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PNP: Physical Assessment > Eyes > Flashcards

Eyes Flashcards

1
Q

Two critical periods with eye development

A
  1. During first 6 weeks of life, must have light reach the rods and cones otherwise child will be blind (critical period 1); bilateral red reflex in eye
  2. Critical period 2: needing to see an object as one (ensuring there is no double vision) within first 6 years; making sure there is no turn and no two-line-difference in eye or that parent doesn’t continually patch the eye, otherwise they will become amblyopia (can’t see out of one eye)
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2
Q

Myopia

A

NEAR-SIGHTED; Occurs when the anterior-posterior diameter of the eye is too long relative to the refracting power of the cornea and lens

  • Eyeball lengthens around the time that feet grow (around/before puberty); child may start needing classes around this type
  • Long eyeballs cause myopia
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3
Q

Hyperopia

A

FAR-SIGHTED; Hyperopic eye is too short relative to the refracting power of the eye.
– The focal point of the image occurs posterior to the retina and the image that forms on the retina is blurred.

*Babies have hyperopia

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4
Q

Astigmatism

A

Another type of refractive error that causes blurred vision.
– Astigmatism occurs because the optical system of the eye, particularly the cornea, is not perfectly spherical

*Refractive area because cornea is pointed

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5
Q

Strabismus: esotropia

A

Convergent Squint; inward deviation

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6
Q

Strabismus: exotropia

A

Divergent Squint; outward deviation

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7
Q

Latent Strabismus

A

Becomes apparent only on dissociation of the vision
of the eyes (e.g. on covering one eye) and is termed a
phoria (exophoria, esophoria, hyperphoria).

-Can be more prominent with fatigue, illness, or with lack of attention.

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8
Q

Hypertropia

A

condition of misalignment of the eyes (strabismus), whereby the visual axis of one eye is higher than the fellow fixating eye.
*Vertical strabismus: when eyes can’t look up at same level

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9
Q

Hypotropia

A

similar condition, focus being on the eye with the visual axis lower than the fellow fixating eye
*Problem looking downward

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10
Q

Esophoria

A

Characterized by tendency toward inward deviation of the eye usually due to extra- ocular muscle imbalance with good fusion

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11
Q

Exophoria

A

Form of heterophoria in which there is a tendency of the eye to deviate outward.

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12
Q

Incomitant Strabismus

A

Limited eye movement and size of deviation is different in different fields of gaze
– Occurs most commonly where there is paralysis of one or more extraocular muscles.

  • Paralysis of one of the extraocular muscles; very worrisome; can be due to myasthenia gravis, a brain tumor, congenital problems
  • need to find out what the cause is
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13
Q

Hirschberg test

A

shine light in center of eye and light should go to same place in pupil (corneal light reflex)

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14
Q

Bruckner test (red reflex)

A

Take optholmosic and stand a foot away and look at pupil in both eyes; get red reflex in each pupil

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15
Q

Cover test (two types)

A

Two types: Regular and alternating

Face patient eye-to-eye, bring palm of hand and cover one eye and count to 5 and then uncover eye, when uncovering, you are looking for any movement of the patient’s eye. Then repeat it on the opposite side. Repeat this again on both eyes one more time. There should be no movemet

  1. Regular: One eye, twice, looking for any movement
    * Picks up atropia
  2. Alternating: cover the eye, but before uncovering it, alternate back and forth from covering and uncovering the eye; look for any movement as doing the alternating cover
    * Picks up aphoria
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16
Q

Strabismic Amblyopia

A

Poor aim; one eye deviates and the eyes see different images

Results from abnormal binocular interaction.
* Causes the fovea of the two eyes to be presented with different images

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17
Q

Anisometropic amblyopia

A

Poor focus; the less hypertropic eye is preferred and the other is blurred

  1. Similar to strabismic amblyopia, the fovea in anisometropic amblyopia also are presented with different images.
  2. Caused by unequal refractive error
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18
Q

Refractive amblyopia

A

Poor clarity; severely distorted image
*Can occur with cataracts

Occurs most commonly in hyperopic patients, but it may occur in patients with myopia or astigmatism.

