Chapter 7 Red Eyes Table 7-3

A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that: a. The eyes converge to focus on the light. b. Light is reflected at the same spot in both eyes. c. The eye focuses the image in the center of the pupil. d. Constriction of both pupils occurs in response to bright light.

ANS: D The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina. The other responses are not correct.

49. A man who has had gout for several years comes to the clinic with a problem with his toe. On examination, the nurse notices the presence of hard, painless nodules over the great toe; one has burst open with a chalky discharge. This finding is known as: a. Callus. b. Plantar wart. c. Bunion. d. Tophi.

ANS: D Tophi are collections of monosodium urate crystals resulting from chronic gout in and around the joint that cause extreme swelling and joint deformity. They appear as hard, painless nodules (tophi) over the metatarsophalangeal joint of the first toe and they sometimes burst with a chalky discharge (see Table 22-6). (See Table 22-6 for descriptions of the other conditions.)

bitting surface of the teeth may become abraded or notched by recurrent trauma: holding nails or opening bobby pins between teeth. Teeth show normal contour, size and spacing not like in Hutchinson

Abrasion of Teeth with Notching

Pain- Moderate, aching, deep Vision- decreased; photophobia Ocular discharge- absent Pupil- small and irregular Cornea- clear or slightly clouded; injection confined to corneal limbus Significance- Associated with systemic infections, Herpes zoster, tuberculosis, or autoimmune disease; refer promptly

Acute Iritis

caused by bacterial infection from S. pneumoniae or H. influenzae. Sx: earache, fever, and hearing loss. Red eardrums, loses its landmarks, and bulges laterally, toward the examiner's eye. Spontaneous rupture of the drum may follow, with discharge of purulent material into the ear canal.

Acute Otitis Media with Purulent Effusion

Pain- Severe, aching, deep Vision- decreased Ocular discharge- absent Pupil- dilated, fixed Cornea- Streamy, cloudy Significance- Acute increase in intra-ocular pressure, constitutes an emergency

Acute angle closure- glaucoma

Uncommon form of gingivitis that occurs suddenly in young Adults and adolescents accompanied by fever, malaise, and enlarged lymph nodes. Ulcers develop in papillae and then destructive necrosis with gray pseudomembrane. Gums bleed and breath is foul: red painful gums bleed easily

Acute necrotizing Ulcerative gingivitis

12. A sudden, painless unilateral vision loss may be caused by which of the following? A) Retinal detachment B) Corneal ulcer C) Acute glaucoma D) Uveitis

Ans: A Chapter: 07 Page and Header: 196, The Health History Feedback: Corneal ulcer, acute glaucoma, and uveitis are almost always accompanied by pain. Retinal detachment is generally painless, as is chronic glaucoma.

Glaucoma is the leading cause of blindness in African-Americans and the second leading cause of blindness overall. What features would be noted on funduscopic examination? A) Increased cup-to-disc ratio B) AV nicking C) Cotton wool spots D) Microaneurysms

Ans: A Chapter: 07 Page and Header: 201, Health Promotion and Counseling Feedback: It is important to screen for glaucoma on funduscopic examination. The cup and disc are among the easiest features to find. AV nicking and cotton wool spots are seen in hypertension. Microaneurysms are seen in diabetes.

You note that a patient has anisocoria on examination. Pathologic causes of this include which of the following? A) Horner's syndrome B) Benign anisocoria C) Differing light intensities for each eye D) Eye prosthesis

Ans: A Chapter: 07 Page and Header: 211, Techniques of Examination Feedback: Anisocoria can be associated with serious pathology. Remember to exclude benign causes before embarking on an intensive workup. Testing the near reaction in this case may help you to find an Argyll Robertson or tonic (Adie's) pupil.

Unequal Pupil Represents a defect in the constriction or dilation of one pupil

Anisocoria

When larger pupil cannot constrict properly Due to: trauma, open angle glaucoma and impaired parasympathetic innervation to the iris CNIII paralysis

Anisocoria is greater in bright light than in dim light

When smaller pupil cannot dilate properly, as in Horner Syndrome. Due to: interruption of the sympathetic innervation Assess for near reaction

Anisocoria is greater in dim light

This is raised nodule shows the lustrous surface and telangiectatic vessels of basal cell carcinoma, common slow growing malignancy that rarely metastasizes. More frequent in fair skinned people overexposed to sunlight

Basal Cell carcinoma

an acute infection caused by Corynebacterium diphtheriae, is now rare. Prompt dx may lead to life saving tx. The throat is dull red, and a gray exudate is present on the uvula, pharynx and tongue. The airway may become obstructed. Prompt dx may save

Diphtheria

New onset of dysconjugate gaze in adults usually results from cranial nerve injuries, lesions, or abnormalities form causes such as trauma, multiple sclerosis, syphilis and others

Disorders of Cranial nerves

The lower lid margin turn outward, exposing the palpebral conjuctiva. Punctum of lower lid turns outward causing eye to no longer drain well. TEARING OCCURS. Common in older adults

Ectropion

More common in the elderly inward turning of the lid margin The lower lashes irritate the conjuctiva and lower cornea Ask the patient to squeeze the lids together and then open them, them check for an entropion that is less obvious

Entropion

Localized ocular inflammation of the episcleral vessels. Vessels appear movable over the scleral surface. May be nodular or show only redness and dilated vessels Seen in rheumatoid arthritis, Sjogren Syndrome, and herpes zoster

Episcleritis

Unilateral blindness does not cause anisocoria as long as the sympathetic and parasympathetic innervation to both irises is normal. A light directed into the seeing eye produces a direct rxn in that eye and a consensual rn in the blind eye. A light directed into the blind eye, however, causes no response in either eye.

