1
Assessment of Head, Eye, Assessment of Head, Eye, Ear, Nose and Throat (HEENT)Ear, Nose and Throat (HEENT)
Hakim Shah
2
Objectives Assessment of head Assessment of Eye History Inspection Eye tests
– Visual Acuity– Visual Field– Confrontation test– Corneal reflex, corneal light reflex– Pupil reaction (direct/Consensual)– Cover test– Accommodation– Convergent– Fundascopy
Finding abnormalities Documentation
3
HEAD
Head - inspection and palpation– Size– shape– Symmetry– Hair distribution– Scar– Wound/wwelling– Tenderness– Lesion– Hygiene– Dandruff
4
A & P of Eye
The eye is a sphere that contains 3 concentric coats: the outer fibrous sclera, the middle vascular choroid, and the inner nervous retina.
The cornea is very sensitive to touch—corneal reflex—touch of cotton– trigeminal nerve carries afferent sensation (V), facial nerve stimulates the blink (VII).
The muscles of the cilliary body control the thickness of the lens. The lense bulges for focusing on near objects. In presbyopia the lens gets harder to move/muscles lose their strength
5
Cont…
The muscles in the iris control pupillary constriction. Stimulation of the parasympathetic branch of CN III causes constriction, stimulation of the sympathetic branch causes dilation. Pupil also reacts to ambient light and accomodation.
The anterior chamber is posterior to the cornea and in front of the iris and lens. It contains the aqueous humor that is produced by the ciliary body.. Intraocular pressure is determined by a balance between the amount of aqueous produced and resistance to its outflow to the angle of the anterior chamber.
6
Cont…
The optic disk is the place where nerve fibers from retina converge– color varies from creamy yellow orange to pink.
7
8
External Landmarks
Eye LidEye BrowInner canthusOuter canthusLacrimal punctumIris, pupil, conjunctiva, outer canthus
Palpebral fissure—elliptical open space between the eyelids
In the inner canthus, the caruncle is the small fleshly mass containing sebaceous glands
9
Cont…
Palpebral conjunctiva —lines the lids and is clear with many blood vessels, bulbar conjunctiva overlays the eyeball—does not cover the cornea.
Limbus is the border between the cornea and sclera
Drainage of tears---lacrimal glands secrete tears which drain into the puncta, then the nasolacrimal sac, then the duct which empties into the inferior meatus of the nose.
Meibomian glands are sebaceous glands that secrete an oily lubricating material into the lids.
10
11
Circulation of the aqueous humourCirculation of the aqueous humour
12
Visual pathways Visual pathways
13
Common eye complaintsCommon eye complaints
Visual changes– Loss of vision– Refractive errors
• Hyperopia (farsightedness) difficulty with close work• Myopia (near-sightedness) difficulty with distances• Presbyopia (aging vision)
– Blurred vision– Squint– Changes in color vision
14
Cont…
Sudden visual loss suggests retinal detachment, vitreous hemorrhage, or occlusion of central retinal artery, also strokes, TIAs
Will see slow central loss with nuclear cataract, macular degeneration
Peripheral loss in open angle glaucoma—also discuss visual field defects.
Blurred vision gradually seen with refractive errors, also high blood sugar levels
With digitalis will see increased yellow vision, or viagra increased blue vision.
15
Common ComplaintsCommon Complaints
Eye Pain– Sudden or gradual– Photophobia– Pain when you blink– Sensation of something in the eye– Headaches– Pain on movement of the eye
Redness Floaters and Flashes Tearing or dryness Discharge
16
Cont…
Redness—trauma, infection, allergy, increased pressure (great chart on page 179 of your book) Pattern of redness is important
floaters=--spots in front of eyes. They are caused by condensations of vitreus humor Common after middle age—only serious if accompanied by flashes of light, if also shade over or cobweb, may mean retinal detachment
17
Floater
18
Cont…
Tearing or dryness or discharge Tearing overproduction of tears or obstruction of
outflow (epiphora) Dryness faulty secretion by lacrimal or accessory
tear glands—sjogren’s syndrome Discharge—can be watery, mucoid (allergic or
viral) or purulent—bacterial
Antimalarial, antituberculous, anti-glaucoma, and anti inflammatory drugs can cause eye disorders.