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19
Q

Deprivation amblyopia

A
  1. Least common and most serious type of amblyopia
  2. Severe visual deprivation due to occlusion of the visual axis or severe distortion of the foveal image.
    * When the vision doesn’t reach the back of the eye
    * Very serious becasuse when rods & cons aren’t developed you can’t see at all
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20
Q

Test for amblyopia

A

Vision Screen

  • Using Instrumentation in younger infants
  • Optotypes in children starting at age 3 year.
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21
Q

What is the best way to assess for esotropia?

A

Cover test

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22
Q

Head tilt assessment

A

Head tilt can be sign of brain tumor, strabismus, hyperopia

*MRI is the only way to evaluate a child with a new head tilt and maybe some headache
that may be an early sign of a brain tumor

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23
Q

Ocular Motility Assessment (4 steps)

A

1st: Stand or sit 3 to 6 feet in front of the child.
2nd: Ask the patient to follow your finger with their eyes without moving their head.
3rd: Check the movement of the eye in the six cardinal directions using a cross or double “H” pattern.
4th: Check convergence by moving your finger toward the bridge of the patient’s nose
* In an older child (around 8-9), take finger and head towards bridge of nose and child should cross eyes following finger in and pupils should get smaller

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24
Q

Hirschberg Test (2)

A

Corneal Light Reflex

  1. If both reflexes are located 0.5 mm nasal to the center of the pupil, the Hirschberg test is negative, and no strabismus is present
  2. If one reflex is located in a position other than 0.5 mm nasal, the Hirschberg test is positive, and strabismus is suspected
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25
Q

Cover test pearls (3)

A
  1. Watch for small, or “flick”, movements of the eye.
  2. A small angle strabismus is often not cosmetically visible and is difficult to detect with the corneal light reflex test.
  3. A small flick can be detected with the cover- uncover test.
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26
Q

Red reflex Buckner Test Steps (7 steps)

A

1st: Darken the room as much as possible.

2nd: Adjust the ophthalmoscope so that the light is
no brighter than necessary.

3rd: Adjust the aperture to a plain white circle.

4th: Set the diopter dial to zero unless you have
determined a better setting for your eyes.

5th: Use your left hand and left eye to examine
the patient’s left eye.

6h: Use your right hand and right eye to examine
the patient’s right eye.

7th: Ask the patient to stare at a point on the wall or corner of the room.

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27
Q

Buckner Test Assessment (5)

A
  1. Identify strabismus as well as asymmetric refractive errors
  2. Isometropic refractive errors=retinal reflexes are similar in appearance and brightness.
  3. If unequal refractive errors exist, the retinal reflexes will differ in brightness.
  4. if the retinal reflexes are not symmetric with the Bruckner test, anisometropia is suspected.
  5. Strabismus can also result in asymmetry of the retinal reflexes.
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28
Q

Testing Monocular Vision

A

Make sure the child cannot peek around the patch.
*Get them used to a patch by working with the child up close
Control the exam by making sure child can’t peak around the patch; have them use the patch by working with the child close up rather than at a distance; important to check one eye at a time

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29
Q

Pinhole Test for Vision screening

A
  1. Put a several small pinhole in a 3X5 inch card
  2. If the patient visual acuity improves with viewing through a pinhole, refractive error is cause of decreased vision
  3. A pinhole can improve vision to 20/30 even when there is large refractive error
  4. Useful when patient comes without glasses
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30
Q

Fixation Methods to Evaluate Vision

A
  1. Gross assessment of visual ability ! Bright or colorful object is placed in front of the child
  2. Fixation on the object is noted
  3. Move object slowly across the patient’s visual field
  4. Note whether or not the patient follows the object as it moves
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31
Q

Central Fixation to Evaluate Vision

A

Patient looks directly at the target ! Child does not look off center; follows target smoothly accurately
*With poor vision, difficulty with locking in on target; Poor fixation and poor vision

Patient should be able to follow target smoothly…

32
Q

Photorefractive Screening

A

Photorefractive screening is a vision screening technique used to screen for amblyogenic factors, such as strabismus, media opacities, and significant refractive errors, in 1 or both eyes in children

*Similar to red reflex; takes a picture you can stare at
Picture above is a mesotropia because one eye has white area on top of red reflex and the other eye has a normal red reflex

33
Q

Autorefraction

A

Can help confirm difficult or unusual refractions, as well as to refract nonverbal or uncooperative patients.
*Cannot prescribe on this alone due to accuracy issues

34
Q

Pupils (4)

