NCMA 121: HEALTH ASSESSMENT 2ND

ASSESSMENT OF THE
EYES
SEMESTER
MARCH
AY 2021-2022
07
MIDTERMS LECTURER: MA’AM CORA P. QUINTO 1ST YEAR NURSING

WEEK 7: ASSESSMENT OF THE EYE

TOPIC
SUBTOPIC
SUB-SUBTOPIC

ASSESSMENT OF THE EYES

● 70 % of all sensory information reaches the brain through
the eyes Anatomy of the
● Any disorder will interfere with your client’s ability to Eye
function independently, perceive the world, and enjoy its
beauty

External Structures of
the Eye
A cross - section of the Eye

Extraocular
Muscles
CHOROID Maintains blood supply to the eye

VITREOUS HUMOR Maintains the placement of the

retina and the eyeballs spherical
shape

‘ CORNEA Refracts light rays entering the

eye

PUPIL Permits light to enter the eyes

LENS Refracts and focuses light into the

retina

Lacrimal RETINA Receives visual stimuli and

Apparatus transmits images to the brain for
processing

SCLERA Maintains the eye size and shape

 EYEBROWS ○ Uncovered eyes will read the TOP letter (which is the
● Inspect For Hair Distribution, Alignment, Skin And letter “E”) at 20 ft.

◾
Quality And Movement
Normal
○ Hair evenly distributed; skin intact, Symmetrically
○ Glance on the chart and on the patient making sure
that he only reads with 1 eye and not with both eyes
○ Test each eye separately, then together with and

◾ aligned; equal movement

Deviations from normal
○ Loss of hair;
without corrective lenses (OD (right eye), OS (left
eye) & OU (both eyes))
○ Note smallest line of print patient is able to read with
○ Scaling and flakiness of skin no more than two mistakes
○ Unequal alignment and movement of eyebrow

EYELASHES
◾
○ Alternate method using pocket vision screener:
Have patient hold pocket vision screener about
14 inches from eye and proceed testing as the
● Inspecting The Eyelashes chart

◾
- Note distribution, inversion or eversion
Normal
○ Present and curving outward
● Take Note
○ Visual acuity is assessed in one eye at a time, and
then in both eyes together with the client comfortably

◾ ○ No crusting or infestation
Deviations from normal
○ Absence of eyelashes
○ Lice or ticks at base of eyelashes
○ Inflammation
○ Inverted eyelashes (it can scratch or damage the
cornea)
○ Everted eyelashes: Ectropion (can lead to
excessive drying of eyes)
○ Exophthalmos (usually seen in patients with
hyperthyroidism) (visible sclera between iris and
upper lid)
EYELIDS
● Note edema, lesions
● Inspect for the surface characteristics, position in relation
◾
to the cornea, ability to blink, and frequency of blinking
Normal
○ Upper eyelid normally covers one-half of the
upper iris.
○ Palpebral fissures are symmetrical.
○ Eyelids in contact with the eyeball.
○ No lesions.
○ Inspect for the surface characteristics, position in
relation to the cornea, ability to blink, and
sitting or standing.
○ The right eye is tested with the left eye covered; then
the left eye is tested with the right eye covered.
○ Then both eyes are tested together.
○ Visual acuity is measured with or without corrective
lenses and the client stands at a distance of 20 feet
from the chart.
○ The score on R eye might not be the score on L eye
POCKET VISION SCREENER
○ Have patient hold pocket vision screener about 14 inches
from eye and process testing as the chart
○ This is used for patients with known nearsightedness
○ It is also used to check nearsightedness
● Scoring
◾
○ For example:
If a client can only read the topmost letter (E), his
◾ or her score is 20/200
Meaning that the letter he / she recognized or
identified IS READ BY A CLIENT WITH
◾ NORMAL VISION AT A DISTANCE OF 200 FT.
The client can read it only at a distance of 20 feet
but they cannot read it at 200 feet

