EYES

Structures / Landmarks to remember: Conjunctiva membrane covering most of the anterior surface - protects the eye from foreign bodies and desiccation Lacrimal Gland located in temporal region of superior eyelid - produces tears that moisten the eye Sclera dense, avascular structure that appears as white of the eye Cornea continuous with sclera, anterior part of globe - sensory innervation primarily for pain Iris produces the color of the eye Pupil central aperture of iris - controls the amt of light reaching the retina

DEVELOPMENTAL VARIATIONS A. INFANTS & CHILDREN - term babies are hyperopic (farsighted) with visual acuity of 20/200 - peripheral vision is fully developed at birth, central vision develops later - by 2 or 3 months, lacrimal ducts begin carrying tears and infant gains voluntary control of eye muscles - by 6 months, vision has developed sufficiently enough to differentiate colors - by 9 months, binocular is perceived - young children have myopic acuity (nearsighted) - adult acuity is achieved by about 6 yrs. Old

B. PREGNANT WOMEN
- mild corneal edema, especially in 3rd trimester - corneal thickening - increase in corneal epithelial pigmentation (Krukenberg spindles) - ptsosis may develop for unknown reasons - subconjunctival hemorrhages may occur/resolve spontaneously

C. OLDER ADULTS
- major physiologic change is progressive change in near point of accommodation - by 45 yrs, lens becomes more rigid and ciliary muscle of iris becomes weaker - results in presbyopia (difficulty with accommodation and decrease in near vision) - old fibers are compressed centrally, forming a more dense central region that may cause loss of clarity of lens and contribute to cataract formation

I. REVIEW OF RELATED HISTORY

A. HISTORY OF PRESENT ILLNESS
Difficulty with vision one or both eyes, corrected by lens; cataracts, adequacy of color vision; presence of halos Pain in or around the eye; burning, itching, or nonspecific uncomfortable or gritty sensation Secretions color, consistency, duration, tears that run, decreased tear formation, conjunctival redness Medications use of any eyedrops or ointments, antibiotics, artificial tears, mydriatics, myotics

B. PAST MEDICAL HISTORY

Trauma to part or whole structure or supporting structures Surgery Chronic Illness hypertension, diabetes, collagen vascular diseases, inflammatory bowel disease, glaucoma

C. FAMILY HISTORY
Retinoblastoma or Cancer of retina Color blindness, near- or far-sighted,strabismus (both eyes do not focus simultaneously), amblyopia (impairment of vision) Chronic Illness diabetes, glaucoma, allergies

D. PERSONAL AND SOCIAL HISTORY

Employment exposure to chemicals, foreign bodies or high-speed machinery Activities sporting activities that might cause injury Allergies type, seasonal, associated symptoms Corrective lens last changed, how long worn, date of last eye exam

E. DEVELOPMENTAL VARIATIONS
1. INFANTS AND CHILDREN - preterm (resuscitated, ventilator or oxygen used, retinopathy diagnosis, cerebral palsy) - failure of infant to gaze at mothers face or other objects; failure to blink when bright lights or threatening movements are made - white area in pupil on a photograph; inability of one eye to reflect light properly - excessive tearing over lower eyelid - strabismus some or all of the time - excessive rubbing of eyes in young children; inability to reach for and pick up small objects; necessity of bringing objects close to examine them; double vision - necessity of sitting near front of class to see the board in school aged children; poor progress in school not explained by intellectual ability

2. PREGNANT WOMEN
- presence of disorders that can cause ocular complications such as pregnancy induced hypertension or diabetes - use of topical eye meds may cross placental barrier

3. OLDER ADULTS
- visual acuity: decreases in central vision, distortion, use of dim light to increase, complaints of glare - production of excess tearing or complaints of blurred vision - dry eyes - development of scleral brown spots - difficulty in performing near work without lenses - nocturnal eye pain

