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  1. 1. EyesEyes
  2. 2. External AnatomyExternal Anatomy Sensory Organ for vision -Situated in bony, orbital cavity for protection – Eyelids= shades that add protection form injury, strong light , dust – Eyelashes= hairs to filter dust & dirt
  3. 3. External AnatomyExternal Anatomy
  4. 4. Limbus – border b/t the cornea & sclera Palpebral fissures – elliptical open space b/t lids Canthus- corners of the eye where the lids meet, inner & outer Caruncle – sm. Fleshy mass containing sebaceous glands at inner canthus
  5. 5.  Within the upper eyelid – Tarsal plates, connective tissue gives upper lid shape – Meibomian glands, in the plates, lubricate the lids, stops overflow of tears, airtight seal when lids closed
  6. 6. Exposed part of the eye – Conjunctiva, folded envelope b/t eyelids & eyeball  thin mucous membrane, transparent protective covering of the exposed part of the eye.  Palpebral conjunctiva lines the lids, is clear but has sm .bld. Vessels  Bulbar conjunctiva is over eyeball, white sclera show through, merges at limbus with cornea
  7. 7. Cornea – clear, covers & protects iris & pupil
  8. 8.  Lacrimal apparatus – irrigates conjunctiva & cornea – 3 parts A. Lacrimal gland, upper, outer corner of eye = tears B. Puncta= inner canthus, tear drainage C. Nasolacrimal duct= allows tears to drain from puncta to nasolacrimal sac. Tears then empty into the inferior meatus of the nose
  9. 9. Extraoccular musclesExtraoccular muscles  6 muscles – Attach eyeball to orbit – Straight and rotary movement – Four straight muscles 1. Superior rectus 2. Inferior rectus 3. Lateral rectus 4. Medial rectus
  10. 10.  Two slanting/ oblique muscles 5. Superior 6. Inferior Humans have a Binocular, single – image visual system – Eyes normally move as a pair
  11. 11. • Eye movement stimulated by Cranial Nerves • III Oculomotor • IV Trochlear • VI Abducens
  12. 12. Internal AnatomyInternal Anatomy  The eye has 3 layers, the outer & inner layer can be viewed using opthalmascope 1. Sclera (outer layer) tough, protective, white covering connects with the -  Cornea – transparent, protects pupil & iris – helps focus light on retina
  13. 13. 2. Middle layer  Choroid – dark pigmentation to prevent internal light reflection, supplies bld. to retina  Pupil – PERRLA  Lens – biconvex disc, transparent, thickness controlled by ciliary body, bulges = near; flattens = distant  Anterior chamber – posterior to cornea, anterior to iris & lens, has aqueous humor supplies nutrients & drains wastes
  14. 14. 3. Inner layer – Retina – visual receptive layer – light waves changed to nerve impulses  Retinal structures  Optic disc – retinal fibers meet & form optic nerve, nasal side of retina, creamy yellow orange to pink, round or oval shape, physiologic cup inside the disc for bld.vessels to enter & exit  Retina vessels – paired arteries & veins
  15. 15.  Macula – temporal side of fundus, darker pigmented region, surround the fovea centralis  Fovea Centralis- area of sharpest & keenest vision, Very sensitive to light
  16. 16. Visual Pathways & FieldsVisual Pathways & Fields  Objects reflect light  Rays refracted by cornea, aqueous humor, lens, vitreous body and onto retina.  Light stimulus is changed to nerve impulses, travel thru optic nerve to visual cortex in occipital lobe  Image on retina is upside down & reversed. At the optic chiasm retinal fibers cross over. Right side of brain looks at left side of world.
  17. 17. Visual reflexesVisual reflexes  Pupillary light reflex – bright light = constriction – Direct light reflex – Consensual light reflex  Fixation – ability to track an object & keep image on the fovea, can be impaired by drugs, alcohol, fatigue & inattention  Accomodation – for near vision = pupil constriction & convergence of eyes
  18. 18. Subjective dataSubjective data Vision difficulty Pain Strabismus, diplopia Redness, swelling Watering, discharge Past history ocular problems Glaucoma
  19. 19. Glasses/ contacts Medications Vision loss- coping mechanisms Self–care behaviors
  20. 20. Objective dataObjective data The Physical ExamThe Physical Exam  Preparation – Position- sitting, head at eye level  Equipment – Snellen eye chart- visual acuity – Handheld visual screener-near vision – Opaque card – Penlight – Applicator stick – Ophthalmoscope
  21. 21. Test visual acuityTest visual acuity Snellen eye chartSnellen eye chart  Stand 20 ft. from chart  Glasses / contacts (Document )  Remove eye wear, retest  Normal visual acuity is 20/20 – top # is distance person is standing from the chart  Vision 20/30 refer to opthalmologist or optometrist  If unable to see largest letters, move to 10 feet – record as 10/200
  22. 22. Test for near visionTest for near vision Vision screener People > 40yrs or difficulty reading Test each eye with glasses Hold card 14in. from eyes Normal result 14 / 14 Test using any available reading material if no card available
  23. 23. Presbyopia is a normal physiological change in near vision occurs with aging = note if the person moves the card farther away
  24. 24. Test visual fieldsTest visual fields Confrontation testConfrontation test Compares peripheral vision with a tester who has normal peripheral vision 2 ft. apart, eye level Tester & client cover opposite eyes Tester advances finger in the periphery – Superiorly ( 50 degrees ) – Inferiorly ( 70 degrees ) – Temporally ( 90 degrees )
  25. 25. Inspect Extraoccular MuscleInspect Extraoccular Muscle FunctionFunction Corneal light reflex Cover test Diagnostic positions test – 6 Cardinal Positions of Gaze
  26. 26. Inspect Extraocular MuscleInspect Extraocular Muscle FunctionFunction Corneal Light Reflex ( The Hirschberg Test) assesses parallel eye alignment – Shine light toward person’s eyes – Tell to stare directly ahead – Hold light 12 in. away – Light should reflect on both corneas in same spot
  27. 27.  Cover Test- detects deviated alignment – Stare straight at examiner’s nose – Cover 1 eye of the person being examined with opaque card – Normally the uncovered eye should maintain a steady, fixed gaze – Covered eye- should stare straight ahead when covered & then uncovered. If muscle weakness exists the covered eye will relax and then jump to fixed position when uncovered..
