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Examination of the Eye & Ear. Professor Janet M. Galiczewski RN,CCRN,MSN,ANP. A & P Outer Eye. External Eye. Eyelid : Distributes tears, limits light entering eye, protects eye. Upper lid covers 2-3 mm of iris but NOT pupil. The lower lid sits directly on the lower ring of the iris

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Examination of the eye ear

Examination of the Eye & Ear

Professor Janet M. Galiczewski

RN,CCRN,MSN,ANP



External eye
External Eye

  • Eyelid: Distributes tears, limits light entering eye, protects eye. Upper lid covers 2-3 mm of iris but NOT pupil. The lower lid sits directly on the lower ring of the iris

  • Palpebral Fissure: Opening between eyelids.

  • Conjunctiva: Thin membrane covering most of the anterior surface of eye & eyelid, protects eye.


  • Lacrimal Gland: located in temporal region of eyelid. Produces tears ( drain into lacrimal sac from puncta to nasolacrimal duct to nasopharynx).

  • Puncta is the only visible portion of the lacrimal apparatus.


Eye muscles eom s
Eye Muscles (EOM’s)

  • EOM’s are responsible for eye movement

  • 4 Rectus

  • 2 Oblique

  • Innervated by CN III, CN IV, CN VI

  • Levator palpebrae muscle which raises upper eyelid innervated by CN III



Internal eye
Internal Eye

  • Sclera: “White of the Eye,” protective, provides structure. The optic nerve is attached to it at the back of the eye.

  • Cornea: continuous with sclera, transparent dome shaped window that covers iris, pupil,& anterior chamber. Provides most of the eyes optical power.

  • 1. Refracts light

  • 2. Eye focus (fixed)

  • 3. Protects - nerve endings sensitive to touch, temp, & chemicals


  • Aqueous Humor: Fluid produced by ciliary body that flows from posterior chamber through pupil to anterior chamber. Controls pressure inside eye.

  • Iris: Circular, contractile muscular disc containing pigmented cells. Regulates the light levels inside eye.

  • Pupil:Center of iris.Tiny sphincter muscles constrict pupil to light & tiny dilator muscles dilates eye in dim light.


  • Lens:Their purpose is to focus light on the retina. The lens have ability to change shape and to adjust to close & distant vision. This is called accommodation.

  • Retina: Sensory network that lines the back of the eye, transforms light impulses to electrical impulses.Impulses travel via optic nerve to cerebral cortex. Here they are transformed into images.

  • 1. Cones:macula portion of retina, central vision, bright light, color appreciation

  • 2. Rods: spread throughout peripheral retina, peripheral & night vision, dim light


Mechanisms of vision
Mechanisms of Vision

  • Vision depends on light rays which enter eye, passes through cornea & pupil, then focus on retina by the lens.

  • Vision may be altered from local or systemic disease.


Examination of the eye
Examination of the Eye

  • Review of systems

  • Inspection of external structures.

  • Measurement of visual acuity.

  • Determination of visual fields.

  • Evaluation of Extraocular Movement.

  • Estimation of Intraocular pressure.

  • Exploration of Ocular Fundus.


Review of systems
Review of Systems

  • Start with open ended questions….

  • Onset of problem gradual or sudden?

  • Problem seeing close work or distance?

  • Pain or headaches?

  • Last eye exam

  • Glasses or contact lens


Inspection of external structures
Inspection of External Structures

  • Eyelids: Inspect blinking, external surface for lesions, superficial vascularity, edema.

  • Ptosis

  • Check position of lids for Eversion, Inversion.

  • Check Enophthalmos, Exophthalmos


Eyelids cont
Eyelids (cont).

  • Check for corneal drying

  • Palpate for ocular tension.

  • Check Lacrimal apparatus

  • Eyebrows, Eyelashes: note quantity, distribution, color, texture.

    • Sty

    • Chalazion


Conjunctiva sclera
Conjunctiva & Sclera

  • Examine palpebral conjunctiva lining the lids & bulbar conjunctiva covering sclera.

  • Note: color, vascular patterns, nodules, swelling.

  • Conjunctivitis


Cornea lens iris
Cornea, Lens & Iris

  • Using oblique lighting note: scars, irregularities, foreign bodies, opacities

  • Check iris for crescent shadow on medial side of iris (no shadow should be seen).

  • Arcus Senilis


Pupils
Pupils

  • Note: size, shape, equality (slight inequality may be normal (anisocoria).

  • Check pupillary reaction to light.

    • Look for Direct reaction

    • Consensual reaction

      • Identify as: prompt or brisk (normal), sluggish, or absent.


Visual acuity
Visual Acuity

  • Snellen Chart-Check distant visual acuity, color.

    • Ex. 20/30 vision. 20=distance from chart.

      30=distance at which normal eye can read that line of letters.

