Jarvis: Physical Examination & Health Assessment, 3rd Canadian

Edition

Chapter 15: Eyes

Key Points

This section discusses key points about the structure and function of the eyes.

 The external anatomy of the eye includes many structures. Each eye is protected by
the bony orbital cavity, surrounded with a cushion of fat.
o The eyelids further protect the eye from injury, strong light, and dust. The
upper eyelid is larger and more mobile. Eyelashes curve outward from the lid
margin to filter out dust and dirt. When the eyes are closed, the lid margins
approximate completely.
o The palpebral fissure is the elliptical space between the eyelids. The canthus
is the corner of the eye, where the lids meet. The caruncle (a small fleshy
mass containing sebaceous glands) is located at the inner canthus. A stripe of
connective tissue, the tarsal plate, gives shape to the upper lid. The tarsal
plates contain meibomian glands, which secrete an oily lubricant onto the
lids.
o The conjunctiva, a thin mucous membrane, is a transparent protective
covering of the exposed part of the eye. The lacrimal apparatus provides
constant irrigation. Tears drain into the puncta, located on the upper and
lower lids at the inner canthus.
o Six muscles attach the eyeball to its orbit: the superior, inferior, lateral, and
medial rectus muscles and the superior and inferior oblique muscles.
These muscles direct eye movement and are stimulated by cranial nerves III,
IV, and VI.
 The internal anatomy of the eye also includes many structures. The eye has three
concentric coats or layers.
o The outer layer is the sclera, a tough, protective, white covering that is
continuous anteriorly with the smooth, transparent cornea. The cornea, which
is part of the refracting media of the eye, covers the iris and the pupil.
o The middle layer is the choroid, which has dark pigmentation to prevent
light from reflecting internally and is highly vascular to deliver blood to the
retina. The choroid is continuous with the ciliary body and the iris. The
ciliary body controls the thickness of the lens. The iris serves as a diaphragm,
varying the opening at its centre. Its muscle fibres contract and dilate the
pupil, controlling how much light enters the retina.
o The inner layer is the retina, which is the visual receptive layer of the eye. In
the retina, light waves are changed into nerve impulses.

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 Visual reflexes include the pupillary light reflex, fixation, and accommodation.
o The pupillary light reflex is the normal constriction of the pupils when bright
light shines on the retina.
o Fixation is a reflex direction of the eye toward an object attracting a person’s
attention.
o Accommodation is the adjustment of the eye for near vision. It is
accomplished by ciliary muscle movement.
 The eyes undergo age-related changes.
o At birth, eye function is limited. Peripheral vision is intact in newborns. The
macula is absent at birth but is mature by age 8 months. Eye movement is poorly
coordinated, but matures by age 3 to 4 months. The eyeball reaches adult size by
age 8 years.
o With aging, lacrimal gland involution causes decreased tear production and
dry, burning eyes. Pupil size decreases, and the lens loses elasticity, causing
presbyopia. The transparent fibres of the lens begin to thicken and yellow,
resulting in senile cataract. Visual acuity may diminish gradually after age 50
years. In older adults, the three most common causes of decreased visual
functioning are cataracts, glaucoma diabetic retinopathy, and macular
degeneration.
This section presents critical points about subjective and objective assessments of
the eyes.
 To obtain subjective data, ask questions that investigate these topics:
o Vision difficulty, including decreased acuity, blurring, and blind spots
o Eye pain
o Strabismus or diplopia
o Redness or swelling
o Watering or discharge
o A history of ocular problems
o Glaucoma
o Use of glasses or contact lenses
o Self-care behaviours
 Medications
 Coping with vision changes or loss
 To obtain objective data, first test central visual acuity with a Snellen or other eye
chart. For those over age 40 years or who have difficulty reading, also test near
vision.

Copyright © 2019 Elsevier, Inc.

Key Points 15-3

 Next, assess visual fields by using the confrontation test.

 Continue by observing extraocular muscle function. To do this, assess the corneal
light reflex by using the Hirschberg test. Also, perform the cover–uncover test and
the diagnostic positions test, which is known as the six cardinal positions of gaze.
 Then, inspect the external eye structures. After a general inspection, specifically
assess the eyebrows, eyelids and lashes, eyeball alignment, conjunctiva and
sclera, upper lid eversion, and lacrimal apparatus.
 Move on to inspect anterior eyeball structures. Observe the cornea and the lens.
And assess the iris and pupil, particularly noting their size, shape, and equality; the
pupillary light reflex; and accommodation.
 Finally, inspect the ocular fundus by using an ophthalmoscope.
o Observe the optic disc, noting its colour, shape, and margins and estimating
the cup-to-disc ratio.
o Inspect the retinal vessels, assessing their number, colour, calibre, and
arteriovenous crossings. Estimate the artery–vein ratio, and check for
tortuosity and pulsations.
o Evaluate the colour and integrity of the fundus.
o Inspect the macula last because it may cause watering, discomfort, and pupil
constriction.
 Adapt your examination techniques based on the patient’s developmental status. For
example, use age-appropriate tools to assess visual acuity, such as a picture chart or
Snellen E chart for a child. Also, adjust your expected findings on the basis of the
patient’s age.
 When assessing the eyes, incorporate health promotion concepts. Regular
comprehensive examinations should be encouraged for timely recognition of any
visual impairment.

Copyright © 2019 Elsevier, Inc.