19
Emergency Emergency
need to see ophthalmologist NOW– Pain and Sudden loss of vision– New vision changes
• Blind spot• Loss of peripheral vision• Halos around lights• Blurred vision
– Eye injury
20
History and Review of SystemsHistory and Review of Systems
History– allergies– presence of disorders that affect the eye
(DM, HTN, Thyroid) – last eye exam– eye surgery– Injuries
21
Cont…Cont…
-Styes– Family history
• (DM, glaucoma, macular degeneration, cataracts, strabismus, corneal dystrophy)
– Social, sexual history– Employment– Medication
22
Review of systemsReview of systems
ROS– eye pain or redness– cataracts or eye pain– night vision– discharge or excess tears– Corrective lenses– diplopia, strabismus– blurred vision– photophobia
23
Eye exam: areas of examinationEye exam: areas of examination
Visual acuity Visual fields Conjunctiva and
sclera Cornea, lens, and
pupils
Extraocular movements
Fundi including:– Optic disc and cup– Retina– Retinal vessels
24
Vision testingVision testing
Visual Acuity (CN II)Color visionVisual fields
25
Vision test
Always check vision if patient presents with any eye complaint!!!
If not assessed document reason, and plans to assess
Review OD,OS, OU hand-held version for presbyopiaColor vision—have them look at
special charts. Genetic basis
26
Color vision chart
27
Visual Acuity Always check visual acuity first before the rest of
exam. Also don’t want them to say they were fine until the nurse practitioner started to examine them. If they wear glasses check with glasses on.
Acuity: Snellen eye chart; patient stands 20 feet away;
each eye alone then both; numerator=distance person from chart, denominator distance normal eye can see figures. Larger denominator—worse sight. 20/200 legally blind. 20/40 refer for correction
28
Cont…
If a person cannot read the largest letters on the chart, determine whether he can count fingers, detect hand motion, or perceive light.
Rosenbaum handheld checks for presbyopia
Any available print For assessing very low vision—count
fingers, detect hand motion, detect light.
29
Cont…
Patient should be allowed to wear their glasses and the results are referred to as best corrected vision.
Usually give them the line if they can get more than ½ half the letters in the line
Do not have to check every line on chart. Have them start with the smallest line they are able to read.
30
DocumentationVisual acuityVisual acuity
– (20/20)• distance person from chart/distance normal
eye can see figures
OD ………oculus dexter (the right eye)
OS ……… oculus sinister (the left eye)
OU ……… oculus uterque (both eyes
31
32
Hand held versionHand held version
33
Visual acuityVisual acuity
20/15-20/25 normal vision20/30-20/70 near normal vision20/80-20/160 moderate low vision.
This level usually insufficient for driver’s license
20/200-20/400 U.S. definition for legal blindness
34
Visual fieldsVisual fields
Gross measure of peripheral vision.Assumes that yours is normal.May detect deficits with glaucoma,
pituitary tumors, strokesCheck this if pt complains of spots
or holes in their vision
35
Cont… Visual Fields: Confrontation test . Gross measure of
peripheral vision. Assumes that yours is normal. Can also ask person to tell you how many fingers they see
Some lesions along the visual pathway may develop insidiously and the patient may not be aware of any changes in the visual fields until late in the course of the disease
A temporal defect in visual field of one eye suggests a nasal defect in the field of the other eye.
Blind spot—physiological scotoma 15-20- degrees temporal to central fixation
If you find a defect, try to establish its boundaries
36
Scotoma (Blind Spot)
Age-related maculopathy
Retinitis pigmentosa
Normal field of vision.
37
38
Visual fields by confrontationVisual fields by confrontation
39
Visual inspectionVisual inspection
General EyebrowsEyelids/lashesEyeballs
Conjunctiva and Sclera
Lacrimal apparatus
Eversion of upper lid
40
Normal conjunctivaNormal conjunctiva
41
Lid lag or ptosis?Lid lag or ptosis?
42
Herpes zosterHerpes zoster
43
styestye
44
Episcleritis—localized ocular redness from inflammation of the episcleral vessels. In natural light vessels appear pink, and are moveable over the scleral surface. Usually benign and self limited.
45
Subconjunctival hemorrhage—usually results form trauma, bleeding disorders, or a sudden increase in venous pressure such as cough. No pain, visual, change or discharge.
