Eyes and Visual System

Chapter 16

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 Health History: Risk Factors
Cataracts, glaucoma, macular degeneration
• Age
• Family history
• Gender
• Ethnicity
• Smoking
• Alcohol Intake
• Medications
• Chronic diseases
• Cataracts
• Glaucoma
• Macular degeneration
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 General Health History
Present health status
• Have you noticed changes in vision?
• When was last eye examination? Outcome?
Have you been tested for glaucoma?
• Do you smoke? If yes, how much and for how
long?
• Do you drink alcohol? How much? How often?
• Chronic illnesses or conditions such as diabetes
mellitus or hypertension?
• Taking any medications? What? When did you
start taking them?
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 General Health History

Present health status (cont.)

• Do you use eyedrops? For what reason? What kind
of drops? How often?
• Do you wear contact lenses or glasses?
– When were they prescribed? For what problem? Are
contact lenses soft, hard, or extended wear? Do you ever
sleep with contact lenses? How often do you clean
glasses? Contact lenses? How do you clean them?

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 General Health History
Present health status (cont.)
• Do you wear sunglasses in sunlight?
• Do you wear protective eyewear when playing
sports?
• Does your job involve vision risks?
– Are there sparks or flying bits of metal that could
injure eyes? What actions do you take to protect
eyes? Safety goggles?

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 General Health History
Past medical history
• Had any problems with eyes or vision?
– Past problems with eye, such as infections, may recur
and may help explain current visual problems
• Had any surgery on eyes? What procedure,
when, and what outcome? Had injury or trauma
to eyes?
– Incidence of injury or surgery may provide information
about eye or visual problems (eye surgery is a risk
factor for glaucoma)

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 General Health History
Family history
• Does anyone in your family have cataracts?
• Glaucoma?
• Diabetes mellitus?
• Nearsightedness (myopia)?
• Farsightedness (hyperopia)?
All these conditions have familial tendencies,
and may affect vision. If there is a positive
answer to any of these conditions, the client’s
risk of developing them increases
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 Problem-Based History
• Principal areas to be investigated are:
– Difficulty with vision
– Pain
– Erythema or edema (or both)
– Watering or discharge
As with symptoms in all areas of health
assessment, a symptom analysis is completed
that includes location, quality, quantity,
chronology, setting, associated manifestations,
alleviating factors, and aggravating factors
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 Problem-Based History
• Difficulty with vision
– What type of difficulty are you having with vision?
When did it begin? Suddenly or gradually? Affect
one eye or both? Constant, or come and go?
Blurring? Cloudiness? Images out of focus?
Spots (floaters) in front of your eyes?
– See a halo or multicolored rings around objects
or lights?
– Noticed a “blind spot”? Does it move as you shift
gaze? Has peripheral vision decreased?

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 Problem-Based History
• Difficulty with vision (cont.)
– Have vision problems interfered with daily life? Describe
how. Do you require books with large print, on audiotape,
or in Braille?
– See a curtain coming down across line of vision in one or
both eyes? Do you have difficulty seeing at night? Clients
with detached retina report curtain coming down over
affected eye
– Difficulty seeing at night? Night blindness can occur in
optic atrophy, glaucoma, or vitamin A deficiency

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 Problem-Based History
• Eye pain
– Describe the pain. Is it sharp? Dull? Throbbing?
Burning? Itching? How intense is pain on a scale of 0 to
10?
– When did the eye pain start? Did it begin suddenly or
gradually? Where is it felt? Sudden onset may be from a
detached retina and requires immediate medical care
– What do you think is causing the pain? Do you feel that
there is something in your eye? Do you have a
headache?
– What makes the pain worse? What makes it better? How
have you treated it? How effective was the treatment?

