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152 Cards in this Set
- Front
- Back
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Subjective Data: vision loss |
Assess coping methods with vision loss Unilateral or bilateral Sudden vs Gradual Total vs. Partial (part of vision field) Central (Mac degeneration) vs Peripheral (glaucoma) Permanent vs intermittent |
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Amaurosis Fugax |
Temporary monocular vision loss Inflammation of temporal artery (Arteritis) Mural thrombus r/t arrhythmia (Afib) Decreased bloodflow to retina "Blinds, shades" over eyes |
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Subjective Data: Vision problems ROS |
Vision loss Blurring Floaters or flashes of light Halos around lights (digoxin toxicity or narrow angle glaucoma) Blind spots/Scotoma Night blindness Strabismuss Diplopia |
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Retinal or vitreous detachment |
Showers of floaters |
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Scotoma |
Blind spots r/t glaucoma or visual pathway disorders (ocular migraines) |
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Strabismus |
Crossed eyes Lazy eye Assessed in childhood, before 6 yrs or it could lead to permanent blindness Deviation of an eye Weak eye muscles Paralysis of EOM, sign of ICP, CN III vulnerable to damage from brain swelling |
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Diplopia |
Double vision |
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Night blindness |
r/t optic atrophy (age related), glaucoma, Vitamin A deficiency |
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Subjective Data: Eye pain |
If pain is sudden with vision changes, consider it as an EMERGENCY Quality of pain OLD CART Photophobia |
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Photophobia |
Light sensitivity |
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Subjective Data: Redness/Swelling |
Infection Allergies (often seasonal) Dryness Mechanical (foreign body) |
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Subjective Data: Watering or Tearing |
Epiphora Discharge Matted lashes |
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Epiphora |
Excessive tearing May be due to irritants, allergies, infection, or obstruction of lacrimal ducts (won't flow into nose) |
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Collection of purulent exudate in AM |
Bacterial infection antibiotics |
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Subjective Data: History |
Eye injury/Trauma Eye infection Eye Surgery Congenital problems (strabismus) Allergies Medical history (DM, HTN, hyperthyroid) Last eye exam Use of contacts, glasses, care of contacts Medications (ocular side effects, ie. cataracts with prednisone) |
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Eye infection |
Vaginal infections at time of birth may cause Gonorrhea, herpes may require mom to have C-Section |
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Diabetic retinopathy |
Diabetics need annual eye exams Leading cause of blindness May have eye changes within 10 yrs of diagnosis Fasting glucose > 126 twice increases risk of retinopathy
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Family Eye History |
Myopia Hyperopia Color Blindness Glaucoma Macular degeneration (may have hereditary link) |
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Myopia |
Near sighted Distance vision is impaired r/t inapporpriate refraction of light rays on retina |
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Hyperopia |
Far Sighted Near vision impaired r/t inappropriate refraction of light rays on retina |
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Oculus Dexter |
OD Right eye |
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Oculus Sinister |
OS Left eye |
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Oculus unites |
OU Both eyes |
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Test Visual Acuity: Far vision |
CN II - Optic Snellen chart from 20 foot distance Test each eye individually, then both eyes Normal 20/20 Test without glasses to determine level of visual acuity Test with glasses to determine how well vision is corrected CA requires 20/40 or better for driving |
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Legally blind |
Snellen test of 20/200 after correction |
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Test Visual Acuity: Near Vision |
CN II - Optic Jaegar, Rosenbaum, newprint (14-16 inch distance) |
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Presbyopia |
Decreased power of accommodation with aging Decreased ability of lense to change shape for near vision Corrected with bifocals Usually 42-46 yrs |
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Test Visual Fields (Peripheral Vision) |
CN II - optic Confrontation test Face pt at 2 ft, cover one eye Assess when pt can see finger in periphery 4 fields assessed (superior, inferior, temporal, nasal) "Visual fields are full by confrontation, no field cuts, CN II intact) |
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EOMs |
Six muscles are attached to the eyeball for straight and rotary movement Each muscle is coordinated ith the same muscle in the other eye so that eye movement is parallel/conjugate CN III, IV, VI responsible for eye movement |
