Physical Assessment: Eyes

Front 1

Palpebral Fissure

Back 1

open space between the two eyelids, that when open the upper lid covers part of the iris (color of eye)
When closed, the lid margins approximate completely.close tightly

Front 2

Pupil

Back 2

the central transparent area (showing as blackbut really just open to the interior part of the eye).
-allows light to enter the retina

Front 3

Sclera

Back 3

-white outer area

Front 4

Limbus

Back 4

The border btw the cornea and sclera

Front 5

Canthus

Back 5

-corner of the eye (both medial and lateral sides)
-the angle where the lids meet

Front 6

Caruncle

Back 6

Small fleshy mass
-contains sebaceous glands in inner canthus

Front 7

Iris

Back 7

The grey/blue area surrounding the pupil

Front 8

Tarsal Plate

Back 8

– strip of connective tissue gives shape to the upper lid.

Front 9

Meibomian glands

Back 9

-modified sebaceous glands
-secrete an oily lubricating material onto the lids
-help with airtight seal when lids are closed
-prevents tears from overflowing.

Front 10

Conjunctiva

Back 10

- thin mucus membrane folded like an envelope between lids and eye ball that is a transparant protective covering
2 types:
Palpebral conjunctiva lines the lids and is clear-lines the inside of the upper and lower lids
-looks pink b/c of blood vessels in eyebut clear
-conjunctavitislook more distinct, bigger, clear
Bulbar conjunctiva overlays the eyeball with the white sclera showing through – merges with cornea at limbus.Thin mucusmore noticable w/ conjunctavitis

Front 11

Lacrimal Apparatus

Back 11

Gland-in upper outter area
tears wash across eye
-->into the superior and inferior punctum
-->drain into the nose
Eye drops-may taste it bc it drains into noseinto mouth
Provides constant irrigation
Secretes tears which flow across the eye and drain into the puncta.
Tears then drain into the nasolacrimal sac and then the nose.

Front 12

Internal Anatomy of the Eye

Back 12

3 layers
1. sclera- outer layer– tough, protective white covering.-continuous with the smooth, transparent cornea. (which covers iris and pupil) ,
2. choroid middle layer – darkly pigmented to prevent light from reflecting internally
-highly vascular to deliver blood to the retina.
-continuous with ciliary body and the iris.
-The lens (divides the eye into the anterior and posterior segments) is a transparent structure located behind the pupil. The lens keeps viewed objects in continual focus on the retina
3. retina.- inner layer – visual receptive layer of eye – in the retina, light waves turned into nerve impulses –
What you’re looking at when you look inside the eye

Front 13

Function of Cilliary Body, Pupil, and Iris

Back 13

Cilliary-controls the thickness of the lens,- Lens bulges for focus on near objects and flattens for far object
Iris-diaphragm->varying the opening at its center, the pupil, to control the amount of light admitted onto the retina.
Pupil-allows light into retina for vision
-contracts in bright light for near vision
-dilates in dim light for far vision

Front 14

Compartments of the Eye

Back 14

2 compartments:
1. The anterior compartment, behind the cornea and in front of the iris and lens,
-contains a clear liquid called aqueous humor, produced by the ciliary body.
-The continuous flow of fluid serves to deliver nutrients to the surrounding tissues and to drain metabolic waste.
-Intraocular pressures is determined by the balance between the amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber.
2. The posterior chamber is filled with a clear gel-like substance called vitreous humor
-get old-->gel clumps together-->issues w/ vision

Front 15

Cranial Nerve Innervation of the Extraocular Muscles

Back 15

CNVI (abducens)-lateral rectus
-abducts the eye
CNIV (trochlear)-superior oblique (down and in)
-abduction, depression
CN III (oculomotor)-the rest
-superior (abduction, depression), inferior (elevation, abduction), medial rectus (adduction), inferior oblique (depression)

Front 16

Extraocular Muscles

Back 16

6 muscles attatched to eyeball
-direct stright and rotary movements
-4 straight muscles
superior(up)
inferior (down)
lateral (out)
medial (in)
2 oblique
superior
inferior

each muscle cordinated w one on other eye

Front 17

Opthalmoscope View

Back 17

-red reflex-reflection of light
-retinal vessels
-retinal field or background
-optic disc
-macula

