Assessment of the Eyes
The eye and the ear are
sensory structures that connect us with the environment. They allow us to
perceive our surroundings through sight and sound. Disorders of the eye and the
ear can range from minor annoyances to life-threatening problems. Most problems
do not result in acute illness; however, they may be associated with more
serious neurological conditions such as brain tumor, stroke, or head injury.
No matter what the cause,
visual and hearing problems can have a major impact on physiological
functioning as well as psychological and social well-being. Early detection
reduces the likelihood of problems related to social interaction.
Determining whether a patient
has adequate vision and hearing is crucial before assessing mental status or
providing instructions.The eyes and the ears are common sites of injury; they
also exhibit structural variations as a result of age, cultural background, and
genetic inﬂuences. Although, for the sake of clarity, the eyes and the
ears are covered separately here, they are usually examined along with the head
and neck because of their location.
A thorough assessment of the
eyes and the ears includes vision and hearing screenings and examination of the
external and internal structures.The assessment provides not only speciﬁc
data about the eyes and the ears but also vital information on the health
status of other systems.
Before you begin your
assessment, an understanding of the anatomy and physiology of the eyes and the
ears is essential. You need to be able to identify normal structures before you
can identify abnormal ﬁndings, accurately perform the assessment, and
correctly interpret your ﬁndings. This chapter covers assessment of the
eyes ﬁrst and then assessment of the ears.
Anatomy and Physiology Review: The Eye
The primary function of the
eye is vision, including central and peripheral vision, near and distance
vision, and differentiation of colors. To accomplish these tasks, the external
and internal structures of the eye work together to receive and transmit images
to the occipital lobe of the brain for interpretation.Visual difﬁculties
can result from disease or injury to any of the structures involved in the
and Functions of the Eye. The eye consists of internal and
external structures that support or protect it.
We See. The ability to see objects in the environment
depends on light waves that reﬂect off images. Natural lighting produces
gradations of shading that help to determine an object’s shape and position in
the environment.The light rays pass through the cornea, anterior chamber,
pupil, lens, and posterior chamber to the back of the eye (retina).The
pupil,which is actually created by the aperture of a muscular layer of tissue
called the iris,dilates or constricts to allow more or less light onto the
retina.The lens, an elastic biconvex disc, bends the light waves entering the
eye by either ﬂattening or increasing the lens curvature.The precise functioning
of the pupil and iris together allows a clear image to focus on the retina.
Several conditions result from
variations in how or where the light rays entering the eye converge and focus.
People with myopia (nearsightedness) need to hold objects close to the eye to
see them clearly. In the myopic eye, the globe is elongated, causing light rays
to focus in front of the retina.When the globe is shorter than normal, light
rays focus at a point beyond the retina,producing a condition called hyperopia
(farsightedness). People with hyperopia must move close objects farther away to
see them clearly. Astigmatism is an irregular curvature of the lens or cornea
that causes light rays to scatter, blurring images on the retina (Fig. 12.6).
The retina is rich in sensory neurons, which are
necessary for reception and transmission of accurate images. The retina
contains specialized nerve cells called rods, which are sensitive to dim light,
and cone cells, which are sensitive to bright light and color. From the rods
and cones of the retina, the visual image is transmitted to the optic
disc,where the nerve ﬁbers of the retina converge to enter the optic
Nerve ﬁbers from the
optic disc join to form the optic nerve.The neural impulses are then
transmitted by the optic nerve to the optic track and optic radiations, where
they are interpreted by the visual cortex. Nerve ﬁbers from the nasal
portion of each eye cross over to the opposite side of the brain at the optic
chiasm. Fibers from the temporal portion of the retina of each eye do not cross
over before being received by the visual cortex in the occipital lobe of the
With Other Body Systems. The functions of the eyes are
interconnected with those of the cardiovascular, musculoskeletal, and
The Cardiovascular System. The optic
fundus is the only area in the body where blood vessels can be directly
observed without using invasive techniques.Use of an ophthalmoscope provides
direct visualization of the optic disc, where the vessels that supply the
retina emerge.Changes in the optic disc, blood vessels, macula, and general
background of the retina can reveal systemic problems with circulation as a
result of chronic hypertension (HTN) or diabetes. Or they can reveal localized
circulatory problems that occur with glaucoma, increased intracranial pressure,
and other neurological problems.