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CN III - Oculomotor |
Innervates all EOMs except for superior oblique and lateral rectus Superior Rectus: up to temple Inferior Rectus: down to jaw Medial Rectus: to bridge of nose Inferior oblique: Up to forehead |
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CN IV: Trochlear |
Superior Oblique EOM: down to nose |
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CN VI: Abducens/Abduction |
Lateral rectus EOM: out to ear Abducts outward |
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Eye Movement: Horizontal and temporal |
Lateral Rectus CN VI |
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Eye Movement: Up and Temporal |
Superior Rectus CN III |
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Eye Movement: Down and Temporal |
Inferior rectus CN III |
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Eye Movement: Horizontal and Nasal |
Medial rectus CN III |
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Eye Movement: Up and Nasal |
Inferior Oblique CN III |
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Eye Movement: Down and Nasal |
Superior Oblique CN IV |
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Test EOMs |
Hold chin to avoid movement Have pt follow an object through 6 cardinal positions of gaze Detect any non-parallel movements (comparing both eyes) |
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Nystagmus |
Involuntary movement of eyeballs 1-2 beat normal in extreme lateral gaze Abnormal in all other positions of gaze |
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Corneal light reflex |
Tests the parallel alignment of the eyes Instruct the pt to look straight ahead Direct light source toward nasal bridge - not position of the light on each cornea - light should fall on same spot of each eye |
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Strabismus: Esotropia |
Inward turn |
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Strabismus: Exotropia |
Outward turn |
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Cover Test |
Detects eye muscle weakness Ask pt to focus on a fixed object while covering one eye A weak eye will drift when covered Quickly remove obstruction: if covered eye moves to reestablish fixation, it has EOM weakness Repeat bilaterally Document presence/absence of eye drift |
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Esophoria |
Nasal/inward drift during cover test |
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Exophoria |
Temporal/outward drift during cover test |
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Eyebrows |
Should have symmetrical movement - CN VII Note skin problems, lesions, seborrhea Note eyebrow fullness or loss |
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Hypothyroidism and eyebrows |
Loss of outer 1/3 of brows |
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Trichotillomania |
Irresistible urge to pull out hair |
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Eyelids |
Protect eyes from injury, strong light, and dust Contain meibomian glands (inside lid) Note lesions, rashes, swelling, redness, discharge |
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Meibomian glands |
Lubricates lids Prevents evaporation of tears Provides an airtight seal when eyes are closed |
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Basal Cell CA |
Papule on eyelid with ulcerated center |
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Hordeolum |
Sty Localized staph infection of hair follicle at lid margin Painful, red, swollen |
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Chalazion |
Infection or retention cyst of a meibomian gland Swelling with no tenderness Firm, discrete nodule on lid |
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Blepharitis |
Inflammation of eyelid secondary to staph infection or seborrheic dermatitis Red, scaley, crusted lid margin Treat with baby shampoo |
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Edema of eyelid |
Allergies Renal disease Heart disease Infants from birth trauma |
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Entropion |
Inward curve of lid and lashes Can irritate the conjunctiva and cause conjunctivitis Occures with weak muscles and part of normal aging |
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Ectropion |
Excessive outward lash and lid curve Most prominant on medial side Causes increased tearing, loss of tears, dry eyes Occurs with muscle loss and normal aging Can cause conjunctivitis r/t exposure of palpebral conjunctiva |
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Palpebral fissures |
Space between eyelids Upper lid covers part of the iris when eyes are open Lower lid is at the limbus |
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Limbus |
Border between cornea and sclera Border between sclera and iris Bulbar conjunctiva merges with the cornea |
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Lid lag |
Occurs with exophthalmus Visible white rim of sclera between upper lid and iris during downward movement of eyes Occures with hyperthyroidism, facial paralysis |
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Ptosis |
Drooping of upper lid May involve CN III, V, VII First symptom in 75% cases of myesthenia gravis |
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Canthus |
Corner of the eye Angle where lids meet Referred to as medial/inner or lateral/outer |
