04 - assessment of eyes & ears

8/10/2019 04 - Assessment of Eyes & Ears

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Assessment of

Eyes and Ears

By B.Lokay, MD, PhDInstitute of Nursing, TSMU



Eye Anatomy – Why Study It?



Why should you care?

Optometrist – Doctor of optometry, 4 year

undergrad + 4 year optometry school

Ophthalmologists – Medical doctors

In general, optometrists practice primary

and preventive eye care, while

ophthalmologists perform eye surgery

What do nurses do?



History

Vision difficulty? Halos around lights – in glaucoma

Scotoma – blind spot in visual field – in

glaucoma, optic nerve, and visual pathwaydisorder

Night blindness – Vit A deficiency,glaucoma,

Eye pain?

Photophobia – inability to tolerate light Childhood strabismus?

A history of crossed eyes? AKA “lazy eye”

Redness or swelling? Infections?



History cont.

Excessive or lack of tearing?

May be due to irritants or obstruction in drainage

Past history of ocular problems? Glaucoma? Family history?

Use of glasses or contact lenses?

When tested last? Any medications?



Anatomy of

Eyelid

Eyelids (L. palpebrae) protect the

cornea and eyeball from injury Canthi (sing. canthus) are corners of

the eye, also called angles of eye

Caruncle is located near medialcanthus and contains sebaceous

glands Tarsal plates are made of connective

tissue and strengthen eyelid. Theycontain meibomian (tarsal) glandswhich secrete lipid to create airtightseal when closed and also prevent

eyelids from sticking together



Inspecting External Ocular

Structures General Note if facial expression is relax or

tense

Eyebrows Note if movement is symmetrical

Eyelids and lashes Note if any redness, swelling,

discharge or lesions

Note if eyelid closes completely and ifdrooping

Pallor of lower lid is good indicator ofanemia

For upper eyelid, use applicator stickto fold the eyelid over



Abnormalities in Eyelids

Ectropion

Lower lid rolls out, causing an

increase in tearing

The eyes feel dry and itchy due toinappropriate itching

Increase risk for inflammation

Occurs mostly in elderly due to

atrophy of elastic tissue

Entropion

The lower lid rolls in

Foreign body sensation



Abnormalities in Eyelids

Periorbital edemaMay occur with local

infection or systemic

condition

PtosisOccurs with

neuromuscularweakness (myastheniagravis) or CN IIIdamage



Lesions on the

Eyelids Blepharitis

Inflammation of eyelids

Staph or dermatitis

Burning, itching, tearing,

foreign body sensation, pain

Chalazion

A cyst in or an infection of

meibomian gland

Nontender, firm, overlying

skin freely movable

Hordeolum (Stye)

Localized Staph infection of

hair follicle at lid margin

Painful, red, swollen, purulent



Anatomy of the Eye

Lacrimal apparatus

provides irrigation of

conjunctiva

Lacrimal glands – secrete

lacrimal fluid (tears)

Lacrimal ducts – lacrimal

fluid to conjunctiva

Lacrimal canaliculi

(puncti) – drain fluid into

Nasolacrimal duct –

conveys lacrimal fluid to

nasal cavity



Inspecting the Lacrimal Apparatus

Inspect for bulges

or pressure near

canaliculi

Dacryocystitis Inflammation of the

lacrimal sac and/or

nasolacrimal duct

Dacryoadenitis Infection of lacrimal

gland

DacryocystitisDacryoadenitis



Anatomy of Extraocular Muscles 4 rectus (straight)

2 oblique

Innervations

SO4 – Superior oblique m. CN IV (trochlear n.)

LR6 – Lateral rectus m.

CN VI (abducens n.)

AO3 – All other muscles

CN III ( Trigeminal n.)



Extraocular muscle movement



Extraocular Muscle Dysfunction



Anatomy of the Eyeball – Outer Layer

Sclera – toughprotective whitecovering (posterior5/6)

Cornea – transparent part ofthe fibrous coatcovering the anteriorof the eyeball(anterior 1/5)

Conjunctiva –

transparentprotective coveringof exposed part ofeye (palpebralconjunctiva coversinside of eyelash)

Corneal reflex – lightly touching the eye with cotton

stimulates a blink.

