assessment of eyes and ears by b.lokay, md, phd institute of nursing, tsmu
TRANSCRIPT
Assessment of Eyes and Ears
By B.Lokay, MD, PhDBy B.Lokay, MD, PhD
Institute of Nursing, TSMUInstitute of Nursing, TSMU
Eye Anatomy – Why Study It?
Why should you care?
Optometrist – Doctor of optometry, 4 year undergrad + 4 year optometry school
Ophthalmologists – Medical doctors In general, optometrists practice primary
and preventive eye care, while ophthalmologists perform eye surgery
What do nurses do?
History
Vision difficulty? Halos around lights – in glaucoma Scotoma – blind spot in visual field – in
glaucoma, optic nerve, and visual pathway disorder
Night blindness – Vit A deficiency, glaucoma,
Eye pain? Photophobia – inability to tolerate light
Childhood strabismus? A history of crossed eyes? AKA “lazy eye”
Redness or swelling? Infections?
History cont.
Excessive or lack of tearing? May be due to irritants or obstruction in drainage
Past history of ocular problems? Glaucoma? Family history? Use of glasses or contact lenses? When tested last? Any medications?
Anatomy of Eyelid
Eyelids (L. palpebrae) protect the cornea and eyeball from injury
Canthi (sing. canthus) are corners of the eye, also called angles of eye
Caruncle is located near medial canthus and contains sebaceous glands
Tarsal plates are made of connective tissue and strengthen eyelid. They contain meibomian (tarsal) glands which secrete lipid to create airtight seal when closed and also prevent eyelids from sticking together
Inspecting External Ocular Structures General
Note if facial expression is relax or tense
Eyebrows Note if movement is symmetrical
Eyelids and lashes Note if any redness, swelling,
discharge or lesions Note if eyelid closes completely and if
drooping Pallor of lower lid is good indicator of
anemia For upper eyelid, use applicator stick
to fold the eyelid over
Abnormalities in Eyelids
Ectropion Lower lid rolls out, causing an
increase in tearing The eyes feel dry and itchy due to
inappropriate itching Increase risk for inflammation Occurs mostly in elderly due to
atrophy of elastic tissue
Entropion The lower lid rolls in Foreign body sensation
Abnormalities in Eyelids
Periorbital edema May occur with local
infection or systemic condition
Ptosis Occurs with
neuromuscular weakness (myasthenia gravis) or CN III damage
Lesions on the Eyelids
Blepharitis Inflammation of eyelids Staph or dermatitis Burning, itching, tearing,
foreign body sensation, pain
Chalazion A cyst in or an infection of
meibomian gland Nontender, firm, overlying
skin freely movable
Hordeolum (Stye) Localized Staph infection of
hair follicle at lid margin Painful, red, swollen, purulent
Anatomy of the Eye Lacrimal apparatus
provides irrigation of conjunctiva Lacrimal glands – secrete
lacrimal fluid (tears) Lacrimal ducts – lacrimal
fluid to conjunctiva Lacrimal canaliculi
(puncti) – drain fluid into Nasolacrimal duct –
conveys lacrimal fluid to nasal cavity
Inspecting the Lacrimal Apparatus
Inspect for bulges or pressure near canaliculi
Dacryocystitis Inflammation of the
lacrimal sac and/or nasolacrimal duct
Dacryoadenitis Infection of lacrimal
gland
DacryocystitisDacryoadenitis
Anatomy of Extraocular Muscles 4 rectus (straight) 2 oblique Innervations
SO4 – Superior oblique m. CN IV (trochlear n.)
LR6 – Lateral rectus m. CN VI (abducens n.)
AO3 – All other muscles CN III ( Trigeminal n.)
Extraocular muscle movement
Extraocular Muscle Dysfunction
Anatomy of the Eyeball – Outer Layer
Sclera – tough protective white covering (posterior 5/6)
Cornea – transparent part of the fibrous coat covering the anterior of the eyeball (anterior 1/5)
Conjunctiva – transparent protective covering of exposed part of eye (palpebral conjunctiva covers inside of eyelash)
Corneal reflex – lightly touching the eye with cotton stimulates a blink.
