Assessing Eyes

CHAPTER 16
Assessing Eyes
Case Study sclera should be seen above or below the limbus (the point
where the sclera meets the cornea).
Susan Jones, a 24-year-old Caucasian Eyelashes are projections of stiff hair curving outward along
woman, presents to the clinic after sus- the margins of the eyelids that filter dust and dirt from air
taining an injury to her right eye. She is entering the eye.
holding her hand over her eye. The conjunctiva is a thin, transparent, continuous mem-
brane that is divided into two portions: a palpebral and a bul-
bar portion. The palpebral conjunctiva lines the inside of the
eyelids, and the bulbar conjunctiva covers most of the anterior
eye, merging with the cornea at the limbus. The point at which
the palpebral and bulbar conjunctivae meet creates a folded
recess that allows movement of the eyeball. This transparent
Structure and Function membrane allows for inspection of underlying tissue and pro-
tects the eye from foreign bodies.
The eye transmits visual stimuli to the brain for interpretation The lacrimal apparatus consists of glands and ducts that
and, in doing so, functions as the organ of vision. The eyeball lubricate the eye (Fig. 16-2). The lacrimal gland, located in
is located in the eye orbit, a round, bony hollow formed by the upper outer corner of the orbital cavity just above the
several different bones of the skull. In the orbit, a cushion of eye, produces tears. As the lid blinks, tears wash across the
fat surrounds the eye. The bony orbit and fat cushion protect eye then drain into the puncta, which are visible on the upper
the eyeball. and lower lids at the inner canthus. Tears empty into the
To perform a thorough assessment of the eye, you need a lacrimal canals and are then channeled into the nasolacrimal
good understanding of the external and internal structures sac through the nasolacrimal duct. They drain into the nasal
of the eye, the visual fields and pathways, and the visual meatus.
reflexes. The extraocular muscles are the six muscles attached to the
outer surface of each eyeball (Fig. 16-3). These muscles con-
EXTERNAL STRUCTURES trol six different directions of eye movement. Four rectus mus-
cles are responsible for straight movement, and two oblique
OF THE EYE
muscles are responsible for diagonal movement. Each muscle
The eyelids (upper and lower) are two movable structures coordinates with a muscle in the opposite eye. This allows for
composed of skin and two types of muscle: striated and parallel movement of the eyes and thus the binocular vision
smooth. Their purpose is to protect the eye from foreign bod- characteristic of humans. Innervation for these muscles is sup-
ies and limit the amount of light entering the eye. In addition, plied by three cranial nerves: the oculomotor (III), trochlear
they serve to distribute tears that lubricate the surface of the (IV), and abducens (VI).
eye (Fig. 16-1). The upper eyelid is larger, more mobile, and
contains tarsal plates made up of connective tissue. These plates
contain the meibomian glands, which secrete an oily substance INTERNAL STRUCTURES
that lubricates the eyelid.
OF THE EYE
The eyelids join at two points: the lateral (outer) canthus and
medial (inner) canthus. The medial canthus contains the puncta, The eyeball is composed of three separate coats or layers (Fig.
two small openings that allow drainage of tears into the lac- 16-4, p. 297). The external layer consists of the sclera and cornea.
rimal system, and the caruncle, a small, fleshy mass that con- The sclera is a dense, protective, white covering that physically
tains sebaceous glands. The white space between open eyelids supports the internal structures of the eye. It is continuous
is called the palpebral fissure. When closed, the eyelids should anteriorly with the transparent cornea (the “window of the
touch. When open, the upper lid position should be between eye”). The cornea permits the entrance of light, which passes
the upper margin of the iris and the upper margin of the pupil. through the lens to the retina. It is well supplied with nerve
The lower lid should rest on the lower border of the iris. No endings, making it responsive to pain and touch.
295
296 UNIT 3 • • • NURSING ASSESSMENT OF PHYSICAL SYSTEMS
Superior oblique Orbit

Pupil
Upper eyelid
Iris Superior rectus
Sclera
Medial rectus
Sclera
Palpebral Medial
fissure canthus
Eyelash
Lower eyelid
Caruncle Lateral rectus
Puncta
Inferior rectus Inferior oblique
FIGURE 16-3 Extraocular muscles control the direction of eye
FIGURE 16-1 External structures of the eye. movement.
CLINICAL TIP rays onto the retina. Adjustments must be made in refrac-
Because of this sensory property, contact with a wisp of tion depending on the distance of the object being viewed.
cotton stimulates a blink in both eyes known as the corneal Refractive ability of the lens can be changed by a change in
reflex. This reflex is supported by the trigeminal nerve, which shape of the lens (which is controlled by the ciliary body).
carries the afferent sensation into the brain, and the facial The lens bulges to focus on close objects and flattens to focus
nerve, which carries the efferent message that stimulates on far objects.
the blink. The choroid layer contains the vascularity necessary to pro-
vide nourishment to the inner aspect of the eye and prevents
The middle layer contains both an anterior portion, which
light from reflecting internally. Anteriorly, it is continuous
includes the iris and the ciliary body, and a posterior layer,
with the ciliary body and the iris.
which includes the choroid. The ciliary body consists of muscle
The innermost layer, the retina, extends only to the ciliary
tissue that controls the thickness of the lens, which must be
body anteriorly. It receives visual stimuli and sends it to the
adapted to focus on objects near and far away.
brain. The retina consists of numerous layers of nerve cells,
The iris is a circular disc of muscle containing pigments
including the cells commonly called rods and cones. These spe-
that determine eye color. The central aperture of the iris is
cialized nerve cells are often referred to as “photoreceptors”
called the pupil. Muscles in the iris adjust to control the pupil’s
because they are responsive to light. The rods are highly sensi-
size, which controls the amount of light entering the eye. The
tive to light, regulate black-and-white vision, and function in
muscle fibers of the iris also decrease the size of the pupil to
dim light. The cones function in bright light and are sensitive
accommodate for near vision and dilate the pupil when far
to color.
vision is needed.
The optic disc is a cream-colored, circular area located on the
The lens is a biconvex, transparent, avascular, encapsu-
retina toward the medial or nasal side of the eye. It is where
lated structure located immediately posterior to the iris. Sus-
the optic nerve enters the eyeball. The optic disc can be seen
pensory ligaments attached to the ciliary body support the
with the use of an ophthalmoscope and is normally round or
position of the lens. The lens functions to refract (bend) light
oval in shape, with distinct margins. A smaller circular area
that appears slightly depressed is referred to as the physiologic
cup. This area is approximately one-third the size of the entire
Lacrimal gland optic disc and appears somewhat lighter/whiter than the disc
borders.
Lacrimal canal The retinal vessels can be readily viewed with the aid of
an ophthalmoscope. Four sets of arterioles and venules travel
through the optic disc, bifurcate, and extend to the periph-
Lacrimal sac ery of the fundus. Vessels are dark red and grow progressively
narrower as they extend out to the peripheral areas. Arterioles
Ducts of Nasolacrimal
carry oxygenated blood and appear brighter red and narrower
lacrimal duct than the veins. The general background, or fundus (Fig. 16-5),
gland varies in color, depending on skin color. A retinal depression
Opening of known as the fovea centralis is located adjacent to the optic
duct (in nose) disc in the temporal section of the fundus. This area is sur-
Lacrimal canal
rounded by the macula, which appears darker than the rest of
the fundus. The fovea centralis and macular area are highly
FIGURE 16-2 The lacrimal apparatus consists of tear (lacrimal) concentrated with cones and form the area of highest visual
glands and ducts. resolution and color vision.
16 • • • ASSESSING EYES 297
Retina Medial rectus muscle

Choroid Conjunctiva
Central retinal Sclera

artery and vein
Optic Lens
disk
Pupil
Anterior
chamber
Optic
nerve
Macula
Cornea
Retinal Iris
vein muscle
Retinal
artery Ciliary
muscle
Vitreous
body Lateral rectus muscle
FIGURE 16-4 Anatomy of the eye.
The eyeball contains several chambers that maintain struc- lar pressure. The aqueous humor filters out of the eye from
ture, protect against injury, and transmit light rays. The anterior the posterior to the anterior chamber then into the canal of
chamber is located between the cornea and iris; the posterior Schlemm through a filtering site called the trabecular meshwork.
chamber is the area between the iris and the lens. These cham- Another chamber, the vitreous chamber, is located in the area
bers are filled with aqueous humor, a clear liquid substance pro- behind the lens to the retina. It is the largest of the chambers
duced by the ciliary body. Aqueous humor helps to cleanse and is filled with a vitreous humor that is clear and gelatinous.
and nourish the cornea and lens as well as maintain intraocu-
VISION
Visual Fields and Visual Pathways
A visual field refers to what a person sees with one eye. The
Fovea
centralis visual field of each eye can be divided into four quadrants:
Physiologic upper temporal, lower temporal, upper nasal, and lower
cup nasal (Fig. 16-6). The temporal quadrants of each visual field
extend farther than the nasal quadrants. Thus, each eye sees
a slightly different view but their visual fields overlap quite a
Optic
disc bit. As a result of this, humans have binocular vision (“two-
eyed” vision) in which the visual cortex fuses the two slightly
different images and provides depth perception, or three-
dimensional vision.
Visual perception occurs as light rays strike the retina, where
they are transformed into nerve impulses, conducted to the
brain through the optic nerve, and interpreted. In the eye,
light must pass through transparent media (cornea, aqueous
humor, lens, and vitreous body) before reaching the retina.
Retinal Macula The cornea and lens are the main eye components that refract
vein (bend) light rays on the retina. The image projected on the
retina is upside down and reversed right to left from the actual
Retinal image. For example, an image from the lower temporal visual
artery
field strikes the upper temporal quadrant of the retina. At the
FIGURE 16-5 Normal ocular fundus. point where the optic nerves from each eyeball cross—the
Left visual field Right visual field LIGHT

