Eyes

By Orest Kornetsky

Eye Anatomy Why Study It?

Why should you care?

Optometrist Doctor of optometry, 4 year
undergrad + 4 year optometry school
Ophthalmologists Medical doctors
In general, optometrists practice primary
and preventive eye care, while
ophthalmologists perform eye surgery
What do nurses do?

History

Vision difficulty?

Eye pain?

Photophobia inability to tolerate light

Childhood strabismus?

Halos around lights in glaucoma

Scotoma blind spot in visual field in
glaucoma, optic nerve, and visual pathway
disorder
Night blindness Vit A deficiency,
glaucoma,

A history of crossed eyes? AKA lazy eye

Redness or swelling?

Infections?

History cont.

Excessive or lack of tearing?

May

be due to irritants or obstruction in drainage

Past history of ocular problems?

Glaucoma? Family history?
Use of glasses or contact lenses?
When tested last?
Any medications?

Anatomy of
Eyelid

Eyelids (L. palpebrae) protect the

cornea and eyeball from injury
Canthi (sing. canthus) are corners of
the eye, also called angles of eye
Caruncle is located near medial
canthus and contains sebaceous
glands
Tarsal plates are made of connective
tissue and strengthen eyelid. They
contain meibomian (tarsal) glands
which secrete lipid to create airtight
seal when closed and also prevent
eyelids from sticking together

Inspecting External Ocular

Structures

General

Eyebrows

Note if facial expression is relax or

tense
Note if movement is symmetrical

Eyelids and lashes

Note if any redness, swelling,

discharge or lesions
Note if eyelid closes completely and if
drooping

Pallor of lower lid is good indicator of

anemia

For upper eyelid, use applicator stick

to fold the eyelid over (Fig 14-17)

Abnormalities in Eyelids

Ectropion

Lower lid rolls out, causing an

increase in tearing
The eyes feel dry and itchy due to
inappropriate itching
Increase risk for inflammation
Occurs mostly in elderly due to
atrophy of elastic tissue

Entropion

The lower lid rolls in

Foreign body sensation

Abnormalities in Eyelids

Periorbital edema
May

occur with local

infection of systemic
condition (CHF)

Ptosis
Occurs

with
neuromuscular
weakness (myasthenia
gravis) or CN III
damage

Lesions on the
Eyelids

Blepharitis

Chalazion

Inflammation of eyelids
Staph or dermatitis
Burning, itching, tearing,
foreign body sensation, pain
A cyst in or an infection of
meibomian gland
Nontender, firm, overlying
skin freely movable

Hordeolum (Stye)

Localized Staph infection of

hair follicle at lid margin
Painful, red, swollen, purulent

Anatomy of the Eye

Lacrimal apparatus
provides irrigation of
conjunctiva
glands secrete
lacrimal fluid (tears)
Lacrimal ducts lacrimal
fluid to conjunctiva
Lacrimal canaliculi
(puncti) drain fluid into
Nasolacrimal duct
conveys lacrimal fluid to
nasal cavity
Lacrimal

Inspecting the Lacrimal Apparatus

Inspect for bulges

or pressure near
canaliculi
Dacryocystitis
Inflammation

of the
lacrimal sac and/or
nasolacrimal duct

Dacryoadenitis
Infection

of lacrimal

gland
Dacryoadenitis

Dacryocystitis

Anatomy of Extraocular Muscles

4 rectus (straight)
2 oblique
Innervations

SO4 Superior oblique m.

LR6 Lateral rectus m.

CN IV (trochlear n.)
CN VI (abducens n.)

AO3 All other muscles

CN III ( Trigeminal n.)

Extraocular muscle movement

Extraocular Muscle Dysfunction

Anatomy of the Eyeball Outer Layer

Sclera tough
protective white
covering (posterior
5/6)
Cornea
transparent part of
the fibrous coat
covering the anterior
of the eyeball
(anterior 1/5)
Conjunctiva
transparent
protective covering
of exposed part of
eye (palpebral
conjunctiva covers
inside of eyelash)

iris

Corneal reflex lightly touching the eye with cotton

stimulates a blink.

Trigeminal n. (afferent)

Facial n. (efferent)

Inspection

Conjunctiva
Sliding

the lower lids down, observe

for redness on conjunctiva and if
eyeball looks moist and glossy
Reddening may be pathogenic

Sclera
Should

be white, although may

have gray-blue hue
Might contain yellowish fatty
deposits beneath the lids

Yellowing of sclera indicates jaundice

Vascular Disorders of Eye

Conjunctivitis

Pink eye
Due to bacterial, viral, allergic, or chemical
irritation
Redness throughout the conjunctiva, but
usually clear around the iris
Purulent discharge usually common
Symptoms: itching, burning, foreign body
sensation

Iritis

Red halo around the iris and cornea

Pupils may be irregular due to swelling
Symptoms: photophobia, blurred vision,
throbbing pain

Inspecting Cornea and Lens

Corneal abrasion

Assess by shining a light

and observing from the
side

Pupillary light reflex

Charted according to size

of pupil
Charted as a ratio of before
light/after light (3/1)
A sluggish response may
be caused by increased
ICP
No response may indicate
neurological damage

