1. . Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Eyes

2. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  "He who knows best knows how little he knows." --Thomas Jefferson

3. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Measure visual acuity, noting the following: Near vision Distant vision Peripheral vision  Inspect the eyebrows for the following: Hair texture Size Extension  Inspect the orbital area for the following: Edema Redundant tissues or edema Lesions 3

4. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Inspect the eyelids for the following: Ability to open wide and close completely Eyelash position Ptosis Fasciculations or tremors Flakiness Redness Swelling  Palpate the eyelids for nodules. 4

5. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Inspect the orbits.  Pull down the lower lids and inspect palpebral conjunctivae, bulbar conjunctiva, and sclerae for the following: Color Discharge Lacrimal gland punctum Pterygium 5

6. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Inspect the external eyes for the following: Corneal clarity Corneal sensitivity Corneal arcus Color of irides Pupillary size and shape Pupillary response to light and accommodation, afferent pupillary defect, swinging flashlight test Nystagmus 6

7. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Palpate the lacrimal gland in the superior temporal orbital rim.  Evaluate muscle balance and movement of eyes with the following: Corneal light reflex Cover-uncover test Six cardinal fields of gaze 7

8. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Ophthalmoscopic examination Lens clarity Red reflex Retinal color and lesions Characteristics of blood vessels Disc characteristics Macula characteristics Depth of anterior chamber 8

9. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Transmits visual stimuli to the brain for interpretation  Occupies orbital cavity/anterior aspect exposed  Direct embryologic extension of the brain  Attached by four rectus muscles/two oblique muscles  Innervated by cranial nerves III, IV, and VI  Connected to brain by cranial nerve II 9

10. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Composed of five structures Eyelid Conjunctiva Lacrimal gland Eye muscles Bony skull orbit 10

11. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Eyelids Distribute tears over eye surface Limit amount of light entering the eye Protect the eye from foreign bodies  Conjunctiva Protects the eye from foreign bodies and desiccation  Lacrimal gland Produces tears that moisten the eye 11

12. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Eye muscles Each eye is moved by six muscles.  Superior, inferior, medial, and lateral rectus muscles  Superior and inferior oblique muscles They are innervated by cranial nerves III (oculomotor), IV (trochlear), and VI (abducens). 12

13. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Five major structures Sclera Cornea Iris Lens Retina 13

14. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Sclera White of the eye Avascular Supports internal eye structures  Cornea Continuous with the sclera anteriorly Clear Sensory innervation for pain Major part of the refractive power of the eye 14

15. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Uvea Iris, ciliary body, and choroids Iris  Dilates/contracts to control amount of light traveling through the pupil to the retina  Lens Immediately behind the iris Changes in lens thickness allow images from varied distances to be focused on retina 15

16. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Retina Sensory network of the eye Transforms light impulses into electrical impulses Cortex interprets impulses as visual objects. Major landmarks of the retina include:  Optic disc, from which the optic nerve originates, together with the central retinal artery and vein  Macula, or fovea, is site of central vision 16

17. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Vision development depends on nervous system maturation and occurs over time Term infants hyperopic [20/400] Peripheral vision fully developed at birth Central vision develops later By 3 to 4 months of age, binocular vision development complete By 6 months, vision developed sufficiently so that the infant can differentiate colors The globe of eye grows as child’s head and brain grow, and adult visual acuity achieved at about 4 years of age 17

18. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  May have changes in vision that correct postpartum 18

19. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  The major physiologic eye change that occurs with aging is a progressive weakening of accommodation (focusing power) known as presbyopia  Loss of lens clarity and cataract formation 19

20. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Red eye (presence of conjunctival redness)  Difficulty with vision  Pain  History of eye surgery  History of recent illness or similar symptoms in the household  Allergies  Secretions  Medications 20

21. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Trauma  Eye surgery  Chronic illness that can affect vision Hypertension/atherosclerotic cardiovascular disease (ASCVD) Diabetes mellitus Glaucoma Inflammatory bowel disease Thyroid dysfunction Autoimmune diseases HIV 21

22. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Retinoblastoma (retinal cancer)  Glaucoma, macular degeneration, diabetes, hypertension,  Color blindness, cataract formation, retinal detachment, or allergies affecting the eye  Nearsightedness, farsightedness, strabismus, or amblyopia 22

23. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Employment exposure  Activities  Use of protective devices during work or activities that might endanger the eye  Corrective lenses  History of cigarette smoking (a risk factor for cataract, glaucoma, macular degeneration, thyroid eye disease) 23

24. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Preterm  Symptoms of congenital abnormalities, including failure of infant to gaze at mother’s face or other objects; failure of infant to blink when bright lights or threatening movements are directed at the face  Strabismus some or all of the time 24

25. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Young children Excessive rubbing of the eyes, frequent hordeola, inability to reach for and pick up small objects, night vision difficulties  School-age children Necessity of sitting near the front of the classroom to see the board; poor progress in school not explained by intellectual ability 25

26. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Visual acuity Decrease in central vision, distortion of central vision, use of dim or bright light to increase visual acuity, complaints of glare, difficulty in performing near work without lenses  Excess tearing  Dry eyes  Development of scleral brown spots  Nocturnal eye pain Sign of subacute angle closure and a symptom of glaucoma 26

27. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Snellen eye chart  Rosenbaum/Jaeger near vision card  Penlight  Cotton wisp  Ophthalmoscope  Eye cover, gauze, or opaque card 27

28. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Use Snellen chart.  Test each eye individually.  Test with and without corrective lenses.  Test for: Central vision Near vision Peripheral vision 28

29. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Near vision Use Rosenbaum pocket screener Each eye tested individually  Peripheral vision Estimate with confrontation test. Accurate measurement requires instrumentation  Color vision Rarely tested in the routine physical examination 29

30. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Surrounding structures Inspect eyebrows for size, extension, and hair texture. Inspect orbital area for edema, puffiness, and sagging tissue below orbit. 30

31. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Eyelid inspection Inspect closed lid for fasciculations and tremors. Check ability to close completely/open widely. Observe margin for flakiness, redness, and swelling. Look for eyelashes. Note eye opening.  Ptosis Note any eversion or inversion of lids. 31

32. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Eyelid palpation Palpate for nodules. Palpate the eye itself through closed lids.  Digital palpation tonometry  Pain 32

33. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Conjunctivae inspection Usually clear, and free of erythema Inspect lower portion by pulling down lower lid Upper lid is inspected only if foreign body is in the eye. Look for redness/exudate. Look for pterygium.  Abnormal growth of conjunctiva that extends over the cornea from the limbus 33

34. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Iris and pupil Inspect iris for pattern, color, and shape. Test for direct/consensual light response. Test pupils for accommodation.  The pupils should constrict when the eyes focus on the near object. Estimate pupil size and compare for equality.  Cornea Examine clarity of the cornea by shining light on it.  Cornea is normally avascular; blood vessels should not be present. 34

35. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Lens Inspect for transparency/clarity.  Sclera Examine to ensure that it is white. Inspect for senile hyaline plaque.  Lacrimal apparatus Inspect lacrimal gland. Palpate lower orbital rim near inner canthus. 35

36. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Inspection of interior eye with ophthalmoscope permits visualization of: Optic disc Arteries Veins Retina 36

37. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Visualize red reflex. Opacities appear as black densities.  Examine Fundus Vascular supply Disc margins Macula 37

38. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Look for unexpected findings such as: Myelinated nerve fibers Papilledema Glaucomatous cupping Drusen bodies Cotton wool bodies Hemorrhages 38

39. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Note symmetry, muscle balance, and presence of red light reflex.  Inspect lids for swelling and epicanthal folds.  Inspect sclera, conjunctiva, pupil, and iris.  Red reflex should be elicited in all newborns 39

40. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  External structure inspection same as for infant  Visual acuity tested with Snellen E game at 3 years of age  Visual acuity tested in younger children by observing activities  Peripheral vision tested in cooperative child  Cranial nerve tests same as for adult  Funduscopy requires patience 40

41. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Retinal examination helps differentiate between chronic hypertension and pregnancy-induced hypertension (PIH). Vascular tortuosity, angiosclerosis, hemorrhage, and exudates may be seen in patients with a long- standing history of hypertension. PIH changes include segmental arteriolar narrowing with a wet, glistening appearance indicative of edema. 41

42. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Extraocular muscles Strabismus: Both eyes do not focus on an object simultaneously.  Exophthalmos Bulging of eye anteriorly out of orbit  Episcleritis Inflammation of the superficial layers of the sclera anterior to the insertion of the rectus muscles 42

43. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Cataracts Opacities in the lens  Diabetic retinopathy (background) Dot hemorrhages or microaneurysms and the presence of hard and soft exudates  Diabetic retinopathy (proliferative) Development of new vessels as result of anoxic stimulation 43

44. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Glaucoma Disease of the optic nerve resulting from increased intraocular pressure 44

45. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Visual field defects Defective vision or blindness in a single eye 45

46. Copyright © 2015 by Mosby, an imprint of Elsevier Inc.  Retinal hemorrhages in infancy Occurs in infant victims of shaken-baby syndrome  Retinoblastoma Embryonal malignant tumor arising from retina 46