The Musculoskeletal System. Movement
of the eyes in a parallel or conjugate manner is made possible by the
coordinated movement of the extraocular muscles. Each of the six extraocular
muscles is responsible for rotating the eyes in a speciﬁc
direction and maintaining the eyes’ conjugate movement. Each extraocular muscle
is innervated by a speciﬁc cranial nerve (CN).
The superior rectus, inferior rectus, medial rectus, and inferior oblique
muscles are innervated by CN III.Damage to CN III can therefore result in
limited range of movement in the upward, downward, nasal, and upper diagonal ﬁelds
of vision.The remaining extraocular muscles, the lateral rectus and superior
oblique, provide movement of the eye in the temporal lateral and nasal inferior
direction, respectively. Damage to the nerves that innervate the lateral rectus
muscle (CN VI) and the superior oblique muscle (CN IV) can result in limited
eye movement in the corresponding directions.
Movement of the eyelid is
controlled by another set of muscles, the orbicularis oculi and the levator
palpebrae.The orbicularis oculi encircles the eyelids and is innervated by CN VII.Damage
to the orbicularis oculi muscle or the part of the cranial nerve that
innervates it results in an inability to close the eyelid completely.The
ability to raise or open the eyelid depends on an intact CN III,which
innervates the levator palpebrae muscle.
Constriction and relaxation of
the muscular tissue of the iris and ciliary body allows visual adaptation.In a
darkened environment,contraction of the smooth muscle of the iris causes the
aperture of the iris or pupil to dilate.As a result,more light enters the
retina and night vision is enhanced. In brightly lighted environments, the
retina does not need to receive additional light; as a result, the pupil is
The ciliary body, located
posterior to the outer edge of the iris, alters the shape of the lens and
allows the eye to adjust to near or far objects, an occurrence referred to as
accommodation. Constriction of the ciliary body results in ﬂattening of
the normal convex shape of the lens. Flattening of the lens facilitates the
eye’s ability to focus on objects in the distance. Relaxation of the ciliary
body allows the lens to assume its normal convex shape and facilitates focusing
on near objects.Both the iris and the ciliary body can be affected by damage to
CN III, resulting in pupil dilatation (mydriasis) and loss of accommodation.
The Neurological System. The ability
to see images depends on an intact visual pathway.From the time when an image
is received on the retina to the time when it is interpreted by the visual
cortex, the neurological system plays a key role. Damage to the retina can
result in diminished visual acuity or diminished color and night vision.Damage
to the optic nerve, a source of retinal nervous tissue, can result in similar
visual changes. Damage to speciﬁc points along the optic track or to the
visual cortex can produce deﬁcits in corresponding visual ﬁelds
The neurological system also
innervates the extraocular eye muscles, which control the movement of the eyes,
and the muscles of the eyelids, which control the opening and closing of the
eyes.The cranial nerves responsible for innervation of each of the six
extraocular muscles include CN III (oculomotor), CN IV (trochlear), and CN VI
(abducens) (Fig. 12.9). Inability of these muscles to function properly is
largely caused by damage to the nerves that innervate the muscles.
pressure from intracranial tumors, head injuries, or severe intracranial
hemorrhage may impinge on CN II (optic), CN III, CN IV, or CN VI, causing speciﬁc
eye changes.The optic nerve innervates the retina and is surrounded by a
meningeal sheath that is continuous with the meninges of the brain.When
intracranial pressure increases, the pressure is transmitted from the brain to
the optic disc,where swelling occurs.
Pressure on a speciﬁc
part of the optic nerve tract can produce visual loss (hemianopia) on the ipsilateral (same side)
or contralateral (opposite side) visual ﬁeld, depending on the location
of the injury or lesion.
