Eye

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Assessment of Head, Eye, Assessment of Head, Eye, Ear, Nose and Throat (HEENT)Ear, Nose and Throat (HEENT)

Hakim Shah

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Objectives Assessment of head Assessment of Eye History Inspection Eye tests

– Visual Acuity– Visual Field– Confrontation test– Corneal reflex, corneal light reflex– Pupil reaction (direct/Consensual)– Cover test– Accommodation– Convergent– Fundascopy

Finding abnormalities Documentation

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HEAD

Head - inspection and palpation– Size– shape– Symmetry– Hair distribution– Scar– Wound/wwelling– Tenderness– Lesion– Hygiene– Dandruff

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A & P of Eye

The eye is a sphere that contains 3 concentric coats: the outer fibrous sclera, the middle vascular choroid, and the inner nervous retina.

The cornea is very sensitive to touch—corneal reflex—touch of cotton– trigeminal nerve carries afferent sensation (V), facial nerve stimulates the blink (VII).

The muscles of the cilliary body control the thickness of the lens. The lense bulges for focusing on near objects. In presbyopia the lens gets harder to move/muscles lose their strength

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Cont…

The muscles in the iris control pupillary constriction. Stimulation of the parasympathetic branch of CN III causes constriction, stimulation of the sympathetic branch causes dilation. Pupil also reacts to ambient light and accomodation.

The anterior chamber is posterior to the cornea and in front of the iris and lens. It contains the aqueous humor that is produced by the ciliary body.. Intraocular pressure is determined by a balance between the amount of aqueous produced and resistance to its outflow to the angle of the anterior chamber.

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Cont…

The optic disk is the place where nerve fibers from retina converge– color varies from creamy yellow orange to pink.

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External Landmarks

Eye LidEye BrowInner canthusOuter canthusLacrimal punctumIris, pupil, conjunctiva, outer canthus

Palpebral fissure—elliptical open space between the eyelids

In the inner canthus, the caruncle is the small fleshly mass containing sebaceous glands

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Cont…

Palpebral conjunctiva —lines the lids and is clear with many blood vessels, bulbar conjunctiva overlays the eyeball—does not cover the cornea.

Limbus is the border between the cornea and sclera

Drainage of tears---lacrimal glands secrete tears which drain into the puncta, then the nasolacrimal sac, then the duct which empties into the inferior meatus of the nose.

Meibomian glands are sebaceous glands that secrete an oily lubricating material into the lids.

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Circulation of the aqueous humourCirculation of the aqueous humour

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Visual pathways Visual pathways

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Common eye complaintsCommon eye complaints

Visual changes– Loss of vision– Refractive errors

• Hyperopia (farsightedness) difficulty with close work• Myopia (near-sightedness) difficulty with distances• Presbyopia (aging vision)

– Blurred vision– Squint– Changes in color vision

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Cont…

Sudden visual loss suggests retinal detachment, vitreous hemorrhage, or occlusion of central retinal artery, also strokes, TIAs

Will see slow central loss with nuclear cataract, macular degeneration

Peripheral loss in open angle glaucoma—also discuss visual field defects.

Blurred vision gradually seen with refractive errors, also high blood sugar levels

With digitalis will see increased yellow vision, or viagra increased blue vision.

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Common ComplaintsCommon Complaints

Eye Pain– Sudden or gradual– Photophobia– Pain when you blink– Sensation of something in the eye– Headaches– Pain on movement of the eye

Redness Floaters and Flashes Tearing or dryness Discharge

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Cont…

Redness—trauma, infection, allergy, increased pressure (great chart on page 179 of your book) Pattern of redness is important

floaters=--spots in front of eyes. They are caused by condensations of vitreus humor Common after middle age—only serious if accompanied by flashes of light, if also shade over or cobweb, may mean retinal detachment

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Floater

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Cont…

Tearing or dryness or discharge Tearing overproduction of tears or obstruction of

outflow (epiphora) Dryness faulty secretion by lacrimal or accessory

tear glands—sjogren’s syndrome Discharge—can be watery, mucoid (allergic or

viral) or purulent—bacterial

Antimalarial, antituberculous, anti-glaucoma, and anti inflammatory drugs can cause eye disorders.

