ASSESSMENT

of the EYES
CU 7

Ppt Prepared by:

Trinidad J. Salcedo’2024
OLFU-QC
 LEARNING OUTCOMES:
1. Discuss structures & functions of the eyes.
2. Assess client’s distant & near visual acuity, visual
fields, corneal light reflex & eye movements.
3. Differentiate between normal & abnormal findings
of the eye & vision
4. Analyze all data from the interview & physical
assessment to formulate valid nursing diagnosis,
collaborative problems, & /or referrals.
 INTRODUCTION
The EYES are sensory organs responsible for vision.
Vision affects how an individual interacts &
communicates with the world.

The eye is the structure through which light is

gathered to produce vision.

ASSESSMENT OF THE EYES

• 70 % of all sensory information reaches the brain
through the eyes. Transmit visual stimuli to the brain
for interpretation
ANATOMY OF THE EYE
A CROSS - SECTION OF THE EYE
 ANATOMY OF THE EYE
Extraocular Muscles Lacrimal Apparatus
 EYE ANATOMY & PHYSIOLOGY REVIEW
EYES - located in the orbital cavities of the skull. Only anterior aspect of the eye is
exposed; layers & membranes serve several purposes.
Accessory structures of the eyes provide protection & responsible for movement.
3 LAYERS OF THE EYE:
1. SCLERA – outermost layer helps maintain shape of the eye.
Support & protect structures of the eye.
Maintains the eye size.
CORNEA – clear, transparent part of sclera & form anterior 1/6 of the eye.
Considered window of the eye.
Allows light to enter & refracts light rays entering the eye.
2. CHOROID – middle layer, vascular pigmented layer.
Maintains blood supply to the eye.
 EYE ANATOMY & PHYSIOLOGY REVIEW
In CHOROID layer, we have:
IRIS – circular colored, muscular aspect of this layer & located in the anterior
portion of the eye.
Responds to light by making the pupil larger or smaller.
PUPIL – located at the center of the iris.
Permits light to enter the eyes or allows light to travel inside the eye.
MIDRIASIS – dim light cause iris to respond by enlarging the pupil size
MIOSIS- bright light causes the iris to respond by decreasing the amount of
light entering the eye.
OCULOMOTOR NERVE – 3rd cranial nerve that controls pupillary constriction
(parasympathetic branch) & dilation (sympathetic branch) of the pupil.
LENS – refracts & focuses light into the retina.
 EYE ANATOMY & PHYSIOLOGY REVIEW
3. RETINA – 3rd layer, innermost membrane & sensory portion of the eye.
Direct extension of the optic nerve, helps change light waves to neuro impulses for
interpretations as visual impulses by the brain.
Receives visual stimuli & transmits images to the brain for processing.
Rods - function in dim light & called peripheral vision receptors.
Cones - function in bright light & called central vision receptors & provide color to
sight.
OPTIC DISC - nasal aspect of the retina where optic nerve & retina meet.
MACULA – responsible for central vision with yellow & pit like center called fovea
centralis.
VITREOUS HUMOR – maintains placement of retina & eyeballs in spherical
shape
AQUEOUS HUMOR - clear, watery fluid between cornea & the front of the vitreous.
Bathes & nourishes the lens & maintains pressure within the eye.
 ASSESSMENT OF THE EXTERNAL EYE
INSPECT for the EYEBROWS - Inspect for hair distribution,
alignment, skin & quality.
NORMAL DEVIATIONS FROM NORMAL
Hair evenly distributed; skin intact Loss of hair; scaling & flakiness of skin
Symmetrically aligned; equal movement Unequal alignment & movement of
eyebrows.
INSPECT for the EYELASHES - Note distribution, inversion or
eversion
Present & curving outward; Absence of eyelashes
No crusting or infestation Lice or ticks at base of eyelashes;
Inflammation; Inverted & everted
eyelashes
Everted eyelashes (Ectropion) - can lead
to excessive drying of eyes
 ASSESSMENT OF THE INTERNAL EYE
INSPECT the FUNDUS of the EYES USING
OPTHALMOSCOPE

