EYE ASSESSMENT/TESTS: Snellen Test: A Snellen test uses a chart with different sizes of letters or forms to evaluate your

visual acuity-that is, the sharpness of your vision. The test shows how accurately you can see from a distance. The level of vision is usually measured using a Snellen chart or equivalent. It is viewed at 6 metres (20 feet). A visual acuity of 6/6 indicates that the chart was viewed at 6 metres, and the lowest line that could be read was labelled . What is tonometry? Tonometry is a method of measuring the pressure in the eye. Tonometry is used to determine the pressure in the eye by measuring the tone or firmness of its surface. A tonometry test measures the pressure inside your eye, which is called intraocular pressure (IOP). This test is used to check for glaucoma, an eye disease that can cause blindness by damaging the nerve in the back of the eye (optic nerve). Damage to the optic nerve may be caused by a buildup of fluid that does not drain properly out of the eye.

Ophthalmoscopy: Examination of the interior of the eye, including the lens, retina and optic nerve, by indirect or direct ophthalmoscopy. Indirect ophthalmoscopy employs a head lamp device to shine a very bright light into the eye. This is generally done by an ophthalmologist.

Direct ophthalmoscopy is in more common usage. The examiner uses a device the size of a flashlight to examine the eye. The device consists of a concave mirror and a battery-powered light (contained within the handle). The operator looks through a single monocular eyepiece into the patient's eye. The ophthalmoscope is equipped with a rotating disc of lenses to permit the eye be examined at different depths and magnifications. This may be enhanced by drugs that dilate the pupil and enlarge the opening into the structures within the eye. Gonioscopy- Examination of the angle of the anterior chamber of the eye with a gonioscope or with a contact prism lens. Perimetry 1. The determination of the limits of the visual field. 2. The mapping of the sensitivity contours of the visual field. Static perimetry: The most common type of modern visual field testing employs a device with fixed light sources, either stationary pinpoint light sources or projected dots within a large white bowl. Popular devices include the Octopus or the Humphrey-Zeiss field analyzer. These tests are automated and run by the onboard computer, thus minimizing the time spent by a technician running the test.

Kinetic perimetry: The process utilizes moving light sources, such as the traditional workhorse Goldman perimeter. This test produces an island map of peripheral visual perception intensity. Fixation monitoring as well as movement of the light source require a dedicated trained technician throughout the entire test. This test is particularly useful in weeding out malingerers. Amsler grid: It's an important tool to test macular vision in and around the center of the retina and detect specific conditions such as macular degeneration Fluorescein angiography: A test to examine blood vessels in the retina, choroid, and iris of the eye. A special dye is injected into a vein in the arm and pictures are taken as the dye passes through the blood vessels in the eye Ishihara test- a test for color vision deficiency that uses a series of pseudoisochromatic plates on which numbers or letters are printed in dots of primary colors surrounded by dots of other colors; the figures are discernible by patients with normal color vision. COMMON EYE DRUGS; Cholinergic drugs are also used in control of glaucoma, a disease that is caused by increased pressure inside the eye. The most common drugs used for this purpose are demecarium (Humorsol) and echthiophate (Phospholine iodide).

The main use of beta blockers is to treat high blood pressure. Some also are used to relieve the type of chest pain called angina or to prevent heart attacks in people who already have had one heart attack. These drugs may also be prescribed for other conditions, such as migraine, tremors, and irregular heartbeat. In eye drop form, they are used to treat certain kinds of glaucoma. Drugs used in the treatment of open-angle glaucoma or ocular hypertension. At specific dosages they lower the intraocular pressure (IOP), supposedly by increasing the outflow of aqueous humour via the uveoscleral pathway. Common agents include latanoprost, travoprost, bimatoprost (a synthetic prostamide structurally related to prostaglandin) and unoprostone isopropyl. Bimatoprost reduces IOP by increasing the uveoscleral outflow as well as the trabecular outflow. TERMS Accommodation: In medicine, the ability of the eye to change its focus from distant to near objects (and vice versa). This process is achieved by the lens changing its shape. Accommodation is the adjustment of the optics of the eye to keep an object in focus on the retina as its distance from the eye varies. It is the process of adjusting the focal length of a lens. Anisocoria: Both pupils are usually of equal size. If they are not, that is termed anisocoria (from "a-", not + "iso", equal + "kore", pupil = not equal pupils).

