Advanced Heath Assessment and Differential Diagnosis Module 2

Internal Eye: Lens

-A biconvex, transparent structure located immediately behind the iris -Supported circumferentially by fibers arising from the ciliary body (the lens is highly elastic, and contraction or relaxation of the ciliary body changes its thickness) -Changes in lens thickness allow images from varied distances to be focused on the retina

Macular Degeneration

-Also called age-related macular degeneration (AMD or ARMD)l is caused when part of the retina deteriorates -Dry (atrophic): Gradual breakdown of cells in the macula that results in a gradual blurring of central vision -Wet (exudate ot neovascular): new abnormal blood vessels grow under the center of the retina. The blood vessels leak, bleed, and scar the retina, distorting or destroying central vision. Vision loss may be rapid. -Leading cause of legal blindness in people older than 55 years in the United States

Eye Examination: Infants

-Begin by inspecting the infants external eye structures -Note the size of the eyes, paying particular attention to small or differently sized eyes -Note symmetry, muscle balance, and presence of red light reflex (red reflex should be elicited in all newborns -Inspect lids for swelling (birth trauma) and epicanthal folds, and position -To detect epicanthal folds, look for a vertical fold of skin nasally that covers the lacrimal caruncle -Prominent epicanthal folds are an expected variant in Asian infants and may be seen in infants of other racial and ethnic backgrounds, but they may also be suggestive of Down syndrome or other congenital anomalies -Observe the alignment and slant of the palpebral fissures of the infants eye -Draw and imaginary line through the medial canthi and extend the line past outer canthi of the eyes the assess slant -Inspect the lid level covering eye -Observe the distance between the eyes, looking for wide spacing, or hypertelorism -Inspect the sclera, conjunctiva, pupil, and iris -Inspect and compare cornea sizes (enlarged corneas may be a sign of congenital glaucoma)

External Eye: Eyelid

-Composed of skin, striated muscle, the tarsal plate, and conjunctiva. -Meibomian glands in the eyelid provide oils to the tear film. -The Taurus provides a skeleton for the eyelid. -The eyelid distributes tears over the surface of the eye, limits the amount of light entering it, and protects the eye from foreign bodies.

Internal Eye: Cornea

-Continuous with the sclera anteriorly -Clear -Sensory innervation for pain -Major part of the refractive power of the eye -Avascular

Personal and Social History: Eye

-Employment exposure -Activities -Use of protective devices during work or activities that might endanger the eye -Corrective lenses -History of cigarette smoking (a risk factor for cataract, glaucoma, macular degeneration, thyroid eye disease) -Date of last eye examination

External Examination: Cornea

-Examine clarity of the cornea by shining light tangentially on it -Cornea is normally avascular and blood vessels should not be present -Test sensitivity (CN V) by touching the cornea with a cotton wisp to elicit blink, which indicates intact sensory fibers of CN V and mortar fibers of CN VII -Decreased corneal sensation is often associated with diabetes, herpes simplex, and herpes zoster viral infections or is a sequela of trigeminal neuralgia or ocular surgery -Inspect for corneal arcus (arcus senilis), which is composed of lipids deposited in the periphery of the cornea and may form a complete circle -An arcus is seen in many individuals older than 60 years. If present before age 40, arcus senilis may indicate a lipid disorder

External Examination: Sclera

-Examine to ensure that it is white -Inspect for senile hyaline plaque, which appear as a dark, slate gray pigment just anterior to the insertion of the medial rectus muscle -The sclera should be visible above the iris only when the eyelids are wide open -If liver or hemolytic disease is present, the sclera may become pigmented and appear either yellow or green

Eye Examination: Children

-External structure inspection is the same as described for the infant -Visual acuity tested in younger children by observing activities such as the ability to fixate on and follow an object -Beginning at 4 years of age use LEA or HOTV to test acuity -Photoscreening is recommended as an alternative to visual acuity screening for ages 3 to 5 -Visual acuity tested with vision charts at 5 years of age at 10 ft -Peripheral vision tested in cooperative child -CN tests same as for adult -Funduscopy requires patience

