1. Vision difficulty.

 Any difficulty seeing or any blurring? Any blind spots?

Come on suddenly, or progress slowly? In one eye or both?

 •Constant, or does it come and go?

 •Do objects appear out of focus, or does it feel like a clouding over objects?

Does it feel like “grayness” of vision?

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 •Do spots move in front of your eyes? One or many? In one or both eyes?

•Any halos/rainbows around objects? Or rings around lights?

•Any halos/rainbows around objects? Or rings around lights?

•Any night blindness?

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Floaters are common with myopia or after middle age due to condensed vitreous fibers.

Usually not significant, but acute onset of floaters (“shade” or “cobwebs”) occurs with retinal detachment.

Halos around lights occur with acute narrow-angle glaucoma.

Scotoma, a blind spot surrounded by an area of normal or decreased vision, occurs with glaucoma, with optic nerve disorders.

Night blindness occurs with optic atrophy, glaucoma, or vitamin A deficiency.

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2. Pain.

Any eye pain? Please describe.

 •Come on suddenly?

 •Quality—a burning or itching? Or sharp, stabbing pain? Pain with bright light?

 •A foreign body sensation? Or deep aching? Or headache in brow area?

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Sudden onset

Refer immediately.

Quality is valuable in diagnosis.

Photophobia

Note: Some common eye diseases cause no pain (e.g., cataract, glaucoma).

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3. Strabismus, diplopia.

•Ever see double? Constant, or does it come and go? In one eye or both?

Strabismus is a deviation in the axis of the eye.

 Diplopia is the perception of two images of a single object.

4. Redness, swelling.

Any redness or swelling in the eyes?

 •Any infections? Now or in the past?

When do these occur? In a particular time of year?

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5. Watering, discharge.

watering

•Any discharge? Any matter in the eyes? Is it hard to open your eyes in the morning?

What color is the discharge?

 •How do you remove matter from your eyes?

Lacrimation (tearing) and epiphora (excessive tearing) are due to irritants or obstruction in drainage of tears.

Purulent discharge is thick and yellow.

Crusts form at night.

Assess hygiene practices and knowledge of cross-contamination.

6. Past history of ocular problems.

Any history of injury or surgery to eye? Or any history of allergies?

7. Glaucoma.

Ever been tested for glaucoma? Results?

 •Any family history of glaucoma?

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8. Use of glasses or contact lenses.

Do you wear glasses or contact lenses? How do they work for you?

 •Last time your prescription was checked? Was it changed?

 •If you wear contact lenses, are there any problems such as pain, photophobia, watering, or swelling?

 •How do you care for contacts? How long do you wear them? How do you clean them?

Do you remove them for certain activities?

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Assess self-care behaviors.

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9. Self-care behaviors.

Last vision test? Ever tested for color vision?

 •Any environmental conditions at home or at work that may affect your eyes?

For example, flying sparks, metal bits, smoke, dust, chemical fumes?

If so, do you wear goggles to protect your eyes?

Self-care behaviors for eyes and vision.

Work-related eye disease (e.g., an auto mechanic with a foreign body from metal working or radiation damage from welding).

10.

What medications are you taking? Systemic or topical? Do you take any medication specifically for the eyes?

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Some medications affect the eyes (e.g., prednisone may cause cataracts or increased intraocular pressure).

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11.

If you have experienced a vision loss, how do you cope? Do you have books with large print, books on audio tape or CD, braille?

 •Do you maintain your living environment the same?

 •Do you sometimes fear complete loss of vision?

aging adult

1. 

Have you noticed any visual difficulty with climbing stairs or driving? Any problem with night vision?

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aging adult

2. 

When was the last time you were tested for glaucoma?

 •Any aching pain around eyes? Any loss of peripheral vision?

 •If you have glaucoma, how do you manage your eyedrops?

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Compliance may be a problem if symptoms are absent. Assess ability to administer eyedrops.

aging adult

3. 

Is there a history of cataracts?

Any loss or progressive blurring of vision?

4. 

Do your eyes ever feel dry? Burning?

What do you do for this?

5.

Any decrease in usual activities, such as reading or sewing?

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Decreased tear production may occur with aging.