Equal pupils and one blind eye

Teeth may be eroded by chemical action, exposing the yellow brown dentin. This results from recurrent regurgitation of stomach contents as in bulimia.

Erosion of teeth

Form of strabismus in which one or both eyes turns inward The condition can be constantly present or intermittently "crossed eye"

Esotropia

A 6-year-old child is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with the parents and child? A) Handwashing can prevent the spread of the disease to others. B) The importance of compliance with antibiotic therapy C) Signs and symptoms of complications, such as meningitis and septicemia D) The likely need for surgery to prevent scarring of the conjunctiva

Ans: A Feedback: The nurse must inform the parents and child that viral conjunctivitis is highly contagious and instructions should emphasize the importance of handwashing and avoiding sharing towels, face cloths, and eye drops. Viral conjunctivitis is not responsive to any treatment, including antibiotic therapy. Patients with gonococcal conjunctivitis are at risk for meningitis and generalized septicemia; these conditions do not apply to viral conjunctivitis. Surgery to prevent scarring of the conjunctiva is not associated with viral conjunctivitis.

A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis? A) Ptosis B) Exophthalmos C) Ectropion D) Epicanthus

Ans: B Chapter: 07 Page and Header: 255, Table 7-6 Feedback: Exophthalmos is the condition when the eyeball protrudes forward. If it is bilateral, it suggests the presence of Graves' disease. If it is unilateral, it could still be caused by Graves' disease. Alternatively, it could be caused by a tumor or inflammation in the orbit.

A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. He denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis? A) Dacryocystitis B) Chalazion C) Hordeolum D) Xanthelasma

Ans: C Chapter: 07 Page and Header: 256, Table 7-7 Feedback: A hordeolum, or sty, is a painful, tender, erythematous infection in a gland at the margin of the eyelid.

Physiologic cup is enlarged, occupying more than half of the disc's diameter, at times extending to the edge of the disc. Retinal vessels sink in and under the cup, and may be displaced nasally. Appearance- white, tiny disc vessels absent Seen in optic neuritis, multiple sclerosis, temporal arteritis

Optic Atrophy

Marked arteriolar-venous crossing changes are seen, especially along the inferior vessels. Copper wiring of the arterioles is present. A cotton-wool spot is seen just superior to the disc. Incidental disc drusen are also present but are unrelated to HTN.

Hypertensive Retinopathy

Punctate exudates visible, some scattered, others radiate from the fovea to form a macular star. Cause- severe HTN retinopathy, which is often accompanied by papilledema

Hypertensive Retinopathy with Macular star

Elevated intracranial Pressure Intraaxonal edema along the optic nerve Appearance- pink, hyperemic, loss of venous pulsations, disc vessels more visible, more numerous, curve over the borders of the disc. Disc swolled with margins blurred Physiologic CUP NOT VISIBLE Seen in intracranial mass, lesion, or hemorrhage, meningitis

Papilledema

Perforations are holes in the eardrum, usually from purulent infections of the middle ear. They may be central, if not involving the margin of the drum, or marginal, when the margin is involved. The membrane covering the perforation may be notably thin and transparent. The more common central perforation is illustrated here. A reddened ring of granulation tissue surrounds the perforation, indicating chronic infection. The eardrum itself is scarred, and no landmarks are visible. Discharge from the infected middle ear may drain out through the perforated opening, which ofter closes in the healing process, as in the next photo. There may be associated earache or even hearing loss, especially if the perforations are large.

Perforation of the Eardrum

common during adolescense, early adulthood, and pregnancy. The gingival margins are reddened and swollen, and the interdental papillae are blunted, swollen and red. Brushing the teeth makes gums bleed. Plaque is not visible

Marginal Gingivitis

Myelinated nerve fibers less common finding, but dramatic finding. Irregular white patches with feathered margins, they obscure the disc edge and retinal vessels, No pathologic significance.

Medullated nerve fibers

Tiny, round, red spots commonly seen in and around the macular area. They are minute dilations of very small retinal vessels; the vascular connections are too small to e seen with an ophthalmoscope. a hallmark of DIABETIC RETINOPATHY

Micro-aneurysms

Note tiny red dots or micro-aneurysms note a ring of hard exudates (white spots) located supero-temporally. Retinal thickening ore edema in the area of the hard exudates can impair visual acuity if it extends into the center of the macula. Detection requires specialized stereoscopic examination

Non-proliferative Retinopathy, Moderately Severe

In the superior temporal quadrant, note the large retinal hemorrhage between two cotton-wool patches, beading of the retinal vein just above them, and tiny tortuous retinal vessels above the superior temporal artery.

Non-proliferative Retinopathy, Severe

This normal right eardrum the tympanic membrane is pinkish gray. ote the malleus lying behind the upper part of the drum. Above the short process lies the pars flaccida. The remainder of the drum is the pars tensa. From the umbo, the bright cone of light fans anteriorly and downward. Posterior to the malleus, part of the incus is visible behind the drum. The small blood vessels along the handle of the malleus are normal.

Normal Eardrum (right)

The color of the fundus has a grayish brown, almost purplish cast, which comes from pigment in the retina and the choroid that characteristically obscures the choroidal vessels; no tessellation is visible.

Normal Fundus of a dark-skinned person

Appearance- yellowish orange to creamy pink disc vessels tiny disc margins sharp physiologic cup located centrally or somewhat temporally May be absent. Its diameter from side to side is usually less than half that of the disc.