The pupil may appear to open (dilate) and close (constrict) but it is really the iris that is the prime mover; the pupil is merely the absence of iris. The size of the pupil determines how much light is let into the eye. With anisocoria, the larger pupil lets more light enter the eye. Aphakia- Absence of crystalline lens totally or partially from field of vision, from any cause except after cataract extraction. Aphakia is mainly congenital or as result of LENS DISLOCATION AND SUBLUXATION. Chemosis: Swelling around the iris (the colored circle that surrounds the pupil) due to edema (swelling) of the bulbar conjunctiva (the clear membrane that coats the outer surface of the eye). Diplopia: A visual symptom in which a single object is perceived by the visual cortex as two objects rather than one. Disorders associated with this condition include REFRACTIVE ERRORS; STRABISMUS; OCULOMOTOR NERVE DISEASES; TROCHLEAR NERVE DISEASES; ABDUCENS NERVE DISEASES; and diseases of the BRAIN STEM and OCCIPITAL LOBE. Emmetropia- The state of refraction of the eye in which parallel rays, when the eye is at rest, are focused exactly on the retina.

Enucleation-Removal of an entire structure (such as an eyeball or tumor), without rupture, as one shells the kernel of a nut. Removal or destruction of the nucleus of a cell. Evisceration- the process whereby tissue or organs that usually reside within a body cavity are displaced outside that cavity, usually through a traumatic disruption of the wall of the cavity; evisceration of bowel. Removal of the contents of the eyeball, leaving the sclera and sometimes the cornea. Exenteration- Removal of internal organs and tissues, usually radical removal of the contents of a body cavity. hyphemaBlood in the anterior chamber of the eye.

Miosis: Pupillary constriction. This may result from congenital absence of the dilatator pupillary muscle, defective sympathetic innervation, or irritation of the CONJUNCTIVA or CORNEA. Contraction of the pupil. Mydriasis: Dilation of the pupils induced by eyedrops. The opposite of miosis.

Nystagmus- Involuntary rhythmic oscillation of the eyeballs, either pendular or with a slow and fast component.Papilledema: Swelling of the head of the optic nerve, a sign of increased intracranial pressure. The optic nerve head, also called the optic disk or papilla, is the area where the optic nerve (the nerve that carries messages from the eye to the brain) enters the eyeball. Photophobia: Abnormal sensitivity to light. This may occur as a manifestation of EYE DISEASES; MIGRAINE; SUBARACHNOID HEMORRHAGE; MENINGITIS; and other disorders. Photophobia may also occur in association with DEPRESSION and other MENTAL DISORDERS. Exophthalmos- Protrusion of one or both eyeballs; can be congenital and familial, or due to pathology, such as a retroorbital tumor (usually unilateral) or thyroid disease (usually bilateral). Scotoma: A localized defect in the visual field bordered by an area of normal vision. This occurs with a variety of EYE DISEASES (e.g., RETINAL DISEASES and GLAUCOMA); OPTIC NERVE DISEASES, and other conditions.

Strabismus: A condition in which the visual axes of the eyes are not parallel and the eyes appear to be looking in different directions. In divergent strabismus, or exotropia, the visual axes diverge. If the visual axes converge, it is called convergent strabismus or esotropia. The danger with strabismus is that the brain cones may come to rely more on one eye than the other and

that part of the brain circuitry connected to the less-favored eye fails to develop properly, leading to amblyopia (blindness) in that eye. EARS Acoustic: Having to do with sound or hearing. The acoustic nerve (the 8th cranial nerve) is concerned with hearing and the sense of balance and head position. An acoustic neuroma is a tumor on the acoustic nerve.