Macular degeneration causes a loss in central vision acuity.

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TEST CENTRAL VISUAL ACUITY

Snellen Eye Chart

The Snellen alphabet chart is the most commonly used and accurate measure of visual acuity.

It has lines of letters arranged in decreasing size.

Place the Snellen alphabet chart in a well-lit spot at eye level.

Position the person on a mark exactly 20 feet from the chart.

Hand over an opaque card with which to shield one eye at a time during the test; inadvertent peeking may result

when shielding the eye with the person's own fingers (Fig. 14-9).

If the person wears glasses or contact lenses, leave them on. Remove only reading glasses because they will blur distance vision.

Ask the person to read through the chart to the smallest line of letters possible.

Encourage trying the next smallest line also. (Note: Use a Snellen picture chart for people who cannot read letters. See p. 303.)

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snellen eye chart

Record the result using the numeric fraction at the end of the last successful line read. I

ndicate whether the person missed any letters or if corrective lenses were worn—for example, “Right 20/30 − 1, with glasses.”

That is, the right eye scored 20/30, missing one letter.

Normal visual acuity is 20/20. Contrary to some people's impression, the numeric fraction is not a percentage of normal vision.

Instead, the top number (numerator) indicates the distance the person is standing from the chart, and the denominator gives the distance at which a normal eye could have read that particular line.

Thus “20/30” means, “You can read at 20 feet what the normal eye can see from 30 feet away.”

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If the person is unable to see even the largest letters, shorten the distance to the chart until it is seen and record that distance (e.g., “10/200”).

If visual acuity is even lower, assess whether the person can count your fingers when they are spread in front of the eyes or distinguish light perception from your penlight.

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The larger the denominator, the poorer the vision.

If vision is poorer than 20/30, refer to an ophthalmologist or optometrist.

Impaired vision may be due to refractive error, opacity in the media (cornea, lens, vitreous),

or disorder in the retina or optic pathway.

Near Vision

For people older than 40 years or for those who report increasing difficulty reading,

test near vision with a handheld vision screener with various sizes of print (e.g., a Jaeger card) (Fig. 14-10).

Hold the card in good light about 35 cm (14 inches) from the eye—this distance equals the print size on the 20-foot chart.

Test each eye separately, with glasses on.

A normal result is “14/14” in each eye, read without hesitancy and without moving the card closer or farther away.

When no vision screening card is available, ask the person to read from a magazine or newspaper

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Presbyopia,

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TEST VISUAL FIELDS

Confrontation Test

This is a gross measure of peripheral vision.

It compares the person's peripheral vision with your own, assuming yours is normal.

Position yourself at eye level with the person, about 2 feet away.

Direct the person to cover one eye with an opaque card, and with the other eye to look straight at you.

Cover your own eye opposite to the person's covered one.

You are testing the uncovered eye.

Hold a pencil or your flicking finger as a target midline between you and slowly advance it in from the periphery in several directions (Fig. 14-11, A and B).

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Ask the person to say “now” as the target is first seen; this should be just as you see the object also.

(This works with all but the temporal visual field, with which you would need a 6-foot arm to avoid being seen initially!

With the temporal direction, start the object somewhat behind the person.)

 Estimate the angle between the anteroposterior axis of the eye and the peripheral axis where the object is first seen.

Normal results are about 50 degrees upward, 90 degrees temporally, 70 degrees down, and 60 degrees nasally (Fig. 14-12).

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If the person is unable to see the object as the examiner does, the test suggests peripheral field loss.

 In an older adult, this screens for glaucoma.

Refer to a specialist for more precise testing (see Table 14-5, Visual Field Loss, on p. 316).

Acutely diminished visual fields occur with diseases of the retina and stroke.

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INSPECT EXTRAOCULAR MUSCLE FUNCTION

Corneal Light Reflex (The Hirschberg Test)

Assess the parallel alignment of the eye axes by shining a light toward the person's eyes.

Direct the person to stare straight ahead as you hold the light about 30 cm (12 inches) away.

Note the reflection of the light on the corneas; it should be in exactly the same spot on each eye.

See the bright white dots in Fig. 14-30 for symmetry of the corneal light reflex.