Trigeminal n. (afferent) Facial n. (efferent)

iris



Inspection

Conjunctiva Sliding the lower lids down, observe

for redness on conjunctiva and ifeyeball looks moist and glossy

Reddening may be pathogenic

Sclera Should be white, although may

have gray-blue hue

Might contain yellowish fattydeposits beneath the lids Yellowing of sclera indicates jaundice



Vascular Disorders of Eye

Conjunctivitis “Pink eye”

Due to bacterial, viral, allergic, or chemical

irritation Redness throughout the conjunctiva, but

usually clear around the iris

Purulent discharge usually common

Symptoms: itching, burning, foreign body

sensation Iritis

Red halo around the iris and cornea

Pupils may be irregular due to swelling

Symptoms: photophobia, blurred vision,

throbbing pain



Inspecting Cornea and Lens

Corneal abrasion Assess by shining a light

and observing from theside

Pupillary light reflex Charted according to size

of pupil

Charted as a ratio of beforelight/after light (3/1)

A sluggish response maybe caused by increasedICP

No response may indicateneurological damage

PERRLA:

Pupils Equal, Round,

React to Light and

Accommodation

How to chart

pupillary light reflex?



Anatomy of the Eyeball –

Middle Layer Choroid – provides vascularity toretina

Pupil – variable-sized, black circularor slit shaped opening in the centerof the iris that regulates the amountof light that enters the eye. Appears

black because most of the lightentering the pupil is absorbed by thetissues inside the eye.

Lens – biconvex disc controlled bythe ciliary muscle to produce farvision when flat

Anterior chamber Aqueous humor is produced by the

ciliary body and secreted intoposterior chamber of eye.

From there, aqueous humor travelsto the anterior chamber where itexits through the Canal of Schlemm

Determines intraocular pressure

Canal of Schlemm

Increase leads toGlaucoma



Vascular Disorders of Eye

Glaucoma Excessive pressure in eye

due to blockage of outflowfrom anterior chamber

This puts pressure on opticnerve

Redness around the iris,dilated pupils

Symptoms: suddenclouding of vision, suddeneye pain, and halos around

lights

Physiology review: Aqueous humor is produced by the ciliary body

and secreted into posterior chamber of eye. From

there, aqueous humor travels to the anterior

chamber where it exits through the Canal of Schlemm



Disorders of Opacity of Lens

Cataract



Anatomy of the Eyeball –

Inner Layer Retina – visually

receptive layer where

light waves are changed

to nerve impulses

Optic disc – area where

the optic nerve enters the

eyeball

Fovea centralis – area ofmost acute vision



Inspecting the Ocular Fundus

Using an ophthalmoscope to inspectthe internal surface of the retina,anterior chamber, lens, and vitreous.

Darken the room to dilate the pupils

Remove eye glasses, contacts maystay in

Ask person to stare at distant object

Hold ophthalmoscope close to youreye and move to within a few inches

of the person’s face A red glow filling the pupil is called

the red reflex and is caused by lightreflecting off the retina

Cataracts appear as opaque blackareas against the red reflex



Inspecting the Optic Disc and Retina

Normal optic disc is:

Yellow-orange to pink

Round or oval Distinct margins

Normal retina is:

Arteries in each

quadrant

Arteries are bright red



Visual pathways



Testing Visual Reflexes Pupillary light reflex

Constriction of pupils when bright light shines on the retina

Direct light reflex – constriction of same sided pupil

Consensual light reflex – simultaneous constriction of both pupils

The impulse is carried afferently by CN II and efferently by CN III

Accommodation Adaptation of eye for near vision

Ask person to focus on distant object (dilates the pupils). Thenask person to shift gaze to near object few inches away. Anormal response is pupillary constriction and convergence ofaxes of the eyes



Testing Visual Accuity

Snellen Eye Chart Standing 20 feet from the

chart

Test one eye at a time bycovering the other eye

Leave contact lenses andglasses on, unless theglasses are readingglasses

Normal vision is 20/20

Near vision Use Jaeger card (smaller

version of Snellen chart) or just read newspaper



Testing Visual Fields

Confrontation test Measures peripheral vision

compared to examiner(assuming examiner’s vision isnormal)

Both examiner and pt coverone eye with a card, standabout 2 feet away, andmaintain eye contact

Advance finger, starting fromperiphery, and ask patient to

say “now” when the finger isfirst visible

Inability to see when theexaminer sees suggestsperipheral field loss



Testing Ocular Muscle

Function Cover Test

Detects deviated alignment of eyes

Ask pt. to stare straight at your nose andcover one of the pt.’s eyes with a card

