Examination of the Eye & Ear

Professor Janet M. GaliczewskiProfessor Janet M. Galiczewski

RN,CCRN,MSN,ANPRN,CCRN,MSN,ANP

A & P Outer Eye

External Eye

EyelidEyelid: Distributes tears, limits light entering eye, : Distributes tears, limits light entering eye, protects eye. Upper lid covers 2-3 mm of iris but protects eye. Upper lid covers 2-3 mm of iris but NOT pupil. The lower lid sits directly on the lower NOT pupil. The lower lid sits directly on the lower ring of the irisring of the iris

Palpebral Fissure: Palpebral Fissure: Opening between eyelids.Opening between eyelids.

Conjunctiva:Conjunctiva: Thin membrane covering most of Thin membrane covering most of the anterior surface of eye & eyelid, protects eye.the anterior surface of eye & eyelid, protects eye.

Lacrimal Gland:Lacrimal Gland: located in temporal located in temporal region of eyelid. Produces tears ( drain into region of eyelid. Produces tears ( drain into lacrimal sac from puncta to nasolacrimal lacrimal sac from puncta to nasolacrimal duct to nasopharynx).duct to nasopharynx).

Puncta is the only visible portion of the Puncta is the only visible portion of the lacrimal apparatus.lacrimal apparatus.

Eye Muscles (EOM’s) EOM’s are responsible for eye movement EOM’s are responsible for eye movement 4 Rectus4 Rectus 2 Oblique2 Oblique Innervated by CN III, CN IV, CN VIInnervated by CN III, CN IV, CN VI Levator palpebrae muscle which raises Levator palpebrae muscle which raises

upper eyelid innervated by CN IIIupper eyelid innervated by CN III

A&P Inner Eye

Internal Eye

ScleraSclera:: “White of the Eye,” protective, provides “White of the Eye,” protective, provides structure. The optic nerve is attached to it at the structure. The optic nerve is attached to it at the back of the eye.back of the eye.

Cornea:Cornea: continuous with sclera, transparent dome continuous with sclera, transparent dome shaped window that covers iris, pupil,& anterior shaped window that covers iris, pupil,& anterior chamber. Provides most of the eyes optical power.chamber. Provides most of the eyes optical power.

1. Refracts light 1. Refracts light 2. Eye focus (fixed)2. Eye focus (fixed) 3. Protects - nerve endings sensitive to touch, 3. Protects - nerve endings sensitive to touch,

temp, & chemicals temp, & chemicals

Aqueous HumorAqueous Humor:: Fluid produced by Fluid produced by ciliary body that flows from posterior ciliary body that flows from posterior chamber through pupil to anterior chamber. chamber through pupil to anterior chamber. Controls pressure inside eye. Controls pressure inside eye.

Iris:Iris: Circular, contractile muscular disc Circular, contractile muscular disc containing pigmented cells. Regulates the containing pigmented cells. Regulates the light levels inside eye.light levels inside eye.

PupilPupil:Center of iris.Tiny sphincter muscles :Center of iris.Tiny sphincter muscles constrict pupil to light & tiny dilator constrict pupil to light & tiny dilator muscles dilates eye in dim light. muscles dilates eye in dim light.

Lens:Lens:Their purpose is to focus light on the Their purpose is to focus light on the retina. The lens have ability to change shape retina. The lens have ability to change shape and to adjust to close & distant vision. This is and to adjust to close & distant vision. This is called accommodation.called accommodation.

Retina:Retina: Sensory network that lines the back Sensory network that lines the back of the eye, transforms light impulses to of the eye, transforms light impulses to electrical impulses.Impulses travel via optic electrical impulses.Impulses travel via optic nerve to cerebral cortex. Here they are nerve to cerebral cortex. Here they are transformed into images.transformed into images.

1. 1. Cones:Cones:macula portion of retina, central macula portion of retina, central vision, bright light, color appreciation vision, bright light, color appreciation

2. 2. Rods:Rods: spread throughout peripheral retina, spread throughout peripheral retina, peripheral & night vision, dim light peripheral & night vision, dim light

Mechanisms of Vision

Vision depends on light rays which enter Vision depends on light rays which enter eye, passes through cornea & pupil, then eye, passes through cornea & pupil, then focus on retina by the lens.focus on retina by the lens.

Vision may be altered from local or Vision may be altered from local or systemic disease.systemic disease.

