Eyes and Ears

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Eyes and Ears

• Special Senses

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Eyes

• Review the function and structure of the eye.

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A P - External Eye
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Lacrimal Apparatus
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6 Extraocular Muscles
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A P - Internal Eye
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Internal Structure

• Outer Layer
• transparent cornea covers the iris
• sclera - protects and site for attachment of
  extraocular muscles
• Middle Layer
• pupil - SNS dilates. PNS constricts,
• vitreous humor maintains shape,
• Inner Layer
• retina- extension of optic nerve, receives light
  impulses to be transmitted to occipital lobe
• Optic disc vessels converge at center,
  yellow-orange in colour, round or oval,
  physiologic cup within the disc (smaller lighter
  circle).
• Retinal vessels paired artery vein
• Fovea centralis -Macula slightly darker pigment
  at center has the sharpest and keenest vision due
  to cones and rods.

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Visual Pathways
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EYE

• Health History
• Subjective information

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Health History

• Age
• Infant/Child
• Peripheral vision intact in newborn
• Most neonates (80) are born farsighted
  (gradually decreases after 7 to 8 years)
• Macula (area of keenest vision) begins
  development by 4 months and is mature by 8
  months.
• Decreased eye cordination at birth, eye movement
  sometime sluggish to eyes

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Health History

• Age
• Middle age
• Presbyopia(difficulty with near vision)
• Hypertensive Retinopathy
• Visual acuity diminished gradually after 50 yrs

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Health History

• Age (contd)
• Elderly
• Develop cataracts (lens opacity),
• glaucoma (increased ocular pressure) and
• macular degeneration (loss of central vision)
• Entropion, ectropion
• External eye changes wrinkling and drooping
• Dry eyes- Lacrimal glands involute decreased
  tear production, dryness and burning

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Health History

• Gender- Female - dry eyes
• Race- Glaucoma (African Americans), melanona of
  eye (Caucasians)
• Common chief complaints
• Changes in visual acuity
• Pain
• Drainage
• Itching
• Dryness

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Health History

• Characteristics of chief complaints
• Location
• Quality
• Associated manifestations
• Aggravating and alleviating factors
• Setting
• Timing

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Past Health History

• Medical eye-specific
• Surgical eye-specific
• Medications
• Allergies
• Injuries and accidents
• Special needs
• Childhood illnesses

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Past Health History

• Family
• Social
• Work environment
• Health maintenance activities
• Diet
• Use of safety devices
• Health check-ups

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Assessment of the Eye

• Equipment
• Ophthalmoscope
• Penlight
• Vision charts
• Vision occluder
• General approach
• Lighting
• Environment

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Preparation for Physical Exam of the Eye

• Position the client sitting up with the head at
  your eye level
• Use orderly approach moving from the extraocular
  structures to the intraocular structure(1-6 p 348)

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Visual Acuity

• Assessment of Cranial nerve II
• Distance vision - Use Snellen Chart N 20/20
• Myopia (nearsightedness)
• Amblyopia (loss of visual acuity due to
  uncorrected strabismus crossed eyed or
  DM,alcoholism, uremia)
• Near vision - use Rosebaum or snellen card
• N reading is possible at 14 inches until late
  30-40s
• Hyperopia (farsightedness)
• Color vision
• N can id primary colors on snellen chart

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Visual Fields

• Confrontation technique
• Assess all fields
• N pt covers 1 eye, use own visual field as
  control, can see stimulus at 90temporally,
  60nasally, 50superiority, 70inferiority

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Visual Fields

• Types of defects
• (p352 image)
• Hemianopsia
• Circumferential blindness
• Unilateral blindness

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External Eye and Lacrimal Apparatus

• Eyelids- inspect
• N symmetrical eyelids, can raise eyelids
  symmetrically (CN 3)
• Abnormal findings
• Ptosis (drooping of lid)
• Exophthalmos (protrusion of eyes out of orbit)
• Entropion(turning inward or inversion of lower
  lid)
• ectropion (outward turning of lower eyelid)
• hordeolum (acute localized inflammation- internal
  conjunctival side of lid, external sty)

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External Eye and Lacrimal Apparatus

• Lacrimal apparatus- inspect, palpate
• N no enlgmt, no swelling or no redness, no
  exudate and minimal tearing. No dischrg from
  punctum apon palpation.
• Abnormal findings
• dacryoadenitis (acute inflammation of lacrimal
  gland)
• dacryocystitis - obstruction of lacrimal duct dt
  inflammation

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Extraocular Muscle Function CN III, IV, VI

• Corneal light reflex (Hirschberg test)
• Cover/uncover test
• Cardinal fields of gaze

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Extraocular Muscle Function CN III, IV, VI

• Corneal light reflex (Hirschberg test)
• N light reflex seen symmetrically in center of
  each eye
• Abnormal findings
• due extraocular muscle weakness
• extropia (outward turning of eye
• esotropia (inward turning or eye)