While noting the uncovered eye, move

away the card A normal response is a steady fixed gaze

Diagnostic Position Test Ask pt. to hold head straight and move

finger in all positions, holding it about 12

inches away A normal response is parallel tracking of

the objects with both eyes

Nystagmus

Fine oscillating movements around the iris

Normal at extreme lateral gaze



Developmental Considerations –

Infants and Children Strabismus – must be detected

and treated early to preventpermanent disability

Esotropia – inward turning of eye

Exotropia – outward turning of eye

Color vision – due to inherited X-linked recessive trait, occurs moreoften in boys

External eye structures – an

upward lateral slope together withepicanthal folds occurs in Downsyndrome

Ophthalmia neonatum – conjunctivitis due to bacteria, virus,or chemical irritation



Developmental Considerations –

Aging Decrease in visual

acuity, diminishedperipheral vision

Ectropion (drooping oflower lid) or entropion(eyelids turning in)

Pinguecula – yellownodules due to

thickening ofconjunctiva as a resultof prolonged exposureto sun, wind, and dust



Developmental Considerations -

Aging Arcus senilis – gray-

white arc seen around

the cornea. Due todeposition of lipids.

No effect on vision

Xanthelasma – raised

yellow plaques.Normal



Ear Anatomy



Ear Physiology

External Ear External auditory meatus funnels sound waves, which reflect off the

tympanic membrane to produce vibrations

Cerumen (ear wax) protects the tympanic membrane from foreignsubstances

Middle ear Malleus, incus, and stapes and eustachian tube

Function to: Conduct sound vibrations from tympanic membrane (outer ear) to cochlea

(inner ear)

Protect the cochlea by reducing the amplitude of sounds

Eustachian tube allows equalization of air pressure

Inner ear Vestibule and semicircular canals

Allow brain to sense body position and relation of angle of head to gravity

Cochlea Transfers vibrations from stapes into nerve impulses



The outer ear catches the waves of sound and funnelsthem down the ear canal (about an inch long) and flushup against the ear drum. The ear drum (tympanicmembrane) is the boundary between the outer ear and

the middle ear.



In the middle ear, the malleus picks up the vibrationsfrom the eardrum, passes them to the incus which thenpasses them to the stapes. The stapes terminates in atiny footplate that fits precisely into the contact point or

window of the inner ear.



The window of the inner ear is the contact point of thecochlea. The vibrations set up rolling waves in thecochlear fluid which stimulate different areas of themembrane, which rubs against specialized cells calledhair cells. This friction creates electrical impulsestransmitted by the cochlear nerve.



CN VIII is responsible for signal transduction fromvestibule and cochlea to the brainstem. From brainstem,a signal is sent to the cerebral cortex to interpret the

sound.



Hearing Loss

Conductive

Mechanical dysfunction of external or middle ear

Partial hearing lossMay be caused by impacted cerumen, foreign bodies,

perforated tympanic membrane, pus or serum in

middle ear, or otosclerosis (hardening of stapes)

May be fixed Sensorineural

Dysfunction of inner ear, CN VIII, or cerebral cortex

Cannot be fixed



Developmental Considerations Infants

Greater risk for otitis media (middle ear infections) due to shortereustachian tube

Aging

Cilia lining ear canal become coarse and stiff, impeding sound waves

Cerumen more common

Dry cerumen – gray and flaky. More common in Asians and Native

Americans Wet cerumen – brown and moist. More common in whites and

blacks

Presbycusis - degenerative sensorineural hearing loss

Auditory reaction time increases



Obtaining History

Earaches? (otalgia) Location, character, intensity, associative and alleviating factors

May be directly due to ear disease or maybe referred pain from aproblem in teeth or oropharynx

A viral or bacterial upper respiratory infection may migrate up theeustachian tube and involve the middle ear

Infections? Frequency? Occurred in childhood?

Discharge? (otorrhea) May suggest infection or perforated eardrum Typically with perforation, ear pain drainage

Otitis externa – purulent, sanguineous, or watery

Acute otitis media with perforation – purulent discharge



More History

Trouble hearing? Gradual our sudden?