Trigeminal n. (afferent) Facial n. (efferent)
iris
Inspection
Conjunctiva Sliding the lower lids down, observe
for redness on conjunctiva and if eyeball looks moist and glossy
Reddening may be pathogenic Sclera
Should be white, although may have gray-blue hue
Might contain yellowish fatty deposits beneath the lids
Yellowing of sclera indicates jaundice
Vascular Disorders of Eye
Conjunctivitis “Pink eye” Due to bacterial, viral, allergic, or chemical
irritation Redness throughout the conjunctiva, but
usually clear around the iris Purulent discharge usually common Symptoms: itching, burning, foreign body
sensation Iritis
Red halo around the iris and cornea Pupils may be irregular due to swelling Symptoms: photophobia, blurred vision,
throbbing pain
Inspecting Cornea and Lens
Corneal abrasion Assess by shining a light
and observing from the side
Pupillary light reflex Charted according to size
of pupil Charted as a ratio of before
light/after light (3/1) A sluggish response may
be caused by increased ICP
No response may indicate neurological damage
PERRLA:Pupils Equal, Round,React to Light and Accommodation
How to chart pupillary light reflex?
Anatomy of the Eyeball – Middle Layer
Choroid – provides vascularity to retina
Pupil – variable-sized, black circular or slit shaped opening in the center of the iris that regulates the amount of light that enters the eye. Appears black because most of the light entering the pupil is absorbed by the tissues inside the eye.
Lens – biconvex disc controlled by the ciliary muscle to produce far vision when flat
Anterior chamber Aqueous humor is produced by the
ciliary body and secreted into posterior chamber of eye.
From there, aqueous humor travels to the anterior chamber where it exits through the Canal of Schlemm
Determines intraocular pressure
Canal of Schlemm
Increase leads toGlaucoma
Vascular Disorders of Eye
Glaucoma Excessive pressure in eye
due to blockage of outflow from anterior chamber
This puts pressure on optic nerve
Redness around the iris, dilated pupils
Symptoms: sudden clouding of vision, sudden eye pain, and halos around lights
Physiology review:Aqueous humor is produced by the ciliary bodyand secreted into posterior chamber of eye. From there, aqueous humor travels to the anterior chamber where it exits through the Canal of Schlemm
Disorders of Opacity of Lens
Cataract
Anatomy of the Eyeball – Inner Layer Retina – visually
receptive layer where light waves are changed to nerve impulses
Optic disc – area where the optic nerve enters the eyeball
Fovea centralis – area of most acute vision
Inspecting the Ocular Fundus
Using an ophthalmoscope to inspect the internal surface of the retina, anterior chamber, lens, and vitreous.
Darken the room to dilate the pupils Remove eye glasses, contacts may
stay in Ask person to stare at distant object Hold ophthalmoscope close to your
eye and move to within a few inches of the person’s face
A red glow filling the pupil is called the red reflex and is caused by light reflecting off the retina Cataracts appear as opaque black
areas against the red reflex
Inspecting the Optic Disc and Retina
Normal optic disc is: Yellow-orange to pink Round or oval Distinct margins
Normal retina is: Arteries in each
quadrant Arteries are bright red
Visual pathways
Testing Visual Reflexes Pupillary light reflex
Constriction of pupils when bright light shines on the retina Direct light reflex – constriction of same sided pupil Consensual light reflex – simultaneous constriction of both
pupils The impulse is carried afferently by CN II and efferently by CN III
Accommodation Adaptation of eye for near vision Ask person to focus on distant object (dilates the pupils). Then
ask person to shift gaze to near object few inches away. A normal response is pupillary constriction and convergence of axes of the eyes
Testing Visual Accuity
Snellen Eye Chart Standing 20 feet from the
chart Test one eye at a time by
covering the other eye Leave contact lenses and
glasses on, unless the glasses are reading glasses
Normal vision is 20/20 Near vision
Use Jaeger card (smaller version of Snellen chart) or just read newspaper
Testing Visual Fields Confrontation test
Measures peripheral vision compared to examiner (assuming examiner’s vision is normal)
Both examiner and pt cover one eye with a card, stand about 2 feet away, and maintain eye contact
Advance finger, starting from periphery, and ask patient to say “now” when the finger is first visible
Inability to see when the examiner sees suggests peripheral field loss
