NurseReview.Org - Eyes

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NurseReview.Org - Eyes

  1. 1. Eyes
  2. 2. External Anatomy <ul><li>Sensory Organ for vision </li></ul><ul><li>-Situated in bony, orbital cavity for protection </li></ul><ul><ul><li>Eyelids= shades that add protection form injury, strong light , dust </li></ul></ul><ul><ul><li>Eyelashes= hairs to filter dust & dirt </li></ul></ul>
  3. 3. External Anatomy External Anatomy
  4. 4. <ul><li>Limbus – border b/t the cornea & sclera </li></ul><ul><li>Palpebral fissures – elliptical open space b/t lids </li></ul><ul><li>Canthus- corners of the eye where the lids meet, inner & outer </li></ul><ul><li>Caruncle – sm. Fleshy mass containing sebaceous glands at inner canthus </li></ul>
  5. 5. <ul><li>Within the upper eyelid </li></ul><ul><ul><li>Tarsal plates, connective tissue gives upper lid shape </li></ul></ul><ul><ul><li>Meibomian glands, in the plates, lubricate the lids, stops overflow of tears, airtight seal when lids closed </li></ul></ul>
  6. 6. <ul><li>Exposed part of the eye </li></ul><ul><ul><li>Conjunctiva, folded envelope b/t eyelids & eyeball </li></ul></ul><ul><ul><ul><li>thin mucous membrane, transparent protective covering of the exposed part of the eye. </li></ul></ul></ul><ul><ul><ul><li>Palpebral conjunctiva lines the lids, is clear but has sm .bld. Vessels </li></ul></ul></ul><ul><ul><ul><li>Bulbar conjunctiva is over eyeball, white sclera show through, merges at limbus with cornea </li></ul></ul></ul>
  7. 7. <ul><li>Cornea – clear, covers & protects iris & pupil </li></ul>
  8. 9. <ul><li>Lacrimal apparatus – irrigates conjunctiva & cornea </li></ul><ul><ul><li>3 parts </li></ul></ul><ul><ul><ul><li>Lacrimal gland, upper, outer corner of eye = tears </li></ul></ul></ul><ul><ul><ul><li>Puncta= inner canthus, tear drainage </li></ul></ul></ul><ul><ul><ul><li>Nasolacrimal duct= allows tears to drain from puncta to nasolacrimal sac. Tears then empty into the inferior meatus of the nose </li></ul></ul></ul>
  9. 11. Extraoccular muscles <ul><li>6 muscles </li></ul><ul><ul><li>Attach eyeball to orbit </li></ul></ul><ul><ul><li>Straight and rotary movement </li></ul></ul><ul><ul><li>Four straight muscles </li></ul></ul><ul><ul><ul><li>Superior rectus </li></ul></ul></ul><ul><ul><ul><li>Inferior rectus </li></ul></ul></ul><ul><ul><ul><li>Lateral rectus </li></ul></ul></ul><ul><ul><ul><li>Medial rectus </li></ul></ul></ul>
  10. 12. <ul><li>Two slanting/ oblique muscles </li></ul><ul><ul><li>Superior </li></ul></ul><ul><ul><li>Inferior </li></ul></ul><ul><li>Humans have a Binocular, single – image visual system – Eyes normally move as a pair </li></ul>
  11. 13. <ul><li>Eye movement stimulated by Cranial Nerves </li></ul><ul><ul><li>III Oculomotor </li></ul></ul><ul><ul><li>IV Trochlear </li></ul></ul><ul><ul><li>VI Abducens </li></ul></ul>
  12. 16. Internal Anatomy <ul><li>The eye has 3 layers, the outer & inner layer can be viewed using opthalmascope </li></ul><ul><ul><ul><li>Sclera (outer layer) tough, protective, white covering connects with the - </li></ul></ul></ul><ul><ul><ul><ul><li>Cornea – transparent, protects pupil & iris – helps focus light on retina </li></ul></ul></ul></ul>