46
Allergic conjunctivitisAllergic conjunctivitis
47
XanthelasmaXanthelasma
48
BlepharitisBlepharitis
49
Periorbital cellulitisPeriorbital cellulitis
50
Periorbital cellulitisPeriorbital cellulitis
51
EctropionEctropion
52
ChalazionChalazion
Beady nodule protruding on lid. Infection or retentuion cyst of meiobian gland. Non-tender, firm , discrete swelling with freely movable skin overlying nodule. If inflamed, it points inside—not on lid margin in contrast with stye.
53
May need to flip eyelidMay need to flip eyelid
54
Normal FindingsNormal Findings
Orbits symmetrical eyelids smooth, nontender, no discharge tear ducts nontender and free of discharge eyelashes free of scales or granulation Adequate surface lubrication and moisture Conjunctiva clear and moist Sclera white and opaque Cornea smooth and transparent
55
Extraocular muscle functionExtraocular muscle function
Alignment• Cover test• Corneal light reflex
Cardinal Fields of gaze
CN III, IV, VI
56
Extra ocular muscle function Extra ocular muscle function (EOMs)(EOMs)Checking alignment and cranial
nerves III, IV, VIAlignment
– Cover test– Corneal light reflex
Cardinal fields of gaze (6 positions)
57
Cover testCover test
58
Extraocular movements (EOMs)Extraocular movements (EOMs)
Cardinal fields of gaze (CN III, IV, VI)– Movement that is not parallel can
indicate either a problem with muscle weakness or one of the cranial nerves.
Also checking for nystagmusCheck for lid lag here
59
60
Accommodative strabismusAccommodative strabismus
61
Which cranial nerveWhich cranial nerve
Oblique superior muscle paralysis/cranial nerve IV
62
What nerve palsy is this?What nerve palsy is this?
CN6- Lateral rectus paralysis
63
Anterior eyeball structuresAnterior eyeball structures
Cornea and lensCorneal light reflexCorneal reflex (CN V, CN III)IrisPupils
64
PtergiumPtergium
Ptergium is a triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea, usually form the nasal side—reddening may occur intermittently, may interfere with vision as it encroaches upon the pupil
65
CataractCataract
66
Anterior chamber assessmentAnterior chamber assessment
Is it clear, filled with pus or blood? – Blood-hyphema– Pus-hypopyon
Chamber depth– When chamber becomes shallow, iris is
convex as it becomes bowed forward over the lens
– Shallow chamber may indicate narrow angle glaucoma (angle closure glaucoma)
67
HyphemaHyphema
68
PupilsPupils
Inspect:– Size– Shape– Symmetry of pupils
Pupillary inspection– Note unequal pupils, dilated and fixed pupils,
constricted pupils, no response to light Miosis—constriction Mydriasis-dilation Anisocoria-pupillary inequality
– Found in 20% of normal people
69
Pupillary reaction testingPupillary reaction testing
Direct pupillary reaction to lightConsensual pupillary reaction to
lightAccomodationConvergence
70
Cont…
Pupils: equal, round, reactive to light, and accomodation (PERRLA)
Unequal pupils indicative of CNS injury or aniscoria Differentiate direct and consensual. Optic nerve II responsible for afferent signal, cranial
nerve III—responsible for pupillary constriction. Accomodation: focus on distant object then shift gaze
to near object; should see pupils constrict and convergence of axis of eyes
Review findings if person is blind in one eye. Fixed dilated pupils=brain stem disease
71
Cont…
Argyll Robertson—accomodates doesn’t react. CNS syphyllis, alcoholism, DM. It accomodates quickly when looking at something close.
Dilates briskly when looking at something far away
Sometimes difficult to see the pupilliary reflexes in someone with very dark eyes.
72
Accommodation and convergenceAccommodation and convergence
73
Horner’s syndromeHorner’s syndrome
Note the left ptosis and pupillary constriction.The affected pupil, though small, reacts briskly to light and near effort. Ptosis of the eyelid is present sometimes with loss of sweating on the forehead of the same side.
74
Healing corneal abrasionHealing corneal abrasion
75
Normal FindingsNormal Findings
Iris flat and circular with even bilateral pigmentation
Pupils round and equally reactive to light with proper accommodation (PERRLA)
Clear lenses
76
Internal Eye StructuresInternal Eye Structures Red reflex Optic disc
– note size, color, shape, margins, Physiologic cup
Retinal vessels– note number, color, A:V ratio, A:V crossing
General background – color and clarity
Macula– size, color, location, Fovea
77
Fundascopy
Observation of the fundus may show disease of the eye or abnormalities that indicate disease elsewhere in the body.
