The eye is the sensory organ that transmits visual stimuli to the brain for interpretation. The eyes are connected to the brain by the optic nerve

The eye is the sensory organ that transmits visual stimuli to the brain for interpretation. The eyes are connected to the brain by the optic nerve

Internal Eye The internal structures of the eye are composed of three separate coats. The outer wall of the eye is composed of the sclera posteriorly and the cornea anteriorly. The middle layer or uvea consists of the choroid posteriorly and the ciliary body and iris anteriorly. The inner layer of nerve fibers is the retina.

External Eye The external eye is composed of the eyelid, conjunctiva, lacrimal gland, eye muscles, and the bony skull orbit The orbit also contains fat, blood vessels, nerves, and connective tissue that support the eye. The eyelid is composed of skin, striated muscle, the tarsal plate, and conjunctiva. The eyelids are composed of skin, conjunctiva, and striated and smooth muscle. They distribute tears, limit light, and protect the eyes. The conjunctiva is a thin mucous membrane covering most of the anterior surface of the eye and eyelid. It protects the eye from foreign bodies. The lacrimal gland provides moisture. Tears flow over the cornea and drain into the lacrimal sac and nasal meatus.

The sclera is the dense, avascular white portion of the eye that supports the internal structure of eye. The cornea constitutes the anterior sixth of the globe and is continuous with the sclera. It is optically clear, has rich sensory innervation and is avascular. It is a major part of the refractive power of the eye. The cornea contains pain receptors, separates the aqueous humor from the external environment, and permits light to travel through the lens. The iris contains pigment cells that produce the color of the eye. The center of the iris is the pupil, where light travels to retina. The iris controls light by dilating or contracting the pupil. The lens of the eye is elastic and changes its thickness to focus on images far or near. The retina is the sensory network of the eye. It transforms light impulses into electric impulses transmitted to the optic nerve. Neural impulses transmit along the optic nerve, reaching the optic cortex. The macula, or fovea, allows color perception and central vision.

Older Adults Presbyopia Loss of lens clarity and cataract formation Older adults. With aging, there is a progressive change in the near point of accommodation. By 45 years of age, the lens becomes more rigid and the ciliary muscle of iris becomes weaker, leading to presbyopia. Lens fibers develop throughout life, and the dense central region may cause cataract formation or a decrease in clarity of the lens

Use Snellen chart Each eye tested individually Test with and without corrective lenses If vision less than 20/20, conduct pinhole test Near vision - Use Rosenbaum pocket screener Each eye tested individually Peripheral vision -Estimate with confrontation test Accurate measurement requires instrumentation Is It Blurry or Is It Double? Blurred vision and diplopia are sometimes confused by the patient. Blurred vision represents a problem with visual acuity and there are many causes. Diplopia is the perception of two images and may be monocular or binocular. Monocular diplopia is an optical problem; binocular diplopia is an alignment problem

A fasciculation (or "muscle twitch”) is a small, local, involuntary muscle contraction (twitching) visible under the skin arising from the spontaneous discharge of a bundle of skeletal muscle fibers. Fasciculations have a variety of causes, the majority of which are benign, but can also be due to disease of the motor neurons.

Normal Findings Eye movements are smooth without sclera exposure above iris. Conjunctiva are pink; sclerae are clear. Cornea is clear; corneal reflex is intact. Pupils are equal, round, and react to light. Red reflex is present. Discs are cream- colored, borders well-defined. 3:5 a:v ratio, no nicking, hemorrhage, or exudates noted. Typical Variations If sclera is dark and rust-colored, senile hyaline plaque may be present. Retina pigment varies with complexion. Disc margin color is dark if skin is dark. Sty is caused by Staphylococcus .

Normal Findings Older Adults With aging, there is a progressive change in near point of accommodation. By 45 years of age, lens becomes more rigid and ciliary muscle of iris becomes weaker. Typical Variations Drusen bodies become more yellow with aging. Lens fibers develop throughout life, and dense central region may cause cataract formation or a decrease in clarity of the lens.

PERRLA record the pupil size and shape (round) at rest and note if the size is equal or unequal note the direct response, meaning constriction of the illuminated pupil, as well as the consensual response, meaning constriction of the opposite pupil. Test the pupillary response to accommodation. Normally, the pupils constrict while fixating on an object being moveEye alignmentd from far away to near the eye. Consensual - Shine pen light in one eye look for both the direct (same eye) and consensual (other eye) reactions. Record pupil size in mm and any asymmetry or irregularity

History of Present Illness Present problem data focus on eyelid drooping, difficulty with vision, eye pain, secretions, or medications used. Visual perception and related symptoms such as double vision should be investigated Hordeola A hordeolum is a bacterial infection of either the meibomian glands or ciliary glands. Patients will present with an acutely swollen and edematous upper or lower eyelid. Visual function will be normal. There may be an associated conjunctivitis and possibly mucopurulent discharge. The lids will be extremely sensitive to palpation, and there may be an associated pustular, pimple-like lesion at the lid margin or, less commonly, at the dermis.

