Lecture 3: Eyes Flashcards

1
Q

Learning Objectives

A

Learn the structure and function of the external and internal components of the eyes
Learn the methods of examination of vision and external eye
Differentiate between normal and abnormal findings of the eye and vision
Record the assessment accurately

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2
Q

Abbreviations of eyes

A

OD (oculus dexter) right eye
OS (oculus sinister) left eye
OU (oculus uterque) bilateral eyes

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3
Q

External Eye Anatomy:

Eyelids

A

Protective mechanisms

Lids
Eyelashes
When lids closed, margins approximate
When lids open upper lid covers part of iris

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4
Q

External Eye Anatomy:

Canthus

A

Corners of the eye

-Lateral and Medial

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5
Q

Upslanting Palperbral Fissure

A

normal: horizontal line from lateral to medial canthus

abnormal: upslanted eyes

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6
Q

External Eye Anatomy

Conjunctiva

A

Conjunctiva
- Transparent protective covering
- Mucous membrane

pink eye: viral infection that is treated like bacterial

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7
Q

External Eye Anatomy:

Lacrimal Gland

A

Upper outer corner
Drain at puncta
Secretes tears
Provide constant irrigation to keep conjunctiva and cornea lubricated

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8
Q

Internal Anatomy:
Outer Layer
Middle Layer
Inner Layer

A

Outer layer: fibrous sclera
Middle layer: vascular choroid
Ciliary body and iris
Pupil
Lens
Anterior chamber
Inner layer: nervous retina
Transparent vitreous body
Optic disc
Retinal vessels
Macula

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9
Q

Internal Anatomy: Outer Layer
- sclera
- cornea

A

Sclera:
tough, protective, white covering
Continuous anteriorly with cornea

Cornea:
Covers iris and pupil
part of refracting media of eye
Very sensitive to touch

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10
Q

Internal Anatomy:
Middle Layer
- choroid

A

Choroid:
darkly pigmented
- prevents light from reflecting internally

heavily vascularized to deliver blood to retina
- Anteriorly is continuous with ciliary body and iris

need special equipment to examine but can see hypertension or brain tumors on occasion

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11
Q

Internal Anatomy:
Middle Layer
- ciliary body
- iris
- pupil

A

Ciliary body
Alters curvature of lens

Iris:
Contract pupil:
- in bright light
- to accommodate for near vision

Pupil: round
CN III
- Parasympathetic (“breed and feed”):: causes constriction of pupil
- Sympathetic (fight or flight) dilates pupil and elevates eyelid

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12
Q

Internal eye Anatomy: middle layer
- lens

A

Lens:
- biconvex disc located just posterior to pupil
- Transparent
- Refracts to keep a viewed object in focus on retina
- *Thickness controlled by ciliary body

  • lens more spherical to focus on near objects
  • flattens for far objects
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13
Q

Internal Anatomy:

Inner Layer
Retina

A

Retina: visual receptor
Changes light waves into nerve impulses
Retinal structures:
(optic disc
retinal vessels
general background
Macula)

Optic Disc- fibers from the retina converge to form the optic nerve

The inner layer cannot be seen with the naked eye. You need to use an opthalmoscope

This is an advanced practice skill

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14
Q

Extraocular Muscles (EOMs)

A

CN 3, 4, 6 : All 3 work together for conjugate movement of the eye or movement of both eyes in the same direction to maintain binocular gaze.

Humans require conjugate movement

Requires both muscles and nerves

CN III: Oculomotor nerve
innervates all the rest: the superior, inferior, and medial rectus and the inferior oblique muscles

CN IV: Trochlear nerve
superior oblique muscle

CN VI: Abducens nerve
lateral rectus muscle

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15
Q

Pupillary Light Reflex

A

The retina detects the brightness of light

Pupils respond by constricting

Direct light reflex:
Pupil constricts when exposed to bright light
Consensual light reflex
simultaneous constriction

The sensory afferent CN II optic nerve carries the message in

The motor efferent CN III oculomotor nerve carries the message out

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16
Q

Visual Reflexes: Accommodation

A

adaptation of eye for near vision
- Ciliary muscles contract
- Increases curvature of lens
- Pupils constrict

Tested by:
Convergence
Pupillary constriction

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17
Q

Subjective Data

A

Vision difficulty: decreased acuity, blurring, blind spots

Pain

Redness, swelling

Infections in the past

Watering

Discharge
- Color
(purluent: bacterial or watery)

History of ocular problems

Surgery

Allergies

Glaucoma

Cataracts

Macular Degeneration

Family History

Medications: for eyes and others

Use of glasses or contact lenses

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18
Q

Physical Assessment Equipment

A

Equipment needed:
Snellen eye chart
Handheld visual screener
Opaque card or occluder
Penlight
Ophthalmoscope

