1. Physical examination Eyes Assessment
Internal
Prepared by :
B.Sc.N :Azhar Talib Hameed
Supervisor:
Assisst.Proff.Dr :Sahar Adham

2. Equipment Ophthalmoscope Penlight Clean gloves
Snellen chart, Snellen E chart, Rosenbaum Near Vision Pocket Screening card
Vision occluder
Cotton-tipped applicator

3. Standard Precautions Hand hygiene PPE(personal protective equipment)
Save handling & cleaning of potentially contaminated equipment or surfaces in the patient environment
Respiratory hygiene-cough antiquate

4. Visual Acuity (VA)
Visual acuity is a measure of the ability of the eye to distinguish two stimuli separated in space. Measurement of visual acuity in clinical practice assumes that the cone photoreceptor has the ability to discriminate two objects in space.

5. Distance Vision Near Vision Color Vision Visual Acuity (VA)
VA contain 3 parts:
Distance Vision
Near Vision
Color Vision

6. Part 1 (Distance Vision)
Distance Vision: Ability to see distant objects. typically measured at a distance of 6 meters. Measure by Snellen chart. Snellen chart : A chart for testing visual acuity, usually consisting of letters, numbers, or pictures printed in lines of decreasing size which a patient is asked to read or identify at a fixed distance.

8. Steps of exam:
Ask the patient to stand or sit facing the Snellen chart at a distance of 20 feet.
If the patient normally wears glasses, ask that they be removed. Contact lenses may be left in the eyes.
Instruct he patient to cover the left eye with the occluder (Figure 12-5B) and to read as many lines on the chart as possible.
Note the number at the end of the last line the patient was able to read.

9. Steps of exam:
If the patient is unable to read the letters at the top of the chart, move the patient closer to the chart. Note the distance at which the patient is able to read the top line.
Repeat the test, occluding the right eye.
Repeat the test, using both eyes.
If the patient normally wears glasses, the test should be repeated with the patient wearing the glasses. Note this test as corrected.
If the patient is unable to read any of the Snellen chart, other gross measures of visual acuity must be used.These include the ability to Count the number of fingers the examiner holds up, or if there is perception of light. In addition, the Tumbling E chart can be used to assess visual acuity in illiterate patients.

11. Normal & Abnormal Findings
Normal: The standard normal visual acuity equates to the vision of 6/6 or 20/20 when viewing a predetermined standard target at 6 m (UK) or 20 ft (USA).
Abnormal: The patient is unable to read the chart with an uncorrected visual acuity of 20/30 in one eye, vision in both eyes is different by two lines or more, or acuity is absent.
Causes:
Refractive error related to a difference in the refractive power of the cornea.
myopia (nearsightedness). the axial length of the globe is longer than normal, resulting in the image not being focused directly on the retina; this condition can be changed with corrective lenses.
Amblyopia If the patient is amblyopic, no corrective lenses will improve vision. Amblyopia is the permanent loss of visual acuity resulting from strabismus that was not corrected in early childhood, or certain medical conditions (alcoholism, diabetes mellitus).

12. Abnormal Findings

13. Abnormal Findings
The patient may have corneal opacities that are congenital, from lesions that have scarred the cornea (e.g., herpes simplex), from trauma, or from degeneration and dystrophies.
Visual acuity can be decreased because of opacities of the lens caused by senile or traumatic cataracts.
Systemic autoimmune diseases such as inflammatory bowel disease arthritis, or other collagen vascular diseases can be associated with inflammation of the iris (iritis), which will affect visual acuity. Iritis can also be idiopathic.
Inflammation of the retina caused by toxoplasmosis or by the presence of blood in the vitreous humor following hemorrhage can be responsible for decreased visual acuity.
Systemic diseases, such as hypertension or diabetes mellitus, a trauma may damage the choroid and retina, causing decreased visual acuity.
Visual acuity can be impaired by pathology affecting the optic nerve, such as multiple sclerosis, tumors or abscesses of the nerve itself, optic atrophy, papilledema resulting from increased intracranial pressure optic neuritis, or neovascularization of the optic nerve.