Past Medical History: Eye

-Eye surgery: condition requiring surgery, cataract removal, laser vision correction, date of surgery, outcome -Chronic illness that can affect vision -->Hypertension/atherosclerotic cardiovascular disease (ASCVD) -->Diabetes mellitus -->Glaucoma -->Inflammatory bowel disease -->Thyroid dysfunction -->Autoimmune diseases -->Human immunodeficiency virus -Medications: steroids, hydroxychloroquine, antihistamines, antidepressants, antipsychotics, antiarrhythmics, immunosuppressants, glaucoma eye drops, beta-blockers

Cataract Formation Risk Factors

-Family history of cataracts -Steroid medication use -Exposure to ultraviolet light -Cigarette smoking -Diabetes mellitus -Aging

Anatomy and Physiology of the Eye: Pregnant Women

-Hypersensitivity and changes in the refractory power of the eye -Tears contain an increased level of lysozyme, resulting in a greasy sensation and perhaps blurred vision for contact lens wearers -Corneal edema/thickening occurs -Diabetic retinopathy may worsen -Intraocular pressure falls most notably during the latter half of pregnancy -Subconjunctival hemorrhages may occur/resolve spontaneously

External Examination: Eyelid Inspection

-Inspect closed lid for fasciculations and tremors -Check ability to close completely/open widely -Observe margin for flakiness, redness, and swelling -Look for eyelashes -Note eye opening (ptosis) -Note any eversion or inversion of lids -Periorbital edema is always abnormal

External Examination: Surrounding Structures

-Inspect eyebrows for size, extension, and hair texture -Note whether the eyebrows extend beyond the eye itself or end short of it. Do they extend past the temporal canthus (if the eyebrows are coarse or do not extend past the temporal canthus, the patient may have hypothyroidism -Inspect orbital area for edema, puffiness, and sagging tissue below orbit -Puffiness may be represent loss of elastic tissue that occurs with aging

External Examination: Lens

-Inspect for transparency and clarity -Shining a light on the lens may cause it to appear gray or yellow, but light should still pass through through

External Examination: Iris and Pupil

-Inspect iris for pattern, color, and shape -Expect them to be round, regular, and equal -Test for direct/consensual light response -Test pupils for accommodation (the pupils should contract when the eyes focus on the near object) -Estimate pupil size and compare for equality

External Examination: Lacrimal Apparatus

-Inspect the lacrimal gland -Palpate lower orbital rim near inner canthus -The puncta should be seen as slight elevations with a central depression on both the upper and lower lid margins nasally. -Lacrimal glands are rarely enlarged but may become enlarged in some conditions such as tumors, lymphoid infiltration, sarcoid disease, and Sjogren syndrome

Internal Eye: Uvea

-Iris, ciliary body, and choroids comprise the uveal tract -The iris is a circular, contractile muscular disk containing pigment cells that produce the color of the eye (dilates/contracts to control amount of light traveling through the pupil to the retina) -The ciliary body produces the aqueous humor (fluid that circulates between the lens and cornea) and contains the muscles controlling accommodation -The choroid is a pigmented, richly vascular layer that supplies oxygen to the outer layer of the retina

Eye Examination: Older Adults

-Lacrimal glands begin to involute and tear production decreases -Drusen bodies can appear as small, discrete spots that are slightly more yellow than the retina. With time the spots enlarge -Similar appearing lesions may occur in many conditions that affect the pigment layers of the retina, but most commonly they are a consequence of the aging process, and depending on size and number, are a precursor of senile macular degeneration -Most common causes of decreased visual function include glaucoma, cataracts, and macular degeneration

Physical Exam Preview: Ophthalmoscopic Exam

-Lens clarity -Red relex -Retinal color and lesions -Characteristics of blood vessels -Disc characteristics -Macula characteristics -Depth of anterior chamber

External Eye: Lacrimal Gland

-Located in the temporal region of the superior eyelid and produces tears that moisten the eye -Tears flow over the cornea and drain via the canaliculi to the lacrimal sac and duct and then into the nasal meatus

External Examination: Eyelid Palpation

-Palpate for nodules -Palpate the eye itself through closed lids (digital palpation tonomtery, pain) -Palpation of the orbit is one of the simplest methods for intraocular pressure assessment -Pain on palpation is consistent with scleritis, orbital cellulitis, and cavernous sinus thrombosis -An eye that feels very firm and resists palpation may indicate severe glaucoma or retrobulbar tumor