Normal Optic Disc

The fundus is redder

Normal fundus of a light skinned person

looks gray when seen by a flashlight. If the pupil is widely dilated, the gray opacity is surrounded by a black rim

Nuclear cataract

The pupil is large and fixed to light and near effort. Ptosis of the upper eyelid (due to impaired CNIII) Lateral deviation of the eye downward and outward

Oculomotor Nerve (CN III) Paralysis

Inner ear disorder involves cochlear nerve and neuronal impulse transmission to the brain. Causes include loud noise exposure, inner ear infections, trauma, acoustic neuroma, congenital and familial disorders, and aging Usual age- middle or later years Ear Canal and Drum- problem not visible Effects- higher registers are lost, so sound may be distorted, hearing worsens in noisy environment, voice may be loud because hearing is difficult Weber- Sound lateralizes to good ear-inner ear or cochlear nerve damage impairs transmission to affected ear. Rinne Test- AC longer than BC. The inner ear or cochlear nerve is less able to transmit impulses regardless of how vibrations reach the cochlea. The normal patter prevails.

Sensorineural Loss

caused by viral upper respiratory infections (otitis media with serous effusion) or by sudden changes in atmospheric pressure as from flying or diving (otitic barotrauma). The Eustachian tube cannot equalize the air pressure in the middle ear and outside air. Air is absorbed from the middle ear into the bloodstream, and serous fluid accumulates in the middle ear instead. Sx: fullness and popping sensations in the ear, mild conduction hearing loss, and pain sometimes. Amber fluid behind the eardrum is seen, air bubbles may be seen as well

Serous Effusion

Oral Hairy Leukoplakia

Whitish, raised, symptomatic plaques with a feathery or corrugated pattern most often occurring on the lateral aspect of the tongue Can not be scratched off. Caused by EBV, seen in HIV and AIDS

yellowish, waxy deposits on the upper eyelids, Cholesterol filled plaques on one or both eyelids Half of affected patients have hyperlipidemia, it is also common in primary biliary cirrhosis

Xanthelasma

Yeast infection from Candida. Thick white plaques are somewhat adherent to the underlying mucosa. Caused by prolonged tx with antibiotics or corticosteroids.

Thrush on the palate (Candidiasis)

Pupil is large (dilated), regular, unilateral Rxn to light is reduced severely and slowed or absent Constriction during the near vision is present but slow (tonic) In Bright light affected pupil can't constrict due to parasympathetic denervation. Slow accomodation causes blurred vision

Tonic Pupil (Adie Pupil)

A deposit of uric acid crystals characterized of chronic tophaceous gout. It appears as hard nodules in the helix or anti-helix and may discharge chalky white crystals through the skin. It also may appear near the joints, hands, feet and other areas. It usually develops after chronic sustained high blood levels of uric acid.

Tophi

midline bony growth in the hard palate , fairly common in adults, it is harmless

Torus Palatinus

is a scarring process of the middle ear from otitis media that involves deposition of hyaline and calcium and phosphate crystals in the eardrum and middle ear. When severe it may entrap the ossicles and cause conductive hearing loss. You can see large, chalky white patch with irregular margins. Does not usually impair hearing

Tympanosclerosis

Fissured tongue

benign condition characterized by deep grooves (fissures) in the top surface of the tongue; associated. Food may get stuck in there and become irritating.

inflammation of the pharynx; sore throat; scratchy. Causes: viral and bacterial. If teh patient has no fever, exudate or enlargement of cervical lymph nodes, teh chances of infection by either two common causes Group A streptococci and Epstein Barr virus( mono) are reduced

pharyngitis

1. A primary care provider may suspect cataract formation in a patient with which finding? a. Asymmetric red reflex b. Corneal opacification c. Excessive tearing d. Injection of conjunctiva

ANS: A An asymmetric red reflex may be a finding in a patient with cataracts. Corneal opacification, excessive tearing, and corneal injection are not symptoms of cataracts.

26. A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would: a. Consider this a normal finding. b. Assess the pupillary light reflex for possible blindness. c. Continue with the examination, and assess visual fields. d. Expect that a 2-week-old infant should be able to fixate and follow an object.

ANS: A By 2 to 4 weeks an infant can fixate on an object. By the age of 1 month, the infant should fixate and follow a bright light or toy.

During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling "dry and itchy." Which action by the nurse is correct? a. Assessing the eye for a possible foreign body b. Documenting the finding as ptosis c. Assessing for other signs of ectropion d. Contacting the prescriber; these are signs of basal cell carcinoma

ANS: C The condition described is known as ectropion, and it occurs in older adults and is attributable to atrophy of the elastic and fibrous tissues. The lower lid does not approximate to the eyeball, and, as a result, the puncta cannot effectively siphon tears; excessive tearing results. Ptosis is a drooping of the upper eyelid. These signs do not suggest the presence of a foreign body in the eye or basal cell carcinoma.

35. A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that she may have: a. Macular degeneration. b. Vision that is normal for someone her age. c. The beginning stages of cataract formation. d. Increased intraocular pressure or glaucoma.

ANS: A Macular degeneration is the most common cause of blindness. It is characterized by the loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision. These findings are not consistent with vision that is considered normal at any age.

When a light is directed across the iris of a patient's eye from the temporal side, the nurse is assessing for: a. Drainage from dacryocystitis. b. Presence of conjunctivitis over the iris. c. Presence of shadows, which may indicate glaucoma. d. Scattered light reflex, which may be indicative of cataracts.

ANS: C The presence of shadows in the anterior chamber may be a sign of acute angle-closure glaucoma. The normal iris is flat and creates no shadows. This method is not correct for the assessment of dacryocystitis, conjunctivitis, or cataracts.

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that she may have: a. Macular degeneration. b. Vision that is normal for someone her age. c. The beginning stages of cataract formation. d. Increased intraocular pressure or glaucoma.

ANS: A Macular degeneration is the most common cause of blindness. It is characterized by the loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision. These findings are not consistent with vision that is considered normal at any age.

A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient: a. Has poor vision. b. Has acute vision. c. Has normal vision. d. Is presbyopic.

