1. Assessment of Eyes and Ears

2. Eye Anatomy – Why Study It?

3. Why should you care?
Optometrist – Doctor of optometry, 4 year undergrad + 4 year optometry school
Ophthalmologists – Medical doctors
In general, optometrists practice primary and preventive eye care, while ophthalmologists perform eye surgery
What do nurses do?

4. History Vision difficulty? Eye pain? Childhood strabismus?
Halos around lights – in glaucoma
Scotoma – blind spot in visual field – in glaucoma, optic nerve, and visual pathway disorder
Night blindness – Vit A deficiency, glaucoma,
Eye pain?
Photophobia – inability to tolerate light
Childhood strabismus?
A history of crossed eyes? AKA “lazy eye”
Redness or swelling?
Infections?

5. History cont. Excessive or lack of tearing?
May be due to irritants or obstruction in drainage
Past history of ocular problems?
Glaucoma? Family history?
Use of glasses or contact lenses?
When tested last?
Any medications?

6. Anatomy of Eyelid
Eyelids (L. palpebrae) protect the cornea and eyeball from injury
Canthi (sing. canthus) are corners of the eye, also called angles of eye
Caruncle is located near medial canthus and contains sebaceous glands
Tarsal plates are made of connective tissue and strengthen eyelid. They contain meibomian (tarsal) glands which secrete lipid to create airtight seal when closed and also prevent eyelids from sticking together
Caruncle physiology?

7. Inspecting External Ocular Structures
General
Note if facial expression is relax or tense
Eyebrows
Note if movement is symmetrical
Eyelids and lashes
Note if any redness, swelling, discharge or lesions
Note if eyelid closes completely and if drooping
Pallor of lower lid is good indicator of anemia
For upper eyelid, use applicator stick to fold the eyelid over

8. Abnormalities in Eyelids
Ectropion
Lower lid rolls out, causing an increase in tearing
The eyes feel dry and itchy due to inappropriate itching
Increase risk for inflammation
Occurs mostly in elderly due to atrophy of elastic tissue
Entropion
The lower lid rolls in
Foreign body sensation

9. Abnormalities in Eyelids
Periorbital edema
May occur with local infection or systemic condition
Ptosis
Occurs with neuromuscular weakness (myasthenia gravis) or CN III damage

10. Lesions on the Eyelids Blepharitis Chalazion Hordeolum (Stye)
Inflammation of eyelids
Staph or dermatitis
Burning, itching, tearing, foreign body sensation, pain
Chalazion
A cyst in or an infection of meibomian gland
Nontender, firm, overlying skin freely movable
Hordeolum (Stye)
Localized Staph infection of hair follicle at lid margin
Painful, red, swollen, purulent

11. Anatomy of the Eye
Lacrimal apparatus provides irrigation of conjunctiva
Lacrimal glands – secrete lacrimal fluid (tears)
Lacrimal ducts – lacrimal fluid to conjunctiva
Lacrimal canaliculi (puncti) – drain fluid into
Nasolacrimal duct – conveys lacrimal fluid to nasal cavity

12. Inspecting the Lacrimal Apparatus
Inspect for bulges or pressure near canaliculi
Dacryocystitis
Inflammation of the lacrimal sac and/or nasolacrimal duct
Dacryoadenitis
Infection of lacrimal gland
Dacryoadenitis
Dacryocystitis

13. Anatomy of Extraocular Muscles
4 rectus (straight)
2 oblique
Innervations
SO4 – Superior oblique m.
CN IV (trochlear n.)
LR6 – Lateral rectus m.
CN VI (abducens n.)
AO3 – All other muscles
CN III ( Trigeminal n.)

