{"id":2994,"date":"2024-08-13T10:35:34","date_gmt":"2024-08-13T14:35:34","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/?post_type=chapter&#038;p=2994"},"modified":"2025-08-01T09:28:12","modified_gmt":"2025-08-01T13:28:12","slug":"external-eye-assessment-and-anterior-eyeball-assessment","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/external-eye-assessment-and-anterior-eyeball-assessment\/","title":{"raw":"External Eye Assessment and Anterior Eyeball Assessment","rendered":"External Eye Assessment and Anterior Eyeball Assessment"},"content":{"raw":"<span style=\"color: #000000\">The external eye assessment and anterior eyeball assessment includes assessing all visible eye-related structures: the area surrounding the eye, the eyelids, and the anterior eyeball. The assessment includes:<\/span>\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li><span style=\"color: #000000\">General Inspection<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Pupillary light reflex and accommodation.<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<h2><span style=\"color: #000000\"><strong>General inspection<\/strong><\/span><\/h2>\r\n<span style=\"color: #000000\">This assessment should be done with the client looking straight ahead. Steps in the assessment include:<\/span>\r\n<ol start=\"1\">\r\n \t<li><span style=\"color: #000000\">Inspect for <strong>symmetry<\/strong> and <strong>placement<\/strong> of the eyebrows, eyes, eyelids, and [pb_glossary id=\"3356\"]palpebral fissures[\/pb_glossary].<\/span><\/li>\r\n<\/ol>\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li><span style=\"color: #000000\">Normally, the eye area is symmetrical, with the eyebrows and eyes at the same level on the left and right side. The upper eyelids should cross the [pb_glossary id=\"3357\"]limbus[\/pb_glossary] and sit above the pupil so that you can see some of the upper iris (i.e., iris above the pupil). The palpebral fissures should be equal bilaterally, and you should observe even distribution of eyelashes and eyebrow hair. Symmetry is a normal finding, but be aware that eye shape varies by ethnic background and can include eyes that are upward- or downward-turned, round, or almond-shaped, with a monolid or double eyelid.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Describe the appearance and location of any asymmetry such as eyelid drooping or retraction or unequal palpebral fissures. Describe any loss of eyelashes or loss of hair across eyebrows.<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<ol start=\"2\">\r\n \t<li><span style=\"color: #000000\">Inspect <strong>eyeball alignment<\/strong> in sockets.<\/span><\/li>\r\n<\/ol>\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li>Normally, eyeballs are aligned in the eye socket and are not protruding or sunken. See <strong>Figure 6<\/strong>.<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/figure-6-300x300.jpg\" alt=\"\" width=\"359\" height=\"359\" class=\"aligncenter wp-image-3314 \" \/>\r\n<p style=\"padding-left: 80px\"><span style=\"color: #000000\"><strong>Figure 6<\/strong>: Aligned eyeballs. (Photo by ABSOLUT on Unsplash:<\/span> <a href=\"https:\/\/unsplash.com\/photos\/ai-generated-portrait-of-a-model-looking-at-camera-with-red-lipstick-cmq6oysFais\" style=\"text-align: initial;font-size: 1em\" target=\"_blank\" rel=\"noopener\">weblink<\/a><span style=\"text-align: initial;font-size: 1em;color: #000000\">).\u00a0<\/span><\/p>\r\n\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Abnormal findings may include<\/span> <a href=\"https:\/\/www.nidirect.gov.uk\/conditions\/exophthalmos-bulging-eyes\" target=\"_blank\" rel=\"noopener\">protrusion of the eyeballs<\/a> <span style=\"color: #000000\">in which they bulge out of the socket (medical term: exophthalmos, also known as proptosis). This can be associated with eyelid retraction in which you can see visible sclera above the iris. The most common cause of this is [pb_glossary id=\"3358\"]hyperthyroidism[\/pb_glossary]. Another abnormal finding is<\/span> <a href=\"https:\/\/www.allaboutvision.com\/symptoms\/sunken-eyes-enophthalmos\/\" target=\"_blank\" rel=\"noopener\">sunken eyeballs<\/a> <span style=\"color: #000000\">(medical term: enophthalmos). This can be associated with age in which the client experiences atrophy around the eye, but it can also be associated with other conditions such as physical trauma.