Snellen Chart

-Position the patient 20 feet (6 m) away from the Snellen chart -Ensure the chart is well lighted -Test each eye individually by covering one eye with an opaque card or gauze, being care to avoid applying pressure to the eye -If you test the patient with and without corrective lenses, record the reading separately and always test vision without glasses first -Ask the patient to identify all of the letters, beginning at any line -Determine the smallest line in which the patient can identify all of the letters and record the visual acuity -When testing the second eye, you may want to ask the patient to read the line from right to left to reduce the chance of recall influencing the response -Visual acuity is recorded as a fraction in which the numerator indicates the distance of the patient from the chart, and the denominator indicates the distance at which the average eye can read the line. The smaller the fraction the worse is the vision.

Review of Related History: Pregnant Women

-Presence of disorders that can cause ocular complications such as pregnancy-induced hypertension (PIH) or gestational diabetes -Symptoms indicative of PIH: diplopia, scotomata, blurred vision, or amaurosis -Use of topical eye medications that may cross placenta

Review of Related History: Infants and Children

-Preterm: resuscitative efforts, mechanical ventilatory or oxygen use, retinopathy of prematurity, birth weight, gestational age, sepsis, intracranial hemorrhage -Maternal history of sexually transmitted infections: zika virus, TORCH (toxoplasmosis., Other [syphilis, varicella zoster, parvovirus B-19], rubella, cytomegalovirus, and herpes) infections -Congenital abnormalities of the eye or surrounding structures -Symptoms of congenital abnormalities including failure of infant to gaze at mothers face or other objects; failure of infant to blink when bright lights or threatening movements are directed at face -White area in the pupil on examination or on a photograph (leukodoria), which may indicate retinoblastoma or other serious intraocular problems -Excessive tearing or discharge -Strabismus some or all of the time -Young children: excessive rubbing of the eyes, frequent hordeola, inability to reach for and pick up small objects, night vision difficulties -School-age children: Necessity of sitting near the front of the classroom to see the bored; poor progress in school not explained by intellectual ability

External Eye: Conjunctiva

-Protects the eye from foreign bodies and desiccation -Clear thin mucous membrane. -The palpebral conjunctiva coats the inside of the eyelids -The bulbar (or ocular) conjunctiva covers the outer surface of the eye. -The bulbar conjunctiva protects the anterior surface of the eye with the exception of the cornea and the surface of the eyelid in contact with the globe.

History of Present Illness: Eye

-Red eye (presence of conjunctival redness) -Difficulty with vision: one or both eyes, corrected by lenses -Recent injury or foreign body: sleeping in contact lenses -Pain: with or without loss of vision, in or around the eye, superficial or deep, insidious or abrupt in onset; burning, itching, or nonspecific uncomfortable or gritty sensation -History of welling, infections, or eye surgery -History of recent illness or similar symptoms in the household -Allergies: type, seasonal, associated symptoms -Eye Secretions: color (clear or yellow), consistency (watery or purulent), duration, tears that run down the face, decreased tear formation (with sensation of gritty eyes) -Medications: eye drops or ointments, antibiotics, artificial tears, mydriatics; glaucoma medications, antioxidant vitamins (to prevent macular degeneration), steroids. Vision Problem -Eyelids: hordeola (stye: acute infection of sebaceous glands of Zeis), ptosis, chalazion (chronic blockage of meibomian gland), growths, masses -Involves one or both eyes -Cataracts -Color vision -Halos, floaters, diplopia Trauma to the eye as a whole or a specific structure or supporting structures

Eye Examination: Pregnant Women

-Retinal examination helps differentiate between chronic hypertension and pregnancy-induced hypertension (PIH) -->Vascular tortuosity, angiosclerosis, hemorrhage, and exudates may be seen in patients with a long standing history of hypertension -->PIH changes include segmental arteriolar narrowing with a wet, glistening appearance indicative of edema -Detachment of the retina may occur with spontaneous reattachment after hypertension is successfully controlled -Cycloplegia and mydriatic agents should be avoided unless retinal disease is suspected -->Systemic absorption -Use of nasolacrimal duct occlusion after installation of topical eye medication may reduce systemic absorption if absolutely necessary