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19
Q

Objective Data

A

Vision-CN II- Optic
- Distance vision
- Near Vision
- Peripheral Vision

EOM’s

Fundoscopic Exam
- (advanced practice)

20
Q

Snellen Chart

A

Lines of letters arranged in decreasing size

20 feet from chart

Use opaque card to shield one eye at a time during test

Check vision with glasses/contact lenses ON
= Remove only reading glasses
= Client can miss 2 letters per line

21
Q

Testing Distance Vision

A

using snellen:

Stand client behind 20-foot line in front of Snellen
Identify use of corrective lenses
If client wears glasses, they should be left on unless they are reading glasses (reading glasses blur distance vision
Use opaque card/occluder to cover eye not being tested
Ask to client to read through chart to smallest line of letters possible
Test right eye, left eye, both eyes
Record the result using numeric fraction at the end of the last successful line read.

Indicate whether the client missed an letters and if any corrective lenses were worn

22
Q

Interpretation of Distance Vision Test

A

Numerator is the distance the patient is from the eye chart (always 20 ft)

Denominator is the distance a person with normal vision would have been able to see the eye chart

Higher the second number, the poorer the vision

Interpret 20/40 missing one letter, both eyes without glasses:
- Client can read at 20 feet what the normal eye can see from 40 feet away
- Chart- Both eyes 20/40 (-1), without glasses

  • Refer any client with vision worse than 20/30 for further evaluation
23
Q

Testing Nearsightedness

A

Jaeger :

Newsprint sized-letters
12-14 inches away
This distance equals the print size on 20-foot chart
Use corrective lenses
Normal is 14/14 in each eye

24
Q

Testing Peripheral Vision

A

Confrontation:

Confrontation
Cover eye opposite yours
Position at eye level of tester, about 2 feet away
Slowly advance wiggling finger
Gross test
Assumes acuity of tester

25
Q

Testing Color Vision

A

Ishihara Test:

Color blindness an inherited recessive X-linked trait affecting:
8% of White males
4% of African American males
rare in females

26
Q

Extraocular Muscle Function

Corneal Light Reflex

A

Corneal Light Reflex
Also known as Hirschberg test
- shine light toward eyes from 12 inches, while they stare straight ahead
- The reflection of the light should be seen same “clock location” in each eye

If you look at this picture you see the reflection of light, in the two corneas, at the same exact spot or symmetrical, about clock position 12

27
Q

Extraocular Muscle Function:

cover/uncover test

A

Have patient stare at distant object
Cover one eye with a card
then uncover
Normal: no moving
When weaker eye is covered- it will drift to a relaxed position
Once the eye is uncovered, it will quickly move back to reestablish fixation
The uncovered eye is weaker- when the stronger eye is covered, the weaker eye moves to refocus

28
Q

Extraocular Muscle Function:

Diagnostic Position Test

A

Diagnostic Position Test
- AKA 6 cardinal positions of gaze
- CN III, IV, VI
*Focus on object 12 inches away
*Coordination of movement & parallel
*Nystagmus (fine oscillating movement) normal in newborn, abnormal in adult

Draw the letter “H” in mid air and have client follow your finger

Nystagmus at extreme lateral gaze normal but at other positions could indicate multiple sclerosis, brain lesion.

29
Q

Inspection of Eyes

A

Eyebrows
-Symmetrical
-Evenly distributed

Eyelids
-Upper lids normally overlap superior part of iris
-Lids should approximate when lids are closed

Eyelashes
-Evenly distributed along lid margins and curve outward

Eyeballs
-Aligned in sockets with no protrusion or sunken appearance

Conjunctiva and sclera
- Ask person to look up; using thumbs, slide lower lids down along orbital rim
*Eyeball should look moist and glossy
- Conjunctivae should be clear and white over sclera; pink over lower lids
- Note any color change, swelling, or lesions

Corena and Lens
- Shine light from side across cornea
- Normal:
* clear, shiny, gray-blue in dark skin
- There should be no opacities (cloudiness) in:
*cornea, anterior chamber, lens behind the pupil

Iris and Pupil
Iris normally appears:
- Flat, Round ,Even coloration

Pupil normally appears
- round
- equal size in both eyes

Pupillary Light Reflex:
Darken room
Ask person to gaze into distance
this dilates pupils
Advance a light in from side and note response
Normal:
constriction of same-sided pupil (direct light reflex)
simultaneous constriction of the other pupil (consensual light reflex)

Accommodation:
Ask person to focus on a distant object
This dilates pupils
Have person shift gaze to near object, such as your finger held about 7 to 8 cm (3 inches) from nose
Normal response includes
Pupillary constriction
Convergence of axes of eyes

