ch 16- assessing eyes

strabismus (tropia)

A constant malalignment of the eye axis, strabismus is defined according to the direction toward which the eye drifts and may cause amblyopia.

corneal abnormalities

A corneal scar, which appears grayish white, usually is due to an old injury or inflammation. Early pterygium, a thickening of the bulbar conjunctiva that extends across the nasal side.

mydriasis

Dilated and fixed pupils, typically resulting from central nervous system injury, circulatory collapse, or deep anesthesia.

eye discharge

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

double vision (diplopia)

Double vision (diplopia) may indicate increased intracranial pressure due to injury or a tumor.

inspect eyelids and eyelashes

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. Failure of lids to close completely puts client at risk for corneal damage. An inverted lower lid is a condition called an entropion, which may cause pain and injure the cornea as the eyelash brushes against the conjunctiva and cornea. Ectropion, an everted lower eyelid, results in exposure and drying of the conjunctiva. Both conditions (see Abnormal Findings 16-3) interfere with normal tear drainage. Redness and crusting along the lid margins suggest seborrhea or blepharitis, an infection caused by Staphylococcus aureus. Hordeolum (stye), a hair follicle infection, causes local redness, swelling, and pain. A chalazion, an infection of the meibomian gland (located in the eyelid), may produce extreme swelling of the lid, moderate redness, but minimal pain Though usually abnormal, entropion and ectropion are common in older clients.

glaucoma

Enlarged physiologic cup occupying more than half of the disc's diameter Pale base of enlarged physiologic cup Obscured and/or displaced retinal vessels

excessive watering or tearing of the eye. In one eye or both eyes

Excessive tearing (epiphora) is caused by exposure to irritants or obstruction of the lacrimal apparatus. Unilateral epiphora is often associated with foreign body or obstruction. Bilateral epiphora is often associated with exposure to irritants, such as makeup or facial cleansers, or it may be a systemic response.

do you wear sunglasses?

Exposure to ultraviolet radiation puts the client at risk for the development of cataracts (opacities of the lenses of the eyes). Consistent use of sunglasses during exposure minimizes the client's risk.

palpate the lacrimal apparatus

Expressed drainage from the puncta on palpation occurs with duct blockage.

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.

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. During the vision test, note any client behaviors (i.e., leaning forward, head tilting, or squinting) that could be unconscious attempts to see better.

jaegar test

Near vision is assessed in clients over 40 years of age by holding the pocket screener (Jaeger test) or newspaper print 14 in from the eye. Clients who have decreased accommodation to view closer print will have to move the card or newspaper further away to see it.

trouble seeing at night

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

Psuedostrabismus

Normal in young children, the pupils will appear at the inner canthus (due to the epicanthic fold).

chalazion

infected meibomian gland

conjuctivitis

inflammation of the conjunctiva (pink eye)

diffuse episcleritis

inflammation of the sclera

entropion

inward turning of the rim of the eyelid

ectropion

outwardly turned lower lid

exopthalmos

protruding eyeballs and retracted eyelids

blepharitis

staphylococcal infection of the eyelid

hordeolum

(stye) red, painful pustule that is a localized infection of hair follicle at eyelid margin

do you have 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.

assess the red reflex

Abnormalities of the red reflex most often result from cataracts. These usually appear as black spots against the background of the red light reflex. Two types of age-related cataracts are nuclear cataracts and peripheral cataracts The red reflex should be easily visible through the ophthalmoscope. The red area should appear round, with regular borders.

when was your last eye exam?

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. 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.

miosis

Also known as pinpoint pupils, miosis is characterized by constricted and fixed pupils—possibly a result of narcotic drugs or brain damage.

cotton wool patches

Also known as soft exudates, cotton wool patches have a fluffy cotton ball appearance, with irregular edges. Appear as white or gray moderately sized spots on retinal background Caused by arteriole microinfarction Associated with diabetes mellitus and hypertension

irregularly shaped iris

An irregularly shaped iris causes a shallow anterior chamber, which may increase the risk for narrow-angle (closed-angle) glaucoma.

anisocoria

Anisocoria is pupils of unequal size. In some cases, the condition is normal; in other cases, it is abnormal. For example, if anisocoria is greater in bright light compared with dim light, the cause may be trauma, tonic pupil (caused by impaired parasympathetic nerve supply to iris), and oculomotor nerve paralysis. If anisocoria is greater in dim light compared with bright light, the cause may be Horner syndrome (caused by paralysis of the cervical sympathetic nerves and characterized by ptosis, sunken eyeball, flushing of the affected side of the face, and narrowing of the palpebral fissure).

superficial (flame-shaped) retinal hemorrhages

Appear as small, flame-shaped, linear red streaks on retinal background Hypertension and papilledema are common causes.