Family History: Eye

-Retinoblastoma (retinal cancer) -->Often an autosomal dominant disorder -Glaucoma -Macular degeneration -Diabetes -Hypertension -Other conditions that may impact vision or eye health -Cataracts or cataract formation -Color blindness -Retinal detachment -Retinitis pigmentosa, -Allergies affecting the eye -Nearsightedness -Farsightedness -Strabismus -Amblyopia

Examination and Findings: Eye Equipment

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

External Examination: Conjunctivae Inspection

-Usually translucent, clear, and free of erythema -Inspect lower portion (palpebral) by pulling down lower lid -Note translucency and vascular pattern -Upper lid is inspected only if foreign body is in eye -Look for redness/exudate -An erythematous or cobblestone appearance, especially on the tarsal conjunctiva, may indicate an allergic reaction or infectious conjunctivitis -Bright red blood in a sharply defined area surrounded by healthy-appearing conjunctiva indicates subconjunctival hemorrhage (the blood stays red because of direct diffusion of oxygen through the conjunctiva) -Look for pterygium (abnormal growth of conjunctiva that extends over the cornea from the limbus)

Internal Eye: Sclera

-White of the eye -Avascular -Supports internal eye structures

Retinal Hemorrhages in Infancy

Abnormal bleeding of the retinal blood vessels Occurs in infant victims of shaken-baby syndrome -Results from acceleration-deceleration impact head injury in abusive head trauma (shaken-baby syndrome) -->Usually bilaterally -Hypertension -Bleeding problems/leukemia -Meningitis/sepsis/endocarditis -Vasculitis -Retinal diseases -Anemia -Hypoxia/hypotension

Pterygium

Abnormal growth of conjunctiva that extends over the cornea from the limbus Occurs more commonly on the nasal side, but may arise on the temporal side Common in people heavily exposed to ultraviolet light Can interfere with vision if it advances over the pupil

Iritis Constrictive Response

Acute uveitis is commonly unilateral; constriction of pupil accompanied by pain and reddened eye, especially adjacent to the iris

Adie Pupil (Tonic Pupil)

Affected pupil dilated and reacts slowly or fails to react to light; responds to convergence Causes -Impairment of post ganglionic parasympathetic innervation to sphincter pupillae muscle or ciliary malfunction; often accompanied by diminished deep tendon reflexes

Hordeolum (Stye)

An acute suppurative inflammation of the follicle of an eyelash can cause an erythematous or yellow lump Generally caused by a staphylococcal infection

Cotton Wool Spot

An ill-defined yellow area due to infarction of the nerve layer of the retina.

Retinitis Pigmentosa

Autosomal recessive disorder in which genetic defects cause cell death, predominately in the rod photoreceptors Associated conditions: -Deafness (Usher syndrom) -Paralysis of one or more extraocular muscles, dysphagia, ataxia, and cardiac conduction defects are seen in the mitochondrial DNA disorder (Kearns-Sayre syndrome) -Intellectual delay, peripheral neuropathy, acanthotic (spiked) red blood cells, acacia, steatorrhea, absence of very low-density lipoprotein (VLDL)

Argyll Robertson Pupil

Bilateral, miotic, irregularly shaped pupils that fail to constrict with light but retain constriction with convergence Pupils may or may not be equal in size Causes: -Neurosyphilis -Lesions in the midbrain where afferent pupillary fibers synapse

Strabismus

Both eyes do not focus on an object simultaneously but can focus with either eye -Paralytic, caused by impairment of one or more extraocular muscles -Nonparalytic with no primary muscle weakness -->May be a sign of increased intracranial pressure -Cranial nerve III is particularly vulnerable to damage from brain swelling

Exophthalmos

Bulging of eye anteriorly out of orbit -Can be from an increase in valve of orbital contents -Most common cause is Graves disease in which abnormal connective tissue is deposited in the obit and extraocular muscles -Bilateral or unilateral -When unilateral, a retro-orbital tumor must be considered

External Eye

Composed of five structures: -Eyelid -Conjunctiva -Lacrimal Glad -Eye muscles -Bony skull orbit (contains fat, blood vessels, nerves, and supporting connective tissue)