  13. 17. <ul><ul><ul><li>Middle layer </li></ul></ul></ul><ul><ul><ul><ul><li>Choroid – dark pigmentation to prevent internal light reflection, supplies bld. to retina </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pupil – PERRLA </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Lens – biconvex disc, transparent, thickness controlled by ciliary body, bulges = near; flattens = distant </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Anterior chamber – posterior to cornea, anterior to iris & lens, has aqueous humor supplies nutrients & drains wastes </li></ul></ul></ul></ul>
  14. 18. <ul><li>Inner layer – Retina – visual receptive layer – light waves changed to nerve impulses </li></ul><ul><ul><li>Retinal structures </li></ul></ul><ul><ul><ul><li>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 </li></ul></ul></ul><ul><ul><ul><li>Retina vessels – paired arteries & veins </li></ul></ul></ul>
  15. 19. <ul><ul><ul><li>Macula – temporal side of fundus, darker pigmented region, surround the fovea centralis </li></ul></ul></ul><ul><ul><ul><li>Fovea Centralis- area of sharpest & keenest vision, Very sensitive to light </li></ul></ul></ul>
  16. 21. Visual Pathways & Fields <ul><li>Objects reflect light </li></ul><ul><li>Rays refracted by cornea, aqueous humor, lens, vitreous body and onto retina. </li></ul><ul><li>Light stimulus is changed to nerve impulses, travel thru optic nerve to visual cortex in occipital lobe </li></ul><ul><li>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. </li></ul>
  17. 23. Visual reflexes <ul><li>Pupillary light reflex – bright light = constriction </li></ul><ul><ul><li>Direct light reflex </li></ul></ul><ul><ul><li>Consensual light reflex </li></ul></ul><ul><li>Fixation – ability to track an object & keep image on the fovea, can be impaired by drugs, alcohol, fatigue & inattention </li></ul><ul><li>Accomodation – for near vision = pupil constriction & convergence of eyes </li></ul>
  18. 26. Subjective data <ul><li>Vision difficulty </li></ul><ul><li>Pain </li></ul><ul><li>Strabismus, diplopia </li></ul><ul><li>Redness, swelling </li></ul><ul><li>Watering, discharge </li></ul><ul><li>Past history ocular problems </li></ul><ul><li>Glaucoma </li></ul>
  19. 27. <ul><li>Glasses/ contacts </li></ul><ul><li>Medications </li></ul><ul><li>Vision loss- coping mechanisms </li></ul><ul><li>Self–care behaviors </li></ul>
  20. 28. Objective data The Physical Exam <ul><li>Preparation </li></ul><ul><ul><li>Position- sitting, head at eye level </li></ul></ul><ul><li>Equipment </li></ul><ul><ul><li>Snellen eye chart- visual acuity </li></ul></ul><ul><ul><li>Handheld visual screener-near vision </li></ul></ul><ul><ul><li>Opaque card </li></ul></ul><ul><ul><li>Penlight </li></ul></ul><ul><ul><li>Applicator stick </li></ul></ul><ul><ul><li>Ophthalmoscope </li></ul></ul>
  21. 29. Test visual acuity Snellen eye chart <ul><li>Stand 20 ft. from chart </li></ul><ul><li>Glasses / contacts (Document ) </li></ul><ul><li>Remove eye wear, retest </li></ul><ul><li>Normal visual acuity is 20/20 – top # is distance person is standing from the chart </li></ul><ul><li>Vision 20/30 refer to opthalmologist or optometrist </li></ul><ul><li>If unable to see largest letters, move to 10 feet – record as 10/200 </li></ul>
  22. 30. Test for near vision <ul><li>Vision screener </li></ul><ul><li>People > 40yrs or difficulty reading </li></ul><ul><li>Test each eye with glasses </li></ul><ul><li>Hold card 14in. from eyes </li></ul><ul><li>Normal result 14 / 14 </li></ul><ul><li>Test using any available reading material if no card available </li></ul>
