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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


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
  • 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

Color: Light Red

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

Light Reflex: Bright


Color: Dark Red

Size: Larger

Light Reflex: Less bright or absent

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)