Eye assessment

2. ASSESSMENT, HISTORY TAKING,
PHYSICAL EXAMINATION AND
INVESTIGATIONS RELATED TO EYE
DISORDERS
-BY SHWETA SHARMA
M.SC. NURSING I YEAR
AIIMS, JODHPUR

3. INTRODUCTION
•The eye is a unique organ because its external anatomy
can be assessed easily.
•Internal eye structures, including blood vessels and
central nervous system tissue (retina and optic nerve)
are also easily visualized through cornea without invasive
procedures.
• The effects of many systemic problems, such as
infections, cancer, vascular disorders and autoimmune
disorders, can be detected during an internal eye
examination.

4. ANATOMY AND PHYSIOLOGY OF
EYES

6. HISTORY
•Demographic data
•Exploration of chief complaint and related manifestations
•Review of systems
•Past medical history
•Past surgical history
•Allergies and medications
•Dietary habits
•Psychosocial history and lifestyle
•Family health history

7. Biographical and demographic
data-
Patient's full name
Age -The incidence of cataract, dry eye, retinal
detachment, glaucoma, etc increase with age.
Birth date
Gender- Hereditary color vision deficits are more
common in men than in women.
Address and contact telephone number
Occupation.

8. Current health-
•Chief complaint-
Change or loss of vision, headache or eyestrain.
Sometimes the client may be unable to verbalize a
specific complaint, and the chief complaint could be as
vague as “something is wrong with my eyes.”
•Clinical manifestations-
Pain (Ophthalmalgia), abnormal vision, abnormal
appearance, abnormal sensation, etc.

10. Review of systems-
Past medical history-
• Diabetes mellitus
• Rheumatoid arthritis
• Thyroid disorders
• Childhood vaccinations, particularly for measles
• Hypertension, multiple sclerosis and myasthenia gravis
• If the client wears eyeglasses or contact lenses, ask when the last
eye examination took place and when the prescription was last
changed.
• Hospitalizations related to the eyes or brain, including a history of
head or eye trauma

11. Surgical history-
• Laser-assisted in-situ keratomileusis (LASIK)
• Radial keratotomy (RK)
• Cataract removal
• Glaucoma treatment, or eye muscle correction.
• History of brain or facial surgeries should also be assessed as these have
the potential to affect vision.
Allergies-
• Any allergies to medications (eye drops)
• Inhalants (dust, chemicals or pollens)
• Environmental contacts (cosmetics or pollens)
• Allergic manifestations include eye redness, tearing and itching.

12. Medications-
• Note the name, dose, and frequency the medication is taken.
• Ask about use of over-the-counter eye drops, as those with antihistamines
and decongestants can dry the ocular surface.
• Record current eye and systemic medications being used, and all other
current and past ocular disorders.
Dietary habits-
• Herbal remedies and dietary supplements.
• Vitamins, believing these substances will prevent the development of vision
problems such as cataract, and macular degeneration.
• Diets rich in fruits, vegetables, and fish or supplements of antioxidants C, E
and beta-carotene.

13. Social history-
• It includes occupational hazards, leisure activities and hobbies, and
health management behaviours.
• Assess the client’s work and/or hobbies that may include exposure to
irritating fumes, smoke, or air-borne particles. Assess participation in
activities that increase the risk for eye or head trauma (such as football,
racquetball or baseball) as well as those that increase the risk of foreign
body injury or abrasion (e.g. hiking or gardening). Address client use of
protective eye gear (such as safety goggles or sunglasses) when
engaging in these activities.
Family health history –
• Strabismus, glaucoma, myopia, hyperopia, diabetes, retinoblastoma,
retinitis pigmentosa, and macular degeneration tend to appear in
families.

14. PHYSICAL EXAMINATION
Techniques-
1.Inspection
2.Palpation

15. External eye

16. •Eye position- Symmetry and alignment.
•Eyebrows- Symmetry, hair distribution, skin conditions
and movement.
•Eyelids and eyelashes- Placement and symmetry.
Elevate the eyebrows to inspect the upper lids for
lesions. Inspect the lower lids by asking the client to
open the eyes. Examine skin of the eyelids and orbit by
palpating for texture, firmness, mobility, and integrity
of the underlying tissues. Assess the blink response.
Blinking is an involuntary reflex that occurs bilaterally
up to 20 times a minute.

17. Eyeballs and lacrimal apparatus-
• Normally, the eyeballs feel firm and symmetrical. Visualize
the lacrimal apparatus by retracting the upper lid and having
the client look down. The area should be free of swelling,
oedema and excessive moisture, and there should be no
regurgitation of fluid from sac or puncta.
Conjunctiva and sclera-
• Inspect the conjunctiva and sclera for colour changes,
texture, vascularity, lesions, thickness, secretions, and
foreign bodies. Healthy conjunctivae are pink to light red. If
the lower palpebral conjunctivae are normal, the upper
palpebral conjunctivae usually are not inspected.

18. Cornea and anterior chamber- The depth of the chamber
between the cornea and iris is normally about 3 mm.

19. Iris and pupil-
•PERRLA
•Pupil abnormalities may be
caused by neurologic disease,
intraocular inflammation, iris
adhesions, systemic or ocular
medication side effects, or
surgical alteration.