14. Part 2 (Near Vision)
This is similar to the distance vision test, but it is held only 14 inches (35 centimeters) away. By ((Rosenbaum Near Vision Pocket Screening card))
Steps of exam:
Have the patient sit comfortably and hold the card 14 inches from the face without moving it.
Ask the patient to read the smallest line possible. If other printed material is used, you will be able to gain only a general understanding of the patient's near vision.

16. Normal & Abnormal Findings
Normal: Until the patient is in the late 30s to the late 40s, reading is generally possible at a distance of 14 inches.
Abnormal:
A patient in this age range who cannot read at 14 inches is considered presbyopia. Younger persons may have difficulty seeing up close because they have hyperopia, or farsightedness .
The normal aging process causes the lens to harden (nuclear sclerosis), decreasing its ability to change shape and therefore focus on near objects.

17. Part 3 Color Vision
is an ability of human to perceive differences between light composed of different wavelengths (i.e., different spectral power distributions) independently of light intensity. Color vision is usually tested in young children. If there is suspicion that the patient has a color vision deficit. At the age of 3 to 6 years, the child is examined by means of images intended for the examination. And he must recognize the shapes with pictures within 3 seconds.

19. Normal & Abnormal Findings
The patient should be able to identify colors correctly. Abnormal Findings : The color vision defect is designated as red/green, blue/yellow, or complete when the patient sees only shades of gray. Defects in color vision can result from diseases of the optic nerve, macular degeneration, pathology of the fovea centralis, nutritional deficiency,or heredity.

20. Visual fields
The confrontation technique is used to test visual fields of each eye (CN II). The Visual field of each eye is divided into quadrants, and a stimulus is presented in each quadrant.
Steps of exam:
Sit or stand approximately two to three feet away from and opposite the patient, with your eyes at the same level as the patient's.
Have the patient cover the right eye with the right hand or an occluder.
Cover your left eye in the same manner.
Have the patient look at your uncovered eye with his or her uncovered eye.
Hold your free hand at arm's length equidistant from you and the patient and move it or a held object such as a pen into your and the patient's field of vision from nasal, temporal, superior, and inferior angles.
Ask the patient to say "now" when your hand is seen moving into the field of vision. Use your own visual fields as the control for comparison to the patient's.
Repeat the procedure for the other eye.

22. Normal & Abnormal Findings
The patient is able to see the stimulus at about 90° temporally, 60° nasally,50 superiorly, and 70° inferiorly Abnormal Findings : if the patient is unable to identify movement that you perceive, a defect in the visual field is presumed. Defects in the patient's visual field can be associated with tumors, strokes. or neurological diseases such as glaucoma or retinal detachment.

24. Anterior Chamber Examination
The anterior chamber is that compartment of the eye found between the Cornea and the iris. The space between the flat plane of the iris and the periphery of cornea must be adequate to allow drainage of aqueous fluid out of the eye.
Steps of exam:
Face the patient and shine a light obliquely through the anterior chamber from the lateral side toward the nasal side (Figure 12-28).
Observe the distribution of light in the anterior chamber (Figure ).
Repeat the procedure with the other eye.
Normal Findings : In a normal eye, the entire iris will be illuminated.
Abnormal Findings:The eye has a narrow angle, with the decreased space between the iris and the cornea appearing as a crescent-shaped shadow on the far portion of the iris. aging progresses, the lens thickens, which may cause even further narrowing of the angle.

26. Iris examination
With the penlight, inspect the iris for color, nodules, and vascularity. Normally, the color is evenly distributed over the iris, although there can be a mosaic variant. It is normally smooth and without apparent vascularity. Abnormal:A heavily pigmented, slightly elevated area is visible in the iris. This lesion can be benign iris nevus or a malignant melanoma. An iris nevus is much more common than melanoma. he inferior portion of the iris is obscured by blood. This is a hyphema and is caused by bleeding from vessels in the iris as a result of direct trauma to the globe. It can also occur as a result of eye surgery. an absent wedge portion of the iris is abnormal. The shape of the iris changes after surgical removal of a cataract, the pupil may also have an irregular shape.