Examination of the Eye

Review of systemsReview of systems Inspection of external structures.Inspection of external structures. Measurement of visual acuity.Measurement of visual acuity. Determination of visual fields.Determination of visual fields. Evaluation of Extraocular Movement.Evaluation of Extraocular Movement. Estimation of Intraocular pressure.Estimation of Intraocular pressure. Exploration of Ocular Fundus.Exploration of Ocular Fundus.

Review of Systems

Start with open ended questions….Start with open ended questions…. Onset of problem gradual or sudden?Onset of problem gradual or sudden? Problem seeing close work or distance?Problem seeing close work or distance? Pain or headaches?Pain or headaches? Last eye examLast eye exam Glasses or contact lensGlasses or contact lens

Inspection of External Structures Eyelids:Eyelids: Inspect blinking, external Inspect blinking, external

surface for lesions, superficial surface for lesions, superficial vascularity, edema.vascularity, edema.

PtosisPtosis Check position of lids for Eversion, Check position of lids for Eversion,

Inversion.Inversion. Check Enophthalmos, ExophthalmosCheck Enophthalmos, Exophthalmos

Eyelids (cont).

Check for corneal dryingCheck for corneal drying Palpate for ocular tension.Palpate for ocular tension. Check Lacrimal apparatusCheck Lacrimal apparatus

Eyebrows, Eyelashes:Eyebrows, Eyelashes: note note quantity, distribution, color, quantity, distribution, color, texture.texture.

StySty

ChalazionChalazion

Conjunctiva & Sclera

Examine palpebral conjunctiva lining the Examine palpebral conjunctiva lining the lids & bulbar conjunctiva covering sclera.lids & bulbar conjunctiva covering sclera.

Note: color, vascular patterns, nodules, Note: color, vascular patterns, nodules, swelling.swelling.

ConjunctivitisConjunctivitis

Cornea, Lens & Iris

Using oblique lighting note: scars, Using oblique lighting note: scars, irregularities, foreign bodies, opacitiesirregularities, foreign bodies, opacities

Check iris for crescent shadow on medial Check iris for crescent shadow on medial side of iris (no shadow should be seen).side of iris (no shadow should be seen).

Arcus SenilisArcus Senilis

Pupils

Note: size, shape, equality (slight inequality Note: size, shape, equality (slight inequality may be normal (anisocoria).may be normal (anisocoria).

Check pupillary reaction to light.Check pupillary reaction to light. Look for Direct reactionLook for Direct reaction Consensual reactionConsensual reaction

Identify as: prompt or brisk (normal), Identify as: prompt or brisk (normal), sluggish, or absent.sluggish, or absent.

Visual Acuity

Snellen Chart-Check distant visual Snellen Chart-Check distant visual acuity, color.acuity, color. Ex. 20/30 vision. Ex. 20/30 vision. 20=distance from chart.20=distance from chart.

30=distance at 30=distance at which which normal normal eye can read eye can read that line that line of letters.of letters.

PresbyopiaPresbyopia Myopia (near-sightedness)Myopia (near-sightedness) Hyperopia (far-sightedness)Hyperopia (far-sightedness)

Visual Fields

Defined as the entire area seen by an eye Defined as the entire area seen by an eye when its gaze is fixed on a central point.when its gaze is fixed on a central point.

Superficially tested by comparing the pts. Superficially tested by comparing the pts. peripheral vision with your own.peripheral vision with your own.

Technique: “Confrontation”Visual FieldsTechnique: “Confrontation”Visual Fields

Extraocular Movements (EOM)

To detect weakness or paralysis of To detect weakness or paralysis of extraocular muscles.extraocular muscles.

Corneal Light ReflexCorneal Light Reflex EOM’S “H” Pause to detect nystagmus EOM’S “H” Pause to detect nystagmus

(fine rhythmic oscillation of the eyes).(fine rhythmic oscillation of the eyes). Combine with convergence.Combine with convergence. Check for lidlag.Check for lidlag.

Opthalmoscopy (Fundoscopy)

Important in evaluation of local disorders Important in evaluation of local disorders (cataract, retinal detachment, or systemic (cataract, retinal detachment, or systemic disease)disease)

The light beam passes through the cornea to The light beam passes through the cornea to aqueous humor of the anterior chamber to aqueous humor of the anterior chamber to lens to the vitreous humor, strikes the retina lens to the vitreous humor, strikes the retina & structures that make up fundus of the eye.& structures that make up fundus of the eye.

Fundus-internal surface of the retinaFundus-internal surface of the retina

Opthalmoscopy (Fundoscopy)cont. Image of the optic disc, blood vessels, Image of the optic disc, blood vessels,

retina, macula, fovea.retina, macula, fovea. Technique- if you wear glasses leave on or Technique- if you wear glasses leave on or

correct for deficit with ophthalmoscope.correct for deficit with ophthalmoscope. Turn lens disc to “O”Turn lens disc to “O” Keep index finger on lens disc to focus Keep index finger on lens disc to focus

during exam.during exam.

