1. Questions to ask in the PQRST
1.1. Visual difficulty
1.2. Pain
1.3. Strabismus
1.3.1. Deviation on the parallel axes of 2 eyes
1.4. Diplopia
1.4.1. The perception of two images in a single object
1.5. Redness
1.6. Swelling
1.7. Watering
1.8. Discharge
1.9. Hx of ocular problems
1.10. Glaucoma
1.11. Lens usage
2. Objective Data
2.1. Snellen Eye Chart
2.1.1. Snellen alphabet chart is most commonly used and accurate measure of visual acuity.
2.1.2. It has lines of letters arranged in decreasing size.
2.1.3. Place chart in a well-lit spot at eye level; position the person exactly 20 feet from chart; hand the person an opaque card with which to shield one eye at a time during test.
2.1.4. If the person wears glasses or contact lenses, leave them on; remove only reading glasses.
2.1.5. Ask the person to read through chart to smallest line of letters possible; encourage trying next smallest line also.
2.1.6. Iif the person is unable to see even largest letters, shorten distance to chart until the person sees it, and record that distance (e.g., 10/20).
2.1.7. If visual acuity even lower, assess whether the person can count your fingers when they are spread in front of eyes or distinguish light perception from your penlight.
2.2. Near Vision: Hand-held visual card/screener
2.2.1. Screens for peripheral vision
2.2.2. Patient covers one eye with card
2.2.3. The nurse covers their opposite eye
2.2.4. The nurse is testing the uncovered eye
2.2.5. Holding a wiggling finger, as a target midline between the nurse and the patient and slowly advance it to peripheral in several directions
2.3. Peripheral vision: Confrontation test
2.3.1. Corneal light reflex: light should shine on the same spot in both eyes
2.3.1.1. Asymmetry indicates deviation in alignment of the eye muscles or paralysis
2.4. 6 Fields of Gaze
2.4.1. Ask patient to follow finger movements in 6 directions
2.4.1.1. Normal: able to track with both eyes
2.4.1.1.1. Abnormal: No lateral movements, indicates muscle weakness
3. Abnormal Findings
3.1. Periorbital edema
3.1.1. Lids swollen and puffy occurs with local infection, crying, trauma, CHF, allergies
3.2. Exophthalmos
3.2.1. Forced displacement of the eyeballs and wide palpebral fissures, associated with hyperthyroidism
3.3. Enophthalmos
3.3.1. Narrow palpebral fissures, eyeball recessed caused by loss of fat
3.3.1.1. Dehydration, chronic wasting illnesses
3.4. Ptosis
3.4.1. Drooping caused my neuromuscular weakness
3.4.1.1. Myasthenia Gravis
3.5. Upward palpebral slant
3.5.1. Large space between eyes
3.5.1.1. Trisomy 21
3.6. Ectropion
3.6.1. Lower lid loose, eversion, rolling out, exposed palpebral conjunctiva
3.6.1.1. Bell's Palsy
3.7. Conjunctivitis
3.7.1. Infection of the conjunctiva
3.7.1.1. Pink eye
3.7.1.1.1. Bacterial infection
3.7.1.1.2. Allergy
3.7.1.1.3. Chemical
3.7.1.2. Itching , buring, feels like something is in the eye
3.8. Iritis
3.8.1. Deep. dull, halo around the iris
3.8.1.1. Trauma, burn, viruses
3.8.2. Pupil shape may be irregular and swelling
3.8.3. Photophobia, constricted pupils, blurred vision, pain
3.9. Primary Angle Closure Glaucoma
3.9.1. Acute narrow arrow glaucoma show circumcorneal redness around the iris and dilated pupils
3.9.1.1. Cornea looks steamy
3.9.1.1.1. Sudden clouding of vision, pain, seeing halos
3.10. Subconjunctival Hemorrhage
3.10.1. Red patch on sclera, usually not serious
3.10.1.1. May occur to increased pressure with coughing, vomiting, straining
3.11. Corneal abrasion
3.11.1. Scratch on cornea
3.11.1.1. Blunt trauma, foreign object
3.11.1.1.1. Pain, photophobia
3.12. Cataract
3.12.1. Formation of clouding of crystalline lens
3.12.1.1. Leading cause of blindess
4. Anatomy of the Eye
4.1. Sclera: White, protective and tough
4.2. Pupil: Round, regular and affected by PNS, SNS, light & accomodation
4.2.1. PERRLA: Pupils are Equal, Round, Reactive to Light and Accommodation
4.3. PNS: Constricts
4.3.1. Light constricts
4.4. SNS: Dilates
4.4.1. Dark dilates
4.5. Accomodation: Ability to fixate on object
4.5.1. Pupils will constrict with a close object
4.5.1.1. Pupils will dilate with a distance object
4.5.1.1.1. When Pupils are nonreactive to accommodation, it means they don't adjust
4.6. Extraocular Muscles
4.6.1. 6 Muscles that allow rotary movement
4.6.1.1. Should be coordinated
4.6.2. Innervated and stimulated by cranial nerves
4.6.3. Cranial Nerve 111 (oculomotor)
4.6.3.1. Six fields of gaze
4.6.3.1.1. Most eye movements, pupil constriction
4.6.4. Cranial Nerve 1V (trochlear)
4.6.4.1. Downward, outward, inward movement
4.6.5. Cranial Nerve V1 (abducens)
4.6.5.1. Outward movement
5. The Aging Adult
5.1. Pupil size Decreases
5.2. Presbyopia: Loss of lens elasticity
5.2.1. Presbyopia :Lens loses elasticity, becoming hard and glasslike, which decreases ability to change shape to accommodate for near vision.
5.3. Cataract: thick, yellow deposit usually after 70 years of age
5.4. Visual acuity decreases
5.5. Decreased orbital fat ->->-> Sunken eyes
5.6. Less eyelashes around face and orbit
5.7. Dry eyes
5.8. pseudoptosis
5.8.1. Drooping of eyelid
5.9. Xanthelasma:
5.9.1. Plaques in inner canthus
5.10. Most Common Abnormalities
5.10.1. Cataract: A clouding of crystalline lens
5.10.1.1. Often due to ultraviolet radiation
5.10.1.1.1. Leading cause of blindness
5.10.2. Glaucoma: increased intraocular pressure->->-> Loss of peripheral vision
5.10.2.1. African americans
5.10.2.2. Increase with family risk
5.10.3. Age-related macular degeneration (AMD): macula cells die→ → → Central vision loss
5.10.3.1. Increase of prevalence after 75 years of age
5.10.3.2. Causcasions
5.10.3.3. R/F’s: smoking, light eyes, HTN, Hypercholesterolemia, female
5.10.4. Diabetic retinopathy: leading cause of blindness between 24-74 years
6. Pupil Size
6.1. Normal resting size: 3-5 mm
6.1.1. Miosis:Constricted and Fixed Pupils
6.1.1.1. Brain and Nervous System Injury, Drugs, glaucoma treatment drops
6.1.2. Mydriasis: Dilated and Fixed pupils
6.1.2.1. Brain injury, dark room, fear, drugs