How to chart
pupillary light reflex?
PERRLA:
Pupils Equal, Round,
React to Light and
Accommodation

Anatomy of the Eyeball

Middle Layer

Canal of Schlemm

Choroid provides vascularity to

retina
Pupil variable-sized, black circular
or slit shaped opening in the center
of the iris that regulates the amount
of light that enters the eye. Appears
black because most of the light
entering the pupil is absorbed by the
tissues inside the eye.
Lens biconvex disc controlled by
the ciliary muscle to produce far
vision when flat
Anterior chamber

Aqueous humor is produced by the

ciliary body and secreted into
posterior chamber of eye.
From there, aqueous humor travels
to the anterior chamber where it
exits through the Canal of Schlemm
Determines intraocular pressure

Increase leads to
Glaucoma

Vascular Disorders of Eye

Physiology review:
Aqueous humor is produced by the ciliary body
and secreted into posterior chamber of eye. From
there, aqueous humor travels to the anterior
chamber where it exits through the Canal of Schlemm

Glaucoma

Excessive pressure in eye

due to blockage of outflow
from anterior chamber
This puts pressure on optic
nerve
Redness around the iris,
dilated pupils
Symptoms: sudden
clouding of vision, sudden
eye pain, and halos around
lights

Disorders of Opacity of Lens

Cataract

Anatomy of the Eyeball

Inner Layer

Retina visually
receptive layer where
light waves are changed
to nerve impulses
Optic disc area where
the optic nerve enters the
eyeball
Fovea centralis area of
most acute vision

Inspecting the Ocular Fundus

Using an ophthalmoscope to inspect

the internal surface of the retina,
anterior chamber, lens, and vitreous.
Darken the room to dilate the pupils
Remove eye glasses, contacts may
stay in
Ask person to stare at distant object
Hold ophthalmoscope close to your
eye and move to within a few inches
of the persons face
A red glow filling the pupil is called
the red reflex and is caused by light
reflecting off the retina

Cataracts appear as opaque black

areas against the red reflex

Inspecting the Optic Disc and Retina

Normal optic disc is:

Yellow-orange

to pink

Round

or oval
Distinct margins

Normal retina is:

Arteries

in each
quadrant
Arteries are bright red

Visual pathways

Testing Visual Reflexes

Pupillary light reflex

Constriction of pupils when bright light shines on the retina

Direct light reflex constriction of same sided pupil
Consensual light reflex simultaneous constriction of both
pupils
The impulse is carried afferently by CN II and efferently by CN III

Accommodation

Adaptation of eye for near vision

Ask person to focus on distant object (dilates the pupils). Then
ask person to shift gaze to near object few inches away. A
normal response is pupillary constriction and convergence of
axes of the eyes

Testing Visual Accuity

Snellen Eye Chart

Standing 20 feet from the

chart
Test one eye at a time by
covering the other eye
Leave contact lenses and
glasses on, unless the
glasses are reading
glasses
Normal vision is 20/20

Near vision

Use Jaeger card (smaller

version of Snellen chart) or
just read newspaper

Testing Visual Fields

Confrontation test

Measures peripheral vision

compared to examiner
(assuming examiners vision is
normal)
Both examiner and pt cover
one eye with a card, stand
about 2 feet away, and
maintain eye contact
Advance finger, starting from
periphery, and ask patient to
say now when the finger is
first visible
Inability to see when the
examiner sees suggests
peripheral field loss

Testing Ocular Muscle

Function

Cover Test

Detects deviated alignment of eyes

Ask pt. to stare straight at your nose and
cover one of the pt.s eyes with a card
While noting the uncovered eye, move
away the card
A normal response is a steady fixed gaze

Diagnostic Position Test

Ask pt. to hold head straight and move

finger in all positions, holding it about 12
inches away
A normal response is parallel tracking of
the objects with both eyes

Nystagmus

Fine oscillating movements around the iris

Normal at extreme lateral gaze

Developmental Considerations
Infants and Children

Strabismus must be detected

and treated early to prevent
permanent disability
Esotropia inward turning of eye
Exotropia outward turning of eye

Color vision due to inherited Xlinked recessive trait, occurs more

often in boys
External eye structures an
upward lateral slope together with
epicanthal folds occurs in Down
syndrome
Ophthalmia neonatum
conjunctivitis due to bacteria, virus,
or chemical irritation

Developmental Considerations
Aging

Decrease in visual
acuity, diminished
peripheral vision
Ectropion (drooping of
lower lid) or entropion
(eyelids turning in)
Pinguecula yellow
nodules due to
thickening of
conjunctiva as a result
of prolonged exposure
to sun, wind, and dust

Developmental Considerations Aging

Arcus senilis graywhite arc seen around

the cornea. Due to
deposition of lipids.
No effect on vision
Xanthelasma raised
yellow plaques.
Normal

THE END
EYE HOPE YOU HAVE
A GREAT DAY!!!