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Caruncle |
Small, fleshy mass of the inner canthus containing sebaceous glands |
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Lacrimal Apparatus |
Glands, ducts and lacrimal sac Forms tears to irrigate conjunctiva and cornea Keeps eyes moist and lubricated |
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Lacrimal glands |
Located in upper outer corner of eyes Secretes tears that drain across eye into puncta Tears then drain into lacrimal sac through nasolacrimal duct and empty info inferior meatus in the nose |
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Puncta |
Located at upper and lower inner canthus |
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Dacrocystitis |
Infection and blockage of lacrimal sac and duct Pain, warmth, redness, swelling, purulent discharge from puncta when pressure applied to lacrimal sac May need systemic and topical antibiotics |
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Eyeballs |
Inspect for color, moisture, swelling, discharge, lesions Should be algigned without sunken or protruding appearance |
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Enophthalmos |
Sunken eyeballs Dehydration |
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Exophthalmos |
Bulgin eyeballs Hyperthyroidism, Graves disease, retro-orbital tumor Could be result of increased volume in orbital contents, abnormal connective dissue deposits in orbit and EOMs Trauma could cause complete or partial dislocation of theeye |
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3 Concentric Coatings |
Sclera (Anterior surface) Choroid (middle layer) Retina (inner layer) |
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Sclera |
Only seen anteriorly Tough, fibrous, white outer covering under transparent bulbar conjunctiva Injected: scleral redness Icterus: sceral jaundice |
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Bulbar Conjunctiva |
Thin protective mucous membrane covering the sclera (not cornea) |
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Conjunctivitis |
"Pink Eye" Mechanical (foreign object), allergic, viral, bacterial Itching, burning, foreign body sensation Eyes are red and irritated Red at periphery, clear around iris |
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Subjunctival hemorrhage |
Not serious, not treated Secondary to increased ICP, should resolve in a couple of weeks Often happens at night Coughing, sneezing, weight lifting, childbirth, straining with BM, trauma, vomiting |
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Pinguecula |
Yellowish nodules on bulbar conjunctiva at 3 and 9 o'clack R/t thickening secondary to sun, wind, dust exposure |
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Pterygium |
Overgrowth of conjunctival tissue Starts at inner canthus and progresses toward cornea Triangular shape Progressive, may require laser surgery to correct |
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Palpebral conjunctiva |
Continuation of the mucous membrane that covers the inner eyelid Pink in caucasion, gray with brown macules in dark skinned Check for palpebral pallor (lower lid), may be anemia or cyanosis Eye pain or foreign body sensation: evert (rll with q tip and inspect upper lid |
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Cornea |
Transparent covering to protect the pupil and iris Helps refract light rays to focus on the inner retina Damaged cornea affects vision Should be smooth and clear, abnormal findings include cloudiness in cornea, anterior chamber, or lens |
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Cataract |
Lens opacity Pupil may appear cloudy |
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Corneal Arcus |
Grayish around cornea at limbus Normal in pts > 60 yrs May indicate lipid abnormality |
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Corneal abrsion/ulcer |
Secondary to scratch or foreign object, rheumatologic disorder (connective tissue disease, RA, lupus, Wegener granulomatosis, polyarteritis nodosa), viral infection (herpes simplex), bacterial infection, dryness or poor lacrimal gland fxn Very painful, photophobic, blurry vision, sensation of foreign object, erythema of lids and conjunctiva, purulent exudates Usually stain eyes to see
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Keratitis |
Inflammation of cornea |
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Astigmatism |
Spherical curve of the cornea is asymmetric around eye, light rays are spread over a diffuse area rather than a focal point on the retina Blurred vision May be corrected with glasses or contacts |
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Test corneal reflex |
Touch cotton wisp to eye Should blink if CN V and CN VII intact Decreased blink reflex could be neuro lesion |
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CN V |
Trigeminal Carries afferent sensation to brain |
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CN VII |
Facial Carries efferent message that stiumlates blink reflex |
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Iris |
Normally round with even color Contracts and expands to control pupil size Color of iris varies (genetic recessive trait) |
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Iritis |
