ OD then OS 12  ◼ VA is line in which > ½ letters are read ◼ For example, 20/40 means that at 20 feet the patient can only read letters a "normal" person can read from twice that distance Visual fields Assessment of the external eye & lacrimal apparatus 1-Eyelids,eyelashes,eyebrows 2- lacrimal apparatus Examination Technique Normal Findings Abnormal Findings Inspection and Palpation The upper lid margin Ptosis: Drooping of the Inspect the eyelids, should be between upper lid may be attributed the upper margin of the eyebrows, and eyelashes. to oculomotor nerve iris and the upper -Note width and position of margin of the pupil. damage. palpebral fissures. 13 -Blinking -symmetrical, involuntary movement, 15 blink/min. Assess ability of eyelids to -The upper - Retracted lid margins, close. and lower lids close which allow for easily and meet viewing of the sclera when completely when the eyes are open, closed. suggested hyperthyroidism. Exophthalmos Lagophthalmos: Failure of lids to close completely puts -Note the position of the - The lower eyelid client at n inverted lower lid eyelids in comparison is upright with no which risk for corneal with the eyeballs. Also note inward or outward damage any unusual turning. Entropion: A may cause Turnings, Color Eyelashes are pain and injure Swelling Lesions evenly distributed Ectropion: an averted lower Discharge and curve outward eyelid, results in exposure along the lid and drying of the conjunctiv margins - Observe for redness, Skin on both blepharitis,: Redness and swelling, discharge, or eyelids is without crusting along the lid lesions. redness, margins swelling, or Suggest an infection caused lesions. by staphylococcus Hordeolum :a hair follicle infection, causes local redness, swelling, and pain. Chalazion:, an infection of the meibomian gland (located in the eyelid), - Observe the position -Eyeballs are Exophthalmos: Protrusion of and alignment of symmetrically the eyeballs accompanied - the eyeball in the eye aligned in sockets by retracted eyelid margins socket. without protruding is termed or sinking. Sunken eyeballs with dehydration seen 14  Testing Extraocular Muscle Function Assessment Procedure Normal Findings Abnormal Findings Perform corneal light reflex The reflection of Asymmetric position of the test. This test assesses parallel light on the corneas light reflex indicates. alignment of the eyes. Hold a should be in the Deviated alignment :may penlight approximately12 exact same spot on due to muscle weakness or inches from the client’s face. each eye, which paralysis. Shine the light toward the indicates parallel Strabismus(tropia) ‫ حول‬:a bridge of the nose while the alignment. constant misalignment one client stares straight ahead. eye being deviated. Note the light reflected on the Esotropia: eye turns corneas. inward Exotropia :eye turns outward Perform cover/uncover test. The uncovered eye phoria: ‫ الحول‬latent The cover test detects should remain fixed misalignment of an deviation in alignment or straight ahead. The eye,exist. strength and slight deviations covered eye should Esophoria: nasal or inward in eye movement remain fixed drift‫احوالل إنسي‬ by interrupting the fusion straight ahead after Exophoria:a temporal or reflex that normally keeps the being out ward drift eyes parallel. uncovered. ‫حول للخارج‬ Perform the positions Eye movement Failure of eyes to follow test/cardinal field of should be smooth movement symmetrically gaze(Extraocular Muscle and symmetric in any or all directions Movement) assesses eye throughout all six indicates a weakness in muscle strength and cranial directions. one or more extraocular nerve function. muscles or dysfunction of the cranial nerve that innervates the particular muscle. Nystagmus :involuntary movement ‫الرأرأة تذبذب المقلتين السريع‬ ‫الإلرادي‬ 15 Amblyopia(strabismus Extraocular muscle function ◼ Corneal light reflex (Hirschberg Test) Extraocular muscle function 16  Anterior segment structures Conjunctiva ,Sclera, Cornea, Anterior Chamber, Pupil, Lens Assessment Procedure Normal Findings Abnormal Findings Inspect the bulbar Bulbar conjunctiva is Conjunctivitis :(pink conjunctiva and clear, moist, and eye). sclera. smooth. Underlying Generalized redness of -Observe clarity, structures are clearly the conjunctiva color, and texture. visible. Sclera is white. Areas of dryness are -Inspect the palpebral -The lower and upper associated with conjunctiva. palpebral conjunctivae allergies or trauma. are clear and free of -Pterygium: a benign