Front 18

Retinal vessels in Opthalmoscope View

Back 18

four sets of vessels emerge from the optic disc and extend outward becoming smaller at the periphery.
Each set includes and arteriole and vein , vessels are named for quadrant superior nasal, inferior nasal, superior temporal and inferior temporal.
paired artery and vein for each of 4 quadrants – smaller as reach periphery.
Arteries brighter red and narrower , thin sliver of light-pulsation of vein near disc is normal

Front 19

Retinal Field of background in Opthalmoscope View

Back 19

generally varies from light red to dark brown-red depending on skin color
– should see no lesion like hemorrhages, exudates , microaneurysms

Front 20

Optic Disc in Opthalmoscope View

Back 20

optic disc- most prominent structure – head of optic nerve located toward the medial or nasal side of the eye has following characteristics
creamy yellow-orange to pink
round or oval
margins are distinct and sharply demarcated especially on temporal side
physiologic cup – visualized as a light area near center or disc.inside disc where vessels enter and exit,

Front 21

Assessing Eye Function

Back 21

Test pupillary light reflex to assess visual pathway function

Front 22

Visual Field

Back 22

A visual field is the entire areas seen by an eye when it looks at a central point
-visual fields are normally limited by the brows above, by the cheeks below, and by the nose medially.
-When a person is using both eyes, the two visual fields overlap in an area of binocular vision.
-Laterally, vision is monocular

Front 23

Visual Pathways

Back 23

-for an image to be seen, light reflected from it must pass through the pupil and be focused on sensory neurons in the retina.
-Projected upside down and reversed right to left
-Nerve impulses are conducted through the retina, optic nerve, optic chiasm (where the two nerves meet and cross over) and optic tract on each side
-then on though a curving tract called the optic radiation.
-any break in that path-->visual impairness

Front 24

Pupillary Light Reflex

Back 24

-Afferent CNII
-Efferent CNIII
-constriction of pupil in response to light
-direct-constriction from direct exposure to light
-consensual-constriction from other eyes exposure to light
-flash light in left eye->travels to optic chaism->brain thinks it needs to constrict the pupil->goes out CN3->tells BOTH eyes to constrict

Front 25

Fixation Reflex

Back 25

-maintaining of the visual gaze on a single location.
-image is fixed in center of visual field.(fovea)
- very rapid ocular movements to place object in center of vision
- impaired with drugs alcohol fatigue etc.

Front 26

Accommodation Reflex

Back 26

adaptation of eye for near vision
- accomplished by increasing curvature of the lens through movement of ciliary muscles – observe through convergence of the axes of the eyeballs and pupillary constriction.
-finger out (pupils dilate)->move finger in->pupils will constrict

Front 27

Subjective Health History Qs for Eyes

Back 27

1. Vision difficulty (decreased acuity, blurring, blind spots)
2. Pain
3. Strabismus, diplopia (double vision)
4. Redness, swelling
5. Watering, discharge
6. Past history of ocular problems
7. Glaucoma
8. Use of glasses or contact lenses
9. Self-care behaviors

Front 28

Physical Exam for Eyes

Back 28

Assess visual acuity
Inspect lids and lashes,conjunctiva,sclerae, iris, cornea
Shape and size of pupils
Corneal light reflex
Direct and consensual reflex
Accommodation:convergence
Extraocular movements
Visual fields
Funduscopic

Front 29

Assessment for visual acuity

Back 29

Assess visia acuity-place patient 20 feet away from snell chart
read smallest line possible (w/ or w/ out glasses)
First line-distance where they are positionedALWAYS 20
Second number-distance where the normal eye would have read the chart (20/20 vision)
20/50 is when someone reads a line at 20 feet where someone w/ 20/20 could read at 50 ft
If there is a mistake-you say 20/20-1 (1 mistake) or -2
20/200-legal blindness in the best eye

Front 30

Myopia

Back 30

occurs when the anterior-posterior diameter of the eye is too long relative to the refracting power of the cornea and lens
-can’t see long-distance
-near-sighted

Front 31

Hyperopia

Back 31

eye is too short relative to the refracting power of the eye.
The focal point of the image occurs posterior to the retina and the image that forms on the retina is blurred.
-can’t see too short

Front 32

Presbyopia

Back 32

– beginning in the fifth decade, ability of lens to accommodate decreases, resulting in progressive difficult in reading fine print
-bad w/ near and far-bad w/ reading

Front 33

Inspection of the External Eye

Back 33

-Eyebrows- no scaling or lesion, present bilaterally, move symmetrically

Eyelids - upper lids overlap superior part of iris and approximate completely with lower lids when closed.
-Skin intact without redness, swelling, discharge or lesions.
ptosis - drooping of eyelid –
Appromixate w/ top of the ear
Lashes - Lashes evenly distributed along lid margins and curve outward.  

