1. EyesEyes

2. External AnatomyExternal Anatomy
Sensory Organ for vision
-Situated in bony, orbital cavity for
protection
– Eyelids= shades that add protection form
injury, strong light , dust
– Eyelashes= hairs to filter dust & dirt

3. External
AnatomyExternal
Anatomy

4. Limbus – border b/t the cornea & sclera
Palpebral fissures – elliptical open space b/t
lids
Canthus- corners of the eye where the lids
meet, inner & outer
Caruncle – sm. Fleshy mass containing
sebaceous glands at inner canthus

5.  Within the upper eyelid
– Tarsal plates, connective tissue gives upper
lid shape
– Meibomian glands, in the plates, lubricate the
lids, stops overflow of tears, airtight seal
when lids closed

6. Exposed part of the eye
– Conjunctiva, folded envelope b/t eyelids &
eyeball
 thin mucous membrane, transparent protective
covering of the exposed part of the eye.
 Palpebral conjunctiva lines the lids, is clear but has
sm .bld. Vessels
 Bulbar conjunctiva is over eyeball, white sclera
show through, merges at limbus with cornea

7. Cornea – clear, covers & protects iris &
pupil

9.  Lacrimal apparatus – irrigates conjunctiva
& cornea
– 3 parts
A. Lacrimal gland, upper, outer corner of eye = tears
B. Puncta= inner canthus, tear drainage
C. Nasolacrimal duct= allows tears to drain from
puncta to nasolacrimal sac. Tears then empty into
the inferior meatus of the nose

11. Extraoccular musclesExtraoccular muscles
 6 muscles
– Attach eyeball to orbit
– Straight and rotary movement
– Four straight muscles
1. Superior rectus
2. Inferior rectus
3. Lateral rectus
4. Medial rectus

12.  Two slanting/ oblique muscles
5. Superior
6. Inferior
Humans have a Binocular, single – image
visual system – Eyes normally move as a
pair

13. • Eye movement stimulated by Cranial
Nerves
• III Oculomotor
• IV Trochlear
• VI Abducens

16. Internal AnatomyInternal Anatomy
 The eye has 3 layers, the outer & inner
layer can be viewed using opthalmascope
1. Sclera (outer layer) tough, protective,
white covering connects with the -
 Cornea – transparent, protects pupil &
iris – helps focus light on retina

17. 2. Middle layer
 Choroid – dark pigmentation to prevent
internal light reflection, supplies bld. to retina
 Pupil – PERRLA
 Lens – biconvex disc, transparent, thickness
controlled by ciliary body, bulges = near;
flattens = distant
 Anterior chamber – posterior to cornea,
anterior to iris & lens, has aqueous humor
supplies nutrients & drains wastes

18. 3. Inner layer – Retina – visual receptive
layer – light waves changed to nerve
impulses
 Retinal structures
 Optic disc – retinal fibers meet & form optic
nerve, nasal side of retina, creamy yellow orange
to pink, round or oval shape, physiologic cup
inside the disc for bld.vessels to enter & exit
 Retina vessels – paired arteries & veins

19.  Macula – temporal side of fundus, darker pigmented
region, surround the fovea centralis
 Fovea Centralis- area of sharpest & keenest vision,
Very sensitive to light

21. Visual Pathways & FieldsVisual Pathways & Fields
 Objects reflect light
 Rays refracted by cornea, aqueous humor, lens,
vitreous body and onto retina.
 Light stimulus is changed to nerve impulses, travel
thru optic nerve to visual cortex in occipital lobe
 Image on retina is upside down & reversed. At the
optic chiasm retinal fibers cross over. Right side
of brain looks at left side of world.

23. Visual reflexesVisual reflexes
 Pupillary light reflex – bright light = constriction
– Direct light reflex
– Consensual light reflex
 Fixation – ability to track an object & keep image
on the fovea, can be impaired by drugs, alcohol,
fatigue & inattention
 Accomodation – for near vision = pupil
constriction & convergence of eyes

26. Subjective dataSubjective data
Vision difficulty
Pain
Strabismus, diplopia
Redness, swelling
Watering, discharge
Past history ocular problems
Glaucoma

27. Glasses/ contacts
Medications
Vision loss- coping mechanisms
Self–care behaviors

28. Objective dataObjective data
The Physical ExamThe Physical Exam
 Preparation
– Position- sitting, head at eye level
 Equipment
– Snellen eye chart- visual acuity
– Handheld visual screener-near vision
– Opaque card
– Penlight
– Applicator stick
– Ophthalmoscope

29. Test visual acuityTest visual acuity
Snellen eye chartSnellen eye chart
 Stand 20 ft. from chart
 Glasses / contacts (Document )
 Remove eye wear, retest
 Normal visual acuity is 20/20 – top # is distance
person is standing from the chart
 Vision 20/30 refer to opthalmologist or
optometrist
 If unable to see largest letters, move to 10 feet –
record as 10/200

30. Test for near visionTest for near vision
Vision screener
People > 40yrs or difficulty reading
Test each eye with glasses
Hold card 14in. from eyes
Normal result 14 / 14
Test using any available reading material if
no card available

31. Presbyopia is a normal physiological
change in near vision occurs with aging =
note if the person moves the card farther
away

