1. Today's Medical Assistant
2nd edition
Chapter 21
Eye and Ear Assessment and Procedures

2. Introduction to the Eye
MA is responsible for performing a variety of eye assessments and procedures
Visual acuity test: screening test to detect deficiencies in vision
What type of procedures might be performed by a medical assistant who is employed by an ophthalmologist?
What types of procedures might be performed by a medical assistant who is employed by an ENT specialist?
What signs would alert the MA that a patient has a hearing problem?

3. Introduction to the Eye
Color visions assessment
Requires specially prepared colored plates
Color blindness: inability to distinguish certain colors
Red and green most common
Why is it important for a person to see red and green colors?
What types of jobs would it not be possible for an individual with a color deficiency to do?

4. Introduction to the Eye
Eye irrigations and instillations
Irrigation: Washing a body canal with a flowing solution
Instillation: Dropping a liquid into a body cavity
Why would an eye irrigation be performed?
Why would an eye instillation be performed?

5. Visual Acuity Visual acuity: Acuteness or sharpness of vision
Normal visual acuity:
Can see clearly
Able to distinguish fine details
Close up and at a distance
Normal visual acuity is 20/20.
What symptoms might be exhibited by a child with a visual acuity problem?

6. Visual Acuity
Errors of refraction: most common cause of defects in visual acuity
Refraction: Bending of the parallel light rays coming into the eye so they can be focused on the retina
Notice the point of focus on the slide.

7. Visual Acuity
Errors of refraction: most common cause of defects in visual acuity
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
What are the types of lenses available for a patient?
Is there a corrective surgery available for errors of refraction?

8. Visual Acuity
Errors of refraction: most common cause of defects in visual acuity
Myopia (nearsighted): Eyeball is too long from front to back
Causes light rays to be brought to a focus in front of retina
Difficulty seeing objects at a distance
May squint and have HA from eye strain
Corrective lenses (eyeglasses, contact lenses) or laser surgery can correct the condition - allows light rays to come to a focus on the retina
What is another problem school children may have in addition to squinting?

9. Visual Acuity
Errors of refraction: most common cause of defects in visual acuity
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 the condition - cause light rays to focus on the retina
A convex plus lens is used in corrective lenses.

10. Visual Acuity
Errors of refraction: most common cause of defects in visual acuity
Astigmatism:
Causes distorted and blurred vision for both near and far objects
Normal cornea - round or spherical shape; smooth
With astigmatism: cornea is curved into an oval shape - causes light rays to focus on two different points on the retina (instead of one point); results in distorted and blurred vision
Often occurs with myopia or hyperopia
Can be corrected with corrective lens

11. Visual Acuity
Errors of refraction: most common cause of defects in visual acuity
Presbyopia: Decrease in elasticity of lens
Usually begins after age 40 years
Results in a decreased ability to focus clearly on close objects
Can be corrected with corrective lenses (reading glasses)
Are corrective lenses used for this condition?
What are bifocals?
What technological advances have occurred in the manufacturing of bifocals?

12. Visual Acuity Types of eye specialists
Ophthalmologist: Physician specializing in the diagnosis and treatment of diseases and disorders of the eye
Prescribes ophthalmic and systemic medications
Performs eye surgery
Optometrist: Licensed primary healthcare 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
What are some examples of eye diseases and disorders that are handled by an ophthalmologist?
List one type of eye surgery.

13. Assessment of Distance Visual Acuity (DVA)
Used to diagnose myopia
Along with other tests
Snellen eye chart most often used
What other tests can be used to diagnose myopia?
Describe the different products available for a Snellen eye chart (example: lighted view box) and discuss the advantages and disadvantages of each.

14. Assessment of Distance Visual Acuity (DVA)
Types of charts
Letters in decreasing sizes
Used for school-aged children and adults
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
The MA should explain the test to the patient before the procedure.
Why shouldn’t the patient be allowed to “study” the chart before the examination?
Should corrective lenses be left on during this examination?

15. 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
Two numbers next to each row of letters
Number above the line: distance at which the test is conducted (20 feet)
Number below the 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
Why should the area be well lit?
Why should the test be performed at a distance of 20 feet?
Give some examples of areas in the medical office in which a distance of 20 feet is available.

16. Conducting a Snellen Test
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
What is meant by a DVA of 20/80?

17. Conducting a Snellen Test
Acuity of each eye is 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
How would you chart that corrective lenses were worn by the patient?

18. Conducting a Snellen Test
Snellen Eye Test

19. Conducting a Snellen Test
Eye occluder: held over eye not being tested
Patient's hand should not be tested
May encourage peaking through fingers - especially in children
Instruct patient to leave eye not being tested open
Closing eye: causes squinting of eye being tested
What would the MA use to disinfect the eye occluder?
How does squinting temporarily affect vision?