PERRLA
Record expected response to all these maneuvers as PERRLA
Pupils
Equal
Round
Reactive to
Light and
Accommodation
Ex. Documentation: PERRLA 4/3, react briskly

30
Q

Inspection and Palpation

A

Lacrimal Apparatus
- Normally puncta drain tears into lacrimal sac
- Presence of excessive tearing may indicate blockage of nasolacrimal duct
- Check by pressing index finger against sac
- Pressure will slightly evert lower lid

31
Q

Abnormalities of the Pupil:
Miosis

A

pinpoint pupils, constricted and fixed, narcotic drugs or brain damage

32
Q

Abnormalities of the Pupil:
Mydriasis

A

dilated and fixed pupils, from CNS injury, injury

33
Q

Abnormalities of the Pupil:
Ansiocoria

A

pupils of unequal size, could be normal or abnormal

  • Greater in bright light compared with dim light, cause could be trauma
  • Greater in dim light compared with bright light, cause could be Horner syndrome, caused by paralysis of the cervical sympathetic nerves
34
Q

Errors of Refraction

A

Refraction: bending of light rays

Myopia, Hyperopia, Presbyopia, Astigmatism

Most people have one or more of them
Refractive errors can usually be corrected with eyeglasses or contact lenses

35
Q

EOR Myopia

A

Nearsightnedness:

  • Can clearly see close objects, but distant objects are blurry
  • Light rays focus in front of the retina
    *clear near vision
    *blurry distance vision

Causes:
Globe is too long
Cornea is too curved

36
Q

EOR Hyperopia

A

Farsightedness:
- Difficulty focusing on small print
- Light focuses behind the retina
*blurry vision up close
*clear vision far away

Causes:
- Globe is too short
- Cornea is too flat in relation to the length of the eye

37
Q

EOR Presbyopia

A

Lens stiffens with age
- becomes less flexible and unable to accommodate to near
- ability to focus on small print becomes difficult

Presbyopia will happen to 100% of the population sometime during midlife

37
Q

EOR Presbyopia

A

Lens stiffens with age
- becomes less flexible and unable to accommodate to near
- ability to focus on small print becomes difficult

Presbyopia will happen to 100% of the population sometime during midlife

38
Q

EOR Astigmatism

A

When the cornea is shaped more like a football than a basketball, it causes distortion and blurry vision as light enters the eye

Instead of one focus point, there are multiple focus points when light enter the eye

39
Q

Ptosis

A

“Drooping eye”
Occurs from neuromuscular weakness (Myasthenia Gravis), oculomotor (CN III) damage, or sympathetic nerve damage (Horner’s Syndrome)
Gives the person a “sleepy” appearance and impairs vision

40
Q

Strabismus

A

Strabismus is disparity of the eye axes
Constant malalignment of the eye axis

  • Esotropia: eye turns in
  • Exotropia: eye turns out
  • Hypertropia: eye turns up
  • Hypotropia: eye turns down

These need to be identified early in life sometimes children can wear eye patches to make the eye stronger or there are surgical procedures available.

41
Q

Exophthalmos

A

“Protruding Eyes”
Forward displacement of the eyeballs and widened palpebral fissures
Upper lid rests well above the limbus (border between the cornea and sclera and white sclera is visible

Associated with thyroid disease with hyperthyroidism or an overactive thyroid

Forward displacement and widened palpebral fissures (the distance and shape between the two corners of the opening of the eye)

42
Q

Ectropion

A

Outwardly turned lower lid
The lower lid is loose and rolls out.
Puncta cannot siphon tears effectively, so excess tearing results.
Eyes feel dry and itchy because tears do not drain correctly.

43
Q

Ectropion

A

Outwardly turned lower lid
The lower lid is loose and rolls out.
Puncta cannot siphon tears effectively, so excess tearing results.
Eyes feel dry and itchy because tears do not drain correctly.

44
Q

Entropion

A

Inwardly turned lower eyelid
Lower lid rolls in because of spasm of lids or scar tissue contracting.
Constant rubbing of lashes may irritate the cornea
The person feels a “foreign body” sensation

45
Q

Periorbital Edema

A

Upper and lower lids are swollen and puffy.
Lid tissues are loosely connected so excess fluid is easily apparent.
Occurs with:
Crying
CHF
Renal failure
Allergies
Hypothyroidism

46
Q

Charting example

A

5/15/23 1120AM- Snellen 20/20 both eyes with glasses. Near 14/14 right, left, and both c ̅ glasses. Peripheral fields intact bilateral per confrontation, equal to examiner. PERRLA 4/3. EOMs intact bilateral. R eye dark brown, L eye hazel. Corneas clear. Sclera white. Conjunctiva pink. Brows and lashes dark brown full bilateral. Lid coverage symmetrical bilateral. ————————–Signature UANS