Eye Variations: Age-Related Variations

Taking into account developmental considerations when assessing the eye

requires knowledge of the variations in anatomy and physiology that occur with
growth and development. Interpretation of findings in relation to normative
values and abnormal findings contributes to a comprehensive health
assessment. Below are the variations in the structures and functions of the eye
by age group.

Population
Considerations
Group

Infants and The eyes should be symmetrical, and pupils equal and responsive to light. The
children iris in dark-skinned neonates is usually brown and in light-skinned neonates is a
slate gray-blue. The iris begins to change to its permanent shade by 3 months of
age. The eyelids may be edematous at birth with little to no tears being present.
For the first 6 weeks of life, neonates will fixate on bright lights and moving
objects, and by 6 weeks, vision in both eyes (binocular vision) begins to develop.
By 8 years of age, the eyes reach adult size. The red reflex should be elicited
beginning at birth. Assessment of the extraocular muscles’ ability to function is
 performed as early as possible in children because delay can lead to permanent
visual damage. Until age 4 months, lateral deviation of the eyes is considered a
normal finding.1

Pregnant Many complain of dry eyes and may discontinue wearing contact lenses
females throughout pregnancy. Many also notice some visual changes (blurriness or
distorted vision), which are due to shifting fluid in the cornea, but this disappears
a few weeks after childbirth.2

Older adults The lenses of the eye lose elasticity and the ciliary muscles become weaker,
usually in the mid-40s. This results in a decreased ability of the lens to change
shape to accommodate for near vision (presbyopia). There is a loss of fat around
the orbit of the eye that contributes to a drooping appearance. Tear production
decreases, causing burning of the eyes. The cornea may appear cloudy (arcus
senilis). Pupillary light reflex is slower, with the pupils appearing smaller in
size. The blood vessels within the eye appear paler in color. Cataract formation
can occur. Loss of central vision can occur, resulting in macular degeneration.3

Eye Variations: Psychosocial Considerations

Lack of visual acuity and visual impairment can cause psychosocial distress in
the following ways:4

 Developmental delays and the need for special assistive social and
education services may be indicated for children with visual impairment.
 The loss of independence and a decrease in the quality of life for adults
can be due to visual impairments.
 Stress on families and individuals may occur when a family member has
vision difficulties. Job opportunities become limited, and the ability to
perform activities of daily living (ADLs) related to health care becomes
compromised with visual difficulties.
 Making eye contact with others varies among people by age group,
gender, and culture, especially during the communication process, and
visual problems can have a negative effect on this.
Eye Variations: Cultural Considerations

Cultural variations in the shape, size, and color of the eyes are seen when
performing a health assessment. Below are some considerations when caring for
clients of different cultures or cultural attributes.5

Culture or Attribute Eye Variation

Asian Prominent epicanthic folds covering the inner canthus of the eye

Caucasian Incidence of macular degeneration is higher than in other groups at 75

years and above. Cataracts occur more frequently in Caucasian females
 than in any other group.

African American Glaucoma occurs more frequently in African Americans than in

Hispanics and Caucasians.

Hispanic Higher rate of visual impairment than any other group

Dark-skinned May have dark pigmented spots on the sclera and the retina may appear
individuals darker

Individuals with Have a lighter retina and better night vision but are more sensitive to
light-colored eyes bright sunlight and artificial light

When assessing clients, other cultural considerations might include: 6

 Myopia occurs more frequently in those living in industrialized nations.

 Individuals from underdeveloped nations have higher rates of blindness
than those from other nations due to trachoma, vitamin A deficiency, river
blindness, and other infectious diseases.

Eye Variations: Environmental Considerations

Environmental considerations play a role in the assessment of the eye. Some of
these include:7

 Excessive sun exposure without the use of sunglasses may promote

cataract formation.
 Deficiency of vitamin A may cause night blindness.
 Medications may have a side effect that causes excessive corneal
dryness, vision changes, or increased intraocular pressure.
 For those who wear contact lenses, it is important to inquire which type
they wear (hard versus soft, extended wear versus daily change) and
evaluate their cleaning routine.
 Makeup and applicators should be discarded every 3 months in order to
minimize the possibility of eye infections.
 Trauma or damage to the eye can occur at work, during recreational
activities, and in social environments. Safety glasses or protective
goggles are recommended when the eye is at risk as seen in carpentry,
welding, and clinical laboratories to prevent debris or splashes from
entering the eye.

Abnormalities of the Eye: Visual Acuity

The ability of the eye to refract light rays and focus them on the retina is
referred to as visual acuity. One determinant in these refractive and focusing
processes is the shape of the eye. Below are the abnormal findings of visual
acuity and their descriptions.12

Abnormal Finding Description

Emmetropia Normal refractive condition of the eye in which light rays are brought into sharp
focus on the retina

Myopia Generally an inherited condition; occurs when the eye is longer than normal. As
(nearsightedness) a result, light rays focus in front of the retina.

Hyperopia An inherited condition in which the eye is shorter than normal. The light rays
(farsightedness) focus behind the retina.

Astigmatism A familial condition in which the refraction of light is spread over a wide area
rather than on a distinct point on the retina. The cornea curves more in one
direction than another, resulting in the light being refracted and focused on two
focal points on or near the retina. Vision in astigmatism may be blurred or
 doubled.

Presbyopia Age-related condition in which the lens of the eye loses the ability to
accommodate. The light is focused behind the retina, and focus on near objects
becomes difficult.