II. EXAMINATION AND FINDINGS

A. VISUAL TESTING - color vision is rarely tests in routine physical exam - always talk to pt and explain procedure, especially in regards to pain Snellen Chart measurement of visual acuity discrimination of small details tests cranial nerve II (optic nerve) and is essentially a measurement of central vision - position patient 20 ft. from chart, making sure it is well lit - test ea. eye individually by covering the opposite eye, being careful to apply pressure - ask patient to identify letters beginning at any line - reference to a colored line tests for color blindness - determine smallest line patient can identify all letters (can miss 2, on 3 use the line before) - when testing 2nd line, ask patient to read line from right to left to keep him from memorizing letters - test patient with and without corrective lenses, recording the readings separately - visual acuity is recorded as a fraction in which the numerator indicates the distance of the Patient from the chart - denominator indicates distance at which the average eye can read the line - 20/200 means that the pt can read at 20 ft what the average person can read at 200 ft - smaller fraction, worse myopia (nearsightedness) - vision not correctable to better than 20/200 is considered legal blindness - document fraction found on chart next to line that was completely and correctly read Confrontation Test accurately measures peripheral vision - sit or stand opposite patient at eye level at a distance of about 2 ft. - ask patient to cover left eye while you cover right (should be looking at each others eye) - extend arm midway between you and patient and move it centrally with fingers moving

- have patient tell you when moving fingers are 1st seen - compare pts response to the time you 1st note the moving fingers - imprecise and can be considered significant only when it is abnormal - ex. documentation peripheral within that of testers

B. EVALUATE MUSCLE BALANCE AND MOVEMENT OF EYES

- full movement of eyes is controlled by integrated function of cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) and six extraocular muscles Cover / Uncover Test used when there is an imbalance found with the corneal light reflex test - measurement for nerve damage and muscle weakness - ask pt to stare straight ahead at a near fixed point - cover one eye and observe uncovered eye for movement - remove cover and watch for movement of newly uncovered eye as it fixes on the object - movement of the covered or uncovered eye may indicate either esotropia (form of strabismus where one or both eyes deviate inward) or exotropia (form of strabismus where one or both eyes deviate outward) - document movement or as none detected in cover/uncover test Six Cardinal Fields of Gaze left & right superior/inferior rectus, left & right inferior/superior oblique, medial rectus, left & right lateral rectus nystagmus involuntary rhythmic movements of eyes that can occur in horizontal, vertical, rotary, or mixed patterns - jerking nystagmus is characterized by faster movements in one direction and is defined by its rapid phase - if eye moves rapidly to right and then slowly drifts leftward, patient is said to have nystagmus to the right

C. INSPECTION
Abbreviations that must be spelt out but doctors continue: OD = right eye OS = left eye OU = both eyes Quick documentation note that can be used ONLY if all tests are positive:

P pupils E equal R round R - reacts to L. light (direct/consensual A accommodation or indirect/consensual) 1. Eyebrows inspect for symmetry, size, extension, and texture of hair - if eyebrows are coarse or do not extend beyond temporal canthus, patient may have hypothyroidism 2. Orbital Area inspect for edema, puffiness, or sagging tissue below the orbit - periorbital edema is always abnormal - may represent presence of thyroid hypoactivity, allergies, or (especially in youth) presence of renal disease - flat, slightly raised, irregularly shaped, yellow tinted lesions on periorbital tissues represent depositions of lipids and may suggest abnormality of lipid metabolism xanthelasma elevated plaque of cholesterol deposited most commonly in nasal portion of either upper or lower lid 3. Eyelids examine lightly closed eyes for fasciculations or tremors of lids (sign of hyperthyroidism) - inspect eyelids for ability to close completely and open widely - observe for flakiness, redness or swelling on eyelid margin - eyelashes should be present on both lids and should turn outward - when eye is open, superior lid should cover a portion of iris but not the pupil itself - if more of one iris than the other is covered or extends over the pupil, ptosis of that lid may be present, indicating congenital or acquired weakness of levator muscle or a paresis of a branch of the 3rd cranial nerve - record the difference - note whether the lids evert or invert - when lower lid is turned away from eye, ectropion is present and may result in excessive tearing - when lower lid is turned inward toward the globe, entropion may cause corneal and

