ASSESSMENT OF THE EYE

 the orbit is shaped like a four-sided pyramid, surrounded on three sides by the sinuses:
ethmoid (medially), frontal (superiorly), and maxillary (inferiorly).

 The four rectus muscles and two oblique muscles (see Fig. 63-2) are innervated by
cranial nerves (CNs) III, IV, and VI.
 The eyelids contain multiple glands (sebaceous, sweat, and lacrimal).
 With every blink, the eyelids wash the cornea and conjunctiva with tears.
 The conjunctiva, a thin transparent mucous membrane, provides a barrier to the
external environment extending under the eyelids (palpebral conjunctiva) and over the
sclera (bulbar conjunctiva). The junction of the two portions is known as the fornix.
 The eyeball is composed of the following three layers:
 The outer dense fibrous layer, including the sclera and transparent cornea
The middle vascular layer, containing the iris, ciliary body, and choroid
 The inner neural layer, including the retina, optic nerve, and visual pathway
 Outer Layer
 o Sclera – tough white connective tissue ( white of the eye) located anteriorly and
posteriorly. The sclera is the white avascular dense fibrous structure that helps maintain
the shape of the eyeball and protects the intraocular contents.

o Cornea - transparent tissue through which light enters the eye; located anteriorly;
main refracting surface of the eye. It is composed of five layers: the epithelium,
Bowman membrane, stroma, Descemet membrane, and endothelium. It contains high
concentrations of nerve fibers and is extremely sensitive to pain.

 the eyeball also has three fluid-containing chambers. The aqueous-filled anterior
chamber lies between the posterior cornea and the anterior iris and pupil.
 aqueous humor (transparent nutrient-containing fluid that fills the anterior and
posterior chambers of the eye) is produced in the posterior chamber by the ciliary body
 Vitreous humor, which is composed mostly of water and encapsulated by a hyaloid
membrane, helps maintain the shape of the eye.
 Middle Layer
o Choroid – highly vascular layer, nourishes retina; located posteriorly;
o Ciliary body – anterior to choroid, secretes aqueous humor; muscles change shape of
lens. consists of ciliary processes, ciliary muscles, and zonular fibers (ligaments) that
work together to form aqueous fluid and control focusing through the zonular fibers
that suspend the crystalline lens.
o Iris – pigmented membrane behind cornea, gives color to eye; located anteriorly. Pupil
is a circular opening in the middle of the iris that constricts or dilates to regulate amount
of light entering the eye. The dilator and sphincter muscles of the iris control pupil size.
The dilator muscles are controlled by the sympathetic nervous system. The sphincter
muscles are controlled by the parasympathetic nervous system.
 Internal structure:

 Lens, an avascular and almost completely transparent biconvex structure held in

position by zonular fibers in the ciliary body. The lens enables focusing for near and
distance vision through accommodation, the process by which the lens of the eye
adjusts the focal length to focus a clear image on the retina.
 The retina—the innermost surface of the fundus composed of neural tissue—is an
extension of the optic nerve.
 The sensory retina contains the photoreceptor cells: rods and cones. The rods are
responsible for night or low light vision. The cones are retinal photoreceptor cells
essential for visual acuity, color discrimination, and fine detail. Cones are distributed
throughout the retina, with their greatest concentration in the fovea. Rods are absent in
the fovea.
 The optic nerve head, or optic disc, is the physiologic blind spot in each eye.
 The chiasm is the anatomic point at which the nasal fibers from the nasal retina of each
eye cross to the opposite side of the brain.
 ptosis (drooping of the eyelid), ectropion (turning out of the lower eyelid), or entropion
(turning in of the lower eyelid). Entropion may involve trichiasis (turning in of the
eyelashes) nystagmus (involuntary oscillating movement of the eyeball).
 A direct ophthalmoscope is a handheld instrument with various plus and minus lenses
 The indirect ophthalmoscope is an instrument commonly used by the ophthalmologist
to see larger areas of the retina, although in an unmagnified state.
 slit lamp is a binocular microscope mounted on a table. This instrument enables the user
to examine the eye with magnification of 10 to 40 times the real image.
 Tonometry is an essential part of a diagnostic evaluation; it measures IOP to screen for
and manage glaucoma.
 Color Vision Testing

- The ability to differentiate colors has a dramatic effect on the activities of daily living
(ADLs).