  28. 28. Diagnostic Positions TestDiagnostic Positions Test  6 cardinal positions of gaze – – Determines muscle weakness during movement – Person must hold head steady – Follow movement of object (examiner’s finger, pen etc) only with eyes – Hold object 12 in. from person – Move thru each position, clockwise, hold , then back to center – Normal response= parallel tracking with both eyes
  29. 29. During this test be aware of Nystagmus-fine jerky movement seen around the iris Mild nystagmus in extreme lateral gaze is normal but not normal in any other position
  30. 30. Inspect External StructuresInspect External Structures  General – movement & facial expression (squinting?)  Eyebrows – 2(bilateral), symmetrical (look the same; move the same)  Eyelids & Lashes – present, approximate when closed, no redness, swelling, discharge, lesions?  Eyeballs- alignment, ? Protrusion? Sunken?  Conjunctiva & Sclera – moist, glossy, clear, white sclera
  31. 31. Eversion of the upper eyelid FYI – we will not do this examine in lab see pg. 312 for technique – usually done for complaint of eye pain due to foreign body
  32. 32. Lacrimal Apparatus – Person looks down – Using thumbs, slide outer part of upper lid along bony orbit – Note redness or swelling – Press index finger against lacrimal sac at inner canthus – Normal response is slight eversion of lower lid, no tearing or discharge
  33. 33. Anterior Eyeball StructuresAnterior Eyeball Structures Cornea & lens Iris & pupil – Size & shape – Pupillary light reflex – Accommodation
  34. 34. Cornea & LensCornea & Lens Shine light from side across cornea Check smoothness, clarity Normally no opacities
  35. 35. Iris and PupilIris and Pupil Iris = flat, round, regular, even color bilaterally. Pupils = PERRLA – Resting size norm = 3-5mm – 5% population have pupils of 2 diff. Sizes called Anisocoria
  36. 36. Pupillary Light Reflex – Darken room – Person gazes straight ahead – Advance light from the side  Direct light reflex  Consensual light reflex – Measure pupil size before & after light reflex – Measurement R3/1 L3/1 =both pupils measure 3mm in resting state & 1mm with light
  37. 37. Accomodation – focus on distant object -dilatation of pupils – Shift gaze to near object – pupils constrict & converge Record the normal response to these tests as  PERRLA = Pupils Equal, Round, React to Light and Accomodation
  38. 38. Ocular Fundus (internalOcular Fundus (internal surface of retina)surface of retina) Use Opthalmoscope- try keeping both eyes open- practice looking at a ring on your finger. Become familiar with the instrument before you examine your partner’s eyes
  39. 39. Diopter of opthalmoscope – Black numbers = +diopter, focus on near objects – Red numbers = - diopter, focus on further objects Use ophthalmoscope in darkened room = dilates pupils
  40. 40. Remove examiner’s and person’s eyeglasses but contact lenses may be left in. Select lg. White aperture light Person should focus on a distant object and try & remain still Examiner hold ophthalmoscope in Right hand to right eye to eamine person’s right eye
  41. 41. Begin 10in away at 150 lateralangle & advance Keep sight of red reflex Adjust lens to +6 as you advance till your foreheads almost touch. Adjust diopter to focus. – Normal vision set at 0. Nearsighted use red #s. Farsighted use black.
  42. 42. Retinal backgroundRetinal background Light – dark red normally Note Lesions – Size, shape, color, distribution
  43. 43. Macula & Fovea CentralisMacula & Fovea Centralis Last in Funduscopic exam – 1 DD in size – Darker than rest of fundus – Foveal light reflex – Exam last
  44. 44. Retinal VesselsRetinal Vessels Arteries Veins COLOR Light red Dark red SIZE Smaller 2/3 to 4/5 diam. Of veins Larger LIGHT REFLEX Bright Inconspicuous absent
  45. 45. Read Aging & DevelopmentalRead Aging & Developmental ConsiderationsConsiderations Review Abnormalities of the Eyes
  46. 46. 3 most common causes of3 most common causes of decreased visual functioning indecreased visual functioning in the older adultthe older adult Cataract (lens opacity) Glaucoma (increased ocular pressure) = loss of peripheral vision Macular degeneration (breakdown of cells in the macula lutea) = loss of central vision