Upper Upper Upper To iris To iris
temporal nasal temporal (direct (consensual
reaction) reaction)
Lower Lower Lower
temporal nasal temporal
Optic Frontal lobe

nerve Optic
chiasm
Oculomotor
Optic Optic nerve
tract T
Temporal nerve
llobe Optic
tract
Sen
Sensory
To visual Motor
cortex
FIGURE 16-7 The pupils admit light that travels over the visual
pathways. If a light focuses on only one eye, the pupil responds
Occipital to ensure that the light needed for vision can enter but not so
lobe
Visual cortex much that eye damage would result. The other pupil responds in
the same manner. This phenomenon of direct pupillary response
FIGURE 16-6 Visual fields and visual pathways. Each eye has a and consensual pupillary response is a reflex governed by the
slightly different view of the same field. However, the views oculomotor nerve.
overlap significantly, which accounts for binocular vision.
optic chiasma—the nerve fibers from the nasal quadrant of

each retina (from both temporal visual fields) cross over to
Health Assessment
the opposite side. At this point, the right optic tract contains
only nerve fibers from the right side of the retina and the left
COLLECTING SUBJECTIVE DATA:
optic tract contains only nerve fibers from the left side of the THE NURSING HEALTH HISTORY
retina. Therefore, the left side of the brain views the right side Beginning when the nurse first meets the client, assessment
of the world. of vision provides important information about the client’s
ability to interact with the environment. Changes in vision are
Visual Reflexes often gradual and go unrecognized by clients until a severe
The pupillary light reflex causes pupils immediately to constrict problem develops. Therefore, asking clients specific questions
when exposed to bright light. This can be seen as a direct reflex, about their vision may help with early detection of disorders.
in which constriction occurs in the eye exposed to the light, or With recent advances in medicine and surgery, early detection
as an indirect or consensual reflex, in which exposure to light in and intervention are increasingly important.
one eye results in constriction of the pupil in the opposite eye First, gather data from the client about his or her current
(Fig. 16-7). These protective reflexes, mediated by the oculo- level of eye health. Also discuss any personal and family his-
motor nerve, prevent damage to the delicate photoreceptors tory problems that are related to the eye. Collecting data con-
by excessive light. cerning environmental influences on vision as well as how any
Accommodation is a functional reflex allowing the eyes to problems are influencing or affecting the client’s usual activi-
focus on near objects. This is accomplished through move- ties of daily living is also important. Answers to these types of
ment of the ciliary muscles, causing an increase in the curva- questions help to evaluate a client’s risk for vision loss and,
ture of the lens. This change in shape of the lens is not vis- in turn, present ways that the client may modify or reduce the
ible. However, convergence of the eyes and constriction of the risk of eye problems. The following questions provide guid-
pupils occur simultaneously and can be seen. ance in conducting the interview.
History of Present Health Concern

QUESTION RATIONALE
Visual Problems
Describe any recent visual difficulties or changes in your vision that Sudden changes in vision are associated with acute problems such as
you have experienced. Were they sudden or gradual? head trauma or increased intracranial pressure. Gradual changes in
vision may be related to aging, diabetes, hypertension, or neurologic
disorders.
Do you see spots or floaters in front of your eyes? Spots or floaters are common among clients with myopia or in
clients over age 40. In most cases, they are due to normal physi-
ologic changes in the eye associated with aging and require no
intervention.
Do you experience blind spots? Are they constant or intermittent? A scotoma is a blind spot that is surrounded by either normal or
slightly diminished peripheral vision. It may be from glaucoma.
Intermittent blind spots may be associated with vascular spasms
(ophthalmic migraines) or pressure on the optic nerve by a tumor
or intracranial pressure. Consistent blind spots may indicate retinal
detachment. Any report of a blind spot requires immediate attention
and referral to a physician.
Do you see halos or rings around lights? Seeing halos around lights is associated with narrow-angle
glaucoma.
Do you have trouble seeing at night? Night blindness is associated with optic atrophy, glaucoma, and
vitamin A deficiency.
Do you experience double vision (diplopia)? Double vision (diplopia) may indicate increased intracranial pressure
due to injury or a tumor.
Other Symptoms
Do you have any eye pain or itching? Do you have pain with bright Burning or itching pain is usually associated with allergies or super-
lights (photophobia)? Describe. ficial irritation. Throbbing, stabbing, or deep, aching pain suggests
a foreign body in the eye or changes within the eye. See procedure
for assessing eye trauma and presence of foreign body at the end of
the physical assessment section. Most common eye disorders are not
associated with actual pain. Therefore, immediately refer reports of
eye pain.
Do you have any redness or swelling in your eyes? Redness or swelling of the eye is usually related to an inflammatory
response caused by allergy, foreign body, or bacterial or viral infection.
Do you experience excessive watering or tearing of the eye? If so, is it Excessive tearing (epiphora) is caused by exposure to irritants or
in one eye or both eyes? obstruction of the lacrimal apparatus. Unilateral epiphora is often
associated with foreign body or obstruction. Bilateral epiphora is
often associated with exposure to irritants, such as makeup or facial
cleansers, or it may be a systemic response.
Have you had any eye discharge? Describe. Discharge other than tears from one or both eyes suggests a bacte-
rial or viral infection.
Personal Health History

QUESTION RATIONALE
Have you ever had problems with your eyes or vision? A history of eye problems or changes in vision provides clues to the
current health of the eye.
Have you ever had eye surgery? Surgery may alter the appearance of the eye and the results of future
examinations.
Continued on following page

Personal Health History (Continued)

QUESTION RATIONALE
Describe any past treatments you have received for eye problems Client may not be satisfied with past treatments for vision problems.
(medication, surgery, laser treatments, corrective lenses). Were these
successful? Were you satisfied?
What types of medications do you take? Ocular side effects of drugs are often unrecognized or overlooked.
Some medications reported to have ocular side effects include
corticosteroids, lovastatin, pyridostigmine, quinidine, risperidone, and
rifampin (Kent, Shukla, & Hutnik, 2007).
When was your last eye examination? A thorough eye examination is recommended for healthy clients
without risk factors every 2 years, for ages 18 through 60; annually
for those age 61 and older (American Optometric Association [AOA],
2006–2012). All clients at risk for eye problems should be examined
annually or as recommended by their physician.
Do you perform the test for macular degeneration using the Amsler’s To perform the Amsler test properly, clients should wear their glasses
chart? How do you use this chart and how often? What do you see if they normally do so. They should use the bottom portion to view
when you use it? the chart if they wear bifocals. The Amsler’s chart should be posted
on a wall at eye level (Fig. 16-8, p. 302). Clients should stand 12–14
feet (comfortable reading distance) away from it and cover one eye.
With the other eye, they should look at the center dot. Any areas
of distortion, graying, blurring, or blank spots should be marked
on the chart and they should notify their physician. If they have
already developed a baseline with distortions that their primary care
provider is aware of, then they should report any changes from their
baseline to their primary care provider. Clients over the age of 45 or
with a family history of retinal problems, such as macular degenera-
tion, should have their eyes checked periodically (American Macular
Degeneration Foundation [AMDF], 2012).
Refer the client to http://www.amd.org/living-with-amd/resources-
and-tools/31-amsler-grid.html to download the Amsler grid with
directions to use to test for any visual changes (Macular Degenera-
tion Partnership, 2012).
Do you have a prescription for corrective lenses (glasses or contacts)? The amount of time the client wears the corrective lenses provides
Do you wear them regularly? If you wear contacts, how long do you information on the severity of the visual problem. Clients who do not
wear them? How do you clean them? wear the prescribed corrective lenses are susceptible to eyestrain.
Improper cleaning or prolonged wearing of contact lenses can lead to
infection and corneal damage.
Have you ever been tested for glaucoma? What were the results? Tonometry is used to measure pressure within the eye. Normal eye
pressures range from 10 to 21 millimeters of mercury (mm Hg). Eye
pressures greater than 22 mm Hg increase one’s risk for develop-
ing glaucoma. However, people with normal eye pressure may
develop glaucoma (AOA, 2013) (see Evidence-Based Practice 16-1,
p. 303).
Family History
QUESTION RATIONALE
Is there a history of eye problems or vision loss in your family? Many eye disorders have familial tendencies. Examples include
glaucoma, refraction errors, allergies, and macular degeneration. Ap-
proximately 11 million people in the United States have some form of
age-related macular degeneration, which is a major cause of visual
impairment in the U.S. It is estimated that nearly 22 million will have
macular degeneration by the year 2050 (American Health Assistance
Foundation [AHAF], 2012). See Evidence-Based Practice 16-2 on
page 304.
Lifestyle and Health Practices

QUESTION RATIONALE
Are you exposed to conditions or substances in the workplace or Injuries or diseases may be related to exposure in the workplace
home that may harm your eyes or vision (e.g., chemicals, fumes, or home. These problems can be minimized or avoided altogether
smoke, dust, or flying sparks)? Do you wear safety glasses during with hazard identification and implementation of safety measures.
exposure to harmful substances? It is important to teach the client to use protective eyewear when
engaging in recreational activities and hazardous situations (Healthy
People 2020, 2011).
Do you wear sunglasses during exposure to the sun? Exposure to ultraviolet radiation puts the client at risk for the
development of cataracts (opacities of the lenses of the eyes; see
Evidence-Based Practice 16-3, p. 305). Consistent use of sunglasses
during exposure minimizes the client’s risk.
Has your vision loss affected your ability to care for yourself? To Vision problems may interfere with the client’s ability to perform
work? usual activities of daily living. The client may be unable to read medi-
cation labels or fill insulin syringes. If the vision problem is severe, the
client’s ability to perform hygiene practices or prepare food may be
affected. Vision problems may affect a client’s ability to work if the
job is one that depends on sight, such as a pilot or bus driver.
What visual aids do you use to assist you with your visual loss (mag- It is important to assist the client to access and use assistive and
nifying glasses, audiotapes, CDs, special glasses for viewing televi- adaptive visual devices to improve one’s activities of daily living
sion, large-numbered phones, large-print checks, large print books)? (Healthy People, 2020, 2011).
Describe your typical diet. What have you eaten in the last 24 hours? The American Optometric Association (2012) explains that research
Do you take any vitamins or supplements? has linked nutrition to a decreased risk of age-related macular
degeneration (AMD) as follows:
Lutein and zeaxanthin found in green leafy vegetables, eggs, and oth-
er foods reduce the risk of chronic eye diseases, including age-related
macular degeneration and cataracts (Richer et al., 2004; Christen
et al., 2008). Foods rich in these nutrients include kale, spinach, col-
lards, turnip greens, corn, green peas, broccoli, romaine lettuce, green
beans, eggs, and oranges.
Vitamin C can decrease the risk of cataracts and reduce the risk of
age-related macular degeneration when taken with other essential
nutrients (Age-Related Disease Study Research Group, 2007; Christen
et al., 2008)
Vitamin E in its most biologically active form is a powerful anti-
oxidant found in nuts, fortified cereals, and sweet potatoes. It is
thought to protect cells of the eyes from damage caused by unstable
molecules (Age-Related Disease Study Research Group, 2007).
Two omega-3 fatty acids have been shown to be important for
proper visual development and retinal function (Chew, 2007).
Zinc is an essential trace mineral or “helper molecule.” It plays a vital
role in bringing vitamin A from the liver to the retina in order to pro-
duce melanin, a protective pigment in the eyes (Grahn et al., 2001).
Beta-carotene supplements have been known to decrease one’s risk
of developing cataracts and AMD. However, research shows this may
increase the risk of lung cancer in people who smoke (especially
those smoking more than 20 cigarettes per day), former smokers,
have been exposed to asbestos, or drink one or more alcoholic bever-
ages and also smoke. Beta-carotene from food alone does not seem
to have this risk (Medline, 2012).
Do you smoke? How many packs and for how long? Tobacco smoking has been found to be strongly associated with a
higher prevalence of nuclear and cortical cataracts (Krishnaiah et al.,
2005).
Amsler’s Chart to Test Your Sight
Instructions for Use

1. Tape this page at eye level where light is consistent and
without glare.
2. Put on your reading glasses and cover one eye.
3. Fix your gaze on the center black dot.
4. Keeping your gaze fixed, try to see if any lines are distorted
or missing.
5. Mark the defect on the chart.
6. Test each eye separately.
7. If the distortion is new or has worsened, arrange to see your
ophthalmologist at once.
8. Always keep the Amsler’s Chart the same distance from your
eyes each time you test.
FIGURE 16-8 Amsler grid.
Case Study
The case study introduced at the beginning of the chapter is now used to demonstrate how a nurse would use
the COLDSPA mnemonic to explore Ms. Jones’s presenting concerns.
Mnemonic Question Data Provided

