chapter 16 (health assessment)

Have you ever had problems with your eyes or vision?

A history of eye problems or changes in vision provides clues to the current health of the eye.

Do you experience blind spots? Are they constant or intermittent?

A scotoma is a blind spot that is surrounded by either normal or slightly diminished peripheral vision. It may be from glaucoma. Intermittent blind spots may be associated with vascular spasms (ophthalmic migraines) or pressure on the optic nerve by a tumor or increased intracranial pressure. Consistent blind spots may indicate retinal detachment. Any report of a blind spot requires immediate attention and referral to an ophthalmologist.

When was your last eye examination?

All clients at risk for eye problems should be examined annually or as recommended by their primary care provider. A thorough eye examination is recommended for healthy clients without risk factors every 2 years, for ages 18 through 60; annually for those aged 61 and older (American Optometric Association [AOA], 2015d). However, the U.S. Preventive Services Task Force (USPSTF, 2015) asserts that the current evidence is insufficient to assess the balance of benefits and harms of screening for visual acuity for the improvement of outcomes in older adults.

Do you have any eye pain or itching? Do you have pain with bright lights (photophobia)? Describe.

Burning or itching pain is usually associated with allergies or superficial irritation. Throbbing, stabbing, or deep, aching pain suggests a foreign body in the eye or changes within the eye. See procedure for assessing eye trauma and presence of foreign body at the end of the physical assessment section. Most common eye disorders are not associated with actual pain. Therefore, immediately refer reports of eye pain.

Do you have a prescription for corrective lenses (glasses or contacts)? Do you wear them regularly? If you wear contacts, how long do you wear them? How do you clean them?

Clients who do not wear the prescribed corrective lenses are susceptible to eyestrain. Improper cleaning or prolonged wearing of contact lenses can lead to infection and corneal damage.

Have you had any eye discharge? Describe.

Discharge other than tears from one or both eyes suggests a bacterial or viral infection.

Do you wear sunglasses during exposure to the sun?

Exposure to ultraviolet radiation puts the client at risk for the development of cataracts (opacities of the lenses of the eyes; see Evidence-Based Practice 16-3). Consistent use of sunglasses during exposure minimizes the client's risk.

Assessing the client's visual acuity and eye is always a concern to the nurse. This information may already be documented in the client's record or obtained from the client's history. However, the nurse needs to know all parts of the eye examination to be able to fully understand the status of the client's eyes and vision. In the acute care setting the nurse typically assesses the client's gross vision, peripheral vision, external eye structures, and papillary response. However, in school settings the school nurse may need to use the Snellen Chart to more accurately assess for visual loss in the child. In the home setting it may be necessary to do the additional visual and eye tests to determine the need for further assessment by the primary care provider and to detect early signs of more serious eye conditions (e.g., increased intracranial pressure). Assessment of the internal eye in intensive care settings is important to check for optic disc swelling due to intracranial swelling or in specialized settings to further assess for glaucoma. See the chart below for a general overview.

General Routine Screening: Focused Specialty Assessment Test distant visual acuity. Test near visual acuity. Test visual fields for gross peripheral vision. Inspect the eyelids and eyelashes. Observe the position and alignment of the eyeball in the eye socket. Inspect the bulbar conjunctiva and sclera. Inspect the lacrimal apparatus. Inspect the iris and pupil. Assess pupillary reaction to light. Focused Specialty Assessment: Perform corneal light reflex test. Perform cover test. Perform the cardinal fields of gaze test. Inspect the palpebral conjunctiva. Palpate the lacrimal apparatus. Inspect the cornea and lens. Assess accommodation of pupils. Use ophthalmoscope to inspect the optic disc, retinal vessels and background, fovea and macula, and anterior chamber.

Lifestyle and Health Practices: Are you exposed to conditions or substances in the workplace or home that may harm your eyes or vision (e.g., chemicals, fumes, smoke, dust, or flying sparks)? Do you wear safety glasses during exposure to harmful substances?

Injuries or diseases may be related to exposure in the workplace or home. These problems can be minimized or avoided altogether with hazard identification and implementation of safety measures. It is important to teach the client to use protective eyewear when engaging in recreational activities and hazardous situations (Healthy People 2020, 2015).