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 Five major structures: -Sclera -Cornea -Iris -Lens -Retina

Lipemia Retinalis

Creamy white appearance of retinal vessels that occurs with excessively high serum triglyceride levels -Occurs when the serum triglyceride level exceeds 2000 mg/dL -Seen in some of the hyperlidiemic states

Visual Field Defects

Defective vision or blindness in a single eye -Bitemporal hemianopia is caused by a lesion, most commonly a pituitary tumor, interrupting optic chiasm -Homonymous hemianopia can be caused by a lesion arising in optic nerve radiation on either side of the brain -May be consequence of degenerative changes within the eye or from a lesion of the optic nerve anterior to its decussation -Most common cause is interruption of the vascular supply to the optic nerve

Band Keratopathy

Deposition of calcium in the superficial cornea -Most commonly in patient with chronic corneal disease -May occur in patient with hypercalcemia, hyperparathyroidism, and occasionally in individuals with trauma, renal failure, sarcoidosis or syphilis

Diabetic Retinopathy (Proliferative)

Development of new vessels as result of anoxic stimulation -Vessels grow out of the retina toward the vitreous humor -May occur in peripheral retina or on optic nerve itself -New vessels lack supporting structure of healthy vessels and are likely to hemorrhage -Bleeding from these vessels is a major cause of blindness in patients with diabetes -Laser therapy can often control this neovascularization and prevent blindness

Glaucoma

Disease of the optic nerve resulting from increased intraocular pressure Nerve cells die, usually due to excessively high intraocular pressure, producing a characteristic appearance of the optic nerve (increased cupping) -Acute angle: May occur acutely with dramatically elevated intraocular pressure if the iris blocks the exit of aqueous humor from the anterior chamber -Open angle: Caused by decreasing aqueous humor absorption leads to increased resistance and painless buildup of pressure in the eye -May also be congenital as a result of improper development of the eyes aqueous outflow system

Retinopathy of Prematurity (ROP)

Disruption of normal progression of retinal vascular development in preterm infant -Results in abnormal proliferation of blood vessels -Most common in infants with a birth weight of less than or equal to 1500 g or gestational age of less than or equal to 30 weeks

Corneal Ulcer

Disruption of the corneal epithelium and stroma -Connective tissue disease, such as rheumatoid arthritis, Sjogren syndrome, or a systemic vasculitic disorder -Infection: viral infection (herpes simplex), bacterial infection -Extreme dryness: incomplete lid closure or poor lacrimal gland function -Prolonged use of contact lens

Diabetic Retinopathy (Background or Nonproliferative)

Dot hemorrhages or microaneurysms and the presence of hard and soft exudates -Hard exudates are the result of lipid transudation through incompetent capillaries -Soft exudates (also called cotton-wool spots) are caused by infarction

Ptosis

Drooping of the upper eyelid, which indicates a congenital or acquired weakness of the levator muscle or a paresis of a branch of the third cranial nerve

External Eye: Extraocular Muscles

Each eye is moved by six muscles They are innervated by cranial nerves III, IV, and VI The oblique muscles -Superior oblique (cranial nerve IV, trochlear) -Inferior oblique (cranial nerve III, oculomotor) The rectus muscles -Superior rectus (cranial nerve III, oculomotor) -Inferior rectus (cranial nerve III, oculomotor) -Medial rectus (cranial nerve III, oculomotor) -Lateral rectus (cranial nerve VI, abducens)

Retinoblastoma

Embryonal malignant tumor arising from retina -Usually develops during the first 2 years of life -Transmitted either by autosomal dominant trait or by chromosomal mutation -Most common retinal tumor in children

Physical Exam Preview: Muscle Balance and Movement of Eyes

Evaluate muscle balance and movement of eyes with the following: -Corneal light reflex -Cover-uncover test -Six cardinal fields of gaze

Ears, Nose, and Throat

Examination of the ears, nose and throat provides information about their integrity and function, as well as the associated respiratory and digestive tracts The special senses of smell, hearing, equilibrium, and taste are also located in the ears, nose, and mouth

External Examination

Examination performed in systemic manner beginning with appendages (I.e., the eyebrows and surrounding tissue) and moving inward. Techniques -Inspection -Palpation

