ASSESSMENT of the EYES and VISION

The Human Eye

Eye Assessment
Review of External Anatomy
Review of Terms:
• Eyelids- a protective fold of skin and muscle that can be closed to cover the
front of the eyeball
• Palpebral fissure- separation between the upper and lower eyelids.
• Limbus- area in eyeball where cornea and sclera meets
• Canthus- the corner or angle at each side of the eye
• Tarsal Plates (strips of connective tissue that give the upper lid shape)
• Meibomian glands- sebaceous gland in the eyelid
• Conjunctiva (Bulbar and Palpebral
• Lacrimal apparatus
Extraocular Muscles
• Give the eye straight and rotary motion
• Each muscle is coordinated to ensure axes remain parallel
• Muscles are: superior and inferior rectus, medial and lateral rectus and
superior and inferior obliques
• Human focus on one image only
• Movement of the EOMs is by CN III, IV and VI
Internal Anatomy
• Eye is composed of three concentric coats
1. Outer fibrous layer called the Sclera
2. Middle vascular layer called the Choroid
3. Inner layer is the visual receptive layer called Retina
• Cornea- clear, front part of the eye. The cornea is the first part of the eye that bends
(or refracts) the light and provides most of the focusing power.
• Pupil- a hole in the center of the iris that changes size in response to changes in
lighting. It gets larger in dim lighting conditions and gets smaller in brighter lighting
conditions.
 Internal Anatomy
• Retina- the visual receptive layer of the eye wherein light waves are changed
into nerve impulses
• Optic disc -area where the fibers from the retina converge to form the optic
nerve
• Retinal vessels – include a paired artery and vein extending to each quadrant
• Macula – located on the temporal side of the fundus. Receives and transmits
light from the center of the visual field
Visual Pathways and Visual Fields

• Light rays are refracted through the cornea>>aqueous humor>>lens>>vitreous

body and strike the retina. The retina then transform the light stimulus into
nerve impulses through the optic nerve and optic tract to the visual cortex of
the occipital lobe
• Image formed in the retina is upside down and reversed from its actual
appearance in the outside world.
Visual Reflexes
Pupillary light reflex is normal constriction of the pupils when bright light shines
on the retina
• Direct light reflex (same eye)
• consensual light reflex (other eye) reactions
• Accomodation-adaptation of the eye for near vision
Developmental Considerations
• At birth, No macula until 4 months of age
• 3-4 months - can fixate on a single image with both eyes.
• Eyeball reaches full size by age 8 but consistency changes
• During pregnancy, lacrimal gland function changes. Eyes may become more
sensitive and dry.
• Aging adult
• Development of Arcus Senilis
• Presbyopia ( decreased power of accomodation)
• Cataract or lens opacity
• Decreased adaptation to darkness
• Glaucoma or increased ocular pressure
• Macular degeneration- most common cause of blindness. Cause is unknown.

History
1. Visual difficulties-blurring, halos, blind spots, spots present, any loss of peripheral
vision
2. Pain-quality, onset, severity
3. Strabismus or diplopia
4. Redness or swelling
5. Watering or discharge
 6. Past history of ocular problems
7. Glaucoma?
8. Use of corrective lenses?
9. Last vision test
10. Medications
11. Aids of any kind?
Additional History
Infants and Children
• Any vaginal infections at time of delivery
• Developmental milestones
• Vision testing at school?
• Eye safety at home?
Aging Adult
• Any vision difficulties in taking stairs? Problems with vision at night?
• Last eye exam?
• Any eye dryness? Remedies?
• History of cataracts? Loss of vision?
• Decreased ability in reading or sewing?
Eye Assessment
• Should be carried out in an orderly fashion
• Moving from the extraocular to the intraocular stuctures
• Usually includes testing of associated cranial nerves & can be performed in the
following order:
1. Determination of Visual Acuity
2. Determination of Visual Fields
3. Assessment of external eye & lacrimal apparatus
4. Evaluation of extraocular muscle function
5. Assessment of anterior segment structures
6. Assessment of posterior segment structures
Planning
• Place client in well lighted room
• Nurse must be able to control natural and overhead lighting during some portions
of the examination
Delegation
• Duly licensed doctors and assistive personnel (nurses)
Equipment
• Cotton tip applicator
• Gauze square
• Examination gloves
• Millimeter ruler
• Penlight
• Snellen’s or E chart
• Opaque card or occluder
Implementation
 • Explain procedure. Discuss how results will be used in planning further care
• Wash hands and apply gloves
• Provide privacy
• Inquire history
Determination of Visual Acuity
• Measure of visual acuity tests Cranial Nerve II, is a measure of central vision
• measures how well you see at various distances. It is the familiar eye chart
test.
1. Snellen chart-has number at the end of each line of letters indicates the
degree of visual acuity when measured at a distance of 20 feet. The
numerator 20 is the distance in feet between the chart and the client. The
denominator 20 is the distance from which the normal eye can read the
lettering, which correspond to the number at the end of each letter line;
therefore the larger the denominator the poorer the vision.
2. Illiterate E chart-for those who are illiterate and unfamiliar with the
western alphabet. The letter E faces in different directions.
Determination of Visual Acuity
Functional Vision Test – if client is unable to see top of line in Snellen chart
(20/200)

1. Light perception- shine light at lateral position & turn off lightings. Record “LP”
if positive
2. Hand movements- Move hand slowly back and forth at 1 ft, & stopping
periodically. Ask client to tell you when hands stop moving. Record the vision “HM 1
ft”
3. Counting fingers- Hold some fingers from client’s face at 1 ft distance. Record “CF
1 ft”