14. Extraocular muscle movement

15. Extraocular Muscle Dysfunction

16. Anatomy of the Eyeball – Outer Layer
Sclera – tough protective white covering (posterior 5/6)
Cornea – transparent part of the fibrous coat covering the anterior of the eyeball (anterior 1/5)
Conjunctiva – transparent protective covering of exposed part of eye (palpebral conjunctiva covers inside of eyelash)
iris
Corneal reflex – lightly touching the eye with cotton stimulates a blink.
Trigeminal n. (afferent) Facial n. (efferent)

17. Inspection Conjunctiva Sclera
Sliding the lower lids down, observe for redness on conjunctiva and if eyeball looks moist and glossy
Reddening may be pathogenic
Sclera
Should be white, although may have gray-blue hue
Might contain yellowish fatty deposits beneath the lids
Yellowing of sclera indicates jaundice

18. Vascular Disorders of Eye
Conjunctivitis
“Pink eye”
Due to bacterial, viral, allergic, or chemical irritation
Redness throughout the conjunctiva, but usually clear around the iris
Purulent discharge usually common
Symptoms: itching, burning, foreign body sensation
Iritis
Red halo around the iris and cornea
Pupils may be irregular due to swelling
Symptoms: photophobia, blurred vision, throbbing pain

19. Inspecting Cornea and Lens
Corneal abrasion
Assess by shining a light and observing from the side
Pupillary light reflex
Charted according to size of pupil
Charted as a ratio of before light/after light (3/1)
A sluggish response may be caused by increased ICP
No response may indicate neurological damage
How to chart
pupillary light reflex?
PERRLA:
Pupils Equal, Round,
React to Light and
Accommodation

20. Anatomy of the Eyeball – Middle Layer
Canal of Schlemm
Choroid – provides vascularity to retina
Pupil – variable-sized, black circular or slit shaped opening in the center of the iris that regulates the amount of light that enters the eye. Appears black because most of the light entering the pupil is absorbed by the tissues inside the eye.
Lens – biconvex disc controlled by the ciliary muscle to produce far vision when flat
Anterior chamber
Aqueous humor is produced by the ciliary body and secreted into posterior chamber of eye.
From there, aqueous humor travels to the anterior chamber where it exits through the Canal of Schlemm
Determines intraocular pressure
Increase leads to
Glaucoma

21. Vascular Disorders of Eye
Physiology review:
Aqueous humor is produced by the ciliary body
and secreted into posterior chamber of eye. From
there, aqueous humor travels to the anterior
chamber where it exits through the Canal of Schlemm
Glaucoma
Excessive pressure in eye due to blockage of outflow from anterior chamber
This puts pressure on optic nerve
Redness around the iris, dilated pupils
Symptoms: sudden clouding of vision, sudden eye pain, and halos around lights
Excessive cup-disc ratio of optic disc

22. Disorders of Opacity of Lens
Cataract

23. Anatomy of the Eyeball – Inner Layer
Retina – visually receptive layer where light waves are changed to nerve impulses
Optic disc – area where the optic nerve enters the eyeball
Fovea centralis – area of most acute vision

24. Inspecting the Ocular Fundus
Using an ophthalmoscope to inspect the internal surface of the retina, anterior chamber, lens, and vitreous.
Darken the room to dilate the pupils
Remove eye glasses, contacts may stay in
Ask person to stare at distant object
Hold ophthalmoscope close to your eye and move to within a few inches of the person’s face
A red glow filling the pupil is called the red reflex and is caused by light reflecting off the retina
Cataracts appear as opaque black areas against the red reflex

25. Inspecting the Optic Disc and Retina
Normal optic disc is:
Yellow-orange to pink
Round or oval
Distinct margins
Normal retina is:
Arteries in each quadrant
Arteries are bright red
Scleral crescent or pigment crescent pic?

