Eye assessment

Eye assessment

1. ASSESSMENT, HISTORY TAKING, PHYSICAL EXAMINATION AND INVESTIGATIONS RELATED TO EYE DISORDERS -BY SHWETA SHARMA M.SC. NURSING I YEAR AIIMS, JODHPUR

2. INTRODUCTION The eye is a unique organ because its external anatomy can be assessed easily. Internal eye structures, including blood vessels and central nervous system tissue (retina and optic nerve) are also easily visualized through cornea without invasive procedures. The effects of many systemic problems, such as infections, cancer, vascular disorders and autoimmune disorders, can be detected during an internal eye examination.

3. ANATOMY AND PHYSIOLOGY OF EYES

4. HISTORY Demographic data Exploration of chief complaint and related manifestations Review of systems Past medical history Past surgical history Allergies and medications Dietary habits Psychosocial history and lifestyle Family health history

5. Biographical and demographic data- Patient's full name Age -The incidence of cataract, dry eye, retinal detachment, glaucoma, etc increase with age. Birth date Gender- Hereditary color vision deficits are more common in men than in women. Address and contact telephone number Occupation.

6. Current health- Chief complaint- Change or loss of vision, headache or eyestrain. Sometimes the client may be unable to verbalize a specific complaint, and the chief complaint could be as vague as “something is wrong with my eyes.” Clinical manifestations- Pain (Ophthalmalgia), abnormal vision, abnormal appearance, abnormal sensation, etc.

7. Review of systems- Past medical history- Diabetes mellitus Rheumatoid arthritis Thyroid disorders Childhood vaccinations, particularly for measles Hypertension, multiple sclerosis and myasthenia gravis If the client wears eyeglasses or contact lenses, ask when the last eye examination took place and when the prescription was last changed. Hospitalizations related to the eyes or brain, including a history of head or eye trauma

8. Surgical history- Laser-assisted in-situ keratomileusis (LASIK) Radial keratotomy (RK) Cataract removal Glaucoma treatment, or eye muscle correction. History of brain or facial surgeries should also be assessed as these have the potential to affect vision. Allergies- Any allergies to medications (eye drops) Inhalants (dust, chemicals or pollens) Environmental contacts (cosmetics or pollens) Allergic manifestations include eye redness, tearing and itching.

9. Medications- Note the name, dose, and frequency the medication is taken. Ask about use of over-the-counter eye drops, as those with antihistamines and decongestants can dry the ocular surface. Record current eye and systemic medications being used, and all other current and past ocular disorders. Dietary habits- Herbal remedies and dietary supplements. Vitamins, believing these substances will prevent the development of vision problems such as cataract, and macular degeneration. Diets rich in fruits, vegetables, and fish or supplements of antioxidants C, E and beta-carotene.

10. Social history- It includes occupational hazards, leisure activities and hobbies, and health management behaviours . Assess the client’s work and/or hobbies that may include exposure to irritating fumes, smoke, or air-borne particles. Assess participation in activities that increase the risk for eye or head trauma (such as football, racquetball or baseball) as well as those that increase the risk of foreign body injury or abrasion (e.g. hiking or gardening). Address client use of protective eye gear (such as safety goggles or sunglasses) when engaging in these activities. Family health history – Strabismus, glaucoma, myopia, hyperopia, diabetes, retinoblastoma, retinitis pigmentosa, and macular degeneration tend to appear in families.

11. PHYSICAL EXAMINATION Techniques- Inspection Palpation

12. External eye

13. Eye position- Symmetry and alignment. Eyebrows - Symmetry, hair distribution, skin conditions and movement. Eyelids and eyelashes- Placement and symmetry. Elevate the eyebrows to inspect the upper lids for lesions. Inspect the lower lids by asking the client to open the eyes. Examine skin of the eyelids and orbit by palpating for texture, firmness, mobility, and integrity of the underlying tissues. Assess the blink response. Blinking is an involuntary reflex that occurs bilaterally up to 20 times a minute.

14. Eyeballs and lacrimal apparatus- Normally, the eyeballs feel firm and symmetrical. Visualize the lacrimal apparatus by retracting the upper lid and having the client look down. The area should be free of swelling, oedema and excessive moisture, and there should be no regurgitation of fluid from sac or puncta. Conjunctiva and sclera- Inspect the conjunctiva and sclera for colour changes, texture, vascularity, lesions, thickness, secretions, and foreign bodies. Healthy conjunctivae are pink to light red. If the lower palpebral conjunctivae are normal, the upper palpebral conjunctivae usually are not inspected.

15. Cornea and anterior chamber- The depth of the chamber between the cornea and iris is normally about 3 mm.

16. Iris and pupil- PERRLA Pupil abnormalities may be caused by neurologic disease, intraocular inflammation, iris adhesions, systemic or ocular medication side effects, or surgical alteration.