 The photoreceptor cells responsible for color vision are the cones, and the greatest area
of color sensitivity is in the macula—the area of densest cone concentration.
 The Amsler grid is a test often used for patients with macular problems, such as macular
degeneration.
 Ultrasonography is a valuable diagnostic technique, especially when the view of the
retina is obscured by opaque media such as cataract or hemorrhage.
 Optical coherence tomography is a technology that involves low- coherence
interferometry
 Fundus photography is used to detect and document retinal lesions. The patient’s pupils
are usually widely dilated before the procedure.
 Angiography is done using fluorescein or indocyanine green as contrast agents.
Fluorescein angiography is used to evaluate clinically significant macular edema,
 document macular capillary nonperfusion, and identify retinal and choroidal
neovascularization (growth of abnormal new blood vessels) in AMD.
 Perimetry testing evaluates the field of vision. Visual field testing (i.e., perimetry) helps
identify which parts of the patient’s central and peripheral visual fields have useful
vision. It is most helpful in detecting centralscotomas (blind or partially blind areas in
the visual field) in macular degeneration and the peripheral field defects in glaucoma
and retinitis pigmentosa.
 Ophthalmic refraction is the determination of the refractive errors of
the eye for the purpose of vision correction and consists of placing
various types of lenses in front of the patient’s eyes to determine which
lens best improves the patient’s vision.
 myopia are said to be nearsighted and have blurred distance vision
 Vision impairment is defined as having best corrected visual acuity of
20/40 or worse in the better-seeing eye. Low vision describes visual
impairment that requires the use of devices and strategies to perform
visual tasks.
 Blindness is having best corrected visual acuity that can range from
20/400 to no light perception. The clinical definition of absolute
blindness is the absence of light perception.
 Legal blindness is a condition of impaired vision in which a person has
best corrected visual acuity that does not exceed 20/200 in the better
eye or whose widest visual field diameter is 20 degrees or less
 glaucoma is used to refer to a group of ocular conditions characterized
by elevated IOP
 Medical management of glaucoma relies on systemic and topical ocular
medications that lower IOP.
 Many ocular medications are used to treat glaucoma (see Table 63-5),
including miotics, beta-blockers, alpha2-agonists
 By restoring the eye’s natural fluid balance, trabeculectomy surgery
stabilizes the optic nerve and minimizes further visual field damage
 A cataract is a lens opacity or cloudiness (see Fig. 63-8). Cataracts are
responsible for visual disability in 18 million people worldwide
(Grossman & Porth, 2014).
 Cataracts can develop in one or both eyes at any age. The three most
common types are traumatic, congenital, or senile cataract
 Painless, blurry vision is characteristic of cataracts. The person
perceives that surroundings are dimmer, as if their glasses need
cleaning. Light scattering is common, and the person experiences
 reduced contrast sensitivity, sensitivity to glare, and reduced visual
acuity.
 Alpha-antagonists (particularly tamsulosin [Flomax], which is used for
treatment of enlarged prostate) are known to cause a condition called
intraoperative floppy iris syndrome.
 Keratoconus, the most common type of corneal dystrophy, is
characterized by a conical protuberance of the cornea with progressive
thinning on protrusion and irregular astigmatism.
 Fuchs (pronounced Fooks) dystrophy is manifested by a slow death of
cells in the endothelial cornea.
 Acetazolamide(diamox) and osmotic agents (oral glycerine or IV mannitol) to decrease
IOP to provide a soft eyeball for surgery