Cultural, and Ethnic Variations
Infants. Several variations may be
noted in the eyes of infants.The shape, slope, spacing, and color of the eyes
should be noted. Normal shape is oval. Slope is determined by drawing an
imaginary line through the inner canthus to the occiput. Except in people of
Asian descent, the slope line transects the outer canthus.Measurement of the
distance between various structures of the eye can be plotted on a growth
chart.Normal spacing measurements are plotted between the 10th and the 90th percentiles.
Infants usually open their
eyes when held upright, permitting inspection of the iris,pupil,and sclera.The
color of the iris after birth is normally blue-gray in light-skinned infants
and brown in darker-skinned infants. Permanent eye color is usually established
by 9 months of age.White specks in the iris called Brushﬁeld spots can
be a normal variant or a sign of Down syndrome. Edema of the eyelids and
irritation of the conjunctiva may be caused by birth trauma or silver nitrate
prophylaxis.The sclera is very thin at birth, so it may have a slightly blue
A gross assessment of visual
acuity is made by testing for pupillary light reﬂexes and also by noting
the infant’s behavior.The pupils should normally constrict to light. After 3
weeks, if no pupillary light reﬂex is present, blindness is indicated.
However, the presence of pupillary reaction alone does not conﬁrm an
infant’s ability to see. A blink reﬂex in response to bright light and
observing the infant for ability to follow objects or light with the eyes conﬁrm
that some degree of vision is intact. By 2 to 4 weeks, an infant should be able
to ﬁxate on an object and,by 1 month, to ﬁxate and follow an
object.An infant’s visual acuity is usually about 20/200;20/20 vision is
usually achieved by school age.
During the ﬁrst 1 to 2
months, infants’ eye movements are often disconjugate (not working in unison),
making screening for strabismus difﬁcult. Persistence of disconjugate
eye movements after this time may indicate strabismus and warrants referral to
a specialist. In infants, the fundoscopic examination is difﬁcult but
still important.The internal structures of the eye should be examined regularly
during the ﬁrst few years of life.One of the ﬁrst things to note
is the presence of a red reﬂex,which is a normal ﬁnding.Absence
of a red reﬂex may indicate congenital cataracts or retinal detachment.
The general background in infants is typically paler than that in adults
because the blood vessels to the area are not fully developed. The macula is
also not fully developed until about 1 year of age.
Toddlers. Visual acuity in toddlers is
determined by the Allen test, which uses picture cards of seven common objects.
The child should successfully identify three of the seven objects at a distance
of 15 feet. If the child cannot do so, move closer until he or she is able to
The corneal light reﬂex
can provide an initial, rapid screening test for strabismus that can be
followed by additional measures as the child grows. Untreated strabismus can lead
to permanent visual damage. Eventually, the brain suppresses information from
the affected eye, and visual acuity in that eye deteriorates.
Preschool Children. Between the
ages 3 and 5, the Snellen E chart,which uses various sizes of Es facing in
different directions, can usually be used to determine visual acuity.Normal
visual acuity for a 3-year-old is approximately 20/40 or better. By the time
the child is 4 years old, visual acuity should be about 20/30 or better.
School-Age Children. By the time
a child is about 5 to 6 years old, normal visual acuity approximates that of
the adult—20/20 in both eyes. You should continue using the Snellen E chart
until the child has acquired reading skills and can easily verbalize the
letters seen on the Snellen chart. Some degree of myopia (nearsightedness)
often occurs during adolescence. Children should be screened for defects in
color perception (colorblindness) between 4 and 8 years of age. Though many
forms of color blindness exist, most cases involve inherited recessive X-linked
traits in males that affect the ability to distinguish red and green.
Older Adults. Many changes in the structure and function of
the eye occur with aging. Both central and peripheral visual acuity may be
diminished with advanced age. Changes in near vision occur around the fourth
and ﬁfth decades, often resulting in decreased ability to focus clearly
on near objects (presbyopia).The adult may compensate for these changes by holding
near objects farther away.
