SENSES

THE VISUAL SYSTEM

The eye is a unique

organ because its
external anatomy may
be easily assessed.
Even the internal eye
is visible through the
cornea, where blood
vessels and Central
Nervous System
tissues (the retina and
optic nerve) may be
visualized without the
use of x-rays or
invasive procedures.

External Structures of the

Eyelids (palpebrae) and Eye

eyelashes: protect the

eye from foreign
particles

Conjunctiva
Palpebral Conjunctiva:
pink; lines inner
surface of eyelids
Bulbar Conjunctiva:
white with small blood
vessels, covers
anterior sclera

External Structures of the

Eye
Lacrimal apparatus (lacrimal

gland and its ducts and

passages): produces tears to
lubricate the eye and moisten
the cornea; tears drain into the
nasolacrimal duct, which
empties into nasal cavity.
Tears- lipids, dissolve salts,
glucose, urea, CHON, lysozyme
Meibomian glands- oil secreting
gland on upper and lower lids
Movement of the eye is
controlled by six extraocular
muscles.

Internal Structures of the

Eye
Three Layers of the Eyeball
Outer Layer
Sclera: tough, white
connective tissue (white
of the eye); located
anteriorly and posteriorly
Cornea: transparent
avascular tissue , convex
in shape and 0.5 mm
thick , through which light
enters the eye. Powerful
lens that bends and direct
light to the retina. Derives
O2 from the envt.

Internal Structures of the

Middle Layer /Uveal tract Eye

middle vascular layer that

furnishes blood supply to the
retina
Choroid: highly vascular
layer; located between
retina and sclera,
compose of 3 layers of
vessels attached that
both ciliary body and
optic nerve; nourishes the
retina
Ciliary body: anterior to
choroids, secretes
acqueous humor; muscles
change shape of lens

Internal Structures of the

Eye
Middle Layer
Iris: pigmented membrane
behind cornea; gives color
to the eye; located
anteriorly; color is
determined by the degree
of pigmentation; 2 iris
muscles (sphincter and
dilator) determine pupil
diameter hence regular
amount of light entering
the eye
Pupil: a circular opening in
the middle of the iris that
constricts or dilates to
regulate amount of light
entering the eye.

Internal Structures of the

Eye

RETINA - Thin semitransparent layer of nerve

tissue that forms the innermost lining of the
eye
Light-sensitive layer composed of rods and
Inner Layer: Retina cones (visual cells)
a.1 Cones: specialized structure for fine
discrimination and color vision; 6 million and
concentrated at the center peak sensitive to
red, green, and blue
Macula center of the retina about
5mm in dm; yellowish spot with
depressed center known as fovea
(point of finest vision)
a.2 Rods: more sensitive to light than cones;
aid in peripheral vision; about 125 million
distributed in the periphery of the retina;
fxns best in dim light (night vision/scotopic
vision); sensitive to green and yellow;
damage could lead to night blindness
Optic disk: area in retina for entrance of
optic nerve; has no photoreceptors, blind
spot

Internal Structures of the

Eye
Lens: transparent body that focuses image on
retina
biconcave avascular, 4mm thick, 9 mm in dm,
suspended behind the iris, consist of 65% H2O and
75% CHON
Fluids of the Eye
Aqueous Humor: clear, watery fluid in anterior and
posterior chambers in anterior part of the eye; serves
as refracting medium and provides nutrients to lens
and cornea; contributes to the maintenance of
intraocular pressure.
Vitreous Humor: clear, gelatinous material that fills
posterior cavity of the eye; maintains transparency and
form of the eye. Account about 2/3 of the eye fluid

Visual Pathways
Light passes through the
cornea, aqueous humor, lens
and vitreous humor. Retina
(rods and cones) translates
light waves
into
neural
impulses that travel over the
optic nerves.
Optic
nerves for each eye meet at
the optic chiasm
Optic nerves continue from
optic chiasm as optic tracts
and travel to the cerebrum
(occipital lobe), where visual
impulses are perceived and
interpreted.

