Assessment of

Eyes and Ears

By B.Lokay, MD, PhD
Institute of Nursing, TSMU

Eye Anatomy Why Study It?

Why should you care?

Optometrist Doctor of optometry, 4 year
undergrad + 4 year optometry school
Ophthalmologists Medical doctors
In general, optometrists practice primary
and preventive eye care, while
ophthalmologists perform eye surgery
What do nurses do?

History

Vision difficulty?

Eye pain?

Photophobia inability to tolerate light

Childhood strabismus?

Halos around lights in glaucoma

Scotoma blind spot in visual field in
glaucoma, optic nerve, and visual pathway
disorder
Night blindness Vit A deficiency,
glaucoma,

A history of crossed eyes? AKA lazy eye

Redness or swelling?

Infections?

History cont.

Excessive or lack of tearing?

May

be due to irritants or obstruction in drainage

Past history of ocular problems?

Glaucoma? Family history?
Use of glasses or contact lenses?
When tested last?
Any medications?

Anatomy of
Eyelid

Eyelids (L. palpebrae) protect the

cornea and eyeball from injury
Canthi (sing. canthus) are corners of
the eye, also called angles of eye
Caruncle is located near medial
canthus and contains sebaceous
glands
Tarsal plates are made of connective
tissue and strengthen eyelid. They
contain meibomian (tarsal) glands
which secrete lipid to create airtight
seal when closed and also prevent
eyelids from sticking together

Inspecting External Ocular

Structures

General

Eyebrows

Note if facial expression is relax or

tense
Note if movement is symmetrical

Eyelids and lashes

Note if any redness, swelling,

discharge or lesions
Note if eyelid closes completely and if
drooping

Pallor of lower lid is good indicator of

anemia

For upper eyelid, use applicator stick

to fold the eyelid over

Abnormalities in Eyelids

Ectropion

Lower lid rolls out, causing an

increase in tearing
The eyes feel dry and itchy due to
inappropriate itching
Increase risk for inflammation
Occurs mostly in elderly due to
atrophy of elastic tissue

Entropion

The lower lid rolls in

Foreign body sensation

Abnormalities in Eyelids

Periorbital edema
May

occur with local

infection or systemic
condition

Ptosis
Occurs

with
neuromuscular
weakness (myasthenia
gravis) or CN III
damage

Lesions on the
Eyelids

Blepharitis

Chalazion

Inflammation of eyelids
Staph or dermatitis
Burning, itching, tearing,
foreign body sensation, pain
A cyst in or an infection of
meibomian gland
Nontender, firm, overlying
skin freely movable

Hordeolum (Stye)

Localized Staph infection of

hair follicle at lid margin
Painful, red, swollen, purulent

Anatomy of the Eye

Lacrimal apparatus
provides irrigation of
conjunctiva
glands secrete
lacrimal fluid (tears)
Lacrimal ducts lacrimal
fluid to conjunctiva
Lacrimal canaliculi
(puncti) drain fluid into
Nasolacrimal duct
conveys lacrimal fluid to
nasal cavity
Lacrimal

Inspecting the Lacrimal Apparatus

Inspect for bulges

or pressure near
canaliculi
Dacryocystitis
Inflammation

of the
lacrimal sac and/or
nasolacrimal duct

Dacryoadenitis
Infection

of lacrimal

gland
Dacryoadenitis

Dacryocystitis

Anatomy of Extraocular Muscles

4 rectus (straight)
2 oblique
Innervations

SO4 Superior oblique m.

LR6 Lateral rectus m.

CN IV (trochlear n.)
CN VI (abducens n.)

AO3 All other muscles

CN III ( Trigeminal n.)

Extraocular muscle movement

Extraocular Muscle Dysfunction

Anatomy of the Eyeball Outer Layer

Sclera tough
protective white
covering (posterior
5/6)
Cornea
transparent part of
the fibrous coat
covering the anterior
of the eyeball
(anterior 1/5)
Conjunctiva
transparent
protective covering
of exposed part of
eye (palpebral
conjunctiva covers
inside of eyelash)

iris

Corneal reflex lightly touching the eye with cotton

stimulates a blink.