What visual aids do you use to assist you with your visual loss (magnifying glasses, audiotapes, CDs, special glasses for viewing television, large-numbered phones, large-print checks, large print books)?

It is important to assist the client to access and use assistive and adaptive visual devices to improve one's activities of daily living (Healthy People 2020, 2015).

Family History: Is there a history of eye problems or vision loss in your family?

Many eye disorders have familial tendencies. Examples include glaucoma, refraction errors, allergies, and macular degeneration. Approximately 11 million people in the United States have some form of age-related macular degeneration, which is a major cause of visual impairment in the United States. It is estimated that nearly 40 million will have macular degeneration worldwide by the year 2020 (Bright Focus Foundation, 2017b). See Evidence-Based Practice 16-2.

Perform the cardinal fields of gaze test, which assesses eye muscle strength and cranial nerve function. Instruct the client to focus on an object you are holding (approximately 12 in from the client's face). Move the object through the six cardinal positions of gaze in a clockwise direction, and observe the client's eye movements (Fig. 16-12).

NORMAL FINDINGS: Eye movement should be smooth and symmetric throughout all six directions. ABNORMAL FINDINGS: Failure of eyes to follow movement symmetrically in any or all directions indicates a weakness in one or more extraocular muscles or dysfunction of the cranial nerve that innervates the particular muscle (see Abnormal Findings 16-2). Nystagmus—an oscillating (shaking) movement of the eye—may be associated with an inner ear disorder, multiple sclerosis, brain lesions, or narcotics use.

ASSESSMENT PROCEDURE NORMAL FINDINGS: ABNORMAL FINDINGS Evaluating Vision Test distant visual acuity. Position the client 20 ft from the Snellen or E chart (see Assessment Guide 16-1) and ask her to read each line until she cannot decipher the letters or their direction (Fig. 16-9). Document the results.

NORMAL FINDINGS: Normal distant visual acuity is 20/20 with or without corrective lenses. This means that the client can distinguish what the person with normal vision can distinguish from 20 ft away. ABNORMAL FINDINGS: Myopia (impaired far vision) is present when the second number in the test result is larger than the first (20/40). The higher the second number, the poorer the vision. A client is considered legally blind when vision in the better eye with corrective lenses is 20/200 or less. Refer any client with vision worse than 20/30 for further evaluation.

Test near visual acuity. Use this test for middle-aged clients and others who have difficulty with near vision or with reading. Give the client a hand-held vision chart (e.g., Jaeger reading card, Snellen card, or comparable chart) to hold 14 in from the eyes. Have the client cover one eye with an opaque card before reading from top (largest print) to bottom (smallest print). Repeat test for other eye (see Assessment Guide 16-1).

NORMAL FINDINGS: Normal near visual acuity is 14/14 (with or without corrective lenses). This means that the client can read what the normal eye can read from a distance of 14 in. ABNORMAL FINDINGS: Presbyopia (impaired near vision) is indicated when the client moves the chart away from the eyes to focus on the print. It is caused by decreased accommodation.

TESTING EXTRAOCULAR MUSCLE FUNCTION Perform corneal light reflex test. This test assesses parallel alignment of the eyes. Hold a penlight approximately 12 in from the client's face. Shine the light toward the bridge of the nose while the client stares straight ahead. Note the light reflected on the corneas.

NORMAL FINDINGS: The reflection of light on the corneas should be in the exact same spot on each eye, which indicates parallel alignment. ABNORMAL FINDINGS: Asymmetric position of the light reflex indicates deviated alignment of the eyes. This may be due to muscle weakness or paralysis (Abnormal Findings 16-2).

Perform cover test. The cover test detects deviation in alignment or strength and slight deviations in eye movement by interrupting the fusion reflex that normally keeps the eyes parallel. Ask the client to stare straight ahead and focus on a distant object. Cover one of the client's eyes with an opaque card (Fig. 16-11). As you cover the eye, observe the uncovered eye for movement. Now remove the opaque card and observe the previously covered eye for any movement. Repeat test on the opposite eye.