deep (dot-shaped) retinal hemorrhages

Appear as small, irregular red spots with blurred edges on retinal background Lie deeper in retina than superficial retinal hemorrhages Associated with diabetes mellitus

inspect the cornea and lens

Areas of roughness or dryness on the cornea are often associated with injury or allergic responses. Opacities of the lens are seen with cataracts Arcus senilis, a normal condition in older clients, appears as a white arc around the limbus (Fig. 16-17). The condition has no effect on vision.

arteriovenous nicking, tapering, and banking

Arteriovenous crossing abnormality characterized by vein appearing to stop short on either side of arteriole Caused by loss of arteriole wall transparency from hypertension

subconjunctival hemmorhage

Bright red patches in conjunctiva of eyes due to ruptured blood vessels

eye pain or itching? Pain with bright lights (photophobia)

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.

inspect the retinal vessels

Changes in the blood supply to the retina may be observed in constricted arterioles, dilated veins, or absence of major vessels. Initially hypertension may cause a widening of the arterioles' light reflex and the arterioles take on a copper color. With long-standing hypertension, arteriole walls thicken and appear opaque or silver. Arterial nicking, tapering, and banking are abnormal AV crossings caused by hypertension or arteriosclerosis

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.

Inspect retinal background

Cotton-wool patches (soft exudates) and hard exudates from diabetes and hypertension appear as light-colored spots on the retinal background. Hemorrhages and microaneurysms appear as red spots and streaks on the retinal background

Inspect the palpebral conjunctiva

Cyanosis of the lower lid suggests a heart or lung disorder. A foreign body or lesion may cause irritation, burning, pain, and/or swelling of the upper eyelid. This procedure is stressful and uncomfortable for the client. It is usually only done if the client complains of pain or "something in the eye."

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

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 Nystagmus—an oscillating (shaking) movement of the eye—may be associated with an inner ear disorder, multiple sclerosis, brain lesions, or narcotics use. A couple of oscillating movements of nystagmus at extreme lateral gaze is considered normal.

inspect the bulbar conjunctive and sclera

Generalized redness of the conjunctiva suggests conjunctivitis (pink eye). Areas of dryness are associated with allergies or trauma. Episcleritis is a local, noninfectious inflammation of the sclera. The condition is usually characterized by either a nodular appearance or by redness with dilated vessels (see Abnormal Findings 16-3). Yellow sclera occurs when the client has jaundice or icterus. Bright red areas on the sclera indicate a subconjunctival hemorrhage. These are often caused by sneezing, coughing, or vomiting, which may break a blood vessel. This may lead to accumulation of trapped blood, which is not quickly absorbed. It is harmless and disappears in 1-2 wks Yellowish nodules on the bulbar conjunctiva are called pinguecula. These harmless nodules are common in older clients and appear first on the medial side of the iris and then on the lateral side.

inspect anterior chamber

Hyphemia occurs when injury causes red blood cells to collect in the lower half of the anterior chamber Hypopyon usually results from an inflammatory response in which white blood cells accumulate in the anterior chamber and produce cloudiness in front of the iris

e chart

If the client cannot read or has a handicap that prevents verbal communication, the E chart is used. The E chart is configured just like the Snellen chart but the characters on it are only Es, which face in all directions. The client is asked to indicate by pointing which way the open side of the E faces. If the client wears glasses, they should be left on, unless they are reading glasses (reading glasses blur distance vision).

test pupillary reaction to light

Monocular blindness can be detected when light directed to the blind eye results in no response in either pupil. When light is directed into the unaffected eye, both pupils constrict.

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

Unilateral blindness (e.g., blind right eye)

Lesion in (right) eye or (right) optic nerve

Right visual field loss—right homonymous hemianopia or similar loss of vision in half of each field

Lesion in right optic tract or lesion in temporal loop (optic radiation)

Bitemporal hemianopia (loss of vision in both temporal fields)

Lesion of optic chiasm

describe typical diet

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

phoria (mild weakness)

Noticeable only with the cover test, phoria is less likely to cause amblyopia than strabismus. Esophoria is an inward drift and exophoria an outward drift of the eye.

paralytic strabismus

Noticeable with the positions test, paralytic strabismus is usually the result of weakness or paralysis of one or more extraocular muscles. The nerve affected will be on the same side as the eye affected (for instance, a right eye paralysis is related to a right-side cranial nerve). The position in which the maximum deviation appears indicates the nerve involved. 6th nerve paralysis: The eye cannot look to the outer side A client with left 4th nerve paralysis looks down and to the right. In left 6th nerve paralysis, the client tries to look to the left. The right eye moves left, but the left eye cannot move left. A client with left 3rd nerve paralysis looks straight ahead. 4th nerve paralysis: The eye cannot look down when turned inward.

nuclear cataract

Nuclear cataracts appear gray when seen with a flashlight; they appear as a black spot against the red reflex when seen through an ophthalmoscope.

