Download Chapter 11 Eyes Physical Examination Preview Eyes Measure

Chapter 11
Eyes
Physical Examination Preview
Eyes
Measure visual acuity, noting the following:
Near vision
Distant vision
Peripheral vision
Inspect the eyebrows for the following:
Hair texture
Size
Extension
Eyes (Cont.)
Inspect the orbital area for the following:
Edema
Redundant tissues or edema
Lesions
Eyes (Cont.)
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.
Eyes (Cont.)
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
Eyes (Cont.)
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
Eyes (Cont.)
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
Eyes (Cont.)
Ophthalmoscopic examination
Lens clarity
Red reflex
Retinal color and lesions
Characteristics of blood vessels
Disc characteristics
Macula characteristics
Depth of anterior chamber
Anatomy and Physiology
The Eye
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
External Eye
Composed of five structures
Eyelid
Conjunctiva
Lacrimal gland
Eye muscles
Bony skull orbit
External Eye: Functions
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
External Eye: Functions (Cont.)
Lacrimal gland
Produces tears that moisten the eye
External Eye: Functions (Cont.)
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).
External Eye: Functions (Cont.)
The oculomotor nerve controls:
Levator palpebrae superioris (which elevates and retracts the upper eyelid)
All extraocular muscles, except for the superior oblique muscle and the lateral
rectus muscle
External Eye: Functions (Cont.)
The superior oblique is the only muscle innervated by the trochlear nerve.
The lateral rectus muscle is the only muscle innervated by the abducens nerve.
Internal Eye
Composed of three layers
Outer fibrous layer
Sclera posteriorly and cornea anteriorly
Middle layer
Choroid posteriorly and ciliary body/iris anteriorly
Inner layer
Retina
Internal Eye (Cont.)
Five major structures
Sclera
Cornea
Iris
Lens
Retina
Internal Eye (Cont.)
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
Internal Eye (Cont.)
Uvea
Iris, ciliary body, and choroids comprise the uveal tract.
The iris is a circular, contractile muscular disc containing pigment cells that produce the
color of the eye.
Dilates/contracts to control amount of light traveling through the pupil to the retina
The ciliary body produces the aqueous humor and contains the muscles controlling
accommodation.
The choroid is a pigmented, richly vascular layer that supplies oxygen to the outer layer
of the retina.
Internal Eye (Cont.)
Lens
A biconvex, transparent structure located immediately behind the iris
Supported circumferentially by fibers arising from the ciliary body
Contraction or relaxation of the ciliary body changes its thickness.
Changes in lens thickness allow images from varied distances to be focused on retina
Internal Eye (Cont.)
Retina
Sensory network of the eye
Transforms light impulses into electrical impulses, which are transmitted through:
Optic nerve
Optic tract
Optic radiation
Visual cortex
Consciousness in the cerebral cortex
Internal Eye (Cont.)
Retina
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
Internal Eye (Cont.)
Infants and Children
Eye forms during the first 8 weeks of gestation.
May become malformed due to maternal drug ingestion or infection
Lacrimal drainage is complete at birth.
By 2 to 3 weeks of age, the lacrimal gland begins producing the full volume of tears.
Infants and Children (Cont.)
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
Pregnant Women
Hypersensitivity and changes are seen in the refractory power of the eye.
Tears contain an increased level of lysozyme, resulting in a greasy sensation and perhaps
blurred vision for contact lens wearers.
Corneal edema/thickening occurs.
Diabetic retinopathy may worsen.
Intraocular pressure falls.
Subconjunctival hemorrhages may occur/resolve spontaneously.
Older Adults
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
Review of Related History
History of Present Illness
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
Past Medical History
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
Family History
Retinoblastoma (retinal cancer)
Often an autosomal dominant disorder
Glaucoma, macular degeneration, diabetes, hypertension, or others that may impact vision or eye
health
Color blindness, cataract formation, retinal detachment, retinitis pigmentosa, or allergies affecting
the eye
Nearsightedness, farsightedness, strabismus, or amblyopia
Personal and Social History
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)
Infants and Children
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
Infants and Children (Cont.)
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
Pregnant Women
Presence of disorders that can cause ocular complications such as pregnancy-induced
hypertension (PIH) or diabetes
Symptoms indicative of PIH
Diplopia, scotomata, blurred vision, or amaurosis
Use of topical eye medications that may cross placenta
Older Adults
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
Examination and Findings
Equipment
Snellen eye chart
Rosenbaum/Jaeger near vision card
Penlight
Cotton wisp
Ophthalmoscope
Eye cover, gauze, or opaque card
Visual Testing
Test for:
Central vision
Near vision
Peripheral vision
Visual Testing (Cont.)
Use Snellen chart.
Test each eye individually.
Test with and without corrective lenses.
If vision less than 20/20, conduct pinhole test.
This maneuver permits light to enter only central portion of lens
Should result in an improvement in visual acuity by at least one line on the chart if
refractive error is responsible for the diminished acuity
Visual Testing (Cont.)
Near vision
Use Rosenbaum pocket screener
Each eye tested individually
Color vision
Rarely tested in the routine physical examination
Visual Testing (Cont.)
Peripheral vision
Estimate with confrontation test.
Accurate measurement requires instrumentation.
External Examination
Examination performed in systematic manner beginning with appendages and moving inward
Techniques
Inspection
Palpation
External Examination (Cont.)
Surrounding structures
Inspect eyebrows for size, extension, and hair texture.
Inspect orbital area for edema, puffiness, and sagging tissue below orbit.
External Examination (Cont.)
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.
External Examination (Cont.)
Eyelid palpation
Palpate for nodules.
Palpate the eye itself through closed lids.