 BINOCULAR VISION ability of the

eyes to fuse 2 images into a single
image
Near vision contraction of the
ciliary muscles which increases
curvature of the lens and brings near
objects into focus on the retina
Far vision accomplished by relaxing
ciliary muscle and flattening the lens

ASSESSMENT OF THE EYE

4 MOST COMMON PREVENTABLE
CAUSES OF PERMANENT VISION LOSS
IN DEVELOPED NATION:
1)
2)
3)
4)

Amblyopia
Diabetic Retinopathy
Age related maculopathy
Glaucoma

 Biographical and Demographic data

Incidence of cataracts, dry eye,
retinal detachment, glaucoma,
esotropia, exotropia increases with
age
Hereditary color vision deficits are
more common among men (7%) than
women (0.5%)
Exploration of Current Manifestations
Chief Complaint most common is a
change or loss of vision; it may also
be headache or eyestrain. Chief
complaint is often a vague problem as
something is wrong with my eye.

Symptom analysis

Abnormal Vision considerations

include:
a refractive (focusing) error, such as in
the presence of glare or halos in
uncorrected refractive error, scratches
on glasses, dilated pupils, corneal
edema, or cataract
interference from lid ptosis (drooping
eyelid)

DIPLOPIA

clouding or interference in the

cornea, lens, aqueous or vitreous
space
malfunction of the retina, optic
nerve or intracranial visual
pathway
flashing or flickering light- may
indicate retinal traction or
migraine
floating spots may represent
normal vitreous body strands or
pathologic presence of blood,
pigment, or inflammatory cells in
the vitreous body
Diplopia double vision, may be
caused by refractive correction,
muscle imbalance, neurologic d/o

RETINAL DETACHMENT

NORMAL VISION

MACULAR DEGENERATION
-loss of central vision

GLAUCOMA
-loss of peripheral vision

CATARACT
-hazy & out of focus

DIABETIC RETINOPATHY
-blind spot

 Abnormal Appearance most common is red eye.

Includes growth or lesions, edema, and abnormal
position
Diseases causing red eye:
Conjunctivitis bacterial, viral, allergic, and irritative
Herpes Simplex Keratitis inflammation of the cornea
Scleritis inflammation of the sclera
Angle- closure glaucoma sudden occlusion of the anterior
chamber angle by iris tissue
Adnexal disease stye, dacryocystitis, blepharitis, lid lesions
(carcinoma), thyroid disease and vascular lesion
Subconjunctival Hemorrhage accumulation of blood in the
potential space between the conjunctiva and sclera
Pterygium abN growth of tse that progresses over the cornea
Keratoconjunctivitis sicca inflammation assoc. w/ lacrimal
def.
Abrasions and foreign bodies hyperemic response
AbN lid fxn bells palsy, opthalmopathy, or lesion that
cause ocular occlusion

Abnormal Sensation
non-specific complaints
include eyestrain, pulling,
pressure, fullness or
generalized headache.
Eye pain
Foreign- body sensation
Deeper internal aching
Itching

Abnormal Sensation
Dryness, burning,
grittiness and mild
foreign-body
sensation
Tearing
Increased ocular
secretions usually
indicate viral or
bacterial infections
and may also be
present in allergic
and non-infectious
irritations.

Past Health History

RETINOBLASTOMA
Childhood and
infectious Diseases
Ask about systemic
disorders with possible
ocular sequelae such as
diabetes mellitus,
retinoblastoma, thyroid
disorders, rheumatoid
arthritis exposure to
STDs such as syphilis
and AIDS. Inquire about
vaccinations,
particularly for measles.