ANS: A Normal visual acuity is 20/20 in each eye; the larger the denominator, the poorer the vision.

24. In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. On the basis of this finding, the nurse would: a. Suspect that an opacity is present in the lens or cornea. b. Check the light source of the ophthalmoscope to verify that it is functioning. c. Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina. d. Continue with the ophthalmoscopic examination, and refer the patient for further evaluation.

ANS: C The red glow filling the person's pupil is the red reflex and is a normal finding caused by the reflection of the ophthalmoscope light off the inner retina. The other responses are not correct.

22. When assessing the pupillary light reflex, the nurse should use which technique? a. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction. b. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction. c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. d. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose.

ANS: C To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction.

32. In a patient who has anisocoria, the nurse would expect to observe: a. Dilated pupils. b. Excessive tearing. c. Pupils of unequal size. d. Uneven curvature of the lens.

ANS: C Unequal pupil size is termed anisocoria. It normally exists in 5% of the population but may also be indicative of central nervous system disease.

Which are risk factors for development of cataracts? (Select all that apply.) a. Advancing age b. Cholesterol c. Conjunctivitis d. Smoking e. Ultraviolet light

ANS: A, D, E Most older adults will develop cataracts. Smoking and UV light exposure hasten the development of cataracts. Cholesterol and conjunctivitis are not risk factors.

A patient has an elevated, yellowish-white lesion adjacent to the cornea at the 3 o'clock position of the right eye. The provider notes pinkish inflammation with dilated blood vessels surrounding the lesion. What will the provider tell the patient about this lesion? A. artificial tear drops are contraindicated B. spontaneous bleeding is likely C. UVB eye protection is especially important D. Visine may be used for symptomatic relief

ANS: C This patient has a pinguecula which has become inflamed. Wide- brimmed hats and sunglasses wit UVB protection should be advised since UVB light will make this worse. Artificial tear drops are recommended to reduce irritation. Therese types of lesions typically do not bleed spontaneously. Visine is contraindicated because chronic vasoconstriction may lead to rebound inflammation

A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a: a. Chalazion. b. Hordeolum (stye). c. Dacryocystitis. d. Blepharitis.

ANS: B A hordeolum, or stye, is a painful, red, and swollen pustule at the lid margin. A chalazion is a nodule protruding on the lid, toward the inside, and is nontender, firm, with discrete swelling. Dacryocystitis is an inflammation of the lacrimal sac. Blepharitis is inflammation of the eyelids

The nurse is performing the diagnostic positions test. Normal findings would be which of these results? a. Convergence of the eyes b. Parallel movement of both eyes c. Nystagmus in extreme superior gaze d. Slight amount of lid lag when moving the eyes from a superior to an inferior position

ANS: B A normal response for the diagnostic positions test is parallel tracking of the object with both eyes. Eye movement that is not parallel indicates a weakness of an extraocular muscle or dysfunction of the CN that innervates it.

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? a. Decrease in tear production b. Unequal pupillary constriction in response to light c. Presence of arcus senilis observed around the cornea d. Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles

ANS: B Pupils are small in the older adult, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric. The assessment findings in the other responses are considered normal in older persons.

The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true? a. The right side of the brain interprets the vision for the right eye. b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. c. Light rays are refracted through the transparent media of the eye before striking the pupil. d. Light impulses are conducted through the optic nerve to the temporal lobes of the brain.

ANS: B The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The light rays are refracted through the transparent media of the eye before striking the retina, and the nerve impulses are conducted through the optic nerve tract to the visual cortex of the occipital lobe of the brain. The left side of the brain interprets vision for the right eye

The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia? a. Degeneration of the cornea b. Loss of lens elasticity c. Decreased adaptation to darkness d. Decreased distance vision abilities .

ANS: B The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia

The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia? a. Degeneration of the cornea b. Loss of lens elasticity c. Decreased adaptation to darkness d. Decreased distance vision abilities

ANS: B The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia.

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that: a. At 30 feet the patient can read the entire chart. b. The patient can read at 20 feet what a person with normal vision can read at 30 feet. c. The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye. d. The patient can read from 30 feet what a person with normal vision can read from 20 feet.

ANS: B The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.

A patient reports using artificial tears for comfort because of burning and itching in both eyes but reports worsening symptoms. The provider notes redness and discharge along the eyelid margins with clear conjunctivae. What is the recommended treatment? a. Antibiotic solution drops four times daily b. Warm compresses, lid scrubs, and antibiotic ointment c. Oral antibiotics given prophylactically for several months d. Reassurance that this is a self-limiting condition

ANS: B This patient has symptoms of blepharitis without conjunctivitis. Initial treatment involves lid hygiene and antibiotic ointment may be applied after lid scrubs. Antibiotic solution is used if conjunctivitis is present. Oral antibiotics are used for severe cases. This disorder is generally chronic.

33. A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include: a. Loss of central vision. b. Shadow or diminished vision in one quadrant or one half of the visual field. c. Loss of peripheral vision. d. Sudden loss of pupillary constriction and accommodation.

ANS: B With retinal detachment, the person has shadows or diminished vision in one quadrant or one half of the visual field. The other responses are not signs of retinal detachment.

A mother asks when her newborn infant's eyesight will be developed. The nurse should reply: a. "Vision is not totally developed until 2 years of age." b. "Infants develop the ability to focus on an object at approximately 8 months of age." c. "By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object." d. "Most infants have uncoordinated eye movements for the first year of life."

ANS: C Eye movements may be poorly coordinated at birth, but by 3 to 4 months of age, the infant should establish binocularity and should be able to fixate simultaneously on a single image with both eyes.

30. The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should: a. Check for the presence of exophthalmos. b. Suspect that the patient has hyperthyroidism. c. Ask the patient if he or she has a history of heart failure. d. Assess for blepharitis, which is often associated with periorbital edema.

