Assessment of eye

1. UNIT II
Nursing Managementof patientwith
disordersof eye

2. Review of anatomy & physiology of eye
⚫The eye is one of the most complex organs of the human body.
Each one of the two eyeballs is located in the orbit, where it
takes up about one-fifth of the orbital volume. The remaining
space is taken up by the extraocular muscles, fascia, fat, blood
vessels, nerves and the lacrimal gland.
⚫The eye has three layers or coats, three compartments and
contains three fluids
⚫1. The three coats of the eye are as follows:
(a) Outer fibrous layer:
• cornea
• sclera
(b) Middle vascular layer (“uveal tract”):
• iris
• ciliary body
• choroids.

3. Cont….
(c) Inner nervous layer:
• pigment epithelium of the retina
• retinal photoreceptors
• retinal neurons.
2. The three compartments of the eye are as follows:
(a)Anterior chamber – the space between the cornea and
the iris.
(b)Posterior chamber – the triangular space between the
iris anteriorly, the lens and zonule posteriorly, and the
ciliary body.
(c)Vitreous chamber – the space behind the lens and
zonule

4. Cont….
3. The three intraocular fluids are as follows:
⚫ (a) Aqueous humour – a watery, optically clear solution of
water and electrolytes similar to tissue fluids except that
aqueous humour has a low protein content normally.
⚫(b) Vitreous humour –a transparent gel consisting of a three-
dimensional network of collagen fibres with the interspaces
filled with polymerised hyaluronic acid molecules and water. It
fills the space between the posterior surface of the lens, ciliary
body and retina.
⚫(c) Blood –blood contributes to the maintenance of intraocular
pressure. Most of the blood within the eye is in the choroid.
The choroidal blood flow represents the largest blood flow per
unit tissue in the body. It might be that the choroid serves as a
heat exchanger for the retina, which absorbs energy as light
strikes the retinal pigment epithelium.

5. Structure of eye

6. Surface of the eye
⚫The surface of the eye and the inner surface of the eyelid are
covered with a clear membrane called the conjunctiva.
⚫Light is focused into the eye through the clear, dome-shaped
front portion of the eye called the cornea.
⚫Behind the cornea is a fluid-filled space called the anterior
chamber. The fluid is called aqueous humor. The eye is always
producing aqueous humor. Tomaintain a constant eye pressure,
aqueous humor also drains from the eye in an area called
the drainage angle.
⚫Behind the anterior chamber is the eye’s iris (the colored part of
the eye) and the dark hole in the middle called the pupil.
Muscles in the iris dilate (widen) or constrict (narrow) the pupil
to control the amount of light reaching the back of the eye.

7. Cont….
⚫Directly behind the pupil sits the lens. The lens
focuses light toward the back of the eye. The lens
changes shape to help the eye focus on objects up
close. Small fibers called zonules are attached to the
capsule holding the lens, suspending it from the eye
wall. The lens is surrounded by the lens capsule,
which is left in place when the lens is removed
during cataract surgery.
⚫By helping to focus light as it enters the eye, the
cornea and the lens both play important roles in
giving us clear vision. In fact, 70% of the eye's focusing
power comes from the cornea and 30% from the lens.

8. Cont….
⚫The vitreous cavity lies between the lens and the back of
the eye. A jellylike substance called vitreous humor fills the
cavity.
⚫Light that is focused into the eye by the cornea and lens
passes through the vitreous onto the retina— the light-
sensitive tissue lining the back of the eye.
⚫A tiny but very specialized area of the retina called
the macula is responsible for giving us our detailed, central
vision. The other part of the retina, the peripheral retina,
provides us with our peripheral (side) vision.

9. Cont….
⚫The retina has special cells called photoreceptors. These
cells change light into energy that is transmitted to the
brain. There are two types of
photoreceptors: rods and cones. Rods perceive black and
white, and enable night vision. Cones perceive color, and
provide central (detail) vision.
⚫The retina sends light as electrical impulses through
the optic nerve to the brain.

10. Nursing Assessment
Nursing assessment includes health history & physical
examination.
Health history:
An ophthalmic history includes:
Demographic data-name, age, sex,incidence of cataracts, dry
eyes, retinal detachment, glaucoma, ectropia(eyes turning
inward), exotropia (eyes turning outward) increses with age.
Hereditary color vision deficits are more common in men than in
women.
Current health-Ocular manifestations can be divided into three
basic categories:
1. Vision
2. Appearance
3. Sensations of pain & discomfort

11. Cont…
1. Vision-includes visual changes or loss of vision can be caused
by abnormalities in the eye or anywhere along the visual
pathway. Consideration includes
 Refractive error
 Interference from lid ptosis( drooping eyelid)
 Clouding or interference in the cornea, lens, aqueous or
vitreous space
 Malfunction of the retina, optic nerve or intracranial pathway.
2. Abnormal appearance- the most common abnormal appearance
is a red eye.
3. Abnormal sensation- eye pain is often poorly localized. Non
specific complaints include eyestrain, pulling, pressure,
fullness or generalized headache.Foreign body sensation,
dryness itching, burning can be asked.