Character Describe the sign or symptom (feeling, appear- “My right eye really hurts. It feels scratchy,
ance, sound, smell, or taste if applicable). like there is something in my eye.”
Onset When did it begin? “A couple of hours ago, when I accidentally
poked my key in my eye.”
Location Where is it? Does it radiate? Does it occur “Only my right eye.”
anywhere else?
Duration How long does it last? Does it recur? “It hurts constantly.”
Severity How bad is it? How much does it bother you? Client rates pain as 4 on a scale of 0 to 10.
Pattern What makes it better or worse? “It hurts when I blink and feels better if I
keep my eye shut.”
Associated factors/How What other symptoms occur with it? How “My right eye is watery and my vision is
it Affects the client does it affect you? blurry, making it difficult to drive.”
After investigating Susan Jones’s recent eye trauma, that would harm her eyes. She states that she wears sun-
the nurse continues with the health history. Ms. Jones glasses about 80% of the time when exposed to the sun.
reports that she has never had a problem with her eyes Ms. Jones reports that the only medication she takes is
or vision. She states that she has never had eye surgery an occasional Tylenol for headache. Client states that her
or any type of eye treatment. Ms. Jones reports that her last eye examination was 2 years ago and that her vision
father has glaucoma. She denies exposure to substances was “perfect.”
16-1 EVIDENCE-BASED HEALTH PROMOTION AND DISEASE PREVENTION: GLAUCOMA
INTRODUCTION for glaucoma. This recommendation was based on the con-

Glaucoma is the second leading cause of blindness after cata- clusion that there is insufficient evidence to know the extent
racts. Mayo Clinic (2010b) says it is often referred to as “the that screening would reduce impaired vision or quality of
silent thief of sight” because it can damage vision very gradually life, and that treatment of increased IOP and early POAG
with no noticeable loss of vision until the disease is advanced. results in some harm, including eye irritation and a risk of
Mayo Clinic (2010b) and National Glaucoma Research (2011a) cataracts.
describe glaucoma as a group of eye conditions resulting in Mayo Clinic (2010b) has noted that POAG “gives few
optic nerve damage usually caused by abnormally high intra- warning signs or symptoms until permanent damage has
ocular pressures. already occurred,” and recommends regular eye examina-
There are several types of glaucoma. Symptoms differ for tions. According to Mayo Clinic, the American Academy of
the two most common types of glaucoma—primary open- Ophthalmology recommends a comprehensive eye exam for
angle glaucoma (POAG) and acute angle-closure glaucoma all adults starting at age 40, and every 3 to 5 years for those
(AACG) (AOA, 2013). The U.S. Preventive Services Task Force without glaucoma risk factors, and yearly screening after
(2005) reported that POAG is the most prevalent type of glau- age 60. For people with known risks for glaucoma or who
coma in the United States, with 2.5 million people having are African American, periodic eye exams are recommended
POAG in 2000 and 130,000 people becoming blind as a result starting between ages 20 and 39, and every 1 to 2 years after
of the disease. Causes of glaucoma may include eye injury, age 40. Other organizations that make similar recommenda-
inflammation, tumor, advanced cataracts, or diabetes, but tions are the Department of Veterans Affairs and the Ameri-
often there is no known cause. can Optometric Association.
POAG signs and symptoms include (Mayo Clinic, 2010b):
RISK ASSESSMENT
• Gradual loss of peripheral vision, usually in both eyes
• Tunnel vision in the advanced stages The U.S. Preventive Services Task Force (2005) and Mayo Clinic
AACG signs and symptoms include (Mayo Clinic, 2010b): (2010b) list POAG risk factors:
• Severe eye or eyebrow pain • Increased IOP above 21 mm Hg. However, it is important
• Severe headache to note that 25% to 50% of those with glaucoma have
• Nausea and vomiting (accompanying the severe eye normal IOP.
pain) • African American ethnicity (African Americans are up to
• Sudden onset of visual disturbance, often in low light 5 times more likely to have glaucoma, which occurs at a
• Blurred vision younger age compared to the average population (see
• Rainbow halos around lights National Glaucoma Research, 2011b).
• Reddening of the eye • Mexican American and Asian American ethnicity—these
two groups also face an increased risk.
HEALTHY PEOPLE 2020 GOAL • Advancing age (especially over age 60 for Caucasians; over
Healthy People 2020 objectives (2011) related to vision focus age 40 for African Americans)
on preserving sight and preventing blindness. The objectives • Family history of glaucoma
are: “address screening and examinations for children and • Diabetes
adults, early detection and timely treatment of eye diseases • Hypothyroidism
and conditions, injury prevention, and the use of vision reha- • Eye injuries, tumors, inflammatory processes
bilitation services.” • Prolonged corticosteroid use (especially corticosteroid eye
drops)
GOAL • Nearsightedness
Improve the visual health of the Nation through prevention,
early detection, timely treatment, and rehabilitation. CLIENT EDUCATION
Teach Clients
OBJECTIVE • Get regular eye exams and treat any elevated IOP promptly.
Reduce visual impairment due to glaucoma from a 2008 base- • Wear protective eye gear if involved in activities that risk
line of 13.7 per 1,000 population aged 45 years and over to eye injury.
12.3 per 1,000, a reduction of 10%. • Maintain optimum body weight and blood pressure to
avoid diabetes, or control diabetes if present.
SCREENING • Eat a varied, well-rounded, and healthy diet. The National
Mayo Clinic (2010a) proposes that early diagnosis and treat- Glaucoma Research, 2011a, notes that “there is no scien-
ment of glaucoma is necessary to minimize or prevent optic tific evidence suggesting that certain vitamins and min-
nerve damage and limit glaucoma-related vision loss. The erals prevent glaucoma or delay its progress. However,
U.S. Preventive Services Task Force (USPSTF, 2005) found that carotenoids (especially lutein and zeaxanthin), antioxi-
screening was able to detect increased intraocular pressure dants (such as vitamins C and E), vitamins A and D, zinc
(IOP) and early POAG in adults. However, there was insuffi- and omega-3 fatty acids may all contribute to better vision
cient evidence to recommend for or against screening adults overall.”
16-2 EVIDENCE-BASED HEALTH PROMOTION AND DISEASE PREVENTION:

MACULAR DEGENERATION
INTRODUCTION with visual impairment using assistive and adaptive devices

Macular degeneration is a major cause of visual impair- in 2008 to 12.3%).
ment that affects the macula portion of the retina. Vision is • Increase the use of vision rehabilitation services by people
affected in the central visual fields, which impacts on activi- with visual impairment (from 30.1 per 1,000 people with vi-
ties such as reading, driving, and recognizing faces of people sual impairment using vision rehabilitation services in 2008
standing in front of the affected person. According to Bright to 33.1% per 1,000).
Focus Foundation (2012), age-related macular degeneration SCREENING
is the leading cause of vision loss in Americans over 60 years
of age, and is the second leading cause of blindness world- The U.S. Preventive Services Task Force (2009) does not recom-
wide, and the number is expected to double to 22 million mend screening for visual acuity in older adults due to insuffi-
by 2050. cient evidence to assess the balance of benefits and harms of
Bright Focus Foundation (2012) reports that age-related screening for visual acuity for the improvement of outcomes
macular degeneration (AMD) is the “second-highest cause in older adults. However, the USPSTF lists the recommenda-
of irreversible blindness in the world.” Vision 2020 (2010) tions of other organizations:
reports WHO statistics for AMD worldwide. According to the • American Academy of Ophthalmology: comprehensive eye
data, AMD is the leading cause of blindness in the industrial- examinations every 1 to 2 years for persons 65 years or old-
ized countries. AMD “is responsible for 8.7% of all blindness er who have no risk factors
(3 million people) due to eye diseases, ranging from close to • American Optometric Association Consensus Panel on
0% in sub-Saharan Africa to 50% in industrialized countries. Comprehensive Adult Eye and Vision Examination: annual
The number affected is expected to double by the year 2020 eye examinations for adults 61 years or older
as a result of the ageing of the world’s population.” • American College of Obstetricians and Gynecologists: eval-
There are two types of AMD: dry and wet. The dry form is uation and counseling about visual acuity screening for all
the most common, accounting for 85% to 90% of AMD diag- women 65 years or older
noses (Bright Focus Foundation, 2012). A person may have Visual acuity tests and the Amsler grid (Fig. 16-8, p. 302)
both dry and wet forms, which may affect one or both eyes. are two screening tests performed that do not require dila-
Also, the speed of the disease’s progress may vary from slow tion of the pupils.
to rapid; the dry form “may advance and cause loss of vision RISK ASSESSMENT
without turning into the wet form,” or the dry form in early
stages or in late stages may change into the wet form of AMD Risk factors listed by Bright Focus Foundation (2012) include:
(Bright Focus Foundation, 2012). In the wet form, abnormal • Advancing age (3.8% of Americans between the ages of 50
new blood vessels form deep in the sensory retina, which and 59 have either intermediate or advanced AMD. By 70
can leak or bleed and result in marked loss of central vision to 79 years of age, this number increases to 14.4% (Bright
in one or both eyes. Each year after the onset of wet AMD Focus Foundation, 2012).
in one eye, 15% of persons develop the wet form in their • Smoking (increases risk 2- to 5-fold; affects blood vessels in
second eye. retina)
According to the National Eye Institute (2009), the most • Family history of AMD
common early symptom of dry AMD is blurred vision; the • Gender (females more likely to be affected)
classic and most common symptom of wet AMD is that • Obesity (BMI > 30)
straight lines appear crooked. Drusen, yellow pigments of • Race (Caucasians more affected than any other group)
extracellular metabolic waste, may be the first sign of AMD • Light eye color
(Bright Focus Foundation, 2012). However, these deposits • Prolonged sun exposure (UV light directly damages retinal
are frequently found in the eyes of older adults, so the tissue)
increase in size and number of the deposits is the indicator • High fat, high cholesterol, high sugar/low antioxidant
of AMD. diet
• Hypertension (narrows blood vessels in retina) or blood
HEALTHY PEOPLE 2020 GOAL pressure above 120/80 mmHg
Healthy People 2020 objectives (2011) related to vision focus • Cardiovascular disease
on preserving sight and preventing blindness. The objectives • Inactivity (probably related to vascular oxygen levels)
“address screening and examinations for children and adults, • AMD in one eye
early detection and timely treatment of eye diseases and con- • Genetic predisposition (several genes associated with AMD)
ditions, injury prevention, and the use of vision rehabilitation CLIENT EDUCATION
services.”
Teach Clients
GOAL The National Eye Institute (2009) recommends the following
Improve the visual health of the nation through prevention, for lifestyle modifications to decrease the risk of developing
early detection, timely treatment, and rehabilitation. AMD or to slow the progress of AMD:
• Don’t smoke.
OBJECTIVES • Get regular exercise (break a sweat at least three times a
• Reduce visual impairment due to AMD from a 2008 base- week).
line of 15.6 per 1,000 population aged 45 years and over to • Keep blood pressure in a normal range.
14.0 per 1,000, a reduction of 10%. • Control other medical conditions, such as cardiovascular
• Increase the use of assistive and adaptive devices by people disease.
with visual impairment (from baseline 11.2% of people • Maintain a healthy weight.
• Protect eyes from overexposure to sunlight with sunglasses • Two food-related research areas include:
and hats. • Preventing AMD by eating a low glycemic index diet
• Eat a varied and nutritious diet that includes leafy green veg- • National Eye Institute’s (2003) study on the preven-
etables, fruit, fish, and foods containing vitamins D, E, and tive effectiveness of a supplement formulation called
C, beta carotene and omega-3 fatty acids. “Vision foods” in- AREDS, which “found that taking a specific high dose
clude dark green, yellow, and orange fruits and vegetables: formula of antioxidants and zinc (500 milligrams of vi-
• Lutein-containing foods: dark, leafy greens such as spin- tamin C, 400 International Units of vitamin E, 15 mil-
ach, collard greens and kale; as well as okra, broccoli, ligrams of beta-carotene, 80 milligrams of zinc as zinc
papaya, oranges, mango, green beans, peaches, sweet oxide, and two milligrams of copper as cupric oxide)
potatoes, lima beans, squash, red grapes, green bell may delay or prevent intermediate age-related macular
pepper, and egg yolks. degeneration from progressing to the advanced stage”
• Zeaxanthin-containing foods include yellow corn, squash, (see report for more details of the results).
oranges, mango, kale, apricots, peaches, and orange bell • Have regular eye examinations as recommended by an eye
pepper. doctor according to age and eye condition.
• Also include foods high in vitamin C, vitamin E and • Use the Amsler grid test at home (e.g., put it on the refrig-
omega-3 fatty acids. erator door and use it daily).
Although beta carotene supplements have been • If diagnosed with AMD, vision rehabilitation and aids may
shown to slow the progression of AMD, if be useful.
you are a current or ex-smoker, you should not take these • Note: once diagnosed with AMD, there is no harm in using
supplements because they may lead to an increased risk of eyes for reading, watching TV, or other activities since eye
lung cancer (NEI, 2009). damage will not increase.