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Emergency Emergency

need to see ophthalmologist NOW– Pain and Sudden loss of vision– New vision changes

• Blind spot• Loss of peripheral vision• Halos around lights• Blurred vision

– Eye injury

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History and Review of SystemsHistory and Review of Systems

History– allergies– presence of disorders that affect the eye

(DM, HTN, Thyroid) – last eye exam– eye surgery– Injuries

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Cont…Cont…

-Styes– Family history

• (DM, glaucoma, macular degeneration, cataracts, strabismus, corneal dystrophy)

– Social, sexual history– Employment– Medication

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Review of systemsReview of systems

ROS– eye pain or redness– cataracts or eye pain– night vision– discharge or excess tears– Corrective lenses– diplopia, strabismus– blurred vision– photophobia

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Eye exam: areas of examinationEye exam: areas of examination

Visual acuity Visual fields Conjunctiva and

sclera Cornea, lens, and

pupils

Extraocular movements

Fundi including:– Optic disc and cup– Retina– Retinal vessels

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Vision testingVision testing

Visual Acuity (CN II)Color visionVisual fields

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Vision test

Always check vision if patient presents with any eye complaint!!!

If not assessed document reason, and plans to assess

Review OD,OS, OU hand-held version for presbyopiaColor vision—have them look at

special charts. Genetic basis

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Color vision chart

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Visual Acuity Always check visual acuity first before the rest of

exam. Also don’t want them to say they were fine until the nurse practitioner started to examine them. If they wear glasses check with glasses on.

Acuity: Snellen eye chart; patient stands 20 feet away;

each eye alone then both; numerator=distance person from chart, denominator distance normal eye can see figures. Larger denominator—worse sight. 20/200 legally blind. 20/40 refer for correction

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Cont…

If a person cannot read the largest letters on the chart, determine whether he can count fingers, detect hand motion, or perceive light.

Rosenbaum handheld checks for presbyopia

Any available print For assessing very low vision—count

fingers, detect hand motion, detect light.

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Cont…

Patient should be allowed to wear their glasses and the results are referred to as best corrected vision.

Usually give them the line if they can get more than ½ half the letters in the line

Do not have to check every line on chart. Have them start with the smallest line they are able to read.

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DocumentationVisual acuityVisual acuity

– (20/20)• distance person from chart/distance normal

eye can see figures

OD ………oculus dexter (the right eye)

OS ……… oculus sinister (the left eye)

OU ……… oculus uterque (both eyes

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Hand held versionHand held version

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Visual acuityVisual acuity

20/15-20/25 normal vision20/30-20/70 near normal vision20/80-20/160 moderate low vision.

This level usually insufficient for driver’s license

20/200-20/400 U.S. definition for legal blindness

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Visual fieldsVisual fields

Gross measure of peripheral vision.Assumes that yours is normal.May detect deficits with glaucoma,

pituitary tumors, strokesCheck this if pt complains of spots

or holes in their vision

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Cont… Visual Fields: Confrontation test . Gross measure of

peripheral vision. Assumes that yours is normal. Can also ask person to tell you how many fingers they see

Some lesions along the visual pathway may develop insidiously and the patient may not be aware of any changes in the visual fields until late in the course of the disease

A temporal defect in visual field of one eye suggests a nasal defect in the field of the other eye.

Blind spot—physiological scotoma 15-20- degrees temporal to central fixation

If you find a defect, try to establish its boundaries

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Scotoma (Blind Spot)

Age-related maculopathy

Retinitis pigmentosa

Normal field of vision.

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Visual fields by confrontationVisual fields by confrontation

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Visual inspectionVisual inspection

General EyebrowsEyelids/lashesEyeballs

Conjunctiva and Sclera

Lacrimal apparatus

Eversion of upper lid

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Normal conjunctivaNormal conjunctiva

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Lid lag or ptosis?Lid lag or ptosis?

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Herpes zosterHerpes zoster

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styestye

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Episcleritis—localized ocular redness from inflammation of the episcleral vessels. In natural light vessels appear pink, and are moveable over the scleral surface. Usually benign and self limited.

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Subconjunctival hemorrhage—usually results form trauma, bleeding disorders, or a sudden increase in venous pressure such as cough. No pain, visual, change or discharge.

