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336 PHYSICAL EXAMINATION
A. Eyes midline
B. Left lateral gaze
C. Left lateral inferior gaze
D. Right lateral inferior gaze
E. Right lateral gaze
F. Right lateral superior gaze
G. Left lateral superior gaze
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UNIT 2
Vitamin deficiency, especially thiamine (which may occur in chronic
P
alcoholism), may cause extraocular muscle palsy and nystagmus. Usually CN VI
is affected.
Herpes zoster, syphilis, scarlet fever, whooping cough and botulism are
P
infections that may affect CN III, IV and VI, causing extraocular muscle palsy.
A
If one eye deviates down and the other eye deviates up, it is called skew
deviation.
Cerebellar disease or a lesion in the pons on the same side as the eye that is
P
deviated down may cause skew deviation.
A
There is a rhythmic, beating, involuntary oscillation of the eyes as the object is
held at points away from the midline. Movement is usually lateral, vertical or
rotary. Nystagmus can be jerky, with fast and slow components, or rhythmic,
similar to the pendulum of a clock.
Nystagmus may be caused by a lesion in the brain stem, cerebellum, vestibular
P
system, or along the visual pathways in the cerebral hemispheres.
HEALTH EDUCATION
Eye hygiene – assessment and education
If a consumer wears contact lenses, inquire what type is worn. Ask the consumer what the
disinfecting criteria are for that type of lens, the frequency of lens replacement, and the
daily duration of wear time. Determine whether the consumer is adhering to these protocols.
Failure to comply with contact lens cleaning procedures, wear time, and recommended
replacement schedule can lead to corneal abrasions and ocular infections.
Persons who use eye make-up should be sure to replace such items as old mascara
and eyeliner frequently to avoid the possibility of bacterial colonisation. In the event of an
episode of conjunctivitis, all items should be discarded to prevent reinfection from make-up
that could be contaminated.
FIGURE 10.14 Cardinal elds of gaze
Examination of anterior segment structures
Inspection
Conjunctiva
To assess the bulbar conjunctiva:
E
1. Separate the lid margins with the fingers.
2. Have the consumer look up, down, and to the right and left.
3. Inspect the surface of the bulbar conjunctiva for colour, redness, swelling,
exudate or foreign bodies. Note whether there is injection or redness
around the cornea or towards the periphery.
4. With the thumb, gently pull the lower lid towards the cheek and inspect the
surface of the bulbar conjunctiva for colour, inflammation, oedema, lesions
or foreign bodies.
The bulbar conjunctiva is transparent, with small blood vessels visible in it. It
N
should appear white except for a few small blood vessels, which are normal. No
swelling, injection, exudate, foreign bodies, or lesions are noted.
The palpebral conjunctiva is examined only when there is a concern about its
A P
condition. Examining the palpebral conjunctiva is advanced practice, and is
usually not undertaken by most nurses.
A
A yellow nodule is noted on the nasal side of the bulbar conjunctiva adjacent to
the cornea. It may be on the temporal side as well. This lesion is painless unless
it becomes inflamed.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
EYES 337
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This lesion is called a pinguecula. It is a nodular degeneration of the
P
conjunctiva and is thought to be a result of increased exposure to ultraviolet
light.
A
A unilateral or bilateral triangle-shaped encroachment onto the conjunctiva is
abnormal (
Figure 10.15). This lesion always occurs nasally and remains painless
unless it becomes ulcerated. If the lesion covers the cornea, loss of vision may
occur.
This lesion is called a pterygium and is caused by excessive ultraviolet light
P
exposure.
A
The consumer exhibits a sudden onset of a painless, bright red appearance on
the bulbar conjunctiva.
This is a subconjunctival haemorrhage and may result from the pressure exerted
P
during coughing, sneezing, or a Valsalva manoeuvre. It can also be attributed to
FIGURE 10.15 Pterygium
COUR TESY OF SA LIM I. BUT RUS, M.D., SE NIOR ATTE NDING,
DEPARTMENT OF OPHTHALMOLOGY, WASHINGTON HOSPITAL
CENT ER, WASHING TON, DC, & AS SOCIATE C LINICAL P ROFESS OR,
GEORG ETOWN UN IVERSI TY MEDIC AL CENT ER, WASHING TON, DC.
anticoagulant medications or uncontrolled hypertension.