External structures of the eye
also undergo signiﬁcant changes with advanced age. Tissues of the
eyelids lose elasticity and fatty deposits, causing the eyes to appear sunken. The
lower eyelid may sag away from the globe. The latter condition, called ectropion, is signiﬁcant because the
punctum,which drains the tears, is no longer in contact with the globe,
resulting in constant tearing.The laxity that develops in the eyelids may also
lead to an inward turning of the eyelids, referred to as entropion.With
entropion, the punctum also may not be able to drain tears. In addition, the
eyelashes may rub the conjunctiva and cornea, causing pain and injury to the
cornea. Older adults also may experience dry eyes because of a decrease in tear
Changes in the internal
structures of the eye are also common with aging.The lens becomes more opaque
and yellowish, obscuring the transfer of light rays to the retina. This
clouding of the lens is referred to as senile cataract. Arcus senilis, a white
opaque ring around the edge of the cornea resulting from fat deposits, is a
common benign ﬁnding. The older adult’s pupil size at rest is generally
smaller than that of younger adults. Pupillary reaction to light and
accommodation slow because of decreased ability to constrict and relax.The
general background is paler, and the blood vessels of the eye may show signs of
the same atherosclerotic processes that are occurring elsewhere throughout the
body.Visual ﬁelds may be less than normal. Other visual changes that
occur with aging reﬂect degeneration of the rods and cones. Color vision
may be less vivid as a result of degeneration of the cones, and night vision
may be impaired because of degeneration of the rods.
Several eye diseases also
occur more commonly in older adults. Macular degeneration and glaucoma, the two
leading causes of blindness in older adults, show a signiﬁcant increase
People of Different Cultures and Ethnic Groups.
Differences in physical characteristics of the eye and differences in the risk
of certain eye diseases are found in various ethnic groups.People of Asian
origin typically have an epicanthal fold at the medial canthus,giving the eyes
an almond-shaped appearance. The outer canthus also may slant in an upward
direction. In African Americans and others with normally dark skin,
brown-pigmented spots on the sclera, referred to as muddy sclera, are common.
In dark-skinned people, the color of the optic disc is also typically darker
orange, and the retinal background is darker red than in fair-skinned people.An
African American person’s sclera also may have a blue-gray appearance or a
yellowish cast at the peripheral margins. The incidence and severity of glaucoma
is greater in African Americans than in people of other races. Cataracts also
occur with greater frequency in people living in sunny climates.
the Eye Assessment. Assessment
of the eye includes taking a thorough health history and performing a physical
examination. Data obtained are combined and analyzed to determine the patient’s
existing health status and to identify potential health risks and disorders of
The health history addresses the patient’s personal and family history
of eye diseases and diseases that affect the eye. A comprehensive health
history also allows the nurse to identify areas of the physical examination
that require more or less depth. The health history will include biographical
data, current health status,past health history, family history, a review of
systems, a psychosocial proﬁle, and a
detailed eye history. If time is an issue and you are unable to perform a
complete health history,perform a focused eye history.
Biographical Data. First, review the patient’s medical
records, intake surveys, and other sources of data to identify her or his age,
occupation, gender, and ethnic background. This information will help you
decide what questions to ask and how to interpret subsequent history and examination
ﬁndings. For example, the way you measure visual acuity and interpret
the ﬁndings differs greatly with the patient’s age. The patient’s
occupation can be a source of environmental risk for eye injury.Gender may be a
factor in certain disorders such as colorblindness,which is more common in
males. Knowledge of the patient’s race or ethnic group is useful when
interpreting many physical examination ﬁndings.
Current Health Status. Begin by asking about the person’s
chief complaint, asking him or her to describe the problem in his or her own
words.Use the PQRST format to probe further about any symptoms reported. If the
person has an eye problem, focus your questions on the eye symptoms prioritized
Loss. Vision loss refers to the inability to see the shape,
size, position,or color of objects. Vision loss may be complete, resulting in
the inability to perceive light from dark,or incomplete, causing the person to
see objects with varying degrees of detail.
Pain. Eye pain is a subjective sensation of discomfort in
the eye that may be caused by trauma, irritation, infection,or neurological
Vision. Double vision (diplopia) refers to seeing two
overlapping images because of the inability of the eyes to focus on an object
and to move in a conjugate manner.Double vision can be caused by a variety of
conditions, including diseases of the cerebellum, cranial nerves, and
Tearing. Tears are normally produced by the lacrimal gland,
located along the upper outer orbit of the eye, and are distributed over the
eye by blinking.Tearing is a discharge of clear,watery ﬂuid as a result
of the inability of the tears to drain through the punctum and into the
nasolacrimal duct.Tearing occurs in a variety of conditions such as infections;
irritation;and exposure to chemicals, irritants,or allergens.