ANS: C Periorbital edema occurs with local infections, crying, and systemic conditions such as heart failure, renal failure, allergy, and hypothyroidism. Periorbital edema is not associated with blepharitis.

A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? a. Perform the confrontation test. b. Assess the individual's near vision. c. Observe the distance between the palpebral fissures. d. Perform the corneal light test, and look for symmetry of the light reflex.

ANS: C Ptosis is a drooping of the upper eyelid that would be apparent by observing the distance between the upper and lower eyelids. The confrontation test measures peripheral vision. Measuring near vision or the corneal light test does not check for ptosis.

Smooth Tongue (Atrophic Glossitis)

A smooth and often sore tongue that has lost its papillae suggests a deficiency in riboflavin, niacin, folic acid, vitamin B12, pyridoxine, or iron, or treatment with chemotherapy.

36. A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion? a. Smooth and clear corneas b. Opacity of the lens behind the cornea c. Bleeding from the areas across the cornea d. Shattered look to the light rays reflecting off the cornea

ANS: D A corneal abrasion causes irregular ridges in reflected light, which produce a shattered appearance to light rays. No opacities should be observed in the cornea. The other responses are not correct.

Which assessment alerts the nurse to the possible presence of a cataract in a client? a. Loss of central vision b. Loss of peripheral vision c. Dull aching in the eye and brow areas d. Blurred vision and reduced color perception

ANS: D As the lens becomes opaque and less able to refract light appropriately, the client experiences blurred vision and a reduced ability to distinguish among different colors. The development of a cataract does not typically cause loss of peripheral or central vision, nor does it result in aching in the brow area.

A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should: a. Examine the retina to determine the number of floaters. b. Presume the patient has glaucoma and refer him for further testing. c. Consider these to be abnormal findings, and refer him to an ophthalmologist. d. Know that floaters are usually insignificant and are caused by condensed vitreous fibers.

ANS: D Floaters are a common sensation with myopia or after middle age and are attributable to condensed vitreous fibers. Floaters or spots are not usually significant, but the acute onset of floaters may occur with retinal detachment.

Candidiasis

(white, cheesy, curdlike patch on buccal mucosa due to superficial fungal infection, can be scratched off with a tongue depressor.

Formation of new blood vessels. They are more numerous, more tortuous, and narrower than neighboring blood vessels in the area and form disorderly looking red arcades. A common feature of the proliferative stage of DIABETIC Retinopathy. The vessels may grow into the vitreous, where retinal detachment or hemorrhage may cause loss of vision

Neovascularization

The nurse is testing a patient's visual accommodation, which refers to which action? a. Pupillary constriction when looking at a near object b. Pupillary dilation when looking at a far object c. Changes in peripheral vision in response to light d. Involuntary blinking in the presence of bright light ANS: A The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The other responses are not correct.

ANS: A The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The other responses are not correct.

25. The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal? a. Optic disc that is a yellow-orange color b. Optic disc margins that are blurred around the edges c. Presence of pigmented crescents in the macular area d. Presence of the macula located on the nasal side of the retina

ANS: A The optic disc is located on the nasal side of the retina. Its color is a creamy yellow-orange to a pink, and the edges are distinct and sharply demarcated, not blurred. A pigmented crescent is black and is due to the accumulation of pigment in the choroid.

During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? Select all that apply. a. Patient may experience sensitivity to light, nausea, and halos around lights. b. Patient experiences tunnel vision in the late stages. c. Immediate treatment is needed. d. Vision loss begins with peripheral vision. e. Open-angle glaucoma causes sudden attacks of increased pressure that cause blurred vision. f. Virtually no symptoms are exhibited.

ANS: B, D, F Open-angle glaucoma is the most common type of glaucoma; virtually no symptoms are exhibited. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed-angle glaucoma.

A patient has a gradually enlarging nodule on one upper eyelid and reports that the lesion is painful. On examination, the lesion appears warm and erythematous. The provider knows that this is likely to be which type of lesion? a. Blepharitis b. Chalazion c. Hordeolum d. Meibomian

ANS: C Although hordeolum and chalazion lesions both present as gradually enlarging nodules, a hordeolum is usually painful, while a chalazion generally is not. Blepharitis refers to generalized inflammation of the eyelids. Meibomian is a type of gland near the eye.

4. When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system: a. Causes pupillary constriction. b. Adjusts the eye for near vision. c. Elevates the eyelid and dilates the pupil. d. Causes contraction of the ciliary body.

ANS: C Stimulation of the sympathetic branch of the autonomic nervous system dilates the pupil and elevates the eyelid. Parasympathetic nervous system stimulation causes the pupil to constrict. The muscle fibers of the iris contract the pupil in bright light to accommodate for near vision. The ciliary body controls the thickness of the lens.

27. The nurse is assessing color vision of a male child. Which statement is correct? The nurse should: a. Check color vision annually until the age of 18 years. b. Ask the child to identify the color of his or her clothing. c. Test for color vision once between the ages of 4 and 8 years. d. Begin color vision screening at the child's 2-year checkup.

ANS: C Test boys only once for color vision between the ages of 4 and 8 years. Color vision is not tested in girls because it is rare in girls. Testing is performed with the Ishihara test, which is a series of polychromatic cards.

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed? a. Perform the confrontation test. b. Ask the patient to read the print on a handheld Jaeger card. c. Use the Snellen chart positioned 20 feet away from the patient. d. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches.

ANS: C The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision.

A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next? a. Refer the patient to an ophthalmologist or optometrist for further evaluation. b. Assess whether the patient can count the nurse's fingers when they are placed in front of his or her eyes. c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again. d. Shorten the distance between the patient and the chart until the letters are seen, and record that distance.