OPHTHALMOSCOPE - handheld instrument

to view the fundus of the eye by the
projection of light through prism that bends
the light 90 degrees.
❖ There are lenses labeled with a negative
or positive number, a unit called diopter.
❖ Red numbers indicate negative diopter for
myopic or nearsighted clients.
❖ Black numbers indicate a positive for
hyperopic or farsighted clients.
 ASSESSMENT OF THE EXTERNAL EYE
INSPECT FOR THE EYELIDS
Inspect for the surface, characteristics, position in relation to the cornea,
ability to blink, & frequency of blinking.
Note for edema, lesions.
NORMAL DEVIATIONS FROM NORMAL
Upper eyelid normally covers Asymmetry of lids: CN III damage, stroke
one-half of upper iris
Palpebral fissures symmetrical PTOSIS of both eyelids: Myasthenia gravis
Eyelids in contact with eyeball. LESIONS ON EYELIDS: Basal cell carcinoma;
Squamous cell carcinoma
No lesions XANTHELASMA – lipidosis
No edema CHALAZION – enlargement of meibomian gland
HORDEOLUM / STYE – caused by an infection
VISUAL ACUITY – SNELLEN’S CHART
 TESTING VISUAL ACUITY
VISUAL ACUITY – capacity to detect, resolve
or recognize the details of objects.
Ability to discern letters or numbers at a
given distance
PROCEDURE: Testing Distant Vision
1. Position (standing or seated) client exactly
20 ft. (6.1 meters) from the Snellen Chart.
Chart should be eye level.
2. Instruct patient to cover up 1 eye with pad
or opaque card.
3. Uncovered eye read the TOP letter (which
is the letter “E”) at 20 ft. from left to right
down to the smallest letters.
4. Glance on the chart & making sure that
client only reads with 1 eye & not with both
eyes.
 TESTING VISUAL ACUITY
5. Test each eye separately, then
together with & without corrective
lenses
OD - Oculus Dextrus (right eye)
OS - Oculus Sinister (left eye)
OU - Oculus Uterque (both eyes).
6. Note smallest line of print that
client is able to read with no more
than two mistakes.
Alternate method using pocket
vision screener: Have patient hold
pocket vision screener about 14
inches from eye & proceed testing
as the chart.
 TESTING VISUAL ACUITY
TAKE NOTE: Visual acuity is assessed in one eye at a time, then in both eyes
together with the client comfortably sitting or standing.
The right eye is tested with the left eye covered; then the left eye is tested with the
right eye covered. Then, both eyes are tested together.
Visual acuity is measured with or without corrective lenses the client stands at a
distance of 20 feet from the chart.
o The score on Rt. eye might not be the score on Lt. eye.
SCORING
For example: If a client can only read the top most letter (E), his or her score
is 20/200. Meaning that the letter he recognized or identified IS READ BY A
CLIENT WITH NORMAL VISION AT A DISTANCE OF 200 FT. The client can
read it only at a distance of 20 feet but they cannot read it at 200 feet.
NORMAL: 20 / 20 - Normal acuity
20 / 15 - better vision
DEVIATION FROM NORMAL: 20 / 200 – legally blind
Smaller fraction eg. 20 / 40
 JAEGER TEST
NEAR VISION ACUITY- an eye chart used in
testing.
⮚ Card which paragraphs of text are printed
⮚ Held by a client at a fixed distance (14
inches)
⮚ Must hold print farther away to see clearly
because of decreased ability of lens to
accommodate to near objects.
NORMAL
⮚ 14 / 14
DEVIATION FROM NORMAL
⮚ Smaller fraction (e.g., 14/18)
⮚ MYOPIA – Nearsightedness
⮚ HYPEROPIA – Farsightedness
⮚ PRESBYOPIA – Farsightedness due to aging
 ROSENBAUM CHART
Test near vision acuity same as Jaeger
Test
⮚ Snellen’s card is held by a client at a
distance of 12 to 14inches (30.5 to
35.5 cms) from the eyes.
⮚ Read letters from top of card down to
smallest line that the client can see.
⮚ Cover one eye with opaque card or
eye pad
⮚ Repeat test with other eye then, with
both eyes.
NORMAL –recorded as fraction 14/14 in
each eye.
⮚ If patient is corrective lenses, test
with it.
 SNELLEN E CHART
SNELLEN E CHART - “Tumbling E” Eye Chart
1. Can detect nearsightedness in young children who don’t
yet know all letters of the alphabet. (good “game” to a child
who might be apprehensive about his/her first eye exam.
2. Test the distance visual acuity of children or adults who
cannot communicate verbally due to a physical or mental
disability, language barrier or other reasons.
Procedure:
❖ Place a chart on a wall or easel 10 feet away & cover one
eye with a hand or some item that completely blocks the
vision of the covered eye.
❖ Eye patch with an elastic band is a good choice to cover.
❖ Start with large single E at the top of the chart. Show
client three parallel “fingers” of the E & ask them to show
you with the fingers on their hand which direction the
“fingers” on the E are pointing. If possible, show other
orientations of an E to confirm that the person being
tested understands the task.
 ISHIHARA TEST
❑ Color perception / vision test for RED – GREEN
color deficiencies.
❑ Have patient identify color bars on Snellen eye
chart.
❑ Have patient identify figure embedded in the
Ishihara chart.
NORMAL - Identifies embedded figures in the Ishihara
cards or identifies colored bars on the Snellen eye
chart.
DEVIATIONS FROM NORMAL - Inability to detect the
embedded number or letter in the Ishihara chart:
Defect in color perception (color blindness).
TYPES OF COLOR BLINDNESS:
Deuteranomaly - Common type of red-green color
blindness that makes green look more red.
Protanomaly - makes red look more green less bright.
Protanopia & deuteranopia both unable to tell the
difference between red & green at all.
 TESTING VISUAL ACUITY