Needs immediate referral Marked photophobia, blurred vision, throbbing pain Iris swells causing constricted and ragged edge of pupil May have red eye up to iris |
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Pupils |
Should be round and equal in size Varies with ANS stimulation Usually constricts with bright light and dilate with dim light Controlled by afferent CN II (Sensory) and efferent CN III (motor) |
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Sympathetic stimulation |
Mydriasis: pupil dilates Fear, pupils dilate as a defense mechanism to allow for increased light and vision |
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Parasympathetic stimulation |
Miosis: pupil constricts |
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Anisocoria |
Unequal pupils Occurs normally in 5% of population Could be suspicous for increased ICP Pupillary response should be equal even though size is unequal |
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Test pupillary light reflex |
Direct: constriction of same pupil Consensual: constriction of opposite pupil Document R 3/1 = 3/1 L |
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Test accomodation |
Ability to adjust vision from far to near Focus on a distant object (pupils dilate) Adjust focus to near object moving toward nose Pupils should constrict and converge Document PERRLA |
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Lens |
Transparent Posterior to pupil Ciliary body controls lens thickness and changes shape to accomodate for near and far objects |
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Retina |
Inner layer Contains optic disc, retinal vessels, backgrounds, and macula Conains transparent vitreous body |
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Fundoscopic/Ophthalmoscopic Exam |
Use for examining inernal eye - small aperture for undilated pupils Use right eye to examine right eye Begin 10 inches from pt, 15 degrees laterally Find the red reflex Adjust diopters to bring structure into focus Even when dilating the pupil only 1/3 of the fundus/retina is visualized |
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Red Reflex |
Red glow in pupils Reflection off retina Corneal scars or cataract may obscure red reflex |
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Anterior Chamber |
Between cornea and iris/lens Contains aqueous humor: produced continuously by viliary body, normally clear |
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Intraocular pressure |
Normally 13-22 mmHg Determined by amt of aqueous solution produced and resistance to outflow at the angle of the anterior chamber Glaucoma = IOP>22 mmHg |
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Glaucoma |
IOP > 22 mmHg Chokes the blood supply to retina Measured by tonometry Can cause blindness Affects peripheral vision Asymptomatic until late stages: clouding vision, sudden eye pain, halos around lights, HA |
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Narrow Angle Glaucoma |
AKA closed angle Impaired drainage of aqueous humor Causes increased IOP |
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Open Angle Glaucoma |
Angle that drains the aqueous humor is normal, but doesn't function normally Etiology unknown Most common type |
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Anterior structures |
Look for abnormalities: opacities, dark shadows, black dots May occure with cataracts or hemorrhages of vitreous humor |
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Fundus (eye grounds) |
Color varies depending on skin color (darker skin = darker fundus) Should be clear between markers Abnormal findings: hemorrhages, exudates, microaneurysms - seen in HTN, DM retinopathy Focus on posterior structures of fundus: optic disc, retinal vessels, background, macula Adjust diopter to visualize fundus - Normal vision: 0 diopter - Myopia: red diopter - Hyperopia: black or green diopter |
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Optic disc |
Area where gibers from retina converge to form optic nerve (CN II) Note color, shape, margins Located on NASAL side Yellow to pink, round to oval, distinct margins (may have some fuzziness at nasal border) Abnormal: fuzzy margins (papilledema, disc edema) r/t HTN, HTN crisis, increased ICP Usually 1.5 mm in diameter Physiologic cup Measure lesions in disc diameters, 2 DD temporal side |
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Physiologic cup |
Smaller circle within optic disc where blood vessels exit |
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Retinal Vessels |
Consist of paired arteries (light red, smaller) and veins (dark red, larger) Follow vessels to all 4 quadrants of retina Grow progressively smaller toward periphery Note A/V crossing defects - Narrowing, tapering, nicking: seen in HTN retinopathy |
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Macula |
Responsible for central vision Assess by having pt look directly into light Difficult to find in undilated eyes Color is dark Located on temporal side Contains rods (motion detection and night vision) and cones (detailed vision and color) Contains Fovea centralis (center of macula): area of sharpest vision |
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Glaucoma and Macular degeneration |
If pt has both, blindness occures Glaucoma: peripheral vision loss Mac Degen: central vision loss |
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Visual pathway : light and images |