  23. 31. <ul><li>Presbyopia is a normal physiological change in near vision occurs with aging = note if the person moves the card farther away </li></ul>
  24. 32. Test visual fields Confrontation test <ul><li>Compares peripheral vision with a tester who has normal peripheral vision </li></ul><ul><li>2 ft. apart, eye level </li></ul><ul><li>Tester & client cover opposite eyes </li></ul><ul><li>Tester advances finger in the periphery </li></ul><ul><ul><li>Superiorly ( 50 degrees ) </li></ul></ul><ul><ul><li>Inferiorly ( 70 degrees ) </li></ul></ul><ul><ul><li>Temporally ( 90 degrees ) </li></ul></ul>
  25. 34. Inspect Extraoccular Muscle Function <ul><li>Corneal light reflex </li></ul><ul><li>Cover test </li></ul><ul><li>Diagnostic positions test </li></ul><ul><ul><li>6 Cardinal Positions of Gaze </li></ul></ul>
  26. 35. Inspect Extraocular Muscle Function <ul><li>Corneal Light Reflex ( The Hirschberg Test) assesses parallel eye alignment </li></ul><ul><ul><li>Shine light toward person’s eyes </li></ul></ul><ul><ul><li>Tell to stare directly ahead </li></ul></ul><ul><ul><li>Hold light 12 in. away </li></ul></ul><ul><ul><li>Light should reflect on both corneas in same spot </li></ul></ul>
  27. 36. <ul><li>Cover Test- detects deviated alignment </li></ul><ul><ul><li>Stare straight at examiner’s nose </li></ul></ul><ul><ul><li>Cover 1 eye of the person being examined with opaque card </li></ul></ul><ul><ul><li>Normally the uncovered eye should maintain a steady, fixed gaze </li></ul></ul><ul><ul><li>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.. </li></ul></ul>
  28. 37. Diagnostic Positions Test <ul><li>6 cardinal positions of gaze – </li></ul><ul><ul><li>Determines muscle weakness during movement </li></ul></ul><ul><ul><li>Person must hold head steady </li></ul></ul><ul><ul><li>Follow movement of object (examiner’s finger, pen etc) only with eyes </li></ul></ul><ul><ul><li>Hold object 12 in. from person </li></ul></ul><ul><ul><li>Move thru each position, clockwise, hold , then back to center </li></ul></ul><ul><ul><li>Normal response= parallel tracking with both eyes </li></ul></ul>
  29. 39. <ul><li>During this test be aware of Nystagmus- fine jerky movement seen around the iris </li></ul><ul><li>Mild nystagmus in extreme lateral gaze is normal but not normal in any other position </li></ul>
  30. 40. Inspect External Structures <ul><li>General – movement & facial expression (squinting?) </li></ul><ul><li>Eyebrows – 2(bilateral), symmetrical (look the same; move the same) </li></ul><ul><li>Eyelids & Lashes – present, approximate when closed, no redness, swelling, discharge, lesions? </li></ul><ul><li>Eyeballs- alignment, ? Protrusion? Sunken? </li></ul><ul><li>Conjunctiva & Sclera – moist, glossy, clear, white sclera </li></ul>
  31. 41. <ul><li>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 </li></ul>
  32. 44. <ul><li>Lacrimal Apparatus </li></ul><ul><ul><li>Person looks down </li></ul></ul><ul><ul><li>Using thumbs, slide outer part of upper lid along bony orbit </li></ul></ul><ul><ul><li>Note redness or swelling </li></ul></ul><ul><ul><li>Press index finger against lacrimal sac at inner canthus </li></ul></ul><ul><ul><li>Normal response is slight eversion of lower lid, no tearing or discharge </li></ul></ul>
  33. 46. Anterior Eyeball Structures <ul><li>Cornea & lens </li></ul><ul><li>Iris & pupil </li></ul><ul><ul><li>Size & shape </li></ul></ul><ul><ul><li>Pupillary light reflex </li></ul></ul><ul><ul><li>Accommodation </li></ul></ul>