<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n[embed]https:\/\/youtu.be\/5DR6v19gHlM[\/embed]\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Video 1<\/strong>: Inspection for symmetry and placement of the eyebrows, eyes, eyelids, and palpebral fissures and inspection of eyeball alignment [0.43 seconds].<\/span><\/p>\r\n\r\n<div><\/div>\r\n<ol start=\"3\">\r\n \t<li><span style=\"color: #000000\">Inspect for <strong>[pb_glossary id=\"129\"]lesions[\/pb_glossary]<\/strong>, <strong>swelling<\/strong>, and <strong>discolouration<\/strong> (such as redness) of the eyelids and around the eyes.<\/span><\/li>\r\n<\/ol>\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Normally, you will not observe lesions, swelling, or discolouration, but be aware that some lesions are normal. For example, freckles and nevi can be considered normal, but you should always use the ABCDE mnemonic to assess. [pb_glossary id=\"3359\"]Lentigo\/lentigines[\/pb_glossary] are caused by sun exposure and may appear on the face around the eyes. The area around the eyes is normally the same colour as the rest of the face, although the skin below the eyes may be a slightly darker shade.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">If present, describe the appearance and location of any lesions, swelling, and discolouration. Common lesions associated with swelling and redness include [pb_glossary id=\"3360\"]hordeolum[\/pb_glossary] and [pb_glossary id=\"3361\"]chalazia[\/pb_glossary]. Intraocular hemorrhage (bleeding in the eye) can be visualized in the sclera of the eye and caused by conditions such as physical injury or retinal detachment.<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<ol start=\"4\">\r\n \t<li><span style=\"color: #000000\">Inspect for any <strong>discharge<\/strong> associated with the eyes.<\/span><\/li>\r\n<\/ol>\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Normally, you will observe no discharge, although a small amount of crust around the eyes (sometimes called \u201csleep\u201d) is normal after first waking up.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">If present, describe the colour (clear, purulent, sanguineous, serosanguineous), consistency (thin, thick, stringy), quantity (mild, moderate, severe), and location of discharge.<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<div style=\"text-align: left\">\r\n<div>\r\n\r\n[embed]https:\/\/youtu.be\/GQY0HHsFNrk[\/embed]\r\n\r\n<\/div>\r\n<span style=\"color: #000000\"><strong>Video 2<\/strong>: Inspect for lesions, swelling, discolouration and discharge. [0.27 seconds].<\/span>\r\n\r\n<\/div>\r\n<div><\/div>\r\n<ol start=\"5\">\r\n \t<li><span style=\"color: #000000\">Inspect the <strong>cornea<\/strong>, <strong>lens<\/strong>, and <strong>sclera<\/strong> on the anterior eyeball. It can be helpful to look directly at the eyeball from the front of the client and also look at the eyeball when standing at the side of the client while shining a penlight tangentially across the eyeball in order to better visualize the eyeball.<\/span><\/li>\r\n<\/ol>\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Normally, the cornea are smooth and the lens and cornea are clear. The sclera may be white or may have a soft (muted) greyish-blue tone in clients with darker skin (see <strong>Figure 7<\/strong>). You may observe flat small brown specs (freckles) on some sclera (<strong>Figure 8<\/strong>), particularly in clients with darker skin tones.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Abnormal findings include corneal abrasions (scratches), which are often painful. The cornea and lens may be cloudy, sometimes having a milky appearance (<strong>Figure 9<\/strong>).<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Grey-eye-300x227.jpg\" alt=\"\" width=\"353\" height=\"267\" class=\"alignnone wp-image-3318\" \/> <img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Blue-eye-300x266.jpg\" alt=\"\" width=\"297\" height=\"263\" class=\"alignnone wp-image-3319\" \/>\r\n\r\n<span style=\"color: #000000\"><strong>Figure 7<\/strong>: Greyish-blue tone (left) and white tone (right) sclera.