Past Medical History Questions should be asked about past eye trauma, treatment and results, previous eye surgery and outcome, any chronic illnesses affecting vision, and medications used.

Family History Pertinent data include familial occurrence of retinoblastoma or cancer of retina, color blindness, nearsightedness, or any other condition similar to patient’s eye condition.

Personal and Social History Relevant data include employment, activities, allergies, medications, eye lenses, and protective device use. Exposure to irritants and activity risks should be delineated. Routine care of eyes and eye devices should be explored.

Older adults. Data specific to older adults pertain to any changes in visual acuity, excessive tearing, blurred vision, deposits in cornea, scleral brown spots, difficulty with near work, and nocturnal eye pain

Exopthalmos-an increase in the volume of the orbital content, causing protrusion of the globes forward. (Graves disease) Episcleritis- inflammation of the superficial layers of the sclera anterior to the insertion of the rectus muscles. Etiology unknown, however it is a common manifestation of chron’s disease, rheumatoid arthritis, and other autoimmune disorders. Band keratophthy-I produced by deposition of calcium in the superficial cornea. It appears as a line where the eyelids close just below the pupil; it passes over the cornea. Seen with chronic corneal disease but may occur in hyperparathroidism and occasionally seen in individuals with renal failure/syphilis. Corneal ulcer-disruption of the corneal epithelium/stroma caused by viral/bacterial infection (or by desiccation rt incomplete lid closure or poor lacrimal gland function) Those at risk contact lens wearers. Strabismus- condition where OS/OD do not focus on an object simultaneously. Paralytic=impairment of 1 or more extra ocular muscles or their nerve supply (cranial nerves 2-3-6). Non paralytic has no primary muscle weakness. The pt. can focus with each eye but not simultaneously (etiology infantile cataract or retinoblastoms). Hemianopia is a blindness or reduction in vision in one half of the visual field due to damage of the optic pathways in the brain. This damage can result from acquired brain injuries caused by stroke, tumor or trauma

Horner Syndrome-caused by the interruption of the sympathetic nerve supply to the eye and results in ipsilateral miosis/mild ptosis (caused by interruption of their cervical sympathetic trunk due to medalstiastinal tumors, bronchogenic carcinoma, metastatic tumors, or operative trauma) Cataracts-Common abnormality it is an opacity occurring in the lens, most commonly from denaturation of lens protein caused by ageing. Most 65> have some evidence of lens opacification. Optic Atrophy-is ther result of the death of nerve fibers/myelin sheaths. Primary symptom is loss of central/peripheral vision or both. The disc or a portion of it loses its yellowish pink hue and becomes stark white. Diabetic Retinopathy (Background) is marked by dot hemorrhages or microaneurysms and the presence of hard/soft exudates. Hard=lipid transudation through incompetent capillaries. Soft= infarction of the nerve layer. Diabetic Retinopathy (Proliferative) is the development of new vessels as the result of anoxic stimulation.

Lipemia retinalis is a dramatic condition that occurs when the serum triglyceride level exceeds 20000mg/dL. Commonly seen in diabetic ketoacidosis and in some of the hyperlipidemic states. Retinitis pigmentosa-an autosomal recessive condition characterized by the development of night blindness and loss of peripheral vision. Cytomegalovirus-infection that is a common cause of blindness in immune compromised individuals (HIV). Characterized by hemorrhage, exudates, and necrosis of the retina. (pizza pie appearance in retina) Glaucoma-is a disease of the optic nerve whenin the nerve cells die, producing a characteristic appearance of the optic nerve “increased cupping”. S/S intense ocular pain, blurred vision, halos around lights, a red eye, and dilated pupil. Etiology acute related to dramatic elevated Intraocular pressure if the iris blocks the exit of aqueous humor form the anterior chamber. Chronic (more common) symptoms are absent exce4pt for gradual loss of peripheral vision over a period of years. Chorioretinal inflammation – an inflammatory process that involves both the choroid and retina. Coomon cause today is laser therapy for diabetic retinopathy, but can also be a conseque4ce of infectious agents “histoplasmosis, cytomegalovirus or toxoplasmosis during fetal life”. Chorodial nevus- are pigmented lesions of the choroid. (melanoma)