Sclera
E
While assessing the conjunctiva, inspect the sclera for colour, exudate, lesions
and foreign bodies.
In light-skinned individuals, the sclera should be white with some small,
N
superficial vessels and without exudate, lesions or foreign bodies. In
dark-skinned individuals, the sclera may have tiny brown patches of melanin, or
a greyish-blue or ‘muddy’ colour.
A
The colour of the sclera is uniformly yellow.
This condition is known as jaundice or scleral icterus and is due to colouring of
P
the sclera with bilirubin, which infiltrates all tissues of the body. This is an early
manifestation of systemic conditions such as hepatitis, sickle cell disease,
gallstones and physiological jaundice of the newborn.
A
The sclera is blue.
This finding is a distinctive feature of osteogenesis imperfecta and is due to the
P
thinning of the sclera, which allows the choroid to show through.
CHAPTER 10
REFLECTION IN PRACTICE
Corneal abrasion
You are examining a 55-year-old male with severe eye pain, photophobia and tearing.
This is his fourth visit in the past 6 months. His previous three visits were for conrmed
corneal abrasions caused by not wearing protective eye wear while servicing machinery
(particularly while lying underneath the machinery looking up). While you are examining the
consumer, he tells you that he hates wearing protective glasses because they fog up and he
can’t see what he is doing. What type of physical examination would you perform? List some
strategies you could use to promote eye health in this consumer.
Cornea
E
1. Stand in front of the consumer.
2. Shine a penlight directly on the cornea.
3. Move the light laterally and view the cornea from that angle, noting colour,
discharge and lesions.
The corneal surface should be moist and shiny, with no discharge, cloudiness,
N
opacities or irregularities.
A
A greyish, well-circumscribed ulcerated area on the cornea is abnormal
Figure 10.16).
(
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
FIGURE 10.16 Corneal ulceration. Note the
injection and hypopyon (purulent material
in the anterior chamber), which frequently
occur with corneal ulceration.
COUR TESY OF SA LIM I. BUT RUS, M.D., SE NIOR ATTE NDING,
DEPARTMENT OF OPHTHALMOLOGY, WASHINGTON HOSPITAL
CENT ER, WASHING TON, DC, & AS SOCIATE C LINICAL P ROFESS OR,
GEORG ETOWN UN IVERSI TY MEDIC AL CENT ER, WASHING TON, DC.
338 PHYSICAL EXAMINATION
Cornea
Anterior chamber
Normal angle
Narrow angle
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UNIT 2
FIGURE 10.17 Arcus senilis
COUR TESY OF SA LIM I. BUT RUS, M.D., SE NIOR ATTE NDING,
DEPARTMENT OF OPHTHALMOLOGY, WASHINGTON HOSPITAL
CENT ER, WASHING TON, DC, & AS SOCIATE C LINICAL P ROFESS OR,
GEORG ETOWN UN IVERSI TY MEDIC AL CENT ER, WASHING TON, DC.
FIGURE 10.18 Keratoconus
COUR TESY OF SA LIM I. BUT RUS, M.D., SE NIOR ATTE NDING,
DEPARTMENT OF OPHTHALMOLOGY, WASHINGTON HOSPITAL
CENT ER, WASHING TON, DC, & AS SOCIATE C LINICAL P ROFESS OR,
GEORG ETOWN UN IVERSI TY MEDIC AL CENT ER, WASHING TON, DC.
FIGURE 10.19 Examining the anterior
chamber
The most common cause of this condition is a corneal ulceration resulting from
P
a bacterial infection.
A
A tree-like configuration on the corneal surface is identified. The consumer
complains of mild discomfort, photophobia and, in some cases, blurred vision
(depending on the location of the lesions).
This type of ulceration is caused by the herpes simplex virus. The consumer
P
usually has a history of having had a cold sore somewhere on the face.
A
There is a hazy grey ring about 2mm in width just inside the limbus (
This common finding is
P
arcus senilis, a bilateral, benign degeneration of the
Figure 10.17).
peripheral cornea. It can be found at any age but is most common in older
individuals. If found in a young person, may be associated with
hypercholesterolaemia.
A
A steamy or cloudy cornea is abnormal. The consumer also has ocular pain.
Glaucoma is caused by increased intraocular pressure. Refer to anterior chamber
P
assessment.
