EYES AND EARS

EYES

Pupils should be Equal, Round, Reactive to Light and Accommodation (PERRLA).

Constriction is the normal reaction to light and near accommodation. There should be
consensual response (bilateral).

Normal pupil is 3-7mm in diameter.

Snellen Chart – an eye test that can be used to measure visual acuity. Normal vision is 20/20.
Legal definition of blindness is 20/200.

Rosenbaum Chart – a handheld card for measuring near visual acuity..

Ishihara test – an eye test consists of a number of colored plates which contains a circle of
dots appearing randomized in color and size.

EYE DISORDERS

Glaucoma - is a group of eye conditions that damage the optic nerve which is vital for good
vision.
Myopia – nearsightedness (denominator of Snellen is greater), corrected by concave lens,
(near-cave)
Hyperopia - farsightedness (numerator of Snellen is greater) corrected by convex lens (far-
vex).
Presbyopia – loss of elasticity of the lens due to aging, loss of the ability to see close objects.
Astigmatism – an uneven curvature of the cornea that prevents horizontal and vertical rays
from focusing on the retina.
Strabismus - occurs when the eyes do not line up or they are crossed. One eye, however,
usually remains straight at any given time.

Common forms of strabismus include:

● Esotropia – one or both eyes turn inward toward the nose

● Exotropia – one or both eyes turn out; also called wall-eyed 
● Hypertropia – one or both eyes turn up
● Hypotropia – one or both eyes turn down
Nystagmus - is a vision condition in which the eyes make repetitive, uncontrolled movements
and these often result in reduced vision and depth perception and can affect balance and
coordination. These involuntary eye movements can occur from side to side, up and down, or in
a circular pattern.

Amblyopia - often called lazy eye. A problem that is common in children. Amblyopia is a result
of the brain and the eyes not working together. The brain ignores visual information from one
eye, which causes problems with vision development.

Age-Related Macular Degeneration (AMD) - a disease that blurs the sharp, central vision
needed to see straight-ahead.  It affects the part of the eye called the macula that is found in the
center of the retina

Cataract - a clouding of the lens of the eye.  It often leads to poor vision at night, especially
while driving, due to glare from bright lights

Eyestrain – a common condition that occurs when your eyes get tired from intense use, such
as while driving long distances, or staring at a computer/laptop screens and other digital
devices.

Red eyes – is a condition where the sclera has become reddened or “bloodshot” that is occur
when small blood vessels that are present on the surface of the eye become enlarged and
congested with blood. This happens due to an insufficient amount of oxygen being supplied to
the cornea or the tissues covering the eye.

Nyctalopia – “night blindness” is a symptom of an underlying disease such as retinal problem.

The blindness prevents you from seeing well at night or in poor lightning.

Color blindness – occurs when you are unable to see colors in a normal ways and also known
as color deficiency. It often happens when someone cannot distinguish between certain colors
and usually happens between color greens, reds, and occasionally blues.

Floaters – are a small dark shape that floats across your vision. They can look like spots,
threads, squiggly lines, or even little cobwebs.

Dry eyes – occur when tear glands don’t produce enough tears or when your tears evaporate
too quickly.

Epiphora – “watery eye” an overflowing of tears. A clinical condition that constitutes insufficient
tear film drainage from the eyes.
Conjunctivitis – “pink eye” an inflammation or infection of the transparent membrane
(conjunctiva) that lines your eyelid and covers the white part

of the eyeball. When small blood vessels in the conjunctiva become inflamed, they’re more
visible. This is what causes the whites of the eyes to appear

reddish or pink.

Test for Glaucoma:

Tonometry – measures the intraocular pressure N = 8-21 mmHg

Perimetry – loss of peripheral vision (tunnel vision).

Ophthalmoscopy – “cupping of the optic disc”.

Gonioscopy – measures the angle to differentiate closed and open angle glaucoma.

 EXAMINATION OF THE EYE

 An examination of the eye includes an external examination, examination by ophthalmoscope,

and an assessment of the functions of the eye.
A. External Examination. The anterior segment of the eyes and their appendages can be
examined by visual inspection.
● Note the general appearance of the eyelids, eyelashes, and lacrimal apparatus. Observe
for:
(a) Redness around the eye.
(b) Discharge or crusting.
(c) Growths on eyes or eyelids.
(d) Excessive tearing.
● Position and mobility can be observed by having the patient rotate the eyes, looking up,
down, and to each side.
B. Pupillary Response. Normal pupils are rounded, centrally placed, and generally equal in
size. (About 25 percent of normal individuals
have pupils slightly unequal in size.)
● Reaction to light. Seat the patient in an area with even lighting and instruct him to fix his
gaze on a distant object. Cover one eye and
shine a flashlight in front of the exposed eye. The pupil should contract (constrict)
because of the light. This response is called a
direct reaction. The covered pupil should also contract. This response is called a
consensual reaction.
 ● Near point reaction. When the gaze is changed from a distant object to an object close
at hand, the pupils should contract.