• Ishihara Test
 ALLEN CARD TEST
❖ Distance of 3 meter; set of seven
card with each card containing a
single picture
❖ Used for 2 years old child & older;
first shown cards at close range
with both eyes open & asked to
name each picture
NORMAL - Child should successfully
identify three of the seven objects at a
distance of 15 feet.
DEVIATIONS FROM NORMAL -
Macular degeneration or diseases that
affect the cones that mediate color
vision.
 EYE PALPATION
EYEBALL - Gently palpate below eyebrow & note
firmness of eyeball
❖ Precaution: Do not palpate eyeball in patients with eye
trauma or known glaucoma
NORMAL
❖ Globe is firm & nontender
DEVIATIONS FROM NORMAL
❖ Excessively firm or tender globe
❖ Indicating glaucoma

CONJUNCTIVA - mucous membrane that covers the

front of the eye & lines inside of the eyelids.
 ASSESSING CONJUNCTIVA *
INSPECT THE BULBAR INSPECT THE PALPEBRAL
CONJUNCTIVA (lying over the CONJUNCTIVA (LINING THE
sclera) for color, texture & presence EYELIDS) BY EVERTING THE
of lesions LIDS
NORMAL NORMAL - shiny, smooth,
❖ Transparent, capillaries pink or red
sometimes evident DEVIATIONS FROM NORMAL
❖ Sclera appears white ❖ Extremely pale
❖ Darker or yellowish & with small ❖ Extremely red, nodules or
brown macules in dark skinned other lesions
clients are normal
DEVIATIONS FROM NORMAL
❖ Jaundiced sclera, excessively
pale sclera, reddened sclera;
lesions or nodules.
 INSPECTING THE BULBAR CONJUNCTIVA
❖ Have client keep the head straight while
looking from side to side then up toward
the ceiling.
❖ Observe clarity, color, & texture.
NORMAL - Bulbar conjunctiva over globes
are clear, with few underlying blood vessels
& white sclera visible.