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Asymmetry of the light reflex indicates deviation in alignment from eye muscle weakness or paralysis. If you see this, perform the cover test.

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Cover Test

This test detects small degrees of deviated alignment by interrupting the fusion reflex that normally keeps the two eyes parallel.

Ask the person to stare straight ahead at your nose even though the gaze may be interrupted.

With an opaque card, cover one eye. As it is covered, note the uncovered eye.

A normal response is a steady fixed gaze (Fig. 14-13, A).

Meanwhile, the macular image has been suppressed on the covered eye.

If muscle weakness exists, the covered eye will drift into a relaxed position.

Now uncover the eye and observe it for movement.

It should stare straight ahead (Fig. 14-13, B). If it jumps to re-establish fixation, eye muscle weakness exists.

Repeat with the other eye.

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If the eye jumps to fixate on the designated point, it was out of alignment before.

A phoria is a mild weakness noted only when fusion is blocked.

Tropia is more severe—a constant malalignment of the eyes (see Table 14-1, Extraocular Muscle Dysfunction, on p. 311).

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Diagnostic Positions Test

Leading the eyes through the six cardinal positions of gaze will elicit any muscle weakness during movement (Fig. 14-14).

Ask the person to hold the head steady and to follow the movement of your finger, pen, or penlight only with the eyes.

Hold the target back about 12 inches so the person can focus on it comfortably,

and move it to each of the six positions, hold it momentarily, then back to center.

Progress clockwise.

A normal response is parallel tracking of the object with both eyes.

In addition to parallel movement, note any nystagmus—a fine, oscillating movement best seen around the iris.

Mild nystagmus at an extreme lateral gaze is normal; nystagmus at any other position is not.

Finally, note that the upper eyelid continues to overlap the superior part of the iris, even during downward movement.

You should not see a white rim of sclera between the lid and the iris.

If noted, this is termed “lid lag.”

Eye movement is not parallel.

Failure to follow in a certain direction indicates weakness of an extraocular muscle (EOM) or dysfunction of cranial nerve innervating it.

Nystagmus occurs with disease of the semicircular canals in the ears, a paretic eye muscle, multiple sclerosis, or brain lesions.

Lid lag occurs with hyperthyroidism.

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INSPECT EXTERNAL OCULAR STRUCTURES

Begin with the most external points, and logically work your way inward.

General

Already you will have noted the person's ability to move around the room, with vision functioning well enough to avoid obstacles and to respond to your directions.

Also note the facial expression; a relaxed expression accompanies adequate vision.

Groping with hands.

Squinting or craning forward.

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Eyebrows

Look for symmetry between the two eyes.

Normally the eyebrows are present bilaterally, move symmetrically as the facial expression changes,

and have no scaling or lesions (Fig. 14-15).

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Unequal or absent movement with nerve damage.

Scaling with seborrhea.

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Eyelids and Lashes

The upper lids normally overlap the superior part of the iris and approximate completely with the lower lids when closed.

The skin is intact without redness, swelling, discharge, or lesions.

The palpebral fissures are horizontal in non-Asians,

whereas Asians normally have an upward slant.

Note that the eyelashes are evenly distributed along the lid margins and curve outward.

Lid lag with hyperthyroidism.

Incomplete closure creates risk for corneal damage.

Ptosis, drooping of upper lid.

Periorbital edema, lesions (see Tables 14-2 and 14-3).

Ectropion and entropion (see Table 14-2, Abnormalities in the Eyelids, p. 313).

Eyeballs

The eyeballs are aligned normally in their sockets with no protrusion or sunken appearance.

African Americans normally may have a slight protrusion of the eyeball beyond the supraorbital ridge.

Exophthalmos (protruding eyes) and enophthalmos (sunken eyes) (see Table 14-2).

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Conjunctiva and Sclera

Ask the person to look up. Using your thumbs, slide the lower lids down along the bony orbital rim.

 Take care not to push against the eyeball. Inspect the exposed area (Fig. 14-16).

The eyeball looks moist and glossy. Numerous small blood vessels normally show through the transparent conjunctiva.

Otherwise, the conjunctivae are clear and show the normal color of the structure below—pink over the lower lids and white over the sclera.

