ASSESSMENT OF EYE

MATERIALS:
1. Snellen Chart
2. Handheld Snellen (Rosenbaum Chart)
3. Ishihara Plates
4. Penlight
5. Opaque card
6. Cotton buds

NARRATION: Whenever we do the eye assessment, we are mainly assessing the

cranial nerve 2 which is the optic nerve. We also assess the
oculomotor, trochlear, abducens nerves or the cranial nerves 3, 4,
6.
INSPECTION
Inspect the eye first
Pull down the lower eye and inspect for the lower palpebral conjunctiva
Use cotton buds to inspect for Upper palpebral conjunctiva
Palpate the lacrimal gland and nasolacrimal duct

FINDINGS: the eyeball is symmetrically aligned in sockets without protruding or

sinking
The eyebrows have the same with hair color; symmetric; evenly
distributed
Lashes are short, evenly spaced & curled outward; lower lid
margins at bottom edge of iris; upper lid margins at bottom edge of
iris; upper lid margins cover approximately 2mm of iris; lid margins
pink & moist & without swelling or lesions; upper & lower lids close
easily & meet completely when closed.
The bulbar conjunctiva and sclera are clear, moist, smooth & with
tiny vessels visible; sclera are white
The palberal conjunctiva are pink, moist, & free of swelling, lesions,
foreign bodies, trauma or abnormal discharges
 Lacrimal puncta is visible without swelling or redness; no
tenderness or drainage noted; minimal lacrimation
Cornea & lens are transparent; lens are clear
The iris is also round; uniform color
DIRECT AND CONSENSUAL
NURSE: Kindly stare at that ____ for me sir

- Lights from side to the center (note if it constricts)

- Light from the side on the other eye to the center

FINDINGS: lacking

ACCOMODATION

NURSE: Okay sir, stare again on that object

- Place the pen in the midline far from the patient
- Then, iduol ang pen sa tunga
- Note if muadto sa tunga ang mata

FINDINGS: pupils are equal, round, and reactive to light and accommodation
(PERRLA)

DISTAL VISUAL ACUITY TEST

Now we’re going to test visual acuity using a Snellen Chart and what you gonna do is to
have your patient about 20 feet from the chart.
It is also important to ask your patient if he wears glasses because if he does, let him
wear that through this test

NURSE: Okay sir kitaa palihug ang chart didto and itry to read the lowest line that
na imo mabasahan for me. First, i-cover nato imo right eye, then imo left eye, then adto
na idungan both eyes. Okay?
N: Cover your right eye?
What line can you read?
Okay sa pikas mata napud Sir nya ingna ko unsa na line imo Mabasa
Pakibasa nya ko Sir

FINDINGS: This means that he has 20/20 vision and this means that he can see the
same lines of letters at 20 feet that a person with normal vision can see at
20 feet.

NEAR VISUAL ACUITY TEST

NURSE: Okay sir, I want you to hold this Rosenbaum chart for about 14 feet, same
thing Sir no. Cover with your right eye first, then basaha ang palihug ang
pinakaubos na imo Mabasa. Okay?

- Okay good. Left nasad ang icover sir, same thing. Basaha palihug ang pinaka
ubos na imo Mabasa. Okay?

FINDINGS: Okay the client can read 14 feet that a person with normal visual acuity
can read at 14 feet.

ISHIHARA PLATE TEST

NURSE: Next will check for the color vision. It is a very important part of the eye
exam to know what is now the function of the optic nerve or cranial nerve
2

NURSE: Okay sir, can you read what numbers can you see in the chart?
Okay good!
FINDINGS: The client was able to identify all six screening Ishihara plates hence this
does not indicate that the client has color blindness.

CONFRONTATION TEST

NURSE: Now we’ll be performing the Confrontation test with the finger counting
method.

NURSE: Okay sir kindly cover your left eye and say what number you are seeing
Good Sir, now on the right?
NURSE: Okay good!

FINDINGS: lacking

PERFORM EXTRAOCULAR MUSCLE FUNCTION TESTS

CORNEAL LIGHT REFLEX

MATERIAL:
- PENLIGHT
- With the corneal light reflex test, we are testing for the ocular alignment by
reflecting your pen light off the patient’s pupils.
- Here, we are looking for esotropia, exotropia, hypertropia, or hypotropia

NURSE: Sir, kindly focus on the Snellen chart.

(SHINE TWO FEET AWAY IN THE MIDLINE)

FINDINGS: Reflection of light is noted at same location of both eyes on the medial
upper aspect of the pupil.
Thus the patient is negative for any sort of disk symmetry between in the
gaze.
COVER TEST
NURSE: Okay, let’s now have the cover test
(Place index card on left)
(Place index card on right)

FINDINGS: Uncovered eye remains fixed; covered eye does not move as cover is
removed

SIX CARDINAL GAZE

NURSE: Okay Sir, follow my hand with your eyes only Sir, okay?
Performs
NURSE: Both eyes move in a smooth, coordinated manner in all 6 directions
 ASSESSMENT OF THE EAR

MATERIALS:
1. Tuning Fork
2. Watch with second hand
3. Penlight
4. Disposal gloves

INSPECT THE EXTERNAL EAR STRUCTURES

NURSE: Okay sir, let me check your ears

- Checks the Auricle and lobule size and shape, position, lesions/discoloration,
and discharge
- Palpate the auricle and mastoid process

FINDINGS: lacking

HEARING AND EQUILIBRIUM TEST

Nurse: Okay Sir can you have one finger sa imo dunggan sir, and tell me kung
unsay imo nabati-an. Okay?
(Mu-hagawhaw ug 2 syllables)
Nurse: Okay good! Sa pikas napud sir.
(Mu-hagawhaw ug 2 syllables)
NURSE: Okay good sir. Please tell me sir if asa ka mas nakabati ug tarung sir ha?
(Activates Tuning Fork and place it at the midline)
NURSE: Okay good!
NURSE: Okay sir ingna ko sir ha ug wala na kay mabati-an okay?
(Activates tuning fork and place it sa mastoid process)
(I-balhin dayon sa air in a perpendicular manner)
(REPEAT ON THE OTHER EAR)
NURSE: Okay sir, close your feet lang and arms sa kilid. Then close your eyes for
20 seconds.
(Romberg Test)