  34. 47. Cornea & Lens <ul><li>Shine light from side across cornea </li></ul><ul><li>Check smoothness, clarity </li></ul><ul><li>Normally no opacities </li></ul>
  35. 48. Iris and Pupil <ul><li>Iris = flat, round, regular, even color bilaterally. </li></ul><ul><li>Pupils = PERRLA </li></ul><ul><ul><li>Resting size norm = 3-5mm </li></ul></ul><ul><ul><li>5% population have pupils of 2 diff. Sizes called Anisocoria </li></ul></ul>
  36. 49. <ul><li>Pupillary Light Reflex </li></ul><ul><ul><li>Darken room </li></ul></ul><ul><ul><li>Person gazes straight ahead </li></ul></ul><ul><ul><li>Advance light from the side </li></ul></ul><ul><ul><ul><li>Direct light reflex </li></ul></ul></ul><ul><ul><ul><li>Consensual light reflex </li></ul></ul></ul><ul><ul><li>Measure pupil size before & after light reflex </li></ul></ul><ul><ul><li>Measurement R3/1 L3/1 =both pupils measure 3mm in resting state & 1mm with light </li></ul></ul>
  37. 50. <ul><li>Accomodation </li></ul><ul><ul><li>focus on distant object -dilatation of pupils </li></ul></ul><ul><ul><li>Shift gaze to near object – pupils constrict & converge </li></ul></ul><ul><li>Record the normal response to these tests as </li></ul><ul><li>PERRLA = Pupils Equal, Round, React to Light and Accomodation </li></ul>
  38. 51. Ocular Fundus (internal surface of retina) <ul><li>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 </li></ul>
  39. 52. <ul><li>Diopter of opthalmoscope </li></ul><ul><ul><li>Black numbers = +diopter, focus on near objects </li></ul></ul><ul><ul><li>Red numbers = - diopter, focus on further objects </li></ul></ul><ul><li>Use ophthalmoscope in darkened room = dilates pupils </li></ul>
  40. 53. <ul><li>Remove examiner’s and person’s eyeglasses but contact lenses may be left in. </li></ul><ul><li>Select lg. White aperture light </li></ul><ul><li>Person should focus on a distant object and try & remain still </li></ul><ul><li>Examiner hold ophthalmoscope in Right hand to right eye to eamine person’s right eye </li></ul>
  41. 54. <ul><li>Begin 10in away at 15 0 lateral angle & advance </li></ul><ul><li>Keep sight of red reflex </li></ul><ul><li>Adjust lens to +6 as you advance till your foreheads almost touch. Adjust diopter to focus. </li></ul><ul><ul><li>Normal vision set at 0. Nearsighted use red #s. Farsighted use black. </li></ul></ul>
  42. 56. Retinal background <ul><li>Light – dark red normally </li></ul><ul><li>Note Lesions </li></ul><ul><ul><li>Size, shape, color, distribution </li></ul></ul>
  43. 57. Macula & Fovea Centralis <ul><li>Last in Funduscopic exam </li></ul><ul><ul><li>1 DD in size </li></ul></ul><ul><ul><li>Darker than rest of fundus </li></ul></ul><ul><ul><li>Foveal light reflex </li></ul></ul><ul><ul><li>Exam last </li></ul></ul>
  44. 59. Retinal Vessels Inconspicuous absent Bright LIGHT REFLEX Larger Smaller 2/3 to 4/5 diam. Of veins SIZE Dark red Light red COLOR Veins Arteries
  45. 60. Read Aging & Developmental Considerations Review Abnormalities of the Eyes
  46. 61. 3 most common causes of decreased visual functioning in the older adult <ul><li>Cataract (lens opacity) </li></ul><ul><li>Glaucoma (increased ocular pressure) = loss of peripheral vision </li></ul><ul><li>Macular degeneration (breakdown of cells in the macula lutea) = loss of central vision </li></ul>

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