Major Illnesses and Hospitalizations

Ask about hypertension, multiple sclerosis,
myasthenia gravis, and adult onset of thyroid
disorders, rheumatoid arthritis, and DM.
Inquire also when was the last eye exam and
if there is any history of head or eye trauma
related to vehicular accidents, sports, injury,
or other unintentional events. Ocular
diseases and structural problems include
refractive errors, strabismus, amblyopia,
cataracts, glaucoma, retinal detachment

Medications- Ask for both

prescription and OTC drugs (insulin,
oral hypoglycemics, and thyroid
replacement hormones, OTC drops,
antihistamines and decongestants)
Allergies allergies on medications
and other substances such as
inhalants (dusts, chemicals or
pollens) and contactants (cosmetics
or pollens

 Family Health History ask about

strabismus, glaucoma, myopia and
hyperopia, migraine, retinoblastoma,
macular degeneration, retinitis
pigmentosa, sickle cell anemia and DM
Psychosocial History and Lifestyle
occupational hazards, leisure activities
and hobbies, and health mgmt, driving
history, exposure to irritating fumes,
smoke, or airborne particle, use of safety
garments, insufficient lighting, harsh or
glaring light, contact sports, outdoor
activities such as gardening, hiking, etc.

Review of Systems (ROS)

inquire about manifestations such

as headaches and problems with
sinusitis. Ask if such manifestations
occur with pain or discomfort, visual
changes, swelling, redness, or
drainage from the eyes.

PHYSICAL EXAMINATION
Examination of the eyes include
assessment of external structures,
using inspection and palpation,
extracocular movements (EOMs),
visual acuity, and visual fields
(peripheral vision)

External eye examination

Eye position assess eye position for symmetry

and alignment
Eyebrows inspect for symmetry, hair
distribution, skin condition and movement
Eyelids and Eyelashes for placement and
symmetry
PTOSIS
PTOSIS
ENTROPION
EXTROPION
ENTROPION

 Blink response an involuntary

reflex that occurs bilaterally up
to 20 times a minute
Eyeballs palpate for symmetry
and firmness.
Lacrimal Apparatus observe
the area for swelling or
tenderness. Inspect the area
between the lower lid and the
nose. Gently palpate the area
over the lower orbit rim near the
inner canthus.

 Conjunctivae and Sclerae

inspect for color changes,
texture, vascularity,
lesions, thickness,
secretions and foreign
bodies.
Corneal reflex performed
to assess the function of
the 5th (trigeminal) cranial
nerve.
Cornea inspect for
abnormalities such as
surface irregularities and
cloudiness (opacity).
ARCUS SENILIS

 Anterior Chamber inspect

for clarity and transparency
with no shadow cast upon
the irises.
Iris and Pupil assess or
test for PERRLA, and direct
and consensual response.
AbN if with photophobia,
irregular or unequal pupils
(anisocuria)
AbN pupil may be due to
neurologic dse, intaocular
inflammation, iris
adhesions, ocular meds S/E

Ocular motility/ Extraocular Muscle

Test
provides information about the
extraocular muscles; the orbit; the
oculomotor, trochlear and abducen
nerves; the brain stem connection
and the cerebral cortex. Note for
speed, smoothness, range and
symmetry of ocular movements and
observe for unsteadiness of fixation.

NYSTAGMUS

Corneal Light Reflex Test

(Hirschbergs Test)
determines eye alignment
STRABISMUS
TROPIA/PHORIA

ESOTROPIA
EXOTROPIA
HYPERTROPIA
HYPOTROPIA

Cover-Uncover Test

assess eye
muscle
function and
alignment for
tropia and
phoria.

Visual acuity

Testing visual acuity is the

standard and routine method used to
determine the clarity of the ocular
media (cornea, lens and vitreous)
and the function of the visual
pathway from the retina to the brain.
Traditionally measured with the
SNELLEN CHART at a distance of 20
feet.

 Test near vision w/ card or newsprint

held 12 to 14 in from the clients eyes
Correctives lenses maybe worn if
needed
If client becomes familiar with the
letters through repeated examn, have
the client read the letters backward
If client can read most of the letter in a
particular line but misses 1 or 2,
document the visual acuity as 20/40 - 2

SNELLEN CHART

Visual acuity
A 20/20 vision is normal; the patient can
read at 20 feet what a person with
normal vision can read at 20 feet.
A visual acuity of 20/60 means that the
patient can read at a distance of 20 feet
only what a patient with a normal vision
can read at 60 feet

Visual acuity
The patient with myopia has results of 20/30
or greater, signifying that the patient can
read at 20 feet only what a person with
normal vision can read at 30 feet.
Hyperopia results are 20/15 or less; that is
the patient can read at 20 feet what a person
with normal vision can read at 15 feet.
Legal blindness is defined as 20/200 or less
with corrected vision (glasses or contact
lenses) or less than 20 degrees of visual field
in the better eye.

