Examination of the Eye & Ear

1. Examination of the Eye & Ear Professor Janet M. Galiczewski RN,CCRN,MSN,ANP

2. A & P Outer Eye

3. External Eye • Eyelid: Distributes tears, limits light entering eye, protects eye. Upper lid covers 2-3 mm of iris but NOT pupil. The lower lid sits directly on the lower ring of the iris • Palpebral Fissure: Opening between eyelids. • Conjunctiva: Thin membrane covering most of the anterior surface of eye & eyelid, protects eye.

4. Lacrimal Gland: located in temporal region of eyelid. Produces tears ( drain into lacrimal sac from puncta to nasolacrimal duct to nasopharynx). • Puncta is the only visible portion of the lacrimal apparatus.

5. Eye Muscles (EOM’s) • EOM’s are responsible for eye movement • 4 Rectus • 2 Oblique • Innervated by CN III, CN IV, CN VI • Levator palpebrae muscle which raises upper eyelid innervated by CN III

6. A&P Inner Eye

7. Internal Eye • Sclera: “White of the Eye,” protective, provides structure. The optic nerve is attached to it at the back of the eye. • Cornea: continuous with sclera, transparent dome shaped window that covers iris, pupil,& anterior chamber. Provides most of the eyes optical power. • 1. Refracts light • 2. Eye focus (fixed) • 3. Protects - nerve endings sensitive to touch, temp, & chemicals

8. Aqueous Humor: Fluid produced by ciliary body that flows from posterior chamber through pupil to anterior chamber. Controls pressure inside eye. • Iris: Circular, contractile muscular disc containing pigmented cells. Regulates the light levels inside eye. • Pupil:Center of iris.Tiny sphincter muscles constrict pupil to light & tiny dilator muscles dilates eye in dim light.

9. Lens:Their purpose is to focus light on the retina. The lens have ability to change shape and to adjust to close & distant vision. This is called accommodation. • Retina: Sensory network that lines the back of the eye, transforms light impulses to electrical impulses.Impulses travel via optic nerve to cerebral cortex. Here they are transformed into images. • 1. Cones:macula portion of retina, central vision, bright light, color appreciation • 2. Rods: spread throughout peripheral retina, peripheral & night vision, dim light

10. Mechanisms of Vision • Vision depends on light rays which enter eye, passes through cornea & pupil, then focus on retina by the lens. • Vision may be altered from local or systemic disease.

11. Examination of the Eye • Review of systems • Inspection of external structures. • Measurement of visual acuity. • Determination of visual fields. • Evaluation of Extraocular Movement. • Estimation of Intraocular pressure. • Exploration of Ocular Fundus.

12. Review of Systems • Start with open ended questions…. • Onset of problem gradual or sudden? • Problem seeing close work or distance? • Pain or headaches? • Last eye exam • Glasses or contact lens

13. Inspection of External Structures • Eyelids: Inspect blinking, external surface for lesions, superficial vascularity, edema. • Ptosis • Check position of lids for Eversion, Inversion. • Check Enophthalmos, Exophthalmos

14. Eyelids (cont). • Check for corneal drying • Palpate for ocular tension. • Check Lacrimal apparatus • Eyebrows, Eyelashes: note quantity, distribution, color, texture. • Sty • Chalazion

15. Conjunctiva & Sclera • Examine palpebral conjunctiva lining the lids & bulbar conjunctiva covering sclera. • Note: color, vascular patterns, nodules, swelling. • Conjunctivitis

16. Cornea, Lens & Iris • Using oblique lighting note: scars, irregularities, foreign bodies, opacities • Check iris for crescent shadow on medial side of iris (no shadow should be seen). • Arcus Senilis

17. Pupils • Note: size, shape, equality (slight inequality may be normal (anisocoria). • Check pupillary reaction to light. • Look for Direct reaction • Consensual reaction • Identify as: prompt or brisk (normal), sluggish, or absent.