Opthalmoscopy (Fundoscopy)cont. Darken room-dimly lit, switch on Darken room-dimly lit, switch on

ophthalmoscope light to round beam of ophthalmoscope light to round beam of white light.white light.

Use your Use your RightRight hand & hand & RightRight eye for pts. eye for pts. RightRight eye. Same for Left. eye. Same for Left.

You & pts. Eyes should be at same level.You & pts. Eyes should be at same level. Instruct pt to look up & over your shoulder Instruct pt to look up & over your shoulder

at a fixed point on the wall.at a fixed point on the wall.

Opthalmoscopy (Fundoscopy)cont. From about 15 inches away from pt & 15 degrees From about 15 inches away from pt & 15 degrees

lateral to pt. Line of visionlateral to pt. Line of vision Shine light beam into pupilShine light beam into pupil You will see Red Reflex (orange, red glow in You will see Red Reflex (orange, red glow in

pupil) Cataract will interrupt.pupil) Cataract will interrupt. Keep beam on red reflex, move in 15 degrees to Keep beam on red reflex, move in 15 degrees to

pts line of sight, until scope is close. You will pts line of sight, until scope is close. You will see the OPTIC DISC.(yellow /orange or creamy see the OPTIC DISC.(yellow /orange or creamy pink; oval or round).pink; oval or round).

Ophthalmoscopy (Fundoscopy)cont. If only vessels seen trace back to disc (bring If only vessels seen trace back to disc (bring

disc into sharp focus)disc into sharp focus) Pattern of Exam:Red Reflex, Disc, Vessels, Pattern of Exam:Red Reflex, Disc, Vessels,

Retina including Macula.Retina including Macula. Red Reflex: note opacities, dark lines, black Red Reflex: note opacities, dark lines, black

spots.spots. Disc Color: yellow, orange to creamy pink, Disc Color: yellow, orange to creamy pink,

disc diameter is about 1.5 mmdisc diameter is about 1.5 mm

Vessels

ArteriesArteries Color: Light RedColor: Light Red Size: Smaller Size: Smaller

Diameter (2/3 less Diameter (2/3 less than vein).than vein).

Light Reflex: BrightLight Reflex: Bright

VeinsVeins Color: Dark RedColor: Dark Red Size: LargerSize: Larger Light Reflex: Less Light Reflex: Less

bright or absentbright or absent

Fundoscopy (cont).

HTN: arterioles become narrow & tortuous,HTN: arterioles become narrow & tortuous, Ratio (A/V) decreases to 1:2 or 1:3 (Normal 2:3, Ratio (A/V) decreases to 1:2 or 1:3 (Normal 2:3,

4:5).4:5). AV Nicking-Kinking or indentation of the venule AV Nicking-Kinking or indentation of the venule

at a crossing.at a crossing. Retina: Note-lesions, size, shape, color, Retina: Note-lesions, size, shape, color,

distribution.distribution. Hemorrhage: may appear flame shaped, deep red Hemorrhage: may appear flame shaped, deep red

spots.spots.

Fundoscopy (cont).

ExudatesExudates: Hard or soft: Hard or soft Soft:”cotton wool exudates” fluffy, fuzzy Soft:”cotton wool exudates” fluffy, fuzzy

outlineoutline Hard: smaller with discrete bordersHard: smaller with discrete borders Next, move laterally to inspect macula Next, move laterally to inspect macula

(temporal)(temporal) FoveaFovea tiny pinpoint of bright in center of tiny pinpoint of bright in center of

macula.macula.

Fundoscopy (cont).

Senile Macular Degeneration:important Senile Macular Degeneration:important cause of impaired central vision in elderly. cause of impaired central vision in elderly. Look for hemorrhage, exudate, cysts.Look for hemorrhage, exudate, cysts.

Degree of retinal changes direct relationship Degree of retinal changes direct relationship to severity of disease.to severity of disease.

A & P of the EAR Sensory organ:Function is to identify, locate Sensory organ:Function is to identify, locate

interpret sound.interpret sound. Maintain equilibrium. Maintain equilibrium. Divided into 3 parts:External,Middle,Inner.Divided into 3 parts:External,Middle,Inner.