Trigeminal n. (afferent)

Facial n. (efferent)

Inspection

Conjunctiva
Sliding

the lower lids down, observe

for redness on conjunctiva and if
eyeball looks moist and glossy
Reddening may be pathogenic

Sclera
Should

be white, although may

have gray-blue hue
Might contain yellowish fatty
deposits beneath the lids

Yellowing of sclera indicates jaundice

Vascular Disorders of Eye

Conjunctivitis

Pink eye
Due to bacterial, viral, allergic, or chemical
irritation
Redness throughout the conjunctiva, but
usually clear around the iris
Purulent discharge usually common
Symptoms: itching, burning, foreign body
sensation

Iritis

Red halo around the iris and cornea

Pupils may be irregular due to swelling
Symptoms: photophobia, blurred vision,
throbbing pain

Inspecting Cornea and Lens

Corneal abrasion

Assess by shining a light

and observing from the
side

Pupillary light reflex

Charted according to size

of pupil
Charted as a ratio of before
light/after light (3/1)
A sluggish response may
be caused by increased
ICP
No response may indicate
neurological damage

How to chart
pupillary light reflex?
PERRLA:
Pupils Equal, Round,
React to Light and
Accommodation

Anatomy of the Eyeball

Middle Layer

Canal of Schlemm

Choroid provides vascularity to

retina
Pupil variable-sized, black circular
or slit shaped opening in the center
of the iris that regulates the amount
of light that enters the eye. Appears
black because most of the light
entering the pupil is absorbed by the
tissues inside the eye.
Lens biconvex disc controlled by
the ciliary muscle to produce far
vision when flat
Anterior chamber

Aqueous humor is produced by the

ciliary body and secreted into
posterior chamber of eye.
From there, aqueous humor travels
to the anterior chamber where it
exits through the Canal of Schlemm
Determines intraocular pressure

Increase leads to
Glaucoma

Vascular Disorders of Eye

Physiology review:
Aqueous humor is produced by the ciliary body
and secreted into posterior chamber of eye. From
there, aqueous humor travels to the anterior
chamber where it exits through the Canal of Schlemm

Glaucoma

Excessive pressure in eye

due to blockage of outflow
from anterior chamber
This puts pressure on optic
nerve
Redness around the iris,
dilated pupils
Symptoms: sudden
clouding of vision, sudden
eye pain, and halos around
lights

Disorders of Opacity of Lens

Cataract

Anatomy of the Eyeball

Inner Layer

Retina visually
receptive layer where
light waves are changed
to nerve impulses
Optic disc area where
the optic nerve enters the
eyeball
Fovea centralis area of
most acute vision

Inspecting the Ocular Fundus

Using an ophthalmoscope to inspect

the internal surface of the retina,
anterior chamber, lens, and vitreous.
Darken the room to dilate the pupils
Remove eye glasses, contacts may
stay in
Ask person to stare at distant object
Hold ophthalmoscope close to your
eye and move to within a few inches
of the persons face
A red glow filling the pupil is called
the red reflex and is caused by light
reflecting off the retina

Cataracts appear as opaque black

areas against the red reflex

Inspecting the Optic Disc and Retina

Normal optic disc is:

Yellow-orange

to pink

Round

or oval
Distinct margins

Normal retina is:

Arteries

in each
quadrant
Arteries are bright red

Visual pathways

Testing Visual Reflexes

Pupillary light reflex

Constriction of pupils when bright light shines on the retina

Direct light reflex constriction of same sided pupil
Consensual light reflex simultaneous constriction of both
pupils
The impulse is carried afferently by CN II and efferently by CN III

Accommodation

Adaptation of eye for near vision

Ask person to focus on distant object (dilates the pupils). Then
ask person to shift gaze to near object few inches away. A
normal response is pupillary constriction and convergence of
axes of the eyes

Testing Visual Accuity

Snellen Eye Chart

Standing 20 feet from the

chart
Test one eye at a time by
covering the other eye
Leave contact lenses and
glasses on, unless the
glasses are reading
glasses
Normal vision is 20/20

Near vision

Use Jaeger card (smaller

version of Snellen chart) or
just read newspaper

Testing Visual Fields

Confrontation test

Measures peripheral vision

compared to examiner
(assuming examiners vision is
normal)
Both examiner and pt cover
one eye with a card, stand
about 2 feet away, and
maintain eye contact
Advance finger, starting from
periphery, and ask patient to
say now when the finger is
first visible
Inability to see when the
examiner sees suggests
peripheral field loss