conjunctival irritation, increasing the risk of secondary infection erythematous yellow lump - acute suppurative inflammation of follicle of eyelash -hordeolum or styblepharitis crusting along eyelashes 4. Conjunctiva usually inapparent, clear, and free of erythema - easily inspected by having patient look upward while you draw the lower lid downward - inspect upper tarsal conjunctiva only when there is a suggestion that a foreign body maypresent - observe for increased erythema or exudate - erythema or cobblestone appearance may indicate allergic or infectious conditions - bright red blood in sharply defined area surrounded by healthy appearing conjunctiva indicates subconjunctival hemorrhage pterygium abnormal growth of conjunctiva that extends over cornea from limbus - more commonly on nasal side - more common in people heavily exposed to ultraviolet light 5. Sclera ensure that it is white - if liver disease is present, sclerae may become pigmented and appear either yellow or green - senile hyaline plaque appears as dark, rust-colored pigment just anterior to insertion of medial rectus muscle - presence does not imply disease but should be noted 6. Cornea examine for clarity by shining a light tangentially on it - blood vessels should not be present - sensitivity controlled by cranial nerve V (trigeminal) corneal arcus(arcus senilis) composed of lipids deposited in periphery of cornea - may form a complete circle (circus senilis) - seen in majority of individuals over 60 - if present before age 40, may indicate lipid disorder, most commonly type II hyperlipidemia 7. Iris pattern should be clearly visible - irides are same color 8. Pupils note any irregularity in shape - - should be round, regular, and equal in size - test for response to light both directly and consensually - darken room so that pupils dilate - shine penlight directly into eye and note whether pupil constricts - note consensual response of opposite pupil constricting simultaneously with tested pupil - exam center position Constriction to Accommodation Test testing for papillary response to accommodation is of diagnostic importance only if there is a defect in papillary response to light - failure to respond to direct light but retaining constriction during accommodation is sometimes seen in patients with diabetes or syphilis - as patient to look at a distant object and then at a test object held 10 cm from bridgeof nose - pupils should constrict when eyes focus on near object miotic pupil fails to dilate in dark mydriasis dilation of more than 6 mm and failure of pupils to constrict with light anisocoria inequality of papillary size D. PALPATE - palpate eyelids for nodules - note whether they meet completely - if closed lids do not completely cover globe (lagophthalmos), cornea may become dried and be at increased risk for infection - palpate eye itself - determine whether it feels hard or can be gently pushed into orbit without causing discomfort - if it feels very firm and resists palpation, may indicate glaucoma, hyperthyroidism, or presence of retroorbital tumor - palpate region of lacrimal gland and lower orbital rim near inner canthus - glands are rarely enlarged E. MISCELLANEOUS - inspection of interior of eye permits visualization of optic disc - with patient looking at distant fixation point, direct light of ophthalmoscope at pupil from about 12 away

- 1st visualize red reflex, caused by light illuminating the retina - any opacities in path of light will stand out as black densities - absence of red reflex is often result of improperly positioned ophthalmoscope, but may also indicate total opacity of pupil by cataract or hemorrhage into vitreous humor - Drusen bodies can appear as small, discrete spots that are slightly pinker than retina - with time spots enlarge and become more yellow - may occur in many conditions that affect pigment layers of retina, but most commonly are a consequence of aging process and may be precursor of senile macular degeneration - when noted to be increasing in number or intensity of color, individual should be given Amsler grid - grid is used to evaluate central vision - pt is instructed to observe grid with ea. eye and note any distortion of grid pattern F.DEVELOPMENTAL VARIATIONS 1. Infants often shut their eyes tightly when exam is attempted - begin by inspecting external structures - note size of eyes, paying particular attention to small or differently sized eyes - inspect eyelids for swelling, epicanthal folds, and position - look for vertical fold of skin nasally that covers lacrimal caruncle - prominent epicanthal folds are common in Asians, but may suggest Down Syndrome in other ethnic groups - inspect level of eyelid covering the eye - look for sclera above iris - observe distance between eyes, looking for wide spaces, or hypertelorism associated with mental retardation - inspect sclera, conjunctiva, pupil, and iris of ea. eye 2. Children perform inspection of external structures as described for infants - visual acuity is tested (when child is cooperative) with Snellen E Game, usually at about 3 - if child wears glasses, vision should be tested both with and without corrective lenses and recorded separately Anticipated Visual Acuity: 3 yrs 20/50 4 yrs 20/40 5 yrs 20/30 6 yrs 20/20 - exam of extraocular movements and cranial nerves is performed as with adults - peripheral vision can be tested in cooperative children

