This document provides information on performing a physical assessment of the eyes and ears. It discusses important landmarks to inspect in the eyes including the eyelids, eyebrows, lacrimal apparatus and positioning. Common eye conditions like blepharitis, chalazion, styes, ptosis, and nystagmus are described. Assessment techniques for the eyes include checking visual acuity, extraocular muscle function, visual fields, pupillary response, and ophthalmoscopy. For the ears, inspection, otoscopy and tests of auditory function like the Weber test and Rinne test are outlined. Common causes and presentations of conductive and sensorineural hearing loss are also summarized.

1. Physical Assessment of Eye and
Ear
by
Dr. Nahla Shaaban khalil
Critical Care Nursing Department
Cairo university

2. Important landmarks of the external eye

3. 1. Structures to Inspect
•Position and alignment of eyes
•Eyebrows
•Eyelids
•Lacrimal Apparatus
Inspection of eye

4. Blepharitis is an
inflammation along
the edges of the
eyelids.
can experience
irritated, itchy
eyelids that may
appear greasy and
crusted with scales
that cling to the
lashes.
blepharitis

5. chalazion
is a bacterial
infection of
the oil
glands just
behind the
base of the
eyelashes.

6. stye
is a bacterial
infection
involving one or
more of the small
glands near the
base of your
eyelashes. It is
similar to a boil or
a pimple and is
often painful

7. ptosis
is a drooping or
falling of the
upper or lower
eyelid

8. Nystagmus
Involuntary eye
movement ,may
be congenital or
acquired in life

9. subconjunctival hemorrhage
A bright hemorrhagic
patch on the bulbar
conjunctiva caused by
rupture and bleeding of a
superficial small
capillary, due to ↑
pressure–

10. is blood in the front
(anterior chamber of the eye
It may appear as a reddish
tinge, or it may appear as a
small pool of blood at the
bottom of the iris or in the
cornea.
Hyphema

11. Anisocoria
unequal
pupils) of less
than 1 mm

12. hypopyon:
(layer of white
blood cells
[WBCs] in the
anterior
chamber).

13. -Entropion
Eyelid usually the lower
lid) folds inward.

14. Ectropion:
the
lower eyelid
turns
outwards.

15. the swelling (or edema)
of the conjuctiva It is
due to exudation
Chemosis:

16. Pterygium
a wing like structure,
especially an abnormal
triangular fold of
membrane in the
interpalpebral fissure,
extending from the
conjunctiva to the cornea.

17. Eyes
Visual Acuity
3.Checks acuity
with Snellen and
from proper
distance
4.Checks acuity
both eyes
separately

18. Snelling Eye Chart
Hand held eye chart

19. Visual Acuity
Hold card approx 14” from pt’s nose  Ask pt to cover one eye
 Read smallest line  Cover other eye and repeat

20. Extraocular Muscles and Direction of Movement
The extraocular movements of each are controlled by the 4 rectus and 2 oblique muscles
The extraocular movements may be tested by having the patient move the eye in the
direction controlled by each muscle.
This may be accomplished by having the patient move their eyes in the
six cardinal direction depicted on this diagram.

22. Six Cardinal Positions of Gaze
Need our picture

23. Extraocular Movements
•Ask the pt to hold his/her head still and to follow your finger
with their eyes

24. Convergence and
Accommodation
Needs illustration

25. 17 –20: Visual Fields
•Ask the pt to cover
one eye
•Cover your opposite
eye
•Ask the pt to look
straight ahead
•Place one hand in the
plane between the
patient and the
examiner out of your
vision
•Move the hand and
ask the patient when
he/she can see your
hand

26. 19. Both eyes should be
checked for stimulation
simultaneously.
•Place hands in the
lateral field of both eyes
ask the pt to note which
hand is moving and at
some point move both
hands.
•Each of the examiners
hands should be visible
by only one of the pt’s
eyes.
•If the pt can only see
one hand moving when
both handsare moving,
this may indicate a small
defect in the occipital
cortex.