Opthalmologist vs optometrist Optometrist are primary health care providers for the eye and visual system. They examine, diagnose, and medically treat eye diseases, non-surgical injuries, and disorders of the eyes and visual system, including refractive problems such as near- or far-sightedness, and identify related systemic medical conditions affecting the eyes and ocular adnexa. Adnexa refers to the appendages of an organ for the eye it would be the lacrimal glands, eyelids, and extraocular muscles. Opthalmologist Physician specializing in the diagnosis and treatment of disorders of the eye

Snelling chart- the higher the second number the poorer the vision. Any client with vision worse than 20/30 should be referred for further evaluation. Corneal reflect that is asymmetric may be due to muscle weakness or paralysis. Nystagmus (oscillating shaking) movement of the eye may be associated with an inner ear disorder, MS, brain lesions, or narcotic use. Left eyelid drop ptosis may be attributed to oculo-motor nerve damage, myasthenia gravis, weakened muscle or tissue. If redness discharge or crusting was noted could be indicative of infection.

Swelling of the lacrimal gland may be visible in the lateral aspect of the upper eyelid. It may be caused by blockage, infection, or an inflammatory condition. Redness or swelling around the puncta may indicate an infectious or inflammatory condition. Excessive tearing may indicate a noslacrimal sac obstruction. Expressed drainage from the puncta on palpation occurs wit duct blockage. Aras of roughness/dryness on cornea associated with injury or allergic response. Opacity of lens is seen with cataracts. When Pupils on unequal in size and slow to react and accommodate – Neuro exam should follow and physician should be notified ASAP. Left optic disc with edema and blurred margins might indicate hypertension or increased intracranial pressure. You would refer this patient to the physician for further evaluation. If the anterior chamber is not transparent you would assess for eye injury ie trauma. Direct hit to eye (punch/baseball) could cause injury that manifest with red blood cells collecting in the lower half of the anterior chamber. – Hyphemia ( Or an inflammatory response could cause white blood cells to accumulate in the anterior chamber and produce cloudiness in front of the iris which is hypopyon)

  ANSWER: Record the finding in the patient’s record This finding is consistent with senile plaque and does not indicate emergency or disease process but should be charted as a finding. With hyperlipidemia, yellow plaques are seen. Hit to the eye would most likely cause Hyphemia. Ophtalmolgist is for diagnosis and treatment of eye diseases/disorders.   DIF: Cognitive Level: Application REF: Page 292  

  ANSWER :Prominent epicanthal folds Prominent epicanthal folds, or slanting of the eyes, may be normal in Asian infants, but in other ethnic groups it may indicate Down syndrome. are round yellow deposits, which form within the layer under the retina. Papilledema is optic disc swelling that is caused by increased intracranial pressure. The swelling is usually bilateral and can occur over a period of hours to weeks. Narrow palpebral fissures are not associated with Down syndrome.   DIF: Cognitive Level: Application REF: Page 300

  ANSWER :Prominent epicanthal folds Prominent epicanthal folds, or slanting of the eyes, may be normal in Asian infants, but in other ethnic groups it may indicate Down syndrome. are round yellow deposits, which form within the layer under the retina. Papilledema is optic disc swelling that is caused by increased intracranial pressure. The swelling is usually bilateral and can occur over a period of hours to weeks. Narrow palpebral fissures are not associated with Down syndrome.   DIF: Cognitive Level: Application REF: Page 300

Eyes RNRS210 Chapter 11

Objectives

Resources Eyes The Joy of Visual Perception: A Web Book By Peter K. Kaiser, Web/HTML Support by Rod Potter York University. Extensive illustrated online resource with some fascinating interactive online activities under "Fun Things". Physical Examination - Study Guides From Richard Rathe, MD, University of Florida; illustrated site that includes Examination of the Eye. Vision Problems in the U.S.--Prevalence of Adult Vision Impairment and Age-Related Eye Diseases in America "A joint project of the National Eye Institute and Prevent Blindness America"; includes a map demonstrating rates of vision impairment and blindness, and related tables

Resources Eyes Seeing, smelling, and hearing the world. Howard Huges Medical Institute The structure of the eye. Kevin Patterson, St. Petersburg College. Human Eye Anatomy, Physiology and pathology of the Human Eye Ted M. Montgomery, Optometric Physician

Equipment Snellen eye chart Rosenbaum/Jaeger near vision card Penlight Cotton wisp Ophthalmoscope Eye cover, gauze, or opaque card