◾ frequency of blinking
Deviations from normal
◾ Normal
○ 20 / 20 is the Normal acuity
○ Asymmetry of lids: CN III damage, stroke
○ Ptosis of both eyelids: Myasthenia gravis
○ Lesions on eyelids: Basal cell carcinoma
◾ ○ 20 / 15 is a better vision
Deviations from normal
○ 20 / 200 – legally blind
○ Lesions on eyelids: Squamous cell carcinoma ○ Smaller fraction eg. 20 / 40
○ Xanthelasma (accumulation of lipids in the skin)
– lipidosis JAEGER TEST
○ Chalazion – enlargement of meibomian gland
(meibomian gland is the oil gland) ○ An eye chart used in testing NEAR
○ Hordeolum / Stye – caused by an infection VISION ACUITY
○ A card which paragraphs of text
TESTING VISUAL ACUITY are printed
VISUAL ACUITY ○ Held by a client at a fixed distance
● Visual acuity is the ability to discern letters or numbers at a (14 inches)
given distance ○ Person must hold the print farther
away to see clearly because of the
THE SNELLEN CHART decreased ability of the lens to
accommodate near objects.
- Named after a Dutch
ophthalmologist, Doctor
Snellen
Herman ◾ Normal

● The Procedure
◾ ○ 14 / 14
Deviations from normal
○ A smaller fraction (e.g.,
○ Have client stand 20 ft. away 14/18): Person must hold
from the Snellen Chart print farther away to see
○ Cover up 1 eye with pad clearly because of decreased ability of lens to
accommodate to near objects
 ○ Myopia – Nearsightedness
○ Hyperopia – Farsightedness
○ Presbyopia – Farsightedness due to aging
SNELLEN E CHART
○ Also known as the “Tumbling E” Eye Chart
○ Useful to test the distance visual acuity of
CHILDREN or ADULTS who cannot
communicate verbally due to physical /
mental disability, language barrier or other
reasons
ISHIHARA TEST
○ Color perception / vision test for
RED – GREEN color deficiencies
○ Named after the designer, Dr.
Shinobu Ishihara
○ Have patients identify color bars on
Snellen eye charts.
○ Have patient identify figure
embedded in the Ishihara chart
◾ Normal
○ Correctly identifies embedded figures in the
Ishihara cards or identifies colored bars on the
◾ Snellen eye chart.
Deviations from normal
○ Inability to detect the embedded number or letter
in the Ishihara chart:
○ Defect in color perception (color blindness)
ALLEN CARD TEST
○ Done at a distance of 3 meter
○ Consist of a set of seven card with
each card containing a single
picture
○ Usually used for 2 years old child
and older
○ The child is first shown cards at
close range with both eyes open
and is asked to name each picture
◾ Normal
○ The child should successfully identify three of the
◾ seven objects at a distance of 15 feet
Deviations from normal
○ Macular degeneration or diseases that affect the
cones that mediate color vision
PALPATION
EYEBALL
○ Gently palpate below eyebrow and note firmness of
eyeball
○ Precaution: Do not palpate eyeball in patients with eye
trauma or known glaucoma because this can increase
◾
pressure and can increase or aggravate the pain
Normal
◾ - Globe is firm and nontender
Deviations from normal
- Excessively firm or tender globe, Indicating
glaucoma
CONJUNCTIVA
○ The mucous membrane that covers the front of the eye
and lines the inside of the eyelids
INSPECTING THE BULBAR
CONJUNCTIVA
● Have the client keep the head
straight while looking from side to
side then up toward the ceiling.
● Observe clarity, color, and texture.
● Normal
○ Bulbar conjunctiva over globes
are clear, with few underlying
blood vessels and white sclera
visible
INSPECTING THE PERIPHERAL
CONJUNCTIVA
● Inspect the palpebral conjunctiva of
the lower eyelid by placing your
thumbs bilaterally at the level of the
lower bony orbital rim and gently
pulling down to expose the palpebral
conjunctiva.
● Normal
○ Palpebral conjunctiva is smooth,
glistening, pinkish-peach
color,with minimal blood vessels
visible
EVERTING THE UPPER EYELID
● Place a cotton-tipped applicator
approximately 1 cm above the eyelid
margin and push down with the
applicator while still holding the
eyelashes.
● Hold the eyelashes against the
upper ridge of the bony orbit just
below the eyebrow, to maintain the
everted position of the eyelid.
● Examine the palpebral conjunctiva
for swelling, foreign bodies, or
trauma.
● Return the eyelid to normal by
moving the lashes forward and