CATARACTS
INTRODUCTION OBJECTIVES
Quoting the World Health Organization (WHO), Vision 2020 • Reduce visual impairment due to cataracts (from baseline
(2011) says that approximately 285 million people world- 109.6 per 1,000 population aged 65 years and over in 2008
wide are visually impaired and 39 million of them are blind. by 10% to 98.6 per 1,000).
Cataracts are the leading cause of blindness. In the United • Increase the use of assistive and adaptive devices by people
States, 70% of the population has cataracts, causing prob- with visual impairment (from baseline 11.2% of people
lems with everyday activities (Mayo Clinic, 2010; Cataracts. with visual impairment using assistive and adaptive devices
com, 2011). in 2008 to 12.3%).
Cataracts are a clouding of the usually clear lens of the • Increase the use of vision rehabilitation services by people
eye, causing a person to see as though looking through a with visual impairment (from 30.1 per 1,000 people with vi-
frosty or foggy window (Mayo Clinic, 2010). Most cataracts sual impairment using vision rehabilitation services in 2008
develop slowly and are most often found in people over to 33.1% per 1,000).
65 years of age. With age, the lens becomes less flexible,
thicker, and less transparent as tissues breakdown or clump SCREENING
together, turning the lens yellow or brown. In addition Mayo Clinic (2010) asserts that early detection and treatment
to aging, however, injury, genetics, or maternal infections of cataracts can greatly reduce the risk of partial or complete
(resulting in infant cataracts) may be causes. Because cata- blindness. The U.S. Preventive Services Task Force (2009) sup-
racts that impair vision are often not readily detectable, a ports this screening for visual acuity in adults older than 65 as
thorough assessment is needed to determine possible preven- screening can lead to improved vision, function, and quality of
tive strategies or need for referral. life, even though their findings showed no direct evidence of
There are numerous types of cataracts. These are catego- benefits of screening. The USPSTF notes that more research is
rized based on location, such as center of the lens, edges of needed to understand why there were “no benefits of screen-
the lens, or back of the lens. ing found, even though impaired visual acuity is common and
effective treatments are available.” Miles (2008–2011) notes
HEALTHY PEOPLE 2020 GOAL that the American Academy of Ophthalmology recommends
Healthy People 2020 objectives (2011) related to vision focus complete eye exams every year or two for persons 65 years or
on preserving sight and preventing blindness. The objectives: older, and more frequent eye exams (even more than once a
“address screening and examinations for children and adults, year) if the person has diabetes or high blood pressure.
early detection and timely treatment of eye diseases and con-
ditions, injury prevention, and the use of vision rehabilitation RISK ASSESSMENT
services.” Mayo Clinic (2010) and Cataracts.com (2011) list the risk fac-
tors for cataracts as:
GOAL • Increasing age (often start developing at 30 years of age,
Improve the visual health of the nation through prevention, but are most prevalent by 75 years of age)
early detection, timely treatment, and rehabilitation. Visual • Diabetes (especially with early-onset cataracts)
impairment puts all people, especially older adults, at risk. • Drinking excessive amounts of alcohol


CATARACTS (Continued)
• Excessive exposure to sunlight steroids, talk with your health care provider to determine
• Exposure to ionizing radiation, such as that used in X-rays eye examination schedule.
and cancer radiation therapy • Wear sunglasses that block UVB rays when outdoors.
• Family history of cataracts • Protect eyes if exposed to ionizing radiation sources (X-rays
• High blood pressure or radiation therapy).
• Obesity (especially with early-onset cataracts) • Avoid smoking or stop smoking.
• Previous eye injury or inflammation • Avoid excessive alcohol intake.
• Previous eye surgery • Maintain healthy weight, exercise most days, and develop
• Prolonged use of corticosteroid medications (ingestion or a plan to lose weight if overweight.
applied to skin) • Eat well-rounded diet with a variety of colorful fruits and
• Smoking vegetables for vitamins, antioxidants, and other nutrients.
• Ask health care provider about antioxidant supplements
CLIENT EDUCATION that have been shown to prevent cataracts.
Teach Clients • Use eye protective equipment if necessary to prevent eye
• Have regular eye examinations—if generally healthy, then injuries.
at least every year starting at 65 years of age. If diabetic or • Seek medical care for prolonged or unusual eye inflamma-
have other risk factors or take such medications as cortico- tion or for any eye injury.
COLLECTING OBJECTIVE DATA: • Disposable gloves (wear as needed to prevent spreading

PHYSICAL EXAMINATION infection or coming in contact with exudate)
The purpose of the eye and vision examination is to identify

any changes in vision or signs of eye disorders in an effort
to initiate early treatment or corrective procedures. Col-
lected objective data should include assessment of eye func-
tion through specific vision tests, inspection of the external
eye, and inspection of the internal eye using an ophthal-
moscope.
For the most part, inspection and palpation of the exter-
nal eye are straightforward and simple to perform. The vision
tests and use of the ophthalmoscope require a great deal
of skill, and thus practice, for the examiner to be capable
and confident during the examination. It is a good idea for
the beginning examiner to practice on friends, family, or
classmates to gain experience and to become comfortable
performing the examinations (see Assessment Guide 16-1,
p. 307).
Preparing the Client

Explain each vision test thoroughly to guarantee accurate
results. For the eye examination, position the client to be
seated comfortably. During examination of the internal eye
with the ophthalmoscope, you will move very close to the cli-
ent’s face to view the retina and internal structures. Explain to
the client that this may be slightly uncomfortable. To ease any
client anxiety, explain in detail what you will be doing and
answer any questions the client may have. Physical Assessment
Before performing eye examination, review and recognize
Equipment structures and functions of the eyes. While performing the
• Snellen or E chart (Assessment Guide 16-1) examination, remember these key points:
• Hand-held Snellen card or near-vision screener • Administer vision tests competently and record the results.
• Penlight • Use the ophthalmoscope correctly and confidently.
• Opaque cards • Recognize and distinguish normal variations from abnor-
• Ophthalmoscope (Assessment Guide 16-2, p. 308) mal findings.
ASSESSMENT GUIDE 16-1 Vision Charts

Snellen Chart E Chart
Used to test distant visual acuity, If the client cannot read or has
the Snellen chart consists of lines of
different letters stacked one above
the other. The letters are large at
E a handicap that prevents verbal
communication, the E chart is used.
The E chart is configured just like
the top and decrease in size from
top to bottom. The chart is placed HN the Snellen chart but the characters
on it are only Es, which face in all
on a wall or door at eye level in a directions. The client is asked to
well-lighted area. The client stands D F N indicate by pointing which way the
20 feet from the chart and covers open side of the E faces. If the client
one eye with an opaque card (which wears glasses, they should be left
prevents the client from peeking
PT X Z on, unless they are reading glasses
through the fingers). Then the client (reading glasses blur distance vi-
UZ D T F 20
reads each line of letters until he or sion). 50
she can no longer distinguish them.

DT F P D H 20
30
20
PH U N T D Z 20
Test Results distinguish any letters, but record the number of letters missed by
Acuity results are recorded somewhat like blood pressure readings— using a minus sign. If the client missed two letters on the 20/30 line,
in a manner that resembles a fraction (but in no way is interpreted the recorded score would be 20/30 –2.
as a fraction). A common example of an acuity test score is 20/20.
Jaeger Test
The top, or first, number is always 20, indicating the distance from
Near vision is assessed in clients over 40 years of age by holding
the client to the chart. The bottom, or second, number refers to the
the pocket screener (Jaeger test) or newspaper print 14 inches
last full line the client could read. Usually the last line on the chart is
from the eye. Clients who have decreased accommodation to view
the 20/20 line. The examiner needs to document whether the client
closer print will have to move the card or newspaper further away
wore glasses during the test. If any letters on a line are missed,
to see it.
encourage the client to continue reading until he or she cannot
Near Vision Test Chart

To be viewed at distance of 35 cm (14”)
20/200 AbCdE35890
20/100 AbCdE35890
20/80 AbCdE35890
20/70 AbCdE35890
20/65 AbCdE357890
20/50 AbCdE357890 20/200 23 pts

20/100 14 pts
20/40 AbCdE357890 20/80 12pts
20/70 10 pts
20/65 9 pts
20/30 AbCdE357890
20/50 8 pts
20/40 7 pts
20/25 AbCdE357890
20/30 5 pts
20/25 4 pts
20/20 3 pts
20/20 AbCdE357890
ASSESSMENT GUIDE 16-2 Ophthalmoscope

