1. Eye and Ear Assessment and Procedures
Chapter 21
Eye and Ear Assessment and Procedures
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2. Pretest
True or False
1. Refraction refers to the bending of light rays so that they can be focused on the retina.
A person who is farsighted has a condition known as myopia.
An optometrist can perform eye surgery.
The Snellen eye test is conducted at a distance of 20 feet.
The Snellen eye chart should be positioned at the patient’s eye level.
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3. Pretest, cont. True or False
An eye instillation may be performed to treat an eye infection.
The function of cerumen is to inhibit the growth of pathogens.
The most specific type of hearing test is the tuning fork test.
Serous otitis media can result in a conductive hearing loss.
An ear instillation may be performed to treat an ear infection.
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4. Content Outline Introduction to Eye and Ear Assessment
Medical assistant is responsible for performing a variety of eye and ear assessments and procedures
Visual acuity test: screening test to detect deficiencies in vision
Hearing test: use of tuning fork or audiometer
Audiometer: instrument that emits sound waves at various frequencies
MA should be alert to signs that indicate the patient might be having difficulty hearing
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5. Introduction to Eye and Ear Assessment, cont.
Color vision assessment
Requires specially prepared colored plates
Color blindness: inability to distinguish certain colors
Red and green most common
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6. Introduction to Eye and Ear Assessment, cont.
Eye and ear irrigations and instillations
Irrigation: washing a body canal with a flowing solution
Instillation: dropping a liquid into a body cavity
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7. Visual Acuity Visual acuity: acuteness or sharpness of vision
Normal visual acuity
Can see clearly
Able to distinguish fine details
Both close up and at a distance
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8. Errors of Refraction
Errors of refraction: most common cause of defects in visual acuity
Refraction: bending of the parallel light rays coming into the eye so that they can be focused on the retina
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9. Errors of Refraction, cont.
Error of refraction: light rays are not being bent properly
Are not focused on retina adequately
Cause: defect in the shape of eyeball
Can be improved with corrective lenses
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10. Myopia Myopia (nearsighted): eyeball too long from front to back
Causes light rays to focus in front of retina
Difficulty seeing objects at a distance
May squint and have headache from eye strain
Corrective lenses (eyeglasses, contact lenses) or laser surgery: can correct condition
Cause light rays to focus on retina
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11. Myopia, cont.
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12. Hyperopia Hyperopia (farsighted): eyeball too short from front to back
Causes light rays to focus behind the retina
Difficulty viewing objects at a reading or working distance
May have blurring, headache, and eye strain while performing close-up tasks
Corrective lenses can correct condition
Cause light rays to focus on retina
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13. Hyperopia, cont.
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14. Presbyopia Presbyopia: decrease in elasticity of lens
Usually begins after age 40
Results in a decreased ability to focus clearly on close objects
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15. Eye Specialists Types of eye specialists
Ophthalmologist: medical doctor specializing in diagnosis and treatment of diseases and disorders of the eye
Prescribes ophthalmic and systemic medications
Performs eye surgery
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16. Eye Specialists, cont.
Optometrist: licensed primary health care provider who has expertise in measuring visual acuity and prescribing corrective lenses
Can diagnose and treat disorders and diseases of the eye
Prescribes ophthalmic medications
Not a physician: cannot prescribe systemic medications or perform eye surgery
Optician: professional who interprets and fills prescription for eyeglasses and contact lenses
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17. Assessment of Distance Visual Acuity (DVA)
Used to diagnose myopia
Along with other tests
Snellen eye chart: most often used
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18. Assessment of Distance Visual Acuity (DVA), cont.
Types of charts
Letters in decreasing sizes
Used for school-aged children and adults
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19. Assessment of Distance Visual Acuity (DVA), cont.
Capital letter E in decreasing sizes (arranged in different directions)
Used for preschool children, non–English-speaking people, nonreaders
Pictures of familiar objects
Used for preschoolers
Less accurate because some children are unable to identify objects
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20. Snellen Big E Chart
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21. Conducting a Snellen Test
Perform in a well-lit room free from distractions
Performed at a distance of 20 feet
Mark off with paint or tape on floor
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22. Conducting a Snellen Test, cont.