ANS: D If the person is unable to see even the largest letters when standing 20 feet from the chart, then the nurse should shorten the distance to the chart until the letters are seen, and record that distance (e.g., "10/200"). If visual acuity is even lower, then the nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight. If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but the nurse must first assess the visual acuity.

The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure? a. Thickness or bulging of the lens b. Posterior chamber as it accommodates increased fluid c. Contraction of the ciliary body in response to the aqueous within the eye d. Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber

ANS: D Intraocular pressure is determined by a balance between the amount of aqueous produced and the resistance to its outflow at the angle of the anterior chamber. The other responses are incorrect.

During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus? a. Presence of tears along the inner canthus b. Blocked nasolacrimal duct in a newborn infant c. Slight swelling over the upper lid and along the bony orbit if the individual has a cold d. Absence of drainage from the puncta when pressing against the inner orbital rim

ANS: D No swelling, redness, or drainage from the puncta should be observed when it is pressed. Regurgitation of fluid from the puncta, when pressed, indicates duct blockage. The lacrimal glands are not functional at birth.

37. An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates: a. Retinal detachment. b. Diabetic retinopathy. c. Acute-angle glaucoma. d. Increased intracranial pressure.

ANS: D Papilledema, or choked disk, is a serious sign of increased intracranial pressure, which is caused by a space-occupying mass such as a brain tumor or hematoma. This pressure causes venous stasis in the globe, showing redness, congestion, and elevation of the optic disc, blurred margins, hemorrhages, and absent venous pulsations. Papilledema is not associated with the conditions in the other responses.

28. The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a "lazy eye" and should: a. Examine the external structures of the eye. b. Assess visual acuity with the Snellen eye chart. c. Assess the child's visual fields with the confrontation test. d. Test for strabismus by performing the corneal light reflex test.

ANS: D Testing for strabismus is done by performing the corneal light reflex test and the cover test. The Snellen eye chart and confrontation test are not used to test for strabismus.

23. The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding? a. Dilation of the pupils b. Consensual light reflex c. Conjugate movement of the eyes d. Convergence of the axes of the eyes

ANS: D The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes. The other responses are not correct.

A 15-year-old high school sophomore presents to the emergency room with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light, with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis? A) Conjunctivitis B) Acute iritis C) Corneal abrasion D) Subconjunctival hemorrhage

Ans: D Chapter: 07 Page and Header: 257, Table 7-8 Feedback: A subconjunctival hemorrhage is a leakage of blood outside of the vessels, which produces a homogenous, sharply demarcated bright red area; it fades over several days, turning yellow, then disappears. There is no associated eye pain, ocular discharge, or changes in visual acuity; the cornea is clear. Many times it is associated with severe cough, choking, or vomiting, which increase venous pressure. It is rarely caused by a serious condition, so reassurance is usually the only treatment necessary.

On routine screening you notice that the cup-to-disc ratio of the patient's right eye is 1:2. What ocular condition should you suspect? A) Macular degeneration B) Diabetic retinopathy C) Hypertensive retinopathy D) Glaucoma

Ans: D Chapter: 20 Page and Header: 918, Techniques of Examination Feedback: This cup-to-disc ratio means that the cup takes up 50% of the disc, which is abnormally large. This is usually an indication of glaucoma, which is a common cause of visual loss in the elderly. The cup-to-disc changes are not seen in diabetes, hypertension, or macular degeneration. Many elderly do not have regular eye examinations and are not screened for glaucoma.

small, irregular pupils usually bilaterally Constrict with near vision and dilate with far vision (normal near rxn) BUT DO NOT REACT TO LIGHT. Seen in neurosyphillis and rarely in diabetes

Argyll Robertson Pupils

In many elderly people the chewing surfaces of the teeth are worn downby repetetive use

Attrition of teeth; Recession of Gums

Chronic inflammation of the eyelids at the base of the hair follicles. INFLAMMATION OF THE EYELIDS Often from S.aureus. There is also scaling seborrheic variant

Blepharitis

Painful hemorrhagic vesicles appear on the tympanic membrane, the ear canal or both. Sx: earache, blood-tinged discharge from teh ear, and conductive hearing loss Caused by mycoplasma, viral, and bacterial otitis media

Bullous Myringitis

Opacity of the lenses visible through the pupil Risk factor are older age, smoking, diabetes, corticosteroid use

Cataracts

A subacute non-tender, usually painless nodule caused by a blocked meibomian gland. May become acutely inflamed but, unlike a stye, usually points inside the lid rather than on the lid margin

Chalazion

This chronic inflammatory lesion starts as a painful, tender papule on the helix or antihelix. Here the upper lesion is at a later stage of ulceration and crusting. Reddening may occur. Biopsy is needed to rule out carcinoma

Chondrodermatitis Helicis

External or middle ear disorder impairs sound conduction to inner ear. Causes: foreign body, otitis media, perforated eardrum, and otosclerosis of ossicles. age- child and young adult up to age 40 Ear canal and drum- usually visible, except in otosclerosis Little effect on sound, hearing seems to improve in noise environment, voice remains soft because inner ear and cochlear nerve are intact Tuning fork at vertex Weber test- Sound lateralizes to impaired ear- room noise not well heard. so detection of vibrations improves Rinne- BC longer than or equal to AC . WHile air conduction through the external or middle ear is impaired, vibrations through bone bypass the problem to reach the cochlea.