The ophthalmoscope is a hand-held instru- Basics of Operation 5. Hold the ophthalmoscope in your right
ment that allows the examiner to view the 1. Turn the ophthalmoscope “on” and hand with your index finger on the lens
fundus of the eye by the projection of light select the aperture with the large round wheel and place it to your right eye
through a prism that bends the light 90 de- beam of white light. The small round (braced between the eyebrow and the
grees. There are several lenses arranged on beam of white light may be used if the nose) if you are examining the client’s
a wheel that affect the focus on objects in client has smaller pupils. There are other right eye. Use your left hand and left eye
the eye. The examiner can rotate the lenses apertures, but they are not typically used if you are examining the client’s left eye.
with the index finger. Each lens is labeled for basic ophthalmologic screening. This allows you to get as close to the
with a negative or positive number, a unit 2. Ask the client to remove any eyeglasses client’s eye as possible without bumping
of strength called a diopter. Red numbers but to keep contact lenses in place. You noses with the client.
indicate a negative diopter and are used for can rotate the lenses to accommodate for
Some Do’s and Don’ts
myopic (nearsighted) clients. Black numbers any refractive errors. However, if the client
Do
indicate a positive diopter and are used has severe refractive errors, glasses should
• Begin about 10 to 15 inches from the
for hyperopic (farsighted) clients. The zero be left on. If you are wearing glasses, you
client at a 15-degree angle to the client’s
lens is used if neither the examiner nor the should remove them, but you should keep
side.
client has refractive errors. contact lenses in place. Removing the
• Pretend that the ophthalmoscope is an
client’s and your glasses enables you to
extension of your eye. Keep focused on
get closer to the client’s eye, allowing for
the red reflex as you move in closer, then
a more accurate inspection.
rotate the diopter setting to see the optic
3. Ask the client to fix his or her gaze on an
disk.
object that is straight ahead and slightly
upward. Don’t
4. Darken the room to allow pupils to • Do not use your right eye to examine
dilate. For a more thorough examination, the client’s left eye or your left eye to
optometrists or ophthalmologists may examine the client’s right eye (your noses
use mydriatic eyedrops to dilate the pu- will bump).
pils to view the posterior eye structures. • Do not move the ophthalmoscope
However, mydriatic drops may precipitate around; ask the client to look into light
acute angle closure glaucoma. Clients to allow you to view the fovea and
with a history of glaucoma or extreme macula.
farsightedness are at risk. • Do not get frustrated—the ophthalmo-
Warn clients who receive logic examination requires practice.
the drops that blurring
and sensitivity to sun will occur and to
avoid driving for 1–2 hours following
dilatation of eyes. Encourage client
to wear sunglasses outside following
dilatation.
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
Evaluating Vision
Test distant visual acuity. Position the Normal distant visual acuity is 20/20 with or Myopia (impaired far vision) is present when
client 20 feet from the Snellen or E chart (see without corrective lenses. This means that the second number in the test result is larger
Assessment Guide 16-1, p. 307) and ask her the client can distinguish what the person than the first (20/40). The higher the second
to read each line until she cannot decipher with normal vision can distinguish from 20 number, the poorer the vision. A client is
the letters or their direction (Fig. 16-9). feet away. considered legally blind when vision in the
Document the results. better eye with corrective lenses is 20/200 or
less. Refer any client with vision worse than
20/30 for further evaluation.
CLINICAL TIP CULTURAL CONSIDERATIONS

If the client wears glasses, Visual acuity varies by race in
they should be left on unless they are U.S. populations. Japanese and Chinese
reading glasses (reading glasses blur Americans have the poorest corrected
distance vision). visual acuity (especially myopia) fol-
lowed by African Americans and Hispan-
During the vision test, note any client ics. Native Americans and Caucasians
behaviors (i.e., leaning forward, head tilting, have the best-corrected visual acuity.
or squinting) that could be unconscious Eskimos are undergoing an epidemic of
attempts to see better. myopia (Andrews & Boyle, 2012).
Test near visual acuity. Use this test for Normal near visual acuity is 14/14 (with or Presbyopia (impaired near vision) is indi-
middle-aged clients and others who com- without corrective lenses). This means that cated when the client moves the chart away
plain of difficulty reading. the client can read what the normal eye can from the eyes to focus on the print. It is
read from a distance of 14 inches. caused by decreased accommodation.
Give the client a hand-held vision chart (e.g.,
Jaeger reading card, Snellen card, or com- OLDER ADULT
parable chart) to hold 14 inches from the CONSIDERATIONS
eyes. Have the client cover one eye with an Presbyopia is a common condition in
opaque card before reading from top (largest clients over 45 years of age.
print) to bottom (smallest print). Repeat test
for other eye (see Assessment Guide Box
16-1, p. 307).
CLINICAL TIP
The client who wears glasses
should keep them on for this test.
Test visual fields for gross peripheral With normal peripheral vision, the client A delayed or absent perception of the exam-
vision. To perform the confrontation test, should see the examiner’s finger at the same iner’s finger indicates reduced peripheral
position yourself approximately 2 feet away time the examiner sees it. Normal visual field vision (Abnormal Findings 16-1, p. 320).
from the client at eye level. Have the client degrees are approximately as follows: Refer the client for further evaluation.
cover the left eye while you cover your • Inferior: 70 degrees
right eye (Fig. 16-10). Look directly at each • Superior: 50 degrees
other with your uncovered eyes. Next, fully • Temporal: 90 degrees
extend your left arm at midline and slowly • Nasal: 60 degrees
move one finger (or a pencil) upward from
below until the client sees your finger (or
pencil). Test the remaining three visual
fields of the client’s right eye (i.e., superior,
temporal, and nasal). Repeat the test for
the opposite eye.
FIGURE 16-9 Testing distant visual acuity. FIGURE 16-10 Performing confrontation test to assess visual
fields.
Evaluating Vision (Continued)

TESTING EXTRAOCULAR MUSCLE FUNCTION
Perform corneal light reflex test. This The reflection of light on the corneas should Asymmetric position of the light reflex indi-
test assesses parallel alignment of the eyes. be in the exact same spot on each eye, cates deviated alignment of the eyes. This
Hold a penlight approximately 12 inches which indicates parallel alignment. may be due to muscle weakness or paralysis
from the client’s face. Shine the light toward (Abnormal Findings 16-2, p. 321).
the bridge of the nose while the client stares
straight ahead. Note the light reflected on
the corneas.
Perform cover test. The cover test detects The uncovered eye should remain fixed The uncovered eye will move to establish
deviation in alignment or strength and slight straight ahead. The covered eye should focus when the opposite eye is covered.
deviations in eye movement by interrupting remain fixed straight ahead after being When the covered eye is uncovered, move-
the fusion reflex that normally keeps the uncovered. ment to reestablish focus occurs. Either
eyes parallel. of these findings indicates a deviation in
alignment of the eyes and muscle weakness
Ask the client to stare straight ahead and (Abnormal Findings 16-2, p. 321).
focus on a distant object. Cover one of the
client’s eyes with an opaque card (Fig. 16-11). Phoria is a term used to describe misalignment
As you cover the eye, observe the uncovered that occurs only when fusion reflex is blocked.
eye for movement. Now remove the opaque
card and observe the previously covered Strabismus is constant malalignment of the
eye for any movement. Repeat test on the eyes.
opposite eye.
Tropia is a specific type of misalignment:
esotropia is an inward turn of the eye, and
exotropia is an outward turn of the eye.
A B
FIGURE 16-11 Performing cover test with (A) eye covered and (B) eye uncovered.
Perform the positions test, which assesses Eye movement should be smooth and sym- Failure of eyes to follow movement sym-
eye muscle strength and cranial nerve func- metric throughout all six directions. metrically in any or all directions indicates
tion. a weakness in one or more extraocular
muscles or dysfunction of the cranial nerve
Instruct the client to focus on an object you that innervates the particular muscle (Abnor-
are holding (approximately 12 inches from mal Findings 16-2, p. 321).
the client’s face). Move the object through
the six cardinal positions of gaze in a clock- Nystagmus—an oscillating (shaking) move-
wise direction, and observe the client’s eye ment of the eye—may be associated with an
movements (Fig. 16-12). inner ear disorder, multiple sclerosis, brain
lesions, or narcotics use.
FIGURE 16-12 Performing positions test.
External Eye Structures

INSPECTION AND PALPATION
Inspect the eyelids and eyelashes. The upper lid margin should be between Drooping of the upper lid, called ptosis,
the upper margin of the iris and the upper may be attributed to oculomotor nerve
Note width and position of palpebral margin of the pupil. The lower lid margin damage, myasthenia gravis, weakened
fissures. rests on the lower border of the iris. No muscle or tissue, or a congenital disorder
white sclera is seen above or below the iris. (Abnormal Findings 16-3, p. 322). Retracted
Palpebral fissures may be horizontal. lid margins, which allow for viewing of the
sclera when the eyes are open, suggest
hyperthyroidism.
Assess ability of eyelids to close. The upper and lower lids close easily and Failure of lids to close completely puts client
meet completely when closed. at risk for corneal damage.
Note the position of the eyelids in compari- The lower eyelid is upright with no inward An inverted lower lid is a condition called an
son with the eyeballs. Also note any unusual or outward turning. Eyelashes are evenly entropion, which may cause pain and injure
• Turnings distributed and curve outward along the lid the cornea as the eyelash brushes against
• Color margins. Xanthelasma, raised yellow plaques the conjunctiva and cornea.
• Swelling located most often near the inner canthus,
• Lesions are a normal variation associated with Ectropion, an everted lower eyelid, results in
• Discharge increasing age and high lipid levels. exposure and drying of the conjunctiva. Both
conditions (Abnormal Findings 16-3, p. 322)
interfere with normal tear drainage.
OLDER ADULT
CONSIDERATIONS
Though usually abnormal, entropion
and ectropion are common in older
clients.
Observe for redness, swelling, discharge, or Skin on both eyelids is without redness, Redness and crusting along the lid margins
lesions. swelling, or lesions. suggest seborrhea or blepharitis, an infec-
tion caused by Staphylococcus aureus.
Hordeolum (stye), a hair follicle infection,
causes local redness, swelling, and pain. A
chalazion, an infection of the meibomian
gland (located in the eyelid), may produce
extreme swelling of the lid, moderate red-
ness, but minimal pain (Abnormal Findings
16-3, p. 322).

External Eye Structures (Continued)
Observe the position and alignment of Eyeballs are symmetrically aligned in sockets Protrusion of the eyeballs accompanied by
the eyeball in the eye socket. without protruding or sinking. retracted eyelid margins is termed exoph-
thalmos (Abnormal Findings 16-3, p. 322)
CULTURAL CONSIDERATIONS
and is characteristic of Graves’ disease (a
The eyes of African Americans
type of hyperthyroidism). A sunken appear-
protrude slightly more than those of
ance of the eyes may be seen with severe
Caucasians, and African Americans of
dehydration or chronic wasting illnesses.
both sexes may have eyes protruding
beyond 21 mm. A difference of more
than 2 mm between the two eyes is
abnormal (Mercandetti, 2007; Weaver
et al., 2010).
Inspect the bulbar conjunctiva and Bulbar conjunctiva is clear, moist, and Generalized redness of the conjunctiva sug-
sclera. Have the client keep the head smooth. Underlying structures are clearly gests conjunctivitis (pink eye).
straight while looking from side to side visible. Sclera is white.
then up toward the ceiling (Fig. 16-13). Areas of dryness are associated with aller-
OLDER ADULT gies or trauma.
Observe clarity, color, and texture.
CONSIDERATIONS
Yellowish nodules on the bulbar con- Episcleritis is a local, noninfectious inflam-
junctiva are called pinguecula. These mation of the sclera. The condition is usually
harmless nodules are common in older characterized by either a nodular appearance
clients and appear first on the medial or by redness with dilated vessels (Abnormal
side of the iris and then on the lateral Findings 16-3, p. 322).
side.
CULTURAL CONSIDERATIONS
Darker-skinned clients may
have sclera with yellow or pigmented
freckles.
Inspect the palpebral conjunctiva.