Anatomy and Physiology of the Eye: Infants and Children

Eye forms during the first 8 weeks of gestation -May become malformed due to maternal drug ingestion, alcohol, or infection Lacrimal drainage is complete at birth By 2 to 3 weeks of age, the lacrimal gland begins producing full volume of tears Vision development depends on nervous system maturation and occurs over time -Term infants are hyperopic (20/400) -Peripheral vision fully developed at birth -Central vision develops later -By 3 to 4 months of age, binocular vision development is complete -By 6 months, vision has developed sufficiently so that the infant can differentiate colors -The globe of the eye grows as the child's head and brain grow, and adult visual acuity is achieved at about 4 years of age

Failure to Respond

Failure to constrict with increased light stimulus Causes: -Iridocyclitis -Retinal degeneration -Optic nerve (CN II) destruction -Midbrain synapses involving afferent papillae fibers or oculomotor nerve (CN III); consensual response is also lost -Impairment of efferent fivers (parasympathetic) that innervate sphincter pupillae muscle -Mydriatics -Brain herniation (fixed dilated pupils)

Epislceritis

Inflammation of the superficial layers of the sclera anterior to the insertion of the rectus muscles Pathophysiology is poorly understood. There are two kinds: -Simple: Intermittent episodes of moderate to sever inflammation often recurring at 1- to 3-month intervals, lasting 7-10 days, and resolving after 2-3 weeks -Nodular: Prolonged attacks of inflammation, typically more painful than simple episcleritis Most cases are idiopathic; may have an underlying systemic condition such as autoimmune disorders, including Crohn disease, rheumatoid arthritis, systemic lupus erythematous, polyarteritis nodosa, psoriatic arthritis, grout, atopy, foreign bodies, chemical exposure, or infection

Chorioretinitis (Chorioretinal Inflammation)

Inflammatory process involving both the choroid and the retina -Most common cause is laser therapy for diabetic retinopathy but may also be seen in histoplasmosis, cytomegalovirus, toxoplasmosis, or congenital rubella infections

Physical Examination Components: Mouth

Inspect and palpate the lips for symmetry, color, and edema Inspect the teeth for: -Occlusion -Caries -Loose or missing teeth -Surface abnormalities Inspect and palpate the gingivae and buccal mucosa for color, lesions, and tenderness Inspect the tongue for color, symmetry, swelling, and ulcerations Assess the function of cranial nerve XII (hypoglossal) Palpate the tongue Inspect the palate and uvula Elicit the gag reflex (cranial nerves IX and X) Inspect the oropharyngeal characteristics of the tonsils and posterior wall of the pharynx

Physical Examination Components: Ears

Inspect the auricles and surrounding area for: -Size, shape, and symmetry -Landmarks -Color -Position -Deformities or lesions Palpate the auricles and mastoid area for tenderness, swelling, and nodules Inspect the auditory canal with an otoscope, noting: -Cerumen -Color -Lesions -Discharge -Foreign bodies Inspect the tympanic membrane for: -Landmarks -Color -Contour -Perforations -Mobility Assess hearing through responses to: -Questions -Whispered voice -Tuning fork for air and bone conduction

Physical Exam Preview: External Eye

Inspect the external eyes for the following: -Corneal clarity -Corneal sensitivity -Corneal arcus -Color of irides -Pupillary size and shape -Pupillary response to light and accommodation, afferent pupillary defect, swinging flashlight test -Nystagmus

Physical Examination Components: Nose and Sinuses

Inspect the external nose, noting: -Shape -Size -Color -Nares Palpate the bridge and soft tissues of the nose, noting: -Tenderness -Displacement of cartilage and bone -Masses Evaluate the potency of the nares Inspect the nasal mucosa and nasal spectrum for: -Color -Alignment -Discharge -Swelling of turbinates -Perforation Inspect the frontal and maxillary sinus area for swelling Palpate the frontal and maxillary sinuses for tenderness, pain, and swelling

Physical Exam Preview: Eyebrows

Inspect the eyebrows for the following: -Hair texture -Size -Extension

Physical Exam Preview: Eyelids

Inspect the eyelids for the following: -Ability to open wide and close completely -Eyelash position -Ptosis -Fasciculations or tremors -Flakiness -Redness -Swelling Palpate the eyelids for nodules