Digital palpation tonometry
Pain
External Examination (Cont.)
Conjunctivae inspection
Usually inapparent, clear, and free of erythema
Inspect lower portion by pulling down lower lid
External Examination (Cont.)
Conjunctivae inspection (Cont.)
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
External Examination (Cont.)
Cornea
Examine clarity of the cornea by shining light on it.
Cornea is normally avascular; blood vessels should not be present.
Inspect for corneal arcus (arcus senilis).
Composed of lipids deposited in the periphery of the cornea
External Examination (Cont.)
Cornea (Cont.)
Test sensitivity (cranial nerve V) by touching the cornea with a cotton wisp to elicit blink
(cranial nerve VII).
External Examination (Cont.)
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.
External Examination (Cont.)
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.
Extraocular Eye Muscles
Test eye movements using six cardinal fields of gaze.
Check for nystagmus.
Note lid lag.
Note exposure of sclera above iris.
Extraocular Eye Muscles (Cont.)
Use corneal light reflex to test extraocular muscle balance.
If imbalanced, perform cover-uncover test.
Ophthalmoscopic Examination
Inspection of interior eye with ophthalmoscope permits visualization of:
Optic disc
Arteries
Veins
Retina
Ophthalmoscopic Examination (Cont.)
Visualize red reflex.
Opacities appear as black densities.
Examine
Fundus
Vascular supply
Disc margins
Macula
Ophthalmoscopic Examination (Cont.)
Look for unexpected findings such as:
Myelinated nerve fibers
Papilledema
Glaucomatous cupping
Drusen bodies
Cotton wool bodies
Hemorrhages
Infants
Note symmetry, muscle balance, and presence of red light reflex.
Inspect lids for swelling and epicanthal folds.
Inspect lid level covering eye.
Note eye spacing.
Inspect sclera, conjunctiva, pupil, and iris.
Infants (Cont.)
Test cranial nerves.
Vision: observe object preference/focus/tracking
Optical blink: note closure and head response to bright light
Corneal reflex: same as adult
Funduscopic examination is deferred until infant is 2 to 6 months old (unless visual problems).
Red reflex should be elicited in all newborns.
Children
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
Pregnant Women
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.
Cycloplegic and mydriatic agents should be avoided unless retinal disease is suspected.
Systemic absorption
Abnormalities
External Eye
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
External Eye (Cont.)
Band keratopathy
Deposition of calcium in the superficial cornea
Corneal ulcer
Disruption of the corneal epithelium and stroma
External Eye (Cont.)
Extraocular muscles
Strabismus: Both eyes do not focus on an object simultaneously.
Paralytic strabismus: One or more extraocular muscles or their nerve supply is impaired.
Nonparalytic strabismus: Patient can focus with either eye but not with both
simultaneously.
May be a sign of increased intracranial pressure
Internal Eye
Horner syndrome
Triad of ipsilateral miosis, mild ptosis, and loss of hemifacial sweating
Results from interruption of sympathetic nerve supply to the eye
Cataracts
Opacities in the lens
Internal Eye (Cont.)
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
Internal Eye (Cont.)
Lipemia retinalis
Occurs when the serum triglyceride level exceeds 2000 mg/dL
Internal Eye (Cont.)
Retinitis pigmentosa
Autosomal recessive disorder in which the genetic defects cause cell death
predominantly in the rod photoreceptors
Internal Eye (Cont.)
Glaucoma
Disease of the optic nerve resulting from increased intraocular pressure
Nerve cells die, producing a characteristic appearance of the optic nerve (increased
cupping).
Internal Eye (Cont.)
Chorioretinal inflammation
Inflammatory process involving both the choroid and the retina
Visual Fields
Visual field defects
Defective vision or blindness in a single eye
Visual Fields (Cont.)
Visual field defects (Cont.)
Bitemporal hemianopia is caused by a lesion, most commonly a pituitary tumor,
interrupting optic chiasm.
Visual Fields (Cont.)
Visual field defects (Cont.)
Homonymous hemianopia can be caused by a lesion arising in optic nerve radiation on
either side of the brain.
Children
Retinoblastoma
Embryonal malignant tumor arising from retina
Children (Cont.)
Retinopathy of prematurity
Disruption of normal progression of retinal vascular development in preterm infant
Children (Cont.)
Retinal hemorrhages in infancy
Occurs in infant victims of shaken-baby syndrome
Children (Cont.)
Swollen eyes in newborn
Drawing a line between eyes to examine for Mongolian slant
Keeping Well
Age-related macular degeneration is the leading cause of visual impairment and blindness in
patients older than 65 years.
Middle-age and older patients should be reminded that studies have demonstrated preservation
of vision with the reduction of age-related macular degeneration in individuals taking highdose antioxidants plus zinc.
Question 1
Corneal sensitivity is controlled by which of the following cranial nerves?
A. CN III
B. CN IV
C. CN V
D. CN VI
Question 2
Which of the following is a genetic eye disorder that should be included in the history and physical
examination, under family history, for all members of the affected families?
A. Constrictive iritis
B. Retinal cancer
C. Oval pupils
D. Retinal hemorrhages
Question 3
In infants pseudostrabismus is usually caused by:
A. Flattened nasal bridge
B. CN III, IV, and VI
C. Ptosis
D. Intellectual disability
Question 4
When testing corneal sensitivity controlled by cranial nerve V, you should expect the patient to
respond by:
A. Brisk blinking
B. Copious tearing
C. Pupil dilation
D. Reflex smiling
Question 5
Calcium deposits in this superficial corneal is called:
A. Arcus senilis
B. Retinoblastoma
C. Band keratopathy
D. Lipemia retinalis