Diagnostic Evaluation DIRECT OPHTHALMOSCOPY A direct ophthalmoscope is a hand-held

instrument with various plus and minus lenses. The lenses can be rotated into place, enabling the
examiner to bring the cornea, lens, and retina into focus sequentially. The examiner holds the
ophthalmoscope in the right hand and uses the right eye to examine the patients right eye. The
examiner switches to the left hand and left eye when examining the patients left eye. During this
examination, the room should be darkened, and the patients eye should be on the same level as
the examiners eye. The patient and the examiner should be comfortable, and both should breathe
normally. The patient is given a target to gaze on and is encouraged to keep both eyes open and
steady. When the fundus is examined, the vasculature comes into focus first. The veins are larger
in diameter than the arteries. The examiner should focus on a large vessel and then follow it
toward the midline of the body, which leads to the optic nerve. The central depression in the disc
is known as the cup. The normal cup is about one third of the disc. The size of the physiologic
optic cup should be estimated. Are the disc margins sharp, or are they blurred? Do the veins have a
silvery or coppery appearance? The periphery of the retina can be examined by having the patient
shift his or her gaze. The last area of the fundus to be examined should be the macula, because this
area is the most light sensitive. The retina of a young person often has a glistening effect, which is
sometimes referred to as a cellophane reflex. The healthy fundus should be free of any lesions.
The examiner should look for intraretinal hemorrhages, which may appear as red smudges or, if
the patient has hypertension, may look somewhatflame shaped. Lipid may be present in the retina
of patients with hypercholesterolemia or diabetes. This lipid has a yellowish appearance. Soft
exudates that have a fuzzy, white appearance (ie, cotton-wool spots) should be noted. The
examiner looks for microaneurysms, which look like little red dots, and nevi. Drusen (ie, small,
hyaline, globular growths), commonly found in macular degeneration, appear to be yellowish
areas with indistinct edges. Small drusen have a more distinct edge. The examiner should sketch
the fundus and document any abnormalities. INDIRECT OPHTHALMOSCOPY The indirect
ophthalmoscope is an instrument commonly used by the ophthalmologist. It produces a bright and
intense light. The light source is affixed with a pair of binocular lenses, which are mounted on the
examiners head. The ophthalmoscope is used with a hand-held, 20-diopter lens. This instrument
enables the examiner to see larger areas of the retina, although in an unmagnified state. SLITLAMP EXAMINATION The slit lamp is a binocular microscope mounted on a table. This
instrument enables the user to examine the eye with magnification of 10 to 40 times the real
image. The illumination can be varied from a broad to a narrow beam of light for different parts of
the eye. For example, by varying the width and intensity of the light, the anterior chamber can be
examined for signs of inflammation. Cataracts may be evaluated by changing the angle of the
light. When a hand-held contact lens, such as a three-mirror lens, is used with the slit lamp, the
angle of the anterior chamber may be examined, as may the ocular fundus.
COLOR VISION TESTING The ability to differentiate colors has a dramatic effect on the
activities of daily living. For example, the inability to differentiate between red and green can
compromise traffic safety. Some careers (eg, commercial art, color photography, airline pilot,
electrician) may be closed to people with significant color deficiencies. The photoreceptor cells
responsible for color vision are the cones, and the greatest area of color sensitivity is in the
macula, the area of densest cone concentration. A screening test, such as the polychromatic plates
discussed in the next paragraph, can be used to establish whether a persons color vision is within
normal range. Color vision deficits can be inherited. For example, red/green color deficiencies are
inherited in an X-linked manner, affecting approximately 8% of men and 0.4% of women.
Acquired color vision losses may be caused by medications (eg, digitalis toxicity) or pathology
such as cataracts. A simple test, such as asking a patient if the red top on a bottle of eye drops
appears redder to one eye than the other, can be an effective tool. Changes in the appreciation of
the gradations of the color red can indicate macular or optic nerve disease. Because alteration in
color vision is sometimes indicative of conditions of the optic nerve, color vision testing is often
performed in a neuro-ophthalmologic workup. The most common color vision test is performed
using Ishihara polychromatic plates. These plates are bound together in a booklet. On each plate of
this booklet are dots of primary colors that are integrated into a background of secondary colors.
