Chapter 14 Eyes 1. Extraocular muscles a.

. Six muscles attach the eyeball to its orbit and serve to direct the eye to points of the persons interest b. Straight (rectus) muscles i. Superior, inferior, lateral and medial rectus muscles c. Slanting (oblique) muscles i. Superior and inferior d. Conjugate movement i. Each muscle is coordinated with one in the other eyes ii. Ensures that when the two eyes move, their axes always remain parallel e. Movement of extraocular muscles is stimulated by three cranial nerves i. VI abducens nerve 1. Innervates the lateral rectus muscle 2. Abducts the eye ii. IV trochlear nerve 1. Innervates the superior oblique muscles iii. III oculomotor nerve 1. Innervates the remaining muscles (superior/inferior/medial rectus and inferior oblique) iv. Direction of movement 1. Up and in inferior oblique 2. In medial rectus 3. Down and in superior oblique 4. Down and out inferior rectus 5. Out lateral rectus 6. Up and out superior rectus 2. Cranial nerves a. I olfactory smell test b. II optic visual acuity/visual fields/pupillary light reflex c. III oculomotor diagnostic positions test d. IV trochlear diagnostic positions test e. V trigeminal cotton wisp on face, check TMJ f. VI abducens diagnostic positions test g. VII facial taste, bilateral movement h. VIII auditory hearing test/whisper test i. IX glossopharyngeal taste, gag reflex j. X vagus gag reflex, ah test k. XI spinoaccessory shrug shoulders against resistance l. XII hypoglossal stick tongue out (midline check) 3. Only parts accessible to exam are the sclera anteriorly and the retina through the opthalmoscope 4. Corneal reflex touch one eye with a wisp of cotton and both eyes blink

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8.

a. V trigeminal nerve i. Carries the afferent sensation into the brain b. VII facial nerve i. Carries the efferent message that stimulates the blink Muscles fibers of the iris a. Contract the pupil in bright light and to accommodate for near vision b. Dilate the pupil in dim light and accommodate for far vision The image formed on the retina is upside down and reversed from its actual appearance in the outside world Visual reflexes a. Pupillary light reflex normal constriction of the pupils when bright light shines on the retina i. When one light is exposed to bright light, a direct light reflex occurs (constriction of that pupil) as well as a consensual light reflex (simultaneous constriction of the other pupil). b. Fixation reflex direction of the eye toward an object attracting a persons attention c. Accommodation adaptation of the eye for near vision i. Increasing the curvature of the lens through movement of the ciliary muscles ii. Lens cannot be observed directly, but convergence (motion toward) of the axes of the eyeballs and pupillary constriction can be observed Aging adult a. Physical changes i. Skin loses elasticity, causing wrinkling and drooping ii. Fat tissues and muscles atrophy iii. Lacrimal glands involute, causing decreased tear production and a feeling of dryness and burning b. Intra-ocular changes i. Pupil size decreases ii. Lens loses elasticity, becoming hard and glasslike 1. Presbyopia decreases the lenss ability to change shape to accommodate for near vision c. Most common causes of decreased visual functioning i. Cataract formation (lens opacity) 1. Results from clumping of proteins in the lens 2. Some cataract formation should be expected by age 70 ii. Glaucoma (increased ocular pressure) 1. Chronic open-angle glaucoma is the most common type a. Gradual loss of peripheral vision iii. Macular degeneration (breakdown of cells in the macula of the retina) 1. Loss of central vision, the area of clearest vision, is the most common cause of blindness

2. Person is unable to read fine print, sew or do fine work and may have difficulty distinguishing faces 3. Peripheral vision is unaffected 9. Subjective data collection a. Vision difficulty (decreased acuity, blurring, blind spots) i. Scotoma a blind spot surrounded by an area of normal or decreased vision, occurs with glaucoma, with optic nerve disorders b. Pain i. Photophobia inability to tolerate light c. Strabismus, diplopia i. Diplopia perception of two images of a single object d. Redness, swelling e. Watering, discharge f. History of ocular problems g. Glaucoma h. Use of glasses or contact lenses i. Self-care behaviors 10. Objective data a. Test central visual acuity i. Snellen eye chart 1. Commonly used and accurate measure of visual acuity 2. Position the person 20 feet away and cover one eye at a time a. Leave on corrective lenses, but remove reading glasses 3. Record results as a fraction a. Numerator indicates the distance the person is standing from the chart and the denominator gives the distance at which a normal eye could read that particular line b. Ex. 20/30 means you can read at 20 feet what the normal eye can see from 30 feet away ii. Near vision 1. Handheld vision screener with various sized print a. Equals the Snellen eye chart print at this distance 2. Test each eye separately with glasses on at 14 inches 3. Record results as a fraction (14/14) b. Test visual fields i. Confrontation test 1. Gross measure of peripheral vision 2. Compares the persons peripheral vision with your own (assuming yours is normal) 3. Face each other, 2 feet apart 4. Cover one eye, you cover the opposite