Determination of Visual Fields

• Confrontation Test- (Peripheral Vision) sit opposite client about one meter
apart. Client covers one eye, you cover the opposite eye. Fully extend your
arm midway between client and yourself, move it centrally with fingers
waving. Have the client tell you when the moving fingers are first seen.
Compare your responses. Somewhat imprecise test.
• CN III, IV, VI test
• Corneal Light Reflex-light 12” in front, look for light reflection in pupils,
Should be even.
• Cardinal fields- stand in front of the client & move finger or pencil through
the 6 cardinal fields of gaze, take to extreme lateral positions
• Common problems of the visual field
1. Scotoma (area of reduced vision),
2. Hemianopia (half of visual field lost),
3. Homonymous quadrantanopia (involving both eyes)
Assessment of External Eye and Lacrimal Apparatus
External examination of eyes consists of:
 1. inspection of the eyelids, surrounding tissues and palpebral fissure.
2. Palpation of the orbital rim may also be desirable, depending on the presenting
signs and symptoms.
3. The conjunctiva and sclera can be inspected by having the individual look up, and
shining a light while retracting the upper or lower eyelid.
4. The cornea and iris may be similarly inspected.
Assessment of External Eye and Lacrimal Apparatus
1. Inspect the eyelids for position and symmetry.
2. Palpate the eyelids for the lacrimal glands.
` a. To examine the lacrimal gland, the examiner, lightly slide the pad of the index
fingeragainst the client’s upper orbital rim.
b. Inquire for any pain or tenderness.
3. Palpate for the nasolacrimal duct to check for obstruction.
a. To assess the nasolacrimal duct, the examiner presses with the index finger against the
client’s lower inner orbital rim, at the lacrimal sac, NOT AGAINST THE NOSE.
b. In the presence of blockage, this will cause regurgitation of fluid in the puncta
 Normal Findings:
Eyelids
 · Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes
are open.
· No PTOSIS noted. (drooping of upper eyelids).
· Meets completely when eyes are closed.
· Symmetrical.
Lacrimal Apparatus
 · Lacrimal gland is normally non palpable.
· No tenderness on palpation.
· No regurgitation from the nasolacrimal duct
Evaluation of Extraocular function
• This test is an examination of the function of the eye muscles. A doctor observes
the movement of the eyes in six specific directions.
• Client are asked to sit or stand with your head erect and a forward gaze. Nurse
will hold a pen or other object 12 inches in front of your face. Nurse will then
move the object in several directions and ask client to follow it their eyes, without
moving their head.
• Normal Results
Normal movement of the eyes in all directions.
• What Abnormal Results Mean
Eye movement disorders may be due to abnormalities of the muscles themselves or
problems in the sections of the brain that control these muscles.
Assessment of Anterior Segment Structures
The anterior segment is the front third of the eye that includes the structures in front
of the vitreous humor: the cornea, iris, ciliary body, and lens
 Assessment of Eye Structures
Implementation
1. Explain procedure. Discuss how results will be used in planning further care
2. Wash hands and apply gloves
3. Provide privacy
4. Inquire history
Assessment of Eye Structures
Eyebrows (hair and skin quality)
Normal findings:
• Hair evenly distributed, skin intact
• Symmetrical eyebrows w/ equal movements
• Deviations from Normal
• Loss of hair, scaling/flakiness of skin
• Unequal alignment / movement of eyebrows
Assessment of Eye Structures
Eyelashes

Normal Findings:
• Equally distributed, curled slightly outward
Deviations:
• Lashes turned inward
Assessment of Eye Structures
Eyelids
Normal Findings:
• Skin intact, no discharge, no discoloration
• Lids close symmetrically
• Approx. 15-20 involuntary blinks/minute, bilateral blinking
• When lids open, no visible sclera above corneas. Upper/lower borders of
cornea are slightly covered

Deviations:
 • Redness, swelling, flaking, crusting, discharge nodules/lesions
• Lids close asymmetrically, incompletely or painfully
• Infrequent blinking
• Ptosis, ectropion lower lids rolled out) or entropion (lower lids rolled in), rim
of sclera visible between lid and iris
Assessment of Eye Structures
Bulbar conjunctiva-retract eyelids, exert pressure over upper & lower bony orbits
and ask client to look up & down & sideways

Normal Findings:
• Transparent, sclera appears white (yellowish in darkskinned)
Deviations from Normal:

• Jaundiced sclera (liver dis), excessively pale sclera, lesions/nodules

(mechanical, chemical, allergic or bacterial damage)
Assessment of Eye Structures
Palpebral Conjunctiva- evert & retract both lower lids & ask client to look up.
Normal Findings:
o Shiny, smooth and pink/red
Deviations from Normal:

o Extremely pale (anemia), red (inflammation), nodules or lesions

Assessment of Eye Structures
Lacrimal Gland-inspect and palpate

Normal Findings:
• No swelling /tenderness over lacrimal gland
Deviations from Normal:
• swelling /tenderness over lacrimal gland
Assessment of Eye Structures
Lacrimal sac and nasolacrimal duct- inspect & palpate

Normal Findings:
• No edema & tearing
Deviations from Normal:
• Increased tearing, regurgitation of fluid on palpation of lacrimal sac
Assessment of Eye Structures
Cornea
1. Inspection: Ask client to look straight, hold penlight at oblique angle of eye &
move light slowly across corneal surface.
Normal Findings:
• Shiny, smooth. Details of iris are visible
• Arcus senilis (grayish w/ white ring around margin in older persons)

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