Inspect the palpebral conjunctiva of the

lower eyelid, place your thumbs bilaterally
at the level of the lower bony orbital rim &
gently pull down to expose the palpebral
conjunctiva.
NORMAL - smooth, glistening, pinkish-
peach color, with minimal blood vessels
visible
INSPECTING THE BULBAR CONJUNCTIVA
 COMMON ABNORMALITIES of CONJUNCTIVA
Conjunctivitis – inflammation & redness
of palpebral & bulbar conjunctiva
Conjunctivitis (Pink eye) - An infection
usually caused by a bacteria or virus
that results in red, itchy, painful.
Anemia - Pale pink conjunctiva.
Conjunctival pallor is an
unhealthy pale appearance to
the palpebral conjunctiva that
can be a sign of anemia.
 EVERTING THE UPPER EYE LID
❖ Place a cotton-tipped applicator
approximately 1 cm above the eyelid
margin & push down with the
applicator while still holding the
eyelashes.
❖ Hold the eyelashes against the upper
ridge of the bony orbit just below the
eyebrow, to maintain everted position
of the eyelid.
❖ Examine palpebral conjunctiva for
swelling, foreign bodies, or trauma.
❖ Return eyelid to normal by moving the
lashes forward & asking the client to
look up & blink.
❖ Eyelid should return to normal.
EVERTING THE UPPER EYE LID
 INSPECTION of the CONJUNCTIVA
CONJUNCTIVA
• Inspect the bulbar conjunctiva (lying over the sclera) for
color, texture & presence of lesions
• NORMAL
o Transparent, capillaries sometimes evident
o Sclera appears white
o Darker or yellowish & with small brown macules in dark
skinned clients are normal
• DEVIATIONS FROM NORMAL
o Jaundiced sclera, excessively pale sclera, reddened sclera;
lesions or nodules
• Inspect the palpebral conjunctiva (lining the eyelids) by
everting the lids
• Normal
o Shiny, smooth, and pink or red
• Deviations from Normal
o Extremely pale, extremely red, nodules or other lesions
 COMMON ABNORMALITIES OF CONJUNCTIVA
Pterygium or pinguecula - Growth Subconjunctival hemorrhage
or thickening of conjunctiva from Eye injury
inner canthal area toward iris.
 COMMON ABNORMALITIES of CONJUNCTIVA
NEVUS - Benign pigmented Conjunctival Papilloma -
congenital discoloration Benign growth
 LACRIMAL
APPARATUS
OF THE EYE
 INSPECTION & PALPATION of the LACRIMAL
APPARATUS
1. INSPECT THE LACRIMAL APPARATUS
❖ 2. PALPATE THE LACRIMAL
✔ Assess areas over the lacrimal glands
APPARATUS
(lateral aspect of upper eyelid) & puncta
✔ Put on disposable gloves to
(medial aspect of lower eyelid)
palpate for nasolacrimal duct to
NORMAL –
assess for blockage
❖ No edema or tenderness or tearing
✔ Use one finger & palpate just
❖ Puncta is visible without swelling or
inside the lower orbital rim
redness
NORMAL –
DEVIATIONS FROM NORMAL -
❖ No drainage should be noted for
❖ Swelling of lateral aspect of upper eyelid
the puncta when palpating the
due to blockage, infection or
nasolacrimal duct
inflammatory condition
DEVIATIONS FROM NORMAL –
❖ Redness / swelling around puncta
❖ drainage from the puncta on
indicates infectious or inflammatory
palpation occurs with duct
condition
blockage.
❖ Excessive tearing indicates nasolacrimal
sac obstruction
 LACRIMAL APPARATUS
LACRIMAL APPARATUS –
❖ Group of organs for production &
drainage of tears;
❖ Protective function - helps keep eyes
moist & free of dust & other irritating
particles.
LACRIMAL GLAND - type of exocrine
glands that secretes tears or fluids, onto
the surfaces of conjunctiva & cornea.
❖ Constant stream of tears washes over
front of the eye & drained off through
2 small openings located in the inner
corner of the eye. Through these
openings tears pass into the lacrimal
canaliculus, then, through the lacrimal
sac into the nasolacrimal duct &
finally into the nasal cavity.
 CORNEA
INSPECT FOR CLARITY & TEXTURE
❖ Ask client to look straight ahead
❖ Hold a penlight at an oblique angle to the eye,
& move the light slowly across the corneal
surface
NORMAL - Transparent, shiny & smooth, details
of iris are visible. In older people, arcus senilis
may be evident
DEVIATIONS FROM NORMAL
❖ Opaque, surface not smooth, white arc around
the limbus
❖ ARCUS SENILIS - common in older adults
caused by fat (lipid) deposits deep in the edge
of the cornea. Arcus senilis doesn't affect
vision, nor does it require treatments. Arcus
senilis under age 40 & considered normal to
elderly.
 CORNEA
CORNEAL LIGHT REFLEX TEST
❖ Shine light directly in patient’s eyes;
note position of the light reflection off
the cornea in each eye.
❖ Note for the sparkle that is the light
reflecting off the cornea
• NORMAL
❖ Light should be seen symmetrically on
each cornea.
• DEVIATION FROM ABNORMAL
❖ Asymmetrical corneal light reflex
❖ Weak extraocular muscles or
strabismus, congenital exotropia
 CORNEA & LENS
CORNEA & LENS
❖ Shine a light on the cornea from an oblique
angle & note clarity & abrasions
Corneal Reflex -
❖ Take a wisp of rolled cotton & gently touch
the cornea, or
❖ Take a needleless syringe filled with air &
shoot a puff of air over the cornea & note for
blinking & tearing