Conductive Loss

Conjunctival injection, diffuse dilation of conjuctival vessels with redness that tends to be maximal peripherally Pain- mild Vision- not affected except for mild blurring due to discharge Ocular discharge- watery, mucoid, or muco-purulent pupil-not affected cornea-clear significance- bacterial, viral, and other infections, highly contagious, allergy, irritation

Conjunctivitis

Thin grayish white arc or circle not quite at the edge of the cornea. Accompanies normal aging but also seen in younger adults, especially African Americans. In young adults, suggests possible hyper-lipoproteinemia. Usually Benign

Corneal Arcus

pain- moderate to severe, superficial Vision- usually decreased Ocular discharge- watery or purulent Pupil- not affected unless iritis develops Cornea- changes depending on cause significance- abrasions, and other injuries, viral, and bacterial infections

Corneal Injury or Infection

Ciliary injection Vessels from limbus are dilated - reddish violet flush Ciliary injection is an important sign of these three conditions, but is not always visible pain, decrease vision, unequal pupils, and clouded cornea

Corneal Injury or Infection Acute Iritis Acute Angle Closure-Glaucoma

Superficial grayish white opacity in teh cornea, secondary to an old injury or to inflammation. Size and shape are variable. Do not confuse with the opaque lens of a cataract, visible on a deeper plane and only through the pupil

Corneal Scar

Sebaceous cyst, a dome-shaped lump in the dermis forms a benign lump closed firm sac attached to the epidermis. A dark dot (black head) may be visible on its surface. Histologically, it is usually either (1) epidermoid cyst, common on the face and neck or (2) a pilar trichilemmal) cyst common in the scalp. Both may become inflamed.

Cutaneous Cyst

Small, rounded, slightly irregular red spots that are sometimes called dot or blot hemorrhages. They occur in a deeper layer on the retina than flame-shaped hemorrhages. DIABETES is a common cause.

Deep Retinal Hemorrhages

Dysconjugate gaze- imbalance in ocular muscle tone Causes: may be hereditary, usually appears in early childhood Classified according to direction.

Developmental disorders

Yellowish round spots that vary from tiny to small. The edges may be soft, as here, or hard. They are haphazardly distributed but may concentrate at the posterior pole between the optic disc and the macula. Consists of dead retinal pigment epithelial cells. Seen in normal aging and age-related macular degeneration.

Drussen

Wide eye stare suggest retracted eyelids Rim of Sclera between upper lid and the iris is visible Retracted lids and lid lag when eyes move from up to down - markedly increase the likelihood for hyperthyroidism especially when accompanied with fine tremor, most skin, and heart rate > 90 bpm. Protrusion of the eyeball Seen in Graves triggered by auto-reactive T-lymphocytes (dry eye, ocular pain, lacrimation. In unilateral exophthalmos consider Graves Disease (thought usually bilateral), trauma , orbital tumor, and granulomatous disorders.

Exophthalmos and Lid Retraction " Lid Lag"

Form of strabismus (eye misalignment) in which one or both of the eyes turn outward, may occur from time to time or may be constant. Found in every age group

Exotropia

-Red throat with white exudate on tonsils -Fever, enlarged cervical nodes = Group A strep or mono Anterior cervical lymph-nodes are usually enlarged in the former, posterior nodes in the latter.

Exudative tonsilitis

Normal sebaceous glands that appear as small yellowish spots in the buccal mucosa or the lips

Fordyce Spots (fordyce Granules)

geographic tongue

Geographic tongue is a harmless (benign) oral condition that gives your tongue a map-like, or geographic, appearance. The distinct look of geographic tongue occurs when parts of your tongue are missing the layer of small bumps called papillae. This causes irregularly shaped smooth, red patches to form on parts of your tongue, like a rash.

Gums enlarged by hyperplasia are swollen into heaped-up masses that may even cover the teeth. The redness of inflammation may coexist. Causes- phenytoin therapy, puberty, pregnancy, and leukemia.

Gingival Hyperplasia

Increased intraocular pressure within the eye leads to increased cupping (backward depression of the disc) and atrophy. The base of the enlarged cup is pale Appearance- death of optic nerve fibers leads to loss of the tiny disc vessels

Glaucomatous Cupping

Black hairy tongue

Hairy yellowish to brown and black hypertrophied and elongated papillae on the tongue's dorsum. Condition associated with candida and bacterial overgrowth, antibiotic therapy and poor dental hygiene.

Creamy or yellowish, often bright, lesions with well-defined "hard" borders. They are small and round but may coalesce into larger irregular spots. They often occur in clusters or in circular, linear, or star-shaped patterns. They are lipi residues of serous leakage from damaged capillaries. Causes include DIABETES and VASCULAR DYSPLASIAS

Hard Exudates

here inflammation has destroyed the superficial tissues to reveal a well - defined, irregular patch of white sclera marked with dark pigment. Size varies from small to very large. Toxoplasmosis is illustrated. Multiple, small, somewhat similar looking areas may be due to laser tx. Here there is also a temporal scar bear the macula.

Healed Chorioretinitis

Affected pupil is small, unilateral, reacts briskly to light and near effort, but dilates slowly, especially in dim light. Anisocoria is > 1mm, with ipsilateral ptosis of the eyelid loss of sweating of the forhead Classic triad: miosis, ptosis, and anhydrosis Lesion on sympathetic pathway IN DIM LIGHT SMALLER PUPIL CAN"T DILATE Causes: ipsilateral brainstem lesions, neck and chest tumors affecting the ipsilateral sympathetic ganglia, orbital trauma or migraines In congenital disease- the involved iris is lighter in color than its fellwo (heterochromia)

Horner Syndrome

smaller and more widely spaced than normal and are notched on their bitting surfaces. Sign of congenital syphilis

Hutchinson teeth in congenital syphilis

deep purple color low grade vascular tumor associated with human herpesvirus 8. Raised/flat lesions

Kaposi Sarcoma

A golden to red brown ring, sometimes shading to green or blue, from copper deposition in the periphery of the cornea found in Wilson disease. Due to rare autosomal recessive mutation of the ATO7B gene on chromosome 13, causing abnormal copper transport, reduced biliary copper excretion, and abnormal accumulation of copper in the liver and tissues throughout the body. Patients present with liver disease, renal failure, and neurologic symptoms of tremor, dystonia, and a variety of psychiatric disorders.