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 Examination: Overview
• Not all techniques are included with every examination;
you may perform some of these techniques only
occasionally
• Exam techniques depend on many variables, including
the reason for the exam, setting, condition and age of
client, skill level of nurse
• Specific findings detected during the examination may
warrant use of additional examination techniques
• It is the nurse’s decision to determine which techniques
are indicated for each examination

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 Examination: Vision
• Test visual acuity (distant vision) using Snellen’s chart
• Test visual acuity (near vision)
– With age there is loss of lens elasticity; this is
presbyopia (the client must move the card farther
away to see it clearly)
• Assess visual fields for peripheral vision using the
confrontation test
• Inspect the extraocular muscles for movement
• Inspect the corneal light reflex for symmetry
(Hirschberg’s test)

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 Examination: External Ocular
Structures
• Inspect eyebrows for hair distribution, underlying
skin, and symmetry
• Inspect eyelids and eyelashes for symmetry,
position, closure, blinking, discharge, and color
• Inspect and palpate globe in bony socket for
position and indentation
• Inspect lacrimal puncta for color, moisture,
discharge, tenderness, and nodules
• Inspect bulbar conjunctiva for color and clarity

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 Examination: Globe of the Eye
• Inspect sclera for color and clarity; sclera should be
white and clear
• Inspect cornea for transparency and surface
characteristics
• Inspect iris for shape and color
• Inspect pupils for size, shape, reaction to light,
consensual reaction, and accommodation

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 Age-Related Variations: Older Adults
• History
– Do you have any trouble with vision when climbing stairs
or driving? (older adults lose depth perception)
– Do you feel that you have lost any peripheral vision? Do
you have problems with night vision? Have you noticed a
change in recognizing colors?
– Do you have cataracts? Have you had cataracts
removed? Have cataracts progressed, causing
decreased vision?
– Do your eyes feel dry or burn? Do you have increased or
decreased tearing? What do you do for these problems?
(tears decrease in quantity, causing dry eyes, which can
be treated with artificial tears)

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 Age-Related Variations:
Older Adults
• Examination: procedures and techniques
• Eye examination conducted the same as
for younger adults

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 Age-Related Variations: Older Adults
• Normal and abnormal findings: normal findings expected of
an older adult may be difficult to distinguish from abnormal
findings
– Central and peripheral vision may decrease after age 70
– Acuity of 20/20 or 20/30 with corrective lenses is
common; accommodation takes longer
– Eyebrows may be thin along the outer edge and
remaining brow hair may appear coarse
– Actual ptosis may occur
– Orbital fat may have decreased, so eyes appear sunken,
or may herniate, causing bulging on lower lid or inner
third the upper lid

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 Clients with Situational Variations
• Clients with decreased or absent vision
– When performing physical assessment on a blind
person, remember to alert client to all actions before
you perform them
– History questions revised to delete those relating to
vision and ocular problems. Questions about pain,
edema, watering, discharge still appropriate
– Additional questions needed concerning how
individual has adapted to loss of sight. Physical
examination includes only inspection of the external
eye structures as described for adult

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 Clients with Situational Variations

• Clients with prosthetic eye

– Clients with enucleation of an eye replaced by
a prosthesis appear to have binocular vision
but have no sight on affected side and must
be approached from sighted side
– Some artificial eyes are permanently
implanted. Others are removed for daily
cleaning

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Common Problems and Conditions:
External Eye

• Hordeolum (sty): acute infection

originating in sebaceous gland of eyelid
• Conjunctivitis: inflammation of palpebral or
bulbar conjunctiva caused by local
infection of bacteria or virus, or by allergic
reaction, systemic infection, or chemical
irritation

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Common Problems and Conditions
Extraocular muscles: strabismus
• Abnormal ocular alignment in which the visual
axes do not meet at the desired point is termed
strabismus.
• Nonparalytic strabismus caused by muscle
weakness, focusing difficulties, unilateral refractive
error, or anatomic differences in eyes
• Paralytic strabismus is a motor imbalance caused
by paresis or paralysis of an extraocular muscle

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 Common Problems and Conditions:
Internal Eye
• Cataract: opacity of crystalline lens, commonly
occurs from denaturation of lens protein caused by
aging
– Cataracts caused by aging usually are central, but
peripheral cataracts are seen in hypoparathyroidism
– Congenital cataracts can result from maternal rubella or
other fetal insults during first trimester of pregnancy
– Trauma to eye can also cause cataracts
• Diabetic retinopathy: visual alteration caused by
diabetes mellitus; changes in retinal capillaries; is
leading cause of blindness from ages 20 to 75;
divided into background and proliferative
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