The dots are arranged in simple patterns, such as numbers or geometric shapes. Patients with
diminished color vision may be unable to identify the hidden shapes. Patients with central vision
conditions (eg, macular degeneration) have more difficulty identifying colors than those with

peripheral vision conditions (eg, glaucoma) because central vision identifies color. AMSLER
GRID The Amsler grid is a test often used for patients with macular problems, such as macular
degeneration. It consists of a geometric grid of identical squares with a central fixation point. The
grid should be viewed by the patient wearing normal reading glasses. Each eye is tested
separately. The patient is instructed to stare at the central fixation spot on the grid and report any
distortion in the squares of the grid itself. For patients with macular problems, some of the squares
may look faded, or the lines may be wavy. Patients with age-related macular degeneration are
commonly given these Amsler grids to take home. The patient is encouraged to check them
frequently, as often as daily, to detect any early signs of distortion that may indicate the
development of a neovascular choroidal membrane, an advanced stage of macular degeneration
characterized by the growth of abnormal choroidal vessels. ULTRASONOGRAPHY Lesions in
the globe or the orbit may not be directly visible and are evaluated by ultrasonography. A probe
placed against the eye aims the beam of sound. High-frequency sound waves emitted from a
special transmitter are bounced back from the lesion and collected by a receiver that amplifies and
displays the sound waves on a special screen. Ultrasonography can be used to identify orbital
tumors, retinal detachment, and changes in tissue composition. Fundus photography is a technique
used to detect and document retinal lesions. The patients pupils are widely dilated during the
procedure, and visual acuity is diminished for about 30 minutes due to retinal bleaching by the
intense flashing lights. FLUORESCEIN ANGIOGRAPHY Fluorescein angiography evaluates
clinically significant macular edema, documents macular capillary nonperfusion, and identif ies
retinal and choroidal neovascularization(ie, growth of abnormal new blood vessels) in age-related
macular degeneration. It is an invasive procedure in which fluorescein dye is injected, usually into
an antecubital area vein. Within 10 to 15 seconds, this dye can be seen coursing through the retinal
vessels. Over a 10-minute period, serial black-and-white photographs are taken of the retinal
vasculature. The dye may impart a gold tone to the skin of some patients, and urine may turn deep
yellow or orange. This discoloration usually disappears in 24 hours. TONOMETRY Tonometry
measures IOP by determining the amount of force necessary to indent or flatten (applanate) a
small anterior area of the globe of the eye. The principle involved is that a soft eye is dented more
easily than a hard eye. Pressure is measured in millimeters of mercury (mm Hg). High readings
indicate high pressure; low readings, low pressure. The three most common types of tonometers
are indentation, applanation, and noncontact. The procedure is noninvasive and is usually painless.
A topical anesthetic eye drop is instilled in the lower conjunctival sac, and the tonometer is then
used to measure the IOP. GONIOSCOPY Gonioscopy visualizes the angle of the anterior chamber
to identify abnormalities in appearance and measurements. The gonioscope uses a refracting lens
that can be a direct or indirect lens. The indirect lens views the mirror image of the opposite
anterior chamber angle and can be used only with a slit lamp. The direct gonioscopic lens gives a
direct view of the angle and its structures. PERIMETRY TESTING Perimetry testing evaluates the
field of vision. A visual field is the area or extent of physical space visible to an eye in a given
position. Its average extent is 65 degrees upward, 75 degrees downward, 60 degrees inward, and
95 degrees outward when the eye is in the primary gaze (ie, looking directly forward). It is a
threedimensional contour representing areas of relative retinal sensitivity. Visual acuity is sharpest
at the very top of the field and declines progressively toward the periphery. Visual field testing (ie,
perimetry) helps to identify which parts of the patients central and peripheral visual fields have
useful vision. It is most helpful in detecting central scotomas(ie, blind areas in the visual f ield) in
macular degeneration and the peripheral field defects in glaucoma and retinitis pigmentosa. The
two methods of perimetric testing are manual and automated perimetry. Manual perimetry
involves the use of moving (kinetic) or stationary (static) stimuli or targets. An example of kinetic
manual perimetry is the tangent screen. A tangent screen is a black felt material mounted on a wall
that has a series of concentric circles dissected by straight lines emanating from the center. It tests
the central 30 degrees of the visual field. Automated perimetry uses stationary targets, which are
harder to detect than moving targets. In this test, a computer projects light randomly in different
areas of a hollow dome while the patient looks through a telescopic opening and depresses a
button whenever he or she detects the light stimulus. Automated perimetry is more accurate than
manual perimetry. Impaired Vision REFRACTIVE ERRORS In refractive errors, vision is
impaired because a shortened or elongated eyeball prevents light rays from focusing sharply on
the retina. Blurred vision from refractive error can be corrected with eyeglasses or contact lenses.
