Professional Documents
Culture Documents
Iris – produces the color of the eye Pupil – central aperture of iris
DEVELOPMENTAL VARIATIONS
A. INFANTS & CHILDREN
- term babies are hyperopic (farsighted) with visual acuity of 20/200
- peripheral vision is fully developed at birth, central vision
develops later
- by 2 or 3 months, lacrimal ducts begin carrying tears and infant gains
voluntary control of eye
muscles
- by 6 months, vision has developed sufficiently enough to differentiate
colors
- by 9 months, binocular is perceived
- young children have myopic acuity (nearsighted)
- adult acuity is achieved by about 6 yrs. old
B. PREGNANT WOMEN
- mild corneal edema, especially in 3rd trimester
- corneal thickening
- increase in corneal epithelial pigmentation (Krukenberg spindles)
- ptsosis may develop for unknown reasons
- subconjunctival hemorrhages may occur/resolve spontaneously
C. OLDER ADULTS
- major physiologic change is progressive change in near point of
accommodation
- by 45 yrs, lens becomes more rigid and ciliary muscle of iris becomes
weaker
- results in presbyopia (difficulty with accommodation and
decrease in near vision)
- old fibers are compressed centrally, forming a more dense central
region that may cause loss of
clarity of lens and contribute to cataract formation
I. REVIEW OF RELATED HISTORY
A. HISTORY OF PRESENT ILLNESS
Difficulty with vision – one or both eyes, corrected by lens; cataracts, adequacy
of color vision; presence of
halos
Pain – in or around the eye; burning, itching, or nonspecific uncomfortable or
gritty sensation
Secretions – color, consistency, duration, tears that run, decreased tear
formation, conjunctival redness
Medications – use of any eyedrops or ointments, antibiotics, artificial tears,
mydriatics, myotics
B. PAST MEDICAL HISTORY
Trauma – to part or whole structure or supporting structures
Surgery
Chronic Illness – hypertension, diabetes, collagen vascular diseases,
inflammatory bowel disease, glaucoma
C. FAMILY HISTORY
Retinoblastoma or Cancer of retina
Color blindness, near- or far-sighted, strabismus (both eyes do not focus
simultaneously), amblyopia
(impairment of vision)
Chronic Illness – diabetes, glaucoma, allergies
E. DEVELOPMENTAL VARIATIONS
1. INFANTS AND CHILDREN
- preterm (resuscitated, ventilator or oxygen used, retinopathy
diagnosis, cerebral palsy)
- failure of infant to gaze at mother’s face or other objects; failure
to blink when bright lights or
threatening movements are made
- white area in pupil on a photograph; inability of one eye to reflect
light properly
- excessive tearing over lower eyelid
- strabismus some or all of the time
- excessive rubbing of eyes in young children; inability to reach for
and pick up small objects;
necessity of bringing objects close to examine them; double
vision
- necessity of sitting near front of class to see the board in school
aged children; poor
progress in school not explained by intellectual ability
2. PREGNANT WOMEN
- presence of disorders that can cause ocular complications such as
pregnancy induced
hypertension or diabetes
- use of topical eye meds may cross placental barrier
3. OLDER ADULTS
- visual acuity: decreases in central vision, distortion, use of dim
light to increase, complaints
of glare
- production of excess tearing or complaints of blurred vision
- dry eyes
- development of scleral brown spots
- difficulty in performing near work without lenses
- nocturnal eye pain
Cover / Uncover Test – used when there is an imbalance found with the
corneal light reflex test
- measurement for nerve damage and muscle weakness
- ask pt to stare straight ahead at a near fixed point
- cover one eye and observe uncovered eye for movement
- remove cover and watch for movement of newly uncovered eye as it
fixes on the object
- movement of the covered or uncovered eye may indicate either
esotropia (form of strabismus where
one or both eyes deviate inward) or exotropia (form of strabismus
where one or both eyes
deviate outward)
- document movement or as “none detected in cover/uncover test”
Six Cardinal Fields of Gaze – left & right superior/inferior rectus, left & right
inferior/superior oblique, medial