20. Conducting a Snellen Test
Snellen Eye Chart

21. Assessing Distance Visual Acuity in Preschoolers
Snellen Big E chart used
Explain the procedure completely to child
Tell child you will be playing a pointing game
Do not force child: results will be inaccurate
Draw a capital E on an index card
Teach child to point in the direction of the open part of the E
By turning the card in different directions
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
What would be the best way to communicate with a child who refuses to perform the examination?

22. Assessing Distance Visual Acuity in Preschoolers
Instructing Child

23. Assessing Distance Visual Acuity in Preschoolers
Snellen Big E Chart

24. Assessment of Near Visual Acuity (NVA)
Assesses patient's ability to read objects close up
At a reading or working distance
Used to detect hyperopia and presbyopia
NVA card: contains different sizes of type:
Ranging from size of newspaper headline down to very small print
Available in a variety of forms:
Printed paragraphs
Printed words
Pictures
The physician may order a visual acuity test if there has been an injury to the eye.
What is the difference between hyperopia and presbyopia?

25. Assessment of Near Visual Acuity (NVA)
To perform NVA testing:
Perform test in well-lit room free of distractions
Patient holds card at a distance of 14 to 16 inches
Reading glasses should be worn (if patient uses them)
Each eye should be tested separately
Eye occluder held over eye not being tested
Instruct patient to keep covered eye open - closing causes squinting of eye being tested
Patient is asked to read each line or paragraph
Why would the patient keep his or her reading glasses on for this test?

26. Assessment of Near Visual Acuity (NVA)
To perform NVA testing:
Observe patient for unusual symptoms
Squinting, tilting of head, watering of eyes - indicates patient is having difficult reading the card
Patient continues until reaching smallest line that can be read
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 are worn
Unusual symptoms exhibited by patient
How would you chart the symptoms observed?

27. Assessment of Near Visual Acuity (NVA)
Near Visual Acuity Chart

28. 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 or brain injury
Disease
Certain drugs
Color vision tests
Often performed in medical office
Basic color vision screening test:
Ask patient to identify red and green lines on Snellen chart
Retinal disease or optic nerve disease may cause defects in color vision.

29. Ishihara Test Detects: Isihara book
Total congenital color blindness
Red-green color blindness
Isihara book
Series of plates consisting of colored dots
Forms a numeral against a background of dots of contrasting colors
Patients with normal color vision: can read appropriate numeral
How would you explain to the patient how to perform the test?

30. Ishihara Test Ishihara Color Plates Patients with defects read dots as
Not forming a number at all
Forming a different number
Identify the numbers in the circles.

31. Ishihara Test 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
Preschool children
Non-English-speaking people
Patient is asked to trace line formed by the colored dots
Using a cotton swab or pencil eraser
Do not allow patient to use finger - over time: soiled fingers can degrade plates
Patients should use a cotton-tipped applicator instead of their finger to trace the lines. Why is this?

32. Ishihara Test Conduct test in a quiet room
Illuminated by natural daylight (if possible)
Otherwise: use electric light adjusted to resemble natural daylight
Using bright sunlight: can change shades of color on plates - may cause inaccurate test results

33. Ishihara Test Test consists of 14 color plates:
Basic test: Plates 1 through 11
Further assessment of patients with red-green deficiency: plates 12 through 14
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

34. 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
Irrigation is used for what type of foreign particles?
What are some examples of harmful chemicals that might get into the eye?

35. Eye Instillation Dropping of a liquid into the lower conjunctival sac
Purpose
Treat eye infections (with medications)
Soothe an irritated eye
Dilate the pupil
Anesthetize the eye during eye examination or treatment
What is the lower conjunctival sac?
What are some examples of ophthalmic medications?
What are some examples of eye infections that would require ophthalmic medication?
What is the purpose of dilating the pupils?

36. Eye Instillation 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
The tip of the medication should not come in contact with the eye.
What are some examples of ophthalmic medications?

37. Introduction to the Ear
MA responsible for performing a variety of ear procedures
Hearing tests may be part of routine PE
MA should be alert to signs that patient is having difficulty in hearing

38. Introduction to the Ear
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

39. 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
Person with normal hearing: can hear frequencies of normal speech
Ranges from 300 to 4000 Hz (hertz or cycles per second)
Patients who exhibit hearing loss:
Referred to otolaryngologist or audiologist
If a patient is not aware of the problem, usually a family member recognizes it.
What are the symptoms of hearing loss?

40. Types of Hearing Loss
Conductive hearing loss: results when there is a physical interference with normal conduction of sound waves through the external and middle ear
Amount of sound reaching inner ear is less than normal
A disposable speculum is used to prevent cross-contamination when examining the ear with an otoscope.
What type of container should be used for disposing of an ear speculum?