BLINK REFLEX –
❖ Brush your index finger across patient’s
eyelashes & note for blinking
NORMAL - Corneal reflex positive.
❖ Cornea & lens clear, smooth, & glistening.
❖ White ring encircling outer rim (arcus senilis)
 CORNEAL ABNORMALITIES
CLOUDY CORNEA - Vit A CORNEAL ABRASIONS & ULCERS-
deficiency; infection which may Roughness & irregularities of cornea
be accompanied by HYPOPION
(pus in anterior chamber)
 CORNEAL ABNORMALITIES
Kayser - Fleischer Ring Corneal Scar
o yellow ring in outer margin o appears grayish white, usually
o WILSON’s disease, due to an old injury or
increased copper absorption inflammation
 CORNEAL ABNORMALITIES
Early Pterygium Negative corneal reflex
o thickening of the bulbar o indicates neurological problem, CN V
conjunctiva that extends & VII. May also be absent or diminished
in people who wear contact lenses
across the nasal side
 LENS ABNORMALITIES
CATARACTS -lens opacities BILATERAL ISOLATED LENS
It is a cloudy area in the lens COLOBOMA associated with bicuspid
of the eye. aortic valve
 SCLERA
Note normal color of Sclera
❖ Should be smooth, white,
glistening
❖ Dark-skinned patients may have
a yellowish cast to the peripheral
sclera with whiter sclera at the
limbus or small brown spots
called Muddy Sclera

COMMON ABNORMAL FINDINGS:

Diffuse Episcleritis - inflammation of the
episclera
Bluish Sclera - osteogenesis imperfecta
Icteric sclera - at the limbus; due to elevated
bilirubin (jaundice
PUPILS
 PUPIL
1. INSPECT PUPIL SIZE & EQUALITY
❖ Should be round & equal bilaterally
❖ Size is larger in children, smaller in
adults
NORMAL RANGE is 3 – 5 mm in adults
(usually 3mm)
❖ 20 % of the population, unequal
pupils (ANISOCORIA) can be a
normal variation.
NORMAL - pupils react appropriately &
the difference is slight, 0.5 mm

Note: REACTION & SPEED in both eyes

 PUPIL
2. TEST PUPILLARY REACTION TO LIGHT.
o Have patient look straight ahead while you bring light in from the side
over the eyes
NORMAL FINDINGS
❖ Direct reaction eye receiving stimulus constricts briskly
❖ Consensual reaction - opposite eye not receiving stimulus directly
also constricts
❖ Normal direct & consensual pupillary response to light is brisk
constriction of the pupil to about 1 mm or less
PUPIL ABNORMALITIES
❖ Tonic Pupil - unilateral large pupil (tonic pupil) that reacts to light
slowly (benign)
❖ Horner’s syndrome - Unequal pupils; affected pupil small but reacts
to light & has ptosis on affected eye related to sympathetic nerve
lesion
 PUPIL ABNORMALITIES
Argyll Robertson Pupils - small & irregular, no reaction to light or
accommodation, associated with neurosyphilis.
Oval pupils - irregularly shaped pupils caused by certain eye
surgeries, transtentorial herniation with 3rd nerve compression

