Head and Neck (Head& Eye)

The Head Anatomy

The External Eye Medial chanthus

The Eye Lacrimal Gland and Nasolacrimal duct

The Eye  Aqueous humour  Ciliary body

The Internal Eye

Visual Pathways

Visual Field

Pathway of Pupillary Reaction

 Extraocular muscles Two oblique/ Four rectus

 Extraocular muscles & cranial nerves Superior rectusCN III (oculomotor) Lateral rectusCN VI (abducens) Inferior rectusCN III (oculomotor) Medial rectusCN III (oculomotor) Superior obliqueCN IV (trochlear) Inferior obliqueCN III (oculomotor)

The Health History; Head & Eye  Headaches  Changes in vision; Hyperopia Presbyopia Myopia  Diplopia  Blurred vision  Scotomas

Headache: Table 7-1, p Primary headache:  Tension headache (bilateral, generalized or localized to back of head)  Migraine  Cluster headache

headache Secondary:  Analgesic rebound  Headache from sinusitis  Meningitis  Temporal  Posttraumatic  Subarachnoid  Brain tumor  Trigeminal neuralagia

Headache  PQRST  One side or bilateral  Continuous or come and go  Chronologic pattern and severity  Associated symptoms  Family hx

Eye  How is your eyes? Visions?  Eye and vision problems Change in vision? Worse during close work or at distances? Change in vision: Hyperopia (farsightedness): difficulty with close work Presbyopia (inability to focus on near objects /aging vision) Myopia (nearsightedness): impaired far vision Double vision (diplopia) ;EOM Blurring? Is the onset sudden or gradual

Eye Hx  Specks (scotomas): o Fixed (lesions in the retina or visual pathway) o Flashing lights (detachment of vitreous from retina)  Does the patient wear glasses  Pain in or around the eyes, redness, excessive tearing or watering

Head Examination  The hair Quantity, distribution, texture, pattern of loss,  The scalp Scaliness, lumps, lesions….  The skull General size and contour, deformities, depressions, lumps, tenderness

Head Examination  The face Facial expression, contour, symmetry, involuntary movement, edema, masses  The skin Color, pigmentation, texture, hair distribution, lesions

The Eyes Examination Important areas of examination  Visual acuity  Visual field  Conjunctiva & sclera  Cornea, lens,& pupils  Extra ocular muscle movement  Fundi, including optic disc & cup, retina, retinal vessels

The Eyes Examination :Inspection  Visual acuity: Snellen eye chart Position the patient 20 feet away Determine the smallest line of print from where the patient can identify more than half of the letters. It expressed as two number: 20/30 20: the distance of patient from the chart 30: the distance at which a normal eye can read the line of letter Legally blind: corrected vision is 20/200

 Visual acuity: continue Near vision; for patients with presbyopia hand held cards distance 14 inches

The Eyes Examination :Inspection  Visual fields by confrontation  Visual field is the entire area seen by an eye when it looks at a central point.  If you find a defect, test one eye at time

The Eyes Examination :Inspection  Position and alignment of the eyes  Eyebrows: quantity, distribution, scaling  Eyelids: width of palpebral fissures, color of lids; adequacy of closure  Lacrimal apparatus: briefly inspect regions of the lacrimal glands and lacrimal duct for swelling, excessive tearing, dryness

The Eyes Examination :Inspection  Conjunctiva and Sclera: color and vascular pattern; ask patients to look up as you depress both lower lids with your thumbs inspect for color and vascular patterns.  Cornea & lens  Iris: color, presence of shadow  Pupils: Size Shape Symmetry Miosis: constriction/ mydriasis: dilation Anisocoria;pupillary inequality of less than 0.5 mm if pupillary reactions normal, it considered benign

The Eyes Examination :Inspection  Pupillary reaction to light: Prevent near reaction by using both the distance and the oblique lighting. Darken the room and use bright light. Observe the direct reaction Observe the consensual reaction If the light reaction is absent, test the near reaction.

The Eyes Examination :Inspection  Inspect the reflection in the corneas: From 2 feets, shine a light to the cornea  Extraocular muscles movements: H shape Observe the parallel, conjugate movement of the eye Any deviation from the normal Observe nystagmus Lid lag Test for convergence: normal up to 5-8 cm

The Eyes Examination :Inspection Lid lag / hyperthyrodism

The Eyes Examination :Inspection  Ophthalmic Examination  How to use the ophthalmoscope:

How to use the ophthalmoscope  Darken the room.  Have the patient sit up with his eyes at your eye level if possible.  Both you and the patient should remove glasses if worn but contact lenses don’t need to be removed

How to use the ophthalmoscope  Switch on the scope light and turn the lens disc until you see the large round beam of white light. Adjust the size of the incident light beam to the size of the pupil.  Shine the light on the back of your hand to check the desired brightness.  Turn the lens disc to the “0” diopter

How to use the ophthalmoscope  Hold the scope in your right hand to examine the patient’s right eye; in your left hand to examine the patient’s left eye  This keeps you from bumping the patient’s nose and gives you more mobility and closer range.  Place yourself 15 inches away from the patient and to the side.  Shine the light beam on the pupil and look for the orange glow in the pupil—the so called red reflex.

How to use the ophthalmoscope  Place the thumb of your other hand across the patient’s eyebrow; this helps keep you steady.  Keeping the light beam focused on the red reflex, move toward the pupil until you are very close to it, almost touching the patient’s eyelashes.  Have the patient sitting with his/her eyes at your eye level  Try to keep both eyes open and relaxed as if gazing into the distance—this minimizes the fluctuating blurriness as eyes accommodate  You may need to lower the brightness to make the examination more comfortable

Perform direct opthalmoscopy  Assess;  Red reflex  Optic disc and physiologic cup  Retinal blood vessels  Retinal background  Macula and fovea

The findings :The Optic Disc  Inspect the disc and note the following: The sharpness or clarity of the disc outline The color of the disc: normally yellowish orange to creamy pink Shape: round or oval Size of the central cup—usually half the diameter of the disc

The findings : The Retinal blood vessels  Note the arteries, veins, and the arteriovenous crossing  The ratio of A:V is 2:3 or 4:5  Crossing not more than 2 disk diameter is normal

The findings : The Retina Distinguishing Arteries from Veins ArteriesVeins ColorLight redDark red SizeSmaller (2/3)Larger Light Reflex Reflection BrightInconspicuous or Absent

The findings : The Macula  View by asking the patient to look directly into the light  The macula is darker than the fundus  The fovea is the center of the macula and its color tiny white  Finally, view the background retina for evidence of red spots (hemorrhages) or yellow spots (exudates)

The findings : Normal Eye Fundus  Disc margins are sharp color: yellowish orange to creamy pink shape: round or oval Cup to disc ratio: less than half  Vessels AV ratio AV crossing No arterial light reflex  Fundus background No exudates or hemorrhages color : red to purplish  Macula macula is located 2.5 disc distance temporal to disc no vessels are noted around Macula it may be slightly pigmented

Abnormal findings/ Eye  Ptosis: Dropping of the upper lid

Abnormal findings/ Eye  Sty: A painful, tender red infection in a gland at the margin of the eyelid.

Abnormal findings/ Eye  Chalazion: Painless nodule, inside the led

Abnormal findings/ Eye  Entropion ; an inward turning of the led margin.  Ectropion ; the margin of the lower lid is turned outward exposing the palpebral conjunctiva  See page 255