Physical Exam Preview: Orbit

Inspect the orbital area for the following: -Edema -Redundant tissues or edema -Lesions Inspect the orbits

Ophthalmoscopic Examination

Inspection of interior eye with regular or PanOptic ophthalmoscope permits visualization of: -Optic disc -Arteries -Veins -Retina Adequate pupil dilation is necessary 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 -Glaucoma cupping -Drusen bodies -Cotton wool bodies -Hemorrhages

Nystagmus

Involuntary rhythmic movements of the yes that can occur in a horizontal, vertical, rotary, or mixed pattern Jerking nystagmus, characterized by faster movements in one direction, is defined by its rapid movement phase

Esotropic Strabismus

Inward deviation of the eye

Papilledema

Loss of definition of the optic disc margin, initially occurs superiorly and inferiorly, then nasally and temporally central vessels pushed forward, and veins are markedly dilated. Venous pulsations are not visible and cannot be induced by pressure applied to the globe Venous hemorrhages may occur

Physical Exam Preview: Visual Acuity

Measure visual acuity, noting the following: -Near vision -Distant vision -Peripheral vision

Cataracts

Opacities in the lens -Most commonly from denaturation of lens protein caused by aging -With aging cataracts are generally central -Peripheral cataracts may occur in hypoparathyroidism -Medication such as steroids can cause cataracts -Congenital cataracts can result form a number of genetic defects, maternal infections such as rubella, or other fetal insults during the first trimester of pregnancy

Exotropic Strabismus

Outward deviation of the eye

Physical Exam Preview: Lacrimal Gland

Palpate the lacrimal gland in the superior temporal orbital rim

Glaucomatous Optic Nerve Head Cupping

Physiologic disc margins are raised with a lowered central area Blood vessels may disappear over the edge of the physiologic disc and be seen again deep within the disc Occasionally atrophy occurs unilaterally; always compare cupping on the two retina Compare with healthy vessels Impairment of blood supply may lead to optic atrophy, causing the disc to appear much whiter than usual The cup is usually not particularly enlarged in contrast to glaucomatous atrophy

Physical Exam Preview: Conjunctiva and Sclerae

Pull down the lower lids and inspect palpebral conjunctivae, bulbar conjunctiva and sclerae for the following: -Color -Discharge -Lacrimal gland punctum -Pterygium

Oculomotor Nerve (CN III) Damage

Pupil dilated and fixed; eye deviated laterally and downward; ptosis

Miosis

Pupillary constriction usually less than 2 mm in diameter Causes: -Iridocyclitis -Miotic eye drops (pilocarpine given for glaucoma) -Opioid abuse

Mydriasis

Pupillary dilation usually greater than 6 mm in diameter Causes: -Coma due to diabetes, alcohol, uremia, epilepsy, or brain tumor -Iridocyclitis -Mydratic or cycloplegic drops (atropine) -Midbrain lesions or hypoxia -Oculomotor (CN III) damage -Acute angle glaucoma -Stimulant abuse (cocaine, amphetamines)

Internal Eye: Retina

Sensory network of the eye Photoreceptors and neurons transform light impulses into electrical impulses, which are transmitted through: -Optic nerve -Optic tract -Optic radiation -Visual cortex -Consciousness in the cerebral cortex The optic nerve passes through the optic foramen along with the ophthalmic artery and vein. The optic nerve communicates with the brain and the autonomic nervous system of the eye. Cortex interprets impulses as visual objects Major landmarks of the retina include: -Optic disc, from which the optic nerve originates, together with the central retinal artery and vein -Macular, or fovea, is the site of central vision

Anatomy and Physiology: Ears and Hearing

Sensory organ that functions in identification, location, and interpretation of sound Aids in the maintenance of equilibrium It is divided into: -External -Middle -Inner

The Eye

Sensory organ that transmits visual stimuli to the brain for interpretation Occupies the orbital cavity Anterior aspect exposed The eye itself is a direct embryologic extension of the brain Attached by four rectus muscles and two oblique muscles Innervated by cranial nerves III, IV, and VI Cranial nerve II, the optic nerve, connects the eye to the brain

Swinging Flashlight Test

Shine the light in one eye and then rapidly swing to the other. There should be a slight dilation in the second eye while the light is crossing the bridge of the nose, but it should constrict equally to the first eye as the light enters the pupil Repeat going in the other direction If the second pupil continues to dilate rather than constrict, an afferent pupillary defect is present also called a Marcus-Gunn pupil.