3. Pregnant Women retinal exam can differentiate between chronic hypertension and pregnancyinduced hypertension - vascular tortuosity, angiosclerosis, hemorrhage, and exudates may be seen in pts with longstanding history of hypertension - because of systemic absorption, cycloplegic and mydriatic agents should be avoided unless there is a need to evaluate for retinal disease - use of nasolacrimal occlusion after instillation of topical eye meds may reduce systemic absorption

III. COMMON ABNORMALITIES

A. EXOPHTHALMOS - increase in volume of orbital content, causing protrusion of globes forward - may be bilateral or unilateral - most common cause is Graves disease - when unilateral, retroorbital tumor must be considered - retraction of upper lid and exposure of sclera above iris may exaggerate B. STRABISMUS (PARALYTIC AND NONPARALYTIC) - both eyes do not focus on an object simultaneously - may be paralytic, caused by impairment of one or more extraocular muscles or their nerve supply - nonparalytic has no primary muscle weakness - pt can focus with either eye but not with both simultaneously - sign of intraocular pathology such as infantile cataract or retinoblastoma C. MIOSIS - bilateral papillary constriction; usually less than 2 mm in diameter D. MYDRIASIS - bilateral papillary dilation; usually more than 6 mm in diameter E. ANISOCORIA unilateral unequal size of pupils

F.CATARACTS common abnormality of lens - - opacity occurring in lens commonly from denaturation of lens protein caused by aging - almost everyone over 65 has some evidence of lens opacification - congenital cataracts can result from maternal rubella or other fetal insults during 1st trimester G. DIABETIC RETINOPATHY (BACKGROUND ) marked by dot hemorrhages or microaneurysms and presence of hard and soft exudates - hard exudates, thought to be result of lipid transudation through incompetent capillaries, have sharply defined borders and tend to be bright yellow - soft exudates are caused by infarction of nerve layer and appear as dull yellow spots with poorly defined margins H. DIABETIC RETINOPATHY (PROLIFERATIVE ) development of new vessels as result of anoxic stimulation - may occur in peripheral retina or on optic nerve itself - new vessels lack supporting structure of healthy vessels and are likely to hemorrhage - bleeding from these vessels is major cause of blindness in patients with diabetes - laser therapy can often control this neovascularization and prevent blindness I. GLAUCOMA abnormal condition of elevated pressure within eye caused by obstruction of outflow of aqueous humor - accompanied by intense ocular pain, blurred vision, red eye and dilated pupil - may occur chronically in which symptoms are absent except for gradual loss of peripheral vision over a period of years J. RETINOBLASTOMA embryonal malignant tumor arising from retina, often during 1st 2 yrs of life - may be transmitted either by autosomal dominant trait or chromosomal mutation - initial signs are white reflex (cats eye reflex) rather than usual red reflex - exam reveals ill-defined mass arising from retina - - often chalky white area of calcification

EARS
Structures to remember during inspection: umbo light reflex

DEVELOPMENTAL VARIATIONS A. INFANTS AND CHILDREN because development of inner ear occurs during 1st trimester, an insult to fetus may impair hearing - external auditory canal is shorter than adults and has upward curve - eustachian tube is relatively wider, shorter, and more horizontal than adults- with growth of lymphatic tissue, specifically adenoids, eustachian tube may become occluded, interfering with aeration of middle ear B. PREGNANT WOMEN capillaries of nose, pharynx, and eustachian tubes become engorged, leading to symptoms of nasal stuffiness, decreased sense of smell, a sense of fullness in ears and impaired hearing C. OLDER ADULTS hearing tends to deteriorate with degeneration of hair cells in organ of Corti, usually after 50 - sensorineural hearing loss 1st occurs with high-frequency sounds and then progresses to tones of lower frequency - hearing deterioration may also result from excess deposition of bone cells along ossicle chain, causing fixation of stapes in oval window - cerumen may become very dry and may totally obstruct external auditory canal, interfering with sound transmission - tympanic membrane becomes more translucent and sclerotic