asking the client to look up and
blink.
● The eyelid should return to normal
CONJUNCTIVA
● Inspect the bulbar conjunctiva (lying over the sclera)
◾
for COLOR, TEXTURE and PRESENCE OF LESIONS
Normal
○ Transparent, capillaries sometimes evident
○ Sclera appears white
○ Darker or yellowish & with small brown macules
◾
in dark skinned clients are normal
Deviations from normal
○ Jaundiced sclera, excessively pale sclera,
●
reddened sclera; lesions or nodules
Inspect the palpebral conjunctiva (lining the eyelids)
◾
by eVERTING THE LIDS
Normal
◾
○ Shiny, smooth, and pink or red
Deviations from normal
○ Extremely pale, extremely red, nodules or other
lesions
◾
COMMON ABNORMALITIES
Conjunctivitis
CORNEAL LIGHT REFLEX TEST
● Shine light directly in the patient's eyes; note the position
◾ - Red palpebral and bulbar conjunctiva
Anemia
of the light reflection off the cornea in each eye.
● Note for the SPARKLE that is the light reflecting off the
◾ - Pale pink conjunctiva
Pterygium or pinguecula
- Growth or thickening of conjunctiva from inner canthal
cornea
● Normal
○ Light should be seen symmetrically on each cornea.
◾ area toward iris
Subconjunctival hemorrhage
● Deviations from normal
○ Asymmetrical corneal light reflex
◾ - Eye injury
Nevus
○ Weak extraocular muscles or strabismus, congenital
exotropia
◾ - Benign pigmented congenital discoloration
Papilloma
- Benign growth
CORNEA AND LENS
● Shine a light on the cornea from an oblique angle
LACRIMAL APPARATUS ● Note clarity and abrasions
INSPECTION & PALPATION OF THE LACRIMAL ● Corneal Reflex
APPARATUS ○ Take a wisp of rolled cotton and gently touch the
cornea, or
● Inspect the Lacrimal Apparatus ○ Take a needleless syringe filled with air and shoot a
○ Assess the areas over the lacrimal glands (lateral puff of air over the cornea
aspect of upper eyelid) and the puncta (the function of ○ Note for blinking and tearing (normal)
the puncta is to collect tears produced by the lacrimal ● Blink Reflex
gland) (medial aspect of lower eyelid) ○ Brush your index finger across patient’s eyelashes
○ Normal and note blinking
- No edema or tenderness or tearing ○ Normal
- Puncta is visible without swelling or redness - Corneal reflex positive.
○ Deviations from normal - Cornea and lens are clear, smooth, and
- Swelling of lacrimal gland visible in the lateral glistening.
aspect of upper eyelid maybe due to blockage, - White ring encircling outer rim (arcus senilis) is a
infection or inflammatory condition normal variant in older adults
- Redness / swelling around the puncta may
indicate infectious or inflammatory condition CORNEAL ABNORMALITIES
- Excessive tearing may indicate a nasolacrimal ● Cloudy cornea
sac obstruction ○ Vit A deficiency; infection which may be
● Palpate the Lacrimal Apparatus accompanied by HYPOPION (pus in
○ Put on disposable gloves to palpate for the anterior chamber)
nasolacrimal duct to assess for blockage
○ Use one finger and palpate just inside the lower ● Corneal abrasions and ulcers
orbital rim ○ roughness and irregularities of cornea
○ Normal
- No drainage should be noted for the puncta when
palpating the nasolacrimal duct ● Kayser - Fleischer ring
○ Deviations from normal ○ yellow ring in outer margin
- Expressed drainage from the puncta on palpation ○ WILSON’s disease, increased copper
on occurs with duct blockage absorption
CORNEA ● Corneal scar
● Inspect for clarity and texture ○ appears grayish white, usually due to an
○ Ask the client to look straight ahead old injury or inflammation
○ Hold a penlight at an oblique angle to the eye, and
move the light slowly across the corneal surface ● Early Pterygium
○ Normal ○ thickening of the bulbar conjunctiva that
- Transparent, shiny and smooth, details of iris are extends across the nasal side
visible
- In older people, arcus senilis may be evident ● Negative corneal reflex
○ Deviations from normal ○ indicates neurological problem, CN V
- Opaque, surface not smooth and VII
- Arcus senilis under age 40 ○ may also be absent or diminished in people who wear
- a normal condition in older clients, appears as a contact lenses
white arc around the limbus
- has no effect on vision LENS ABNORMALITIES
● Cataracts
○ lens opacities