Anatomy External Eye Composed of five structures Eyelid Conjunctiva Lacrimal gland Eye muscles Bony skull orbit

Anatomy 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 Lacrimal gland Produces tears that moisten the eye

Anatomy 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

Anatomy Internal Eye Five major structures Sclera Cornea Iris Lens Retina Internal Eye

Physiology Internal Eye Sclera Supports internal eye structures Cornea Sensory innervation for pain Separates aqueous humor from external environment Permits light transmission through lens to retina Iris Dilates/contracts to control amount of light traveling through the pupil to the retina

Physiology Internal Eye Lens Changes in lens thickness allow images from varied distances to be focused on the retina Retina Sensory network of the eye Transforms light impulses into electrical impulses that are sent to the cerebral cortex Cortex interprets impulses as visual objects

Assessment Visual Testing Test for Distance vision Central vision and visual acuity Peripheral vision Near vision - Use Rosenbaum pocket screener

Assessment External Examination Examination performed in systematic manner beginning with appendages and moving inward Techniques Inspection Palpation

Assessment External Examination Inspection Surrounding structures Inspect eyebrows for size, extension, and hair texture Inspect orbital area for edema, puffiness, sagging tissue below orbit Eyelid inspection Inspect closed lid for fasciculations and tremors Check ability to close completely/open widely Observe margin for flakiness, redness, swelling Look for eyelashes Note eye opening Note any eversion or inversion of lids

Assessment External Examination Inspection Conjunctivae inspection Inspect lower portion by pulling down lower lid Upper lid is inspected only if foreign body is in the eye Look for redness/exudate Look for pterygium Cornea Examine clarity of the cornea by shining light on it Test sensitivity by touching the cornea with a cotton wisp to elicit blink. Blink reflex (using corneal sensitivity) Inspect for corneal arcus

Assessment External Examination Inspection 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

Assessment External Examination Palpation Eyelid palpation Palpate for nodules Palpate the eye itself through closed lids

Inspect and Evaluate Eye alignment Response to light Pupils response direct and accommodation Pupil response direct and consensual

Assessment External Examination Extr-aocular Eye Muscles Test eye movements using six cardinal fields of gaze Check for nystagmus Note lid lag Note exposure of sclera above iris Use corneal light reflex to test extra-ocular muscle balance If imbalanced perform cover-uncover test . Eye fixation

Ophthalmoscope Screw the head onto the power base Match the notches in the Ophthalmoscope head with those on the power source (see illustration) Press down until notches mesh Twist clockwise Pull gently to see if head is secure

Ophthalmoscope-turn on Turn the ophthalmoscope on Press red button on the top rim of the power source handle in a downward direction Twist the button clockwise around the rim. You should be able to see the light in the palm of your hand when you point the narrow end toward your palm.

Ophthalmoscope-view eye View the eye with the ophthalmoscope Turn the vertical dial with your thumb until it is on the “0” setting Find the “large circle of light” by turning the horizontal dial with your thumb

Assessment Ophthalmoscopic Examination Inspection of interior eye with ophthalmoscope permits visualization of Optic disc Arteries Veins Retina Macula Adequate pupil dilation is necessary

Assessment Ophthalmoscopic Examination Visualize red reflex Opacities appear as black densities Examine Fundus Vascular supply Disc margins Macula Look for unexpected findings such as Myelinated nerve fibers Papilledema Glaucomatous cupping Drusen bodies, Hemorrhages

Health History History of Present Illness Eyelids: recurrent hordeola, ptosis Vision correction Vision difficulties: color vision, halos, floaters, diplopia Cataracts Pain Secretions Medications

Health History Past Medical History Trauma Eye surgery Chronic illness that can affect vision Hypertension Diabetes mellitus Glaucoma

Health History Family History Diabetes, Retinal detachment Nearsightedness, Farsightedness Strabismus, Amblyopia Retinoblastoma, Glaucoma Macular degeneration, Retinitis pigmentosa Allergies affecting eye Color blindness Cataract formation

Health History Personal and Social History Employment exposure Activities Allergies Corrective lenses Protective eyewear

Health Promotion Teaching Vision Risk Factors for Cataract Formation Steroid medication use Exposure to ultraviolet light Cigarette smoking Diabetes mellitus Aging

Description of Eye disorders External eye Exophthalmos Episcleritis Band keratopathy Corneal ulcer Extraocular muscles Strabismus (paralytic and non-paralytic) Visual fields Hemianopia