5. Hold a pencil or flicking finger as a target midline between you and slowly advance it in from the periphery in several directions. 6. Indicate when they see the object 7. Compare to examiners observance 8. Older adults screens for glaucoma c. Inspect extraocular muscle function i. Corneal light reflex (Hirschberg test) 1. Assess parallel alignment of the eye axes by shining a light toward the persons eyes 2. Have the person stare straight ahead and hold the light about 12 inches away 3. Note the reflection of the light on the corneas 4. Should be in exactly the same spot on each eye 5. Asymmetry indicates deviation in alignment from eye muscles weakness or paralysis a. Perform cover test ii. Cover test 1. Detects small degrees of deviated alignment by interrupting the fusion reflex that normally keeps the two eyes parallel 2. Stare straight ahead, cover one eye a. Normal response steady, fixed gaze 3. Uncover the eye and observe it for movement a. Normal response steady, fixed gaze b. If it jumps to re-establish fixation, eye muscle weakness exists 4. Repeat with other eye 5. Phoria mild weakness noted only when fusion is blocked 6. Tropia more severe, constant malalignment of the eyes iii. Diagnostics Positions Test 1. Lead the eyes through the 6 cardinal positions of gaze 2. Progress clockwise 3. Elicits any muscle weakness during movement a. Failure to follow in a certain direction indicates weakness of an EOM or dysfunction of cranial nerve innervating it 4. Nystagmus a fine, oscillating movement best seen around the iris a. Mild nystagmus at an extreme lateral gaze is normal; nystagmus at any other position is not 5. You should not see the white rim of sclera between the lid and the iris a. Lid lag associated with hyperthyroidism

d. Inspect external ocular structures (checking for symmetry) i. General ii. Eyebrows iii. Eyelids and lashes iv. Eyeballs v. Conjunctiva and sclera vi. Lacrimal apparatus e. Inspect anterior eyeball structures i. Cornea and lens ii. Iris and pupil 1. Pupillary light reflex a. Darken the room and ask the person to gaze at a distance (dilates the pupil) b. Advance a light from the side and note the response c. Normal response constriction on the samesided pupil (direct light reflex) and simultaneous constriction of the other pupil (consensual light reflex) 2. Accommodation a. Ask the person to focus on a distance object (dilates the pupils) b. Then have the person shift their gaze to a near object (finger ~ 3 inches from their nose) c. Normal response pupillary constriction and convergence of the axes of the eye 3. Record the normal response to these tests as PERRLA a. Pupils Equal, Round, React to Light and Accommodation 11. Aging adult a. Central acuity may decrease b. Eyebrows may be thinner, coarser c. Skin may show sagging and wrinkles d. May appear sunken e. Lacrimal apparatus may decrease tear production, causing the eyes to look dry and lusterless 12. Extraocular muscle dysfunction a. Pseudostrabismus appearance of strabismus because of epicanthic fold b. Strabismus true disparity of the eye axes 13. Eyelid abnormalities a. Periorbital edema local infections, crying, systemic conditions (CHF, renal failure, allergies, Hypothyroidism) b. Exophthalmus forward displacement of the eyeballs thyrotoxicosis, Graves disease, Hyperthyroidism

c. Enophthalmos sunken eyes dehydration, chronic wasting illnesses d. Ptosis drooping upper lid neuromuscular weakness, oculomotor nerve damage, sympathetic nerve damage, congenital e. Upward palpebral slant seen in Down syndrome f. Ectropion loose lower lid aging, trauma g. Entropion lower lid rolled inward spasm, contraction of scar tissue 14. Lesions on the eyelid a. Blepharitis inflammation of the eyelids b. Chalazion beady nodule on the lid c. Hordeolum (stye) localized staph infection of hair follicle d. Dacryocystitis inflammation of the lacrimal sac e. Basal cell carcinoma looks like a papule with an ulcerated center 15. Abnormalities in the pupil a. Anisocoria unequal pupil size b. Monocular blindness direct/consensual response to light in normal eye of a blind person, no response in either eye when light is shined in affected eye c. Mydriasis dilated and fixed pupils d. Miosis constricted and fixed pupils e. Argyll Robertson Pupil no reaction to light, pupil des constrict with accommodation f. Tonic pupil (Adies pupil) sluggish reaction to light and accommodation g. Horners syndrome unilateral, small, regular pupil that reacts to light and accommodation ptosis and absence of sweat on affected side h. Cranial nerve III damage unilateral dilated pupil with no reaction to light or accommodation HyperthyroidismGoiter, is an increase in size of thyroid gland, Graves disease is most common form of hyperthyroidism, manifested by goiter and exophthalmos. Sx include: nervousness, fatigue, wt loss, muscle cramps, and heat intolerance; Signs include: tachy, SOB, excessive sweating, fine muscle tremor, thin, silky hair and skin, infrequent blinking and a staring appearance HypothyroidismAKA Myxedema A deficiency of thyroid hormone, when severe, causes a nonpitting edema or myxedema. Note puffy, edematous face, esp around eyes (periorbital edema), coarse facial features, dry skin, and dry, coarse hair and eyebrows.