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Assessment of the eyes Learning Objectives

At the end of the session, the students shall be able to:

➢identify the equipment needed for eye assessment
➢discuss the importance of assessing the eyes
➢identify and describe normal and abnormal findings in the assessment of
the eyes
➢demonstrate proper assessment of external and internal eye structures

NCM101 –Health Assessment

1st Semester, AY 2020-2021
September 24, 2020

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Important landmarks of the external eye

External Structure of the Eye
• Eyelids
• Lateral and medial canthus
• Eyelashes, conjunctiva
• Lacrimal apparatus
• Extraocular muscles

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Structure of Eye Internal Structure of the Eye

•Sclera, cornea, iris, ciliary body,

•Pupil, lens, choroid, retina, optic disc
•Physiological cup, retinal vessels
•Anterior chamber, posterior chamber

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Vision

•Visual fields
•Visual pathways
•Visual reflexes
•Pupillary light reflex
•Accommodation

Assessment of the Eyes

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Physical Examination: Eyes Steps in Eye Assessment

•Inspection 1. Greet the patient and introduce self.
•Visual acuity 2. Identify the patient using 2 identifiers.
•Visual Fields 3. Gather equipment
•Pupillary Response 4. Explain the procedure to patient.
5. Wash hands, apply gloves and observe appropriate
infection control procedures.
6. Provide for privacy

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Procedure Normal Findings Abnormal Findings

Equipment: 7. Inspect the eyebrows for hair

distribution, alignment and for skin
Eyebrows should be bilateral
and move symmetrically as
Drooping of the upper eye
lid, called ptosis may be
quality the facial expression changes
attributed to oculomotor
• Penlight nerve damage. Retracted
lid margins which allow
8. Inspect eyelashes for evenness of Eyelashes should be evenly
• Clean Gloves distribution and direction of curl distributed along the lids the viewing of sclera when
margin and curve downwards the eyes are open,
• Snellen Chart suggests hyperthyroidism.

9. Inspect eyelids for:
• Surface characteristics
• Position in relation to cornea
• Ability to blink, and frequency of
blinking
• Inspect the lower eyelids while
the client’s eyes are closed
Upper eyelids usually overlap Entropion – inverted lower
the superior part of the iris, eyelid
and approximate completely Ectropion – everted lower
with the lower lids when eyelid
closed

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Procedure Normal Findings
10. Inspect eyeballs Eyeballs are align normally
in their sockets with no
protrusion or sunken
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Procedure
11. Inspect the bulbar conjunctiva
for color, texture and presence of
lesion
• Retract the eyelids with your
thumb and index finger
• Ask the client to look up, down
and side to side
12. Inspect the palpebral
conjunctiva
• Evert both eyelids
• Ask the client to look up
• Gently retract the lower lids with
the index finger
• Evert upper lids if problem is
suspected
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Abnormal Findings
Eye Protrusion
Sunken Eye
Normal Findings Abnormal Findings
The sclera should be Generalized redness of the
china white, clear moist conjunctiva suggests
and smooth. Underlying conjunctivitis.
structures are clearly Areas of dryness are associated
visible. with allergies or trauma
Episcleritis is a local
noninfectious inflammation of
the sclera
Free of swelling, foreign Cyanosis of the lower lid
bodies and lesion suggests a heart or lung disorder
A foreign body lesion may cause
irritation, burning, pain and/or
swelling of the upper eyelid.
Procedure
Inspect the bulbar
conjunctiva for color,
texture and the presence
of lesion
• Retract the eyelids with
your thumb and index
finger
• Ask the Client to look
up, down, and side to
side
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Procedure
13. Inspect and palpate the
lacrimal gland
• Using the tip of your finger, of the lacrimal glad.
palpate the lacrimal gland
• Observe for edema between the
lower lid and the nose
14. Inspect and palpate the
lacrimal sac
• Observe for evidence of
increased tearing
• Used the tip of your finger to
palpate inside the lower orbital
rim near the inner canthus
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Normal Findings
The sclera should be clear,
moist and smooth.
Underlying structures are
clearly visible. Sclera is
white.
Normal Findings
No swelling of redness
should appear over areas
No drainage should be
noted
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Abnormal Finding
Generalized redness of the
conjunctiva suggests
conjunctivitis.
Areas of dryness are
associated with allergies
or trauma
Episcleritis is a local, non
infectious inflammation of
the sclera
Abnormal Findings
Swelling may be visible in the
lateral aspect of the upper
eyelid which may be caused by
blockage. Infection, or an
inflammatory condition
Expressed drainage on palpation
occurs with duct blockage.
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Procedure Normal Findings Abnormal Findings Procedure Normal Findings Abnormal Findings
15. Inspect the cornea for clarity The cornea is Areas of roughness or 17. Inspect the anterior The cornea is Areas of roughness or
and texture transparent with no dryness on cornea chamber for transparency and transparent with no dryness on cornea often
• Ask the client to look straight opacities. often associated with depth opacities. associated with injury or
ahead injury or allergic • Use the same oblique allergic responses.
• Hold penlight at an oblique angle responses. lighting as used to test
to the eye cornea
• Move the light slowly across the
corneal surface 18. Inspect the pupils Normal pupils appear If the difference in pupil
16. Perform corneal sensitivity test A normal response is With • Check for color, shape, round, regular and of size changes throughout
• Ask patient to keep both eyes blinking decreased corneal symmetry of the size equal size in both eyes pupillary response test,
open and look straight ahead sensitivity, the patient the inequality of size is
• Extend your hand before the does not blink. abnormal
client’s field of vision