SCLERA
● Note color of sclera
○ Should be smooth, white, glistening
 ○ Dark-skinned patients may have a yellowish cast to TESTING ACCOMMODATION OF
the peripheral sclera with whiter sclera at the limbus PUPILS
or small brown spots called muddy sclera ● Accommodation (Adjustment of
Eye for Various Distances)
COMMON ABNORMAL FINDINGS ● Convergence of eyes and
● Diffuse Episcleritis constriction of pupil to focus on a
○ inflammation of the episclera near object and dilation of pupil
● Bluish Sclera when looking at a far object
○ osteogenesis imperfecta ● Accommodation may be
● Icteric sclera sluggish in advanced age
○ at the limbus; due to elevated bilirubin (jaundice) ● Hold your finger or a pencil
about 12 to 15 inches from the
PUPILS client.
● Pupil permits light to enter the eyes ● Ask the client to focus on your finger or pencil and to
● Inspect PUPIL SIZE and EQUALITY remain focused on it as you move it closer in toward the
○ Should be round and equal bilaterally eyes.
○ Size is larger in children, smaller in adults ● Accommodation occurs when the client moves his or her

◾
○ Normal range is 3 – 5 mm in adults (usually 3mm)
In about 20 percent of the population, unequal
focus of vision from a distant point to a near object,
causing the pupils to constrict.

◾ pupils (ANISOCORIA) can be a normal variation

If normal, the pupils react appropriately and the
difference is slight, 0.5 mm
● Normal
○ The normal pupil constricts when focused on a near
object and dilates when focused on a far object.
○ Note REACTION and SPEED in both eyes
● Test pupillary reaction to light: CONVERGENCE TEST
○ Have patient look straight ahead while you bring light ● Convergence is assessed by
in from the side over the eyes moving the finger toward the

◾
○ Normal findings
Direct reaction eye receiving stimulus constricts
patient's nose
● Hold a small target, such as a

◾ briskly
Consensual reaction, opposite eye not
penlight, in front of the client and
slowly moves it closer until the client