Note any color change, swelling, or lesions.

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General reddening (see Table 14-6, Vascular Disorders).

Cyanosis of the lower lids.

Pallor near the outer canthus of the lower lid may indicate anemia

(the inner canthus normally contains less pigment).

The sclera is china white, although African Americans occasionally have a gray-blue or “muddy” color to the sclera.

Also in dark-skinned people, you normally may see small brown macules (like freckles) on the sclera,

which should not be confused with foreign bodies or petechiae.

Last, African Americans may have yellowish fatty deposits beneath the lids away from the cornea.

Do not confuse these yellow spots with the overall scleral yellowing that accompanies jaundice.

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Scleral icterus

Tenderness, foreign body, discharge, or lesions.

Eversion of the Upper Lid

This maneuver is not part of the normal examination, but it is useful when you must inspect the conjunctiva of the upper lid, as with eye pain or suspicion of a foreign body.

Most people are apprehensive of any eye manipulation.

Enhance their cooperation by using a calm and gentle, yet deliberate, approach.

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1 Ask the person to keep both eyes open and look down.

This relaxes the eyelid, whereas closing it would tense the orbicularis muscle.

2 Slide the upper lid up along the bony orbit to lift up the eyelashes.

3 Grasp the lashes between your thumb and forefinger and gently pull down and outward.

4 With your other hand, place the tip of an applicator stick on the upper lid above the level of the internal tarsal plates (Fig. 14-17, A).

5 Gently push down with the stick as you lift the lashes up.

This uses the edge of the tarsal plate as a fulcrum and flips the lid inside out.

Take special care not to push in on the eyeball.

6 Secure the everted position by holding the lashes against the bony orbital rim (Fig. 14-17, B).

7 Inspect for any color change, swelling, lesion, or foreign body.

8 To return to normal position, gently pull the lashes

outward as the person looks up.

Lacrimal Apparatus

Ask the person to look down.

With your thumbs, slide the outer part of the upper lid up along the bony orbit to expose under the lid.

Inspect for any redne

Normally the puncta drain the tears into the lacrimal sac.

Presence of excessive tearing may indicate blockage of the nasolacrimal duct.

Check this by pressing the index finger against the sac, just inside the lower orbital rim, not against the side of the nose (Fig. 14-18).

Pressure will slightly evert the lower lid, but there should be no other response to pressure.

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Swelling of the lacrimal gland may show as a visible bulge in the outer part of the upper lid.

Puncta red, swollen, tender to pressure.

Watch for any regurgitation of fluid out of the puncta,

which confirms duct blockage.

INSPECT ANTERIOR EYEBALL STRUCTURES

Cornea and Lens

Shine a light from the side across the cornea, and check for smoothness and clarity.

This oblique view highlights any abnormal irregularities in the corneal surface.

There should be no opacities (cloudiness) in the cornea, the anterior chamber, or the lens behind the pupil.

Do not confuse an arcus senilis with an opacity.

The arcus senilis is a normal finding in aging persons and is illustrated on p. 307.

Iris and Pupil

The iris normally appears flat, with a round regular shape and even coloration.

Note the size, shape, and equality of the pupils.

Normally the pupils appear round, regular, and of equal size in both eyes.

In the adult, resting size is from 3 to 5 mm.

A small number of people (5%) normally have pupils of two different sizes, which is termed anisocoria.

Irregular shape.

Although they may be normal, all unequal-size pupils call for a consideration of central nervous system injury.

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To test the pupillary light reflex, darken the room and ask the person to gaze into the distance.

(This dilates the pupils.) Advance a light in from the side* and note the response.

Normally you will see

(1) constriction of the same-sided pupil (a direct light reflex) and

(2) simultaneous constriction of the other pupil (a consensual light reflex).

In the acute care setting, gauge the pupil size in millimeters, both before and after the light reflex.

Recording the pupil size in millimeters is more accurate when many nurses and physicians care for the same person

or when smallchanges may be significant signs of increasing intracranial pressure.

Normally, the resting size is 3, 4, or 5 mm and decreases equally in response to light. A normal response is recorded as:

[image]

This indicates that both pupils measure 3 mm in the resting state and that both constrict to 1 mm in response to light.