External Ear Auricle:Auricle: varies size & shape. varies size & shape. Should be = in height & sizeShould be = in height & size Structural landmarks of the auricle:Structural landmarks of the auricle:

Helix: prominent outer ridge.Helix: prominent outer ridge. Antihelix: parallel & anterior to helix.Antihelix: parallel & anterior to helix. Tragus: anterior to auditory canal.Tragus: anterior to auditory canal. Antitragus: opposite auditory canal opening.Antitragus: opposite auditory canal opening. Lobule: Soft, lobe at bottom of auricle.Lobule: Soft, lobe at bottom of auricle.

External Auditory Canal:External Auditory Canal: 2.5-3cm length 2.5-3cm length narrows toward mid-portion & widens near narrows toward mid-portion & widens near eardrum.eardrum.

““S” shaped pathway leads to middle ear.S” shaped pathway leads to middle ear. Consists of bone & cartilage covered with Consists of bone & cartilage covered with

thin sensitive skin.thin sensitive skin. Mastoid process: bone behind & below the Mastoid process: bone behind & below the

ear canal ( mastoid part of temporal bone).ear canal ( mastoid part of temporal bone).

Middle Ear

Air filled cavity in temporal bone separated from Air filled cavity in temporal bone separated from external ear by tympanic membrane.external ear by tympanic membrane.

TM (Eardrum):TM (Eardrum): shiny, translucent & pearly grey. shiny, translucent & pearly grey. Sound transmitted by 3 tiny bones: (ossicles) Sound transmitted by 3 tiny bones: (ossicles)

malleous, incus, stapes.malleous, incus, stapes. Eustachian tubeEustachian tube leads to nasopharynx allows for leads to nasopharynx allows for

equalization of air pressure with atmospheric equalization of air pressure with atmospheric pressure (swallowing).pressure (swallowing).

Middle Ear

TMTM visualized (otoscope) as an oblique membrane visualized (otoscope) as an oblique membrane pulled inward at its center by the malleus. You can pulled inward at its center by the malleus. You can locate:locate: Handle of malleousHandle of malleous Short process of malleousShort process of malleous UmboUmbo Cone of light Cone of light Pars flaccidaPars flaccida Pars tensaPars tensa

Inner Ear A curved cavity within a bony labyrinthA curved cavity within a bony labyrinth Consists of a vestibule, semicircular canals, Consists of a vestibule, semicircular canals,

cochlea.cochlea. Cochlea Cochlea contains the organ of corti which contains the organ of corti which

transmits sound impulses to the Cranial transmits sound impulses to the Cranial Nerve VIII (Acoustic).Nerve VIII (Acoustic).

Physiology of Hearing

Vibrations of sound are transmitted to the Vibrations of sound are transmitted to the external ear, then to the eardrum, to the external ear, then to the eardrum, to the ossicles of middle ear to the cochlea (of ossicles of middle ear to the cochlea (of inner ear).inner ear).

Vibrations of cochlea cause the organ of Vibrations of cochlea cause the organ of corti to stimulate impulses in CN VIII corti to stimulate impulses in CN VIII which are transmitted to temporal lobe for which are transmitted to temporal lobe for interpretation .interpretation .

Normal hearing pathway: Normal hearing pathway: Air ConductionAir Conduction

Types of Hearing Loss

Conductive Hearing LossConductive Hearing Loss: Occurs when : Occurs when changes in outer or middle ear impairs changes in outer or middle ear impairs conduction of sound to inner ear.conduction of sound to inner ear.

Air conduction is impeded d/t Excessive Air conduction is impeded d/t Excessive cerumen, foreign body, otitis media, tumor cerumen, foreign body, otitis media, tumor of middle ear, otitis externa, fluid in middle of middle ear, otitis externa, fluid in middle ear (more common in < 40 years old).ear (more common in < 40 years old).

Types of Hearing Loss

Sensorineural Hearing Loss:Sensorineural Hearing Loss: Occurs with Occurs with impairment of organ of corti.impairment of organ of corti.

EX: Sustained exposure to loud noise, EX: Sustained exposure to loud noise, ototoxicity d/t drugs (aminoglycosides, ototoxicity d/t drugs (aminoglycosides, antibiotics, chemo, lasix) syphilis, DMantibiotics, chemo, lasix) syphilis, DM

More common in older peopleMore common in older people Loss often mid to high frequency range.Loss often mid to high frequency range. Mixed Hearing Loss: Mixed Hearing Loss: Both types Both types

combined.combined.

