Eyes and head
what 3 nerves innervate the eye muscles
Abducens: 6 Trochlear: 4 Oculomotor: 3
normal cup:disc ratio
1:2
how thick is the cornea?
1mm
what are you looking for in the vessels of the fundoscopic exam?
arteries vs veins, arteries are 2/3 size and lighter
imperfection of cornea or lens causing some distortion
astigmatism
where would you have the patient look when inspecting the fovea and macula?
directly into the light
what are the 3 layers of the internal eye?
external (fibrous), middle (vascular), internal
constriction of the pupils
miosis
dilation of the pupils
mydriasis
nearsighted vision
myopia
what do you check for at the end of EOMs?
near accommodation and convergence
are pulsations irregular or normal
normal, if they dont have them there is no clinical significance
what should you note for lacrimals?
note swelling, redness of the gland, sac, or puncta
what condition do you look for on far lateral gaze as you perform EOMs?
nystagmus
head of optic nerve where blood vessels enter and exit eye
optic disc
what is the optic disc?
origin of optic nerve
swelling of the optic disc
papilledema
what part of the nervous system controls pupillary constriction
parasympathetic
types of pathological facies
parkinsons, acromegaly, Cushing syndrome, nephrotic syndrome, myxedema
types of salivary glands
parotid, accessory parotid and submandibular
features of nephrotic syndrome
periorbital edema, puffy pale face, swollen lips
depression in the center of the disc
physiologic cup
age related, difficulty focusing near vision
presbyopia
what is the flow of the circulation of aqueous humor?
produced by ciliary body -> posterior chamber -> anterior chamber -> canal of schlemm -> venous circulation
features of acromegaly pathologic facies
prominent brow, enlarged soft tissues, prominent jaw
drooping
ptosis
what should you note for lids?
resting position, symmetry of palpebral fissures, edema, redness, lesions, adequate closure?
what is in the internal layer of the inner eye?
retina
what is the thin delicate layer of nervous tissue that contains photoreceptors (sensitive to light) and the optic disc (origin of optic nerve)
retina
what part of the nervous system controls pupillary dilation?
sympathetic
what is the name of the plate superficial to the meibomian gland of the external eye
tarsal plate
what do you palpate in a head exam?
temporal artery, contour of cranium, salivary ducts, temporomandibular joints (TMJ)
what are the 4 quadrants you should follow the vessels from the disc to the periphery
upper and lower temporal upper and lower nasal
what is the pigmented, vascular layer of the eye?
uveal tract
AV nicking
vein appears to stop abruptly on either side of the artery
most superior part of the skull
vertex
abnormal protrusion of the eyeball commonly seen with hypothyroidism
exophthalmos
outward turning of the eye
exotropia
what is included in the inspection of external soft tissue structures?
1. Lids 2. Lacrimals 3. Lashes
inspection of the eye
1. conjunctive and sclera 2. corneas: lesions, opacities, scars 3. depth of anterior chamber (shadows) 4. evaluate lens: opacities through pupil?
what are the steps for the fundoycopic exam?
1. darken room 2. turn focus to 0 3. hold out hand 4. tell patient to look at a spot on the wall 5. stand 15 inches away and 15 degrees lateral to the patient line of vision 6. shine light into pupil, initiate red reflex 7. move in towards pupil 8. inspect optic disc and retina, follow vessel into a disc
how do you test for near accommodation and convergence?
1. hold object 10 cm from patient eye 2. ask patient to look at object then to the distance 3. pupil shrinks with near gaze 4. eyes should converge when object gets closer to nose
what are you looking for in the fundoycopic exam?
1. red reflex (lens opacities) 2. optic disc 3. vessels 4. retinal background lesions 5. fovea and macula
steps for determining depth of anterior chamber
1. shine light from temporal side 2. look for shadow on nasal side of iris 3. normally won't cast a shadow
steps for corneal light reflex
1. stand 2 feet away 2. shine light, ask patient to look at the light 3. light reflex should be symmetric and slightly nasal from midline
steps for visual acuity
1. stand 20 feet from chart 2. cover 1 eye and read smallest line 3. visual acuity expressed as 2 numbers for both eyes 4. document glasses or contacts (corrected) 5. document missed letters (-2)
how to test visual fields by confrontation
1. stand arms length 2. wiggle and bring fingers forward to center view 3. ask patient to tell you when they see finger movement
what is the size of the optic disc?
1.5 mm
what is part of the head exam
Inspection: 1. position, tilt, tremor, tick, rotation 2. facial symmetry, pathological facies, edema, hirsutism 3. inspect and palpate hair 4. inspect and palpate salivary glands and ducts
what controls the amount of light reaching the retina, controls the size of the pupil, and produces eye color from the pigment
Iris
what is the structure directly deep to the tarsal plate in the eye?
Meibomian gland
what does PERRLA mean?