CLINICAL TIP
This procedure is stressful and
uncomfortable for the client. It is usually
only done if the client complains of pain
or “something in the eye.”
Put on gloves for this assessment procedure. The lower and upper palpebral conjunctivae Cyanosis of the lower lid suggests a heart or
First inspect the palpebral conjunctiva of the are clear and free of swelling or lesions. lung disorder.
lower eyelid by placing your thumbs bilater-
ally at the level of the lower bony orbital
rim and gently pulling down to expose the
palpebral conjunctiva (Fig. 16-14). Avoid
putting pressure on the eye. Ask the client to
look up as you observe the exposed areas.
Evert the upper eyelid. Ask the client to look Palpebral conjunctiva is free of swelling, A foreign body or lesion may cause irritation,
down with his or her eyes slightly open. foreign bodies, or trauma. burning, pain and/or swelling of the upper
Gently grasp the client’s upper eyelashes eyelid.
and pull the lid downward (Fig. 16-15A).
Place a cotton-tipped applicator approxi-

mately 1 cm above the eyelid margin and
push down with the applicator while still
holding the eyelashes (Fig. 16-15B).
FIGURE 16-13 Inspecting the bulbar conjunctiva. FIGURE 16-14 Inspecting palpebral conjunctiva: lower eyelid.
A B
FIGURE 16-15 Everting the upper eyelid.
Hold the eyelashes against the upper ridge

of the bony orbit just below the eyebrow,
to maintain the everted position of the
eyelid. Examine the palpebral conjunctiva for
swelling, foreign bodies, or trauma. Return
the eyelid to normal by moving the lashes
forward and asking the client to look up and
blink. The eyelid should return to normal.

Inspect the lacrimal apparatus. Assess the No swelling or redness should appear over Swelling of the lacrimal gland may be visible
areas over the lacrimal glands (lateral aspect areas of the lacrimal gland. The puncta is in the lateral aspect of the upper eyelid. This
of upper eyelid) and the puncta (medial visible without swelling or redness and is may be caused by blockage, infection, or an
aspect of lower eyelid). turned slightly toward the eye. inflammatory condition. Redness or swelling
around the puncta may indicate an infectious
or inflammatory condition. Excessive tearing
may indicate a nasolacrimal sac obstruction.
Palpate the lacrimal apparatus. Put on No drainage should be noted from the Expressed drainage from the puncta on
disposable gloves to palpate the nasolac- puncta when palpating the nasolacrimal palpation occurs with duct blockage.
rimal duct to assess for blockage. Use one duct.
finger and palpate just inside the lower
orbital rim (Fig. 16-16).
Inspect the cornea and lens. Shine a light The cornea is transparent, with no opacities. Areas of roughness or dryness on the cornea
from the side of the eye for an oblique view. The oblique view shows a smooth and over- are often associated with injury or allergic
Look through the pupil to inspect the lens. all moist surface; the lens is free of opacities. responses. Opacities of the lens are seen
with cataracts (Abnormal Findings 16-4,
OLDER ADULT
p. 323).
CONSIDERATIONS
Arcus senilis, a normal condition in older
clients, appears as a white arc around
the limbus (Fig. 16-17). The condition
has no effect on vision.
Inspect the iris and pupil. Inspect shape The iris is typically round, flat, and evenly Typical abnormal findings include irregularly
and color of iris and size and shape of pupil. colored. The pupil, round with a regular bor- shaped irises, miosis, mydriasis, and anisoco-
Measure pupils against a gauge (Fig. 16-18) der, is centered in the iris. Pupils are normally ria. (For a description of these abnormalities
if they appear larger or smaller than normal equal in size (3 to 5 mm). An inequality in and their implications, see Abnormal Find-
or if they appear to be two different sizes. pupil size of less than 0.5 mm occurs in 20% ings 16-5, p. 323).
of clients. This condition, called anisocoria,
is normal. If the difference in pupil size changes
throughout pupillary response tests, the
inequality of size is abnormal.
FIGURE 16-16 Palpating the lacrimal apparatus. FIGURE 16-17 Arcus senilis.
Pupil Gauge (mm)
1 2 3 4 5 6 7
FIGURE 16-18 Pupillary gauge for measuring pupil size (dilation or constriction) in millimeters (mm).
Test pupillary reaction to light. The normal direct pupillary response is Monocular blindness can be detected when
constriction. light directed to the blind eye results in
Test for direct response by darkening the no response in either pupil. When light is
room and asking the client to focus on a directed into the unaffected eye, both pupils
distant object. To test direct pupil reaction, constrict.
shine a light obliquely into one eye and
observe the pupillary reaction. Shining the
light obliquely into the pupil and asking the
client to focus on an object in the distance
ensures that pupillary constriction is a reac-
tion to light and not a near reaction.
CLINICAL TIP
Use a pupillary gauge to measure
the constricted pupil. Then, document
the finding in a format similar to (but
not) a fraction. The top (or first) number
indicates the pupil’s eye at rest, and the
bottom (or second) number indicates
the constricted size; for example, O.S.
(left eye, oculus sinister) 3/2; O.D. (right
eye, oculus dexter) 3/1.
Assess consensual response at the same The normal consensual pupillary response is Pupils do not react at all to direct and con-
time as direct response by shining a light constriction. sensual pupillary testing.
obliquely into one eye and observing the
pupillary reaction in the opposite eye.
CLINICAL TIP
When testing for consensual
response, place your hand or another
barrier to light (e.g., index card)
between the client’s eyes to avoid an
inaccurate finding.
Test accommodation of pupils. Accom- The normal pupillary response is constriction Pupils do not constrict; eyes do not converge.
modation occurs when the client moves his of the pupils and convergence of the eyes
or her focus of vision from a distant point to when focusing on a near object (accommo-
a near object, causing the pupils to constrict. dation and convergence).
Hold your finger or a pencil about 12 to
15 inches from the client. Ask the client to
focus on your finger or pencil and to remain
focused on it as you move it closer in toward
the eyes (Fig. 16-19).
FIGURE 16-19 Testing accommodation of pupils.


INTERNAL EYE STRUCTURES
Using an ophthalmoscope (Assessment The red reflex should be easily visible Abnormalities of the red reflex most often
Guide 16-2, p. 308), inspect the internal eye. through the ophthalmoscope. The red area result from cataracts. These usually appear
To observe the red reflex, set the diopter at should appear round, with regular borders. as black spots against the background of
0 and stand 10 to 15 inches from the client’s the red light reflex. Two types of age-related
right side at a 15-degree angle. Place your cataracts are nuclear cataracts and periph-
free hand on the client’s head, which helps eral cataracts (Abnormal Findings 16-4,
limit head movement (Fig. 16-20). Shine the p. 323).
light beam toward the client’s pupil.
FIGURE 16-20 Inspecting the red reflex. FIGURE 16-21 Normal ocular fundus (also called the optic disc).
Inspect the optic disc. Keep the light beam The optic disc should be round to oval with Papilledema, or swelling of the optic disc,
focused on the pupil and move closer to the sharp, well-defined borders (Fig. 16-21). appears as a swollen disc with blurred
client from a 15-degree angle. margins, a hyperemic (blood-filled) appear-
The nasal edge of the optic disc may be ance, more visible and more numerous disc
You should be very close to the client’s blurred. The disc is normally creamy, yellow- vessels, and lack of visible physiologic cup.
eye (about 3 to 5 cm), almost touching the orange to pink, and approximately 1.5 mm The condition may result from hypertension
eyelashes. Rotate the diopter setting to bring wide. or increased intracranial pressure (Abnormal
the retinal structures into sharp focus. The Findings 16-6, p. 324).
diopter should be zero if neither the exam- The physiologic cup, the point at which the
iner nor the client has refractive errors. Note optic nerve enters the eyeball, appears on The intraocular pressure associated with
shape, color, size, and physiologic cup. the optic disc as slightly depressed and a glaucoma interferes with the blood supply to
lighter color than the disc. The cup occupies optic structures and results in the following
CLINICAL TIP less than half of the disc’s diameter. The characteristics: an enlarged physiologic cup
The diameter of the optic disc disc’s border may be surrounded by rings that occupies more than half of the disc’s
(DD) is used as the standard of mea- and crescents, consisting of white sclera or diameter, pale base of enlarged physiologic
sure for the location and size of other black retinal pigment. These normal varia- cup, and obscured or displaced retinal
structures and any abnormalities or tions are not considered in the optic disc’s vessels.
lesions within the ocular fundus. When diameter.
documenting a structure within the Optic atrophy is evidenced by the disc being
ocular fundus, also note the position of CULTURAL CONSIDERATIONS
white in color and a lack of disc vessels. This
the structure as it relates to numbers on Optic nerve discs are larger in
condition is caused by the death of optic
the clock. For example, lesion is at 2:00, Blacks, Asians, and Native Americans
nerve fibers (Abnormal Findings 16-6,
1 DD in size, 2 DD from disc. than in Hispanics and non-Hispanic
p. 324).
whites (AOA, 2012; Girkin, 2005; Over-
field, 1995; Weaver et al., 2010).
Inspect the retinal vessels. Remain in Four sets of arterioles and venules should Changes in the blood supply to the retina
the same position as described previously. pass through the optic disc. may be observed in constricted arterioles,
Inspect the sets of retinal vessels by fol- dilated veins, or absence of major vessels
lowing them out to the periphery of each Arterioles are bright red and progressively (Abnormal Findings 16-7, p. 325).
section of the eye. Note the number of sets narrow as they move away from the optic
of arterioles and venules. disc. Arterioles have a light reflex that appears Initially hypertension may cause a widening
as a thin, white line in the center of the arte- of the arterioles’ light reflex and the arteri-
Also note color and diameter of the riole. Venules are darker red and larger than oles take on a copper color. With long-stand-
arterioles. arterioles. They also progressively narrow as ing hypertension, arteriole walls thicken and
they move away from the optic disc. appear opaque or silver.
Observe the arteriovenous (AV) ratio. The ratio of arteriole diameter to vein diam-
eter (AV ratio) is 2:3 or 4:5.
Look at AV crossings. In a normal AV crossing, the vein passing Arterial nicking, tapering, and banking are
underneath the arteriole is seen right up to abnormal AV crossings caused by hyperten-
the column of blood on either side of the sion or arteriosclerosis (Abnormal Findings
arteriole (the arteriole wall itself is normally 16-7, p. 325).
transparent).
Inspect retinal background. Remain in General background appears consistent in Cotton-wool patches (soft exudates) and
the same position described previously and texture. The red-orange color of the back- hard exudates from diabetes and hyper-
search the retinal background from the disc ground is lighter near the optic disc. tension appear as light-colored spots on
to the macula, noting the color and the pres- the retinal background. Hemorrhages and
ence of any lesions. microaneurysms appear as red spots and
streaks on the retinal background (Abnormal
Findings 16-7, p. 325).
Inspect fovea (sharpest area of vision) The macula is the darker area, one disc Excessive clumped pigment appears with
and macula. Remain in the same position diameter in size, located to the temporal side detached retinas or retinal injuries. Macular
described previously. Shine the light beam of the optic disc. Within this area is a star- degeneration may be due to hemorrhages,
toward the side of the eye or ask the client like light reflex called the fovea. exudates, or cysts.
to look directly into the light. Observe the
fovea and the macula that surrounds it.
Inspect anterior chamber. Remain in the The anterior chamber is transparent. Hyphemia occurs when injury causes red
same position and rotate the lens wheel blood cells to collect in the lower half of the
slowly to +10, +12, or higher to inspect the anterior chamber (Fig. 16-22).
anterior chamber of the eye.
Hypopyon usually results from an inflam-
matory response in which white blood cells
accumulate in the anterior chamber and
produce cloudiness in front of the iris
(Fig. 16-23).
FIGURE 16-22 Hyphemia (© 1995 Science Photo Library/CMSP). FIGURE 16-23 Hypopyon.