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

silver wire arteriole

Opaque or silver appearance caused by thickening of arteriole wall Occurs with long-standing hypertension

Left superior quadrant anopia or similar loss of vision (homonymous) in quadrant of each field

Partial lesion of temporal loop (optic radiation)

peripheral cataracts

Peripheral cataracts look like gray spokes that point inward when seen with a flashlight; they look like black spokes that point inward against the red reflex when seen through an ophthalmoscope.

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

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 Presbyopia is a common condition in clients over 45 years of age.

redness or swelling in the eyes?

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

In the case of blunt eye trauma, observe for: Lid swollen shut Blood in anterior chamber White/hazy cornea Irregularly shaped, fixed, dilated, or constricted pupil

Refer client to eye doctor immediately if eye is swollen, blood is observed in anterior chamber, cornea is hazy, or pupils are irregularly shaped, fixed, dilated, or constricted. See a list of common eye injuries and need for referral, especially if injury needs immediate emergency referral (Cleveland Clinic, n.d.)

In the event of an eye trauma in which the client is experiencing eye pain, discomfort, or feels something is in the eye, observe for: Foreign body that remains after gentle washing Perforated globe Blood in eye

Refer the client to an eye doctor immediately if a foreign body cannot be removed with gentle washing, there is perforation of globe, blood in eye, and/or client has impaired vision (Mayo Clinic, 2015a).

microaneurysms

Round, tiny red dots with smooth edges on retinal background Localized dilations of small vessels in retina, but vessels are too small to see Associated with diabetic retinopathy

halos or rings around light

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

hard exudate

Solid, smooth surface and well-defined edges Creamy yellow-white, small, round spots typically clustered in circular, linear, or star pattern Associated with diabetes mellitus and hypertension

spots or floaters in front of 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.

recent problems/changes in vision? 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.

inspect the lacrimal apparatus

Swelling of the lacrimal gland may be visible in the lateral aspect of the upper eyelid. This may be caused by blockage, infection, or an inflammatory condition. Redness or swelling around the puncta may indicate an infectious or inflammatory condition. Excessive tearing may indicate a nasolacrimal sac obstruction.

papilledema

Swollen optic disc Blurred margins Hyperemic appearance from accumulation of excess blood Visible and numerous disc vessels Lack of visible physiologic cup

Inspect fovea (sharpest area of vision) and macula

The macula is the darker area, one disc diameter in size, located to the temporal side of the optic disc. Within this area is a star-like light reflex called the fovea. Excessive clumped pigment appears with detached retinas or retinal injuries. Macular degeneration may be due to hemorrhages, exudates, or cysts.

Test accommodation of pupils

The normal pupillary response is constriction of the pupils and convergence of the eyes when focusing on a near object

inspect the optic disk Note shape, color, size, and physiologic cup.

The optic disc should be round to oval with sharp, well-defined borders Papilledema, or swelling of the optic disc, appears as a swollen disc with blurred margins, a hyperemic (blood-filled) appearance, more visible and more numerous disc vessels, and lack of visible physiologic cup. The condition may result from hypertension or increased intracranial pressure (Abnormal Findings 16-6). The intraocular pressure associated with glaucoma interferes with the blood supply to optic structures and results in the following characteristics: an enlarged physiologic cup that occupies more than half of the disc's diameter, pale base of enlarged physiologic cup, and obscured or displaced retinal vessels. Optic atrophy is evidenced by the disc being white in color and a lack of disc vessels. This condition is caused by the death of optic nerve fibers The diameter of the optic disc (DD) is used as the standard of measure for the location and size of other structures and any abnormalities or lesions within the ocular fundus.

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.

The reflection of light on the corneas should be in the exact same spot on each eye, which indicates parallel alignment. Asymmetric position of the light reflex indicates deviated alignment of the eyes. This may be due to muscle weakness or paralysis

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.

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 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.

do you perform the test for acular degeneration with the amsler chart? how do you use it and how often? what do you see?

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.

do you smoke?

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

have you been tested for glaucoma?

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

inspect the iris and pupil

Typical abnormal findings include irregularly shaped irises, miosis, mydriasis, and anisocoria. If the difference in pupil size changes throughout pupillary response tests, the inequality of size is abnormal. An inequality in pupil size of less than 0.5 mm occurs in 20% of clients. This condition, called anisocoria, is normal.

snellen chart

Used to test distant visual acuity, the Snellen chart consists of lines of different letters stacked one above the other. The letters are large at the top and decrease in size from top to bottom. The chart is placed on a wall or door at eye level in a well-lighted area. The client stands 20 ft from the chart and covers one eye with an opaque card (which prevents the client from peeking through the fingers). Then the client reads each line of letters until he or she can no longer distinguish them.

optic atrophy

White optic disc Lack of disc vessels

copper wire arteriole

Widening of the light reflex and a coppery color Occurs with hypertension

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.

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 A delayed or absent perception of the examiner's finger indicates reduced peripheral vision

ptosis

drooping eye