Front 34

Inspection of the Eyeballs

Back 34

-Eyeballs – aligned normally in socket, no protrusion or sunken appearance

Front 35

Pupil Abnormalities

Back 35

miosis = abnormal constriction of pupil
-narcotisc, paralysis of sympathetic nerves, iritis

mydriasis = abnormal dilation of pupil
-from damage to a CN, III nerve palsy, increased IOP(intra occular pressure), intracranial pressure, midbrain lesions, deep coma, brain death and some drugs like atropine

Anisocoria- unequal pupils
-if pupillary reactions are normal anisocoria is considered normal

Front 36

Inspection of the Conjunctiva and sclera

Back 36

-Conjunctiva and sclera – not swollen, not erythmia (red)
while patient looks up -> slide lower lids down- inspect exposed areas – eyeball moist and glossy,
-Cornea and lens- oblique illumination to identify corneal abrasions or scars– cornea clear, transparent and without vascularization, the conjunctival lining is on the same plane with corneas should be
no cloudiness

Front 37

Inspection of the Iris and Pupil

Back 37

-Iris and pupil – iris is flat with round regular shape and even color.
-Check shape, size and equality of pupils- usually round, regular and equal size (3-5mm normal)

Front 38

Inspection of the Nasolacrimal Duct

Back 38

Press on the duct in the lower inner corner of eye
-make sure there is no pus coming out or clogging

Front 39

Corneal Light Reflex

Back 39

Shine light towards eyes
-light reflection should in in same place on eye-slightly nasal to center of pupils
-abnormal->strabismum

Front 40

Assessment of Direct and Consensual Reaction of Light

Back 40

Direct-shine light in one eye->pupil should constrict
consensual-other eye constricts
abnormalities->blindness

Front 41

Test of Accommodation

Back 41

Performs test for accommodation/convergence
-adaptation of eye for near and far vision, increase curvature of the lens
– observe through convergence of the axes of the eyeballs and pupillary constriction
-focus in distance, (pupils dilate) ->then shift gaze to near object (finger 3 inches)
-response is constriction of pupils and convergence of axes of eye
PERRLA

Front 42

Assessment of Extraocular Movements

Back 42

-finger 12 inches away
-move through 6 cardinal positions of gaze
-check for nysragmus fine oscillating movement
-ok for lateral gaze, bad otherwise (cerebral, ear, drug problem)

Front 43

Assessment of Peripheral Visual Fields

Back 43

Fishbowl
-wiggle fingers from back of head and move them above
-pass brows or cheeks->should see
-remember image flipped and different

Normal: 50 deg up
90 temporal
70 down
60 nasal

Front 44

Optic Nerve Cut

Back 44

Blind

Front 45

Optic Chiasm Cut

Back 45

loose temporal vision on both sides
--bitemporal hemianopsia

Front 46

Right Optic Tract Issue

Back 46

lose temporal on lest visual field and nasal on right
left homonymous hemianopsia
-visual loss in the eyes is similar and involves half of each eye

Front 47

Opthalmoscope

Back 47

-use to look at internal eye
-start 10 inches away on same side as eye looking at
-adjust dipeter to bring fundus to focus
-you and patient normal vision--should be at 0
-should see:
-optic disc
-retinal vessels
-general background
-macula

Front 48

Optic Disc

Back 48

little white circle where all of the blood vessels converge
-sharp on the side farther from edge
-

Front 49

Macula

Back 49

-located two disc diameters temporal to disc
-little red circle

Front 50

Differences in Fundus with Age

Back 50

Everything more distinct in younger person (especially blood vessels)

Front 51

Fundus Abnormalities

Back 51

A-V Nicking-arterial venous crossing not smooth (often in hypertension)
Papilledema-profusion of optic disc->very cloudy, looks swelling and protruding towards you
(increased intracranial pressure-->pushing on optic nerve->makes it swell)