Follow red reflex from two feet away from patient, then close to the eye.
Can see vascular changes due to diabetes or hypertension, and swelling of the optic nerve head due to papilledema or optic neuritis.
78
Cont…
First thing you will see is the branching blood vessels. The bigger darker ones are the veins, smaller brighter structures are the arteries. Changes in the appearance of the arteries (copper wiring) and well as alterations in the arteriovenous crossing pattern occur with atherosclerosis and hypertension. These vessels are more obvious in the superior and inferior part of the retina, normal vein to artery ratio is 3:2.
79
Cont…
Then look for the disc. Follow the branches of the tree until you get to the trunk. Examine the disk for clarity of outline, color, elevation, and condition of the vessels. Usually medially. Measurement in the eye are performed using disk size. There is a great amount of normal variation in the appearance of optic disk size. The physiological cup also varies.
Then check the macula—this is lateral to the disk. This is best seen by asking the person to look directly into the light.
80
81
Fundus (Interior of Eye) Red reflex: absent with hemorrhage or cataracts The optic disk will be slightly oval in shape, color varies
may be white, yellow, pink, or orange Physiologic cup—area inside the disk where blood vessels
exit and enter. Cup width is not more than 1/2 the disc diameter Check the background for lesions, hemorrhages Macular side temporal to disc The arteries appear brighter red and narrower than the
veins. Macula is located on the temporal side of the fundus. It is
the area of sharpest and keenest vision The one advantage of fundal exam is the ability to actually
see what the blood vellels look like inside of someone’s body
82
Opthalmoscope 2 dials: one adjusts for light apertures, the other changes
lenses to correct for the refractive errors of both the examiner and the patient.
LIGHT—small aperture easier for undilated pupil, large aperture standard for dilated pupil, slit or streak helpful in determining various levels of lesions—tumors and disk swelling, green or red-free light helps distinguish veins from arteries. Veins stay blue—arteries turn black. The green light is better for viewing slight alterations in vessels, minute retinal hemorrhages, exudates, obscure changes in the macula,
Myoptic person better start with the minus lenses, hyperoptic person needs plus lenses
Grids are for measuring sizes and distances of lesions.
83
84
Troubleshooting difficulties in using Troubleshooting difficulties in using ophthalmoscopeophthalmoscopeSmall pupilsExtranal lightImproper use of ophthalmoscopeCataract in the patientCorneal reflection
– Use small aperture, polarizing filter
85
86
87
88
Normal FindingsNormal Findings
Optic disc flat and slightly oval or round
Optic nerve border distinctPhysiologic cup paler than optic discRetina of uniform red-orange colorMacula darker than the retina
89
Hypertensive retinopathyHypertensive retinopathy
Group I– Increased light reflex from the arterioles
(copper wire appearance) Group II
– Appearance of arterial-venous crossing changes
Group III– Shiny retina with cotton wool spots,
hemorrhages may also be present Group IV
– Appearance of papilledema
90
Myelinated nerve fibersMyelinated nerve fibers
91
papilledemapapilledema
92
Drusen bodiesDrusen bodies
Drusen bodies—consequence of the aging process and may be a precurser to macular degeneration.
93
Flame hemorrhages—seen in severe hypertension, papilledema, and occlusion of the retinal vein.
94
Flame hemorrhages close to the disk margin may indicate glaucoma
95
Basal Cell carcinomaBasal Cell carcinoma
96
Preseptal cellulitisPreseptal cellulitis
97
What’s this?What’s this?
98
What’s this?What’s this?
99
What’s this?What’s this?
100
Orbital CellulitisOrbital Cellulitis
101
??
102
What do you notice about the blood What do you notice about the blood vessels?vessels?
Proliferative retinopathy
103
Macular degenerationMacular degeneration
104
??
hyphema
105
??
Mature cataract
106
Eye examination summaryEye examination summary
Check visual acuity in each eye Inspect lids, conjunctiva, and sclera Test visual fields by confrontation Test extraocular movements Test pupils for direct and consensual
movements Inspect corneal and iris Assess anterior chamber for depth and
clarity Perform opthalmoscopy to examine fundus
including disk, vessels and macula
107