A
  1. Integrity depends on intact iris, cranial nerve 2 and 3, and sympathetic nerves innervating the eye
  2. Fixate on target at far end of room
  3. Bring object near: pupils become smaller (accommodate)
  4. Child of 8 has 2.5 times more accommodative power than needed but may not be able to use it accurately or appropriately
35
Q

Hippus (3)

A
  1. Normal pupil is in continuous motion dilating
    in and out by contracting a small amount
  2. More prominent in pediatric patients exposed to bright light
  3. When you shine light on pupil it gets smaller and then slightly bigger; prominent in pediatric patients; normally occurs with a small amount of light and pupil dilates in and out; It is an abnormal sign in adult neurosurgical patients
36
Q

Normal Light Pupillary Reflex (3)

A
  1. Consensual reaction – Flash a light in one eye and other pupil reactions
  2. Direct reaction – Ipsilateral pupillary constriction
  3. Check pupil on right eye by moving light to the center until pupillary reacts (direct constriction) and look at other eye to see the consensual reaction
    * Pupil should accommodate and become smaller
37
Q

Aniscoria

A

4mm or more difference in size of right and left pupil

*Not due to drugs, ocular injury, or ocular inflammation

38
Q

Normal Swinging Flashlight Test (4)

A
  1. Swings flashlight back and forth from eye to eye
  2. Rhythmic and timing same for each eye
  3. Hold it over the pupil for 1-2 seconds, slightly below the horizon axis
  4. Both pupils will constrict strongly when light is shining into the eye
39
Q

Technique for Abnormal Pupillary Reflex

A
  1. Swings flashlight back and forth from eye to eye
  2. Rhythm and timing same for each eye
  3. Hold it over the pupil for 1-2 seconds, slightly below the horizon axis
40
Q

Marcus Gunn Pupillary Reflex

A

In Marcus Gunn pupil, the pupil where the light is shined will constrict strongly when light is shining into the eye but as light moves to illuminate the abnormal eye, both pupils dilate (react as though the light was dimmer
*The eye that dilates when the light is shown on it, is the abnormal or Marcus Gunn Pupil

41
Q

Iris Colobama

A

Isolated iris coloboma does not interfere with vision

42
Q

Aniridia

A

Absence of iris; 1/3 will have associated Wilms tumor

43
Q

Stereopsis Testing (5)

A
  1. Random dot stereogram Test distance =40 cm
  2. Perform binocularly with polarized glasses on
  3. Must locate stereo E on 4 of 5 presentations
  4. Tests child s ability to identify the location of the stereo E
  5. Patient puts on glasses and they have to see where the random dot is; Present child with figures in which you can’t see the E unless wearing the glasses
44
Q

What does photophobia and red eye mean?

A

Corneal involvement

45
Q

What does red eye and halos or rainbows mean?

A

Edema of corneal

46
Q

Assessment of the red eye: external inspection of eyes and lids (2)

A
  1. Suspect orbital injury if the eye is red at the
    limbus (the area where the iris meets the sclera).
  2. Ciliary injection and is a sign of corneal injury in a painful eye
47
Q

Limbus

A

area where iris meets the sclera; if there is limbus ciliary injection, it is a sign of corneal injury - do extraocular motility and vision screen

48
Q

Red eye: Ciliary Injection

A
  1. Injection at the limbus
  2. Lessens as it moves to the palpebral conjunctiva
  3. Seen in uveitis, Keratitis, Acute angle glaucoma
    * Can lead to blindness!
49
Q

Red eye: chemosis

A
  1. Swelling of the conjunctiva
  2. Found in acute allergic conjunctivitis and in sick children with pharyngoconjunctival fever (adenoviral infection)
    * Usually caused by allergic conjunctivitis
50
Q

Indications of Uveitis (3)

A
  1. Ciliary injection
  2. Poorly responsive pupil
  3. Photophobia
51
Q

Subconjunctival Hemorrhage

A

Blood under the conjunctiva

52
Q

Causes and signs of subconjunctival Hemorrhage

A
  1. Trauma
    - - Sudden increase of pressure in the chest (sneeze, cough, vomiting, strangulation, etc)
  2. Signs and symptoms may be associated w/
    aching if history of trauma.
  3. Hemorrhage itself does not cause pain generally
53
Q

Cause of corneal abrasian

A

Trauma, foreign body or chemical exposure

54
Q

Signs and Symptoms of Corneal Abrasian (3)