17. Normal physical examination findings

18. DIAGNOSTIC EVALUATION Visual acuity testing For assessing distant vision- Snellen test Random E test For assessing near vision- Jaeger chart

19. Snellen chart

20. RANDOM E TEST

21. JAEGER CHART

22. Confrontation visual field testing

23. Extraocular muscle functions

24. An example of eye movement over a photograph over the span of just two seconds.

25. Direct ophthalmoscopy

26. Abnormal findings include an altered arteriovenous ratio, narrowed arteries, widened veins, pinched-off vessels, abnormal arterial light reflex, excessive tortuosity, numerous arteriovenous nicks, exudates, white patches and focus haemorrhage. Direct ophthalmoscope is one that produces an upright, or unreversed, image of approximately 15 times magnification.

27. Indirect Ophthalmoscopy

28. Produces an inverted, or reversed, image of 2 to 5 times magnification. It employs a head lamp device to shine a very bright light into the eye and a small handheld lens. Provides a wider view of the inside of the eye. It allows a better view of the fundus of the eye, even if the lens is clouded by cataracts.

29. Slit-lamp examination

30. Tonometry

31. Color vision testing

32. Amsler grid

33. Ultrasonography

34. Optical coherence tomography

35. Fundus photography

36. Laser scanning

37. Angiography

38. Perimetry testing

39. RESEARCH ARTICLES 1.Knowledge and practice patterns of Intensive Care Unit nurses towards eye care in Chhattisgarh state A study was conducted by Sonal Vyas, Ashish Mahobia , and Sangeeta Bawankure to present the level of knowledge and practice patterns regarding exposure keratopathy in mechanically ventilated patients among Intensive Care Unit (ICU) nurses in Chhattisgarh state. A previously validated semi-structured questionnaire was administered in the ICU of six multispecialty hospitals in Chhattisgarh in 2014–2015. Most of the questions dealt with frequency of eyelid closure assessment, frequency of cleaning of eyes with saline gauze, using a protocol-based approach for eye care, and documentation of ophthalmic complications. Common barriers to delivery of eye care such as shortage of time and too much writing tasks were also inquired. This study included 120 nurses. Knowledge about high risk of exposure keratopathy in ventilated patient was present in 93% nurses. Only six nurses (5%) followed a strict protocol for eye care, 52 nurses (43%) checked for eyelid closure in the ventilated patients, and 58 (48%) cleaned the eyes frequently. Nurses in cardiac ICU were significantly lesser aware of exposure complications compared to medical ICU nurses. The study concluded that although there is high awareness, practice patterns of ICU nurses were less than desired. Educational initiatives should focus on weaknesses in knowledge and practice noted to improve eye care of patients in ICU.

40. 2.A study on knowledge regarding eye donation among first year nursing students of a nursing school and college of Berhampur, Odisha A cross-sectional study was conducted in May 2016 with 140 first year Nursing students to assess their perception towards eye donation. All participants knew about eye donation and 95.7% said these can be done irrespective of age and sex of the deceased. 55% students told HIV is a contraindication, 10% said that request for eye donations can be made by person himself alive or relatives after death. 15% knew that eye can be donated within six hours of death but none were aware regarding storage of donated eyes before transplantation. Only 2.1% of them heard about Hospital Corneal Retrieval Programme. Television (100%) was the main source of information. All of them personally supported eye donation. The study concluded that nursing students had heard about eye donation but knew less about the details of the procedure. They can contribute to awareness and motivating people for eye donation during their postings in various department in hospital.

41. CONCLUSION As discussed throughout the presentation, learning about eye examination will help the nurses to care better for patients. Nurses can do eye assessment, classify the level of disease, observe the sign and symptoms, provide the necessary nursing care and support the patient psychologically.

42. REFERENCES 1.Janice L. Hinkle, Kerry H. Cheever. Brunner and Suddarth’s Textbook of Medical Surgical Nursing. 2015. New Delhi. Wolters Kluwer.13th Edition. Volume 2. Pg. no. 1839-1846. 2.Lewis. Medical Surgical Nursing Assessment and Management of clinical problems.2015. New Delhi. Elsevier. 2nd Edition. Volume II. Pg. no. 382-392. 3.Joyce M. Black, Jane Hokanson Hawks. Medical Surgical Nursing Clinical Management of Positive Outcomes.2015. New Delhi. Reed Elsevier India Private Limited. Volume II. Pg. no. 1677-1686 4.PubMed. Knowledge and practice patterns of Intensive Care Unit nurses towards eye care in Chhattisgarh state. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6113811/ [cited 21 Nov 2019] 5.IJRMS. A study on knowledge regarding eye donation among first year nursing students of a nursing school and college of Berhampur, Odisha. Available from https://www.msjonline.org/index.php/ijrms/article/view/3984 [cited 21 Nov 2019]