Sluggish or fixed pupil reaction to light o Lack of O2 to optic

nerve or brain or topical or systemic drug effects
Absence of consensual response - Seen in conditions that deprive
those areas of O2
Absent light reflex but no change in power of contraction during
accommodation (Argyll Robertson pupil) o Paralysis & locomotor
ataxia caused by syphilis
 PUPIL SIZE & EQUALITY
MYDRIASIS
❖ Dilated and fixed pupils, typically resulting from central nervous system
injury,
circulatory collapse, or deep anesthesia

MIOSIS
❖ Also known as pinpoint pupils, characterized by constricted and fixed pupils
possibly a result of narcotic drugs or brain damage.
 TESTING ACCOMMODATION OF PUPILS
Accommodation (Adjustment of Eye for NORMAL - The normal pupil
Various Distances) constricts when focused on a near
❖ Convergence of eyes & constriction of object & dilates when focused on a
pupil to focus on a near object & dilation far object.
of pupil when looking at a far object.
❖ Accommodation may be sluggish in
advanced age
❖ Hold your finger or a pencil about 12 to 15
inches from the client.
❖ Ask the client to focus on your finger or
pencil & to remain focused on it as you
move it closer in toward the eyes.
❖ Accommodation occurs when the client
moves his focus of vision from a distant
point to a near object, causing pupils to
constrict
TESTING ACCOMMODATION OF PUPILS
 CONVERGENCE TEST / PERRLA
CONVERGENCE - assessed by
moving the finger toward the
patient's nose, hold a small target,
such as a penlight, in front of the
client & slowly moves it closer until
the client have a double vision.

PERRLA
o P – upils
o E – qual
o R – ound
o R – eactive
o L – ight reacting
o A – ccomodation
ASSESSING PERRLA
Extraocular
Muscles of
the EYE
 Extraocular Movement of the Eye
EYE MOVEMENTS - controlled by muscles innervated by cranial nerves III, IV & VI. Common
damage to these nerves is double vision. Six cranial nerves innervate motor, sensory & autonomic
structures in the eyes.
6 CRANIAL NERVES are:
Optic nerve (CN II),
Oculomotor nerve (CN III),
Trochlear nerve (CN IV),
Trigeminal nerve (CN V),
Abducens nerve (CN VI), & facial nerve (CN VII).

1.OPTIC NERVE (CN II) - purely sensory in the eyes.