<\/span>\r\n\r\n<span style=\"color: #000000\"><strong>Image on left:<\/strong> Author: By Basile Morin - Own work,<\/span> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\" target=\"_blank\" rel=\"noopener\">CC BY-SA 4.0<\/a>, <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=105228490\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=105228490<\/a>\r\n\r\n<span style=\"color: #000000\"><strong>Image on right:<\/strong> Author:<\/span> <a href=\"https:\/\/en.wikipedia.org\/wiki\/User:8thstar\" target=\"_blank\" rel=\"noopener\">8thstar<\/a> at <a href=\"https:\/\/en.wikipedia.org\/wiki\/\" target=\"_blank\" rel=\"noopener\">English Wikipedia<\/a>, <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\" target=\"_blank\" rel=\"noopener\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\" target=\"_blank\" rel=\"noopener\">Attribution-Share Alike 3.0 Unported<\/a><span style=\"color: #000000\"> license,<\/span> <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=1944750\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=1944750<\/a><span style=\"color: #000000\">)<\/span>\r\n\r\n<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Freckle-sclera-223x300.jpg\" alt=\"\" width=\"223\" height=\"300\" class=\"size-medium wp-image-3316 aligncenter\" \/>\r\n\r\n<span style=\"color: #000000\"><strong>Figure 8<\/strong>: Freckle on sclera.<\/span>\r\n\r\n<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Cloudy-cornea-300x221.jpg\" alt=\"\" width=\"300\" height=\"221\" class=\"size-medium wp-image-3317 aligncenter\" \/>\r\n\r\n<span style=\"color: #000000\"><strong>Figure 9<\/strong>: Cloudy lens (probable diagnosis: cataract).<\/span>\r\n\r\n<span style=\"color: #000000\">(Author: Imrankabirhossain,<\/span> <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\" target=\"_blank\" rel=\"noopener\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\" target=\"_blank\" rel=\"noopener\">Attribution-Share Alike 4.0 International<\/a> <span style=\"color: #000000\">license, from:<\/span> <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Intumescent_cataract.jpg\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/wiki\/File:Intumescent_cataract.jpg<\/a><span style=\"color: #000000\">).<\/span>\r\n\r\n&nbsp;\r\n<ol start=\"6\">\r\n \t<li><span style=\"color: #000000\">Inspect the<strong> conjunctiva<\/strong> of the inside of lower and upper eyelids. Place the pads of your thumbs below the client\u2019s eyelids (on the orbital bone) and gently pull downward. Ask the client to look up towards the ceiling while inspecting the inner lower eyelid. Next, place the pads of your thumbs on the orbital bone above the eye and gently pull upward. Begin by inspecting the inner upper eyelid, and then ask the client to look to the right and then to the left while you inspect the outer and inner canthus.<\/span><\/li>\r\n<\/ol>\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Normally, the conjunctiva is transparent with a slightly pink colour particularly over the area that covers the inside of the lower eyelids, visible blood vessels, and no lesions, swelling, or foreign bodies (<strong>Figure 10<\/strong>).<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Describe the location and appearance of any lesions, swelling, foreign bodies, or discolouration. See <strong>Figure<\/strong> <strong>11<\/strong> for an example of a melanoma.<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n&nbsp;\r\n\r\n<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/09\/Eye-1-300x261.jpg\" alt=\"\" width=\"400\" height=\"348\" class=\"aligncenter wp-image-3517\" \/>\r\n\r\n&nbsp;\r\n\r\n<span style=\"color: #000000\"><strong>Figure 10<\/strong>: Transparent conjunctiva with a slightly pink colour, visible blood vessels, no swelling or foreign bodies, small brown macule on right eye medial to the limbus, no other lesions.<\/span>\r\n\r\n<span style=\"color: #000000\">(By http:\/\/commons.wikimedia.org\/wiki\/User:Brazilianboy94 - Own work,<\/span> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\" target=\"_blank\" rel=\"noopener\">CC BY-SA 4.0<\/a>, <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=80905686\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=80905686<\/a>)\r\n\r\n<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Melanoma-blue-eye-300x209.jpg\" alt=\"\" width=\"300\" height=\"209\" class=\"size-medium wp-image-3321 aligncenter\" \/>\r\n\r\n<span style=\"color: #000000\"><strong>Figure 11<\/strong>: Melanoma.