Download Assessment of the eye

Assessment of the eye
Recommend
 Identify cause of eye disorder through systematic and thorough history and examination of the eye.
Failure to do so may lead to loss of sight
Background
 Visual acuity of 6/6 does not exclude a serious eye condition [1]
 Equipment – small powerful torch, visual acuity chart such as Snellen or Snellen E chart, magnification,
cotton bud, fluorescein drops or strip, ophthalmoscope
History: it is important to establish:
 Is the eye disorder a result of trauma?
 a history of how the injury was sustained is vital
 in any high velocity injury, a penetrating injury must be strongly suspected
 if there has been a forceful blunt injury, suspect a “blow out” fracture of the orbit
 The nature of visual symptoms
 loss of vision, pain or grittiness, redness, discharge, double vision
 one or both eyes affected?
 rate of onset
 associated symptoms – e.g. flashing lights, floaters, haloes around lights
 Any past history of eye problems
 current medical problems (eg. diabetes or autoimmune disease)
 medications that can affect the eyes, eye drops / ointment used?
 does the patient wear contact lenses? any surgery on the eyes?
 Any family history of eye problems, e.g. in chronic glaucoma there is a 1:10 risk in first degree relatives
Examination
1. Examine the eye
 Ensure good lighting and use magnification
 Check the cornea, sclera, conjunctiva, eyelid and periorbital areas. The lower lid should be pulled
down to examine the conjunctival lining. Care should be taken not to apply any pressure to the globe if
there is any suggestion of a penetrating eye injury. The lids can be separated by using traction over
the orbital margins thus avoiding any pressure. Never try to pry the eyelids of a child apart to see the
eye. Inadvertent pressure on the globe may make a perforating injury worse. Strong suspicion of such
an injury should be followed by placing a rigid shield on the eye and evacuating to appropriate facility
[2]
 If the patient has a red eye, or a history of a foreign body or a sensation of grittiness in the eye, the
inner aspect of the upper eyelid should be examined by everting the lid (see following pages for
technique). Eversion of the upper eyelid should not be done if there is any suggestion of a
penetrating eye injury
 The anterior chamber should be examined for the presence of blood (hyphaema) or pus (hypopyon)
2. Examine the pupils
 Check the shape of both pupils. The pupils are normally round, regular and of equal size
 Check both pupils’ reaction to light. Coming from the side of the face bring a light to shine on one eye.
Repeat the procedure to the other eye. Normally both pupils constrict when a light is shone on either
eye
 Check both pupils align equally i.e. no obvious squint / deviation
3. Visual Acuity (VA)
 Test the visual acuity of each eye using a Snellen chart at 6 metres in good light. Vision should be
tested with the aid of the patient’s usual distance glasses or contact lenses
 Visual acuity is recorded as 2 numbers. The first being the distance the patient is from the chart in
metres – 6, and the second being the number under the smallest line of letters the patient was able to
discern, ie. 6/5, 6/6, 6/12, etc.
 If there is any abnormality the visual acuity should be checked with the patient looking through a
pinhole
 If the patient cannot read the top line at 6 m the patient can be brought closer to the chart, eg. 3
metres. The first number then becomes 3
 Further assessment may involve Snellen E or Animal charts if literacy issues or counting fingers, hand
movements or perception of light if marked visual loss.
4. Fluorescein examination of the cornea
 Fluorescein is a dye which is taken up by areas of damaged corneal epithelium. When exposed to blue
U.V. light it fluoresces, allowing assessment of the nature and extent of corneal injury
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Contra-indicated if penetrating eye injury
Use - Fluorescein Strips - moisten the strip with a drop of Normal Saline and apply to the
lower conjunctival sac
 Fluorescein Drops - (single dose MINIMS only) instil one drop into the lower conjunctival
sac
Ask the patient to blink. This will distribute the fluorescein over the cornea
Gently irrigate the eye with Normal Saline. This will remove the excess fluorescein
Darken the room and expose the eye to blue filtered, cobalt or “black” light
Corneal fluorescence will reveal the extent of corneal injury
5. Eversion of the eyelid
 This simple procedure is an essential step in the assessment of an injured or red eye
 Foreign bodies are commonly located under the upper lid
 Everting the upper eyelid may reveal signs of eye disease such as trachoma and chalazion. Contraindicated if penetrating eye injury
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grasp the lashes and lid margin between your
thumb and forefinger (1)
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ask the patient to look down
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pull the eyelid gently down and away from the
eye
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place the wooden end of an applicator stick
across the top of the eyelid (2)
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pull the lashes and lid margin out and upward
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fold the lid back over the wooden end of the
applicator. This exposes the underside of the
upper eyelid (3)
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hold the eyelid in this position while you
remove the applicator (4)
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having assessed the underside of the lid and
performed what procedures are necessary,
ask the patient to blink
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the lid will return to its normal position
the inside of the lower lid is assessed by placing your thumb or index finger on the skin below the lower
lid and pressing downward (5)
ask the patient to look upward, to the left and to the right
Padding of the eye
 Routine padding of eyes is no longer recommended
 Leads to loss of depth perception and restriction of visual fields that can interfere
with ambulation particularly negotiating stairs and foot paths [3]
 Patients should not drive with a pad on their eye [3]
 If patients have restricted or no vision in their unaffected eye – padding may make
them blind
 In older patients may increase the risk of falls
 Stops oxygen therefore decreases healing process
 Harbours bacteria
Padding of the eye can be used in the following conditions / situations
 An eye which has local anaesthetic instilled – providing the patient is not planning on
driving. If driving don’t pad eye, keep sunglasses on for 4 hours
 Some large corneal abrasions with significant eye pain caused by ciliary muscle
spasm. However limit padding to 24 hours and consult MO as necessary
Padding of the eye is NEVER to be used in the following conditions
 Penetrating eye injuries – use eye shield / or cut down styrofoam cup
Double padding – acts as a pressure bandage and should not be used unless advised by Ophthalmologist
Eye Tips
Do
 Always check visual acuity and record it
 Test pupillary reaction
 Evert the upper lid when examining the eye
 Pad an eye which has had local anaesthetic in it unless driving (because binocular
vision invalidates insurance)
 Stain the cornea with fluorescein when examining the eye
 X-ray the orbit of a patient who may have suffered a penetrating eye injury from a high velocity metal
fragment, eg. a hammer striking steel (Consult MO)
Don’t
 Give patients local anaesthetic eye drops to take home
 Try to remove a protruding object from a penetrating eye injury
 Put drops or ointment in an eye which has suffered a penetrating injury
 Use steroid eye drops, unless on MO’s orders
 Double pad eye unless advised by Ophthalmologist