The appropriate eyeglass or contact lens is determined by refraction. Refraction ophthalmology

consists of placing various types of lenses in front of the patients eyes to determine which lens
best improves the patients vision. The depth of the eyeball is important in determining refractive
error (Fig. 58-6). Patients for whom the visual image focuses precisely on the macula and who do
not need eyeglasses or contact lenses are said to have emmetropia(normal vision). People who
havemyopiaare said to be nearsighted. They have deeper eyeballs; the distant visual image focuses
in front of, or short of, the retina. Myopic people experience blurred distance vision. When people
have a shorter depth to their eyes, the visual image focuses beyond the retina; the eyes are
shallower and are called hyperopic. People with hyperopiaare farsighted. These patients
experience near vision blurriness, whereas their distance vision is excellent. Another important
cause of refractive error is astigmatism, an irregularity in the curve of the cornea. Because
astigmatism causesa distortion of the visual image, acuity of distance and near vision can be
decreased. Eyeglasses with a cylinder correction or rigid or soft toric contact lenses are
appropriate for these patients. LOW VISION AND BLINDNESS Low visionis a general term
describing visual impairment that requires patients to use devices and strategies in addition to
corrective lenses to perform visual tasks. Low vision is defined as a best corrected visual acuity
(BCVA) of 20/70 to 20/200 (Table 58-1). Blindnessis defined as a BCVA of 20/400 to no light
perception. The clinical definition of absolute blindness is the absence of light perception. Legal
blindness is a condition of impaired vision in which an individual has a BCVA that does not
exceed 20/200 in the better eye or whose widest visual field diameter is 20 degrees or less. This
definition does not equate with functional ability, nor does it classify the degrees of visual
impairment. Legal blindness ranges from an inability to perceive light to having some vision
remaining. An individual who meets the criteria for legal blindness may obtain government
financial assistance. There are more than 1,046,000 legally blind Americans who are 40 years of
age or older. African Americans have a higher rate of blindness than do Caucasians (Preshel &
Prevent Blindness America, 2002). Impaired vision is accompanied by difficulty in performing
functional activities. Individuals with visual acuity of 20/80 to 20/100 with a visual field
restriction of 60 degrees to greater than 20 degrees can read at a nearly normal level with optical
aids. Their visual orientation is near normal but requires increased scanning of the environment
(ie, systematic use of head and eye movements). In a visual acuity range of 20/200 to 20/400 with
a 20-degree to greater than 10-degree visual field restriction, the individual can read slowly with
optical aids. His or her visual
orientation is slow, with constant scanning of the environment; individuals in this category have
travel vision. Individuals with hand motion vision or no vision may benefit from the use of
mobility devices (eg, cane, guide dog) and should be encouraged to learn Braille and to use
computer aids. The most common causes of blindness and visual impairment among adults 40
years of age or older are diabetic retinopathy, macular degeneration, glaucoma, and cataracts,
(Preshel & Prevent Blindness America, 2002). Macular degeneration is more prevalent among
Caucasians, whereas glaucoma is more prevalent among African Americans. Age-related changes
in the eye are described in Table 58-2. Low-Vision Assessment The assessment of low vision
includes a thorough history and the examination of distance and near visual acuity, visual field,
contrast sensitivity, glare, color perception, and refraction. Specially designed, low-vision visual
acuity charts are used to evaluate patients. PATIENT INTERVIEW During history taking, the
cause and duration of the patients visual impairment are identified. Patients with retinitis
pigmentosa, for example, have a genetic abnormality. Patients with diabetic macular edema
typically have fluctuating visual acuity. Patients with macular degeneration have central acuity
problems. Central acuity problems cause difficulty in performing activities that require finer
vision, such as reading. People with peripheral field defects have more difficulties with mobility.