<\/span>\r\n\r\n<span style=\"color: #000000\">(Author: Jonathan Trobe,<\/span> <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\" target=\"_blank\" rel=\"noopener\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by\/3.0\/deed.en\" target=\"_blank\" rel=\"noopener\">Attribution 3.0 Unported<\/a> <span style=\"color: #000000\">license, from:<\/span> <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Iris_melanoma.jpg\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/wiki\/File:Iris_melanoma.jpg<\/a><span style=\"color: #000000\">).<\/span>\r\n\r\n&nbsp;\r\n\r\n[embed]https:\/\/youtu.be\/xvqpJyt599s[\/embed]\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Video 3<\/strong>: Inspect the Cornea, Lens, Sclera, and Conjunctiva. [1.06].<\/span><\/p>\r\n\r\n<div><\/div>\r\n<ol start=\"7\">\r\n \t<li><span style=\"color: #000000\">Note the <strong>findings:<\/strong><\/span><\/li>\r\n<\/ol>\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\"><strong>Normal findings<\/strong> might be documented as: \u201cEyebrows, eyes, eyelids, and palpebral fissures symmetrical. Even distribution of eyebrows and eyelids. Normal alignment of eyeballs with no protrusion or sunken eyeballs. No lesions, swelling, and discolouration of eyelids and around eyes. No eye discharge. Smooth cornea with no abrasions, lens and cornea are clear with white sclera and no lesions. Conjunctiva are transparent with a slightly pink colour, no lesions, swelling, or foreign bodies.\u201d<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">An <strong>abnormal finding<\/strong> might be documented as: \u201cDrooping left eyelid.\u201d<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<div class=\"textbox shaded\">\r\n<h2 style=\"text-align: center\"><span style=\"color: #000000\"><strong>Contextualizing Inclusivity<\/strong><\/span><\/h2>\r\n<span style=\"color: #000000\"><strong>Periorbital hyperpigmentation<\/strong> (sometimes referred to as \u201ccircles\u201d under the eyes) and puffiness (sometimes referred to as \u201cbags\u201d under the eyes) can be genetic, worsen with age (natural atrophy in which the skin begins to sag), and be influenced by other factors such as lack of sleep, allergies, dehydration, and fluid retention. The <strong>skin under the eyes<\/strong> is thin and transparent, so the underlying structures (vasculature) can create darkness under the eyes in which the pigmentation may vary in shades from brown, black, blue, and purple. People with darker skin often have hyperpigmentation around the eyes and darker circles under the eyes related to genetics, while the underlying structures may be more prominent in people with lighter skin.<\/span>\r\n\r\n<span style=\"color: #000000\"><strong>False Eyelashes <\/strong><span style=\"text-align: initial;background-color: initial;font-size: 1em\">were invented more than 100 years ago, but have become a more common cosmetic enhancement in the last 20 years. If a client wears false eyelashes, assess the eyelids for any signs of inflammation, as long-term use without breaks can block the glands and damage the follicles. Remember to use an <\/span><\/span><a href=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/part\/chapter-2\/\" style=\"text-align: initial;background-color: initial;font-size: 1em\" target=\"_blank\" rel=\"noopener\">inclusive<\/a><span style=\"text-align: initial;background-color: initial;font-size: 1em;color: #000000\"> assessment approach because false eyelashes are a gendered and racialized beauty trend that can lead to judgement and discrimination.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 <\/span>\r\n\r\n<span style=\"color: #000000\"><span style=\"text-align: initial;background-color: initial;font-size: 1em\">[pb_glossary id=\"3325\"]Ptosis[\/pb_glossary]<\/span><span style=\"text-align: initial;background-color: initial;font-size: 1em\">, when bilateral, is common with age due to muscle atrophy around the eye. It can also occur in children; if a child is born with it, the ptosis is typically congenital. Surgery may be considered, particularly if it affects vision.<\/span><\/span>\r\n\r\n<span style=\"color: #000000\">Note that <strong>eyebrows<\/strong> change with age: hormonal changes beginning in the 40s can lead to thinning eyebrows (particularly the outer third) in women and more bushy eyebrows and stray hairs in men.