Senses the incoming light & image displayed on the retina &
Transmits this image into the cerebral cortex.
2.OCULOMOTOR NERVE (CN III) - responsible for innervating the major of the extraocular muscles
of the eyes & provides motor innervation to the superior rectus muscle, medial rectus muscle,
inferior rectus muscle, inferior oblique muscle, levator palpebrae superioris muscle, ciliary muscle,
& the sphincter muscle.
 Extraocular movement of the Eye
3.TROCHLEAR NERVE (CN IV) - contributes to the motor function of the
eyes, but only innervates one muscle that attaches to the eyes (Superior
oblique muscle)
4. TRIGEMINAL NERVE (CN V) has three main branches:
Ophthalmic branch (CN V1),
Maxillary branch (CN V2), &
Mandibular branch (CN V3).
Only the ophthalmic branch of the trigeminal nerve innervates the eye which
provides sensory innervation to the eye, works as the afferent part of the
corneal & lacrimation reflex.
The facial nerve is the efferent part of the corneal & lacrimation reflex.
5. ABDUCENS NERVE (CN V1) - innervates only one muscle in the eye, the
lateral rectus muscle. When this muscle contracts, it causes the eye to
abduct.
 Extraocular movement of the Eye
6. FACIAL NERVE (CN V11) - provides
innervation to the muscles of facial
expression, salivation, taste of two-thirds
anterior portion of the tongue & auditory
volume modulation.
In the eyes, the facial nerve is
responsible for eye closure & blinking by
motor innervation of the orbicularis oculi
muscle.
The corneal & lacrimation reflex is a
result of the sensory afferent input from
the ophthalmic branch of the trigeminal
nerve & the efferent output from the
facial nerve
CRANIAL NERVES
External Structure of
Supplies- the eyes.
the EYE
 ASSESS EXTRAOCULAR MUSCLES
POSITION TEST – Look straight ahead, left,
right, straight up, up and to the left, up and
to the right, straight down, down and to the
left, down and to the right. ASSESS THE 8
OCULAR MOVEMENTS TO DETERMINE
ALIGNMENT & COORDINATION and to
evaluate the proper functioning of the
extraocular muscles of the eyes
NORMAL - Both eyes coordinated, move in
unison, with parallel alignment .
DEVIATIONS FROM NORMAL - Movements
not coordinated or parallel; one or both eyes
fail to follow specific directions.
COMMON ABNORMALITIES
Strabismus - squint; deviation of the eye
which the patient cannot overcome
Nystagmus - involuntary rapid movement
(horizontal, vertical, rotatory, or mixed) of
the eyeball
 ASSESS EXTRAOCULAR MUSCLES
TEST FOR EXTRAOCULAR MUSCLES
COVER & UNCOVER TEST
❖ COVER PATIENT’S ONE EYE & HAVE PATIENT
FOCUS ON OBJECT AFAR. UNCOVER EYE &
NOTE ANY DRIFTING.
NORMAL: Gaze is steady when eye is covered &
uncovered. No drifting.
DEVIATIONS FROM NORMAL
❖ Shift in gaze, Movement of eyes to refocus gaze
❖ Weak eye muscles. If uncovered eye shifts in
response to covering opposite eye, covered eye is
dominant
❖ Covered eye shifts after being uncovered, that eye
is weak. Weakness of extraocular muscles or CN
III, IV, & VI, which innervate extraocular muscles
WEAKNESS OF EXTRAOCULAR MUSCLES
CRANIAL NERVES III, IV, & VI

Note: 4th nerve paralysis: The eye cannot

look down when turned inward.

Note: 6th nerve paralysis:

The eye cannot look to the
outer side.
 VISUAL FIELDS
ASSESS EYE MUSCLE STRENGTH
& CRANIAL NERVE FUNCTION
❖ Note for nystagmus - involuntary
rapid movement (horizontal,
vertical, rotatory, or mixed) of the
eyeball.

CARDINAL FIELDS OF GAZE

TEST
Assessing the 6 Extraocular Eye
Muscles by the 6 Cardinal Fields
of Gaze
VISUAL FIELDS
NORMAL FINDINGS
❖ Eye movement should be conjugate
(parallel), smooth & symmetric
throughout all 6 directions
❖ Equal palpebral fissures
❖ Intact extraocular muscles
DEVIATIONS FROM NORMAL
❖ Nystagmus - Limited or
disconjugate movement in one or
more fields of gaze
❖ Ptosis (drooping of upper eyelid)
❖ Eyelid lag
❖ Damage, irritation, or pressure on
corresponding extraocular muscle
or cranial nerve that innervates the
muscle
COMMON ABNORMALITIES:
ASTIGMATISM - History of blurred vision
❖ Corneal irregularity
R/L SUPERIOR
R/L LATERAL
R/L INFERIOR
❖ Refraction of light rays diffused rather than
sharply focused on retina
CONJUNCTIVITIS - Irritation & inflammation of
bulbar & palpebral conjunctiva
❖ Common sources of eye discomfort, caused
by allergies, viruses, or bacterial infections
❖ Manifests as redness of the palpebral
conjunctiva & bloodshot sclera
❖ Purulent drainage usually present if caused
by infection
CATARACT - Abnormal, progressive opacity of
the lens, pupil may appear cloudy & red reflex
absent or darkened
 COMMON ABNORMALITIES
GLAUCOMA – group of eye diseases that damage the optic nerve, often caused by increases
IOP. Tunnel vision & 2nd leading cause of blindness worldwide, may be asymptomatic
S/S include: crescent shadow, firm eyeball, blurred optic disc margins, loss of peripheral
vision & depth perception & contrast sensitivity
2 MAIN TYPES:
1. Primary Open Angle Glaucoma (POAG) – blind spots in the sides (peripheral) or central
vision, associated with loss of central vision & elevated eye pressure, excessive eye pressure is
not required for diagnosis. Tunnel vision in advanced stages
2. Primary Angle Closure Glaucoma (PACG) - acute symptoms including: severe headache, red
eye, blurred vision, dilated pupil, nausea & vomiting, eye pain, halos around lights