A
Any irregularities in the appearance of the cornea are abnormal.
Keratoconus (
P
Figure 10.18) is the conical protrusion of the centre of the cornea. It
is a noninflammatory condition in which the cornea thins, sometimes leading
to the need for corneal transplant surgery.
A corneal scar forms at the site of past injury or inflammation.
P
Corneal laceration can occur secondary to trauma.
P
Anterior chamber
The anterior chamber is that compartment of the eye found between the cornea and
the iris. The space between the flat plane of the iris and the periphery of the cornea
must be adequate to allow drainage of aqueous fluid out of the eye. If this angle is
too narrow, drainage is inadequate, the pressure of the aqueous fluid in the anterior
chamber increases, and glaucoma develops. If intraocular fluid pressure remains
high, optic nerve damage and visual field loss occur.
To differentiate a normal from a narrowed angle:
E
1. Face the consumer and shine a light obliquely through the anterior chamber
from the lateral side towards the nasal side (see
2. Observe the distribution of light in the anterior chamber (see Figure 10.20).
3. Repeat the procedure with the other eye.
Figure 10.19).
Iris
Lens
FIGURE 10.20 Evaluating the angle of the anterior chamber
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
Advanced Assessment
EYES 339
A. Starting position with penlight to side
of pupil
B. Move the penlight directly in front of
the pupil
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In a normal eye, the entire iris will be illuminated.
N
The eye has a narrow angle, with the decreased space between the iris and the
A
cornea appearing as a crescent-shaped shadow on the far portion of the iris.
The narrow angle is an anatomic variant that can predispose an individual to the
P
development of angle-closure glaucoma. As ageing progresses, the lens thickens,
which may cause even further narrowing of the angle.
Iris
E
With the penlight, inspect the iris for colour, nodules and vascularity.
Normally, the colour is evenly distributed over the iris, although there can be a
N
mosaic variant. It is normally smooth and without apparent vascularity.
There is a heavily pigmented, slightly elevated area visible in the iris.
A
This lesion can be a benign iris naevus or a malignant melanoma. An iris naevus
P
is much more common than melanoma.
The inferior portion of the iris is obscured by blood.
A
This is a hyphaema and is caused by bleeding from vessels in the iris as a result
P
of direct trauma to the globe. It can also occur as a result of eye surgery.
An absent wedge portion of the iris is abnormal.
A
The shape of the iris changes after surgical removal of a cataract; the pupil may
P
also have an irregular shape.
CHAPTER 10
Pupil
E
1. Stand in front of the consumer in a darkened room.
2. Note the shape and size of the pupils in millimetres.
3. Move a penlight from the side to the front of one eye without allowing the
light to shine on the other eye (see
4. Observe the pupillary reaction in that eye. This is the direct light reflex.
Note the size of the pupil receiving light stimulus and the speed of pupillary
response to light.
5. Repeat in the other eye.
6. Move the penlight in front of one eye, and observe the other eye for
pupillary constriction. This is the consensual light reflex.
7. Repeat the procedure on the other eye.
8. Instruct the consumer to shift the gaze to a distant object for 30 seconds.
9. Instruct the consumer to then look at your finger or an object held in your
hand about 10cm from the consumer.
10. Note the reaction and size of the pupils. Accommodation occurs when
pupils constrict and converge to focus on objects at close range.
N
The pupils should be deep black, round, and of equal diameter, ranging from
2 to 6mm. Pupils should constrict briskly to direct and consensual light and to
accommodation (CN III). Small differences in pupil size (
normal in some people.
The pupil that constricts to less than 2mm in diameter is termed miotic.
A
Thepupil that dilates to more than 6mm in diameter is termed mydriatic.
Abnormal pupillary size can be caused by medications such as
P
sympathomimetics or parasympathomimetics, iritis, or disorders such as
CN III paralysis, which can occur as a result of a carotid artery aneurysm.
These abnormalities may also be due to nerve damage or trauma (see for
further pathologies).
The pupil has an irregular shape.
A
This is a common finding associated with the surgical removal of cataracts
P
and iridectomy.