<\/span>\r\n\r\n<span style=\"color: #000000\"><strong>Dry eyes<\/strong> can affect people of all ages, but this condition is common in older adults and people experiencing menopause because the lacrimal apparatus production of tears is reduced. This condition can also be caused by adverse effects to medical treatment; it can lead to watery eyes, along with erythema and itchiness.<\/span>\r\n\r\n<span style=\"color: #000000\">Some clients may have an <strong>ocular prosthesis<\/strong> (an artificial eye, as shown in <strong>Figure 12<\/strong>). These are typically made of an acrylic material and customized for a person\u2019s eye socket. The quality of these vary, but many look quite real. In the province of Ontario (Canada), the costs are covered by OHIP (see<\/span> <a href=\"https:\/\/www.ontario.ca\/page\/artificial-eyes-and-facial-prosthetics\" target=\"_blank\" rel=\"noopener\">artificial eyes<\/a><span style=\"color: #000000\">). Explain to clients that prostheses must be removed and cleaned regularly and will require replacement after developmental changes, especially childhood growth spurts.<\/span>\r\n\r\n<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Ocular-prosthesis-300x219.jpg\" alt=\"\" width=\"300\" height=\"219\" class=\"size-medium wp-image-3326 aligncenter\" \/>\r\n<div>\r\n\r\n<span style=\"color: #000000\"><strong>Figure 12<\/strong>: Ocular prosthesis.<\/span>\r\n\r\n<span style=\"color: #000000\">(By MalastiC, from<\/span> <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Colocaci%C3%B3n_Protesis_Ocular_4.jpg\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/wiki\/File:Colocaci%C3%B3n_Protesis_Ocular_4.jpg<\/a><span style=\"color: #000000\">, the<\/span> <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\" target=\"_blank\" rel=\"noopener\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\" target=\"_blank\" rel=\"noopener\">Attribution-Share Alike 4.0 International<\/a> <span style=\"color: #000000\">license.).<\/span><span style=\"background-color: initial;font-size: 1em;text-align: initial\">\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0<\/span>\r\n\r\n<\/div>\r\n<\/div>\r\n<div class=\"textbox textbox--learning-objectives\"><header class=\"textbox__header\">\r\n<h2 style=\"text-align: center\"><strong>Priorities of Care<\/strong><\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n\r\n<span style=\"color: #000000\">Report any abnormal findings to the physician or nurse practitioner.<\/span>\r\n\r\n<span style=\"color: #000000\">In certain cases, findings should be reported immediately:<\/span>\r\n<ul>\r\n \t<li><span style=\"color: #000000\"><strong>New onset\u00a0of drooping eyelid<\/strong> could be a potential sign of stroke. Conduct a primary survey and a focused neurological and eye assessment.<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">If you\u00a0observe an<strong> intraocular hemorrhage<\/strong>, begin with a primary survey, followed by an eye assessment, and sometimes a brief scan of the neurological system.<\/span><\/li>\r\n<\/ul>\r\n<span style=\"color: #000000\">Loss of eyebrow hair or eyelashes is usually not a major concern. However, if the client is also experiencing thinning hair or hair loss on their scalp, along with other symptoms such as fatigue and weight change, you should investigate further.<\/span>\r\n\r\n<span style=\"color: #000000\">Eye hordeolum and chalazions may be treated by applying warm compresses. If they don\u2019t disappear within a few days, you should investigate further.<\/span>\r\n\r\n<\/div>\r\n<\/div>\r\n<div>\r\n<h3><strong>Pupillary light reflex and accommodation<\/strong><\/h3>\r\nThe pupillary light reflex is used to assess the eye\u2019s response to light and innervation of CN II (optic) and CN III (oculomotor) while testing for accommodation assesses the eye\u2019s ability to accommodate for near objects and innervation of CN III (oculomotor). These assessments usually begin with the pupillary light reflex (<strong>Video 4<\/strong>) followed by accommodation (<strong>Video 5<\/strong>), as described below:\r\n<ol>\r\n \t<li>To test <strong>pupillary light reflex<\/strong>, ask the client to look straight ahead at a distant point on the wall behind you (i.e., at the opposite end of the room) to slightly dilate the pupils. If possible, also reduce the lighting in the room to dilate the pupils.