Testing Ocular Muscle

Function

Cover Test

Detects deviated alignment of eyes

Ask pt. to stare straight at your nose and
cover one of the pt.s eyes with a card
While noting the uncovered eye, move
away the card
A normal response is a steady fixed gaze

Diagnostic Position Test

Ask pt. to hold head straight and move

finger in all positions, holding it about 12
inches away
A normal response is parallel tracking of
the objects with both eyes

Nystagmus

Fine oscillating movements around the iris

Normal at extreme lateral gaze

Developmental Considerations
Infants and Children

Strabismus must be detected

and treated early to prevent
permanent disability
Esotropia inward turning of eye
Exotropia outward turning of eye

Color vision due to inherited Xlinked recessive trait, occurs more

often in boys
External eye structures an
upward lateral slope together with
epicanthal folds occurs in Down
syndrome
Ophthalmia neonatum
conjunctivitis due to bacteria, virus,
or chemical irritation

Developmental Considerations
Aging

Decrease in visual
acuity, diminished
peripheral vision
Ectropion (drooping of
lower lid) or entropion
(eyelids turning in)
Pinguecula yellow
nodules due to
thickening of
conjunctiva as a result
of prolonged exposure
to sun, wind, and dust

Developmental Considerations Aging

Arcus senilis graywhite arc seen around

the cornea. Due to
deposition of lipids.
No effect on vision
Xanthelasma raised
yellow plaques.
Normal

Ear Anatomy

Ear Physiology

External Ear

External auditory meatus funnels sound waves, which reflect off the
tympanic membrane to produce vibrations
Cerumen (ear wax) protects the tympanic membrane from foreign
substances

Middle ear

Malleus, incus, and stapes and eustachian tube

Function to:

Conduct sound vibrations from tympanic membrane (outer ear) to cochlea

(inner ear)
Protect the cochlea by reducing the amplitude of sounds
Eustachian tube allows equalization of air pressure

Inner ear

Vestibule and semicircular canals

Allow brain to sense body position and relation of angle of head to gravity

Cochlea

Transfers vibrations from stapes into nerve impulses

The outer ear catches the waves of sound and funnels

them down the ear canal (about an inch long) and flush
up against the ear drum. The ear drum (tympanic
membrane) is the boundary between the outer ear and
the middle ear.

In the middle ear, the malleus picks up the vibrations

from the eardrum, passes them to the incus which then
passes them to the stapes. The stapes terminates in a
tiny footplate that fits precisely into the contact point or
window of the inner ear.

The window of the inner ear is the contact point of the

cochlea. The vibrations set up rolling waves in the
cochlear fluid which stimulate different areas of the
membrane, which rubs against specialized cells called
hair cells. This friction creates electrical impulses
transmitted by the cochlear nerve.

CN VIII is responsible for signal transduction from

vestibule and cochlea to the brainstem. From brainstem,
a signal is sent to the cerebral cortex to interpret the
sound.

Hearing Loss

Conductive
Mechanical

dysfunction of external or middle ear

Partial hearing loss
May be caused by impacted cerumen, foreign bodies,
perforated tympanic membrane, pus or serum in
middle ear, or otosclerosis (hardening of stapes)
May be fixed

Sensorineural
Dysfunction

of inner ear, CN VIII, or cerebral cortex

Cannot be fixed

Developmental
Considerations
Infants

Greater risk for otitis media (middle ear infections) due to shorter
eustachian tube
Aging
Cilia lining ear canal become coarse and stiff, impeding sound waves
Cerumen more common
Dry cerumen gray and flaky. More common in Asians and Native
Americans
Wet cerumen brown and moist. More common in whites and
blacks
Presbycusis - degenerative sensorineural hearing loss
Auditory reaction time increases

Obtaining History

Earaches? (otalgia)

Location, character, intensity, associative and alleviating factors

May be directly due to ear disease or maybe referred pain from a
problem in teeth or oropharynx

Infections?

A viral or bacterial upper respiratory infection may migrate up the

eustachian tube and involve the middle ear

Frequency? Occurred in childhood?

Discharge? (otorrhea)

May suggest infection or perforated eardrum

Typically with perforation, ear pain drainage

Otitis externa purulent, sanguineous, or watery

Acute otitis media with perforation purulent discharge

More History

Trouble hearing?

Gradual our sudden?

Ringing in ears? (tinnitus)

Some are ototoxic

Vertigo? (spinning)

May be a result of medication

Medications?