    • Presbyopia

    • Myopia (near-sightedness)

    • Hyperopia (far-sightedness)


Visual fields
Visual Fields

  • Defined as the entire area seen by an eye when its gaze is fixed on a central point.

  • Superficially tested by comparing the pts. peripheral vision with your own.

  • Technique: “Confrontation”Visual Fields


Extraocular movements eom
Extraocular Movements (EOM)

  • To detect weakness or paralysis of extraocular muscles.

  • Corneal Light Reflex

  • EOM’S “H” Pause to detect nystagmus (fine rhythmic oscillation of the eyes).

  • Combine with convergence.

  • Check for lidlag.


Opthalmoscopy fundoscopy
Opthalmoscopy (Fundoscopy)

  • Important in evaluation of local disorders (cataract, retinal detachment, or systemic disease)

  • The light beam passes through the cornea to aqueous humor of the anterior chamber to lens to the vitreous humor, strikes the retina & structures that make up fundus of the eye.

  • Fundus-internal surface of the retina


Opthalmoscopy fundoscopy cont
Opthalmoscopy (Fundoscopy)cont.

  • Image of the optic disc, blood vessels, retina, macula, fovea.

  • Technique- if you wear glasses leave on or correct for deficit with ophthalmoscope.

  • Turn lens disc to “O”

  • Keep index finger on lens disc to focus during exam.


Opthalmoscopy fundoscopy cont1
Opthalmoscopy (Fundoscopy)cont.

  • Darken room-dimly lit, switch on ophthalmoscope light to round beam of white light.

  • Use your Right hand & Right eye for pts. Right eye. Same for Left.

  • You & pts. Eyes should be at same level.

  • Instruct pt to look up & over your shoulder at a fixed point on the wall.


Opthalmoscopy fundoscopy cont2
Opthalmoscopy (Fundoscopy)cont.

  • From about 15 inches away from pt & 15 degrees lateral to pt. Line of vision

    • Shine light beam into pupil

    • You will see Red Reflex (orange, red glow in pupil) Cataract will interrupt.

    • Keep beam on red reflex, move in 15 degrees to pts line of sight, until scope is close. You will see the OPTIC DISC.(yellow /orange or creamy pink; oval or round).


Ophthalmoscopy fundoscopy cont
Ophthalmoscopy (Fundoscopy)cont.

  • If only vessels seen trace back to disc (bring disc into sharp focus)

  • Pattern of Exam:Red Reflex, Disc, Vessels, Retina including Macula.

  • Red Reflex: note opacities, dark lines, black spots.

  • Disc Color: yellow, orange to creamy pink, disc diameter is about 1.5 mm


Vessels

Arteries

Color: Light Red

Size: Smaller Diameter (2/3 less than vein).

Light Reflex: Bright

Veins

Color: Dark Red

Size: Larger

Light Reflex: Less bright or absent

Vessels


Fundoscopy cont
Fundoscopy (cont).

  • HTN: arterioles become narrow & tortuous,

  • Ratio (A/V) decreases to 1:2 or 1:3 (Normal 2:3, 4:5).

  • AV Nicking-Kinking or indentation of the venule at a crossing.

  • Retina: Note-lesions, size, shape, color, distribution.

  • Hemorrhage: may appear flame shaped, deep red spots.


Fundoscopy cont1
Fundoscopy (cont).

  • Exudates: Hard or soft

  • Soft:”cotton wool exudates” fluffy, fuzzy outline

  • Hard: smaller with discrete borders

  • Next, move laterally to inspect macula (temporal)

  • Fovea tiny pinpoint of bright in center of macula.


Fundoscopy cont2
Fundoscopy (cont).

  • Senile Macular Degeneration:important cause of impaired central vision in elderly. Look for hemorrhage, exudate, cysts.

  • Degree of retinal changes direct relationship to severity of disease.


A p of the ear
A & P of the EAR

  • Sensory organ:Function is to identify, locate interpret sound.

  • Maintain equilibrium.

  • Divided into 3 parts:External,Middle,Inner.


External ear
External Ear

  • Auricle: varies size & shape.

  • Should be = in height & size

  • Structural landmarks of the auricle:

    • Helix: prominent outer ridge.

    • Antihelix: parallel & anterior to helix.

    • Tragus: anterior to auditory canal.

    • Antitragus: opposite auditory canal opening.

    • Lobule: Soft, lobe at bottom of auricle.


  • External Auditory Canal: 2.5-3cm length narrows toward mid-portion & widens near eardrum.

  • “S” shaped pathway leads to middle ear.

  • Consists of bone & cartilage covered with thin sensitive skin.

  • Mastoid process: bone behind & below the ear canal ( mastoid part of temporal bone).


Middle ear
Middle Ear

  • Air filled cavity in temporal bone separated from external ear by tympanic membrane.

  • TM (Eardrum): shiny, translucent & pearly grey.