<\/li>\r\n \t<li>First, assess the pupils for shape, equality, and size.<\/li>\r\n<\/ol>\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li style=\"font-weight: 400\">Normally, the pupils should be round, equal in size and shape, and sized 2 to 8 mm in diameter <strong>(Figure 13<\/strong>). Normal size will depend on the ambient lighting; for example, the diameters of normal pupils are smaller in a well-lit environment (2\u20134 mm) and bigger in a darker environment (4\u20138 mm).<\/li>\r\n \t<li style=\"font-weight: 400\">Abnormal findings may include pupils that are not round, are unequal in size and shape, or are smaller ([pb_glossary id=\"3362\"]miosis[\/pb_glossary]: <strong>Figure 14<\/strong>) or larger ([pb_glossary id=\"3363\"]mydriasis[\/pb_glossary]: <strong>Figure 15<\/strong>) than the normal size.<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Normal-pupil-size-300x194.jpg\" alt=\"\" width=\"300\" height=\"194\" class=\"size-medium wp-image-3327 aligncenter\" \/>\r\n\r\n<span style=\"color: #000000\"><strong>Figure 13<\/strong>: Normal pupil size.<\/span>\r\n\r\n<span style=\"color: #000000\">(By Biswarup Ganguly,<\/span> <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=10066382\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=10066382<\/a>, <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\" target=\"_blank\" rel=\"noopener\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\" target=\"_blank\" rel=\"noopener\">Attribution-Share Alike 3.0 Unported<\/a> <span style=\"color: #000000\">license.)<\/span>\r\n\r\n<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Miosis-eye-300x87.jpg\" alt=\"\" width=\"300\" height=\"87\" class=\"size-medium wp-image-3328 aligncenter\" \/>\r\n\r\n<strong>Figure 14:<\/strong> Miosis.\r\n\r\n(By Thomas Bonini, from: <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Miosis_caused_by_opium_consumption.jpg\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/wiki\/File:Miosis_caused_by_opium_consumption.jpg<\/a>, <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\" target=\"_blank\" rel=\"noopener\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/publicdomain\/zero\/1.0\/deed.en\" target=\"_blank\" rel=\"noopener\">CC0 1.0 Universal Public Domain Dedication<\/a><span style=\"color: #000000\">)<\/span>\r\n\r\n<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Mydriasis-300x178.jpg\" alt=\"\" width=\"300\" height=\"178\" class=\"size-medium wp-image-3329 aligncenter\" \/>\r\n\r\n<\/div>\r\n<div>\r\n\r\n<span style=\"color: #000000\"><strong>Figure 15<\/strong>: Mydriasis.<\/span>\r\n\r\n<span style=\"color: #000000\">(By Nutschig at the English-language Wikipedia,<\/span> <a href=\"http:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/\" target=\"_blank\" rel=\"noopener\">CC BY-SA 3.0<\/a><span style=\"color: #000000\">,<\/span> <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=137216882\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=137216882<\/a><span style=\"color: #000000\">)<\/span>\r\n\r\n<\/div>\r\n<ol start=\"3\">\r\n \t<li><span style=\"color: #000000\">Ask the client to continue looking straight ahead at the distant point on the wall. Turn on your penlight and move it from the right side of the client to directly in front of their right eye. Shine the penlight on the eye, pause for 1\u20132 seconds, and then move the light back out to the side: the light should activate CN II to send a message to the brain, and then CN III should send a message to the pupillary muscles causing pupillary constriction.<\/span><\/li>\r\n<\/ol>\r\n<p style=\"padding-left: 40px\"><span style=\"color: #000000\">When pausing the light on the eye, observe the client\u2019s right eye and left eye for pupillary constriction. If necessary, perform this procedure twice so that you can focus on the right eye (for direct response: meaning the pupil of the eye on the side where the light is introduced constricts), and then focus on the left eye (for consensual response: meaning the pupil of the opposite eye where the light is introduced also constricts). Repeat this step for the left eye and observe direct and consensual responses. Also note the size of the pupil afterwards: it should return to the same size as before the light was introduced.