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Nursing assessment of eye part 2


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Nursing assessment of eye part 2

  1. 1. Nursing Assessment Part II Gauri S. Shrestha, M.Optom, FIACLE
  2. 2. Tonometry <ul><li>Tonometry refers to a clinical technique that provides a measurement of intraocular pressure. </li></ul><ul><li>Indentation tonometry (Schiotz tonometer) is rarely used nowadays. </li></ul><ul><li>Goldmann applanation tonometry- a gold standard. </li></ul><ul><li>Purpose </li></ul><ul><ul><li>To measure intraocular pressure. </li></ul></ul>
  3. 3. <ul><li>Assessment of patient </li></ul><ul><ul><li>Note age of patient on the record. Age above 40 years is a general indication. </li></ul></ul><ul><ul><li>Assess anterior chamber angle depth, iris pattern, neovasularization, and surgery. </li></ul></ul><ul><ul><li>Assess internal eye structures especially optic nerve head to find out glaucomatous changes. </li></ul></ul><ul><li>Required instrument: </li></ul><ul><ul><li>Slit lamp. </li></ul></ul><ul><ul><li>Applanation tonometer </li></ul></ul><ul><ul><li>Topical anesthetics </li></ul></ul><ul><ul><li>Fluorescein strips </li></ul></ul><ul><ul><li>Sterile cotton bud </li></ul></ul><ul><ul><li>Sterile saline solution </li></ul></ul>
  4. 4. <ul><li>Patient preparation </li></ul><ul><ul><li>Explain patient about the nature of the test to seek his or her confidence and co-operation. </li></ul></ul><ul><ul><li>Seat patient comfortably in dimly illuminated room in front of slit lamp. </li></ul></ul><ul><ul><li>Check the diagnosis and purpose of the test. </li></ul></ul><ul><ul><li>Make sure removal of patient's spectacle or contact lenses, if he or she is wearing them. </li></ul></ul>
  5. 5. (Schiotz tonometry) <ul><li>Weight of plunger= force required to flatten cornea </li></ul><ul><li>Amount of pressure exerted is directly read on scale as indicated by needle </li></ul><ul><li>Exact amount of pressure is read from scale nomogram adjusted for weight </li></ul>Gauri S Shrestha, M.Optom
  6. 6. Goldmann applanation tonometry <ul><li>Imbert ficks law: </li></ul><ul><ul><li>Pressure inside the sphere (P)= Force required to flatten its surface/area of flattening </li></ul></ul><ul><li>Diameter of indented area= 3.06mm </li></ul><ul><li>Variation: perkins applanation tonometer </li></ul><ul><li>Pulse air tonometer </li></ul>Gauri S Shrestha, M.Optom
  7. 11. Findings <ul><li>However, it has to be understood that the IOP is not static, but undergoes a diurnal variation. </li></ul><ul><li>Single observation of intraocular pressure can't justify as the suspicion of glaucoma. </li></ul><ul><li>However, mean intraocular pressure of 15mmHg is considered normal. </li></ul><ul><li>Intraocular pressure above 21mmHg is considered elevated. </li></ul><ul><li>Abnormally high intraocular pressure over along period, suggest the presence of glaucoma. </li></ul>
  8. 12. Refraction <ul><li>Refraction pertains to determination of the refractive status of the eye. </li></ul><ul><li>In objective refraction, the examiner determines the refractive state of the eye on the basis of instrumental finding. </li></ul><ul><ul><li>Retinoscope and autorefractor </li></ul></ul><ul><li>In subjective refraction, the examiner determines the refractive state entirely on the basis of the patient's response. </li></ul><ul><li>Cycloplegic refraction is performed in non-verbal, non-communicative, infants, toddlers, and squint patients. </li></ul>
  9. 13. <ul><li>Purpose </li></ul><ul><ul><li>To determine refractive error of patient. </li></ul></ul><ul><ul><li>To help evaluate the cause for non-improvement of vision in some ocular pathology. </li></ul></ul><ul><ul><li>To act as primary treatment for correction of squint, amblyopia, and binocular vision problem </li></ul></ul><ul><li>Required Instruments </li></ul><ul><ul><li>Retinoscope </li></ul></ul><ul><ul><li>Trail frame </li></ul></ul><ul><ul><li>Lens rack </li></ul></ul><ul><ul><li>Lens bar </li></ul></ul>