Two numbers next to each row of letters
Number above line: distance at which test is conducted (20 feet)
Number below line: distance from which a person with normal visual acuity can read the row of letters
Normal DVA: 20/20
Person can read what he or she is supposed to read at 20 feet
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23. Conducting a Snellen Test, cont.
DVA: 20/30
Smallest line the individual could read at 20 feet
People with normal acuity can read this line at 30 feet
DVA: 20/15
Indicates above-average DVA
People with normal acuity can read at 15 feet
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24. Conducting a Snellen Test, cont.
Acuity of each eye measured separately
Traditionally beginning with right eye
If patient wears eyeglasses or contact lenses (except reading glasses)
Keep them on during test
Record in chart that corrective lenses were worn
Also record if corrective lenses were not being worn
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25. Snellen Eye Test
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26. Conducting a Snellen Test, cont.
Eye occluder: held over eye not being tested
Patient's hand should not be used; may encourage peeking through fingers
Instruct patient to leave eye not being tested open
Closing eye: causes squinting of eye being tested
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27. Conducting a Snellen Test, cont.
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28. Snellen Eye Chart
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29. Assessing Distance Visual Acuity in Preschoolers
Snellen Big E chart used
Completely explain procedure to child
Tell child you will be playing a pointing game
Do not force child: results will be inaccurate
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30. Assessing Distance Visual Acuity in Preschoolers, cont.
Draw a capital E on an index card
Teach child to point in the direction of the open part of the E
Phrases to describe open part of E: "fingers" or "legs of table"
Allow child to practice
Praise child when correct
Parent may need to help child hold occluder in place
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31. Snellen Big E Chart
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32. What Would You Do? What Would You Not Do?
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33. What Would You Do? What Would You Not Do?
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34. Assessment of Near Visual Acuity (NVA)
Assesses patient's ability to read objects close up
Used to detect hyperopia and presbyopia
NVA card: contains different sizes of type
Ranging from size of newspaper headline down to very small print
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35. Assessment of Near Visual Acuity (NVA), cont.
Available in variety of forms
Printed paragraphs
Printed words
Pictures
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36. Assessment of Near Visual Acuity (NVA), cont.
To perform NVA testing:
Perform test in well-lit room free of distractions
Patient holds card at a distance of inches
Reading glasses should be worn (if patient uses them)
Each eye tested separately
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37. Assessment of Near Visual Acuity (NVA), cont.
Eye occluder held over eye not being tested
Instruct patient to keep covered eye open
Closing causes squinting of eye being tested
Patient asked to read each line or paragraph
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38. Assessment of Near Visual Acuity (NVA), cont.
Observe patient for unusual symptoms
Squinting, tilting of head, watering of eyes
Indicates patient having difficulty reading card
Patient continues until reaching smallest line that can be read
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39. Assessment of Near Visual Acuity (NVA), cont.
Record results as smallest type patient could read with each eye
Recording based on type of test card used
Also record:
Date and time
If corrective lenses worn
Unusual symptoms exhibited by patient
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40. Near Visual Acuity Chart
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41. Assessment of Color Vision
Classification of defects in color vision
Congenital defect: most common
Inherited (present at birth)
Most often affects males
Acquired defect: acquired after birth
Eye injury
Disease
Certain drugs
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42. Assessment of Color Vision, cont.
Color vision tests detect congenital color vision defects
Often performed in medical office
Basic color vision screening test
Ask patient to identify red and green lines on Snellen chart
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43. Ishihara Test Detects:
Total congenital color blindness
Red-green color blindness
Series of plates: colored dots forming a numeral against a background of dots of contrasting colors
Patients with normal color vision: read appropriate numeral
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44. Ishihara Color Plates
From Ishihara J: Tests for color blindness, Tokyo, 1920, Kanehara
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45. Ishihara Test, cont. Patients with defects read dots as:
Not forming a number at all
Forming a different number
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46. Ishihara Test, cont. First plate can be read correctly by all patients
Used to explain test procedure to patient
Plates with winding colored lines
For patients unable to identify numbers by name
Patient asked to trace line formed by the dots
Used for preschoolers and non–English-speaking persons
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47. Ishihara Test, cont. Conduct test in quiet room
Illuminated by natural daylight
Bright sunlight can change shades of color on plates
Can cause inaccurate test results
Can use electric light
Should adjust to resemble natural daylight
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48. Ishihara Test, cont.