Cholesteatoma: A non-neoplastic keratinizing mass with stratified squamous epithelium, frequently occurring in the meninges, central nervous system, bones of the skull, and most commonly in the middle ear and mastoid region. Conductive Hearing Loss: Hearing loss due to interference with the acoustic transmission of sound to the cochlea. The interference is in the outer or middle ear. Sensorineural Hearing Loss: Hearing loss resulting from damage to the sensory mechanism internal from the oval and round windows.

Deafness- General term for inability to hear. Hearing loss can be present at birth (congenital) or become evident later in life (acquired deafness). The distinction between acquired and congenital deafness specifies only the time that the deafness. Otalgia- Pain in the ear. Otorrhea- A discharge from the ear. cerebrospinal fluid otorrhea- discharge of cerebrospinal fluid through the external auditory canal or through the eustachian tube into the nasopharynx. Rhinorrhea: Medical term for a runny nose. From the Greek words "rhinos" meaning "of the nose" and "rhoia" meaning "a flowing." A discharge from the nose. Tinnitus: Sounds that are perceived in the absence of any external noise source which may take the form of buzzing, ringing, clicking, pulsations, and other noises. Objective tinnitus refers to noises generated from within the ear or adjacent structures that can be heard by other individuals. The term subjective tinnitus is used when the sound is audible only to the affected individual. Tinnitus may occur as a manifestation of COCHLEAR DISEASES; VESTIBULOCOCHLEAR NERVE DISEASES; INTRACRANIAL HYPERTENSION; CRANIOCEREBRAL TRAUMA; and other conditions.

Vertigo: Vertigo is an abnormal sensation that is described by the person as a feeling they are spinning or that the world is spinning around them. It is most often associated with an inner ear problem. An illusion of movement, either of the external world revolving around the individual or of the individual revolving in space. Vertigo may be associated with disorders of the inner ear, vestibular nerve, brainstem, and cerebral cortex. Lesions in the temporal and parietal lobes may be associated with FOCAL SEIZURES that may feature vertigo as an ictal manifestation. (From Adams et al., Principles of Neurology, 6th ed, pp300-1)

DISORDERS:

Acute otitis media: Inflammation of the middle ear in which there is fluid in the middle ear accompanied by signs or symptoms of ear infection: a bulging eardrum usually accompanied by pain; or a perforated eardrum, often with drainage of purulent material (pus). Acute otitis media is the most frequent diagnosis in sick children in the U.S., especially affecting infants and preschoolers. Almost all children have one or more bouts of otitis media before age 6.

What is "swimmer's ear" or acute external otitis? External otitis or "swimmer's ear" is an infection of the skin covering the outer ear and ear canal. Acute external otitis is commonly a bacterial infection caused by streptococcus, staphylococcus, or pseudomonas types of bacteria. The swimmer's ear infection is usually caused by excessive water exposure. When water collects in the ear canal (frequently trapped by wax), the skin will become soggy and serve as an inviting culture media for bacteria. Cuts or abrasions in the lining of the ear canal (for example, from cotton swab injury) can also predispose to bacterial infection of the ear canal. Otosclerosis-The formation of spongy bone in the labyrinth capsule. The ossicles can become fixed and unable to transmit sound vibrations, thereby causing deafness. The abnormal formation of new bone in the middle ear that gradually immobilizes the stapes (stirrup bone) and prevents it from vibrating in response to sound, causing progressive loss of hearing. Otosclerosis usually affects both ears. It is a common disorder, especially among young women. Pregnancy may trigger it. Presbycusis: Age-related hearing loss with gradually progressive inability to hear, especially high frequency sounds. Presbycusis most often occurs in both ears. Because the loss of hearing is so gradual, people with presbycusis may not realize that their hearing is diminishing. They may have trouble distinguishing and understanding conversation in a noisy setting. Environmental exposures (such as to guns, power tools, industrial machinery, or very loud music) contribute significantly to presbycusis, but up to half of presbycusis is genetically determined. Presbycusis is common, affecting a third of people between 65 and 75 years and up to a half of people 75 and over. The hearing loss can usually be corrected with a hearing aid. What causes Meniere's disease? Although the cause of Meniere's disease is unknown, it probably results from an abnormality in the way fluid of the inner ear is regulated. In most cases only one ear is involved, but both ears may be affected in about 10% to 20% of patients. Meniere's disease typically starts between the ages of 20 and 50 years of age (although it has been reported in nearly all age groups). Men