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Extraocular Muscle Function CN III, IV, VI

• Cover/uncover test
• N eyes are aligned, no movement of either eye
• Abnormal findings
• phoria latent misalignment of eye exists

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Extraocular Muscle Function CN III, IV, VI

• 6 Cardinal fields of gaze
• Nboth eyes move smoothly and symmetrically in 6
  fields of gaze converge on the object as it
  converges on then nose
• note nystagmus involuntary movement
• Abnormal findings
• deviations from N

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Anterior Segment Structures

• Conjunctiva- inspect
• N transparent, sm bld vessels, white
• Abnormal findings
• conjunctiva, edema, lesions, foreign bodies,
• Sclera -inspect
• N white , sm bld vessels
• Abnormal findings
• jaundice, blue (osteogenesis imperfecta-thinning
  of sclera)
• Cornea- inspect with penlight
• N corneal surface is moist, shiny
• Abnormal findings
• presence of discharge, cloudiness, opacities,
  irregularities

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Anterior Chamber

• Iris
• Inspect the iris for color, nodules, vascularity
• Neven color or mosaic, smooth no vascularity
• Shine light obliquely through the anterior
  chamber from lateral side towards nasal chamber
• Nthe entire iris will be illuminated
• Abnormal findings
• hyphema (bleeding into iris dt trama)

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Anterior Chamber

• Pupil (CN III)
• darken room note size and shape of pupil, move
  penlight from side to front of eye, observe
  pupillary reaction
• NPERRLA
• N direct light flex (pupil constrict with light)
• N Consensual light reflex (move penlight in
  front of one eye and observe other eye for
  pupillary constriction)
• N Accommodation (pupils constrict as converge
  onto closer object)
• Abnormal findings
• anisocoria - sm diff in pupil size
• oculomotor nerve damage- a fixed and dilated
  pupil is seen (see pg 363)

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Anterior Chamber

• Lens
• shine penlight directly into pupil , note color
  of lens
• N transparent in color
• Abnormal findings
• cataract- cloudiness or opacity in the lens

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Posterior Segment Structures

• Assessment techniques
• use of ophthalmoscope

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Posterior Segment Structures

• Retinal structures
• instruct pt to look at distant object
• use ophthalmoscope, shine into each eye
• N Red Reflex present (pupil appears red through
  ophthalmoscope)
• N observe intact optic disc (on nasal side of
  retina by following any retina vessel centrally)
• Abnormal findings
• absent red reflex - dt cataract

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Posterior Segment Structures

• Macula
• move ophthalmoscope towards ear (temporal lobe)
  and observe for black circle around fovea.
• N macula is darker, avascular area with a
  pinpoint reflective center known as the fovea
  centralis

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Gerontological Variations

• Changes in visual acuity
• Presbyopia
• Cataracts
• Macular degeneration
• Glaucoma

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Review of Normal Findings

• Visual acuity 20/20
• Near vision acuity at 14 inches
• Able to identify all six colors
• Visual fields intact

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Review of Normal Findings

• Eyelids symmetrical no drooping, infections, or
  tumors
• No enlargement, swelling, or redness of the
  lacrimal apparatus
• Light reflex is symmetrical in the center of each
  cornea

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Review of Normal Findings

• Eyes aligned on cover/uncover test
• Extraocular eye movements intact in all six
  fields
• Bulbar conjunctiva is transparent
• Palpebral conjunctiva is pink and moist

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Review of Normal Findings

• Sclera are white, without exudate, lesions, or
  foreign bodies
• Cornea is moist, shiny, without discharge,
  cloudiness, or opacities
• Entire iris is illuminated
• Color of iris is evenly distributed

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Review of Normal Findings

• Pupils are deep, black, round, and of equal
  diameter
• Pupil size is 26 mm
• Lens is transparent
• Red reflex is present
• Optic disc is pinkish orange
• Macula is darker, avascular

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Ears

• Review the function and structure of the Ear

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Anatomy and Physiology of the Ear

• Three sections
• External ear
• Middle ear
• Inner ear
• External ear
• Auricle or pinna

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External, Middle, Inner Ear Structure
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External Ear Structure
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Middle Sar Structures

• Air filled cavity
• Tympanic membrane
• Ossicles ( 3 tiny bones - malleus, incus, stapes)
• 2 muscles involved in movement of ossicles-
  tensor tympani- pulls inward, stapedius - pulls
  outwards
• Eustachian tube - connected to nasopharynx by the
  auditory canal (relieves air pressure within the
  middle cavity) see next slide

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Inner Ear Structures

• Controls hearing and equilibrium/balance
• closed fluid-filled system of interconnecting
  tubes called the Labyrinth
• cochlea (snail shape structure containing
  perilymph endolymph which vibrate and stimulate
  vestibulocochlear nerve CNVIII)
• semicircular canals (provide balance and
  equilibrium for the body)
• vestibule (btwn cochlea semicircular canals)
• Frequency range of 2020,000 Hz
• Decibel range 0140

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Pathways of Hearing

• Air Conduction (AC) most efficient.
• ACgtBC
• Bone Conduction (BC)
• See OH

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Ears

• Health History
• Subjective Data

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Ears-Subjective DataNote the following

• Earache
• Infections
• Discharge (otorrhea)
• Hearing loss
• Environmental noise
• Tinnitus
• Vertigo
• Self care behaviours

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What further information would you gather if the
client is an infant and children?