Eyes. Dry eyes occur when there is insufﬁcient
lubrication of the eye and the bulbar and palpebral conjunctiva become less
moist. It often results in a subjective sensation of irritation, a gritty
sensation or discomfort, especially during blinking.Dryness occurs from trauma
to the eye surface or facial trigeminal nerve paralysis, in certain systemic
diseases, or after taking certain medications.
Drainage. Drainage from the eyes is abnormal and is commonly
associated with eye infections or allergies.
Appearance Changes. Changes in the appearance of the
external eye, such as in the iris, anterior chamber, and sclera, can signal a
variety of problems, including trauma, infection, and systemic disorders.
Vision. Blurred vision refers to an object’s shape and detail
being indistinct and fuzzy. It can occur for near objects as well as for
Past Health History.
This section of the health history focuses on
gathering relevant information about the patient’s past eye health and any
injuries, diseases, or medications that could affect the eyes.The following are
speciﬁc areas related to the eye that
should be explored.
When gathering information on your patient’s family
history, consider familial conditions that may affect the eyes.
Review of Systems.
Changes in the structure and function of the eye may
relate to every other system of the body.The review of systems (ROS) will help
you identify problems in other systems that directly affect the eye and allow
you to pick up on symptoms that you might have missed in your health history by
triggering your patient’s memory.
Psychosocial Proﬁle. The psychosocial proﬁle
may reveal patterns in the patient’s lifestyle that affect health, increase the
risk of health problems, or inﬂuence
adaptation to health problems. Obtaining a psychosocial proﬁle
includes asking the patient about activities of daily living, personal habits,
relationships, roles, coping, and home and work environment.
Anatomical Landmarks. Before beginning your physical
assessment of the eye, review the anatomical landmarks of the external eye
Physical Assessment. During the
physical examination, you will assess the functions and structures of the body,
including a focused examination of the eye.You will use the information
obtained in the health history to guide you and help determine what body
structures and functions should be focused upon. After you have explored the
patient’s key health history information and determined what aspects should be
explored, begin the physical examination.The purpose of the physical
examination is to identify normal, age-appropriate structures and functions of
the eye as well as potential and actual health problems.
Approach. To assess the eye, use the techniques of
inspection and palpation. Begin by testing visual acuity and performing other
assessments that can be completed while you stand at a distance from the
patient. For visual acuity, test and record the ﬁndings for each eye
separately and then together. Standard abbreviations for recording ﬁndings
are OD for the right eye, OS for the left eye, and OU for both eyes.
Performing a General Survey. Before performing the eye
assessment,perform a general survey, noting the patient’s overall appearance.
Observe nutritional status,emotional status,and body habitus,noting changes
that would relate to the eyes.Then inspect for use of corrective lenses,noticeable
visual deﬁcits, and gross eye
abnormalities such as ptosis, exophthalmos, edema, and redness. Also take vital
signs.A temperature elevation may indicate an infection and give the eyes a
glazed appearance. High BP should alert you to look for vascular changes when
performing the fundoscopic examination.
Performing a Head-to-Toe Physical Assessment.
Now examine the patient for more speciﬁc signs of diseases affecting
other organ systems that might have an impact on the eyes and vision.
Performing Physical Assessment of the Eye. A
comprehensive physical examination of the eye involves assessing the functions,
such as vision (distant, near, color, and peripheral), eye muscle functioning,
and pupil reflexes, as well as inspecting the external and internal eye
structures.The sequence for testing visual acuity progresses from testing done
at a distance, such as the visual acuity examination, to observations made at
close range, such as the ophthalmic examination. Proceeding in this sequence
allows the patient to become comfortable with the nurse before examination at
close range is performed. It also allows the nurse to establish the patient’s
degree of visual functioning, which establishes a baseline for conducting the
remainder of the examination. The ophthalmic examination often requires
administration of mydriatic or pupil-dilating eye drops.