ASSESSING EYE TRAUMA
In the event of an eye trauma in which the No foreign body is observed. The eye globe is Refer the client to an eye doctor immediately
client is experiencing eye pain, discomfort, or intact with no indication of blood in eye. if a foreign body cannot be removed with
feels something is in the eye, observe for: gentle washing, there is perforation of globe,
• Foreign body that remains after gentle blood in eye, and/or client has impaired
washing vision (AOA, 2012).
• Perforated globe
• Blood in eye
In the case of blunt eye trauma, observe for: There is no swelling of eye, no blood in ante- Refer client to eye doctor immediately if
• Lid swollen shut rior chamber, cornea is clear, pupils equal eye is swollen, blood is observed in anterior
• Blood in anterior chamber and reactive to light. chamber, cornea is hazy, or pupils are irregu-
• White/hazy cornea larly shaped, fixed, dilated, or constricted
• Irregularly shaped, fixed, dilated, or con- (AOA, 2012).
stricted pupil
See http://www.cteyes.org/CMS/customer-
files/p-edu-SchoolNurses%20Guide%20
Ocular%20Emerg.pdf to know when to refer
client in cases of eye trauma.
Case Study
The chapter case study is now used to in size, located temporally to the optic disc bilaterally.
demonstrate the physical examination Anterior chambers are transparent bilaterally.)
of Susan Jones’s eyes.
The client’s visual acuity in the left
eye is 20/20. Visual acuity of the right VALIDATING AND
eye is 20/30. It is noted that the client DOCUMENTING FINDINGS
is squinting and blinking repeatedly during the exami-
nation. Peripheral vision is intact. Corneal light reflex Validate the eye assessment data that you have collected. This
is symmetric. Extraocular movements smooth and sym- is necessary to verify that the data are reliable and accurate.
metric, with no nystagmus. Eyelids without abnormal Document the assessment data following the health care facil-
widening or ptosis. No redness, discharge, or crusting ity or agency policy.
noted on lid margins. Left eye: Bulbar conjunctiva is
pink, smooth, and moist. Sclera is ivory white. Right
eye: Bulbar conjunctiva is pink, smooth, and moist.
Case Study
Sclera is injected (vessels dilated) and tearing profusely.
Inspection of right palpebral conjunctiva reveals no for- Think back to the case study. The clinic
eign body or edema. No swelling or redness noted over nurse documented the following subjec-
the lacrimal gland bilaterally. Puncta visible, without tive and objective assessment findings of
swelling or redness bilaterally. No drainage with naso- Susan Jones’s eye examination.
lacrimal duct palpation bilaterally. Left cornea is trans-
parent, smooth, and moist, without opacity. Right cor- Biographic Data: SJ, 24-year-old Cauca-
nea is transparent, with an area of roughness noted; it is sian woman. Alert and oriented. Asks
moist with no opacity. Irises are round, flat, and brown and answers questions appropriately.
in color. Pupils are round, reactive to light and accom- Reason for Seeking Health Care: “I accidentally poked
modation; 4 mm is size bilaterally. Pupils converge sym- my key in my eye. My right eye really hurts. It feels
metrically. Red reflex is present bilaterally. Right eye: no scratchy, like there is something in my eye.”
internal eye structures visualized. Left eye: some internal
eye vessels visualized; unable to visualize other internal History of Present Health Concern: The client reports
eye structures. (If pupils are dilated and examiner is that 2 hours ago she accidentally struck her right eye
proficient, a normal internal eye structure examination with a car key. Since then, her right eye has been tearing
would reveal the following: Optic discs creamy white in excessively, become painful with a scratchy sensation,
color, with distinct margins and vessels noted, with no and vision has become blurred.
crossing defects. Retinal background free of lesions and Personal Health History: Ms. Jones reports that she has
orange-red in color bilaterally. Macula 1 disc diameter never had a problem with her eyes or vision. She states
Health Promotion Diagnoses

that she has never had eye surgery or any type of eye
treatment. • Readiness for enhanced visual integrity
Family History: Ms. Jones reports that her father has Risk Diagnoses
glaucoma. • Risk for Eye Injury related to hazardous work area or partici-
Lifestyle and Health Practices: She denies exposure to pation in high-level contact sports
substances that would harm her eyes. She states that she • Risk for Injury related to impaired vision secondary to the
wears sunglasses about 80% of the time when exposed aging process
to the sun. Ms. Jones reports that the only medication • Risk for Eye Injury related to decreased tear production sec-
she takes is an occasional Tylenol for headache. Client ondary to the aging process
states that her last eye examination was 2 years ago and • Risk for Self-Care Deficit (specify) related to vision loss
that her vision was “perfect.”
Actual Diagnoses
Physical Exam Findings: The client’s visual acuity in the • Ineffective Health Maintenance related to lack of knowl-
left eye is 20/20. Visual acuity of the right eye is 20/30. edge of necessity for eye examinations
The client is squinting and blinking repeatedly during • Self-Care Deficit (specify) related to poor vision
the examination. Peripheral vision is intact. Corneal light • Acute Pain related to injury from eye trauma, abrasion, or
reflex is symmetric. Extraocular movements smooth and exposure to chemical irritant
symmetric, with no nystagmus. Eyelids without abnor- • Social Isolation related to inability to interact effectively
mal widening or ptosis. No redness, discharge, or crust- with others secondary to vision loss
ing noted on lid margins. Left eye: Bulbar conjunctiva
is pink, smooth, and moist. Sclera is ivory white. Right
eye: Bulbar conjunctiva is pink, smooth, and moist. SELECTED COLLABORATIVE PROBLEMS
Sclera is injected (vessels dilated) and tearing profusely. After grouping the data, it may become apparent that certain
Inspection of right palpebral conjunctiva reveals no for- collaborative problems emerge. Remember that collaborative
eign body or edema. No swelling or redness noted over problems differ from nursing diagnoses in that they cannot be
the lacrimal gland bilaterally. Puncta visible, without prevented by nursing interventions. However, these physiologic
swelling or redness bilaterally. No drainage with naso- complications of medical conditions can be detected and mon-
lacrimal duct palpation bilaterally. Left cornea is trans- itored by the nurse. In addition, the nurse can use physician-
parent, smooth, and moist, without opacity. Right cor- and nurse-prescribed interventions to minimize the complica-
nea is transparent, with an area of roughness noted; it is tions of these problems. The nurse may also have to refer the
moist with no opacity. Irises are round, flat, and brown client in such situations for further treatment of the problem.
in color. Pupils are round, reactive to light and accom- Following is a list of collaborative problems that may be identi-
modation, 4 mm is size bilaterally. Pupils converge sym- fied when assessing the eye. These problems are worded as Risk
metrically. Red reflex is present bilaterally. Right eye: no for Complications (RC), followed by the problem.
internal eye structures visualized. Left eye: some internal • RC: Increased intraocular pressure
eye vessels visualized; unable to visualize other internal • RC: Corneal ulceration or abrasion
eye structures. (If pupils are dilated and examiner is
proficient, a normal internal eye structure examination
would reveal the following: Optic discs creamy white in MEDICAL PROBLEMS
color, with distinct margins and vessels noted with no After grouping the data, it may become apparent that the cli-
crossing defects. Retinal background free of lesions and ent has signs and symptoms that require medical diagnosis
orange-red in color bilaterally. Macula 1 disc diameter and treatment. Referral to a primary care provider is necessary.
in size, located temporally to the optic disc bilaterally.
Anterior chambers are transparent bilaterally.)
Case Study
After collecting and analyzing the data for
Ms. Jones, the nurse determines that the
Analysis of Data: Diagnostic following conclusions are appropriate:
Reasoning Nursing Diagnoses
• Acute Pain r/t foreign object (car key)
After collecting subjective and objective data pertaining to the
being “stuck” into right eye.
eyes, identify abnormal findings and client strengths. Then
• Risk for infection (right eye) r/t nonsterile foreign
cluster the data to reveal any significant patterns or abnor-
object coming into contact with eye.
malities. The following are some possible conclusions that the
nurse may make after assessing a client’s eyes. Potential Collaborative Problems
• RC: Eye infection
• RC: Corneal ulceration
SELECTED NURSING DIAGNOSES To view an algorithm depicting the process for
The following is a list of selected nursing diagnoses that may diagnostic reasoning in this case, go to .
be identified when analyzing data from eye assessment.
ABNORMAL FINDINGS
ABNORMAL FINDINGS 16-1 Visual Field Defects

When a client reports losing full or partial vision in one or both eyes, the nurse can usually anticipate a lesion as the cause.
Some abnormal findings associated with visual field defects are illustrated here. The darker areas signify vision loss.
Left Visual Field Right Visual Field
Nasal Temporal
field field
1
Left eye Right eye
Frontal lobe
1
Optic nerve
2 Temporal lobe
Optic chiasm
4
Optic tract
3
Temporal loop
(Optic radiation)
Occipital lobe
Finding Possible Source Example

Unilateral blindness (e.g., blind right Lesion in (right) eye or (right) optic Left Eye Right Eye
eye) nerve
Bitemporal hemianopia (loss of vision Lesion of optic chiasm

in both temporal fields)
Left superior quadrant anopia or simi- Partial lesion of temporal loop (optic
lar loss of vision (homonymous) in radiation)
quadrant of each field
Right visual field loss—right homony- Lesion in right optic tract or lesion in
mous hemianopia or similar loss of temporal loop (optic radiation)
vision in half of each field
16 UÊUÊU ASSESSING EYES 321
ABNORMAL FINDINGS
ABNORMAL FINDINGS 16-2 Extraocular Muscle
DYSFUNCTION
Abnormalities found during an assessment of extraocular muscle function are as follows:
CORNEAL LIGHT REFLEX TEST ABNORMALITIES COVER TEST ABNORMALITIES