41. Types of Hearing Loss
Conductive hearing loss: results when there is a physical interference with normal conduction of sound waves through the external and middle ear
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)
What is ordered for impacted cerumen?

42. Types of Hearing Loss
Conductive hearing loss: results when there is a physical interference with normal conduction of sound waves through the external and middle ear
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
What could be prescribed for acute otitis media?

43. Types of Hearing Loss
Conductive hearing loss: results when there is a physical interference with normal conduction of sound waves through the external and middle ear
Cause of conductive loss: often detected by examining the ear canal with an otoscope
Hearing frequently restored by: removing obstruction (e.g., impacted cerumen); treating the disorder (e.g., serous otitis media)

44. Types of Hearing Loss
Sensorineural hearing loss (SNHL): 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
Meniere’s disease can cause this type of hearing loss.

45. Types of Hearing Loss
Sensorineural hearing loss (SNHL): results from damage to inner ear or auditory nerve
Problem with perception of sound waves: results in a hearing deficit – causes:
Hereditary factors
Degenerative changes from the normal aging process (presbycusis)
Intense noise exposure over period of time
Ototoxicity caused by certain medications
Infectious diseases (measles, mumps, meningitis)
Mixed hearing loss: combination of both conductive and sensorineural loss
Identify types of employees that might be exposed to intense noise.
Can loud music cause a sensorineural hearing loss? Is this loss permanent?
Create an environment that might promote the development of noise-induced hearing loss.

46. Hearing Acuity Tests Include Simple gross screening test
Qualitative tests: tuning forks
Quantitative tests: audiometry

47. Hearing Acuity Tests Important to test only one ear at a time
Hearing deficit may exist in only 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
Why is it important to test one ear at a time?

48. Gross Screening Test Simple and quick 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 to 2 feet
If hearing loss is detected
More precise test is performed (tuning fork, audiometry)
If the whisper test is performed, the patient may be asked to plug one ear and then the other.

49. 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 the range of normal speech
How would you clean the tuning fork?

50. Tuning Fork Tests
Weber test: useful when one ear hears better than the other
Fork set in vibration
Base of fork placed on center of patient's head
Patient indicates where sound is heard best
How do you set the fork into vibration?

51. Tuning Fork Tests
Weber test: useful when one ear hears better than the other
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
How would the results be recorded?

52. Tuning Fork Tests
Rinne test: compares the duration of sound perception by air conduction with that of bone conduction
Fork is set in vibration
Base of fork is 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
Where is the mastoid process located?

53. Tuning Fork Tests Rinne Test Results:
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

54. 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
How would you explain the procedure to the patient?

55. Audiometry To perform test: Conduct test in quiet room
Headphones placed snugly over ears
Each ear is assessed separately
Audiometer delivers a single frequency at a time
Starts with low frequencies (250 to 500 Hz) and goes to high frequencies (6000 to 8000 Hz)
Patient signals when sound is heard
Results plotted on a graph (audiogram)
How should the patient signal when the sound is heard?
Why is each ear assessed separately?

56. Tympanometry Tympanometry: helps determine cause of hearing loss
Not a hearing test
Tympanometer: earpiece attached to an electronic device
This is a diagnostic test.

57. Tympanometry
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
If you need to turn after lifting an object: don’t twist
Pivot whole body
Twisting the spine: can cause serious back injury
To carry object to another location
Make sure area of transport is dry and free of clutter
Fluid in the middle ear is usually not treated. If infection is present, antibiotics are prescribed.

58. Ear Irrigation Performed to: Cleanse external ear canal to remove:
Cerumen
Discharge
Foreign body
Relieve inflammation by applying antiseptic solution
Apply heat to ear
When irrigating the ear, the syringe should be inserted toward the roof of the ear to prevent tympanic membrane injury.
What foreign bodies do children frequently insert in their ears?

59. Ear Irrigation Impacted cerumen must be softened before removal:
By instilling warm mineral oil or hydrogen peroxide
Do not perform irrigation if tympanic membrane is perforated
Could result in severe irritation or infection of middle ear
The ear canal must be straightened to reach all areas of the canal.
How is the ear canal straightened for an adult? For a child under the age of 3 years?
What might cause a perforated tympanic membrane?

60. Ear Instillation Dropping of a liquid into the external auditory canal
Performed to
Soften impacted cerumen
Combat infection with antibiotic eardrops
Relieve pain
Ear drops: usually dispensed in a flexible plastic container with an attached dropper
A moistened cotton wick may be used after instillation. Why should the wick be moistened?
What can be used to soften impacted cerumen?
What are some examples of conditions that would require the use of antibiotic eardrops?