Eyes and Ears Special Senses

Review the function and structure of the eye. Eyes Review the function and structure of the eye.

A & P - External Eye

Lacrimal Apparatus

6 Extraocular Muscles

A & P - Internal Eye

Internal Structure Outer Layer Middle Layer Inner Layer transparent cornea covers the iris sclera - protects and site for attachment of extraocular muscles Middle Layer pupil - SNS =dilates. PNS= constricts, vitreous humor maintains shape, Inner Layer retina- extension of optic nerve, receives light impulses to be transmitted to occipital lobe Optic disc: vessels converge at center, yellow-orange in colour, round or oval, physiologic cup within the disc (smaller lighter circle). Retinal vessels: paired artery &vein Fovea centralis -Macula: slightly darker pigment at center has the sharpest and keenest vision due to cones and rods.

Visual Pathways

Health History Subjective information EYE Health History Subjective information

Health History Age Infant/Child Peripheral vision intact in newborn Most neonates (80%) are born farsighted (gradually decreases after 7 to 8 years) Macula (area of keenest vision) begins development by 4 months and is mature by 8 months. Decreased eye cordination at birth, eye movement sometime sluggish to eyes

Health History Age Middle age Presbyopia(difficulty with near vision) Hypertensive Retinopathy Visual acuity diminished gradually after 50 yrs (continues)

Health History Age (cont’d) Elderly Develop cataracts (lens opacity), glaucoma (increased ocular pressure) and macular degeneration (loss of central vision) Entropion, ectropion External eye changes: wrinkling and drooping Dry eyes- Lacrimal glands involute: decreased tear production, dryness and burning (continues)

Health History Gender- Female - dry eyes Race- Glaucoma (African Americans), melanona of eye (Caucasians) Common chief complaints Changes in visual acuity Pain Drainage Itching Dryness (continues)

Health History Characteristics of chief complaints Location Quality Associated manifestations Aggravating and alleviating factors Setting Timing

Past Health History Medical: eye-specific Surgical: eye-specific Medications Allergies Injuries and accidents Special needs Childhood illnesses (continues)

Past Health History Family Social Health maintenance activities Work environment Health maintenance activities Diet Use of safety devices Health check-ups

Assessment of the Eye Equipment General approach Ophthalmoscope Penlight Vision charts Vision occluder General approach Lighting Environment

Preparation for Physical Exam of the Eye Position the client sitting up with the head at your eye level Use orderly approach moving from the extraocular structures to the intraocular structure(1-6 p 348)

Visual Acuity Assessment of Cranial nerve II Distance vision - Use Snellen Chart N= 20/20 Myopia (nearsightedness) Amblyopia (loss of visual acuity due to uncorrected strabismus= crossed eyed or DM,alcoholism, uremia) Near vision - use Rosebaum or snellen card N = reading is possible at 14 inches until late 30-40s Hyperopia (farsightedness) Color vision N = can id primary colors on snellen chart

Visual Fields Confrontation technique Assess all fields N= pt covers 1 eye, use own visual field as control, can see stimulus at 90°temporally, 60°nasally, 50°superiority, 70°inferiority

Visual Fields Types of defects Hemianopsia Circumferential blindness (p352 image) Hemianopsia Circumferential blindness Unilateral blindness

External Eye and Lacrimal Apparatus Eyelids- inspect N = symmetrical eyelids, can raise eyelids symmetrically (CN 3) Abnormal findings Ptosis (drooping of lid) Exophthalmos (protrusion of eyes out of orbit) Entropion(turning inward or inversion of lower lid) ectropion (outward turning of lower eyelid) hordeolum (acute localized inflammation- internal = conjunctival side of lid, & external =sty)

External Eye and Lacrimal Apparatus Lacrimal apparatus- inspect, palpate N = no enlgmt, no swelling or no redness, no exudate and minimal tearing. No dischrg from punctum apon palpation. Abnormal findings dacryoadenitis (acute inflammation of lacrimal gland) dacryocystitis - obstruction of lacrimal duct dt inflammation

Extraocular Muscle Function CN III, IV, VI Corneal light reflex (Hirschberg test) Cover/uncover test Cardinal fields of gaze

Extraocular Muscle Function CN III, IV, VI Corneal light reflex (Hirschberg test) N= light reflex seen symmetrically in center of each eye Abnormal findings due extraocular muscle weakness extropia (outward turning of eye esotropia (inward turning or eye)