Through cornea, aqueous humor, lens, vitreous body to retina |
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Visual pathway: left visual field |
Right side of brain looks at left visual field Image from left field falls on right side of retina and travels down right optic tract |
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Visual pathway: Retina |
Retina changes image/stimulus into nerve impulses that are conducted by optic nerve and optic tract to visual cortex of occipital lobe |
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Left optic tract |
Has fibers from the left half of each retina |
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Right Optic Tract |
Has fibers from the right half of each retina |
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Optic chiasm |
Location where fibers from both temporal visual fields cross over |
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Visual pathway: pathology |
Blockage of optic nerve: unilateral blindness Blockage of optic chiasm: causes bi-temporal hemianopsia (blindness), pituitary tumor Blockage of optic tract: causes homonomous hemianopsia, blindness of same 1/2 of visual fields on both sides Cortical blindness: occipital lobe cortex injury or lesion |
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Developmental considerations: Infant and child vision |
Test light perception by observing blink reflex (at birth) Test pupillary light reflex at 3 weeks Should fixate on yellow, bright objects at 1 mo Should fixate on objects with both eyes at 4 mo (vision is 20/200) Screen vision (with picture cards) around age 2, approx vision 20/40 Check visual fields by age 3 Check color vision (X linked) between 4-8 Ishirara's test: series of polychromatic cards that have numbers imbedded in different colors |
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Developmental considerations: infant and child EOM function |
DO NOT MISS STRABISMUS: asymmetric eye axes If diagnosed after 6 yrs, poor prognosis, results in disues of deviated eye Test by corneal light reflex, cover test, EOMs |
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Amblyopia |
Vision loss or blindness r/t disuse R/t strabismus |
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Developmental considerations: infant and child external eye structures |
Setting sun sign (eyes deviate downward with rim of sclera showing above iris) - may indicate hydrocephalus Iris color: permanentrly differentiates by 6-9 mo Check for bilateral red reflex Observe for tearing (begins after 2-4 weeks, lacrimal glands not fully developed until age 4 |
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Developmental considerations: Aging adult |
May normally have decrease in eyebrow cover on temporal side Xanthelasma Ectropion Entropion Pseudoptosis Dry eyes and burning (decreased fxn of lacrimal gland and entropion) Arcus Senilus Decreased pupil size (problems with night vision, night driving) Senile cataract Floaters Visual acuity may diminish - central visual acuity (85%) remains intact Presbyopia Cataracts, glaucoma, macular degeneration Should be having regular eye exams and glaucoma testing |
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Xanthelasma |
Lipid deposits at inner canthus |
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Pseudoptosis |
Lids may droop and cover eyes r/t loss of elasticity, fat and muscle atrophy, loose skin |
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Arcus Senilus |
Collection of broken down lipids forming a gray/white circle around limbus Seen in hyperlipidemia |
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Senile cataract |
Lens opacifies by age 70 Everyone will develop cataracts if they live long enough |
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Floaters |
Occurs in vitreous r/t condensed vitreous fibers or exudates |
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3 primary causes of vision problems |
Cataracts (lens opacity) - pupils appear cloudy Glaucoma (loss of peripheral vision), genetic Macular Degeneration (loss of central vision) - leading cause of blindness, test changes with amsler grid |
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Risk factors for cataracts |
Family history Steroid medication Exposure to UV light Smoking DM Aging |
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Miosis |
Pupillary constriction < 2mm Iridocyclitis Miotic eye drops (pilocarpine given for glaucoma) Drug abuse |
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Mydriasis |
Pupillary dilation > 6mm Iridocyclitis Mydriatic/cycloplegic drops (atropine) Midbrain lesion (reflex arc) or hypoxia CN III damage Acute-angle glaucoma Drug abuse |
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Failure for pupillary response |
Iridocyclitis Retinal degeneration CN II destruction Midbrain synapses or CN III response lost Impairment of efferent fibers Mydriatic drops |
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Argyll Robertsons pupil |
Bilateral miotic irregularly shaped pupils that fail to constrict with light, but constrit with convergence Neurosyphilis Lesion in midbrain |
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Iritis constructive response |
Acute uvelitis commonly unilateral Accompanied by pain, reddened eyes adjacent to the iris |
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Oculomotor damage |