The patients customary activities of daily living, medication regimen, habits (eg, smoking),
acceptance of the physical limitations brought about by the visual impairment, and realistic
expectations of low-vision aids must also be identified. These aspects of the patients activities are
important indicators for planning care that will include guidelines for safety and referrals to social
services.
assessment
Contrast-sensitivity testing measures visual acuity in different degrees of contrast. The initial test
may take the form of simply turning on the lights while testing the distance acuity. If the patient

can read better with the lights on, the patient can benefit from magnification. Glare testing enables
the examiner to obtain a more realistic evaluation of the patients ability to function in his or her
environment. Glare can reduce a persons ability to see, especially in patients with cataracts.
Devices that test glare, such as the Brightness Acuity Tester, produce three degrees of bright light
to create a dazzle effect while the patient is viewing a target, such as Snellen letters on the wall.
The lights have been calibrated to imitate certain objects that create glare, such as the brightness
of a cars headlights at night. Medical Management Managing low vision involves magnification
and image enhancement through the use of low-vision aids and strategies and through referrals to
social services and community agencies serving the visually impaired. The goals are to enhance
visual function and assist patients with low vision to perform customary activities. Low-vision
aids include optical and nonoptical devices (Table 58-3). The optical devices include convex lens
aids, such as magnifiers and spectacles; telescopic devices; anti-reflective lenses that diminish
glare; and electronic reading systems, such as closed-circuit television and computers with large
print. Continuing advances in computer software provide very useful products for patients with
low vision. Scanners teamed with the appropriate software enable the user to scan printed data into
the computer and have it read by computer voice or to increase the magnification for reading.
Magnifiers can be hand-held or attached to a stand with or without illumination. Telescopic
devices can be spectacle telescopes or clip-on or hand-held loupes. Nonoptical aids include largeprint publications and a variety of writing aids. The Internet continues to expand, and a tele
phone system has been developed that allows access to the Internet and e-mail using voice
commands (see Chart 58-2). Strategies that enhance the performance of visual tasks include
modification of body movements and illumination and training for independent living skills. Head
movements and positions can be modified to place images in functional areas of the visual field.
Illumination is an added feature in magnifiers. Adjusting the lighting helps with reading and other
activities. Simple optical and nonoptical aids are available in low-vision clinics.Referrals to
community agencies may be necessary for lowvision patients living alone who are unable to selfadminister their medications. Community agencies, such as The Lighthouse National Center for
Vision and Aging, offer services to low-vision patients that include training in independent living
skills and the provision of occupational and recreational activities and a wide variety of assistive
devices for vision enhancement and orientation and mobility. VISION RESTORATION FOR THE
BLIND Ophthalmologists have worked toward visual restoration for blind individuals for years,
and computer technology now provides opportunities for restoring sight. For example, a
multipleunit artificial retina chipset (MARC) has been devised for implanting within the eye. The
MARC can be enabled to receive signals from an external camera mounted in a glasses frame. The
acquired image is wirelessly transmitted to the chip, which provides a type of artificial vision and
which, with training, allows the patient to achieve some useful vision. Although the device is still
experimental, some work has been done with patients who have lost vision from retinitis
pigmentosa and age-related macular degeneration (Humayan et al., 1999). Nursing Management
Coping with blindness involves three types of adaptation: emotional, physical, and social. The
emotional adjustment to blindness or severe visual impairment determines the success of the
physical and social adjustments of the patient. Successful emotional adjustment means acceptance
of blindness or severe visual impairment. PROMOTING COPING EFFORTS Effective coping
may not occur until the patient recognizes the permanence of the blindness. Clinging to false
hopes of regaining vision hampers effective adaptation to blindness. A newly blind patient and his
or her family members (especially those who live with the patient) undergo the various steps of
grieving: denial and shock, anger and protest, restitution, loss resolution, and acceptance. The
ability to accept the changes that must come with visual loss and willingness to adapt to those
changes influence the successful rehabilitation of the patient who is blind. Additional aspects to
consider are value changes, independencedependence conflicts, coping with stigma, and learning
to functionin social settings without visual cues and landmarks. People who are blind detect and