Figure 10.21).
anisocoria) may be
FIGURE 10.21 Pupil assessment
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
Advanced Assessment
340 PHYSICAL EXAMINATION
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UNIT 2
FIGURE 10.22 Cataract
COUR TESY OF SA LIM I. BUT RUS, M.D., SE NIOR ATTE NDING,
DEPARTMENT OF OPHTHALMOLOGY, WASHINGTON HOSPITAL
CENT ER, WASHING TON, DC, & AS SOCIATE C LINICAL P ROFESS OR,
GEORG ETOWN UN IVERSI TY MEDIC AL CENT ER, WASHING TON, DC.
When the direct light reflex is defective, the pupil dilates in response to light,
A
but consensual reaction is appropriate. This is called a Marcus Gunn pupil.
Optic nerve damage in the optic chiasm, such as in trauma, results in destruction
P
of the afferent pathways of the pupillary light reflex (deafferented pupil).
The hippus phenomenon occurs after the pupil has been stimulated by direct
A
light. Light causes the pupil to constrict, but then the pupil appears to
rhythmically vacillate in size from a larger to a smaller diameter.
Hippus may be caused by a lesion in the midbrain.
P
The presence of midposition, round, regular and fixed (5–6mm) pupils that may
A
show hippus is abnormal.
These signs usually indicate midbrain damage that interrupts the light reflex but
P
may leave accommodation intact.
Lens
E
1. Stand in front of the consumer.
2. Shine a penlight directly on the pupil. The lens is behind the pupil.
3. Note the colour.
The lens is transparent in colour.
N
One or more of the pupils are not deep black.
A
In an adult, a pearly grey appearance of one or both pupils may indicate an
P
opacity (cloudiness) in the lens (cataract) (see
A senile cataract is the most common type. Progressively blurred distance vision
P
is the main symptom, although near vision may be improved because of greater
convexity of the lens.
A unilateral cataract may occur soon after eye injury caused by a foreign body.
P
Along with the lens opacity, there may be intraocular haemorrhage or aqueous
or vitreous humour leaking from the globe. The consumer reports an immediate
blurring of vision.
Bilateral cataracts found in infants or young children are congenital cataracts.
P
These cataracts are probably genetically determined, although maternal rubella
in the first trimester can also be responsible.
Figure 10.22).
TABLE 10.2 Pupil abnormalities
A
The size of pupils is unequal but both pupils react to light and accommodation.
Inequality of pupillary size is called anisocoria and may be congenital or due
P
to inflammation of ocular tissue or disturbances of neurophthalmic pathways.
A
A xed and dilated pupil is observed on one side. The abnormal pupil does
not react to direct or consensual light stimulation and does not
accommodate. Ptosis and lateral downward deviation may also be noted.
This abnormality is caused by oculomotor nerve damage due to head trauma
P
and increased intracranial pressure. Atropine-like agents applied topically
may cause an even more widely xed and dilated pupil.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
>>
Advanced Assessment
EYES 341
The size of pupils is unequal but both pupils react to light and accommodation.
Inequality of pupillary size is called
anisocoria and may be congenital or due
to inflammation of ocular tissue or disturbances of neurophthalmic pathways.
A
P
A xed and dilated pupil is observed on one side. The abnormal pupil does
not react to direct or consensual light stimulation and does not
accommodate. Ptosis and lateral downward deviation may also be noted.
This abnormality is caused by oculomotor nerve damage due to head trauma
and increased intracranial pressure. Atropine-like agents applied topically
may cause an even more widely xed and dilated pupil.
A
P
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TABLE 10.2 continued>>
A unilateral, small, regularly shaped pupil is observed. Both pupils react
A
directly and consensually and accommodate. Ptosis and diminished or absent
sweating on the affected side may also be noted.
P
This nding is Horner syndrome, which is caused by a lesion of the
sympathetic nerve pathway.
Pupils are bilaterally small and irregularly shaped. They react to
A
accommodation but sluggishly or not at all to light.
P
These abnormalities are Argyll Robertson pupils and are usually caused by
central lesions of neurosyphilis. Other causes include encephalitis, drugs,
diabetes, brain tumours and alcoholism.
A unilateral, large, regularly shaped pupil is noted. The affected pupil's
A
reaction to light and accommodation is sluggish or absent. The patient may
report blurred vision because of the slow accommodation. You may observe
diminished ankle and knee deep-tendon reexes.
P
This abnormality, a tonic or Adie's pupil, is due to impaired sympathetic
nerve supply.