Pseudostrabismus Phoria (Mild Weakness)
Normal in young children, the pupils will appear at the Noticeable only with the cover test, phoria is less likely to
inner canthus (due to the epicanthic fold). cause amblyopia than strabismus. Esophoria is an inward
drift and exophoria an outward drift of the eye.
Strabismus (or Tropia)

A constant malalignment of the eye axis, strabismus is
defined according to the direction toward which the eye The uncovered eye is weaker; when the stronger
drifts and may cause amblyopia. eye is covered, the weaker eye moves to refocus.
Esotropia (eye turns inward).
When the weaker eye is covered, it will

drift to a relaxed position.
Exotropia (eye turns outward).
POSITIONS TEST ABNORMALITIES Once the eye is uncovered, it will quickly

move back to reestablish fixation.
Paralytic Strabismus
Noticeable with the positions test, paralytic strabismus is usually the result of weakness or paralysis of one or more extra-
ocular muscles. The nerve affected will be on the same side as the eye affected (for instance, a right eye paralysis is related to
a right-side cranial nerve). The position in which the maximum deviation appears indicates the nerve involved.
6th nerve paralysis: The eye cannot look to the outer side. 4th nerve paralysis: The eye cannot look down when turned
inward.
In left 6th nerve paralysis, the client tries to look to the left. The
right eye moves left, but the left eye cannot move left.
A client with left 3rd nerve paralysis looks

straight ahead.
A client with left 4th nerve paralysis looks

down and to the right.
ABNORMAL FINDINGS
ABNORMAL FINDINGS 16-3 Abnormalities of the External Eye

Some easily recognized abnormalities that affect the external eye are as follows.
Ptosis (drooping eye) Ectropion (outwardly turned lower Conjunctivitis (generalized inflamma-
lid). tion of the conjunctiva).
Exophthalmos (protruding eyeballs Chalazion (infected meibomian Hordeolum (stye).

and retracted eyelids) gland).
Entropion (inwardly turned lower Blepharitis (staphylococcal infection Diffuse episcleritis (inflammation of
eyelid) of the eyelid). the sclera).
(Used with permission from Tasman, W., &

Jaeger, E. [Eds.], [2001]. The Wills Eye Hospital
atlas of clinical ophthalmology [2nd ed.]. Phila-
delphia: Lippincott Williams & Wilkins.)
ABNORMAL FINDINGS
ABNORMAL FINDINGS 16-4 Abnormalities of the Cornea and Lens
Representative abnormalities of the cornea are illustrated as a corneal scar and a pterygium. Lens abnormalities are repre-
sented by a nuclear cataract and a peripheral cataract. Usually, cataracts are most easily seen by the naked eye.
CORNEAL ABNORMALITIES
Early pterygium, a thickening of the bulbar conjunctiva that

A corneal scar, which appears grayish white, extends across the nasal side. (Used with permission from Tasman, W.,
usually is due to an old injury or inflammation. & Jaeger, E. [Eds.], [2001]. The Wills Eye Hospital atlas of clinical ophthalmol-
ogy [2nd ed.]. Philadelphia: Lippincott Williams & Wilkins.)
LENS ABNORMALITIES
Peripheral cataracts look like gray spokes that point inward

Nuclear cataracts appear gray when seen with a flashlight; when seen with a flashlight; they look like black spokes that
they appear as a black spot against the red reflex when seen point inward against the red reflex when seen through an
through an ophthalmoscope. ophthalmoscope. (Used with permission from Tasman, W., & Jaeger, E.
[Eds.], [2001]. The Wills Eye Hospital atlas of clinical ophthalmology [2nd ed.].
Philadelphia: Lippincott Williams & Wilkins.)
ABNORMAL FINDINGS 16-5 Abnormalities of the Iris and Pupils

IRREGULARLY SHAPED IRIS
An irregularly shaped iris causes a shallow anterior chamber, which may increase the risk for narrow-angle (closed-angle)
glaucoma.
Light
Light

ABNORMAL FINDINGS
ABNORMAL FINDINGS 16-5 Abnormalities of the Iris and Pupils (Continued)

ABNORMALITIES OF THE PUPILS
Miosis
Also known as pinpoint pupils, miosis is characterized by
constricted and fixed pupils—possibly a result of narcotic
drugs or brain damage.
Anisocoria
Anisocoria is pupils of unequal size. In some cases, the condi-
tion is normal; in other cases, it is abnormal. For example, if
anisocoria is greater in bright light compared with dim light,
the cause may be trauma, tonic pupil (caused by impaired
parasympathetic nerve supply to iris), and oculomotor nerve
paralysis. If anisocoria is greater in dim light compared with
bright light, the cause may be Horner’s syndrome (caused by
paralysis of the cervical sympathetic nerves and characterized
by ptosis, sunken eyeball, flushing of the affected side of the
face, and narrowing of the palpebral fissure).
Mydriasis
Dilated and fixed pupils, typically resulting from central
nervous system injury, circulatory collapse, or deep anes-
thesia.
ABNORMAL FINDINGS 16-6 Abnormalities of the Optic Disc

Characteristic abnormal findings during an ophthalmoscopic examination include signs and symptoms of papilledema,
glaucoma, and optic atrophy:
PAPILLEDEMA GLAUCOMA OPTIC ATROPHY

• Swollen optic disc • Enlarged physiologic cup occupy- • White optic disc
• Blurred margins ing more than half of the disc’s • Lack of disc vessels
• Hyperemic appearance from accumu- diameter
lation of excess blood • Pale base of enlarged physiologic cup
• Visible and numerous disc vessels • Obscured and/or displaced retinal
• Lack of visible physiologic cup vessels
Glaucomatous cupping. (Used with permis-

sion from Tasman, W., & Jaeger, E. [Eds.], [2001].
The Wills Eye Hospital atlas of clinical ophthal-
mology [2nd ed.]. Philadelphia: Lippincott Wil-
liams & Wilkins.)
ABNORMAL FINDINGS
ABNORMAL FINDINGS 16-7 Abnormalities of the Retinal Vessels and Background
Characteristic abnormal findings during an ophthalmoscopic examination of the retinal vessels include constricted arte-
rioles, copper wire arterioles, silver wire arterioles, arteriovenous (AV) nicking, AV tapering, and AV banking. Signs and
symptoms follow:
CONSTRICTED ARTERIOLE COPPER WIRE ARTERIOLE SILVER WIRE ARTERIOLE

• Narrowing of the arteriole • Widening of the light reflex and a • Opaque or silver appearance caused
• Occurs with hypertension coppery color by thickening of arteriole wall
• Occurs with hypertension • Occurs with long-standing hyper-
tension
ARTERIOVENOUS NICKING ARTERIOVENOUS TAPERING ARTERIOVENOUS BANKING

• Arteriovenous crossing abnormality • Arteriovenous crossing abnormality • Arteriovenous crossing abnormal-
characterized by vein appearing to characterized by vein appearing to ity characterized by twisting of the
stop short on either side of arteriole taper to a point on either side of the vein on the arteriole’s distal side and
• Caused by loss of arteriole wall arteriole formation of a dark, knuckle-like
transparency from hypertension • Caused by loss of arteriole wall structure
transparency from hypertension • Caused by loss of arteriole wall
transparency from hypertension

ABNORMAL FINDINGS
ABNORMAL FINDINGS 16-7 Abnormalities of the Retinal Vessels and Background (Continued)
COTTON WOOL PATCHES HARD EXUDATE SUPERFICIAL (FLAME-
• Also known as soft exudates, cotton • Solid, smooth surface and well- SHAPED) RETINAL
wool patches have a fluffy cotton defined edges HEMORRHAGES
ball appearance, with irregular edges. • Creamy yellow-white, small, round • Appear as small, flame-shaped, lin-
• Appear as white or gray moderately spots typically clustered in circular, ear red streaks on retinal background
sized spots on retinal background linear, or star pattern • Hypertension and papilledema are
• Caused by arteriole microinfarction • Associated with diabetes mellitus common causes.
• Associated with diabetes mellitus and hypertension
and hypertension
(Used with permission from Tasman, W., & Jaeger,

E. [Eds.], [2001]. The Wills Eye Hospital atlas of
clinical ophthalmology [2nd ed.]. Philadel phia: Lip-
pincott Williams & Wilkins.)
DEEP (DOT-SHAPED) RETINAL MICROANEURYSMS

HEMORRHAGES • Round, tiny red dots with smooth edges on retinal back-
• Appear as small, irregular red spots with blurred edges ground
on retinal background • Localized dilations of small vessels in retina, but vessels
• Lie deeper in retina than superficial retinal hemorrhages are too small to see
• Associated with diabetes mellitus • Associated with diabetic retinopathy
(Used with permission from Tasman, W., & Jaeger, E. [Eds.]. [2001]. The Wills
Eye Hospital atlas of clinical ophthalmology [2nd ed.]. Philadelphia: Lippincott
Williams & Wilkins.)
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Watch and Learn video clips
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CHAPTER 16

Superior oblique Orbit

Retina Medial rectus muscle

Central retinal Sclera

FIGURE 16-4 Anatomy of the eye.

Left visual field Right visual field LIGHT

Optic Frontal lobe

optic chiasma—the nerve ﬁbers from the nasal quadrant of

History of Present Health Concern

Personal Health History

Continued on following page

Personal Health History (Continued)

Lifestyle and Health Practices

Amsler’s Chart to Test Your Sight

Instructions for Use

Mnemonic Question Data Provided

16-1 EVIDENCE-BASED HEALTH PROMOTION AND DISEASE PREVENTION: GLAUCOMA

INTRODUCTION for glaucoma. This recommendation was based on the con-

16-2 EVIDENCE-BASED HEALTH PROMOTION AND DISEASE PREVENTION:

INTRODUCTION with visual impairment using assistive and adaptive devices

16-3 EVIDENCE-BASED HEALTH PROMOTION AND DISEASE PREVENTION:

Continued on following page

16-3 EVIDENCE-BASED HEALTH PROMOTION AND DISEASE PREVENTION:

COLLECTING OBJECTIVE DATA: • Disposable gloves (wear as needed to prevent spreading

The purpose of the eye and vision examination is to identify

Preparing the Client

ASSESSMENT GUIDE 16-1 Vision Charts

she can no longer distinguish them.

Near Vision Test Chart

20/50 AbCdE357890 20/200 23 pts

ASSESSMENT GUIDE 16-2 Ophthalmoscope

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

CLINICAL TIP CULTURAL CONSIDERATIONS

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Evaluating Vision (Continued)

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

FIGURE 16-12 Performing positions test.

External Eye Structures

Continued on following page

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

External Eye Structures (Continued)

Inspect the palpebral conjunctiva.

Place a cotton-tipped applicator approxi-

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

FIGURE 16-15 Everting the upper eyelid.

Hold the eyelashes against the upper ridge

Continued on following page

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

External Eye Structures (Continued)

Pupil Gauge (mm)

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

FIGURE 16-19 Testing accommodation of pupils.

Continued on following page

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

External Eye Structures (Continued)

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

External Eye Structures (Continued)