Extraocular Muscle Function CN III, IV, VI Cover/uncover test N= eyes are aligned, no movement of either eye Abnormal findings phoria =latent misalignment of eye exists

Extraocular Muscle Function CN III, IV, VI 6 Cardinal fields of gaze N=both eyes move smoothly and symmetrically in 6 fields of gaze & converge on the object as it converges on then nose note : nystagmus= involuntary movement Abnormal findings deviations from N

Anterior Segment Structures Conjunctiva- inspect N= transparent, sm bld vessels, white Abnormal findings conjunctiva, edema, lesions, foreign bodies, Sclera -inspect N= white , sm bld vessels jaundice, blue (osteogenesis imperfecta-thinning of sclera) Cornea- inspect with penlight N= corneal surface is moist, shiny presence of discharge, cloudiness, opacities, irregularities

Anterior Chamber Iris Abnormal findings Inspect the iris for color, nodules, vascularity N=even color or mosaic, smooth no vascularity Shine light obliquely through the anterior chamber from lateral side towards nasal chamber N=the entire iris will be illuminated Abnormal findings hyphema (bleeding into iris dt trama)

Anterior Chamber Pupil (CN III) Abnormal findings darken room & note size and shape of pupil, move penlight from side to front of eye, observe pupillary reaction N=PERRLA N= direct light flex (pupil constrict with light) N= Consensual light reflex (move penlight in front of one eye and observe other eye for pupillary constriction) N = Accommodation (pupils constrict as converge onto closer object) Abnormal findings anisocoria - sm diff in pupil size oculomotor nerve damage- a fixed and dilated pupil is seen (see pg 363)

Anterior Chamber Lens Abnormal findings shine penlight directly into pupil , note color of lens N= transparent in color Abnormal findings cataract- cloudiness or opacity in the lens

Posterior Segment Structures Assessment techniques use of ophthalmoscope

Posterior Segment Structures Retinal structures instruct pt to look at distant object use ophthalmoscope, shine into each eye N= Red Reflex present (pupil appears red through ophthalmoscope) N= observe intact optic disc (on nasal side of retina by following any retina vessel centrally) Abnormal findings absent red reflex - dt cataract

Posterior Segment Structures Macula move ophthalmoscope towards ear (temporal lobe) and observe for black circle around fovea. N= macula is darker, avascular area with a pinpoint reflective center known as the fovea centralis

Gerontological Variations Changes in visual acuity Presbyopia Cataracts Macular degeneration Glaucoma

Review of Normal Findings Visual acuity 20/20 Near vision acuity at 14 inches Able to identify all six colors Visual fields intact (continues)

Review of Normal Findings Eyelids symmetrical; no drooping, infections, or tumors No enlargement, swelling, or redness of the lacrimal apparatus Light reflex is symmetrical in the center of each cornea (continues)

Review of Normal Findings Eyes aligned on cover/uncover test Extraocular eye movements intact in all six fields Bulbar conjunctiva is transparent Palpebral conjunctiva is pink and moist (continues)

Review of Normal Findings Sclera are white, without exudate, lesions, or foreign bodies Cornea is moist, shiny, without discharge, cloudiness, or opacities Entire iris is illuminated Color of iris is evenly distributed (continues)

Review of Normal Findings Pupils are deep, black, round, and of equal diameter Pupil size is 2–6 mm Lens is transparent Red reflex is present Optic disc is pinkish orange Macula is darker, avascular

Review the function and structure of the Ear Ears Review the function and structure of the Ear

Anatomy and Physiology of the Ear Three sections External ear Middle ear Inner ear Auricle or pinna (continues)

External, Middle, Inner Ear Structure

External Ear Structure

Middle Sar Structures Air filled cavity Tympanic membrane Ossicles ( 3 tiny bones - malleus, incus, stapes) 2 muscles involved in movement of ossicles- tensor tympani- pulls inward, stapedius - pulls outwards Eustachian tube - connected to nasopharynx by the auditory canal (relieves air pressure within the middle cavity) see next slide

Inner Ear Structures Controls hearing and equilibrium/balance closed fluid-filled system of interconnecting tubes called the Labyrinth cochlea (snail shape structure containing perilymph & endolymph which vibrate and stimulate vestibulocochlear nerve CNVIII) semicircular canals (provide balance and equilibrium for the body) vestibule (btwn cochlea & semicircular canals) Frequency range of 20–20,000 Hz Decibel range 0–140

Pathways of Hearing Air Conduction (AC): most efficient. AC>BC Bone Conduction (BC) See OH

Health History Subjective Data Ears Health History Subjective Data

Ears-Subjective Data **Note the following** Earache Infections Discharge (otorrhea) Hearing loss Environmental noise Tinnitus Vertigo Self care behaviours

What further information would you gather if the client is an infant and children? Ear infections (how many, 1st one?) Parent = 1. Does the child seem to have hearing loss? 2. Does the child put objects in the ears?

