Arlyn C.

Mendenilla Clinical Instructor

To maintain optimum vision, people need to have their eyes examined regularly throughout life.

Examination of the eyes includes

assessment of the; External structures eyes Visual acuity Ocular movement Visual field

The external structures and lacrimal apparatus of the left eye.

Anatomic structures of the right eye, lateral view.

Anatomic structures of the right eye, lateral view.

Common Refractive Errors Myopia Hyperopia Presbyopia Astigmatism

Common Visual problems

Conjunctivitis Dacrocystitis Ectropion Entropion

Hordeolum (sty)
Iritis Photophobia

Mydriasis
Miosis chalazion

Contusions
Catracts Glaucoma

Ptosis

Assessing the Eye Structures and Visual Acuity

Planning
Place the client in an appropriate room for

assessing the eyes and vision. The nurse must be able to control natural and overhead lighting during some portions of the examination.

Preparation
Assemble equipment and supplies: Cotton-tipped applicator Examination gloves Millimeter ruler Penlight Snellens or E chart Opaque card

Implementation
1. 2. 3. 4.

Introduce yourself and verify the clients identity. Explain to the client what you are going to do, why it is necessary, and how the client can cooperate. Perform hand hygiene and observe other appropriate infection control procedures. Provide for client privacy. Inquire if the client has any history of the following:
Family history of diabetes, hypertension, or blood dyscrasia Eye disease, injury, or surgery Last visit to an ophthalmologist Current use of eye medications Use of contact lenses or eyeglasses Hygienic practices for corrective lenses Current symptoms of eye problems

Assessment External eyes 5. Inspect the eyebrows for hair distribution and alignment, and for skin quality and movement. 6. Inspect the eyelashes for evenness of distribution and direction of curl. 7. Inspect the eyelids for surface characteristics, position in relation to the cornea, ability to blink, and frequency of blinking. Inspect the lower eyelids while the clients eyes are closed.

Normal findings Hair evenly distributed; skin intact Eyebrows symmetrically aligned; equal movement Equally distributed; curled slightly outward Skin intact; no discharge; no discoloration Lids close symmetrically Approximately 15 20 involuntary blinks/min;bilateral blinking When lids open, no visible sclera above corneas, & upper & lower borders of cornea are slightly covered

Deviation from normal Loss of hair; scaling and flakeness of skin Unequal alignment and movement of eyebrows Turned inward Redness , swelling, flaking, crusting, plaques, discharge, nodules, lesions Lids close assymetrically, incompletely, or painfully Rapid, monoocular, absent or incomplete blinking Ptosis, ectropion, entropion, rim of the sclera visible bet lid & iris

8. Inspect the bulbar

conjunctiva for color, texture, and the presence of lesions. Retract the eyelids with your finger, exerting pressure over the over the upper and lower bony orbits, & ask the client to look up, down, and from side to side
9. Inspect the

Transparent; Jaundice sclera; capillaries sometimes excessively pale evident; sclera appears sclera; reddened white

sclera; lesion or nodules

palpebral conjunctiva by everting the lids. Evert both lids, & ask the client to look up. Then gently retract the lower lids with the index fingers

Shiny, smooth, and pink or red

Extremely pale; extremely red; nodules or other lesion

10. Evert the upper lids if a problem is suspected. Ask the client to look down while keeping the eyelids slightly open. Gently grasp the clients eyelashes with thumb and forefinger. Pull lashes gently downwards.

Place a cotton-tipped applicator stick about 1cm above the lid margin, and push it gently downward while holding the eyelashes.
Hold the margin of the everted lid or eyelashes against the ridge of the upper bony orbit with the applicator stick or your thumb. Inspect the conjunctiva for color, texture lesions, and foreign bodies.

11. Inspect and palpate the No edema or tenderness over lacrimal gland.
lacrimal gland

Swelling or tenderness over lacrimal gland

Using the tip of your index finger, palpate the lacrimal gland. Observe for edema between the lower lid and the nose. 12. Inspect and palpate the No edema or tearing lacrimal sac and nasolacrimal duct. Observe for evidence of increased tearing. Using the tip of your index finger, palpate inside the lower orbital rim near the inner canthus.

Evidence of increase tearing; regurgitation of fluid on palpation of lacrimal sac

13. Inspect the cornea for clarity and texture. Ask the client to look straight ahead. Hold a penlight at an oblique angle to the eye, and move the light slowly across the corneal surface.

Transparent ,shiny, and smooth; details of the iris is visible In older people, a thin, grayish white ring around the margin, called arcus senelis,, maybe evident Clients blinks when the cornea is touched, indicating that the trigeminal nerve is intact

Opaque; surface not smooth ( maybe a result of trauma or abrasion Arcus senelis in clients under age 40

14. Perform the corneal sensitivity (reflex) test to determine the function of the fifth (trigeminal) cranial nerve. Ask the client to keep both eyes open and look straight ahead. Approach from behind and beside the client, and lightly touch the cornea with a corner of the gauze.