C. Ophthalmoscopic Examination. By looking through the various lenses of an

ophthalmoscope, the trained examiner can view and
assess the internal structures of the eye. This examination is routinely performed by the
physician.
D. Functional Examinations.
● Focusing power (power of accommodation) is tested by placing a line of print close to
the eye, then slowly moving it back to the
point at which the patient is able to read it. The nearest point at which it is readable is
the near point of accommodation.
● Visual field refers to all that can be seen with both eyes fixed straight ahead. To perform
a gross examination of visual field, the
confrontation method is used. Have the patient and the examiner face each other at a
distance of about 2-3 feet, each focusing his
gaze at the other's nose. The examiner should then extend his arm to the side, point his
finger, and slowly move his arm back in, along a
plane half-way between himself and the patient. The examiner's finger should appear in
the patient's visual field at the same time the
examiner sees it (assuming the examiner's visual field is grossly normal)
● Color sense is tested by using specially designed color plates to distinguish reds,
greens, and blues.
● Visual acuity testing is done with the Snellen chart or one of its modifications. Each eye
is tested separately, both with and without
glasses, if worn.
(a) Since the distance at which rays of light from an object are practically parallel
and no accommodation of the lens is necessary to
focus the object, the test is performed at a distance of 6 meters (20 feet),

(b) The Snellen chart contains rows of letters of varying sizes, arranged to that
the normal eye can see them at distances of 6, 9, 12, 15, 21, 30, and 60 meters.
(20, 30, 40, 50, 70, 100, and 200 feet.) If a patient is seated 6 meters (20 feet)
from the chart and can read the line of letters for 6 meters, his vision is
expressed by the fraction 6/6 (or 20/20).

(c) Vision is expressed by a fraction, the numerator denoting the distance at

which the test was performed (normally, 6 meters or 20 feet), and the
denominator denoting the smallest line of letters which could be read at that
distance. If a patient is seated 6 meters from the chart and the smallest line of
letters he is able to read is the one that should be read at a distance of 30
meters, then his vision is expressed at 6/30 (or 20/100).
 (d) If the largest letters on the chart cannot be read at a distance of 6 meters, the
patient is moved toward the chart until he can read the largest letters. Vision is
then expressed as a fraction, with the numerator denoting the distance at which
the largest line could be read, and the denominator denoting the number of the
largest line.

(e) If the patient cannot read the largest line at a distance of one meter, the
examiner tests the patient's ability to see hand motion in front of his face. If the
patient cannot see the examiner's hand at a distance of one or two meters, he is
tested for light perception. A light is flashed from different directions and the
patient is asked from which direction the light appears and when it goes on and,
it goes off. If the patient can do this, the examination is recorded as "light
perception present". If no light perception is present, a person is technically blind.

● These functional examinations are routinely performed by the physician or eye specialist
and it is recommended that nursing personnel be knowledgeable of these examinations.
To do so will facilitate identification of visual abnormalities. A gross examination using
"field expedient techniques" can be performed when the proper equipment and
personnel are not available. For example:

(a) Color sense can be observed by having the patient identify the color of objects
around him.

(b) Gross acuity can be tested by having the patient read signs posted on the
walls. Use signs of different sizes and position the patient at varying distances.
EARS
Divided into three parts: Outer (auricle or pinna, external canal and tympanic membrane);
Middle (3 ossicles, Eustachian tube); and Inner (cochlea, vestibule and semicircular canal).
The 3 ossicles (malleus, incus, and stapes) decrease the magnitude of the sound. The
Eustachian tube connects to nasopharynx to equalize pressure in the middle ear.
Otoscope or auriscope is a tool which shines a beam of light to help visualize and examine the
condition of the ear canal and eardrum.
Tuning fork is a two prolonged metal fork that can be used as an acoustic resonator tool to test
certain types of hearing loss.
To straighten ear canal of adult – pull pinna up and backwards. To straighten ear canal of
child – pull pinna down and backwards.
WEBER TEST – lateralization test that compares right and left ear. Screening test for hearing is
performed by placing the tuning fork on the bridge of the
forehead, nose, or teeth.
Negative = normal finding
● Sound is heard in both ears or is localized at the center of the head
Positive = abnormal finding
● Sound is heard better in impaired ear – bone conductive hearing loss
 ● Sound is heard better in normal ear – sensorial hearing loss

RINNE TEST – compares air conduction with bone conduction by placing a tuning fork on the
mastoid bone and then adjacent to the outer ear.
Positive Rinne = normal finding
● Air conduction is greater than bone conduction
Negative Rinne = abnormal finding
● Bone conduction time is equal to or longer than air conduction – conductive hearing loss.