  • Sound transmitted by 3 tiny bones: (ossicles) malleous, incus, stapes.

  • Eustachian tube leads to nasopharynx allows for equalization of air pressure with atmospheric pressure (swallowing).


Middle ear1
Middle Ear

  • TM visualized (otoscope) as an oblique membrane pulled inward at its center by the malleus. You can locate:

    • Handle of malleous

    • Short process of malleous

    • Umbo

    • Cone of light

    • Pars flaccida

    • Pars tensa


Inner ear
Inner Ear

  • A curved cavity within a bony labyrinth

  • Consists of a vestibule, semicircular canals, cochlea.

  • Cochlea contains the organ of corti which transmits sound impulses to the Cranial Nerve VIII (Acoustic).


Physiology of hearing
Physiology of Hearing

  • Vibrations of sound are transmitted to the external ear, then to the eardrum, to the ossicles of middle ear to the cochlea (of inner ear).

  • Vibrations of cochlea cause the organ of corti to stimulate impulses in CN VIII which are transmitted to temporal lobe for interpretation .

  • Normal hearing pathway: Air Conduction


Types of hearing loss
Types of Hearing Loss

  • Conductive Hearing Loss: Occurs when changes in outer or middle ear impairs conduction of sound to inner ear.

  • Air conduction is impeded d/t Excessive cerumen, foreign body, otitis media, tumor of middle ear, otitis externa, fluid in middle ear (more common in < 40 years old).


Types of hearing loss1
Types of Hearing Loss

  • Sensorineural Hearing Loss: Occurs with impairment of organ of corti.

  • EX: Sustained exposure to loud noise, ototoxicity d/t drugs (aminoglycosides, antibiotics, chemo, lasix) syphilis, DM

  • More common in older people

  • Loss often mid to high frequency range.

  • Mixed Hearing Loss: Both types combined.


Technique for ear examination
Technique for Ear Examination

  • External Ear : Inspection, Palpation

  • Middle Ear: Inspection

  • Auditory Acuity:

    • Whisper

    • Watch

    • Weber

    • Rinne


Technique for ear exam
Technique for Ear Exam

  • External Ear

  • Inspection : Each auricle & surrounding tissue.

  • Note: deformities, lumps, discharge, may see tophi(deposits of uric acid crystals in helix; occurs with gout).

  • Palpate: External ear for tenderness, masses. should be smooth, non tender.

    • Otitis Externa- tender, swollen, narrowed moist external canal

    • Otitis Media- non tender



Ear canal drum otoscope
Ear Canal & Drum : Otoscope

  • Grasp auricle & have pt. Tilt head to opposite side

  • Adult: Pull helix up, back & slightly out.

  • Insert largest speculum that ear will accommodate.

  • Brace hand against pts. Head

  • Insert otoscope into canal-down & forward (reposition head if you can’t visualize landmarks)

  • Inspect & identify any discharge or foreign bodies in ear canal. Note: redness, swelling.

  • Cerumen may obstruct view.


Otoscope cont
Otoscope (cont).

  • Inspect eardrum: note color, contour

  • Otitis Media: red, bulging drum, loss of landmarks, dilated blood vessels may cause spontaneous rupture & conductive hearing loss.

  • Identify bony landmarks: cone of light

  • 7 o’clock -Left Ear

  • 5 o’clock – Right Ear


Otoscope cont1
Otoscope (cont).

  • Move speculum: view as much of drum as possible.

  • Identify:

  • Pars flaccida superiorly,

  • margins of pars tensa, look for perforation.


Auditory acuity cn viii
Auditory Acuity CN VIII

  • Test one ear at a time.

  • Ask pt. To occlude 1 ear with finger or hand.

  • Whisper Test: Stand 1-2 ft. away (behind pt). Exhale & whisper 2 syllable words. Ex. Baseball

  • Ticking Watch: Same procedure as whisper. Pt. Can hear ticking watch from 2ft. away equally.

  • Weber Test: (Lateralization)

    • Set tuning fork into light motion (vibration)


Auditory acuity cn viii1
Auditory Acuity CN VIII

  • Weber Test (cont).

  • Place tuning fork on top of pts. head or forehead.

  • Ask pt. Where he hears it, one or both sides

  • Normal = midline

  • Conductive Hearing loss:Sound lateralizes to impaired ear.

  • Sensorineural Loss: Sound heard in good ear.


Auditory acuity cn viii2
Auditory Acuity CN VIII

  • Rinne Test

  • Compares air & bone conduction .

  • Place vibrating fork at base of mastoid (bone behind ear)

  • When sound no longer heard- place fork @ ear canal & see if pt. can hear.

  • Normal: AC > BC

  • Conductive Hearing Loss: BC=AC or BC>AC

  • Sensorineural Hearing loss: Sound heard longer through air. AC>BC (Normal)


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