rectus, left & right lateral rectus
C. INSPECTION
Abbreviations that must be spelt out but doctors continue: OD = right eye
OS = left eye OU = both eyes
Quick documentation note that can be used ONLY if all tests are positive:
P – pupils E – equal R – round R. L. – reacts to light (direct/consensual
A – accommodation or
indirect/consensual)
2. Orbital Area – inspect for edema, puffiness, or sagging tissue below the
orbit
- periorbital edema is always abnormal - - may represent presence
of thyroid hypoactivity,
allergies, or (especially in youth) presence of renal disease
- flat, slightly raised, irregularly shaped, yellow tinted lesions on
periorbital tissues represent
depositions of lipids and may suggest abnormality of lipid
metabolism
D. PALPATE
- palpate eyelids for nodules
- note whether they meet completely
- if closed lids do not completely cover globe (lagophthalmos),
cornea may become dried
and be at increased risk for infection
- palpate eye itself
- determine whether it feels hard or can be gently pushed into orbit
without causing discomfort
- if it feels very firm and resists palpation, may indicate glaucoma,
hyperthyroidism, or
presence of retroorbital tumor
- palpate region of lacrimal gland and lower orbital rim near inner canthus
- glands are rarely enlarged
E. MISCELLANEOUS
- inspection of interior of eye permits visualization of optic disc
- with patient looking at distant fixation point, direct light of
ophthalmoscope at pupil from about 12”
away
- 1st visualize red reflex, caused by light illuminating the retina
- any opacities in path of light will stand out as black densities
- absence of red reflex is often result of improperly positioned
ophthalmoscope, but may also
indicate total opacity of pupil by cataract or hemorrhage into
vitreous humor
- Drusen bodies can appear as small, discrete spots that are slightly
pinker than retina
- with time spots enlarge and become more yellow
- may occur in many conditions that affect pigment layers of retina,
but most commonly are a
consequence of aging process and may be precursor of senile
macular degeneration
- when noted to be increasing in number or intensity of color,
individual should be given
Amsler grid
- grid is used to evaluate central vision
- pt is instructed to observe grid with ea. eye and note any
distortion of grid pattern
F. DEVELOPMENTAL VARIATIONS
1. Infants – often shut their eyes tightly when exam is attempted
- begin by inspecting external structures
- note size of eyes, paying particular attention to small or
differently sized eyes
- inspect eyelids for swelling, epicanthal folds, and position
- look for vertical fold of skin nasally that covers
lacrimal caruncle
- prominent epicanthal folds are common in Asians, but
may suggest Down
Syndrome in other ethnic groups
- inspect level of eyelid covering the eye
- look for sclera above iris
- observe distance between eyes, looking for wide spaces, or
hypertelorism associated with
mental retardation
- inspect sclera, conjunctiva, pupil, and iris of ea. eye
J. RETINOBLASTOMA – embryonal malignant tumor arising from retina, often during 1st
2 yrs of life
- may be transmitted either by autosomal dominant trait or chromosomal
mutation
- initial signs are white reflex (cat’s eye reflex) rather than usual red
reflex
- exam reveals ill-defined mass arising from retina - - often chalky white
area of calcification
EARS
DEVELOPMENTAL VARIATIONS
A. INFANTS AND CHILDREN – because development of inner ear occurs during 1st
trimester, an insult to fetus may
impair hearing
- external auditory canal is shorter than adult’s and has upward curve
- eustachian tube is relatively wider, shorter, and more horizontal than
adult’s
- with growth of lymphatic tissue, specifically adenoids, eustachian tube
may become occluded,
interfering with aeration of middle ear
C. FAMILY HISTORY
Hearing problems or loss, allergies
E. DEVELOPMENTAL VARIATIONS
1. INFANTS AND CHILDREN – ototoxic antibiotic use, chronic otitis media, playing
with small objects (could
place in ears), behaviors indicating hearing loss (no reaction to loud
or strange noises, no