A graduated scale printed on a handheld vision screener or taped onto a tongue blade facilitates your measurement (see Fig. 23-58 in Chapter 23).

Dilated pupils.

Dilated and fixed pupils.

Constricted pupils.

Unequal or no response to light (see Table 14-4, Abnormalities in the Pupil).

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Test for accommodation by asking the person to focus on a distant object (Fig. 14-19). This process dilates the pupils.

Then have the person shift the gaze to a near object, such as your finger held about 7 to 8 cm (3 inches) from the person's nose.

A normal response includes

(1) pupillary constriction and

(2) convergence of the axes of the eyes.

Record the normal response to all these maneuvers as PERRLA, or Pupils Equal, Round, React to Light, and Accommodation.

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INSPECT THE OCULAR FUNDUS

The ophthalmoscope enlarges your view of the eye so that you can inspect the media (anterior chamber, lens, vitreous) and the ocular fundus (the internal surface of the retina).

 It accomplishes this by directing a beam of light through the pupil to illuminate the inner structures.

 Thus using the ophthalmoscope is like peering through a keyhole (the pupil) into an interesting room beyond.

The ophthalmoscope should function as an appendage of your own eye.

This takes some practice.

Practice holding the instrument and focusing at objects around the room before you approach a “real” person.

Hold the ophthalmoscope right up to your eye, braced firmly against the cheek and brow.

Extend your index finger onto the lens selector dial so that you can refocus as needed during the procedure without taking your head away from the ophthalmoscope to look.

Now look about the room, moving your head and the instrument together as one unit.

Keep both your eyes open; just view the field through the ophthalmoscope.

Recall that the ophthalmoscope contains a set of lenses that control the focus (Fig. 14-20).

The unit of strength of each lens is the diopter.

The black numbers indicate a positive diopter; they focus on objects nearer in space to the ophthalmoscope.

The red numbers show a negative diopter and are for focusing on objects farther away.

To examine a person, darken the room to help dilate the pupils.

(Dilating eyedrops are not needed during a screening examination.

When indicated, they dilate the pupils for a wider look at the fundus background and macular area.

Eyedrops are used only when glaucoma can be completely ruled out, because dilating the pupils in the presence of glaucoma can precipitate an acute episode.)

Remove your eyeglasses and those of the other person; they obstruct close movement and you can compensate for their correction by using the diopter setting.

Contact lenses may be left in; they pose no problem as long as they are clean.

Select the large round aperture with the white light for the routine examination.

 If the pupils are small, use the smaller white light. (Although the instrument has other shape and colored apertures, these are rarely used in a screening examination.)

The light must have maximum brightness; replace old or dim batteries.

Tell the person, “Please keep looking at that light switch (or mark) on the wall across the room, even though my head will get in the way.”

Staring at a distant fixed object helps to dilate the pupils and to hold the retinal structures still.

Match sides with the person.

That is, hold the ophthalmoscope in your right hand up to your right eye to view the person's right eye. You must do this to avoid bumping noses during the procedure.

Place your free hand on the person's shoulder or forehead (Fig. 14-21, A).

This helps orient you in space, because once you have the ophthalmoscope in position, you only have a very narrow range of vision.

Also, your thumb can anchor the upper lid and help prevent blinking.

Retinal Vessels

This is the only place in the body where you can view blood vessels directly. Many systemic diseases that affect the vascular system show signs in the retinal vessels. Follow a paired artery and vein out to the periphery in the four quadrants (see Fig. 14-23), noting these points:

 Number

A paired artery and vein pass to each quadrant. Vessels look straighter at the nasal side.

abn: Absence of major vessels.

2. Color

Arteries are brighter red than veins. Also, they have the arterial light reflex, with a thin stripe of light down the middle.

3. A : V ratio

The ratio comparing the artery-to-vein width is 2 : 3 or 4 : 5.

abn: Arteries too constricted.

Veins dilated.

4. Caliber

Arteries and veins show a regular decrease in caliber as they extend to the periphery.

ABN: Focal constriction.

Neovascularization (proliferation of new vessels).