I. REVIEW OF RELATED HISTORY

A. HISTORY OF PRESENT ILLNESS Vertigo or dizziness onset, description of sensation, associated symptoms (presence or absence of tinnitus, hearing loss, double vision), unsteadiness, meds, Earache onset, concurrent upper respiratory infection, associated symptoms (vertigo, tinnitus), method of cleaning ear canal, meds Hearing Loss (one or both ears) onset, repeated history of cerumen impaction, hears best when?, speech (soft or loud, articulation), management (aids), ototoxic meds (ex. Lasix, diuretics) B. PAST MEDICAL HISTORY Systemic Disease hypertension, cardiovascular, diabetes, bleeding disorder Ear frequent ear problems during childhood; surgery, labyrinthitis, antibiotic use, dosage, and duration C. FAMILY HISTORY Hearing problems or loss, allergies D. PERSONAL AND SOCIAL HISTORY Environmental Hazards exposure to loud, continuous noises; types of protective devices used Ototoxic Drugs lasix, diuretics E. DEVELOPMENTAL VARIATIONS 1. INFANTS AND CHILDREN ototoxic antibiotic use, chronic otitis media, playing with small objects (could place in ears), behaviors indicating hearing loss (no reaction to loud or strange noises, no babbling after 6 mos, no communicative speech, inattention) 2. PREGNANT WOMEN presence of symptoms before pregnancy, exposure to infection 3. OLDER ADULTS hearing loss causing any interference with daily life, ototoxic drugs

II. EXAM AND FINDINGS A. HEARING

- cranial nerve VIII is tested by evaluating hearing - screening begins when patient responds to questions and directions 1. WHISPERED VOICE TEST check patients response to whispered voice, one ear at a time - have patient place a finger in the ear canal and gently move it rapidly up and down - stand to the side of pt. at a consistent distance best for you (approx. 1 2 ft.) away from ear being tested - whisper 1 and 2 syllable words very softly and ask pt. to repeat the words heard - pt. should hear softly whispered words in ea. ear, responding correctly at least 50% of the time 2. WEBER AND RINNE TESTS tuning fork is used to compare hearing by bone conduction with that by air conduction - hold base of tuning fork with one hand without touching the tines, and stroke or tap the tines

gently with your other hand, setting the tuning fork in vibration a. Weber Test place base of vibrating tuning fork on the midline vertex of pt.s head - ask pt. if sound is heard equally in both ears or is better in one ear (lateralization) - pt. should hear sound equally - if sound is lateralized, have pt. identify which ear hears the best - to test reliability of response, repeat procedure while occluding one ear, asking pt. in which ear the sound is best heard - sound should be heard better in occluded ear b. Rinne Test place base of vibrating tuning fork against pts mastoid bone - begin counting or timing interval with watch - ask pt to tell when sound is no longer heard, noting number of seconds - quickly position still vibrating tines - 1 from auditory canal and again ask pt to tell when sound is no longer heard - continue counting or timing interval to determine length of time sound is heard by air conduction - compare number of seconds heard by bone vs. air conduction - air-conducted sound should be heard twice as long as bone - conductive hearing loss results when sound transmission is impaired through external or middle ear - sensorineural hearing loss results from a defect in inner ear that leads to distortion of sound and misinterpretation of speech

B. INSPECTION 1. EXTERNAL EAR- inspect auricles for size, shape, symmetry, landmarks, color, and position on head - shape of landmarks is not significant unless deformities are noted - should have same color as facial skin, without moles, cysts, or other lesions, deformities or nodules - blueness may indicate some degree of cyanosis - pallor or excessive redness may be result of vasomotor instability - unusual size or shape may be familial trait or indicate abnormality - cauliflower ear is the result of blunt trauma and necrosis of underlying cartilage tophi small, whitish uric acid crystals along peripheral margins of auricles may indicate gout sebaceous cysts elevations in skin with punctum indicating blocked sebaceous gland - common position should be almost vertical, with no more than 10 lateral posterior angle - low-set or unusual angle may indicate chromosomal aberrations or renal disorder - examine lateral and medial surfaces and surrounding tissue, noting color, presence of deformities, lesions and nodules Darwin tubercle thickening along upper ridge of helix - expected variation as are preauricular pits - - found in front of ear where upper auricle originates 2. AUDITORY CANAL inspect for discharge, cerumen, color, lesions, foreign bodies and note any odor - purulent, foul-smelling discharge is associated with otitis or foreign body - bloody or serous discharge is suggestive of skull fracture in case of trauma - note discharge, scaling, excessive redness, lesions, foreign bodies, and cerumen - expect to see minimal cerumen, uniformly pink color, and hairs in outer third of canal - cerumen may vary in color and texture and should have no odor - no lesions, discharge, or foreign body should be present 3. TYMPANIC MEMBRANE otoscope is used to inspect, using the largest speculum that will fit comfortably in pts ear - hold handle between thumb and index finger, supported by middle finger (using right hand for right ear and left hand for left ear), which leaves ulnar side of hand to rest against pts head, stabilizing otoscope as it is inserted - tilt pts head toward opposite shoulder and simultaneously pull pts auricle upward and backward in order to straighten auditory canal, giving the best view - inspect for landmarks (umbo, handle of malleus, light reflex), color, contour, and perforations - should have no perforations with a slightly conical contour and a concavity at the umbo