Testing Ocular Muscle Function
Cover Test Detects deviated alignment of eyes Ask pt. to stare straight at your nose and
cover one of the pt.’s eyes with a card While noting the uncovered eye, move
away the card A normal response is a steady fixed gaze
Diagnostic Position Test Ask pt. to hold head straight and move
finger in all positions, holding it about 12 inches away
A normal response is parallel tracking of the objects with both eyes
Nystagmus Fine oscillating movements around the iris Normal at extreme lateral gaze
Developmental Considerations – Infants and Children
Strabismus – must be detected and treated early to prevent permanent disability Esotropia – inward turning of eye Exotropia – outward turning of eye
Color vision – due to inherited X-linked recessive trait, occurs more often in boys
External eye structures – an upward lateral slope together with epicanthal folds occurs in Down syndrome
Ophthalmia neonatum – conjunctivitis due to bacteria, virus, or chemical irritation
Developmental Considerations – Aging Decrease in visual
acuity, diminished peripheral vision
Ectropion (drooping of lower lid) or entropion (eyelids turning in)
Pinguecula – yellow nodules due to thickening of conjunctiva as a result of prolonged exposure to sun, wind, and dust
Developmental Considerations - Aging Arcus senilis – gray-
white arc seen around the cornea. Due to deposition of lipids. No effect on vision
Xanthelasma – raised yellow plaques. Normal
Ear Anatomy
Ear Physiology
External Ear External auditory meatus funnels sound waves, which reflect off the tympanic
membrane to produce vibrations Cerumen (ear wax) protects the tympanic membrane from foreign substances
Middle ear Malleus, incus, and stapes and eustachian tube Function to:
Conduct sound vibrations from tympanic membrane (outer ear) to cochlea (inner ear)
Protect the cochlea by reducing the amplitude of sounds Eustachian tube allows equalization of air pressure
Inner ear Vestibule and semicircular canals
Allow brain to sense body position and relation of angle of head to gravity Cochlea
Transfers vibrations from stapes into nerve impulses
The outer ear catches the waves of sound and funnels them down the ear canal (about an inch long) and flush up against the ear drum. The ear drum (tympanic membrane) is the boundary between the outer ear and the middle ear.
In the middle ear, the malleus picks up the vibrations from the eardrum, passes them to the incus which then passes them to the stapes. The stapes terminates in a tiny footplate that fits precisely into the contact point or window of the inner ear.
The window of the inner ear is the contact point of the cochlea. The vibrations set up rolling waves in the cochlear fluid which stimulate different areas of the membrane, which rubs against specialized cells called hair cells. This friction creates electrical impulses transmitted by the cochlear nerve.
CN VIII is responsible for signal transduction from vestibule and cochlea to the brainstem. From brainstem, a signal is sent to the cerebral cortex to interpret the sound.
Hearing Loss
Conductive Mechanical dysfunction of external or middle ear Partial hearing loss May be caused by impacted cerumen, foreign bodies,
perforated tympanic membrane, pus or serum in middle ear, or otosclerosis (hardening of stapes)
May be fixed Sensorineural
Dysfunction of inner ear, CN VIII, or cerebral cortex Cannot be fixed
Developmental Considerations Infants Greater risk for otitis media (middle ear infections) due to shorter
eustachian tube Aging
Cilia lining ear canal become coarse and stiff, impeding sound waves Cerumen more common
Dry cerumen – gray and flaky. More common in Asians and Native Americans
Wet cerumen – brown and moist. More common in whites and blacks
Presbycusis - degenerative sensorineural hearing loss Auditory reaction time increases
Obtaining History Earaches? (otalgia)
Location, character, intensity, associative and alleviating factors May be directly due to ear disease or maybe referred pain from
a problem in teeth or oropharynx A viral or bacterial upper respiratory infection may migrate up the
eustachian tube and involve the middle ear
Infections? Frequency? Occurred in childhood?
Discharge? (otorrhea) May suggest infection or perforated eardrum Typically with perforation, ear pain drainage
Otitis externa – purulent, sanguineous, or watery Acute otitis media with perforation – purulent discharge
More History
Trouble hearing? Gradual our sudden?