A
  1. Intense sensitivity to light, extreme pain, trouble even opening the eye
  2. Copious tearing
  3. Foreign body sensation
55
Q

Corneal abrasian diagnosis

A

Area of corneal epithelial defect stains with fluorescein dye and lights up with a blue light

56
Q

Hyphema

A

Blood in the anterior chamber (space in between iris and cornea)

57
Q

Causes of hyphema (4)

A
  1. Trauma, blunt or penetrating
  2. May be associated with other eye injury such as corneal abrasion or ppen globe
  3. Extensive subconjunctival hemorrhage
  4. Peaked pupil
58
Q

Conjunctivitis Causes (5)

A
  1. Bacterial: H. influenza (most common), Staph, Chlamydia (very uncommon now)
  2. Viral
  3. Allergic
  4. Toxicity from eye drops
  5. Contact lens related
59
Q

Signs and Symptoms of Bacterial Conjunctivitis (4)

A
  1. Conjunctiva red (eyeball and inside lid)
  2. Purulent discharge (THE hallmark)
  3. Eye lid swelling
  4. One or both eyes
60
Q

Gonococcal Conjunctivitis (3)

A
  1. If excessive purulent discharge, suspect Gonorrhea and send to ER
  2. IV antibiotics required; the one exception that is NOT cured by antibiotic eye drops
  3. GC can infect the cornea, so sight-threatening
61
Q

Viral Conjunctivitis Causes (4)

A
  1. Adenovirus
  2. Herpes Simplex Virus (HSV)
  3. Herpes Zoster Virus (HZV)
  4. Molluscum Contagiosum
62
Q

Signs and Symptoms of Viral Conjunctivitis

A
  1. Irritation, mild light sensitivity, mild FB sensation, swollen lids
  2. Mild conjunctival hyperemia to intense hyperemia with subconjunctival hemorrhages
63
Q

Exam findings of Viral Conjunctivitis

A
  1. Discharge is watery, possibly some mucous, not purulent
    * *This helps distinguish viral from bacterial
  2. Often an enlarged tender lymph node is present in front of the ear (preauricular node)
64
Q

Signs and Symptoms of Herpes

A

Can get any of the following:

  1. Skin vesicles (if present helps with diagnosis)
    * Always refer if there is a fluid filled vesicle
  2. Conjunctivitis (no characteristics to help make diagnosis)
  3. Corneal infection with classic dendrite (the Hallmark of this condition)
65
Q

Causes of Allergic Conjunctivitis

A

Usually environmental allergen; May be seasonal, associated with sneezing and congestion, or isolated

66
Q

Signs and Symptoms of Conjunctivitis

A

Itchy!!

67
Q

Physical Assessment of Allergic Conjunctivitis (4)

A
  1. Diffuse milky conjunctival hyperemia
  2. Swollen conjunctiva
  3. Tearing, maybe slight mucoid discharge
  4. Usually bilateral
  5. Occasionally bumps on tarsal conjunctiva – called follicles, another hallmark of allergy
    * With allergic conjunctivitis you can see under the upper eyelid there are follicular patterns/bumps = hallmark
    * Found in tarsal not on lower
68
Q

Blepharitis (2)

A
  1. Defined as eyelid inflammation/infection
  2. Typical cause of blepharitis (is a combo of):
    - - Staphylococcal infection at lash bases and
    - - Skin oil glands of the eyelid (meibomian glands) being inflamed
69
Q

Chalazion (4)

A
  1. Obstructed meibomian gland
  2. Causes an acute mass in lid; Like a pimple
  3. Initially tender, then not
  4. Often associated with blepharitis
70
Q

Phthiriasis palpebra

A

Lice!! Another cause of blepharitis; usually cause is pubic lice, rarely head or body lice

71
Q

Differential Diagnosis of Blepharitis

A

Phthiriasis palperbra;
Crust in lashes is red brown – not white or clear like typical blepharitis
Why? The lice live off blood so their feces (the crust) is red-brown in color

72
Q

Hypopyon

A

Pus in the anterior segment.

73
Q

Iridocyclitis

A

Inflammation of the iris

74
Q

Iridodonesis

A

Quivering of the iris when the patient moves the eye.

75
Q

Synechia

A

Adhesion between the iris and the cornea.

PNP: Physical Assessment (21 decks)

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