TEST FOR COLOR VISION

ISHIHARA PLATE
Causes: nutritional problems, optic
nerve d/o and problems w/ fovea
centralis
Use for screening people seeking a
license to operate a motor vehicle or
for employment
Scotoma central area blindness

Visual fields
-Used to evaluate peripheral vision
Two Methods
Confrontational
Method
Perimetry assesses peripheral
vision, visual fields
PERIMETRY

Internal Eye Examination

Opthalmoscopic Exam
Direct opthalmoscopy
hand-held direct
opthalmoscope
provides a magnified
(x15) image of the
fundus (posterior
portion of the eye), and
detailed view of disc
and retinal vascular bed

 Indirect opthalmoscopy provides a

stereoscopic picture over a large area
of the retina. The light source comes
from the hand mounted light
The examiner holds a convex lens in
front of the clients eye, and through a
viewing device attached to the
headband, sees inverted reversed image
It provides a binocular visual perception
with depth perception and permits a
wider field of view compared with the
direct method

Tonometry
a method of
measuring intraocular
fluid pressure with the
use of calibrated
instruments that indent
or flatten the corneal
apex.
Normal intraocular
pressure (IOP): 12-20
mmHg

2 types of tonometer
Measures the
force required to
flatten the
corneal apex by
standard
amount

Applanation
tonometer

Hand-held tonometer

Measures the
amount of tension on
the cornea. First, the
cornea is
anesthetized w/
topical anesthetic
drop. While the client
sits and looks
straight forward, the
tonopen is held
perpendicular to the
cornea and tapped
several times directly
on the cornea

Slit-Lamp Examination
Use to illuminate and examine the
anterior segment of the eye under
magnification an optical cross section
of anterior chamber

AUDITORY SYSTEM
Hearing and balance
problems can reduce the
ability to communicate, limit
social activities, and hinder
the constructive use of
leisure time. The ears are a
pair of complex sensory
organs for both hearing and
balance. Their location on
either side of the head
produces binaural hearing,
allows the detection of
sound direction, and aids in
maintaining equilibrium.

STRUCTURES OF THE EAR

External Ear
Auricle (Pinna):
outer projection
of the ear
composed of
cartilage and
covered by skin;
collects
soundwaves.

Parts of cartilage that hold the pinna

Helix outer rim of the pinna

Lobule inferior portion
Concha deepest part leading to the ear canal
Tragus and antitragus triangular folds of
cartilage that protect over the entrance to the
ear canal

STRUCTURES OF THE EAR

External Ear
External auditory canal : lined
with skin; glands secrete
cerumen, providing protection;
transmits sound waves to
tympanic membrane.
Tympanic membrane (eardrum):
located at the end of the
external canal; vibrates in
respond to sound and transmits
vibrations to middle ear.
Thin, translucent, pearly gray
membrane obliquely directed
downward and inward

Middle Ear

A. Ossicles
Three small bones: Malleus
(Hammer) attached to
tympanic membrane, Incus
(Anvil), Stapes (Stirrups)
Ossicles are set in motion
by sound waves from
tympanic membrane.
Sound waves are
conducted by vibration to
the foot plate of the stapes
in the oval window ( an
opening between the
middle and the inner ear.)

Middle Ear
B. Eustachian Tube:

B. Eustachian Tube:
connects nasopharynx and
middle ear; brings air into
middle ear, thus equalizing
pressure on both sides of
the eardrum (maintains
ventilation and pressure).
C. Mastoid Process:
bony protruberance behind
the lower portion of the
pinna. Close to several
impt cranial structures and
internal carotid artery

Inner Ear (Labyrinth)

A. Cochlea

Contains Organ of Corti,

the receptor end-organ for
hearing
Transmits sound waves
from the oval window and
initiates nerve impulses
carried by CN VIII
(acoustic nerve) to the
brain (temporal lobe of
cerebrum.)