Pupil dilated and fixed Eye deviated laterally and downward Ptosis |
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Adie pupil (tonic pupil) |
Affected pupil dilated and reacts slowly or fails to react to light Responds to convergence Caused by impairment of postganglionic parasympathetic innervation to sphincter pupillae muscle of ciliary malfunction Often accompanied by diminished DTR (diabetic neuropathy or ETOH) |
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Pappilledema |
Loss of definition of optic disc margin Central vessels pushed forward, veins markedly dilated Venous hemorrhage may occur Caused by increased ICP transmitted along optic nerve Vision not altered |
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Episcleritis |
Inflammation of superficial layers of the sclera Mild-moderate discomfort, painless injection, watery discharge without crusting May be caused by autoimmune disorders, RA, Crohn disease, lupus, psoriatic arthritis, polyarteritis nodosa, gout, atopy, foreign bodies, chemical exposure, infection |
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Band Keratopathy |
Deposition of calcium in superficial cornea Common in pts with chronic corneal disease, hypercalcemia, hyperparathyroidism, occasionally in trauma, renal failure, sarcoidosis, syphilis Decrease in vision, foreign body sensation and irritation, line just below pupil passes over cornea rather than around the iris, horizontal grayish bands |
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Horner syndrome |
Interruption of sympathetic nerve innervation Can be congenital, acquired, hereditary, result from lesion of the primary neuron, stroke, trauma to brachial plexus, dissecting carotid aneurysm, operative trauma Results in triad of ipsilateral miosis, mild ptosis, loss of hemifacial sweating, anisocoria |
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Diabetic retinopathy: background or non-proliferative |
Dot hemorrhages or microaneurysms, presence of hard and soft exudates (lipid transudation through incompetent capillaries) Asymptomatic initially, blurred vision, distortion, visual acuity loss, blood vessels with balloon-like sacs, blots of hemorrhage on retina, tiny yellow patches of hard exudate |
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Diabetic retinopathy: proliferative |
Development of new vessels as result of anoxic stimulation Vessels grow out of retina toward vitreous humor which lack supporting structure of healthy vessels and are more likely to hemorrhage causing blindness Generally asymptomatic, floaters, blurred vision, progressive vision loss |
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Lipemia Retinalis |
Creamy white appearance of retinal vessels with high serum triglyceride levels ( > 2000) No vision symptoms |
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Retinitis Pigmentosa |
Autosomal recessive disorder which causes cell death predominantly in rod photoreceptors Associated with deafness, paralysis of 1+ EOMs, dysphasia, ataxia, cardiac conduction defects Earliest symptom is night blindness, tunnel vision, painless, optic atrophy |
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Chorioretinitis |
Inflammatory process involving choroid and retina Common after laser therapy for diabetic reinopathy, histoplamosis, CMV, toxoplasmosis, congenital rubella History of cleaning cat litter boxes, laser surgery, pain, reduced visual acuity, floaters, photophobia, sharply defined lesion ending with chorioretinal scar, visual field defect in larger lesions |
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Retinoblastoma |
Embryonic malignant tumor Usually within first 2 yrs, transmitted by autosomal dominant trait or chromosomal mutation Family hx white reflex oh photographs, leukocoria, ill-defined mass on funuscopic exam |
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Preinopathy of prematurity |
Disruption of retinal vascular development in preterm infant, gestational age of 30 weeks or less High oxygen concentration, blood transfusion, respiratory distress Can be mild with no visual defects, or amblyopia, progressive retinal detachment and blindness |
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Retinal hemorrhages in infancy |
Abnormal bleeding of blood vessels in retina Usually from head injury in shaken baby syndrome, usually bilateral Other causes HTN, bleeding problems, leukemia, meningitis, sepsis, endocarditis, vasculitis, retinal diseases (infection, hemangioma), anemia, hypoxia or hypotension |
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Macular degeneration: Dry |
Caused when part of retina deteriorates From gradual breakdown of cells in macula, gradual blurring of central vision Blurred central vision, blind spots, scotomas, straight lines look irregular or bent, objects appear a different color or shape in each eye, micropsia, multiple spots in macula region, thinning and loss of retina and choroid |
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Macular degeneration: Wet |
Caused when part of the retina deteriorates New, abnormal vessels grow under the center of the retina, which leak, bleed, and scar retina, rapid vision loss Blurred or decreased central vision, scotomas, straight lines look irregular or bent, abjects smaller in one eye, different color or shape in each eye Exudates, blood, scarring Leading cause of blindness in 55 yrs and older |