ROMBERG TEST – is an appropriate tool to diagnose sensory ataxia, a gait disturbance

caused by abnormal proprioception involving information
about the location of the joints. It is also proven to be sensitive and accurate means of
measuring the degree of disequilibrium caused by central vertigo,
peripheral vertigo and head trauma.

WHISPER TEST -  is an efficient screening test for detecting hearing impairment.

Schwabach Test – takes a look to compares client’s bone physical phenomenon called
conductivity to it of the examiner, this implies a sensorineural
loss. If the client hears it longer than the examiner, this implies conductive loss.
EAR PROBLEMS
● Ear infections - are the most common illness in infants and young children.
● Tinnitus - a roaring in your ears, can be the result of loud noises, medicines or a variety
of other causes.
● Meniere's disease - may result of fluid problems in your inner ear; its symptoms include
tinnitus and dizziness.
● Ear barotrauma - is an injury to your ear because of changes in barometric (air) or water
pressure.
Some ear disorders can result in hearing disorders and deafness.
EXAMINATION OF THE EAR
Inspect the pinna and the mastoid:
● Obvious deformities or abnormal cartilaginous fragments
● Scars or skin changes
o Including for skin malignancies
● Signs of inflammation
o An inflamed mastoid may push the pinna forward
o Palpate the lymph nodes and pinna, specifically:
● Pre- and post-auricular lymph nodes
● Tragus
o Tragal tenderness is a sign of otitis externa
EXTERNAL EAR CANAL
Inspect the outer aspect of the external ear canal using the otoscope as a light source. Gently
straighten out the ear canal by pulling the
external ear superiorly and posteriorly and look for signs of:
● Wax or a foreign body
● Skin changes or erythema
● Discharge
Tympanic Membrane
Hold the otoscope like a pen between thumb and index finger, left hand for left ear and right
hand for right ear, resting your little finger on the
patient’s cheek – this acts as a pivot.
Gently straighten out the ear canal by pulling the external ear superiorly and posteriorly. For a
normal tympanic membrane, you should
be able to observe:
● Lateral process of malleus
● Cone of light
● Pars tensa and pars flaccida

The cone of light can be used to orientate; it is located in the 5 o’clock position when viewing a
normal right tympanic membrane and in the 7 o’clock position for a normal left tympanic
membrane
For an abnormal tympanic membrane, common signs may include:
● Perforations
● Tympanosclerosis
● Red and bulging membrane
● Retraction of the membrane

Hearing and Equilibrium Test

Rinne Test - Strike the tuning fork (512Hz) against your elbow and place against the mastoid
process (bone conduction), then once patient stops hearing it, hold it near the external ear canal
(air conduction)
● For normal hearing or sensorineural hearing loss, air conduction is heard better than
bone conduction (Rinne positive)
● For conductive hearing loss, bone conduction is heard better than air conduction (Rinne
negative)

Weber Test - Strike the tuning fork (512Hz) against your elbow and place on the patient’s
forehead in the midline. Ask the patient whether the sound is heard in the midline or has
lateralized
 ● For normal hearing, the sound is heard in the midline
● For conductive hearing loss, the sound is loudest on the ipsilateral side to the hearing
deficit
● For sensorineural hearing loss, the sound is loudest on the contralateral side to the
hearing deficit

Whisper test
● Stand 1-2 feet behind client so they cannot read your lips.
● Instruct client to place one finger on tragus of left ear to obscure sound.
● Whisper word with 2 distinct syllables towards client's right ear.
● Ask client to repeat word back.
● Repeat test for left ear.
● Client should correctly repeat 2 syllable word.

Romberg Test
● The patient is asked to remove his shoes and stand with his two feet together. The arms
are held next to the body or crossed in front
of the body.

● The clinician asks the patient to first stand quietly with eyes open, and subsequently with
eyes closed. The patient tries to maintain his balance.
For safety, it is essential that the observer stand close to the patient to prevent potential
injury if the patient were to fall. When the patient closes
his eyes, he should not orient himself by light, sense or sound, as this could influence the
test result and cause a false positive outcome.
The Romberg test is scored by counting the seconds the patient is able to stand with eyes
closed