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Allergic conjunctivitisAllergic conjunctivitis

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XanthelasmaXanthelasma

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BlepharitisBlepharitis

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Periorbital cellulitisPeriorbital cellulitis

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Periorbital cellulitisPeriorbital cellulitis

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EctropionEctropion

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ChalazionChalazion

Beady nodule protruding on lid. Infection or retentuion cyst of meiobian gland. Non-tender, firm , discrete swelling with freely movable skin overlying nodule. If inflamed, it points inside—not on lid margin in contrast with stye.

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May need to flip eyelidMay need to flip eyelid

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Normal FindingsNormal Findings

Orbits symmetrical eyelids smooth, nontender, no discharge tear ducts nontender and free of discharge eyelashes free of scales or granulation Adequate surface lubrication and moisture Conjunctiva clear and moist Sclera white and opaque Cornea smooth and transparent

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Extraocular muscle functionExtraocular muscle function

Alignment• Cover test• Corneal light reflex

Cardinal Fields of gaze

CN III, IV, VI

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Extra ocular muscle function Extra ocular muscle function (EOMs)(EOMs)Checking alignment and cranial

nerves III, IV, VIAlignment

– Cover test– Corneal light reflex

Cardinal fields of gaze (6 positions)

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Cover testCover test

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Extraocular movements (EOMs)Extraocular movements (EOMs)

Cardinal fields of gaze (CN III, IV, VI)– Movement that is not parallel can

indicate either a problem with muscle weakness or one of the cranial nerves.

Also checking for nystagmusCheck for lid lag here

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Accommodative strabismusAccommodative strabismus

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Which cranial nerveWhich cranial nerve

Oblique superior muscle paralysis/cranial nerve IV

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What nerve palsy is this?What nerve palsy is this?

CN6- Lateral rectus paralysis

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Anterior eyeball structuresAnterior eyeball structures

Cornea and lensCorneal light reflexCorneal reflex (CN V, CN III)IrisPupils

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PtergiumPtergium

Ptergium is a triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea, usually form the nasal side—reddening may occur intermittently, may interfere with vision as it encroaches upon the pupil

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CataractCataract

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Anterior chamber assessmentAnterior chamber assessment

Is it clear, filled with pus or blood? – Blood-hyphema– Pus-hypopyon

Chamber depth– When chamber becomes shallow, iris is

convex as it becomes bowed forward over the lens

– Shallow chamber may indicate narrow angle glaucoma (angle closure glaucoma)

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HyphemaHyphema

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PupilsPupils

Inspect:– Size– Shape– Symmetry of pupils

Pupillary inspection– Note unequal pupils, dilated and fixed pupils,

constricted pupils, no response to light Miosis—constriction Mydriasis-dilation Anisocoria-pupillary inequality

– Found in 20% of normal people

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Pupillary reaction testingPupillary reaction testing

Direct pupillary reaction to lightConsensual pupillary reaction to

lightAccomodationConvergence

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Cont…

Pupils: equal, round, reactive to light, and accomodation (PERRLA)

Unequal pupils indicative of CNS injury or aniscoria Differentiate direct and consensual. Optic nerve II responsible for afferent signal, cranial

nerve III—responsible for pupillary constriction. Accomodation: focus on distant object then shift gaze

to near object; should see pupils constrict and convergence of axis of eyes

Review findings if person is blind in one eye. Fixed dilated pupils=brain stem disease

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Cont…

Argyll Robertson—accomodates doesn’t react. CNS syphyllis, alcoholism, DM. It accomodates quickly when looking at something close.

Dilates briskly when looking at something far away

Sometimes difficult to see the pupilliary reflexes in someone with very dark eyes.

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Accommodation and convergenceAccommodation and convergence

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Horner’s syndromeHorner’s syndrome

Note the left ptosis and pupillary constriction.The affected pupil, though small, reacts briskly to light and near effort. Ptosis of the eyelid is present sometimes with loss of sweating on the forehead of the same side.

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Healing corneal abrasionHealing corneal abrasion

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Normal FindingsNormal Findings

Iris flat and circular with even bilateral pigmentation

Pupils round and equally reactive to light with proper accommodation (PERRLA)

Clear lenses

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Internal Eye StructuresInternal Eye Structures Red reflex Optic disc

– note size, color, shape, margins, Physiologic cup

Retinal vessels– note number, color, A:V ratio, A:V crossing

General background – color and clarity

Macula– size, color, location, Fovea

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Fundascopy

Observation of the fundus may show disease of the eye or abnormalities that indicate disease elsewhere in the body.