CHAPTER 10
Both pupils are small, xed, regularly shaped, and do not react to light or
A
accommodation.
P
This abnormality may be caused by opiate ingestion, topical application of
miotic drops or lesions in the brain. Pupils are small, equal and reactive.
Diencephalic injury or metabolic coma may cause these ndings.
Both pupils are dilated and fixed, and do not react to light or accommodation.
A
Severe head trauma, brain stem infarction, and cardiopulmonary arrest
P
(after 4 to 6 min) can lead to these findings.
Light shone into a blind eye (amaurotic pupil) will cause no reaction (direct or
Blind eye
A
consensual) in either pupil. If light is shone in the other eye, and CN III is
intact, both pupils should constrict.
P
Due to a lesion in the retina or the optic nerve, the light stimulus shown in the
Light
amaurotic pupil is unable to pass along the sensory pathway; therefore, the
oculomotor response in both eyes is absent.
REFLECTION IN PRACTICE
Consumer with potential multiple eye pathologies
Sally is a 82-year-old woman with a history of severe asthma and hypertension. Sally lives
with her son Max who is a smoker. Sally has taken oral corticosteroids for 5 years to help
control her asthma. Today, she presents with seeing halos around lights, scratchy dry eyes
and on review Sally is found to be within the morbidly obese weight range with a BMI of 41.
What questions would you pose to this consumer? Knowing Sally’s history, describe some
possible ndings on the physical examination of her eyes.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
342 PHYSICAL EXAMINATION
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UNIT 2
CLINICAL REASONING
Practice tip: Cataract risk factors
Consider the following when assessing consumers:
> Increasing age
> Ultraviolet light exposure (sun exposure)
> Hypertension
> Obesity
> Previous eye injuries or surgery
> Smoking
> Diabetes
> Steroid use (prolonged)
> Excessive alcohol use
Since cataract correction is one of the most common eye-related reasons people seek health
care (second only to refractive error correction), understanding the risk factors for people when
undertaking assessment for other health reasons can lead to early detection. Applying these risk
factors to consumers who do not have cataracts yet can also provide you with an opportunity for
health education to help people prevent their development or at least seek help early.
(MAYO CLINIC, 2021)
EVALUATION OF HEALTH ASSESSMENT AND PHYSICAL
EXAMINATION FINDINGS
In the evaluation phase of a health assessment, the focus is on ensuring the data
gathered is complete, accurate and documented appropriately (see case study as
an example of the focused assessment; see Chapter 22 for a comprehensive health
assessment). In evaluating the data you should:
> draw on your critical thinking and problem-solving skills to make sound clinical
decisions
> act on abnormal data (includes communicating findings to other health
professionals)
> ensure documentation reflects the outcomes of the clinical decisions/actions
taken (refer to Chapter 3, which discusses in detail why documentation is so
important and how this may be undertaken in different health settings).
The case study that follows steps you through this process.
THE CONSUMER WITH SENILE CATARACT
This case study illustrates the application and the objective
documentation of the eye assessment.
HEALTH HISTORY
CASE STUDY
CONSUMER PROFILE 59-year-old male of Nigerian descent
Mr Teroma Kunle, a 59-year-old man, presents complaining of
gradually decreasing vision in both eyes.
CHIEF COMPLAINT ‘Watching television and reading is not as easy as it used to be, even with my glasses.’
HISTORY OF THE PRESENT
ILLNESS
The consumer complains he is nding it more difcult to carry out his daily activities and recognise people at a
distance. He also states he is starting to avoid driving at night due to the glare interrupting his vision.
The consumer has noticed a gradual deterioration in vision over the last 12 months. His symptoms started with
bilateral blurred distance vision. Consultations with an optometrist and new prescription glasses have improved but
not resolved the problem. He also complains of increasing problems with glare, particularly in bright light or when
driving at night, which has been getting progressively worse. The consumer denies any pain or recent injury.