26. Visual pathways

28. Testing Visual Reflexes
Pupillary light reflex
Constriction of pupils when bright light shines on the retina
Direct light reflex – constriction of same sided pupil
Consensual light reflex – simultaneous constriction of both pupils
The impulse is carried afferently by CN II and efferently by CN III
Accommodation
Adaptation of eye for near vision
Ask person to focus on distant object (dilates the pupils). Then ask person to shift gaze to near object few inches away. A normal response is pupillary constriction and convergence of axes of the eyes

29. Testing Visual Accuity
Snellen Eye Chart
Standing 20 feet from the chart
Test one eye at a time by covering the other eye
Leave contact lenses and glasses on, unless the glasses are reading glasses
Normal vision is 20/20
Near vision
Use Jaeger card (smaller version of Snellen chart) or just read newspaper

30. Testing Visual Fields Confrontation test
Measures peripheral vision compared to examiner (assuming examiner’s vision is normal)
Both examiner and pt cover one eye with a card, stand about 2 feet away, and maintain eye contact
Advance finger, starting from periphery, and ask patient to say “now” when the finger is first visible
Inability to see when the examiner sees suggests peripheral field loss

31. Testing Ocular Muscle Function
Cover Test
Detects deviated alignment of eyes
Ask pt. to stare straight at your nose and cover one of the pt.’s eyes with a card
While noting the uncovered eye, move away the card
A normal response is a steady fixed gaze
Diagnostic Position Test
Ask pt. to hold head straight and move finger in all positions, holding it about 12 inches away
A normal response is parallel tracking of the objects with both eyes
Nystagmus
Fine oscillating movements around the iris
Normal at extreme lateral gaze

32. Developmental Considerations – Infants and Children
Strabismus – must be detected and treated early to prevent permanent disability
Esotropia – inward turning of eye
Exotropia – outward turning of eye
Color vision – due to inherited X-linked recessive trait, occurs more often in boys
External eye structures – an upward lateral slope together with epicanthal folds occurs in Down syndrome
Ophthalmia neonatum – conjunctivitis due to bacteria, virus, or chemical irritation

33. Developmental Considerations – Aging
Decrease in visual acuity, diminished peripheral vision
Ectropion (drooping of lower lid) or entropion (eyelids turning in)
Pinguecula – yellow nodules due to thickening of conjunctiva as a result of prolonged exposure to sun, wind, and dust

34. Developmental Considerations - Aging
Arcus senilis – gray-white arc seen around the cornea. Due to deposition of lipids. No effect on vision
Xanthelasma – raised yellow plaques. Normal

35. Ear Anatomy

36. Ear Physiology External Ear Middle ear Inner ear
External auditory meatus funnels sound waves, which reflect off the tympanic membrane to produce vibrations
Cerumen (ear wax) protects the tympanic membrane from foreign substances
Middle ear
Malleus, incus, and stapes and eustachian tube
Function to:
Conduct sound vibrations from tympanic membrane (outer ear) to cochlea (inner ear)
Protect the cochlea by reducing the amplitude of sounds
Eustachian tube allows equalization of air pressure
Inner ear
Vestibule and semicircular canals
Allow brain to sense body position and relation of angle of head to gravity
Cochlea
Transfers vibrations from stapes into nerve impulses

37. The outer ear catches the waves of sound and funnels them down the ear canal (about an inch long) and flush up against the ear drum. The ear drum (tympanic membrane) is the boundary between the outer ear and the middle ear.

38. In the middle ear, the malleus picks up the vibrations from the eardrum, passes them to the incus which then passes them to the stapes. The stapes terminates in a tiny footplate that fits precisely into the contact point or window of the inner ear.

39. The window of the inner ear is the contact point of the cochlea
The window of the inner ear is the contact point of the cochlea. The vibrations set up rolling waves in the cochlear fluid which stimulate different areas of the membrane, which rubs against specialized cells called hair cells. This friction creates electrical impulses transmitted by the cochlear nerve.

40. CN VIII is responsible for signal transduction from vestibule and cochlea to the brainstem. From brainstem, a signal is sent to the cerebral cortex to interpret the sound.