Follow red reflex from two feet away from patient, then close to the eye.

Can see vascular changes due to diabetes or hypertension, and swelling of the optic nerve head due to papilledema or optic neuritis.

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Cont…

First thing you will see is the branching blood vessels. The bigger darker ones are the veins, smaller brighter structures are the arteries. Changes in the appearance of the arteries (copper wiring) and well as alterations in the arteriovenous crossing pattern occur with atherosclerosis and hypertension. These vessels are more obvious in the superior and inferior part of the retina, normal vein to artery ratio is 3:2.

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Cont…

Then look for the disc. Follow the branches of the tree until you get to the trunk. Examine the disk for clarity of outline, color, elevation, and condition of the vessels. Usually medially. Measurement in the eye are performed using disk size. There is a great amount of normal variation in the appearance of optic disk size. The physiological cup also varies.

Then check the macula—this is lateral to the disk. This is best seen by asking the person to look directly into the light.

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Fundus (Interior of Eye) Red reflex: absent with hemorrhage or cataracts The optic disk will be slightly oval in shape, color varies

may be white, yellow, pink, or orange Physiologic cup—area inside the disk where blood vessels

exit and enter. Cup width is not more than 1/2 the disc diameter Check the background for lesions, hemorrhages Macular side temporal to disc The arteries appear brighter red and narrower than the

veins. Macula is located on the temporal side of the fundus. It is

the area of sharpest and keenest vision The one advantage of fundal exam is the ability to actually

see what the blood vellels look like inside of someone’s body

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Opthalmoscope 2 dials: one adjusts for light apertures, the other changes

lenses to correct for the refractive errors of both the examiner and the patient.

LIGHT—small aperture easier for undilated pupil, large aperture standard for dilated pupil, slit or streak helpful in determining various levels of lesions—tumors and disk swelling, green or red-free light helps distinguish veins from arteries. Veins stay blue—arteries turn black. The green light is better for viewing slight alterations in vessels, minute retinal hemorrhages, exudates, obscure changes in the macula,

Myoptic person better start with the minus lenses, hyperoptic person needs plus lenses

Grids are for measuring sizes and distances of lesions.

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Troubleshooting difficulties in using Troubleshooting difficulties in using ophthalmoscopeophthalmoscopeSmall pupilsExtranal lightImproper use of ophthalmoscopeCataract in the patientCorneal reflection

– Use small aperture, polarizing filter

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Normal FindingsNormal Findings

Optic disc flat and slightly oval or round

Optic nerve border distinctPhysiologic cup paler than optic discRetina of uniform red-orange colorMacula darker than the retina

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Hypertensive retinopathyHypertensive retinopathy

Group I– Increased light reflex from the arterioles

(copper wire appearance) Group II

– Appearance of arterial-venous crossing changes

Group III– Shiny retina with cotton wool spots,

hemorrhages may also be present Group IV

– Appearance of papilledema

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Myelinated nerve fibersMyelinated nerve fibers

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papilledemapapilledema

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Drusen bodiesDrusen bodies

Drusen bodies—consequence of the aging process and may be a precurser to macular degeneration.

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Flame hemorrhages—seen in severe hypertension, papilledema, and occlusion of the retinal vein.

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Flame hemorrhages close to the disk margin may indicate glaucoma

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Basal Cell carcinomaBasal Cell carcinoma

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Preseptal cellulitisPreseptal cellulitis

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What’s this?What’s this?

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What’s this?What’s this?

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What’s this?What’s this?

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Orbital CellulitisOrbital Cellulitis

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What do you notice about the blood What do you notice about the blood vessels?vessels?

Proliferative retinopathy

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Macular degenerationMacular degeneration

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hyphema

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??

Mature cataract

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Eye examination summaryEye examination summary

Check visual acuity in each eye Inspect lids, conjunctiva, and sclera Test visual fields by confrontation Test extraocular movements Test pupils for direct and consensual

movements Inspect corneal and iris Assess anterior chamber for depth and

clarity Perform opthalmoscopy to examine fundus

including disk, vessels and macula

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