Visual Acuity Testing. Visual acuity testing involves
determining distant, near, peripheral, and color vision. The Snellen eye chart
is used to test distant vision in adults and children of school age.The patient
stands 20 feet from the chart, covers one eye, and reads the smallest line of
print.He or she continues reading successively smaller lines until he or she
reads them incorrectly (no more than two mistakes allowed per line) or says
that the print is too blurry to distinguish letters.Record the fraction next to
the smallest line of letters that the patient read.The top number, or
numerator, indicates the distance in feet from the chart, and the bottom
number, or denominator, indicates the distance in feet that a person with
normal vision would be able to read the chart. The higher the denominator, the
worse the person’s distant vision.
Have the person cover the
opposite eye and repeat the procedure. After testing each eye individually,
test both eyes simultaneously and record the fraction next to the smallest line
read.A pocket vision screener may also be used. The letters are scaled down and
simulate the Snellen chart,but the card is held only 14 inches from the patient.
Near vision is tested using
Jaeger cards, in which lines of text are repeated in progressively smaller
fonts. Test each eye separately by having the patient cover one eye and read
the smallest line of text while holding the card at a distance of 14 inches. If
Jaeger cards are not available, an alternative method is to have the patient
read a newspaper and then record how far away he or she holds it.
Color vision is tested using
Ishihara’s embedded colors test, which consists of a series of cards displaying
colored dots that contain an embedded colored figure or number. The patient is
asked to identify the figure in each card.An alternative measure is to point to
one of the red or green colored bars on the Snellen eye chart and ask the
patient what color she or he sees (Fig. 12.11).
Peripheral vision in each eye
is measured on two planes—horizontal and vertical—and in four
directions—superior, inferior,medial (nasal), and lateral (temporal), using the
confrontation test. The patient and nurse stand face to face, about 1 to 11⁄2
feet apart.Ask the patient to ﬁx his or her gaze straight ahead and
cover one eye at a time, using his or her hand or an opaque cover.Then wiggle
your ﬁngers or bring a pen or other small object from the periphery to
the center of the visual ﬁeld.Tell the patient to say “now” as soon as
your hand or the object enters his or her peripheral vision.
Repeat this procedure in each
of the four visual ﬁelds, moving in a clockwise direction. Be sure to
start testing from positions that are outside the normal peripheral vision
range; then slowly move your hand or the object into each of the four
peripheral ﬁelds.Measure the degree of peripheral vision using the
patient’s ﬁxed gaze as a base (Fig. 12.12).
You can also test peripheral
vision by comparing the patient’s peripheral vision with yours.This is helpful
in detecting gross peripheral deﬁcits, but the method is somewhat
subjective because you have to assume that you have normal peripheral vision.
Assessment of the Extraocular Muscles. To perform
the corneal light reﬂex test, instruct the patient to ﬁx her or
his gaze straight ahead. Shine a penlight at the bridge of the nose and note
where the light reﬂects on the cornea of each eye. Using the face of a
clock as a guide, determine if the light reﬂex appears at the same clock
position in each eye.The corneal light reﬂex test determines if the eyes
are being maintained in a conjugate position.
The cover/uncover test helps
determine if there is a weakness in the eye muscles of one or both eyes that
can result in disconjugate eye movement.To perform the test, have the patient ﬁx
his or her gaze straight ahead. Stand in front of the patient, cover one of his
or her eyes with a piece of paper, and observe the uncovered eye for movement
indicating re-ﬁxation of the gaze.Remove the cover and observe the
previously covered eye for movement indicating re-ﬁxation of the
gaze.Repeat the procedure for the other eye.The gaze should remain steady in
each eye throughout the test.
Further testing of the
extraocular muscles is done by testing for symmetrical (conjugate) rotation of
the eyes, symmetrical movement of the upper eyelid, and nystagmus in the six
cardinal ﬁelds of gaze test.The six cardinal ﬁelds of gaze tests
the cranial nerves III, IV, and VI and the extraocular muscle.To perform this
test, stand in front of the patient and instruct her or him to look straight
ahead and follow your ﬁnger as you move slowly through the six cardinal ﬁelds.The
patient should hold her or his head still and move only her or his eyes.