IRIS - Assessment of the anterior chamber with oblique flashlight test often reveals forward
bowing of iris
IRITIS - Symptoms include severe eye pain, tearing, sensitivity to light (photophobia) & in
severe cases, diminished visual acuity; if untreated w/ scarring & permanently diminished
vision occur.
PINGUECULA - Painless yellow nodule caused by thickening of bulbar conjunctiva & often
caused by exposure to sunlight or wind
PTERYGIUM - Triangular growth of the bulbar conjunctiva from the nasal side of the eye toward
the pupil, decreased elasticity of the lens, results in decreased ability to focus on near objects,
can obstruct vision if growth occludes the pupil
 COMMON ABNORMALITIES
VISUAL FLOATERS - Specks in the visual field that usually disappears when the patient
looks at them
❖ Caused by small cells floating in the vitreous humor,
❖ May signal retinal separation, Black spot, retinal detachment
RETINAL DETACHMENT - Separation of retinal layer & choroid layer in back of eye
Signs usually develop gradually,
❖ Initial symptoms include, sees large numbers of floaters, flashing lights when eyes
move & slowly expanding shadow in lateral fields of gaze & untreated retinal detachment
results in irreversible blindness
MACULAR DEGENERATION - Diminished visual acuity, Loss of central vision, Increased
pigmentation of macula
RETINITIS PIGMENTOSA - Degeneration of retina, Begins in childhood & may progress to
blindness by middle adulthood, Rods & cones.
❖ Earlier signs may include night blindness, reduced visual fields, pigmentation of the
retina & macular degeneration.
SJÖGREN’S SYNDROME - Immunologic disorder in which lacrimal, salivary & other glands
do not produce enough moisture, causes dryness of the mouth, eyes, & other mucous
membranes, damage to external eye tissues, such as the cornea & conjunctiva, may result
from excessive & prolonged dryness.
DIPLOPIA - “double vision”, visual axes aren’t directed at the object of sight at the same
time, results from misaligned extraocular muscles.
 COMMON ABNORMALITIES
STRABISMUS (crossed or wall eye) 2 TYPES:
❖ Axis of eye deviates & does not fixate on 1. ESOTROPIA - eye turns inward
an object, caused by weak intraocular
muscles or a lesion on the oculomotor
nerve.
❖ Causes disconjugate vision (one eye
deviates from fixated image). Initially,
diplopia results as each eye transmits the
images received 2. EXOTROPIA - eye turns outward
❖ Eventually, brain suppresses images
received from deviating or weak eye
❖ After a period of disuse, visual acuity in
weak eye deteriorates & loss of vision
results
❖ Treatment before age 6 is necessary to
prevent permanent damage
 COMMON ABNORMALITIES
VISUAL HALOS - sees halos & rainbows around
bright lights.
❖ caused by corneal edema as a result of
prolonged wearing of contact lenses &
fluctuation of blood sugar levels

ENUCLEATION - Removal of the eyeballs

OPTIC NERVE PATHWAYS, VISUAL FIELDS &

SELECTED ASSOCIATED VISUAL DEFECTS -
Pressure on a specific part of the optic nerve
tract can produce visual loss (hemianopia) on
the ipsilateral (same side) or contralateral
(opposite side) visual field, depending on the
location of the injury or lesion.
 REFERENCES: from module &
REFERENCES:
From HA Module
Health Assessment in Nursing 6th Edition, Philadelphia:
Wolters Kluwer Weber, J.R., and Kelley, J. H., 2022
Health & Physical Assessment in Nursing, Donita
D’Amico & Colleen Barbarito, 3rd Edition, Copyright 2016,
Pearson Education, published 2019
Fundamentals of Nursing – Kozier & Erbs, 2008, 2016

COURSE TASKS: MIDTERM RLE LAB 1- ASSESSMENT OF THE EYES

QUIZ # 1– HEAD & NECK, EYES