The Eye and Vision

Vision is the sense that has been studied most; of all the sensory receptors in the body 70% are in
the eyes.
Anatomy of the Eye
Vision is the sense that requires the most “learning”, and the eye appears to delight in being
fooled; the old expression “You see what you expect to see” is often very true.

External and Accessory Structures

The accessory structures of the eye include the extrinsic eye muscles, eyelids, conjunctiva, and
lacrimal apparatus.

 Eyelids. Anteriorly, the eyes are protected by the eyelids, which meet at the medial
and lateral corners of the eye, the medial and lateral commissure (canthus), respectively.
 Eyelashes. Projecting from the border of each eyelid are the eyelashes.
 Tarsal glands. Modified sebaceous glands associated with the eyelid edges are the tarsal
glands; these glands produce an oily secretion that lubricates the eye; ciliary glands,
modified sweat glands, lie between the eyelashes.
 Conjunctiva. A delicate membrane, the conjunctiva, lines the eyelids and covers part of
the outer surface of the eyeball; it ends at the edge of the cornea by fusing with the
corneal epithelium.
 Lacrimal apparatus. The lacrimal apparatus consists of the lacrimal gland and a number
of ducts that drain the lacrimal secretions into the nasal cavity.
  Lacrimal glands. The lacrimal glands are located above the lateral end of each eye; they
continually release a salt solution (tears) onto the anterior surface of the eyeball through
several small ducts.
 Lacrimal canaliculi. The tears flush across the eyeball into the lacrimal
canaliculi medially, then into the lacrimal sac, and finally into the nasolacrimal duct,
which empties into the nasal cavity.
 Lysozyme. Lacrimal secretion also contains antibodies and lysozyme, an enzyme that
destroys bacteria; thus, it cleanses and protects the eye surface as it moistens and
lubricates it.
 Extrinsic eye muscle. Six extrinsic, or external, eye muscles are attached to the outer
surface of the eye; these muscles produce gross eye movements and make it possible for
the eyes to follow a moving object; these are the lateral rectus, medial rectus, superior
rectus, inferior rectus, inferior oblique, and superior oblique.

Internal Structures: The Eyeball

The eye itself, commonly called the eyeball, is a hollow sphere; its wall is composed of three
layers, and its interior is filled with fluids called humors that help to maintain its shape.
Layers Forming the Wall of the Eyeball
Now that we have covered the general anatomy of the eyeball, we are ready to get specific.

 Fibrous layer. The outermost layer, called the fibrous layer, consists of the protective
sclera and the transparent cornea.
 Sclera. The sclera, thick, glistening, white connective tissue, is seen anteriorly as the
“white of the eye”.
  Cornea. The central anterior portion of the fibrous layer is crystal clear; this “window” is
the cornea through which light enters the eye.
 Vascular layer. The middle eyeball of the layer, the vascular layer, has three
distinguishable regions: the choroid, the ciliary body, and the iris.
 Choroid. Most posterior is the choroid, a blood-rich nutritive tunic that contains a dark
pigment; the pigment prevents light from scattering inside the eye.
 Ciliary body. Moving anteriorly, the choroid is modified to form two smooth muscle
structures, the ciliary body, to which the lens is attached by a suspensory ligament
called ciliary zonule, and then the iris.
 Pupil. The pigmented iris has a rounded opening, the pupil, through which light passes.
 Sensory layer. The innermost sensory layer of the eye is the delicate two-layered retina,
which extends anteriorly only to the ciliary body.
 Pigmented layer. The outer pigmented layer of the retina is composed pigmented cells
that, like those of the choroid, absorb light and prevent light from scattering inside the
eye.
 Neural layer. The transparent inner neural layer of the retina contains millions of
receptor cells, the rods and cones, which are called photoreceptors because they respond
to light.
 Two-neuron chain. Electrical signals pass from the photoreceptors via a two-neuron
chain-bipolar cells and then ganglion cells– before leaving the retina via optic nerve as
nerve impulses that are transmitted to the optic cortex; the result is vision.
 Optic disc. The photoreceptor cells are distributed over the entire retina, except where
the optic nerve leaves the eyeball; this site is called the optic disc, or blind spot.
 Fovea centralis. Lateral to each blind spot is the fovea centralis, a tiny pit that contains
only cones.
Lens
Light entering the eye is focused on the retina by the lens, a flexible biconvex, crystal-like
structure.