B. Vestibule (utricle and

saccule)
C. Semicircular Canal

ASSESSMENT OF THE EAR

OTOLOGIC HISTORY
Biographical and Demographic
Data
Current Health
Chief complaint common
chief complaints are as follows:
hearing loss, pain, tinnitus, ear
drainage, loss of balance,
vertigo, dizziness, nausea or
vomiting.

Symptom analysis

Hearing loss may occur suddenly or gradually

and can accompany the normal aging process.
The loss may be conductive, sensorineural or r/t
CNS d/o
The patient may report inability to hear certain
words or sounds or that sounds are muffled.
Pain may be perceived as a feeling of fullness in
the ear.

Symptom analysis
Ear drainage can be bloody
(sanguineous), clear
(serous), mixed
(serosanguineous), or
contain pus (purulent).
Drainage may also be
accompanied by an odor.
Tinnitus
Loss of balance may be
accompanied by vertigo.

VERTIGO

a sensation of
motion while the
person is not
moving
DIZZINESS
feeling of
unsteadiness and
a feeling of movt
within the head
or light
headedness

Past Health History

Childhood and Infectious Diseases
Common childhood diseases involving the ears include the
following:
acute middle ear infections (Otitis media)
eardrum perforations resulting from Otitis media
complications of ear infections such as chronic Otitis
media, frequent upper respiratory tract infections
acute and chronic sinus infections
A pneumococcal conjugate vaccine shoes good promise in
preventing initial ear infection and reducing subsequent
episodes of acute otitis media in infants and children
Utero exposure to maternal influenza and rubella may
result in congenital hearing loss in the child
Premature birth may cause hearing problems

Infectious diseases with ear

sequelae include mumps, measles,
and meningitis. Inquire if the patient
has been immunized for mumps,
measles, and haemophilus influenza
type b (Hib).

Major Illnesses
and Hospitalizations

inquire about a history of upper

respiratory tract infection,
tonsillectomy or adenoidectomy, ear
surgery, trauma to the head or ear
such as severe blow or sustained
loud noise exposure or concussion
from sudden changes in air pressure.

Medications use of drugs like

aspirin, aminoglycosides,
analgesics, salicylates, quinine,
chemotherapeutic agents and
protozoal agents
Allergies allergies to
medications and to other
substances, allergies resulting to
stuffiness and congestion
(obstructs flow of air b/w the
middle ear and nose so that air
pressure cannot be equalized).

Psychosocial History occupational

hazards, environmental exposure and
leisure activities and hobbies.
50 dB ordinary speech
70 dB heavy traffic
80 dB uncomfortable to the human
ear
85-90 dB exposure to these for
month or years could cause cochlear
damage
Review of Systems (ROS) ask about
the problems with the nose, sinuses,
mouth, pharynx and throat. Has the
patient experienced head trauma, loss
of balance, dizziness or vertigo

PHYSICAL EXAMINATION

Examination of the ear includes

assessment of hearing acuity, balance and
equilibrium.
Note size, configuration, and angle of
attachment to the head. Note whether
ears protrude if so the degree of
protrusion, the color of the skin of the
ears . Note any lumps, lesions, cysts.
Palpate and manipulate the pinna to
detect, tenderness, nodules or tophi
Inspection and palpation of auricle,
periauricular area, and mastoid area

Examination of the ear canal

2 Methods:
Direct observation
Otoscopic examination
Otoscope a device that
consist of a handle, a light
source, magnifying lens,
and an attachment for
visualizing the earcanal and
ear drum
Pneumatic device bulb to
instill air to the eardrum to
test its mobility and
integrity

C. Tests for Auditory Acuity

assessment
of the middle
and inner ear
for hearing.

Whispered
voice or ticking
watch test

C. Tests for Auditory Acuity

Weber test

C. Tests for Auditory Acuity

Rinne Test

Tests for Vestibular Acuity

Romberg test
Test for
Nystagmus
Caloric test /
Oculovestibular
reflex test

LABORATORY TESTS
Blood

test
Cultures
Tests for Presence
of Cerebrospinal
Fluid
Tissue Specimens

SENSES