  10. 14. <ul><li>Assessment of patient </li></ul><ul><ul><li>Assess visual acuity without glasses, with glasses, and with pinhole. </li></ul></ul><ul><ul><li>Ascertain any media opacity in the eye that obscures viewing of internal structure of the eye such as cataract, corneal opacity. </li></ul></ul><ul><ul><li>Assess any redness in eye, haziness in the media, patient's complaint of eyeball pain, squint, and asthenopia. </li></ul></ul><ul><ul><li>Assess that retina is normal to confirm possibility of vision improvement. </li></ul></ul><ul><li>Patient preparation </li></ul><ul><ul><li>Explain the importance and sequences of procedure to patient to seek his confidence and co-operation. </li></ul></ul><ul><ul><li>Make patient sit comfortably in examination room in front of nurse with eyes at same level as nurse. </li></ul></ul>
  11. 16. Findings <ul><li>Concave lens is required in myopic ametropia </li></ul><ul><li>Convex lens is required in hyperopic ametropia. </li></ul><ul><li>Cylindrical power is required to correct astigmatism which could be either convex or concave. </li></ul><ul><li>The refractive error and visual acuity should be recorded in patient record form as (RE/LE/BE)/ (±Spherical power in DS)/ (±Cylindrical power in DC) X (axis in degree). e.g., RE -2.00DS/ -1.25DC X 180; LE +0.50DS/ -0.75DC X 180. </li></ul>
  12. 18. Color vision test <ul><li>Introduction </li></ul><ul><ul><li>the part of every basic eye examination. </li></ul></ul><ul><ul><li>Normal color vision is said to be trichromatic </li></ul></ul><ul><ul><li>Missing or abnormalities in any one of the receptors which detect these primary colors result in color vision defect. </li></ul></ul><ul><li>Pseudoisochromatic plates </li></ul><ul><li>Farnsworth D-15 test </li></ul><ul><li>Purpose </li></ul><ul><ul><li>To detect red-green deficiency. </li></ul></ul><ul><ul><li>To detect blue-yellow color vision deficiency. </li></ul></ul><ul><ul><li>Identify hereditary and acquired color deficiencies. </li></ul></ul><ul><ul><li>Evaluate macula function. </li></ul></ul>
  13. 19. <ul><li>Assessment of patient </li></ul><ul><ul><li>Assess visual acuity and refraction. </li></ul></ul><ul><ul><li>Observe involuntary to and fro eye movement (nystagmus) </li></ul></ul><ul><ul><li>Assess history of any congenital anomalies in children. </li></ul></ul><ul><ul><li>Review the report of ophthalmologic report on any acquired retinal and optic nerve diseases. </li></ul></ul><ul><ul><li>Review the patient's medication such as ethanbutol, tranquillizers, etc, that can cause color vision alteration. </li></ul></ul><ul><li>Instrumentation </li></ul><ul><ul><li>Ishihara color vision test (pseudoisochromatic plates) or </li></ul></ul><ul><ul><li>Farnsworth D-15 test </li></ul></ul><ul><ul><li>Color vision record sheet for Farnsworth D-15 test. </li></ul></ul><ul><ul><li>Occluder </li></ul></ul>
  14. 20. <ul><li>Patient preparation </li></ul><ul><ul><li>Provide the comfortable sitting arrangement to patient. </li></ul></ul><ul><ul><li>Ask to remove tinted glasses before administering the test. </li></ul></ul><ul><ul><li>Refractive correction should be there or visual acuity should be better than 6/60. </li></ul></ul><ul><ul><li>Ask the patient to avoid color naming. </li></ul></ul><ul><ul><li>Give a fixed, verbal and clear instruction to patient. </li></ul></ul>
  15. 21. Isihara for Anomalous Trichromate
  16. 23. Normal Color Perception Red Color Blind Green Color Blind
  17. 26. How the World look? Red green defect Blue yellow defect Normal
  18. 27. TEST OF STEREOPSIS <ul><li>Stereopsis is the ability to perceive depth or disparity. </li></ul><ul><li>The Titmus stereo test. </li></ul><ul><ul><li>Stereofly in used to test gross stereopsis of 3000 seconds. </li></ul></ul><ul><ul><li>Pictures or figure of different disparity ranging from 400 seconds to 40seconds. </li></ul></ul><ul><li>Purpose </li></ul><ul><ul><li>To grade level of depth perception in strabismus, amblyopia, and ocular diseases. </li></ul></ul>