 Chambers. The lens divides the eye into two segments or chambers; the anterior
(aqueous) segment, anterior to the lens, contains a clear, watery fluid called aqueous
humor; the posterior (vitreous) segment posterior to the lens, is filled with a gel-like
substance called either vitreous humor, or the vitreous body.
 Vitreous humor. Vitreous humor helps prevent the eyeball from collapsing inward by
reinforcing it internally.
 Aqueous humor. Aqueous humor is similar to blood plasma and is continually secreted
by a special of the choroid; it helps maintain intraocular pressure, or the pressure inside
the eye.
 Canal of Schlemm. Aqueous humor is reabsorbed into the venous blood through the
scleral venous sinus, or canal of Schlemm, which is located at the junction of the sclera
and cornea.
Eye Reflexes
Both the external and internal eye muscles are necessary for proper eye function.
  Photopupillary reflex. When the eyes are suddenly exposed to bright light, the pupils
immediately constrict; this is the photopupillary reflex; this protective reflex prevents
excessively bright light from damaging the delicate photoreceptors.
 Accommodation pupillary reflex. The pupils also constrict reflexively when we view
close objects; this accommodation pupillary reflex provides for more acute vision.
Application of the Nursing Process
A. Assessment
1. Subjective Data
a. Nursing History
 Pain - An unpleasant sensation that can range from mild localized discomfort to
agony. Pain has both physical and emotional components. The physical part of pain
results from nerve stimulation. Pain may be contained to a discrete area, as in an
injury, or it can be more diffuse, as in disorders like fibromyalgia. Pain is mediated by
specific nerve fibers that carry the pain impulses to the brain where their conscious
appreciation may be modified by many factors.
 Photophobia - Painful oversensitivity to light. For example, photophobia is often
seen in measles and iritis. Keeping lights dim and rooms darkened is helpful when a
patient has photophobia. Sunglasses may also help.
 Blurred Vision - Lack of sharpness of vision with, as a result, the inability to see fine
detail. Blurred vision can occur when a person who wears corrective lens is without
them. Blurred vision can also be an important clue to eye disease.
 Spots, Floaters - Also known as "floaters", blurry spots that drift in front of the eyes
but do not block vision. The blur is the result of debris from the vitreous casting a
shadow on the retina. The spot is the image formed by a deposit of protein drifting
about in the vitreous, the clear jelly-like substance that fills the middle of the eye.
 Dryness - A deficiency of tears. The main symptom is usually a scratchy or sandy
feeling as if something is in the eye. Other symptoms may include stinging or burning
of the eye; episodes of excess tearing that follow periods of very dry sensation; a
stringy discharge from the eye; and pain and redness of the eye. Sometimes people
with dry eye experience heaviness of the eyelids or blurred, changing, or decreased
vision, although loss of vision is uncommon.
 Diplopia - A condition in which a single object appears as two objects. Also known
as double vision.
 Ptosis - Downward displacement. For example, ptosis of the eyelids is drooping of
the eyelids.
 Proptosis - A condition in which the patient has protruding eyeballs, as in Graves
disease.
 Vision Loss - Loss of vision can occur suddenly or develop gradually over time.
Vision loss may be complete (involving both eyes) or partial, involving only one eye
or even certain parts of the visual field. Vision loss is different from blindness that
was present at birth, and this article is concerned with causes of vision loss in an
individual who previously had normal vision. Vision loss can also be considered as
loss of sight that cannot be corrected to a normal level with eyeglasses. The causes of
loss of vision are extremely varied and range from conditions affecting the eyes to
 conditions affecting the visual processing centers in the brain. Impaired vision
becomes more common with age. Common causes of vision loss in the elderly
include diabetic retinopathy, glaucoma, age-related macular degeneration,
and cataracts.
 Visual Field Loss - Visual field loss occurs when an individual experiences damage
to any part of his or her visual pathway, which is the path that signals travel from the
eye to the brain.

a. Functional Health Problems

1. Objective Data
a. Physical Assessment of Visual System
a.1 Eye Structure

 Eye position
 Lids
 Blink
 Eyeball
 Lacrimal Apparatus
 Conjunctiva
 Cornea
 Anterior Chamber
 Iris, Pupil
a.2 Test of the Eye

 Corneal Reflex
 Corneal Light Reflex
 Cover-uncover Test
a.3 Vision Testing

 Visual Acuity
 Visual Fields
 Special Test
 Color Vision
 Central Area blindness
b. Diagnostic Assessment
b.1 Non-invasive

 Fundus Photography
 Ophthalmometry
 Ophthalmic Radiography
 MRI
 Ultrasonography
 Ophthalmodynamometer
  Electroretinography
 Visual Evoked Response
 Slit-Lamp Examination
 Ampler Grid test
 Refractometry
b.2 Invasive Test

 Fluorescein angiography
 Corneal Staining

B. ANALYSIS/NURSING DIAGNOSIS (Visual and Auditory Function)

1. Disturbed Sensory Perception as evidenced by blurred vision, seeing halos, black spots or
floaters, difficulty hearing, altered sense of balance.
2. Impaired Verbal Communication as evidenced by difficulty comprehending and
maintaining communication, inability to articulate speech, absence of eye contact.
3. Deficient Knowledge: Vision/Hearing Assisting Devices as evidenced by expressions of
helplessness, lack of health-seeking behaviour.
4. Nausea as evidenced by complaints of queasiness, discomfort associated with movement
of head.
5. Risk for injury ineffective health maintenance.

Special Senses Anatomy and Physiology https://nurseslabs.com/special-senses-anatomy-

physiology/
MedTerms Medical Dictionary https://www.medicinenet.com/medterms-medical-
dictionary/article.htm