Eye Examination (cont): Infants

Test cranial nerves -Vision: Observe object preference/focus/tracking -Obtical blink: note closure and head response to bright light -Corneal reflex: same as adult Funduscopic examination deferred until infant is 2 to 6 months old (unless visual problems are present)

Extraocular Eye Muscles

Test eye movements using six cardiac fields of gaze -Check for nystagmus -Note lid lag -Note exposure of sclera above iris Use corneal light reflex to test extraocular muscle balance -If imbalanced, perform cover-uncover test

Visual Testing

Tests for -Central vision -Near vision -Peripheral vision Near vision -Use Rosenbaum pocket screener -Each eye tested individually Peripheral Vision -Estimate with confrontation test -Accurate measurement requires instrumentation Color Vision -Rarely tested in the routine physical examination The discrimination of small visual details test CN II and is essentially a measurement of mental vision

Psudostrabismus

The false appearance of strabismus caused by a flattened nasal bridge or epicanthal folds in infants Psudostrabismus generally disappears by about 1 year of age Use corneal light reflex to distinguish psudostrabismus from strabismus.

Entropion

The lid is turned inward toward the globe. The eye lashes may cause corneal and conjunctival irritation, increasing the risk of secondary infections The patient often reports a foreign body sensation

Anatomy and Physiology of the Eye: Older Adults

The major physiologic eye change that occurs with aging is a progressive weakening of accommodation (focusing power) known as presbyopia Loss of lens clarity and cataract formation

External Eye: Cranial Nerves III, IV, and VI

The oculomotor nerve (III) controls -Levator palpebrae superioris (which elevates and retracts the upper eyelid -All extra ocular muscles expect for the superior oblique muscle and the lateral rectus muscle The superior oblique is the only muscle innervated by the trochlear nerve (IV) The lateral rectus muscle is the only muscle innervated by the abducens nerve (VI)

Horner Syndrome

Triad of ipsilateral mitosis, mild ptosis, and loss of hemifacial sweating Results from interruption of sympathetic nerve supply to the eye -Can be congenital, squired, or hereditary -May result from lesion of the primary neuron, stroke, trauma to the brachial plexus, tumors, dissecting carotid aneurysm, or operative trauma

Anisocoria

Unequal size of pupils Causes: -Congenital (approximately 20% of healthy people have minor or noticeable differences in pupil size, but reflexes are normal) -Local eye medications (constrictors or dilators) -Unilateral sympathetic or parasympathetic pupillary pathway destruction

Review of Related History: Older Adults

Visual Acuity -Decrease in central vision -Distortion of central vision -Use of dim or bright light to increase visual acuity -Complaints of glare -Difficulty performing near work without lenses -Excess tearing -Dry eyes -Nocturnal eye pain: Sign of subacute angle closure and a symptom of glaucoma -Depth perception problems

Ectropion

When the lower lid is turned away from the eye and may result in excessive tearing The inferior punctum, which serves as the tear-collecting system, is pulled outward and the lower lid cannot collect the secretions of the lacrimal gland

Myelinated Retinal Nerve Fibers

White area with soft, ill defined peripheral margins usually continuous with the optic disc. Absence of pigment, feathery margins, and full visual fields help distinguish this being condition from chorioretinitis Nerve finger layer is the innermost retinal surface; the vessels lie deeper in the retina Note how the myelinated nerve fingers obscure areas of the retinal blood vessels, particularly inferiorly

Strabismus

abnormal deviation of the eye

Xanthelasma

flat to slightly raised, oval, irregularly shaped, yellow-tinted lesions on the periorbital tissues that represent depositions of lipids and may suggest that the patient has an abnormality of lipid metabolism; an elevated plaque of cholesterol deposited in macrophages most commonly in the nasal portion of the upper or lower lid