18. Visual Acuity • Snellen Chart-Check distant visual acuity, color. • Ex. 20/30 vision. 20=distance from chart. 30=distance at which normal eye can read that line of letters. • Presbyopia • Myopia (near-sightedness) • Hyperopia (far-sightedness)

20. Visual Fields • Defined as the entire area seen by an eye when its gaze is fixed on a central point. • Superficially tested by comparing the pts. peripheral vision with your own. • Technique: “Confrontation”Visual Fields

21. Extraocular Movements (EOM) • To detect weakness or paralysis of extraocular muscles. • Corneal Light Reflex • EOM’S “H” Pause to detect nystagmus (fine rhythmic oscillation of the eyes). • Combine with convergence. • Check for lidlag.

22. Opthalmoscopy (Fundoscopy) • Important in evaluation of local disorders (cataract, retinal detachment, or systemic disease) • The light beam passes through the cornea to aqueous humor of the anterior chamber to lens to the vitreous humor, strikes the retina & structures that make up fundus of the eye. • Fundus-internal surface of the retina

23. Opthalmoscopy (Fundoscopy)cont. • Image of the optic disc, blood vessels, retina, macula, fovea. • Technique- if you wear glasses leave on or correct for deficit with ophthalmoscope. • Turn lens disc to “O” • Keep index finger on lens disc to focus during exam.

24. Opthalmoscopy (Fundoscopy)cont. • Darken room-dimly lit, switch on ophthalmoscope light to round beam of white light. • Use your Right hand & Right eye for pts. Right eye. Same for Left. • You & pts. Eyes should be at same level. • Instruct pt to look up & over your shoulder at a fixed point on the wall.

25. Opthalmoscopy (Fundoscopy)cont. • From about 15 inches away from pt & 15 degrees lateral to pt. Line of vision • Shine light beam into pupil • You will see Red Reflex (orange, red glow in pupil) Cataract will interrupt. • Keep beam on red reflex, move in 15 degrees to pts line of sight, until scope is close. You will see the OPTIC DISC.(yellow /orange or creamy pink; oval or round).

26. Ophthalmoscopy (Fundoscopy)cont. • If only vessels seen trace back to disc (bring disc into sharp focus) • Pattern of Exam:Red Reflex, Disc, Vessels, Retina including Macula. • Red Reflex: note opacities, dark lines, black spots. • Disc Color: yellow, orange to creamy pink, disc diameter is about 1.5 mm

27. Arteries Color: Light Red Size: Smaller Diameter (2/3 less than vein). Light Reflex: Bright Veins Color: Dark Red Size: Larger Light Reflex: Less bright or absent Vessels

28. Fundoscopy (cont). • HTN: arterioles become narrow & tortuous, • Ratio (A/V) decreases to 1:2 or 1:3 (Normal 2:3, 4:5). • AV Nicking-Kinking or indentation of the venule at a crossing. • Retina: Note-lesions, size, shape, color, distribution. • Hemorrhage: may appear flame shaped, deep red spots.

29. Fundoscopy (cont). • Exudates: Hard or soft • Soft:”cotton wool exudates” fluffy, fuzzy outline • Hard: smaller with discrete borders • Next, move laterally to inspect macula (temporal) • Fovea tiny pinpoint of bright in center of macula.

30. Fundoscopy (cont). • Senile Macular Degeneration:important cause of impaired central vision in elderly. Look for hemorrhage, exudate, cysts. • Degree of retinal changes direct relationship to severity of disease.

31. A & P of the EAR • Sensory organ:Function is to identify, locate interpret sound. • Maintain equilibrium. • Divided into 3 parts:External,Middle,Inner.

32. External Ear • Auricle: varies size & shape. • Should be = in height & size • Structural landmarks of the auricle: • Helix: prominent outer ridge. • Antihelix: parallel & anterior to helix. • Tragus: anterior to auditory canal. • Antitragus: opposite auditory canal opening. • Lobule: Soft, lobe at bottom of auricle.

33. External Auditory Canal: 2.5-3cm length narrows toward mid-portion & widens near eardrum. • “S” shaped pathway leads to middle ear. • Consists of bone & cartilage covered with thin sensitive skin. • Mastoid process: bone behind & below the ear canal ( mastoid part of temporal bone).

34. Middle Ear • Air filled cavity in temporal bone separated from external ear by tympanic membrane. • TM (Eardrum): shiny, translucent & pearly grey. • Sound transmitted by 3 tiny bones: (ossicles) malleous, incus, stapes. • Eustachian tube leads to nasopharynx allows for equalization of air pressure with atmospheric pressure (swallowing).