Presbycusis – gradual sensorineural hearing impairment in the elderly Hearing loss due to trauma is often sudden
Ringing in ears? (tinnitus) May be a result of medication
Medications? Some are ototoxic
Vertigo? (spinning) Subjective – person feels like he or she spins Objective – person feels like room spins
Environmental noise Noise-induced hearing loss
Lesions of External Ear
Gouty Tophi
Otitis Externa
Assessing External Ear
Size and Shape normal is 4-10cm tall
Skin conditions Note edema, inflammation, lesions
Tenderness Location?
Pain in pinna indicates otitis externa Pain at mastoid process indicates mastoiditis or lymphadenitis
External Auditory Meatus Atresia – absence or closure of ear canal Otitis externa may cause purulent discharge Otitis media may cause rupture of tympanic membrane If drainage present following trauma, possible basal skull fracture.
Perform glucose test (CSF (+) for glucose).
Inspecting Using Otoscope
Pull the pinna up and back in adult, straight down in children under 3 years
Hold otoscope upside down and place dorsal side of hand along person’s cheek
Insert speculum slowly and avoid touching the inner section of canal wall, which is sensitive and may cause pain.
Inspecting the External Canal
Note any redness or swelling, lesions, or foreign bodies
If discharge present, note color and odor
OtitisExterna
Inspecting the Tympanic Membrane Normal is shiny and
translucent Flat, slightly pulled in
at the center Valsalva maneuver
causes tympanic membrane to flutter, used to assess drum mobility
Which tympanic membraneis perforated?
Testing Hearing Acuity
Voice test Whisper two syllable words
into one of the person’s ears, while covering the other one. Ask person to repeat what you’ve said.
Tuning fork tests Measure hearing by air
conduction or bone conduction
Weber test Rinne test
Weber Test
Tuning fork is struck and placed on head or forehead, equal distance from both ears
Used to determine if hearing loss is more extensive in one ear than the other
This test cannot confirm normal hearing, because hearing defects affecting both ears equally will produce an apparently normal test result
Rinne Test
Compares air conduction and bone conduction
Place stem of vibrating fork on mastoid process and ask when sound goes away
Quickly invert the fork so the vibrating end is near the ear canal. The person should still hear a sound
Normally the sound is heard longer by air conduction rather than bone conduction In conductive hearing loss, sound
heard longer by bone conduction
Normal Hearing
Conductive Hearing Loss
Sensorineural Hearing Loss
Infants and Children Save otoscopic examination until the end May help to show otoscope to child and let
him or her play with it Stabilize (or ask a parent for help) the
child’s head in order to prevent movement Pull pinna straight down In infants, the tympanic membrane may
look thick and opaque after first few days or after crying
Tympanostomy tubes may be in place if drainage occurs as a result of otitis media
Abnormalities in the Ear Canal
Excessive Cerumen
Acute Otitis Media
Otitis Externa
Question 1
A nurse is performing a voice test to assess hearing. Which of the following describes the accurate procedure for performing this test?
1. Stand 4 feet away from the client to ensure that the client can hear at this distance
2. Quietly whisper a statement and ask the client to repeat it
3. Whisper a statement with the examiner’s back facing the client
4. Whisper a statement while the client blocks both ears
Question 2
A nurse is caring for a client who is hearing impaired. Which of the following approaches will facilitate communication?
1. Speak frequently
2. Speak loudly
3. Speak directly into the impaired ear
4. Speak in a normal tone
Question 3
A client is diagnosed with a disorder involving the inner ear. Which of the following is the most common client complaint associated with a disorder involving this part of the ear?
1. Hearing loss2. Pruritus3. Tinnitus4. Burning in the ear
Question 4
Which of the following statements made by a parent should make the nurse suspicious that the tympanic membrane of a young child has ruptured?
1. “She has been crying all night, but she feels better this morning.”
2. “She has some bloody, yellow-looking stuff coming out of her ear.”
3. “My child does not seem to hear very well.”4. “My child’s earwax is dark brown.”
Question 5
While examining the internal ear, the nurse observes the light reflex on the tympanic membrane. What does this finding indicate?
1. Presence of pus
2. Fluid accumulation
3. Scar tissue
4. Normal finding