NORMAL FINDINGS: The uncovered eye should remain fixed straight ahead. The covered eye should remain fixed straight ahead after being uncovered. ABNORMAL FINDINGS: the uncovered eye will move to establish focus when the opposite eye is covered. When the covered eye is uncovered, movement to re-establish focus occurs. Either of these findings indicates a deviation in alignment of the eyes and muscle weakness (see Abnormal Findings 16-2). Phoria is a term used to describe misalignment that occurs only when fusion reflex is blocked. Strabismus is constant malalignment of the eyes. Tropia is a specific type of misalignment: esotropia is an inward turn of the eye, and exotropia is an outward turn of the eye.

Assess ability of eyelids to close.

NORMAL FINDINGS: The upper and lower lids close easily and meet completely when closed. ABNORMAL FINDINGS: Failure of lids to close completely puts client at risk for corneal damage.

INSPECTION AND PALPATION Inspect the eyelids and eyelashes. Note width and position of palpebral fissures.

NORMAL FINDINGS: The upper lid margin should be between the upper margin of the iris and the upper margin of the pupil. The lower lid margin rests on the lower border of the iris. No white sclera is seen above or below the iris. Palpebral fissures may be horizontal. ABNORMAL FINDINGS: Drooping of the upper lid, called ptosis (formal term blepharoptosis), may be attributed to oculomotor nerve damage, myasthenia gravis, weakened muscle or tissue, or a congenital disorder (Abnormal Findings 16-3). Retracted lid margins, which allow for viewing of the sclera when the eyes are open, suggest hyperthyroidism.

Test visual fields for gross peripheral vision. To perform the confrontation test, position yourself approximately 2 ft away from the client at eye level. Have the client cover the left eye while you cover your right eye (Fig. 16-10). Look directly at each other with your uncovered eyes. Next, fully extend your left arm at midline and slowly move one finger (or a pencil) upward from below until the client sees your finger (or pencil). Test the remaining three visual fields of the client's right eye (i.e., superior, temporal, and nasal). Repeat the test for the opposite eye.

NORMAL FINDINGS: With normal peripheral vision, the client should see the examiner's finger at the same time the examiner sees it. Normal visual field degrees are approximately as follows: Inferior: 70 degrees Superior: 50 degrees Temporal: 90 degrees Nasal: 60 degrees ABNORMAL FINDINGS: A delayed or absent perception of the examiner's finger indicates reduced peripheral vision (Abnormal Findings 16-1). Refer the client for further evaluation.

Do you have trouble seeing at night?

Night blindness is associated with optic atrophy, glaucoma, and vitamin A deficiency.

What types of medications do you take?

Ocular side effects of drugs are often unrecognized or overlooked. Some medications reported to have ocular side effects include alpha-1 blockers, some antiarrhythmics, anticholinergics (including antihistamines, antipsychotics, antispasmodics, cyclic antidepressants, and mydriatics), anticoagulants, antimalarials, bisphosphonates, corticosteroids, digoxin, erectile dysfunction medications, fluoroquinolones and some other antibiotics, and many other medications (Miguel et al., 2014).

There are several types of glaucoma. Signs and symptoms differ for the two most common types of glaucoma—primary open-angle glaucoma (POAG) and acute angle-closure glaucoma (AACG) (Mayo Clinic, 2015b). Common signs and symptoms are:

Open-angle Glaucoma: Patchy blind spots in your side (peripheral) or central vision, frequently in both eyes Tunnel vision in the advanced stages Acute Angle-closure Glaucoma: Severe headache Eye pain Nausea and vomiting Blurred vision Halos around lights Eye redness

Do you have any redness or swelling in your eyes?

Redness or swelling of the eye is usually related to an inflammatory response caused by allergy, foreign body, or bacterial or viral infection.

Do you see halos or rings around lights?

Seeing halos around lights is associated with narrow-angle glaucoma.

Do you see spots or floaters in front of your eyes?