27. Pupil Examination
Stand in front of the patient in a darkened room.
Note the shape and size of the pupils in millimeters.
Move a penlight from the side to the front of one eye without allowing the light to shine on the other eye (Figure 12-30).
Observe the pupillary reaction in that eye. This is the direct light reflex. Note the size of the pupil receiving light stimulus and the speed of pupillary response to light.
Repeat in the other eye.

28. Pupil Examination
Move the penlight in front of one eye, and observe the other eye for pupillary constriction. This is the consensual light reflex.
Repeat the procedure on the other eye.
Instruct the patient to shift the gaze to a distant object for 30 seconds.
instruct the patient to then look at your finger or an object held in your hand about 10 cm from the patient.
Note the reaction and size of the pupils. Accommodation occurs when pupils constrict and converge to focus on objects at close rang. The beginning examiner should focus the beam of light a total of four times, twice in each eye, to assess the direct light reflex and to assess the consensual light reflex. This will ensure accuracy of examination.

29. Normal Findings : The pupils should be deep black, round, and of equal diameter, ranging from 2 to 6 mm. Pupils should constrict briskly to direct and consensual light and to accommodation (CN I). Small differences in pupil size (anisocoria) may be normal in some people.
Abnormal Findings :
The pupil that constricts to less than 2 mm in diameter is termed miotic. The pupil that dilates to more than 6 mm in diameter is termed mydriatic. Abnormal pupillary size can be caused by medications such as sympathomimetics or parasympathomimetics, iritis, or disorders such as CN III paralysis, which can occur as a result of a carotid artery aneurysm. These abnormalities may also be due to nerve damage or trauma (see Table 12-1 for further pathologies).
The pupil has an irregular shape. This is a common finding associated with the surgical removal of cataracts and iridectomy.

30. When the direct light reflex is defective, the pupil dilates in response to light, but consensual reaction is appropriate. This is called a Marcus Gunn pupil. Optic nerve damage in the optic chiasm, such as in trauma, results in destruction of the afferent pathways of the pupillary light reflex (differented pupil).
the hippus phenomenon occurs after the pupil has been stimulated by direct light. Light causes the pupil to constrict, but then the appears to rhythmically vacillate in size from a larger to a smaller diameter. Hippus may be caused by a lesion in the midbrain.
The presence of midposition, round, regular, and fixed (5 to 6 mm) pupils that may show hippus is abnormal. These signs usually indicate midbrain damage that interrupts the light reflex but may leave accommodation intact.

33. Retina & optic disk examination
in a darkened room, ask the patient to remove eyeglasses: contact lenses may be left in place.
Instruct the patient to look at a distant object across the room. This will help to dilate the eyes.
Set the ophthalmoscope on the 0 lens and hold it in front of your right eye with your index finger on the lens selector.
From a distance of 8 to 12 inches from the patient and about 15 to the lateral side, shine the light into the patient's right pupil, eliciting a light reflection from the retina; this is called the red reflex.
While maintaining the red reflex in view, move closer to the patient and move the lens selector from O to the +, or black, numbers so as to focus on the anterior Ocular structures.
For optimum visualization, keep the ophthalmoscope within an inch of the patient's eye (Figure 12-33B).

35. At this point, move the lens selector from the +, or black , numbers, through 0, and into the - , or red, numbers so as to focus on structures progressively more posterior.
Focus on the optic disc at the nasal side of the retina by following any retinal vessels centrally.
You may need to reverse direction along the vessel if the disc does not appear.
Observe the retina for color and lesions; the retinal vessels for configuration and characteristics of their crossing; and the optic disc for color, shape, size, margins, and comparison of cup-to-disc ratio.
Repeat on the left side, using the ophthalmoscope in your left hand to examine the patient's left optic fundus.