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Procedure Normal Findings Abnormal Findings Procedure Normal Findings Abnormal Findings
19. Assess pupil’s direct and Darkening the Monocular blindness 20. Assess pupil’s reaction to The normal Pupils do not
consensual reaction to light room facilitates can be detected accommodation pupillary response constrict eyes do not
• Partially darken the room pupil dilation when light directed
• Ask the client to look straight • Ask the client to look is constriction of converge
ahead
Shining light on to blind eye results in straight ahead at a distant the pupils and
• Using a penlight approaching the pupil provides no response in either point convergence of the
from the side, shine a light on a direct stimulus pupil. When light is • Hold a penlight about 4-5 eyes when focusing
the pupil for pupil directed into the inches (10-12cm) from the on a near object.
• Observe the illumination of the constriction unaffected eye, both client’s nose.
illuminated pupil pupils constrict • Ask the client to shift the
• Shine the light on the pupil again
and observe fort the other pupil gaze from a distant point to
the penlight

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Procedure
21. Asses pupil's reaction
to accommodation
• Ask the client to look
straight ahead at a
distant point
• Hold a penlight about 4-
5 inches from the client’s
nose;
• Ask the client to shift
gaze from a distant point
to the pen light
Normal Findings Abnormal Findings Procedure Normal Findings Abnormal Findings
The normal pupillary Pupils do not constrict; 22. Assess peripheral fields With normal peripheral vision, Delayed or absent perception
response is constriction of eyes do not converge the client should see the of the examiner’s finger
examiner's finger at the same indicates reduced peripheral
the pupils and time the examiner sees it vision. Refer client for further
convergence of the eyes evaluation
when focusing on a near
object

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Procedure Normal Findings Abnormal Findings

23. Perform the cover The uncovered eye should The uncovered eye will move to establish focus when
test. remain fixed ahead. The opposite eye is covered. When the covered eye is uncovered,
• This test covered eye should remain movement to re establish focus occurs.
determines the fixed ahead after being
balance uncovered Phoria – mis alignment that occurs only when fusion reflex is
mechanism that blocked.
keeps the eye Strabismus – constant malalignment of the eyes
parallel.
Tropia – specific malalignment
Esotropia – inward turn of the eye
Exotropia - outward turn of the eye

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Procedure Normal Abnormal

Findings Findings Eye Assessment video guide:

24. Assess Normal distant Myopia https://www.youtube.com/watch?v=YqL6IMGE5os

distance vision visual acuity is (impaired vision)
20/20 with or is present when
without the second
corrective lenses. number in the
test result is
larger than the
first (20/40).

Resource/s:
Wolters Kluwer Health Lippincott William and Wilkins Fifth edition

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