Spots or floaters are common among clients with myopia or in clients over age 40. In most cases, they are due to normal physiologic changes in the eye associated with aging and require no intervention

Describe any recent visual difficulties or changes in your vision that you have experienced. Were they sudden or gradual?

Sudden changes in vision are associated with acute problems such as head trauma or increased intracranial pressure. Gradual changes in vision may be related to aging, diabetes, hypertension, or neurologic disorders.

Have you ever had eye surgery?

Surgery may alter the appearance of the eye and the results of future examinations.

Describe your typical diet. What have you eaten in the last 24 hours? Do you take any vitamins or supplements?

The AOA (2015c) explains that research has linked nutrition to a decreased risk of age-related macular degeneration (AMD) as follows: A well-balanced diet is essential. Lutein and zeaxanthin (in foods or by supplements) found in green leafy vegetables, eggs, and other foods reduce the risk of chronic eye diseases, including age-related macular degeneration and cataracts. Foods rich in these nutrients include kale, spinach, collards, turnip greens, corn, green peas, broccoli, romaine lettuce, green beans, eggs, and oranges. Vitamin C can decrease the risk of cataracts and reduce the risk of age-related macular degeneration when taken with other essential nutrients. Vitamin E in its most biologically active form is a powerful antioxidant which, when taken with antioxidants beta-carotene, vitamin C, and zinc, has been found to slow progression of AMD by 25% in high-risk individuals. It is found in nuts, fortified cereals, and sweet potatoes. It is thought to protect cells of the eyes from damage caused by unstable molecules. Zinc is an essential trace mineral or "helper molecule." It plays a vital role in bringing vitamin A from the liver to the retina in order to produce melanin, a protective pigment in the eyes. Two omega-3 fatty acids have been shown to be important for proper visual development and retinal function (AOA, 2015a). Dietary deprivation of EPA and especially of DHA is related to visual impairment, retinal degradation, and even dry eye syndrome, and to the progression of advanced age-related AMD. Beta-carotene supplements have been known to decrease one's risk of developing cataracts and AMD. However, research shows this may increase the risk of lung cancer in people who smoke (especially those smoking more than 20 cigarettes per day), former smokers, have been exposed to asbestos, or drink one or more alcoholic beverages and also smoke. Beta-carotene from food alone does not seem to have this risk (Tanvetyanon & Bepler, 2008).

Do you perform the test for macular degeneration using the Amsler chart? How do you use this chart and how often? What do you see when you use it?

To perform the Amsler test properly, clients should wear their glasses if they normally do so. They should use the bottom portion to view the chart if they wear bifocals. The Amsler chart should be posted on a wall at eye level (Fig. 16-8). Clients should stand 12-14 ft (comfortable reading distance) away from it and cover one eye. With the other eye, they should look at the center dot. Any areas of distortion, graying, blurring, or blank spots should be marked on the chart and they should notify their physician. If they have already developed a baseline with distortions that their primary care provider is aware of, then they should report any changes from their baseline to their primary care provider. Refer clients to http://www.amd.org/living-with-amd/resources-and-tools/31-amsler-grid.html to download the Amsler grid with directions to use to test for any visual changes (Macular Degeneration Partnership, 2015

Do you smoke? How many packs and for how long?

Tobacco smoking has been found to be strongly associated with eye diseases, doubling the chance of forming cataracts and causing a three-fold risk of developing AMD (Surtenich, 2013).

Have you ever been tested for glaucoma? What were the results?

Tonometry is used to measure pressure within the eye. Normal eye pressures range from 10-21 mm of mercury (mm Hg). Eye pressures greater than 22 mm Hg increase one's risk for developing glaucoma. However, people with normal eye pressure may develop glaucoma (AOA, 2015b) (see Evidence-Based Practice 16-1).

Do you have any vision loss? Has your vision loss affected your ability to care for yourself? To work?

Vision problems may interfere with the client's ability to perform usual activities of daily living. The client may be unable to read medication labels or fill insulin syringes. If the vision problem is severe, the client's ability to perform hygiene practices or prepare food may be affected. Vision problems may affect a client's ability to work if the job is one that depends on sight, such as a pilot or commercial motor vehicle operator.