Pupils are equal, round, and reactive to light accommodation
another name for submandibular duct
Wharton's duct
change in lens caused by contraction of the ciliary muscles that brings the near object into focus
accommodation
difference in pupil size (can be benign)
anisocoria
Is the cornea vascular or avascular?
avascular
is the sclera avascular or vascular?
avascular
most inferior part of the skull
base
inflammation of the eyelid
blepharitis
what are the different conjunctive?
bulbar conjunctive palpebral conjunctiva
if there were opacities of the pupil what is that an indication of?
cataract
what supplies the retina of the eye?
central arteries and veins
a nodule or cyst, usually on the upper eyelid, caused by obstruction in a sebaceous gland
chalazion
arteries vs veins -diameter -color -light reflex
diameter: artery smaller than vein (2:3 ratio) artery is light red, veins are dark red arteries are brighter
what nourishes adjacent layers of the retina?
choroid
what circumferentially supports the lens, aiding in focusing?
ciliary muscle
if you are farsighted (hyperopic) which side would you move the wheel?
clockwise (to the plus/green
what are you looking for with the optic disc?
color, borders, size of physiologic cup, cup/disc ratio
what should you note for lashes?
condition and direction
what test is done for the pupils?
direct and consensual light responses
eyes coming together
convergence
continuous with the sclera and covers the pupil and iris
cornea
if you are nearsighted (myopic) which side would you rotate the focusing wheel?
counterclockwise (to minus/red)
what are you looking for when testing the visual fields?
defects
what is the physiologic cup?
depression in disc
features of myxedema
dry, coarse, sparse hair, lateral eyebrows are thin, peri orbital edema, puffy dull face with dry skin
what is the sclera continuous with?
dura of the CNS which surrounds the optic nerve
outward turning of the rim of the eyelid
ectropion
inward turning of the rim of the eyelid
entropion
inward turning of the eye
esotropia
how do you test extra ocular movements?
follow your finger in the 6 cardinal directions of gaze
tiny bright reflection at center of macula
fovea
posterior, inner part of the eye
fundus
what muscles are innervated by the oculomotor nerve?
superior rectus muscle medial rectus muscle inferior rectus muscle inferior oblique muscle
what is disc cupping a sign of
glaucoma (glaucomatous cupping)
stye
hordeolum
farsightedness
hyperopia
when would you have to document the size of the pupils?
if they are unequal to one another, greater than 5mm, or less than 3 mm
if there is a shadow when checking the depth of the anterior chamber what could this indicate?
increased risk of angle closure glaucoma
what muscle rotates the eye away from the nose around the long axis (extorsion) and moves the eye upward? (elevation)?
inferior oblique
what muscle moves the eye downward (depression)?
inferior rectus
what is part of the middle layer (vascular) of the inner eye?
iris, ciliary body and choroid (uveal tract)
what makes up the uveal tract?
iris, ciliary body, choroid
name the ducts associated with the eye
lacrimal gland, lacrimal sac, canaliculi, puncta, nasolacrimal duct
what muscle moves the eye outward away from the nose? (abduction)
lateral rectus
what muscles are innervated by the abducens nerve?
lateral rectus muscle
what allows for near/distant focus under the control of the ciliary muscle and is subject to osmotic influences
lens
what is the normal size of the cup
less than 1/2 of disc
what is the normal finding for anterior chamber depth?
light illuminates both sides of iris
what is examined last?
macula
what is the area of central vision located lateral to the disc; darker area?
macula
what is the area of central vision in the retina?
macula/fovea
what muscle moves the eye inward toward the nose? (adduction)
medial rectus
tough outer white covering covered by the conjunctiva that provides support
sclera
what is part of the external (fibrous) layer of the inner eye?
sclera and cornea
what should you note about the optic disc?
shape, margins, color, disc abnormalities, pigmented rings or crescents
how would you test direct and consensual light responses
shine light and observe in both eyes
what are you inspecting for the pupils?
size and symmetry
what tests are used for visual acuity?
snellen chart (distant) pocket screener (near)
features of parkinson's pathologic facies
stare, decreased mobility
how does the cornea perform most of the refraction of incoming light?
steep curvature
another name for parotid duct
stensen's duct
what is the name of the artery you can palpate in the temporal region of the head?
superficial temporal artery
what muscle rotates the top of the eye toward the nose around the long axis (intorsion) and moves the eye down (depression)
superior oblique
what muscles are innervated by the trochlear nerve?
superior oblique muscle
what muscle moves the eye upward (elevation)?
superior rectus
what prevents corneal scarring?
tough Bowman's membrane
what should you identify in the retina?
vessels, venous pulsations
term for the entire area seen by the eye when it looks at a central point
visual field
types of humours in the eye
vitreous humour and aqueous humour
what is the normal color of the physiologic cup?
yellowish white, appears brighter than the disc