◾ receiving stimulus directly also constricts

Normal direct and consensual pupillary response
to light is brisk constriction of the pupil to about 1
have a double vision
● PERRLA
○ P – upils
mm or less ○ E – qual
○ R – ound
PUPIL ABNORMALITIES ○ R – eactive
● Tonic Pupil ○ L – ight reacting
○ unilateral large pupil (tonic pupil) that reacts to light ○ A – ccomodation
slowly (benign)
● Horner's syndrome EXTRAOCULAR MUSCLES
○ Unequal pupils; affected pupil small but reacts to light ● Assess 6 OCULAR MOVEMENTS to determine
and has ptosis on affected eye related to sympathetic ALIGNMENT AND COORDINATION
nerve lesion ○ Normal
● Argyll Robertson pupils - Both eyes coordinated, move in unison, with
○ small and irregular with no reaction to light or parallel alignment
accommodation, associated with neurosyphilis ○ Deviations from normal
● Oval pupils - Eye movements not coordinated or parallel; one
○ irregularly shaped pupils may be caused by certain or both eyes fail to follow a penlight in specific
eye surgeries directions
○ may indicate a transtentorial herniation with third
nerve compression COMMON ABNORMALITIES
● Sluggish or fixed pupil reaction to light ● Strabismus
○ Lack of oxygen to optic nerve or brain or topical or ○ squint; deviation of the eye which the patient cannot
systemic drug effects overcome
● Absence of consensual response ● Nystagmus
○ Seen in conditions that compress or deprive those ○ involuntary rapid movement (horizontal, vertical,
areas of oxygen rotatory, or mixed) of the eyeball
● Absent light reflex but no change in power of
contraction during accommodation (Argyll Robertson TEST FOR EXTRAOCULAR MUSCLES
pupil) ● COVER / UNCOVER TEST
○ Paralysis and locomotor ataxia caused by syphilis ○ Cover the patient's one eye and have the
● Mydriasis patient focus on the object afar.
○ Dilated and fixed pupils, typically resulting from ○ Uncover eye and note any drifting.
central nervous system injury, circulatory collapse, or ○ Gaze should be steady when the eye is
deep anesthesia. covered and uncovered. No drifting.
● Miosis ○ Deviations from normal
○ Also known as pinpoint pupils, characterized by - Shift in gaze
constricted and fixed pupils — possibly a result of - Movement of eyes to refocus gaze
narcotic drugs or brain damage. - Weak eye muscles
 - If uncovered eye shifts in response to covering - Damage, irritation, or pressure on corresponding
opposite eye, covered eye is dominant extraocular muscle or cranial nerve that
- If covered eye shifts after being uncovered, that innervates the muscle
eye is weak
- Weakness of extraocular muscles or CN III, IV, COMMON ABNORMALITIES
and VI, which innervate extraocular muscles ● Astigmatism
○ History of blurred vision
○ Corneal irregularity
○ Refraction of light rays diffused rather than sharply
focused on retina
● Conjunctivitis
Weakness of Extraocular ○ Irritation and inflammation of bulbar and palpebral
Muscles Cranial Nerves III, IV, conjunctiva
and VI ○ One of most common sources of eye discomfort
○ Typically caused by allergies, viruses, or bacterial
infections
○ Manifests as redness of the palpebral conjunctiva and
bloodshot sclera
○ Purulent drainage usually present if caused by
infection
● Cataract
○ Abnormal, progressive opacity of the lens
○ Pupil may appear cloudy
4th nerve paralysis: The eye ○ Red reflex absent or darkened
cannot look down when ● Glaucoma
turned inward. ○ Tunnel vision
○ 2nd leading cause of blindness worldwide
○ May be asymptomatic

◾
○ S/s include

◾ crescent shadow

◾
◾
firm eyeball
blurred optic disc margins
6th nerve paralysis:
The eye cannot ◾ loss of peripheral vision and depth perception
contrast sensitivity
look to the outer
side ◾
○ 2 Main Types
Primary Open Angle Glaucoma (POAG)
- associated with loss of central vision and
elevated eye pressure
VISUAL FIELDS - excessive eye pressure is not required for
●
●
R/L SUPERIOR, R/L LATERAL, R/L INFERIOR
Assess EYE MUSCLE STRENGTH and CRANIAL
NERVE FUNCTION
◾ diagnosis
Primary Angle Closure Glaucoma (PACG)
- may present with acute symptoms including
○ Instruct the client to focus on an object you are - red eye
holding (approx. 12in from the client’s face) - dilated pupil
○ Move the object through the 6 cardinal positions of - nausea & vomiting
gaze in a clockwise direction - eye pain
○ Note for nystagmus - halos around lights
- involuntary rapid movement (horizontal, vertical, - may present with acute symptoms including
rotatory, or mixed) of the eyeball assessment of the anterior chamber with
oblique flashlight test often reveals forward