Description of Eye disorders Internal eye Horner syndrome Cataracts Optic atrophy Diabetic retinopathy (background) Diabetic retinopathy (proliferative)

Description of Eye disorders cont.’ Internal eye Lipemia retinalis Retinitis pigmentosa Cytomegalovirus infection Glaucoma Chorioretinal inflammation Choroidal nevus

Documentation Healthy Client Patient denies recent changes in vision. Denies excessive tearing, redness, swelling, or pain of eyes. Denies spots, floaters, or blind spots. States no problem with seeing at night. No previous eye surgeries. No family history of eye problems. Denies exposure to conditions or substances that harm the eyes. Wears sunglasses regularly. Does not wear corrective lenses. Last eye examination was 1 year ago. Subjective

Documentation Healthy Client Acuity tested by Snellen chart: O.D. 20/20, O.S. 20/20. Visual fields full by confrontation. Corneal light reflex shows equal position of reflection. Eyes remain fixed throughout cover test. Extra ocular movements smooth and symmetric with no nystagmus. Eyelids in normal position with not abnormal widening or ptosis. No redness, discharge, or crusting noted on lid margins. Conjunctiva and sclera appear moist and smooth. Sclera white with no lesions or redness. Objective

Documentation Healthy Client cont’. No swelling or redness over lacrimal gland; puncta is visible without swelling or redness; not drainage noted when nasolacrimal duct is palpated. Cornea is transparent, smooth, and moist with no opacities; lens is free of opacities. Irises are round, flat, and evenly colored. Pupils are equal in size and reactive to light and accommodation. Pupils converge evenly. Red reflex present bilaterally. Both optic discs visualized easily, creamy white in color, with distinct margins and vessels noted with no crossing defects. Retinal background free of lesions and orange-red in color. Macular visualized within normal limits. Anterior chamber is transparent. Objective

Documentation Un-healthy Client Patient states trouble with vision at night. First noticed 2 weeks ago while driving and problem has progressed to any night vision activity. Reports occasional tearing and mild pain in O.D, however denies redness or swelling. Denies floaters, spots, or blind spots in visual fields. Had cataract surgery O.S. 1 year ago and has regular follow-up with optometrist. Mother had Macular degeneration. Denies exposure to conditions or substances that harm the eyes. Wears corrective lens and has UV protection and tined lenses. Last eye exam with optometrist 6 months ago. Subjective

Documentation Un-healthy Client Acuity tested by snellen chart with corrective lens on: OD 20/25, OS 20/30. Visual fields full by confrontation. Corneal light reflex shows asymmetric position of the light reflex. Eyes remain fixed through out cover test. Extra ocular movement smooth in O.S., however movement in O.D. was delayed and nystagmus was noted. Right eyelid in normal position with no widening, however left eyelid dropping noted. No redness, discharge, or crusting noted on lid margins. Objective

Documentation Un-healthy Client cont’. Swelling and redness over lacrimal gland; puncta is visible with swelling and redness noted, and drainage was present when nasolacrimal duct is palpated. Cornea has areas of roughness and dryness. Opacity noted on the left cornea. Irises are round, flat, and evenly colored. Pupils are un-equal in size and slow to reactive to light and accommodate. Pupils converge evenly. Red reflex present O.S. Right optic disc visualized easily, creamy white in color, with distinct margins and vessels noted with no crossing defects. Left optic disc easily visualized, however appears swollen and has blurred margins. Retinal background free of lesions and orange-red in color. Macular visualized within normal limits. Anterior chamber hyphemia noted or hypopyon noted..

NCLEX The nurse understands that a dark, rust-colored pigment just anterior to the insertion of the rectus muscle in an 80-year-old woman requires which action? Record the finding in the patient’s record Refer the patient to an ophthalmologist Attribute the finding to type II hyper-lipidemia Ask the patient if she remembers being hit in the eye  

NCLEX Which trait assessed on your client may be suggestive of Down syndrome? Drusen bodies Papilledema Narrow palpebral fissures Prominent epicanthal folds

References Anderson, D. M., Keith, J., Novak, P. A., & Elliot, M. A. (2002). Mosby's Medical, Nursing, & Allied Health Dictionary (6th ed.). St. Louis, MO: Mosby. Jarvis, C. (2000). Eye Assessment. In Physical Examination and Health Assessment (3rd ed., pp. 248) Philadelphia, PA: W. B. Saunders Company. Seidel H., Ball J., Dains J., Benedict G. (2006). Mosby's Guide to Physical Examination (6th ed.). St. Louis, MO: MOSBY Elsevier.