>>
EYES 343
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>>
PAST HEALTH HISTORY MEDICAL HISTORY Hypertension since age 48
Hyperlipidaemia since age 52
SURGICAL HISTORY Denies any previous ocular surgery
ALLERGIES Nil known
MEDICATIONS Hydrochlorothiazide 25mg every morning
Atorvastatin calcium 10mg every day
Denies using any ocular medications
COMMUNICABLE DISEASES Denies
INJURIES AND ACCIDENTS Previous fractured toes as a young man in Nigeria. Now is missing
smallest toe from left foot
SPECIAL NEEDS Wears glasses for distance and near correction (bifocal lenses)
BLOOD TRANSFUSIONS Denies
CHILDHOOD ILLNESSES Chickenpox, age 12, without sequelae
Measles, age 15, without sequelae
IMMUNISATIONS All vaccinations completed when emigrated to Australia at age 15; has
yearly inuenza vaccine
CHAPTER 10
FAMILY HEALTH HISTORY Family history unknown due to being orphaned as a 12-year-old.
SOCIAL HISTORY Widowed with 2 children
ALCOHOL USE Three standard drinks per day, usually beer
TOBACCO USE Smoker; smokes half pack per day × 46 years (23 yr pack history); denies
use of pipes and cigars
DRUG USE Denies
DOMESTIC AND INTIMATE
PARTNER VIOLENCE
SEXUAL PRACTICE Widowed, denies recent sexual partners
TRAVEL HISTORY Denies recent interstate or international travel in the past 10 years
WORK ENVIRONMENT Retired builder
HOME ENVIRONMENT Lives at home, with eldest daughter and her two children (aged 12 and 9);
HOBBIES AND LEISURE
ACTIVITIES
STRESS Denies
EDUCATION Bridging schooling on arriving to Australia, left at 17 to undertake building
ECONOMIC STATUS Middle class ‘blue collar worker’
Denies
smoke detectors and safety switch tted in home
Rebuilding classic cars, gardening, watching sports
apprenticeship
MILITARY SERVICE None
RELIGION Christian
CULTURAL BACKGROUND Nigerian descent
ROLES AND RELATIONSHIPS Close to children; limited extended family; several close friends from
classic cars interest group
CHARACTERISTIC PATTERNS OF
DAILY LIVING
Wakes at 7 a.m., large breakfast with grandchildren most days, either
works in shed on cars, or supports daughter with errands for children;
lunches at home; usually has an afternoon rest; gardens most days;
watches TV and goes to bed around 11 p.m.
>>
344 PHYSICAL EXAMINATION
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>>
HEALTH MAINTENANCE
ACTIVITIES
UNIT 2
PHYSICAL EXAMINATION
EXAMINATION OF VISUAL
ACUITY
EXAMINATION OF VISUAL
FIELDS
EXAMINATION OF
EXTERNAL EYE AND
LACRIMAL APPARATUS
SLEEP 7–8 hours of sleep each night; often feels tired. Poor sleeper
DIET Eats traditional dishes weekly with children
EXERCISE Gardening. No formal exercise program
STRESS MANAGEMENT Denies any
USE OF SAFETY DEVICES Uses seat belt in car; does not wear sunglasses when out of doors
HEALTH CHECK-UPS Sees primary care provider every 6–9 months for management of
hypertension and hyperlipidaemia; has not visited dentist in years; visits
optometrist every 12–18 months for examination
INSPECTION DISTANCE VISION
(WITH GLASSES)
37.2MM Impaired, N 8 (blurred) both eyes
COLOUR VISION
TESTING (ISHIHARA
COLOUR TEST
PLATES)
Confrontation eld testing normal, no eld defects detected
INSPECTION AND PALPATION EYELIDS, EYEBROWS
AND EYELASHES
LACRIMAL
APPARATUS
> 6/12 right eye, 6/9 left eye
> 6/9 with both eyes
Normal (15/15 right and left eye)
Normal, no abnormalities detected
No abnormalities detected
EXAMINATION OF
EXTRAOCULAR MUSCLE
FUNCTION
EXAMINATION OF
ANTERIOR SEGMENT
STRUCTURES
INSPECTION
INSPECTION CONJUNCTIVA Transparent; no swelling, injection, foreign
OPHTHALMOSCOPY WITH
DIRECT OPHTHALMOSCOPE
CORNEAL LIGHT
REFLEX
COVER/UNCOVER
TEST
CARDINAL FIELDS OF
GAZE
SCLERA No abnormalities detected
CORNEA Clear, no opacities or irregularities noted
ANTERIOR CHAMBER Clear and deep
IRIS No irregularities noted
PUPIL Size – 3mm
LENS Pearly grey clouding noted when illuminated
Posterior structures appear normal. View of optic disc and retina blurred
due to opacity in the ocular media (advanced practice only)
Only need to be tested if the consumer is
complaining of double vision (not performed on
this consumer)
bodies or lesions noted
Symmetry – equal
Reaction to light – brisk in right and left eyes to
direct and consensual light
with torch
Advanced Assessment
AMSLER GRID TESTING > Normal
> No distortion or blank spots noted
> Evenly distributed slight blur
EYES 345
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EVALUATION AND CLINICAL REASONING
FOR CASE STUDY
The assessment and clinical decisions you make should
reect your scope of practice. For example, advanced
practice health professionals, such as nurse practitioners and
remote area nurses with endorsement, may be able to make
diagnostic decisions and prescribe medications without referring
to a medical ofcer.