●
CARDINAL FIELDS OF GAZE TEST
Assessing the 6 Extraocular
Eye Muscles by the 6 Cardinal
◾ bowing of iris
assessment of the anterior chamber with oblique
flashlight test often reveals forward bowing of iris
Fields of Gaze ● Iritis
○ Normal Findings
- Eye movement should ◾
○ Symptoms include

◾ severe eye pain

be conjugate (parallel),
smooth and symmetric ◾ tearing
sensitivity to light (photophobia)
throughout
directions
all 6
◾
○ and in severe cases
diminished visual acuity
-

-
Equal
fissures
palpebral

Intact extraocular muscles

◾
○ If untreated

◾ scarring
and permanently diminished vision occur
○ Deviations from normal ● Pinguecula
- Nystagmus ○ Painless yellow nodule caused by thickening of bulbar
- Limited or disconjugate movement in one or more conjunctiva
fields of gaze ○ Often caused by exposure to sunlight or wind
- Ptosis (drooping of upper eyelid)
- Eyelid lag
● Pterygium
○ Triangular growth of the bulbar conjunctiva from the
○
◾
2 types
Esotropia
nasal side of the eye toward the pupil
○ Decreased elasticity of the lens
○ Results in decreased ability to focus on near objects
◾ - eye turns inward
Exotropia
- eye turns outward
○ Can obstruct vision if growth occludes the pupil ● Visual Halos
● Visual Floaters ○ The client sees halos and rainbows around bright
○ Specks in the visual field that usually disappears lights
when the patient looks at them ○ Caused by corneal edema as a result of prolonged
○ Caused by small cells floating in the vitreous humor wearing of contact lenses
○ May signal retinal separation ○ Fluctuation of blood sugar levels

●
◾
○ Black spot
retinal detachment
Retinal Detachment
●

●
Enucleation
○ Removal of the eyeballs
Optic nerve pathways, visual fields, and selected
○ Separation of retinal layer and choroid layer in back of associated visual defects
eye ○ Pressure on a specific part of the optic nerve tract can
○ Signs usually develop gradually produce visual loss (hemianopia) on the ipsilateral

◾
○ Initial symptoms include

◾ seeing large numbers of floaters

(same side) or contralateral (opposite side) visual
field, depending on the location of the injury or lesion

◾ flashing lights when the eyes move

and a slowly expanding shadow in the lateral
fields of gaze
●

●
Nyctalopia
○ Color blindness
Xerophthalmia
○ Untreated retinal detachment results in irreversible ○ Night blindness due to retinol deficiency
blindness ● Xenophthalmia
● Macular Degeneration ○ Conjunctivitis due to trauma
○ Diminished visual acuity ● Myopia
○ Loss of central vision - Nearsightedness
○ Increased pigmentation of macula ● Hyperopia
● Retinitis Pigmentosa - Farsightedness
○ Degeneration of retina ● Presbyopia
○ Begins in childhood and may progress to blindness by - Farsightedness due to aging
middle adulthood
○ Rods and cones

◾
○ Earlier signs may include

◾ night blindness

◾
◾
reduced visual fields
pigmentation of the retina
and macular degeneration
● SJÖGREN’S Syndrome
○ Immunologic disorder in which lacrimal, salivary, and
other glands do not produce enough moisture
○ Causes dryness of the mouth, eyes, and other
mucous membranes
○ Damage to external eye tissues, such as the cornea
and conjunctiva, may result from excessive and
prolonged dryness
● Diplopia
○ “double vision”
○ the visual axes aren’t directed at the object of sight at
the same time
○ results from misaligned extraocular muscles
● Strabismus
○ Axis of eye deviates and does not fixate on an object
○ Also called crossed or wall eye
○ Caused by weak intraocular muscles or a lesion on
the oculomotor nerve
○ Causes disconjugate vision (one eye deviates from
fixated image)
○ Initially, diplopia results as each eye transmits the
images received
○ Eventually, brain suppresses images received from
deviating or weak eye
○ After a period of disuse, visual acuity in weak eye
deteriorates and loss of vision
○ results
○ Treatment before age 6 is necessary to prevent
permanent damage