Presbycusis – gradual sensorineural hearing impairment in theelderly

Hearing loss due to trauma is often sudden Ringing in ears? (tinnitus)

May be a result of medication

Medications? Some are ototoxic

Vertigo? (spinning) Subjective – person feels like he or she spins

Objective – person feels like room spins

Environmental noise Noise-induced hearing loss



Lesions of External Ear

Gouty Tophi

Otitis Externa



Assessing External Ear

Size and Shape normal is 4-10cm tall

Skin conditions Note edema, inflammation, lesions

Tenderness Location?

Pain in pinna indicates otitis externa

Pain at mastoid process indicates mastoiditis or lymphadenitis

External Auditory Meatus Atresia – absence or closure of ear canal

Otitis externa may cause purulent discharge

Otitis media may cause rupture of tympanic membrane

If drainage present following trauma, possible basal skullfracture. Perform glucose test (CSF (+) for glucose).



Inspecting Using Otoscope

Pull the pinna up andback in adult, straightdown in children under 3years

Hold otoscope upsidedown and place dorsalside of hand alongperson’s cheek

Insert speculum slowly

and avoid touching theinner section of canalwall, which is sensitiveand may cause pain.



Inspecting the External Canal

Note any redness or

swelling, lesions, or

foreign bodies

If discharge present,

note color and odor

OtitisExterna



Inspecting the Tympanic

Membrane Normal is shiny and

translucent

Flat, slightly pulled inat the center

Valsalva maneuver

causes tympanic

membrane to flutter,used to assess drum

mobility

Which tympanic membraneis perforated?



Testing Hearing Acuity

Voice test

Whisper two syllable words

into one of the person’s

ears, while covering theother one. Ask person to

repeat what you’ve said.

Tuning fork tests

Measure hearing by air

conduction or boneconduction

Weber test

Rinne test



Weber Test

Tuning fork is struck andplaced on head orforehead, equal distancefrom both ears

Used to determine ifhearing loss is moreextensive in one ear thanthe other

This test cannot confirm

normal hearing, becausehearing defects affectingboth ears equally willproduce an apparentlynormal test result



Rinne Test

Compares air conduction andbone conduction

Place stem of vibrating fork onmastoid process and ask when

sound goes away Quickly invert the fork so the

vibrating end is near the earcanal. The person should stillhear a sound

Normally the sound is heardlonger by air conduction ratherthan bone conduction

In conductive hearing loss,sound heard longer by boneconduction



Conductive Hearing Loss



Sensorineural Hearing Loss



Infants and Children Save otoscopic examination until the end May help to show otoscope to child and let

him or her play with it

Stabilize (or ask a parent for help) thechild’s head in order to prevent movement

Pull pinna straight down

In infants, the tympanic membrane maylook thick and opaque after first few daysor after crying

Tympanostomy tubes may be in place ifdrainage occurs as a result of otitis media



Abnormalities in the Ear Canal

Excessive Cerumen

Acute OtitisMedia

Otitis Externa



Question 1

A nurse is performing a voice test to assesshearing. Which of the following describes theaccurate procedure for performing this test?

1. Stand 4 feet away from the client to ensure that theclient can hear at this distance

2. Quietly whisper a statement and ask the client torepeat it

3. Whisper a statement with the examiner’s back facingthe client

4. Whisper a statement while the client blocks bothears



Question 2

A nurse is caring for a client who is

hearing impaired. Which of the following

approaches will facilitatecommunication?

1. Speak frequently

2. Speak loudly3. Speak directly into the impaired ear

4. Speak in a normal tone



Question 3

A client is diagnosed with a disorderinvolving the inner ear. Which of the

following is the most common clientcomplaint associated with a disorderinvolving this part of the ear?

1. Hearing loss

2. Pruritus3. Tinnitus

4. Burning in the ear



Question 4

Which of the following statements madeby a parent should make the nurse

suspicious that the tympanic membraneof a young child has ruptured?

1. “She has been crying all night, but she feelsbetter this morning.”

2. “She has some bloody, yellow-looking stuffcoming out of her ear.”

3. “My child does not seem to hear very well.”

4. “My child’s earwax is dark brown.”



Question 5

While examining the internal ear, the

nurse observes the light reflex on the

tympanic membrane. What does thisfinding indicate?

1. Presence of pus

2. Fluid accumulation3. Scar tissue

4. Normal finding

04 - assessment of eyes & ears

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