Fundamentally, all health professionals collect, evaluate and
act on consumer-focused health information, which will at times
include referral to, or collaboration with, other healthcare team
members. Nurses assess consumer responses to interventions
and determine when to escalate key changes in a consumer’s
condition. The clinical reasoning cycle provides health professionals with a framework to consider all this information in a
meaningful way for planning consumer care. These phases
are stepped out below, and draw on information presented and
collected during the health history and physical examination. We
then work through the cycle components that are relevant to this
case study (cycle components are bolded).
For Teroma Kunle, the signicant data that needs to be
considered includes the following.
Collecting cues/information
Recall and Review: In the rst instance you will need to reect on
what you know about cataracts, their formation and risk factors.
Chief complaint and history of present illness
> Bilateral progressive decrease in distance and near vision over
the last 12 months.
> Symptoms started with bilateral blurred distance vision; for
example, being unable to recognise people at a distance.
> Complains of glare, especially when driving at night – therefore
has started avoiding this activity.
> Changes to his prescription glasses have improved but not
resolved the problem.
Processing information
Interpret: These symptoms and details of history outline the scope
of the issue for this consumer and how it is affecting his wellbeing
and ability to self-manage this deviation from normal health. It is
important to take the consumer’s age, previous occupation and
health protection practices into consideration along with the
symptoms described.
Discriminate: There is an increasing impact on his activities of
daily living, for example driving at night, which led him to consult
an optometrist.
Relate: New glasses have improved but not resolved the issue.
Medications
> Hydrochlorothiazide 25mg every morning
> Atorvastatin calcium 10mg every day
Tobacco use
> Smoker for 46 years
Interpret and Discriminate: This element of the consumer history
is noteworthy as smoking is associated with higher risk of
developing cataracts.
Hobbies and leisure activities
> Rebuilding classic cars, gardening and watching sports
Use of safety devices
> Does not wear sunglasses when out of doors
Interpret and Discriminate: His previous work was an outdoor role
and all his hobbies involve likely increased exposure to sunlight
(UV light), which is associated with higher risk of developing
cataracts.
Relate: As the consumer’s leisure activities involve increased
exposure to UV light, the non-use of UV ltering glasses is
signicant.
Visual acuity
> Decrease in distance and near visual acuity
Interpret and Discriminate: Visual acuity is measured using the
consumer’s corrective lenses if normally worn.
Infer: This rules out any refractive error; for example, myopia or
hypermetropia.
Relate: Visual acuity can be decreased due to opacities in the
ocular media, including the cornea, lens or vitreous.
Visual eld testing
> Visual elds are normal using confrontation testing
Infer: Normal visual elds generally rule out glaucoma, retinal
detachment and vision loss as the result of tumours, strokes or
other neurological diseases.
Pupil examination
> Pupils are equal, round and 3mm in diameter. They react to
direct and consensual light. No relative afferent papillary
defect (RAPD) is noted.
Relate: RAPD is never present in a consumer whose visual loss is
due to cataract.
Examination of anterior segment structures using a torch
> Cornea – clear and regular
> Lens – pearly grey appearance in both pupils
Relate: A cloudy or pearly grey appearance of the lens when
illuminated with a torch indicates opacity in the lens (cataract).
Ophthalmoscopy with direct ophthalmoscope
> Blurred view of optic disc and retina on ophthalmoscopy
Relate: Blurring of the ophthalmoscopic view into the posterior
segment indicates an opacity in the ocular media, in this case the
lens.
CHAPTER 10
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