35. Middle Ear • TM visualized (otoscope) as an oblique membrane pulled inward at its center by the malleus. You can locate: • Handle of malleous • Short process of malleous • Umbo • Cone of light • Pars flaccida • Pars tensa

36. Inner Ear • A curved cavity within a bony labyrinth • Consists of a vestibule, semicircular canals, cochlea. • Cochlea contains the organ of corti which transmits sound impulses to the Cranial Nerve VIII (Acoustic).

37. Physiology of Hearing • Vibrations of sound are transmitted to the external ear, then to the eardrum, to the ossicles of middle ear to the cochlea (of inner ear). • Vibrations of cochlea cause the organ of corti to stimulate impulses in CN VIII which are transmitted to temporal lobe for interpretation . • Normal hearing pathway: Air Conduction

38. Types of Hearing Loss • Conductive Hearing Loss: Occurs when changes in outer or middle ear impairs conduction of sound to inner ear. • Air conduction is impeded d/t Excessive cerumen, foreign body, otitis media, tumor of middle ear, otitis externa, fluid in middle ear (more common in < 40 years old).

39. Types of Hearing Loss • Sensorineural Hearing Loss: Occurs with impairment of organ of corti. • EX: Sustained exposure to loud noise, ototoxicity d/t drugs (aminoglycosides, antibiotics, chemo, lasix) syphilis, DM • More common in older people • Loss often mid to high frequency range. • Mixed Hearing Loss: Both types combined.

40. Technique for Ear Examination • External Ear : Inspection, Palpation • Middle Ear: Inspection • Auditory Acuity: • Whisper • Watch • Weber • Rinne

41. Technique for Ear Exam • External Ear • Inspection : Each auricle & surrounding tissue. • Note: deformities, lumps, discharge, may see tophi(deposits of uric acid crystals in helix; occurs with gout). • Palpate: External ear for tenderness, masses. should be smooth, non tender. • Otitis Externa- tender, swollen, narrowed moist external canal • Otitis Media- non tender

42. Palpate mastoid process for tenderness, swelling, bruising. • Palpate tragus.

43. Ear Canal & Drum : Otoscope • Grasp auricle & have pt. Tilt head to opposite side • Adult: Pull helix up, back & slightly out. • Insert largest speculum that ear will accommodate. • Brace hand against pts. Head • Insert otoscope into canal-down & forward (reposition head if you can’t visualize landmarks) • Inspect & identify any discharge or foreign bodies in ear canal. Note: redness, swelling. • Cerumen may obstruct view.

44. Otoscope (cont). • Inspect eardrum: note color, contour • Otitis Media: red, bulging drum, loss of landmarks, dilated blood vessels may cause spontaneous rupture & conductive hearing loss. • Identify bony landmarks: cone of light • 7 o’clock -Left Ear • 5 o’clock – Right Ear

45. Otoscope (cont). • Move speculum: view as much of drum as possible. • Identify: • Pars flaccida superiorly, • margins of pars tensa, look for perforation.

46. Auditory Acuity CN VIII • Test one ear at a time. • Ask pt. To occlude 1 ear with finger or hand. • Whisper Test: Stand 1-2 ft. away (behind pt). Exhale & whisper 2 syllable words. Ex. Baseball • Ticking Watch: Same procedure as whisper. Pt. Can hear ticking watch from 2ft. away equally. • Weber Test: (Lateralization) • Set tuning fork into light motion (vibration)

47. Auditory Acuity CN VIII • Weber Test (cont). • Place tuning fork on top of pts. head or forehead. • Ask pt. Where he hears it, one or both sides • Normal = midline • Conductive Hearing loss:Sound lateralizes to impaired ear. • Sensorineural Loss: Sound heard in good ear.

48. Auditory Acuity CN VIII • Rinne Test • Compares air & bone conduction . • Place vibrating fork at base of mastoid (bone behind ear) • When sound no longer heard- place fork @ ear canal & see if pt. can hear. • Normal: AC > BC • Conductive Hearing Loss: BC=AC or BC>AC • Sensorineural Hearing loss: Sound heard longer through air. AC>BC (Normal)