Kayser-Fleischer Ring

A firm nodular , hypertrophic mass of scar tissue extending beyond the area of injury. It may develop in any scarred area but is most common on the shoulders and upper chest. A keloid on a pierced earlobe may have unwanted cosmetic effects. keloids are more common in darker skinned people and may recur following treatment.

Keloid

Early sign of measles (Rubeola), looks like grains of salt on red background on tongue:

Koplik Spots

Normal tonsils may be large without being infected, especially in children. They may protrude medially beyond teh pillars and even to the midline. Here they touch the sides of the uvula and obscure the pharynx. Color is pink.

Large Normal Tonsils

Sub-conjuctival Hemorrhage

Leakage of blood outside of the vessels, producing a homogeneous, sharply demarcated, red area that resolves over 2 wks. pain-absent vision- not affected ocular discharge- absent pupil- not affected cornea-clear Significance- often non, may result from trauma, bleeding disorders, or sudden increase in venous pressure, as from cough

Looking straight ahead- the eye is pulled outward by action of the CN VI. Upward, downward, and inward movements are impaired or lost Ptosis and pupillary dilation may be associated

Left Cranial Nerve III paralysis

Looking down and to the right- Lt eye cannot look down when turned inward, deviation is maximum in this direction

Left Cranial Nerve IV (4) Paralysis

Looking to the right- eyes are conjugate lookin straight ahead- esotropia appears looking to the right- esotropia is maximum

Left Cranial nerve VI (6) paralysis

A thickened white patch may occur anywhere in the oral mucosa. Causes- frequent tobacco chewing or local irritant. Is a benign process but may lead to cancer and should be biopsied, another risk factor is HPV.

Leukoplakia

Produces spoke-like shadows that point gray against black, as seen with a flashlight, or black against red with an ophthalmoscope. A dilated pupil, as shown here, facilitates this observation.

Peripheral Cataract

red spots caused by blood that escapes from capillaries into the tissues. Often caused by accidentally bitting the cheek.

Petechiae

is a small whitish depression in the optic disc, the entry point for the retinal vessels. The cup may be absent at times, usually visible either centrally or toward the temporal side of the disc Grayish spots are often seen at its base.

Physiologic cupping

Harmless yellowish triangular nodule in the bulbar conjuctiva on either side of the iris. Appears frequently with aging, first on the nasal then on the temporal side

Pinguecula

Develops when blood escapes into the potential space between the retina and vitreous. Larger than retinal hemorrhages. Because it is anterior to the retina, it obscures any underlying retinal vessels. In an erect patient, red cells settle, creating a horizontal line of demarcation between plasma above and cells below. Causes: include a sudden increase in ICP.

Pre-retinal Hemorrhage

Red purple papules of granulation tissue form in the gingival interdental papillae, in the nasal cavity, and sometimes on the fingers. They are red, soft, painless, and usually bleed easily. They occur in 1% to 5% of pregnancies and usually regress after delivery

Pregnancy Tumor (Pregnancy Epulis or Pyogenic Granuloma)

This is the same eye, but 2 years later and without tx. Neo-vascularization has increased, now with fibrous proliferations, distortion of the macula, and reduced visual acuity.

Proliferative Retinopathy, Advanced

Note new pre-retinal vessels arising on the disc and extending across the disc margins. visual acuity is still normal, but the risk for visual loss is high. Photocoagulation reduces the risk by > 50%.

Proliferative Retinopathy, with Neo-vascularization

Drooping of the upper eyelid. Causes- Myasthenia gravis, damage to to oculomotor nerve CN: III, damage to the sympathetic nerve supply (Horner syndrome). A weakened muscle, relaxed tissues, and the weight of herniated fat may cause senile ptosis. Ptosis may also be congenital.

Ptosis

chronic rheumatoid arthritis, look for small lumps on the helix or anti-helix and additional nodules elsewhere on the hands and along the surface of the ulna distal to the elbow, and on the knees and heels. Ulceration may result from repeated injuries. These nodules may antedate the arthritis.

Rheumatoid Nodules

Cover-uncover test Corneal reflections are asymmetric (uncovered) Covered left eye-the right eye moves outward to fix on the light, Lt eye moves inward to the same degree Uncover- the Lt eye moves outward to fix on the light and the Rt eye deviates inward again.

Right monocular esotropia

Seen around optic disc Developmental variations appear as either white sclera, black retinal pigment, or both along temporal border of disc.

Rings and Crescents

Cotton-wool patches are white or grayish, ovoid lesions with irregular soft borders. They are moderate in size but usually smaller than the disc. They result from extruded axoplasm from retinal ganglion cells caused by micro-infarcts of the retinal nerve fiber layer. Seen in HTN, DIABETES, HIV, and other viruses.

Soft Exudates: Cotton- Wool Patches

A painful, tender, re infection at the inner or outer margin of the eyelid, usually from staphylococcus aureus ( at the inner margin- from an obstructed meibomian gland; at the outer margin-from an obstructed eyelash follicle or tear gland

Stye (Hodeolum)

Small, linear, flame-shaped, red streaks in the fundi, shaped by the superficial bundles of nerve fibers that radiate from the optic disc in the pattern illustrated (o=optic disc; F= fovea). Sometimes the hemorrhages occur in clusters. Seen in severe HTN, papilledema, and occlusion of the retinal vein, among other conditions. An occasional superficial hemorrhage has a white center consisting of fibrin, which has many causes.

Superficial Retinal Hemorrhages