Abnormalities of the Eye: Visual Fields

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The complete area in which objects can be seen in the periphery as the eye
remains focused on a central point is referred to as the visual field. Changes in
visual fields can occur with:13

 Damage to the retina

 Lesions in the optic nerve or chiasm
 Increased ocular pressure
 Retinal vascular damage

Detecting and mapping out losses in peripheral vision help to determine the
problem.

Abnormalities of the Eye: Cardinal Fields of Gaze

Six extraocular muscles and cranial nerves III, IV, and VI control movements of
the eyes. Assessing the fields of gaze and corneal light reflexes and performing
the cover test can identify weakness in the muscles of the eye or dysfunction of
a cranial nerve.

The inability to direct the axes of the eyes at the same object is a condition
called strabismus. The eye may deviate inward (esotropia) or outward
(exotropia). Nonparallel eye movements and the inability of the eyes to follow in
a certain direction signify problems with the extraocular muscles or cranial
nerves. Listed below are the specific muscles and nerves associated with
abnormal eye movements.14

Disruption of Function

Muscle Cranial Nerve Results

Superior rectus Oculomotor Inability to move eye upward or temporally

Superior oblique Trochlear Inability to move eye down or nasally

Lateral rectus Abducens Inability to move eye temporally

Inferior oblique Oculomotor Inability to move eye upward or temporally

Inferior rectus Oculomotor Inability to move eye downward or temporally

Medial rectus Oculomotor Inability to move eye nasally

Abnormalities of the Eye: Pupillary Response

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Abnormal findings related to the pupils are listed below with their descriptions. 15

Abnormal Pupillary
Description
Response

Adie pupil Also termed tonic pupil, appears as a unilateral and sluggish pupillary response

Argyll Robertson Small, irregular pupils that are nonreactive to light. Usually occurs with central
pupils nervous system disorders such as tumor, syphilis, and narcotic use.

Anisocoria Unequal pupillary size; may be a normal finding or indicate central nervous
system disease

Cranial nerve III A unilaterally dilated pupil that does not react to light; drooping of the eyelid
damage (ptosis) may occur

Horner syndrome Caused by blockage of the sympathetic nerve stimulation. Client appears to have
a unilateral, small regular pupil that is nonreactive to light and drooping of the
 eyelid (ptosis).

Mydriasis Refers to fixed and dilated pupils. This condition may occur with sympathetic
nerve stimulation, glaucoma, central nervous system damage, or deep anesthesia

Miosis Pupils are fixed and constricted. The use of narcotics, damage to the pons, or
certain treatments for glaucoma can cause this condition

Monocular Partial loss of vision in one eye resulting in an absence of pupil response to light
blindness

Abnormalities of the Eye: Structures of the External Eye

Some abnormalities of the structures of the external eye are more serious than
others and will require further evaluation. Abnormalities of the structures of the
external eye are listed below with their descriptions.16

Abnormality Description

Acute A sudden increase in intraocular pressure resulting from blocked flow of fluid from
glaucoma the anterior chamber. The pupil appears oval and dilated, with redness around the
cornea. The cornea appears cloudy. The onset of pain is sudden, with a decrease in
vision and halos around lights. Acute glaucoma requires immediate attention from a
professional.

Basal cell Pearly and waxy skin lesion usually seen on the lower lid and medial canthus
carcinoma

Blepharitis Inflammation of the eyelids, sometimes with burning, itching, and tearing. If a
staphylococcal infection is present, the lids appear red and scaly, and there is crusted
debris on the lids.

Cataract An opacity in the lens, causing the lens to appear cloudy and hazy. Occurs with aging.

Chalazion Firm, nontender nodule on the eyelid, usually due to an infection of the meibomian
gland

Conjunctivitis An infection of the conjunctiva usually caused by a bacteria or virus. This condition
can also result from a chemical exposure.

Ectropion Eversion of the lower eyelid caused by muscle weakness. The palpebral conjunctiva is
exposed.

Entropion Inversion of the lid and lashes caused by muscle spasm of the eyelid. Consequently,
friction from the lashes can cause corneal irritation.

Hordeolum The consequence of a staphylococcal infection of hair follicles on the margin of the
(stye) lids. The eye appears swollen and red, and the client complains of pain.

Iritis Appears as redness around the eye and cornea, and the pupil is irregular in size.
 Vision is compromised, and the client experiences a deep aching type of pain.

Periorbital Swollen and puffy lids that can occur with crying, infection, and systemic problems
edema such as kidney failure, heart failure, and allergies

Ptosis Drooping of the eyelid resulting from cranial nerve damage or systemic
neuromuscular weakness

Abnormalities of the Eye: The Fundus

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When performing the ophthalmoscope examination, abnormal findings related to

the fundus of the eye may be evident. Abnormalities of the fundus are listed
below with their descriptions.17
Abnormalities of
Description
the Fundus

Diabetic Changes occur in the retina and vasculature of the retina in diabetic clients. These
retinopathy include microaneurysms, hemorrhages, macular edema, and retinal exudates
resulting in what is called diabetic retinopathy.

Hypertensive The changes in the retina and vasculature of the retina in response to elevations in
retinopathy blood pressure. Causes for the elevated blood pressure may be atherosclerosis,
heart disease, and kidney disease. During the ophthalmic exam, flame
hemorrhages, nicking of vessels, and “cotton wool” spots are seen, arising from
infarction of the nerve fibers.

Macular This age-related degenerative condition of the central portion of the retina (the
degeneration macula) results in central vision loss while peripheral vision remains intact. Both
eyes are affected at different rates.