  19. 28. <ul><li>Assessment of Patient </li></ul><ul><ul><li>Assess history of asthenopia, ocular pain associated with near work, especially in computer operators. </li></ul></ul><ul><ul><li>Review the ophthalmologic and optometric report of strabismus and diplopia. </li></ul></ul><ul><ul><li>Assess best corrected visual acuity to ascertain amblyopia. </li></ul></ul><ul><ul><li>Review the ophthalmologic and optometric record of ocular diseases that causes decrease in vision </li></ul></ul>
  20. 29. <ul><li>Instrumentation </li></ul><ul><ul><li>Titmus stereo test booklet </li></ul></ul><ul><ul><li>Polarized glasses. </li></ul></ul><ul><li>Patient preparation </li></ul><ul><ul><li>Check the diagnosis and purpose of the test. </li></ul></ul><ul><ul><li>Assess patient's level of consciousness and ability to follow directions. </li></ul></ul><ul><ul><li>Seat patient comfortably in adequately illuminated room. </li></ul></ul>
  21. 30. Tests for Stereopsis: Titmus test
  22. 31. <ul><li>TNO Random dot test </li></ul>Tests for Stereopsis:
  23. 32. Findings <ul><li>Patient can't read any of the disparity cards, means stereopsis is absent, and cause will usually establish the finding. </li></ul><ul><li>When the patient is able to read, the stereo threshold is recorded as the smallest disparity perceived by the patient. </li></ul><ul><li>In general, one can read stereopsis of as fine as 30 seconds of arc. </li></ul>
  24. 33. VISUAL FIELD <ul><li>Every basic eye examination should include some form of visual field evaluation. </li></ul><ul><ul><li>When there is a reason to suspect the presence of a field loss. </li></ul></ul><ul><ul><li>glaucoma, lesions of choroid, retina, and visual pathway. </li></ul></ul><ul><li>Goldman hemispherical projection perimeter and automated field analyzers </li></ul><ul><li>Here, the discussion is limited to visual field testing in confrontation and amsler chart. </li></ul>
  25. 34. <ul><li>Purpose </li></ul><ul><ul><li>To detect visual field defect in periphery as well as central area of field of vision. </li></ul></ul><ul><ul><li>To detects constriction and hemianopia of peripheral field by confrontation. </li></ul></ul><ul><ul><li>To detect alteration in central visual field such as scotoma, blur, distrotion, or spots. </li></ul></ul><ul><ul><li>To refer really necessary cases for a detailed examination of the visual field. </li></ul></ul><ul><li>Assessment of patient </li></ul><ul><ul><li>Check patient’s name, bed number, and identification. </li></ul></ul><ul><ul><li>Check the diagnosis and purpose of the test. </li></ul></ul><ul><ul><li>Assess the need for any restraints. </li></ul></ul><ul><ul><li>Assess patient's level of consciousness and ability to follow directions. </li></ul></ul>
  26. 35. Anatomy of visual field
  27. 36. Visual field testing devices Goldmann VF Automated VF Bernal disc
  28. 37. Automated and goldmann reading
  29. 38. THE AMSLER CHARTS <ul><li>This chart is used for central visual field screening. </li></ul><ul><li>Helpful in screening macular lesions, and vision is reduced without knowing the cause. </li></ul><ul><li>Instrumentation </li></ul><ul><ul><li>Amsler Chart. </li></ul></ul><ul><ul><li>Occluder with head band. </li></ul></ul><ul><li>Patient preparation </li></ul><ul><ul><li>Explain the importance and sequences of procedure to patient to seek his confidence and co-operation. </li></ul></ul><ul><ul><li>A patient is sited comfortably in adequately lit room . </li></ul></ul><ul><ul><li>Arrange uniform background behind the examiner. </li></ul></ul>
  30. 39. Amsler grid test: central visual field test
  31. 40. Micropsia Metamorphopsia Macropsia
  32. 41. Findings <ul><li>When patient notice any distortion, scotoma, interruption or blur, his or her central vision should be considered affected. </li></ul><ul><li>This finding warrants further examination and evaluation. </li></ul>
  33. 42. Field defect Orientation and mobility Reading performance Difficulty identifying faces
  34. 43. VF Loss: Simulations:
  35. 44. Thank you