and women are equally affected. The symptoms may be only a minor nuisance, or can become disabling, especially if the attacks of vertigo are severe, frequent, and occur without warning. Meniere's disease is also called idiopathic endolymphatic hydrops. Labyrinthitis: Inflammation of the labyrinth, the system of intercommunicating canals and cavities within the inner ear responsible for sensing balance. Labyrinthitis may be accompanied by the sudden onset of a feeling of vertigo triggered by head or body movement together with feelings of nausea and malaise. Due to diverse causes including viral and bacterial infections. Acoustic neuroma: A benign tumor that may develop on the hearing and balance nerves near the inner ear. The tumor results from an overproduction of Schwann cells -- small sheet-like cells that normally wrap around nerve fibers like onion skin and help support the nerves. When growth is abnormally excessive, Schwann cells bunch together, pressing against the hearing and balance nerves, often causing gradual hearing loss, tinnitus (ringing in the ears), and dizziness. If the tumor becomes large, it can interfere with the facial nerve, causing partial paralysis, and eventually press against nearby brain structures, becoming lifethreatening Mastoiditis: Inflammation of the mastoid, often secondary to ear infection. Inflammation of the cavity and air cells in the mastoid part of the temporal bone.

EAR TESTS:

Otoscopic examination:- An otoscopic examination is the visual examination of the auditory canal and tympanic membrane using an otoscope.

Purpose: An otoscopic examination is a procedure that examines the auditory canal and tympanic membrane for infection or blockage due to the presence of a foreign object or build up of wax, the tympanic membrane for signs of rupture, puncture, or hearing loss, and the canal for any variations from normal. Some otoscopes can deliver a small puff of air to the eardrum to determine if the eardrum will vibrate (which is normal). An otoscopic examinations is also part of a normal physical examination. Audiometry - The testing of the acuity of the sense of hearing to determine the thresholds of the lowest intensity levels at which an individual can hear a set of tones. The frequencies between 125 and 8000 Hz are used to test air conduction thresholds and the frequencies between 250 and 4000 Hz are used to test bone conduction thresholds. The Weber test is a quick screening test for hearing. It can detect unilateral (one-sided) conductive hearing loss and unilateral sensorineural hearing loss. The test is named after Ernst Heinrich Weber (17951878). The Rinne test is a hearing test.[1] It compares perception of sounds transmitted by air conduction to those transmitted by bone conduction through the mastoid. Thus, one can quickly screen for the presence of conductive hearing loss.

WHISPER TEST

1.

The examiner stands at arm's length (~0.6 m) behind the patient (to prevent lip reading)

2. 3. 4. 5. 6. 7.

The opposite auditory canal is occluded by the patient or examiner and the tragus is rubbed in a circular motion (goal; to block hearing from that ear) The examiner exhales and whispers a combination of numbers and letters (example 4-K-2). Whispering at the end of exhalation is to ensure as quiet and as standardized voice as possible. If the patient responds correctly, hearing is considered normal and no further screening is necessary on that ear. If the patient responds incorrectly, then repeat using a different number-letter combination. If on repeated testing, the patient can answer three out of a possible six numbers-letters correctly, the patient passes. If they cannot answer three out of six or more, the patient fails in that ear. Repeat the sequence in the opposite ear using different combinations of numbers and letters. (Note: patients with memory problems may need a simplified letter/number combination to compensate for their inability to remember)

*Pirozzo S. Whispered voice test for screening for hearing impairment in adults and children: systematic review. BMJ. 2003 October 25;327(7421):967.

Significance Hearing loss prohibits patients from understanding conversations, contributes to cognitive decline, and leads to social isolation. This impairment is the third most chronic impairment among older people. It is also useful to ask the patient and family if they have noticed any changes in hearing, to describe any changes and if they have had any prior treatment. Patients with no wax occlusion of their ear canal and who failed this test have a hearing loss that correlates with 30 dB loss. This level of hearing loss has a significant affect on communication.