1. Objectives • Identify pertinent eye and ear history questions. • Obtain an eye history. • Perform an eye physical assessment. • Document eye assessment findings. • Identify actual / potential health problems stated as nursing diagnoses. • Differentiate between normal and abnormal findings.

2. Structure & Functions External Structures Eyelids and lashes: Protect the eyes Lacrimal glands and ducts: Produce tears Conjunctiva: Provide lubrication

3. Sclera: Gives shape and structure to eye Iris: Controls amount of light entering eye; provides eye color Extraocular muscles: Control eye movement

4. Cornea: Transparent, avascular outer layer of the eyeball Anterior chamber: Filled with aqueous humor Pupil: The aperture of the iris

6. Structure & Functions Internal Structures Optic disc and physiological cup: Area where the optic nerve and the blood vessels enter the eye Retinal blood vessels: Blood supply to eye

7. Retina: Inner layer; receives light waves that are sent to brain and converted into visible perceptions Macula: Avascular, darker area of central vision

10. Relationship to Other Systems Integumentary *Skin covers the lids *Lashes protect the eyes Respiratory *Color changes seen in conjunctiva Digestive *Jaundice seen in sclera *Sight of food can stimulate saliva production

11. Relationship Con’t Cardiovascular *Xanthelasma (fat deposits) can be seen on the eyelids *Can observe blood vessels directly (opthalmoscope) *Observed changes can reveal HTN, Diabetes, Glaucoma, Intracranial Pressure, some CNS disorders  Musculoskeletal *Movement of eyeball & lid; Iris adjusts Pupil  Neurological CN II responsible for vision CN III, IV, VI responsible for movement of eye CN V conveys sensory data from cornea CN VII closes eyelids

12. Relationship Con’t • Reproductive Pleasure selection • Urinary Periorbital edema with renal disease  Immune Conjunctivitis: Environmental Toxins, Allergies, Infection • Endocrine Thyroid, Diabetes

13. DevelopmentalVariations What developmental variations of the eyes might be seen with: • Infants: shape/oval, spacing, vision 20/200 • How is vision determined in Infants? pupillary, response, blink response, ability to follow objects

14. Developmental (Con’t.) • Preschool: Snellen E chart: 3yr old 20/40 4yr old vision 20/30, 5-6yr old normal • School Age: tests: color blindness (pg. 341), regular Snellen • Older adults: All around deterioration

15. Case Study • Laura 55- year-old secretary, widow • History of HTN, DM • Complains of blurred vision, worsened over past several months • Medications include Lasix, Captopril and Glucatrol

16. Vision loss Double vision Eye tearing Eye drainage Eye pain Blurred Vision Dry Eyes Eye Appearance Changes What symptoms would signal a problem with the eyes?

17. Pertinent History Findings • Secretary, 4 hours computer work/day • Blurred vision: constant, and worse with fatigue • Difficult to read, reading glasses not helpful • HTN, DM • Lasix, Captopril, and Glucatrol • + Family history of CV disease, DM, MS • Last eye exam 5 years ago • Widow: son and friends as supports

18. Physical Assessment • Anatomical Landmarks: visual fields (superior, inferior, nasal, temporal) • Approach: inspection, palpation, ophthalmoscopy • Position: sitting • Tools: visual acuity charts (Snellen), penlight, ophthalmoscope, cotton ball, cotton swab, printed material, pg 264 • General survey and head-to-toe scan

20. Visual Acuity • Far vision: Snellen eye chart • Near vision: read newsprint 13 to 15” from eyes • Color vision: identify color bars on Snellen or use color plates • Peripheral vision: come in from the periphery in all fields and note field cuts

22. Inspection of External Structures • Lids and lashes: color, lesions, edema, symmetry, position, crusting and distribution of lashes, infestation • Lacrimal glands and ducts: color, edema, excessive tearing or drainage • Conjunctiva: color, moisture, lesions, and foreign bodies • Sclera: color, moisture, lesions, or tears Should be smooth and white

23. Inspection of External Structures, Con’t • Cornea: clarity--if cloudy could be a Vit A deficiency, abrasions/ulcers--rough, corneal reflex (cotton ball or puff of air) • Anterior chamber: clarity, is there a bulging iris, blood or pus? • Iris: color, size, shape, and symmetry • Pupils: size, shape, reaction to light

24. Palpation of External Structures • Eye ball: consistency and tenderness • Lacrimal glands and ducts: tenderness and excessive tearing

25. Ophthalmoscopy • Red reflex: presence, opacities • Optic disc and physiologic cup: color, size, shape, borders, cup-disc ratio • Retinal vessels: size ratio of arteries and veins, color, arteriole light reflex, crossings • Retina: color, texture, exudates, lesions, hemorrhages, and aneurysms • Macula and fovea: color, size, location, lesions

27. Bits and Pieces: If mydriatics are used: Instruct to wear sunglasses to protect eyes If examining undilated pupils with scope: use smallest white light aperture in darkened room If using eye chart: 1st test without corrective lenses, then with them (reduces likelihood that the measurement without will be influenced) Glazed eyes: febrile state Asymmetry of lids: CN III damage, CVA Eye exams (American Academy of Ophthalmology): Preschool screening (strabismus can lead to blindness) Every 3-5 yrs for African descent ages 20-39 Every 2-4 yrs for anyone ages 40-64 Every 1-2 yrs starting at age 65 Every 1 yr for DM

28. Tips for Practice with an Ophthalmoscope • When examining undilated eyes, use the smallest white light aperture. • Start with small round light and lens set “0” • At 1 ft away and 15 degree angle: pupil • When obtain red reflex, move forward • Use R eye to examine R eye & L to exam L • As you move forward place your hand on their head to orient yourself • Adjust the lens focus as needed with a free finger

29. Thank you very much