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49. Ishihara Test, cont. Test consists of 14 color plates
Basic test: plates 1-11
Further assessment of patients with red-green deficiency: plates 12, 13, and 14
From Ishihara J: Tests for color blindness, Tokyo, 1920, Kanehara
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50. Ishihara Test, cont. Interpretation of results
Normal color vision: 10 or more plates read correctly
Color vision deficiency: 7 or fewer plates read correctly
Defect in color vision: patient referred to ophthalmologist or optometrist
For additional assessment
Use of more precise color vision tests
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51. Eye Irrigation Washing the eye with a flowing solution Purpose
Cleanse the eye by washing away:
Foreign particles
Ocular discharges
Harmful chemicals
Relieve inflammation though application of heat
Apply an antiseptic solution
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52. Eye Irrigation, cont.
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53. Eye Instillation Dropping of a liquid into lower conjunctival sac
Purpose
Treat eye infections (with medications)
Soothe an irritated eye
Dilate the pupil
Anesthetize during eye examination or treatment
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54. Eye Instillation, cont.
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55. Eye Instillation, cont.
Medications instilled in eye may come in the form of:
Liquid (ophthalmic drops)
Usually dispensed in a flexible bottle with an attached dropper
Ointment
Dispensed in a small metal tube with tip for applying medication
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56. What Would You Do? What Would You Not Do?
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57. What Would You Do? What Would You Not Do?
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58. Assessment of Hearing Acuity
Part of complete physical examination
Person can have hearing loss and not be aware of it
Early detection and treatment: may prevent permanent hearing loss
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59. Assessment of Hearing Acuity, cont.
Person with normal hearing: can hear frequencies of normal speech
Ranges from Hz (hertz or cycles per second)
Patients who exhibit hearing loss:
Referred to otolaryngologist or audiologist
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60. Conductive Hearing Loss
Conductive hearing loss: results when there is a physical interference with normal conduction of sound waves through external and middle ear
Most common type of hearing loss
Amount of sound reaching inner ear is less than normal
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61. Conductive Hearing Loss, cont.
Conductive loss in external ear
Caused by an obstruction of external ear canal
Impacted cerumen
External otitis (swimmer's ear)
Foreign bodies
Benign growths (polyps)
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62. Conductive Hearing Loss, cont.
Conductive loss in middle ear
Caused by an obstruction in middle ear
Serous otitis media (fluid in middle ear)
Acute otitis media (infection in middle ear)
Perforated tympanic membrane
Otosclerosis
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63. Conductive Hearing Loss, cont.
Cause of conductive loss: often detected by examining the ear canal with otoscope
Hearing frequently restored by:
Removing obstruction (e.g., cerumen)
Treating the disorder (e.g., serous otitis media)
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64. Sensorineural Hearing Loss
Sensorineural hearing loss: results from damage to inner ear or auditory nerve
Sound is conducted normally through outer and middle ear structures
Problem with perception of sound waves: results in a hearing deficit
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65. Sensorineural Hearing Loss, cont.
Causes
Hereditary factors
Intense noise exposure over period of time
Tumors
Changes from normal aging process
Ototoxicity caused by certain medications
Infectious diseases (measles, mumps, meningitis)
Mixed hearing loss: combination of both conductive and sensorineural loss
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66. What Would You Do? What Would You Not Do?
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67. What Would You Do? What Would You Not Do?
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68. Hearing Acuity Tests Include: Simple gross screening test
Qualitative tests: tuning fork
Highly sensitive tests: audiometry
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69. Hearing Acuity Tests, cont.
Important to test only one ear at a time
Hearing deficit may exist only in one ear
Ear not being tested: blocked by an earplug or masked
Masking: presentation of sound to ear not being tested
So patient's response is based only on hearing in ear being tested
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70. Gross Screening Test Gross screening test
Used to identify a very large hearing impairment
Whisper test: patient asked to repeat simple word or series of numbers
Whispered from a distance of 1-2 feet
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71. Tuning Fork Tests Tuning fork tests
Provide a general assessment of hearing acuity
Use of tuning fork with frequency of 512 or 1024 Hz
These frequencies fall within range of normal speech
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72. Weber Test Weber test: useful when one ear hears better than other
Fork set in vibration
Base of fork placed on center of patient's head
Patient indicates where sound is heard best
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73. Weber Test, cont.