One or both eyelids fail to respond

15. Inspect the anterior chamber for transparency and depth. Use the same oblique lighting used when testing the cornea. 16. Inspect the pupils for color, shape, and symmetry of size.

Transparent No shadows of light on iris Depth of about 3 mm

Black in color;equal in size;normally 3 to 7 mm in diameter; round, smooth border, iris flat and round

Cloudy Crescentshaped shadoes on far side of iris Shallow chamber (possible glaucoma)
Cloudiness, mydriasis, miosis, anisocoria; bulging of iris toward cornea

17. Assess each pupils direct and consensual reaction to light. Partially darken a room.

Illuminated pupil constrict (direct response) Nonilluminated pupils constrict (consensual response)

Neither pupil constricts Unequal response Absent responses

Ask the client to look straight ahead. Using a penlight and approaching from the side, shine a light on the pupil. Observe the response. The pupil should constrict (direct response). Shine the light on the pupil again, and observe the response of the other pupil. It should also constrict (consensual response).

Assess each pupils reaction to accommodation.

18.

Pupils constrict when looking at near object; pupils dilate when looking at far objects; pupils converge when near object is moved toward nose

One or both pupils fail to constrict, dilate or converge

Hold an object about 10 cm from the clients nose. Ask the client to look first at the top of the object and then at a distant object behind the penlight. Alternate the gaze between the near and far objects. Observe the pupil response. Pupils should constrict when looking at the near object and dilate when looking at the far object. Next, move the penlight or pencil toward the clients nose. The pupils should converge. To record normal assessment of the pupils, use the abbreviation PERRLA.

Visual Fields
19. Assess peripheral visual fields. Have the client sit directly facing you at a distance of 6090 cm. Ask the client to cover right eye with the card and look directly at your nose. Cover or close your eye directly opposite the clients covered eye, and look directly at the clients nose.

When looking straight ahead, client can objects in the periphery

Visual field smaller than normal;1/2 vision in 1 or both eyes

Hold an object in your fingers, extend your arm, and move the object into the visual field from various points in the periphery. The object should be at an equal distance from the client and yourself. Ask the client to tell you when the moving object is first spotted.

1. To test the temporal field of the left eye, extend and move your right arm in from the clients right periphery. Temporally, peripheral objects can be seen at right angles to the central point of vision. 2. To test the upward field of the left eye, extend and move the right arm down from the upward periphery. The upward field of vision is normally 50 degrees because the orbital edge is in the way. 3. To test the downward field of the left eye, extend and move the right arm up from the lower periphery. The downward field of vision is normally 70 degrees because the cheekbone is in the way. 4. To test the downward field of the left eye, extend and move the right arm up from the lower periphery. The downward field of vision is normally 70 degrees because the cheekbone is in the way. 5. To test the nasal field of the left eye, extend and move your left arm in from the periphery. The nasal field of vision is normally 50 degrees away from the central point because the nose is in the way.

Repeat the above steps for the right eye.

Extraocular Muscle Tests Normal both eyes coordinated, move in unison, with parallel alignment Deviation eye movement not coordinate or parallel; one or both eyes fail to follow a penlight in a specific direction ex. strabismus

20. Assess six ocular movements to determine eye alignment and coordination. Stand directly in front of client and hold the penlight at a comfortable distance, such as 30 cm in front of the clients eyes. Ask the client to hold head in a fixed position facing you and follow the movements of the penlight with the eyes only. Move the penlight in a slow, orderly manner through the six cardinal fields of gaze. Stop the movement s of the penlight periodically so that the nystagmus can be detected.

21. Assess for location of light reflex by shining a penlight on the pupil in corneal surface (Hirschberg Test).

Lights falls Lights falls off symmetrically center on one eye at both eyes (indicates misalignment)

22. Have the client fixate Uncovered on a near or far object. eye does not Cover one eye and move observe for movement in the uncovered eye (cover test).

If misalignment is present, when dominant eye is covered, the uncovered eye will move to focus on object

Visual Acuity
23. Assess near vision by providing adequate lighting

and asking the client to read from a magazine or newspaper held at a distance of 36 cm (14 in). If the clients normally wears corrective glasses, it should be worn during the test.

Normal - Able to read Deviation difficulty reading newsprint unless due to aging process

A Rosenbaum eye chart maybe used to test near vision. It consist of paragraphs of text or characters in different sizes on 3 x 6 inch card. Be sure the client has a literacy level

Three types of eye charts

24. Assess distance 20/20 vision on snellen chart vision by asking the client to wear corrective lenses unless they are used for reading only. Ask the client to sit or stand 6 meters (20 ft) from Snellens chart, cover the eye not being tested, and identify the letters or characters. Take three readings: right eye, left eye, and both eyes. 25. Perform functional vision tests if the client is unable to see the top line (20/200) of Snellens chart. 26. Document findings in the client record.

Denominator of 40 or more Snellen type chart with corrective lenses