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Entropion
The lower lid rolls in
Foreign body sensation
Abnormalities in Eyelids
Periorbital edema
May occur with local
infection or systemic
condition
Ptosis
Occurs with
neuromuscular
weakness (myasthenia
gravis) or CN III
damage
Lesions on the
Eyelids
Blepharitis
Inflammation of eyelids
Staph or dermatitis
Burning, itching, tearing,
foreign body sensation, pain
Chalazion
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
Lacrimal 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
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.
CN IV (trochlear n.)
LR6 – Lateral rectus m.
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 iris
(anterior 1/5)
Conjunctiva –
transparent
protective covering
of exposed part of
eye (palpebral Corneal reflex – lightly touching the eye with cotton
conjunctiva covers
stimulates a blink.
inside of eyelash)
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)
How to chart
A sluggish response may pupillary light reflex?
be caused by increased
ICP
No response may indicate PERRLA:
neurological damage Pupils Equal, Round,
React to Light and
Accommodation
Anatomy of the Eyeball – Canal of Schlemm
Middle Layer
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 person’s 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
Sensorineural
Dysfunction of inner ear, CN VIII, or cerebral cortex
Cannot be fixed
Developmental
Infants
Considerations
Greater risk for otitis media (middle ear infections) due to shorter
eustachian tube
Aging
Cilia lining ear canal become coarse and stiff, impeding sound waves
Cerumen more common
Dry cerumen – gray and flaky. More common in Asians and Native
Americans
Wet cerumen – brown and moist. More common in whites and
blacks
Presbycusis - degenerative sensorineural hearing loss
Auditory reaction time increases
Obtaining History
Earaches? (otalgia)
Location, character, intensity, associative and alleviating factors
May be directly due to ear disease or maybe referred pain from a
problem in teeth or oropharynx
A viral or bacterial upper respiratory infection may migrate up the
eustachian tube and involve the middle ear
Infections?
Frequency? Occurred in childhood?
Discharge? (otorrhea)
May suggest infection or perforated eardrum
Typically with perforation, ear pain drainage
Otitis externa – purulent, sanguineous, or watery
Acute otitis media with perforation – purulent discharge
More History
Trouble hearing?
Gradual our sudden?
Presbycusis – gradual sensorineural hearing impairment in the
elderly
Hearing loss due to trauma is often sudden
Ringing in ears? (tinnitus)
May be a result of medication
Medications?
Some are ototoxic
Vertigo? (spinning)
Subjective – person feels like he or she spins
Objective – person feels like room spins
Environmental noise
Noise-induced hearing loss
Lesions of External Ear
Otitis Externa
Gouty Tophi
Assessing External Ear
Size and Shape
normal is 4-10cm tall
Skin conditions
Note edema, inflammation, lesions
Tenderness
Location?
Pain in pinna indicates otitis externa
Pain at mastoid process indicates mastoiditis or lymphadenitis
External Auditory Meatus
Atresia – absence or closure of ear canal
Otitis externa may cause purulent discharge
Otitis media may cause rupture of tympanic membrane
If drainage present following trauma, possible basal skull
fracture. Perform glucose test (CSF (+) for glucose).
Inspecting Using Otoscope
Pull the pinna up and
back in adult, straight
down in children under 3
years
Hold otoscope upside
down and place dorsal
side of hand along
person’s cheek
Insert speculum slowly
and avoid touching the
inner section of canal
wall, which is sensitive
and may cause pain.
Inspecting the External Canal
Note any redness or
Otitis
swelling, lesions, or Externa
foreign bodies
If discharge present,
note color and odor
Inspecting the Tympanic
Membrane
Normal is shiny and
translucent
Flat, slightly pulled in
at the center
Valsalva maneuver
causes tympanic
membrane to flutter,
used to assess drum
mobility
Which tympanic membrane
is perforated?
Testing Hearing Acuity
Voice test
Whisper two syllable words
into one of the person’s
ears, while covering the
other one. Ask person to
repeat what you’ve said.
Tuning fork tests
Measure hearing by air
conduction or bone
conduction
Weber test
Rinne test
Weber Test
Tuning fork is struck and
placed on head or
forehead, equal distance
from both ears
Used to determine if
hearing loss is more
extensive in one ear than
the other
This test cannot confirm
normal hearing, because
hearing defects affecting
both ears equally will
produce an apparently
normal test result
Rinne Test
Compares air conduction and
bone conduction
Place stem of vibrating fork on
mastoid process and ask when
sound goes away
Quickly invert the fork so the
vibrating end is near the ear
canal. The person should still
hear a sound
Normally the sound is heard
longer by air conduction rather
than bone conduction
In conductive hearing loss,
sound heard longer by bone
conduction
Normal Hearing
Conductive Hearing Loss
Sensorineural Hearing Loss
Infants and Children
Save otoscopic examination until the end
May help to show otoscope to child and let
him or her play with it
Stabilize (or ask a parent for help) the
child’s head in order to prevent movement
Pull pinna straight down
In infants, the tympanic membrane may
look thick and opaque after first few days
or after crying
Tympanostomy tubes may be in place if
drainage occurs as a result of otitis media
Abnormalities in the Ear Canal
Acute Otitis
Media
Otitis Externa
Excessive Cerumen
Question 1
A nurse is performing a voice test to assess
hearing. Which of the following describes the
accurate procedure for performing this test?
1. Stand 4 feet away from the client to ensure that the
client can hear at this distance
2. Quietly whisper a statement and ask the client to
repeat it
3. Whisper a statement with the examiner’s back facing
the client
4. Whisper a statement while the client blocks both
ears
Question 2
A nurse is caring for a client who is
hearing impaired. Which of the following
approaches will facilitate
communication?
1. Speak frequently
2. Speak loudly
3. Speak directly into the impaired ear
4. Speak in a normal tone
Question 3
A client is diagnosed with a disorder
involving the inner ear. Which of the
following is the most common client
complaint associated with a disorder
involving this part of the ear?
1. Hearing loss
2. Pruritus
3. Tinnitus
4. Burning in the ear
Question 4
Which of the following statements made
by a parent should make the nurse
suspicious that the tympanic membrane
of a young child has ruptured?
1. “She has been crying all night, but she feels
better this morning.”
2. “She has some bloody, yellow-looking stuff
coming out of her ear.”
3. “My child does not seem to hear very well.”
4. “My child’s earwax is dark brown.”
Question 5
While examining the internal ear, the
nurse observes the light reflex on the
tympanic membrane. What does this
finding indicate?
1. Presence of pus
2. Fluid accumulation
3. Scar tissue
4. Normal finding