1. Eyes and Ears
Special Senses

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

3. A & P - External Eye

4. Lacrimal Apparatus

5. 6 Extraocular Muscles

6. A & P - Internal Eye

7. 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.

8. Visual Pathways

9. Health History Subjective information
EYE
Health History
Subjective information

10. 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

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

12. 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)

13. 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)

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

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

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

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

18. 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)

19. 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

22. 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

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

24. 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)

25. 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

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

27. 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)

28. 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

29. 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

30. 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

31. 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)

32. 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)

33. 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

34. Posterior Segment Structures
Assessment techniques
use of ophthalmoscope

35. 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

36. 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

37. Gerontological Variations
Changes in visual acuity
Presbyopia
Cataracts
Macular degeneration
Glaucoma

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

39. 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)

40. 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)

41. 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)

42. 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

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

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

45. External, Middle, Inner Ear Structure

46. External Ear Structure

47. 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

49. 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

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

51. Health History Subjective Data
Ears
Health History
Subjective Data

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

53. 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?

54. Ears – Physical Examination
Objective Data

55. Equipment
Otoscope
Tuning fork
(continues)

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

57. 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)

58. 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

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

60. 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)

61. 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)

62. 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

63. 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

64. 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

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

66. 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.

67. 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

68. 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.

69. 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.