Presbycusis gradual sensorineural hearing impairment in the

elderly
Hearing loss due to trauma is often sudden

Subjective person feels like he or she spins

Objective person feels like room spins

Environmental noise

Noise-induced hearing loss

Lesions of External Ear

Otitis Externa
Gouty Tophi

Assessing External Ear

Size and Shape

Skin conditions

normal is 4-10cm tall

Note edema, inflammation, lesions

Tenderness

Location?

Pain in pinna indicates otitis externa

Pain at mastoid process indicates mastoiditis or lymphadenitis

External Auditory Meatus

Atresia absence or closure of ear canal

Otitis externa may cause purulent discharge
Otitis media may cause rupture of tympanic membrane
If drainage present following trauma, possible basal skull
fracture. Perform glucose test (CSF (+) for glucose).

Inspecting Using Otoscope

Pull the pinna up and

back in adult, straight
down in children under 3
years
Hold otoscope upside
down and place dorsal
side of hand along
persons cheek
Insert speculum slowly
and avoid touching the
inner section of canal
wall, which is sensitive
and may cause pain.

Inspecting the External Canal

Note any redness or

swelling, lesions, or
foreign bodies
If discharge present,
note color and odor

Otitis
Externa

Inspecting the Tympanic

Membrane

Normal is shiny and

translucent
Flat, slightly pulled in
at the center
Valsalva

maneuver
causes tympanic
membrane to flutter,
used to assess drum
mobility

Which tympanic membrane

is perforated?

Testing Hearing Acuity

Voice test

Whisper two syllable words

into one of the persons
ears, while covering the
other one. Ask person to
repeat what youve said.

Tuning fork tests

Measure hearing by air

conduction or bone
conduction
Weber test
Rinne test

Weber Test

Tuning fork is struck and

placed on head or
forehead, equal distance
from both ears
Used to determine if
hearing loss is more
extensive in one ear than
the other
This test cannot confirm
normal hearing, because
hearing defects affecting
both ears equally will
produce an apparently
normal test result

Rinne Test

Compares air conduction and

bone conduction
Place stem of vibrating fork on
mastoid process and ask when
sound goes away
Quickly invert the fork so the
vibrating end is near the ear
canal. The person should still
hear a sound
Normally the sound is heard
longer by air conduction rather
than bone conduction

In conductive hearing loss,

sound heard longer by bone
conduction

Normal Hearing

Conductive Hearing Loss

Sensorineural Hearing Loss

Infants and Children

Save otoscopic examination until the end

May help to show otoscope to child and let
him or her play with it
Stabilize (or ask a parent for help) the
childs head in order to prevent movement
Pull pinna straight down
In infants, the tympanic membrane may
look thick and opaque after first few days
or after crying
Tympanostomy tubes may be in place if
drainage occurs as a result of otitis media

Abnormalities in the Ear Canal

Acute Otitis
Media

Otitis Externa

Excessive Cerumen

Question 1

A nurse is performing a voice test to assess

hearing. Which of the following describes the
accurate procedure for performing this test?
1.
2.
3.
4.

Stand 4 feet away from the client to ensure that the

client can hear at this distance
Quietly whisper a statement and ask the client to
repeat it
Whisper a statement with the examiners back facing
the client
Whisper a statement while the client blocks both
ears

Question 2

A nurse is caring for a client who is

hearing impaired. Which of the following
approaches will facilitate
communication?
Speak frequently
2. Speak loudly
3. Speak directly into the impaired ear
4. Speak in a normal tone
1.

Question 3

A client is diagnosed with a disorder

involving the inner ear. Which of the
following is the most common client
complaint associated with a disorder
involving this part of the ear?
Hearing loss
2. Pruritus
3. Tinnitus
4. Burning in the ear
1.

Question 4

Which of the following statements made

by a parent should make the nurse
suspicious that the tympanic membrane
of a young child has ruptured?
She has been crying all night, but she feels
better this morning.
2. She has some bloody, yellow-looking stuff
coming out of her ear.
3. My child does not seem to hear very well.
4. My childs earwax is dark brown.
1.

Question 5

While examining the internal ear, the

nurse observes the light reflex on the
tympanic membrane. What does this
finding indicate?
Presence of pus
2. Fluid accumulation
3. Scar tissue
4. Normal finding
1.