- bulging tympanic membrane is more conical, usually with a loss of bony landmarks and a distorted light reflex - retracted tympanic membrane is more concave, usually with accentuated bony landmarks and distorted light reflex - should be translucent, pearly gray color - light reflex in right ear should be located at 5:00 position, in left ear at 7:00 position

C. PALPATE- palpate auricles and mastoid area for tenderness, swelling, or nodules - consistency should be firm, mobile, and without nodules - if folded forward, it should readily recoil to usual position - pulling gently on lobule should cause no pain D. DEVELOPMENTAL VARIATIONS 1. INFANTS AND CHILDREN auricle should be well formed, with all landmarks present on inspection - auricles either poorly shaped or positioned below imaginary line are associated with renal disorders and congenital anomalies - newborns auricle is very flexible but should have instant recoil after bending - no skin tags should be present - tympanic membrane is usually in an extremely oblique position until infant is 1 month old - because tympanic membrane does not become conical for several months, light reflex may appear diffuse - limited mobility, dullness, and opacity of pink or red tympanic membrane may be noted in neonates - hearing should be evaluated at regular intervals 2. CHILDREN while using otoscope, pull auricle either downward and back or upward and back to gainbest view of tympanic membrane - as child grows, shape of auditory canal changes to S-shaped curve of adult - if child is crying, tympanic membrane can appear red - - cannot assume redness is hallmark of middle ear infection - pneumatic otoscope is especially important to differentiate red tympanic membrane caused by crying (membrane is mobile) from that resulting from disease (no mobility) - evaluate hearing by observing response to whispered voice and various noisemakers (avoid giving visual cues) - Weber and Rinne tests are used when child understands directions and can cooperate (between 3 4 yrs.) 3. PREGNANT WOMEN tympanic membranes may have increased vascularity and be retracted or bulging with serous fluid 4. OLDER ADULTS inspect auditory canal of pt who wears a hearing aid for areas of irritation from ear mold - tympanic membrane landmarks may appear slightly more pronounced from sclerotic changes - some degree of sensorineural hearing deterioration, marked by greater difficulty understanding speech rather than a reduction in all sounds heard - conductive hearing loss from otosclerosis and cerumen impaction may occur III. COMMON ABNORMALITIES A. OTITIS EXTERNA infection of auditory canal resulting when trauma or moist environment favors bacterial or fungal growth B. MIDDLE EAR EFFUSION inflammation of middle ear resulting in collection of serous, mucoid, or purulent fluid (effusion) in middle ear when tympanic membrane is intact - conductive hearing loss results - causes include obstructed or dysfunctional Eustachian tube, allergies, and enlarged lumphoid tissue in nasopharynx - once obstruction occurs, middle ears absorbs air, creating vaccum, and mucosa secretes transudate into middle ear C. ACUTE OTITIS MEDIA presence of middle ear effusion in conjunction with rapid onset of one or more of the following: ear pain, fever, marked redness or distinct fullness or bulging of tympanic membrane, and hearing loss - most common infection of childhood D. LABYRITHITIS inflammation of labyrinthine canal of inner ear occurs as complication of acute

upper respiratoryinfection - symptoms of severe vertigo, associated with nystagmus, increase in severity with head movement - total sensorineural hearing loss occurs on affected side E. PRESBYCUSIS common auditory disorder in which there is bilateral sensorineural hearing loss associated with aging - loss in perception of auditory stimuli initially of high-frequency sounds and tinnitus - speech may be poorly understood when spoken quickly or when background noise is present