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74. Weber Test, cont. Results of Weber test:
Normal hearing: patient hears sounds equally in both ears
Conductive hearing loss: patient hears sound better in problem ear
Sensorineural hearing loss: patient does not hear the sound as well in problem ear
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75. Rinne Test
Rinne test: compares the duration of sound perception by air conduction with that of bone conduction
Fork is set in vibration
Base of fork placed against bone of mastoid process
Patient indicates when sound is no longer heard
Prongs of fork (still vibrating) placed in the air:
1 inch from opening of ear
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76. Rinne Test, cont.
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77. Rinne Test, cont. Results of Rinne test:
Normal hearing: patient hears sound twice as long through air conduction as through bone conduction
Conductive hearing loss: patient hears the sound longer by bone conduction than by air conduction
Sensorineural hearing loss: sound is reduced; patient also hears sound longer through air conduction than through bone conduction, but not twice as long
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78. Audiometry
Audiometry: measurement of hearing acuity using an audiometer
Audiometer: an instrument that quantitatively measures the various frequencies of sound waves
Provides information on:
How extensive hearing loss is
Which frequencies are involved
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79. Audiometer Courtesy GSI [Grason-Stadler], Milford, NH.
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80. Audiometry, cont. To perform test: Conduct test in quiet room
Headphones placed snugly over ears
Each ear assessed separately
Audiometer delivers a single frequency at a time
Starts with low frequencies ( Hz) and goes to high frequencies ( Hz)
Patient signals when sound is heard
Results plotted on a graph (audiogram)
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81. Audiometry, cont. Courtesy GSI [Grason-Stadler], Milford, NH
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82. Tympanometry Tympanometry: helps determine cause of hearing loss
Not a hearing test
Tympanometer: earpiece attached to an electronic device
Courtesy GSI [Grason-Stadler], Milford, NH
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83. Tympanometry, cont. Earpiece placed snugly in patient's ear
Low-frequency sound waves are directed against eardrum
While pressure is applied in ear canal
Courtesy GSI [Grason-Stadler], Milford, NH
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84. Tympanometry, cont.
Normal ear: eardrum exhibits mobility in response to pressure
Fluid present in middle ear: eardrum will not move (remains stiff)
Used to diagnose serous otitis media
Common cause of temporary hearing loss in children
Results printed on a graphic readout: tympanogram
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85. Ear Irrigation
Washing of the external auditory canal with a flowing solution
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86. Ear Irrigation, cont. Performed to:
Cleanse external ear canal to remove:
Cerumen
Discharge
Foreign body
Relieve inflammation by applying antiseptic solution
Apply heat to ear
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87. Ear Irrigation, cont.
Impacted cerumen must be softened before removal:
By instilling warm mineral oil or hydrogen peroxide (10-15 minutes)
Do not perform irrigation if tympanic membrane is perforated
Could result in severe irritation or infection of middle ear
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88. Ear Instillation Dropping of a liquid into the external auditory canal
a. Usually dispensed in a flexible plastic
container with an attached dropper
Performed to:
Soften impacted cerumen
Combat infection with antibiotic eardrops
Relieve pain
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89. Ear Instillation, cont.
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90. Posttest
True or False
A person who cannot see objects close up has a condition known as amblyopia.
Visual acuity refers to sharpness of vision.
Presbyopia is a decrease in the elasticity of the lens due to the aging process.
An optician fills prescriptions for eyeglasses.
The Snellen Big E chart is used with school-aged children.
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91. Posttest, cont. True or False
The most common color vision defects are congenital in nature.
The external auditory canal of an adult is straightened by pulling the ear downward and backward.
The range of frequencies for normal speech is 300 to 4000 Hz.
Intense noise can result in a sensorineural hearing loss.
Tympanometry is used to diagnose patients with auditory nerve damage.
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