36. Normal & Abnormal Findings
Normal: The red reflex is present. The optic disc is pinkish- orange in color, with a yellow-white excavated center known as the physiologic cup .The ratio of the cup diameter to that of the entire disc is 1:4 to 1:3. The border of the disc may range from a sharp, round demarcation from the surrounding retina to a more blended border, but should be on the same plane as the retina. In general, there are four main vascular branches emanating from the disc, each branch consisting of an arteriole and a venule. The venules are approximately four times the size of the accompanying arterioles and are darker in color. Light often produces a glistening "light reflex" from the arteriolar vessel. Normal arterial-to-venous width is a ratio of 2:3 or 4:5.

38. Abnormal:
The red reflex is absent. The presence of cataracts can prevent the red reflex from being observed due to the opacity of the lens.
The red reflex is absent and the pupil appears white. Leukocoria, or white reflex, is found in retinoblastoma) congenital cataracts, and retinal detachment. This is often referred to as the cat's eye reflex.
The optic disc is pale. Pallor is due to optic atrophy caused by increased intracranial pressure or from congenital syphilis, an intracranial space-occupying lesion (e.g., meningioma), or end-stage glaucoma.
Optic atrophy is abnormal. Optic atrophy occurs in retinitis pigmentosa). Arteriole narrowing and "bone spicule" are also noted on the fundus. There is a loss of central and/or peripheral vision, night blindness, and glare sensitivity in this familial condition.
The physiologic cup exceeds the 1:3 ratio. The disc appears elevated above the plane of the surrounding retina. Disc edema and loss of vision are caused by the papillitis resulting from optic neuritis. The disc is hyperemic, the margins are blurred, and the disc surface is elevated.

39. Disc edema and an elevated disc without loss of vision are found in papilledema (Figure 12-36B), which is caused by increased intracranial pressure obstructing return blood flow from the eye. This is also called a choked disc. Glaucomatous cupping (Figure 12-36C) occurs due to increased intraocular pressure. The physiologic cup is enlarged and may extend to the edge of the optic disc. Blood vessels are displaced nasally.
The normal red stripe of retinal arteries appears instead as a coppercolored stripe. This copper-wire appearance of retinal arteries is characteristic of hypertensive changes.
At the crossing of retinal arteries over veins, the vein is not seen on either side of the overlying artery. This finding is arteriovenous (A-V) nicking, a sign of retinal arteriolar sclerosis that occurs as the walls become thickened and obscure portions of the veins that lie underneath. This can also occur in hypertension.
Superficial retinal hemorrhages are flame-shaped hemorrhages found in the fundi, or they may appear as red hemorrhages with white centers called Roth spots. These hemorrhages form a pattern related to the nerve fibers that radiate from the optic disc. These hemorrhages may be due to severe hypertension, occlusion of the central retinal vein, and papilledema. Roth spots are sometimes associated with infective endocarditis.

40. Deep retinal hemorrhages, or dot hemorrhages, appear as small red dots or irregular spots in the deep layer of the retina (Figure 12-36D). Deep retinal hemorrhages can be associated with diabetes mellitus.
Diffuse preretinal hemorrhages occur in the small space between the vitreous and the retina. Preretinal hemorrhages may occur in conjunction with a sudden increase in intracranial pressure.
Microaneurysms are tiny, round, red dots that can be seen in peripheral and macular areas of the retina (Figure 12-36E).These dots are small retinal vessels that dilate in diabetic retinopathy.
Neovascularization is the formation of new vessels that are very narrow and disorderly in appearance and that may extend into the vitreous (Figure 12-36F). These vessels may bleed, resulting in a loss of vision. Neovascularization occurs in proliferative diabetic retinopathy.
Fluffy white or gray, slightly irregular areas that appear on the retina and are Ovoid in shape are abnormal (Figure 12-36G). Cotton wool spots represent microscopic infarcts of the nerve fiber layer and are due to diabetic or hypertensive retinopaihy

50. End