Observe for smooth, symmetrical movement of the eyes and eyelids.
Assessment of the External Structures. The next phase of the eye
examination involves inspection and palpation of external eye structures.
Careful inspection and palpation can reveal a variety of eye disorders as well
as systemic disorders that affect the eye.
Testing the pupils to
determine reaction to light is important for evaluating neurological function.
Increased intracranial pressure from a head injury, tumor, or stroke may
manifest in speciﬁc pupillary changes. Other conditions such as hypoxia
or brain death or the use of certain medications can also affect the papillary
To test pupillary reﬂex,
observe for direct (same side) and consensual (opposite side) response to a
focused beam of light. Darken the room if possible.Then, using a penlight, ﬂashlight,
or ophthalmoscope light, shine the light onto one eye as you observe whether
the pupil constricts (referred to as a direct response).Repeat the procedure
and note whether the other eye exhibits a consensual response or constriction
to light. Repeat the test for the opposite eye.
Inspection of the anterior
chamber of the eye can reveal a variety of conditions including infection,
trauma, and risk for glaucoma.The shadow test is useful in identifying a
shallow anterior chamber, which is commonly seen in glaucoma.To inspect the
anterior chamber using this test, have the patient look straight ahead. Hold
your penlight at the temporal side of one eye at a 90-degree angle across the
anterior chamber.Without moving the penlight, shine the light across the limbus
of the eye, toward the nose. A crescent-shaped shadow on the nasal side of the
iris indicates a shallow anterior chamber.
Assessment of the Internal Structures. The internal
structures of the eyes are examined last.Using the ophthalmoscope permits the
visualization of the red reﬂex, optic disc, blood vessels, general
background, and macula (Fig. 12.13). Changes in the appearance of these
structures can indicate localized eye disorders and eye trauma as well systemic
The ﬁrst thing you
should see with the ophthalmoscope is a red reﬂex over the pupil
area,which is the reﬂection of light off the retina. Note the color and
clarity of the red reﬂex. Now gradually move closer to the patient while
holding the red reﬂex in sight.When you are approximately 2 inches from the
eye, you should see either blood vessels or the general background of the
retina. Follow the blood vessels nasally back to their origin at the optic
disc. Now examine the optic disc for color, shape, discreteness of the disc
margins, and a paler area near the center called the physiological cup.The
optic disc is located nasally and has a yellow to yellow-orange color,with
sharp distinct edges except for the nasal side,which may be slightly blurred.
Note the size of the
physiological cup compared with the size of the optic disc (cup-to-disc
ratio).The cup should be half the size of the disc or less.The cup is normally
lighter or white in color. Follow the vessels as they leave the optic disc.Note
the size of the arteries compared with the veins (AV ratio).Arteries will
appear smaller and brighter red than veins and will have a light streak reﬂecting
off them. Also note constriction of the vessels and whether or not any nicking
is noted when vessels cross. Inspect the general background for color and
lesions. Color should be a uniform yellow-orange-red color,depending on
individual skin tone.The lighter the skin tone, the lighter the
background.After inspecting the optic disc,vessels,and general background,
examine the macula.The macula is a circular area of slightly darker
pigmentation located about two disc diameters (DD) temporally from the optic
disc. It is the site of central vision and the source of one of the most common
causes of blindness,macular degeneration.
The macula is difﬁcult
to see, especially through undilated pupils.To see it,have the patient look
directly into the ophthalmoscope light.This places the macula into direct view.
■ The eyes are complex sensory
organs that provide specialized functions crucial to neurosensory development
in infancy; to the development of psychosocial,motor,and cognitive skills in
childhood;and to the maintenance of those skills in adulthood.
■ A thorough health
history provides direction for the physical examination, including exploration
of factors that may be related to eye health.
■ A comprehensive
history and physical examination enable early detection and treatment of sight
■ Information from both
the history and the physical examination is then analyzed to determine
appropriate nursing diagnoses.