swelling or lesions. growth of the conjunctiva caused by ultraviolet-light exposure (e.g., sunlight), -Cyanosis of the lower lid suggests a heart or lung d disorder Inspect the lacrimal -No swelling or redness -Swelling of the apparatus. should appear over lacrimal gland may be areas of the lacrimal visible in the lateral gland. aspect of the upper eyelid. This may be caused by blockage, infection, or an inflammatory condition. Palpate the lacrimal No drainage should be Dacryocystitis: apparatus. noted from the Expressed drainage to palpate the puncta when palpating from the puncta on nasolacrimal the nasolacrimal duct. palpation occurs with duct to assess for duct blockage. blockage 17 External eye & lacrimal apparatus Assessment Procedure Normal Findings Abnormal Findings Inspect the cornea and The cornea is roughness or dryness lens. transparent with no on the cornea are opacities. often associated with The oblique view injury or allergic shows a smooth and responses. overall moist surface; the lens is free of opacities. Inspect the iris and The iris is typically Irregularly shaped pupil round, flat, and evenly irises, miosis, mydriasis Inspect shape and colored. ,and anisocoria. color of iris and size and shape of pupil. Test pupillary reaction The normal direct Monocular blindness to light. pupillary response is can be detected when constriction. light directed to the blind eye results in no response in either pupil. Test accommodation The normal pupillary Pupils do not constrict; of pupils. response is eyes do not converge. constriction of the pupils and convergence of the eyes when focusing on a near object (accommodation and convergence). 18 Assessment Procedure Normal Findings Abnormal Findings Anterior chamber The entire iris will be Glaucoma: increased illuminated pressure in the eyeballs lead to damage to optic nerve iris Color distributed over Hyphemia: bleeding the iris, smooth, from vessels in the iris mosaic variant lens Is transparent in color Cataract :cloudiness in the lens posterior segment structures 1-Retinal structures 2-Macula(ophthalmoscope Assessment Procedure Normal Findings Abnormal Findings Inspect the optic disc The optic disc should Papilledema, or be round to swelling of the optic oval with sharp, well- disc, appears as a defined borders swollen disc with blurred margins, a hyperemic The intraocular pressure associated with glaucoma Optic atrophy is evidenced by the disc being white in color and a lack of disc vessels. Observe the The ratio of arteriole arteriovenous (AV) diameter to vein ratio diameter (AV ratio) is 2:3 or 4:5. 19 Inspect retinal General background Cotton-wool patches background. appears consistent (soft exudates) and in texture. The red- hard exudates from orange color of the diabetes and background is lighter hypertension appear near the optic disc. as light-colored spots on the retinal background. Hemorrhages and microaneurysms appear as red spots and streaks on the retinal background Inspect fovea (sharpest The macula is the Excessive clumped area of vision) darker area, one disc pigment appears with and macula. diameter in size, detached retinas or located to the retinal injuries. temporal side of the Macular degeneration optic disc. Within this may be due to area is a star like light hemorrhages, reflex called the fovea. exudates, or cysts. Inspect anterior The anterior chamber Hyphemia occurs when chamber. is transparent. injury causes red blood cells to collect in the lower half of the anterior chamber Posterior segment structures by Ophthalmoscopic Exam ◼ Retinal structures : You should see the retina as a "red reflex." ◼ Macula: Normal color should be creamy yellow-orange to pink. ◼ Diopters are used to measure the power of a lens. Disc swelling, venous engorgement, cotton-wool spots and diffuse retinal hemorrhage. 20 Glaucoma ❖ Risk factors: Old age Myopia African-American race Blood Hypertension Family History Diabetes Mellitus High IOP Smoking ❖ Classification: open-angle glaucoma vs. angle-closure glaucoma primary vs. secondary Cataract ▪ congenital vs. acquired ▪ often age-related ▪ different forms (nuclear, cortical, PSCC) ▪ reversible ▪ very successful surgery Age-Related Macular Degeneration Nursing Diagnosis 1- Disturbed visual sensory perception : - Aging , Stress. 2- Deficient diversional activity : - Poor vision , physical limiter. 3-opportunity to enhance visual integrity 4-Risk for eye injury related to hazardous work area or participation in high level contact sports. 21