Technique for Ear Examination

External Ear : Inspection, PalpationExternal Ear : Inspection, Palpation Middle Ear: InspectionMiddle Ear: Inspection Auditory Acuity:Auditory Acuity:

WhisperWhisper WatchWatch WeberWeber RinneRinne

Technique for Ear Exam

External Ear External Ear InspectionInspection : Each auricle & surrounding tissue. : Each auricle & surrounding tissue. Note: deformities, lumps, discharge, may see Note: deformities, lumps, discharge, may see

tophi(deposits of uric acid crystals in helix; occurs tophi(deposits of uric acid crystals in helix; occurs with gout).with gout).

Palpate:Palpate: External ear for tenderness, masses. should External ear for tenderness, masses. should be smooth, non tender.be smooth, non tender. Otitis Externa- tender, swollen, narrowed moist Otitis Externa- tender, swollen, narrowed moist

external canalexternal canal Otitis Media- non tenderOtitis Media- non tender

Palpate mastoid process for tenderness, Palpate mastoid process for tenderness, swelling, bruising.swelling, bruising.

Palpate tragus.Palpate tragus.

Ear Canal & Drum : Otoscope

Grasp auricle & have pt. Tilt head to opposite sideGrasp auricle & have pt. Tilt head to opposite side Adult: Pull helix up, back & slightly out.Adult: Pull helix up, back & slightly out. Insert largest speculum that ear will accommodate.Insert largest speculum that ear will accommodate. Brace hand against pts. HeadBrace hand against pts. Head Insert otoscope into canal-down & forward Insert otoscope into canal-down & forward

(reposition head if you can’t visualize landmarks)(reposition head if you can’t visualize landmarks) Inspect & identify any discharge or foreign bodies Inspect & identify any discharge or foreign bodies

in ear canal. Note: redness, swelling.in ear canal. Note: redness, swelling. Cerumen may obstruct view.Cerumen may obstruct view.

Otoscope (cont).

Inspect eardrum: note color, contourInspect eardrum: note color, contour Otitis Media:Otitis Media: red, bulging drum, loss of red, bulging drum, loss of

landmarks, dilated blood vessels may cause landmarks, dilated blood vessels may cause spontaneous rupture & conductive hearing spontaneous rupture & conductive hearing loss.loss.

Identify bony landmarks: cone of light Identify bony landmarks: cone of light 7 o’clock -Left Ear7 o’clock -Left Ear 5 o’clock – Right Ear5 o’clock – Right Ear

Otoscope (cont).

Move speculum: view as much of drum as Move speculum: view as much of drum as possible.possible.

Identify:Identify: Pars flaccidaPars flaccida superiorly, superiorly, margins of margins of pars tensa,pars tensa, look for look for

perforation.perforation.

Auditory Acuity CN VIII

Test one ear at a time.Test one ear at a time. Ask pt. To occlude 1 ear with finger or hand.Ask pt. To occlude 1 ear with finger or hand. Whisper Test: Whisper Test: Stand 1-2 ft. away (behind pt). Stand 1-2 ft. away (behind pt).

Exhale & whisper 2 syllable words. Ex. BaseballExhale & whisper 2 syllable words. Ex. Baseball Ticking Watch:Ticking Watch: Same procedure as whisper. Pt. Same procedure as whisper. Pt.

Can hear ticking watch from 2ft. away equally.Can hear ticking watch from 2ft. away equally. Weber Test:Weber Test: (Lateralization) (Lateralization)

Set tuning fork into light motion (vibration)Set tuning fork into light motion (vibration)

Auditory Acuity CN VIII

Weber Test (cont).Weber Test (cont). Place tuning fork on top of pts. head or forehead.Place tuning fork on top of pts. head or forehead. Ask pt. Where he hears it, one or both sidesAsk pt. Where he hears it, one or both sides Normal = midlineNormal = midline Conductive Hearing lossConductive Hearing loss:Sound lateralizes to :Sound lateralizes to

impairedimpaired ear. ear. Sensorineural Loss:Sensorineural Loss: Sound heard in Sound heard in goodgood ear. ear.

Auditory Acuity CN VIII

Rinne TestRinne Test Compares air & bone conduction .Compares air & bone conduction . Place vibrating fork at base of mastoid (bone behind Place vibrating fork at base of mastoid (bone behind

ear)ear) When sound no longer heard- place fork @ ear canal When sound no longer heard- place fork @ ear canal

& see if pt. can hear.& see if pt. can hear. Normal: AC > BCNormal: AC > BC Conductive Hearing LossConductive Hearing Loss: BC=AC or BC>AC: BC=AC or BC>AC Sensorineural Hearing loss:Sensorineural Hearing loss: Sound heard longer Sound heard longer

through air. AC>BC (Normal)through air. AC>BC (Normal)