32. Test visual fieldsTest visual fields
Confrontation testConfrontation test
Compares peripheral vision with a tester
who has normal peripheral vision
2 ft. apart, eye level
Tester & client cover opposite eyes
Tester advances finger in the periphery
– Superiorly ( 50 degrees )
– Inferiorly ( 70 degrees )
– Temporally ( 90 degrees )

34. Inspect Extraoccular MuscleInspect Extraoccular Muscle
FunctionFunction
Corneal light reflex
Cover test
Diagnostic positions test
– 6 Cardinal Positions of Gaze

35. Inspect Extraocular MuscleInspect Extraocular Muscle
FunctionFunction
Corneal Light Reflex ( The Hirschberg
Test) assesses parallel eye alignment
– Shine light toward person’s eyes
– Tell to stare directly ahead
– Hold light 12 in. away
– Light should reflect on both corneas in same
spot

36.  Cover Test- detects deviated alignment
– Stare straight at examiner’s nose
– Cover 1 eye of the person being examined with opaque
card
– Normally the uncovered eye should maintain a steady,
fixed gaze
– Covered eye- should stare straight ahead when covered
& then uncovered. If muscle weakness exists the
covered eye will relax and then jump to fixed position
when uncovered..

37. Diagnostic Positions TestDiagnostic Positions Test
 6 cardinal positions of gaze –
– Determines muscle weakness during movement
– Person must hold head steady
– Follow movement of object (examiner’s finger, pen etc)
only with eyes
– Hold object 12 in. from person
– Move thru each position, clockwise, hold , then back to
center
– Normal response= parallel tracking with both eyes

39. During this test be aware of Nystagmus-fine
jerky movement seen around the iris
Mild nystagmus in extreme lateral gaze is
normal but not normal in any other position

40. Inspect External StructuresInspect External Structures
 General – movement & facial expression
(squinting?)
 Eyebrows – 2(bilateral), symmetrical (look the
same; move the same)
 Eyelids & Lashes – present, approximate when
closed, no redness, swelling, discharge, lesions?
 Eyeballs- alignment, ? Protrusion? Sunken?
 Conjunctiva & Sclera – moist, glossy, clear, white
sclera

41. Eversion of the upper eyelid FYI – we will
not do this examine in lab see pg. 312 for
technique – usually done for complaint of
eye pain due to foreign body

44. Lacrimal Apparatus
– Person looks down
– Using thumbs, slide outer part of upper lid
along bony orbit
– Note redness or swelling
– Press index finger against lacrimal sac at inner
canthus
– Normal response is slight eversion of lower lid,
no tearing or discharge

46. Anterior Eyeball StructuresAnterior Eyeball Structures
Cornea & lens
Iris & pupil
– Size & shape
– Pupillary light reflex
– Accommodation

47. Cornea & LensCornea & Lens
Shine light from side across cornea
Check smoothness, clarity
Normally no opacities

48. Iris and PupilIris and Pupil
Iris = flat, round, regular, even color
bilaterally.
Pupils = PERRLA
– Resting size norm = 3-5mm
– 5% population have pupils of 2 diff. Sizes
called Anisocoria

49. Pupillary Light Reflex
– Darken room
– Person gazes straight ahead
– Advance light from the side
 Direct light reflex
 Consensual light reflex
– Measure pupil size before & after light reflex
– Measurement R3/1 L3/1 =both pupils measure
3mm in resting state & 1mm with light

50. Accomodation
– focus on distant object -dilatation of pupils
– Shift gaze to near object – pupils constrict &
converge
Record the normal response to these tests as
 PERRLA = Pupils Equal, Round, React
to Light and Accomodation

51. Ocular Fundus (internalOcular Fundus (internal
surface of retina)surface of retina)
Use Opthalmoscope- try keeping both eyes
open- practice looking at a ring on your
finger. Become familiar with the instrument
before you examine your partner’s eyes

52. Diopter of opthalmoscope
– Black numbers = +diopter, focus on near
objects
– Red numbers = - diopter, focus on further
objects
Use ophthalmoscope in darkened room =
dilates pupils

53. Remove examiner’s and person’s
eyeglasses but contact lenses may be left in.
Select lg. White aperture light
Person should focus on a distant object and
try & remain still
Examiner hold ophthalmoscope in Right
hand to right eye to eamine person’s right
eye

54. Begin 10in away at 150
lateralangle &
advance
Keep sight of red reflex
Adjust lens to +6 as you advance till your
foreheads almost touch. Adjust diopter to
focus.
– Normal vision set at 0. Nearsighted use red #s.
Farsighted use black.

56. Retinal backgroundRetinal background
Light – dark red normally
Note Lesions
– Size, shape, color, distribution

57. Macula & Fovea CentralisMacula & Fovea Centralis
Last in Funduscopic exam
– 1 DD in size
– Darker than rest of fundus
– Foveal light reflex
– Exam last

59. Retinal VesselsRetinal Vessels
Arteries Veins
COLOR Light red Dark red
SIZE Smaller 2/3 to
4/5 diam. Of
veins
Larger
LIGHT
REFLEX
Bright Inconspicuous
absent

60. Read Aging & DevelopmentalRead Aging & Developmental
ConsiderationsConsiderations
Review Abnormalities of the Eyes

61. 3 most common causes of3 most common causes of
decreased visual functioning indecreased visual functioning in
the older adultthe older adult
Cataract (lens opacity)
Glaucoma (increased ocular pressure) = loss
of peripheral vision
Macular degeneration (breakdown of cells
in the macula lutea) = loss of central vision