5. A-V (arteriovenous) crossing

An artery and vein may cross paths. This is not significant if within 2 DD of disc and if no sign of interruption in blood flow is seen. There should be no indenting or displacing of vessel.

ABN: Crossings more than 2 DD away from disc.

Nicking or pinching of underlying vessel. Vessel engorged peripheral to crossing (see Table 14-10).

6. Tortuosity

Mild vessel twisting when present in both eyes is usually congenital and not significant.

ABN: Extreme tortuosity or marked asymmetry in two eyes.

7. Pulsations

Present in veins near disc as their drainage meets the intermittent pressure of arterial systole. (Often hard to see.)

ABN: Absent pulsations.

General Background of the Fundus

The color normally varies from light red to dark brown-red, generally corresponding with the person's skin color.

Your view of the fundus should be clear; no lesions should obstruct the retinal structures.

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Macula

The macula is 1 DD in size and located 2 DD temporal to the disc (Fig. 14-25).

Inspect this area last in the funduscopic examination.

 A bright light on this area of central vision causes some watering and discomfort and pupillary constriction.

Note that the normal color of the area is somewhat darker than the rest of the fundus but is even and homogeneous.

Clumped pigment may occur with aging.

Within the macula, you may note the foveal light reflex.

This is a tiny white glistening dot reflecting your ophthalmoscope light.

Clumped pigment occurs with trauma or retinal detachment.

Hemorrhage or exudate in the macula occurs with senile macular degeneration.

AGING ADULT

Visual Acuity.

 Perform the same examination as described in the adult section.

Central acuity may decrease, particularly after 70 years of age. Peripheral vision may be diminished.

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In older adults, an increased risk of falls and fractures occurs with a distance visual acuity of 20/25 or greater.

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aging adult

Ocular Structures.

The eyebrows may show a loss of the outer one third to one half of hair because of a decrease in hair follicles. The remaining brow hair is coarse (

Fig. 14-31). As a result of atrophy of elastic tissues, the skin around the eyes may show wrinkles or crow's feet.

The upper lid may be so elongated as to rest on the lashes, resulting in a pseudoptosis.

aging adults

The eyes may appear sunken from atrophy of the orbital fat.

Also, the orbital fat may herniate, causing bulging at the lower lids and inner third of the upper lids.

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aging adult

The lacrimal apparatus may decrease tear production, causing the eyes to look dry and lusterless and the person to report a burning sensation.

Pingueculae commonly show on the sclera (Fig. 14-32

These yellowish, elevated nodules are due to a thickening of the bulbar conjunctiva from prolonged exposure to sun, wind, and dust.

Pingueculae appear at the 3 and 9 o'clock positions—first on the nasal side and then on the temporal side.

Distinguish pinguecula from the abnormal pterygium, also an opacity on the bulbar conjunctiva, but one that grows over the cornea (see Table 14-7).

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aging adult

The cornea may look cloudy with age. An arcus senilis is commonly seen around the cornea (Fig. 14-33).

This is a gray-white arc or circle around the limbus; it is due to deposition of lipid material.

As more lipid accumulates, the cornea may look thickened and raised,

but the arcus has no effect on vision.

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aging adult

Xanthelasma

Fig. 14-34

They commonly occur around the fifth decade of life and more frequently in women.

They occur with both high and normal blood levels of cholesterol and have no pathologic significance.

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Pupils are small in old age, and the pupillary light reflex may be slowed. The lens loses transparency and looks opaque

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aging adult

The Ocular Fundus.

 Retinal structures generally have less shine.

The blood vessels look paler, narrower, and attenuated.

Arterioles appear paler and straighter, with a narrower light reflex.

More arteriovenous crossing defects occur.

A normal development on the retinal surface is drusen, or benign degenerative hyaline deposits (Fig. 14-35).

They are small, round, yellow dots that are scattered haphazardly on the retina.

Although they do not occur in a pattern, they are usually symmetrically placed in the two eyes.

They have no effect on vision.

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Drusen are easily confused with the abnormal finding hard exudates, which occur with a more circular or linear pattern (see Table 14-10, p. 321).

Also, drusen in the macular area occur with macular degeneration.

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