21. Normal physical examination
findings

23. DIAGNOSTIC EVALUATION
•Visual acuity testing
For assessing distant vision-
1. Snellen test
2. Random E test
For assessing near vision-
Jaeger chart

24. Snellen chart

25. RANDOM E TEST

26. JAEGER CHART

27. Confrontation visual field testing

28. Extraocular muscle functions

30. An example of eye movement over a photograph
over the span of just two seconds.

31. Direct ophthalmoscopy

33. •Abnormal findings include an altered
arteriovenous ratio, narrowed arteries, widened
veins, pinched-off vessels, abnormal arterial light
reflex, excessive tortuosity, numerous
arteriovenous nicks, exudates, white patches and
focus haemorrhage.
•Direct ophthalmoscope is one that produces an
upright, or unreversed, image of approximately
15 times magnification.

34. Indirect Ophthalmoscopy

35. •Produces an inverted, or reversed, image of 2 to 5
times magnification.
•It employs a head lamp device to shine a very
bright light into the eye and a small handheld
lens.
•Provides a wider view of the inside of the eye.
•It allows a better view of the fundus of the eye,
even if the lens is clouded by cataracts.

36. Slit-lamp examination

37. Tonometry

38. Color vision testing

39. Amsler grid

40. Ultrasonography

41. Optical coherence tomography

42. Fundus photography

43. Laser scanning

44. Angiography

45. Perimetry testing

47. RESEARCH ARTICLES
1.Knowledge and practice patterns of Intensive Care Unit nurses towards eye care in
Chhattisgarh state
• A study was conducted by Sonal Vyas, Ashish Mahobia, and Sangeeta Bawankure to
present the level of knowledge and practice patterns regarding exposure
keratopathy in mechanically ventilated patients among Intensive Care Unit (ICU)
nurses in Chhattisgarh state. A previously validated semi-structured questionnaire
was administered in the ICU of six multispecialty hospitals in Chhattisgarh in 2014–
2015. Most of the questions dealt with frequency of eyelid closure assessment,
frequency of cleaning of eyes with saline gauze, using a protocol-based approach
for eye care, and documentation of ophthalmic complications. Common barriers to
delivery of eye care such as shortage of time and too much writing tasks were also
inquired. This study included 120 nurses. Knowledge about high risk of exposure
keratopathy in ventilated patient was present in 93% nurses. Only six nurses (5%)
followed a strict protocol for eye care, 52 nurses (43%) checked for eyelid closure in
the ventilated patients, and 58 (48%) cleaned the eyes frequently. Nurses in cardiac
ICU were significantly lesser aware of exposure complications compared to medical
ICU nurses. The study concluded that although there is high awareness, practice
patterns of ICU nurses were less than desired. Educational initiatives should focus
on weaknesses in knowledge and practice noted to improve eye care of patients in
ICU.

48. 2.A study on knowledge regarding eye donation among first year nursing
students of a nursing school and college of Berhampur, Odisha
• A cross-sectional study was conducted in May 2016 with 140 first year
Nursing students to assess their perception towards eye donation. All
participants knew about eye donation and 95.7% said these can be done
irrespective of age and sex of the deceased. 55% students told HIV is a
contraindication,10% said that request for eye donations can be made by
person himself alive or relatives after death. 15% knew that eye can be
donated within six hours of death but none were aware regarding storage of
donated eyes before transplantation. Only 2.1% of them heard about Hospital
Corneal Retrieval Programme. Television (100%) was the main source of
information. All of them personally supported eye donation. The study
concluded that nursing students had heard about eye donation but knew
less about the details of the procedure. They can contribute to awareness
and motivating people for eye donation during their postings in various
department in hospital.

50. CONCLUSION
•As discussed throughout the presentation, learning
about eye examination will help the nurses to care
better for patients.
•Nurses can do eye assessment, classify the level of
disease, observe the sign and symptoms, provide the
necessary nursing care and support the patient
psychologically.

51. REFERENCES
1.Janice L. Hinkle, Kerry H. Cheever. Brunner and Suddarth’s Textbook of Medical
Surgical Nursing. 2015. New Delhi. Wolters Kluwer.13th Edition. Volume 2. Pg. no.
1839-1846.
2.Lewis. Medical Surgical Nursing Assessment and Management of clinical
problems.2015. New Delhi. Elsevier. 2nd Edition. Volume II. Pg. no. 382-392.
3.Joyce M. Black, Jane Hokanson Hawks. Medical Surgical Nursing Clinical
Management of Positive Outcomes.2015. New Delhi. Reed Elsevier India Private
Limited. Volume II. Pg. no. 1677-1686
4.PubMed. Knowledge and practice patterns of Intensive Care Unit nurses towards eye
care in Chhattisgarh state. Available from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6113811/ [cited 21 Nov 2019]
5.IJRMS. A study on knowledge regarding eye donation among first year nursing
students of a nursing school and college of Berhampur, Odisha. Available from
https://www.msjonline.org/index.php/ijrms/article/view/3984 [cited 21 Nov 2019]