incorporate less information about their environment than do sighted people. The blind person
relies on egocentric, sequential, and positional information, which centers on the person and his or
her relationship to the objects in the environment. For example, the topographic concepts of front,
back, left, right, above, and below and measures of distances are most useful in determining the
exact position, sequence, and location of objects in relation to the person who is blind. Although
their basis of information may be different from that of sighted people, people who are blind can

comprehend spatial concepts. The goal of orientation and mobility training is to foster
independence in the environment. Training may be accomplished by using auditory and tactile
cues and by providing anticipatory information. Having a concept of the spatial composition of the
environment (ie, cognitive map) enhances independence of those who are blind. Orientation and
mobility training programs are offered by community agencies serving the blind or visually
impaired. Training includes using mobility devices for travel, the long cane, electronic travel aids,
dog guides, and orientation aids. The basic orientation and mobility techniques used by a sighted
person to assist a person who is blind or visually impaired to ambulate safely and efficiently are
called sighted-guide techniques. Spatial Orientation and Mobility in Institutional Settings.A blind
or severely visually impaired patient requires strategies for adapting to the environment. The
monocular postoperative patient whose functioning eye is restricted by a surgical patch or by
postoperative inflammation requires early ambulation just like any postoperative patient. The
activities of daily living, such as walking to a chair from a bed, require spatial concepts. The
patient needs to know where he or she is in relation to the rest of the room, to understand the
changes that may occur, and how to approach the desired location safely. This requires a
collaborative effort between the patient and the nurse, who serves as the sighted guide. Patients
whose visual impairment results from a chronic progressive eye disorder, such as glaucoma, have
better cognitive mapping skills than the suddenly blinded patient. They have developed the use of
spatial and topographic concepts early and gradually; hence, remembering a room layout is easier
for them. Suddenly blinded patients have more difficulty in adjusting; and emotional and
behavioral issues of coping with blindness may hinder their learning. These patients require
intensive emotional support. The nurse must assess the degree of physical assistance the patient
with a visual deficit requires and communicate this to other health care personnel. The food trays
composition is likened to the face of a clock. For example, the main plate may be described as
being at 12 oclock or the coffee cup at 3 oclock. In the hospital, the bedside table and the call
button must always be within reach. The parts of the call button are explained, and the patient is
encouraged to touch and press the buttons or dials until the activity is mastered. The patient must
be familiarized with the location of the telephone, water pitcher, and other objects on the bedside
table. All articles and furniture must be replaced in the same positions. Introducing oneself on
entering a patients room is always a polite gesture and helps in the orientation of a blind patient.
The nurse should be aware of the importance of technique in providing physical assistance,
developing independence, and ensuring safety. The readiness of the patient and his or her family to
learn must be assessed before initiating orientation and mobility training.
PROMOTING HOME AND COMMUNITY-BASED CARE Teaching Patients Self-Care.The
nurse, social workers, family, and others collaborate to assess the patients home condition and
support system. If available, a low-vision specialist should be consulted before discharge,
particularly for patients for whom identifying and administering medications pose problems. The
level of visual acuity and patient preference help to determine appropriate interventions. For
example, a plastic pill container with dividers that has been prefilled with a weeks supply of
medication can make medication administration easier for some patients, whereas others may
prefer to have medication bottles marked with textured paints. Many patients require referral to
social services. Patients with habits that may jeopardize safety, such as smoking, need to be
cautioned and assisted to make their environment safe. Community Programs and Services.In the
United States, laws such as the Rehabilitation Act, the Civil Rights Act, and the Americans With
Disabilities Act support assistance of the blind. Governmental services include income assistance
through Social Security Disability Income and Supplemental Security Income; health insurance
through Medicaid and Medicare programs; support services, such as vocational rehabilitation
programs offered by the Division of Blind Services; tax exemptions and tax deductions;
Department of Veterans Affairs programs for visually impaired veterans; and U.S. Postal Service
reduced postage for Braille materials and talking books. Some private and nonprofit services are
identified in Resources and Websites at the end of this chapter.