• Ear infections (how many, 1st one?)
• Parent 1. Does the child seem to have
  hearing loss?
• 2. Does the child put objects in the
  ears?

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Ears Physical Examination

• Objective Data

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Equipment

• Otoscope
• Tuning fork

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Assessment of the Ear

• Consists of three parts
• Auditory screening(CN VIII)
• Inspection and palpation of external ear
• Otoscopic assessment

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Auditory Screening

• Voice-whisper test
• instruct pt to occlude 1 ear with finger
• stand 2 feet behind the other ear and whisper
• ask pt to repeat whispered words
• N able to repeat words whispered at a distance
  of 2 feet

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Auditory Screening- Tuning fork tests

• Weber test
• N able to hear sound equally in both ears
• Abnormality
• Determines whether hearing loss is conductive or
  sensorineural

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Auditory Screening- Tuning fork tests

• Rinne test
• Normal finding air conduction gt bone conduction
• Abnormality
• Determines whether hearing loss is conductive or
  sensorineural

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Hearing Loss

• Central deafness occurs with pathologic
  conditions above the junction of the acoustic
  nerve and the brain stem. E.G. brain tumor,
  vascular changes which deprive the inner ear of
  blood supply, CVA.
• Conduction deafness mechanical dysfunction of
  the external or middle ear. Partial loss (must
  increase amplitude). E.G. impacted cerumen,
  foreign bodies, perforated tympanic membrane, pus
  in middle ear.
• Sensorineural deafness pathology of the inner
  ear, CN VIII or auditory areas of the cerebral
  cortex. E.G. presbycusis (gradual nerve
  deterioration), ototoxic drugs (affect the hair
  cells in the cochlea)

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External Ear

• Inspection Palpate
• Note position, size, color, and shape
• N flesh color, top of ear to outer canthus of
  eye, cerumen is moist does not obscure the
  tympanic membrane, no foreign bodies, redness,
  drainage, deformities, nodules, or lesions
• Abnormal findings
• Pale, red, cyanotic
• Small-size or large-size ears
• Purulent drainage
• Clear or bloody drainage
• Hematoma behind ear over mastoid
• Pain or tenderness on palpation

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Otoscopic Assessment

• Inspect both external ear canal using otoscope
• N No redness, swelling, tenderness, lesions,
  drainage, foreign bodies
• Tympanic membrane is pearly gray with
  well-defined landmarks
• Light reflex present at 5 oclock in right ear
  and 7 oclock in left ear
• Tympanic membrane moves when patient blows
  against resistance
• Abnormal findings
• Chalky patches on tympanic membrane
• Severe pain
• Redness, swelling, narrowing, pain
• Drainage
• Hard, dry, very dark yellow cerumen
• Reddened tympanic membrane

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Ear Abnormalities

• Acute Otitis Media
• tympanic membrane is red with decreased
  motility,and possible bulging due inflammation of
  middle ear

• Chronic Acute Otitis Externa
• redness, swelling, narrowing and pain of external
  ear, drainage present due to inflammation of
  external ear

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Risk Factors for Otitis Media

• Less than 2 years of age
• Frequent upper respiratory infections
• Cold weather
• Male gender
• Caucasians, Native Americans, Alaska natives
• Family history
• Smoky environment
• Bottle fed
• Down syndrome

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Ear Abnormalities

• Tympanic Membrane Perforation
• due to untreated ear infection secondary to
  increasing pressure or trama to the ear canal.

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Equilibrium Abnormalities

• Labyrinth becomes inflammed and sends the wrong
  information to the brain.
• Which develops into what we call..
• Vertigo staggering gait, strong spinning,
  whirling sensation.

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Developmental Considerations

• Infants/Children
• Rubella in 1st trimester can damage the organ of
  Corti and impair hearing
• Eustachian tube is shorter and wider, position is
  more horizontal than the adults
• Greater risk for ear infection
• External auditory canal is shorter and sloped is
  opposite to the adults

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Developmental Considerations

• Aging Adult
• Cilia becomes coarse and stiff
• Cerumen is dryer and impaction is a common
  reversible cause of hearing loss.
• Presbycusis occurs with aging 50s (nerve
  degeneration in the inner ear or auditory nerve)
• 70s takes longer to process sensory input and
  to respond to it.

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Transcultural Considerations

• Otitis Media (OM) incidence and severity
  increased in Native Americans, Alaskan and
  Canadian Inuits Hispanics.
• Also increased in premature infants and those
  with Down Syndrome, and bottle fed babies in
  supine position.