27. Pupillary Light Response
Observe reflection of pen light in both pupils. Is it symmetrical?
Test the papillary response to light
•Direct response – pupil constricts in examined eye
•Consensual (Indirect) response – pupil constricts in the opposite eye

28. Swinging Flashlight Test
Detects optic nerve disease vs occular disease
•A bright light is placed in front of one eye and moved
quickly to the other eye, then one or two seconds later
moved quickly back to the first eye.
•The pupils should remain constricted when the light is
taken from one eye quickly to the other

30. Ophthalmoscopy
pg 355
• Red reflex: presence, opacities
• Optic disc and physiologic cup: color,
size, shape, borders, cup-disc ratio
• Retinal vessels: size ratio of arteries and
veins, color, arteriole light reflex, crossings
• Retina: color, texture, exudates, lesions,
hemorrhages, and aneurysms
• Macula and fovea: color, size, location,
lesions

32. Physical Examination
Ears
EARS: Inspects externally bilaterally (including behind ears)
Palpates auricles bilaterally
Otoscopic examination bilaterally
Otoscopic examination performed without pain
Auricles pulled superiorly, posteriorly, and away from patient
Auditory acuity tested (eyes closed if finger rub and you can see movement of
hands or arm)
Auditory acuity tested correctly (each ear independently, etc.)

34. 34

35. 35

36. 36. The ears need to be closely inspected, including behind the ears.
37. Palpate the ears between two fingers for any masses or tenderness.
Now is a good time to ask the patient if he/she has noticed any change in their
hearing.

37. Auditory acuity needs to be tested in both ears independently.
•Having the patient cover their other ear and lightly rubbing your fingers from 3 feet and ask the
patient to tell you when they hear it, and move your fingers closer to the patient can approximate
auditory acuity.
•The patient's eyes need to be closed if you use the finger rub to test acuity, since they may see
your arm or clothing move.You could also cover your mouth and whisper numbers or letters from
three (3) feet and move closer to the patient and have the patient repeat what you are saying.
•The person with normal hearing will be able to hear your fingers anywhere from when you start to

38. Weber Test : The Weber test uses bone conduction to test
lateralization of sound. A tuning fork (ideally, 512 Hz), set in
motion by grasping it firmly by its stem and tapping it on the
examiner's knee or hand, is placed on the patient's head or
forehead. A person with normal hearing hears the sound
equally in both ears or describes the sound as centered in the
middle of the head. A person with such as from otosclerosis or
otitis media, hears the sound better in the affected ear. A person
with resulting from damage to the cochlear or vestibulocochlear
nerve, hears the sound in the better-hearing ear. The Weber test is
useful for detecting unilateral hearing loss38

39. 39

40.  Rinne Test :In the Rinne test (pronounced ), the examiner shifts the
stem of a vibrating tuning fork between two positions: 2 inches from
the opening of the ear canal (for air conduction) and against the
mastoid bone (for bone conduction). As the position changes, the
patient is asked to indicate which tone is louder or when the tone is no
longer audible. The Rinne test is useful for distinguishing between
conductive and sensorineural hearing loss. A person with normal
hearing reports that air-conducted sound is louder than bone-
conducted sound.
40

41. A person with a conductive
hearing loss hears bone-
conducted sound as long as or
longer than air-conducted
sound.
A person with a sensorineural
hearing loss hears air-
conducted sound s and bone-
conducted sounds are equally
diminished
41

42. Conductive Hearing Loss
• Conductive hearing loss
Occurs when sound is not conducted efficiently
through the outer ear canal to the eardrum
and the tiny bones (ossicles) of the middle
ear.
• Conductive hearing loss usually involves a
reduction in sound level or the ability to hear
faint sounds. This type of hearing loss can
often be corrected medically or surgically.

43. causes of conductive hearing loss
- Fluid in the middle ear from colds
• Ear infection (otitis media)
• Allergies (serous otitis media)
• Poor eustachian tube function
• Perforated eardrum
• Benign tumors
• Impacted earwax (cerumen)
• Infection in the ear canal (external otitis)
• Presence of a foreign body

44. Sensorineural Hearing Loss
• Sensorineural hearing loss (SNHL) occurs when
there is damage to the inner ear (cochlea), or to
the nerve pathways from the inner ear to the
brain.
• Most of the time, SNHL cannot be medically or
surgically corrected.
• This is the most common type of permanent
hearing loss.

45. Some possible causes of SNHL:
• Illnesses
• Drugs that are toxic to hearing
• Hearing loss that runs in the family (genetic
or hereditary)
• Aging
• Head trauma
• Malformation of the inner ear
• Exposure to loud noise

46. Otoscope
Holding the Otoscope

47. Otoscopic examination needs to be done bilaterally.
•You should always be visualizing the opening to the ear canal before and
• while advancing the speculum. (This will avoid causing undue pain.)
•In adults, the auricle is pulled posteriorly, superiorly and away from the patient to straig
•This will help facilitate visualization of tympanic membrane.

48. Preventions
• Be caution while removing your wax
• Using ear plug

49. 49

52. Eardrum perforation
• Otalgia
• Bleeding
• Fullness
• Hearing loss: conductive HL
or mixed HL
• Tinnitus
• Shape of perforation is split