41. Hearing Loss Conductive Sensorineural
Mechanical dysfunction of external or middle ear
Partial hearing loss
May be caused by impacted cerumen, foreign bodies, perforated tympanic membrane, pus or serum in middle ear, or otosclerosis (hardening of stapes)
May be fixed
Sensorineural
Dysfunction of inner ear, CN VIII, or cerebral cortex
Cannot be fixed
Otosclerosis – decrease in mobility of oscicle

42. Developmental Considerations
Infants
Greater risk for otitis media (middle ear infections) due to shorter eustachian tube
Aging
Cilia lining ear canal become coarse and stiff, impeding sound waves
Cerumen more common
Dry cerumen – gray and flaky. More common in Asians and Native Americans
Wet cerumen – brown and moist. More common in whites and blacks
Presbycusis - degenerative sensorineural hearing loss
Auditory reaction time increases

43. Obtaining History Earaches? (otalgia) Infections?
Location, character, intensity, associative and alleviating factors
May be directly due to ear disease or maybe referred pain from a problem in teeth or oropharynx
A viral or bacterial upper respiratory infection may migrate up the eustachian tube and involve the middle ear
Infections?
Frequency? Occurred in childhood?
Discharge? (otorrhea)
May suggest infection or perforated eardrum
Typically with perforation, ear pain  drainage
Otitis externa – purulent, sanguineous, or watery
Acute otitis media with perforation – purulent discharge

44. More History Trouble hearing? Ringing in ears? (tinnitus) Medications?
Gradual our sudden?
Presbycusis – gradual sensorineural hearing impairment in the elderly
Hearing loss due to trauma is often sudden
Ringing in ears? (tinnitus)
May be a result of medication
Medications?
Some are ototoxic
Vertigo? (spinning)
Subjective – person feels like he or she spins
Objective – person feels like room spins
Environmental noise
Noise-induced hearing loss

45. Lesions of External Ear
Otitis Externa
Gouty Tophi

46. Assessing External Ear
Size and Shape
normal is 4-10cm tall
Skin conditions
Note edema, inflammation, lesions
Tenderness
Location?
Pain in pinna indicates otitis externa
Pain at mastoid process indicates mastoiditis or lymphadenitis
External Auditory Meatus
Atresia – absence or closure of ear canal
Otitis externa may cause purulent discharge
Otitis media may cause rupture of tympanic membrane
If drainage present following trauma, possible basal skull fracture. Perform glucose test (CSF (+) for glucose).

47. Inspecting Using Otoscope
Pull the pinna up and back in adult, straight down in children under 3 years
Hold otoscope upside down and place dorsal side of hand along person’s cheek
Insert speculum slowly and avoid touching the inner section of canal wall, which is sensitive and may cause pain.

48. Inspecting the External Canal
Note any redness or swelling, lesions, or foreign bodies
If discharge present, note color and odor
Otitis
Externa

49. Inspecting the Tympanic Membrane
Normal is shiny and translucent
Flat, slightly pulled in at the center
Valsalva maneuver causes tympanic membrane to flutter, used to assess drum mobility
Which tympanic membrane
is perforated?

50. Testing Hearing Acuity
Voice test
Whisper two syllable words into one of the person’s ears, while covering the other one. Ask person to repeat what you’ve said.
Tuning fork tests
Measure hearing by air conduction or bone conduction
Weber test
Rinne test

51. Weber Test
Tuning fork is struck and placed on head or forehead, equal distance from both ears
Used to determine if hearing loss is more extensive in one ear than the other
This test cannot confirm normal hearing, because hearing defects affecting both ears equally will produce an apparently normal test result

52. Rinne Test Compares air conduction and bone conduction
Place stem of vibrating fork on mastoid process and ask when sound goes away
Quickly invert the fork so the vibrating end is near the ear canal. The person should still hear a sound
Normally the sound is heard longer by air conduction rather than bone conduction
In conductive hearing loss, sound heard longer by bone conduction

53. Normal Hearing

54. Conductive Hearing Loss

55. Sensorineural Hearing Loss

56. Infants and Children Save otoscopic examination until the end
May help to show otoscope to child and let him or her play with it
Stabilize (or ask a parent for help) the child’s head in order to prevent movement
Pull pinna straight down
In infants, the tympanic membrane may look thick and opaque after first few days or after crying
Tympanostomy tubes may be in place if drainage occurs as a result of otitis media

57. Abnormalities in the Ear Canal
Acute Otitis Media
Otitis Externa
Excessive Cerumen