babbling after 6 mos, no communicative speech, inattention)
3. OLDER ADULTS – hearing loss causing any interference with daily life,
ototoxic drugs
2. WEBER AND RINNE TESTS – tuning fork is used to compare hearing by bone
conduction with that by air
conduction
- hold base of tuning fork with one hand without touching the tines,
and stroke or tap the tines
gently with your other hand, setting the tuning fork in
vibration
a. Weber Test – place base of vibrating tuning fork on the
midline vertex of pt.’s head
- ask pt. if sound is heard equally in both ears or is
better in one ear
(lateralization)
- pt. should hear sound equally
- if sound is lateralized, have pt. identify which ear
hears the best
- to test reliability of response, repeat procedure while
occluding one ear,
asking pt. in which ear the sound is best heard
- sound should be heard better in occluded ear
B. INSPECTION
1. EXTERNAL EAR- inspect auricles for size, shape, symmetry, landmarks,
color, and position on head
- shape of landmarks is not significant unless deformities are noted
- should have same color as facial skin, without moles, cysts, or
other lesions, deformities or
nodules
- blueness may indicate some degree of cyanosis
- pallor or excessive redness may be result of vasomotor instability
- unusual size or shape may be familial trait or indicate abnormality
- cauliflower ear is the result of blunt trauma and necrosis of
underlying cartilage
tophi – small, whitish uric acid crystals along peripheral
margins of auricles may
indicate gout
C. PALPATE
- palpate auricles and mastoid area for tenderness, swelling, or nodules
- consistency should be firm, mobile, and without nodules
- if folded forward, it should readily recoil to usual position
- pulling gently on lobule should cause no pain
D. DEVELOPMENTAL VARIATIONS
1. INFANTS AND CHILDREN – auricle should be well formed, with all landmarks
present on inspection
- auricles either poorly shaped or positioned below imaginary line
are associated with renal
disorders and congenital anomalies
- newborn’s auricle is very flexible but should have instant recoil
after bending
- no skin tags should be present
- tympanic membrane is usually in an extremely oblique position
until infant is 1 month old
- because tympanic membrane does not become conical for
several months, light
reflex may appear diffuse
- limited mobility, dullness, and opacity of pink or red
tympanic membrane may be
noted in neonates
- hearing should be evaluated at regular intervals
2. CHILDREN – while using otoscope, pull auricle either downward and back or
upward and back to gain
best view of tympanic membrane
- as child grows, shape of auditory canal changes to S-shaped curve
of adult
- if child is crying, tympanic membrane can appear red - - cannot
assume redness is hallmark
of middle ear infection
- pneumatic otoscope is especially important to differentiate red
tympanic membrane caused
by crying (membrane is mobile) from that resulting from
disease (no mobility)
- evaluate hearing by observing response to whispered voice and
various noisemakers (avoid
giving visual cues)
- Weber and Rinne tests are used when child understands directions
and can cooperate
(between 3 – 4 yrs.)
4. OLDER ADULTS – inspect auditory canal of pt who wears a hearing aid for
areas of irritation from ear
mold
- tympanic membrane landmarks may appear slightly more
pronounced from sclerotic
changes
- some degree of sensorineural hearing deterioration, marked by
greater difficulty
understanding speech rather than a reduction in all sounds
heard
- conductive hearing loss from otosclerosis and cerumen
impaction may occur
C. ACUTE OTITIS MEDIA – presence of middle ear effusion in conjunction with rapid
onset of one or more of the
following: ear pain, fever, marked redness or distinct fullness or bulging
of tympanic membrane, and
hearing loss
- most common infection of childhood
D. LABYRITHITIS – inflammation of labyrinthine canal of inner ear occurs as
complication of acute upper respiratory
infection
- symptoms of severe vertigo, associated with nystagmus, increase in
severity with head movement
- total sensorineural hearing loss occurs on affected side