12. Cont…
Past health history:
 Childhood & infectious diseases.
 Major illness & hospitalisation.
 Medications.
 Allergies.
Family health history: includes questions regarding
strabismus, glaucoma, myopia, hyperopia.
Psychosocial history

13. Physical examination
⚫External eye:
Eye position- assess eye for symmetry & alignment. Sunken
or protruding eyes.
Eyebrows – Inspect eyebrows for symmetry, hair
distribution, skin conditions & movement.
Eyelids & eyelashes- Examine eyelids & eyelashes for
placement & symmetry.
Blink response- blinking is an involuntary reflexthat occurs
bilaterally upto 20times a minute. Rapid, infrequenr or
asymmetrical blinking is abnormal.
Eyeballs – Palpate the eyeballs for symmetry & firmness.

14. Cont…
Lacrimal appartus –Observe this area for swelling or
tenderness.The eye surface should be moist & without
excess tearing.
Conjuctiva & Sclera – Inspect conjuctiva & sclera for color
changes, texture, lesions, thickness, secretions & foreign
bodies.
Corneal reflex- The corneal reflex test is performed to
assess the function of 5th cranial nerve( trigeminal nerve).
Cornea- Inspect the cornea from an oblique angle while
shining a penlight on the corneal surface.
Iris & Pupil- Inspect the iris & pupil. Iris is inspected for
bulging or uneven coloring. Inspect the pupils for size,
equality, shape & ability to react to light & accommodation.

15. Cont…
Ocular motility- Evaluation of ocular motility provides
information about the extraocular muscles, orbit, the
oculomotor, trochlear & abducens nerves.

16. Cont…
Corneal light reflex test- the corneal light reflex test (
Hirschberg’s test) determines eye alignment.

17. Cont…
Cover –uncover test-This test assesses eye muscle function
& alignment for tropia & phoria.

18. Cont…
Visual acuity- Testing visual acuity is the standard, routine
method used to determine the clarity of the ocular media(
cornea, lens & vitreous) & the function of the visual
pathway from the retina to the brain.

19. Cont…
Visual fields- Visual field testing is used to evaluate
peripheral vision.

20. Cont…
Special testing of vision:
 Color vision

21. Cont…
• Internal eye:
Direct ophthalmoscopy
Indirect ophthalmoscopy
Tonometry
Slit lamp examination
Direct ophthalmoscopy:
The direct ophthalmoscope is an instrument about the size of
a small flashlight (torch) with several lenses that can
magnify up to about 15 times. This type of ophthalmoscope
is most commonly used during a routine physical
examination. The direct ophthalmoscope allows you to look
into the back of the eye to look at the health of the retina,
optic nerve, vasculature and vitreous humor.

22. Direct ophthalmoscopy

23. Indirect ophthalmoscopy
An indirect ophthalmoscope, on the other hand, constitutes a
light attached to a headband, in addition to a small
handheld lens. It provides a wider view of the inside of the
eye. Furthermore, it allows a better view of the fundus of
the eye, even if the lens is clouded by cataracts.An indirect
ophthalmoscope can be either monocular or binocular. It is
used for peripheral viewing of the retina.

24. Indirect ophthalmoscopy

25. Tonometry
Tonometry is a test to measure the pressure insideyour
eyes. The test is used toscreen forglaucoma.

26. Slit lamp examination
It is a special microscope and light that lets your doctor see
your eyes in 3-D, both inside and out. They will use it
along with an ophthalmoscope to look at the back of
your eye. A slit-lamp exam is usually done during a regular
checkup with your eye doctor.

27. Diagnostic tests
Fundus photography
Fundus photography is the process of taking serial
photographs of the interiorof youreye through the
pupil. A fundus camera is a specialized low-power
microscope attached to a camera used to examine
structures such as the optic disc, retina, and lens.

28. Exophthalmometry
The exophthalmometer is designed to measure the
forward protrusion of the eye.

29. Ophthalmic radiography
X-ray, computerised tomography (CT)& magnetic
resonance imaging (MRI) are useful in the evaluation of
orbit & intracranial conditions. Common abnormalities
evaluated by these methods include neoplasms,
inflammatory masses, fractures.
 Ophthalmodynamometry
Electroretinography
Visual evoked response
Fluorescein angiography