Ears – Physical Examination Objective Data

Equipment Otoscope Tuning fork (continues)

Assessment of the Ear Consists of three parts Auditory screening(CN VIII) Inspection and palpation of external ear Otoscopic assessment

Auditory Screening Voice-whisper test instruct pt to occlude 1 ear with finger stand 2 feet behind the other ear and whisper ask pt to repeat whispered words N= able to repeat words whispered at a distance of 2 feet (continues)

Auditory Screening- Tuning fork tests Weber test N= able to hear sound equally in both ears Abnormality Determines whether hearing loss is conductive or sensorineural

Auditory Screening- Tuning fork tests Rinne test Normal finding: air conduction > bone conduction Abnormality Determines whether hearing loss is conductive or sensorineural

Hearing Loss Central deafness: occurs with pathologic conditions above the junction of the acoustic nerve and the brain stem. E.G. brain tumor, vascular changes which deprive the inner ear of blood supply, CVA. Conduction deafness: mechanical dysfunction of the external or middle ear. Partial loss (must increase amplitude). E.G. impacted cerumen, foreign bodies, perforated tympanic membrane, pus in middle ear. Sensorineural deafness: pathology of the inner ear, CN VIII or auditory areas of the cerebral cortex. E.G. presbycusis (gradual nerve deterioration), ototoxic drugs (affect the hair cells in the cochlea)

External Ear Inspection & Palpate Abnormal findings Note position, size, color, and shape N= flesh color, top of ear = to outer canthus of eye, cerumen is moist & does not obscure the tympanic membrane, no foreign bodies, redness, drainage, deformities, nodules, or lesions Abnormal findings Pale, red, cyanotic Small-size or large-size ears Purulent drainage Clear or bloody drainage Hematoma behind ear over mastoid Pain or tenderness on palpation (continues)

Otoscopic Assessment Inspect both external ear canal using otoscope N= No redness, swelling, tenderness, lesions, drainage, foreign bodies Tympanic membrane is pearly gray with well-defined landmarks Light reflex present at 5 o’clock in right ear and 7 o’clock in left ear Tympanic membrane moves when patient blows against resistance Abnormal findings Chalky patches on tympanic membrane Severe pain Redness, swelling, narrowing, pain Drainage Hard, dry, very dark yellow cerumen Reddened tympanic membrane

Ear Abnormalities Acute Otitis Media Chronic & Acute Otitis Externa tympanic membrane is red with decreased motility,and possible bulging due inflammation of middle ear Chronic & Acute Otitis Externa redness, swelling, narrowing and pain of external ear, drainage present due to inflammation of external ear

Risk Factors for Otitis Media Less than 2 years of age Frequent upper respiratory infections Cold weather Male gender Caucasians, Native Americans, Alaska natives Family history Smoky environment Bottle fed Down syndrome

Ear Abnormalities Tympanic Membrane Perforation due to untreated ear infection secondary to increasing pressure or trama to the ear canal.

Equilibrium Abnormalities Labyrinth becomes inflammed and sends the wrong information to the brain. Which develops into what we call….. Vertigo: staggering gait, strong spinning, whirling sensation.

Developmental Considerations Infants/Children Rubella in 1st trimester can damage the organ of Corti and impair hearing Eustachian tube is shorter and wider, position is more horizontal than the adult’s Greater risk for ear infection External auditory canal is shorter and sloped is opposite to the adult’s

Developmental Considerations Aging Adult Cilia becomes coarse and stiff Cerumen is dryer and impaction is a common reversible cause of hearing loss. Presbycusis occurs with aging “50s” (nerve degeneration in the inner ear or auditory nerve) “70s” takes longer to process sensory input and to respond to it.

Transcultural Considerations Otitis Media (OM) incidence and severity increased in Native Americans, Alaskan and Canadian Inuits & Hispanics. Also increased in premature infants and those with Down Syndrome, and bottle fed babies in supine position.