<\/span><\/p>\r\n\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Normally, you should see a direct response and a consensual response of both eyes. Normal constriction is often described as prompt or brisk, meaning it happens right away. Normally, when you remove the light, pupils will return to the same size\/shape they had before you introduced the light.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Abnormal findings include no direct and\/or consensual response (response is absent and pupils do not constrict), or when pupillary constriction is sluggish (slow).<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n[embed]https:\/\/youtu.be\/_T8CwTx7uzU[\/embed]\r\n\r\n<strong>Video 4<\/strong>: Pupillary light reflex test. [0.25 seconds].\r\n<ol start=\"4\">\r\n \t<li><span style=\"color: #000000\">To test<strong> accommodation<\/strong>, first ask the client to stare straight ahead at a distant point on the far wall and if possible, have the lights dimmed to dilate the pupils. While they are staring straight ahead, explain that you are going to move your index finger (or your penlight turned off) in front of their nose and slowly bring it closer to their nose. Ask them to shift their gaze from looking at the distant point on the wall to your finger and stay focused on your finger. Next, place your index finger in front of their nose (about 20\u201330cm from the tip of their nose and slowly move it closer so that it is about 8 cm from the tip of their nose).<\/span><\/li>\r\n<\/ol>\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li><span style=\"color: #000000\">Normally, the client should shift their gaze to your finger (convergence of the eyes inward) accompanied by pupillary constriction.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">Abnormal findings include inability to shift eyes simultaneously and lack of pupillary constriction.<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n[embed]https:\/\/youtu.be\/KZdHjUwiOFM[\/embed]\r\n\r\n<span style=\"color: #000000\"><strong>Video 5:<\/strong> Testing for accommodation. [0.37 seconds].<\/span>\r\n<ol start=\"5\">\r\n \t<li><span style=\"color: #000000\">Note the findings:<\/span><\/li>\r\n<\/ol>\r\n<ul>\r\n \t<li style=\"list-style-type: none\">\r\n<ul>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\"><strong>Normal findings<\/strong> might be documented as: \u201cPupils round, 3 millimetres, and equal in size. Prompt, direct and consensual light reflex noted bilaterally. When testing for accommodation: pupillary constriction and convergence of eyes noted.\u201d (In some institutions, this is sometimes noted as PERRLA: pupils equal, round, and reactive to light and accommodation.)<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\"><strong>Abnormal findings<\/strong> might be documented as: \u201cNo direct or consensual light reflex noted bilaterally.\u201d<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<div class=\"textbox shaded\">\r\n<h2 style=\"text-align: center\"><span style=\"color: #000000\"><strong>Contextualizing Inclusivity<\/strong><\/span><\/h2>\r\n<span style=\"color: #000000\">It can be difficult to evaluate the pupil size and pupillary constriction in clients with dark irises. If necessary, ask them to look up while doing the assessment; this can help. Alternatively, use a second penlight and shine the light tangentially to highlight the iris without causing an unintentional pupillary reflex.<\/span>\r\n\r\n<\/div>\r\n<div>\r\n<div class=\"textbox textbox--learning-objectives\"><header class=\"textbox__header\">\r\n<h2 style=\"text-align: center\">Prioritizing Care<\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n\r\n<span style=\"color: #000000\">One serious finding is a<strong> \u201cblown\u201d <\/strong><strong>pupil<\/strong>: the pupil is dilated and also fixed and unresponsive. This condition resembles mydriasis, as shown above in <strong>Figure 15<\/strong>; it is often associated with brain herniation, meaning the brain tissue shifts due to increased intracranial pressure. Brain herniation can be related to various pathophysiological processes such as brain trauma, stroke, aneurysm, or tumour. New onset of unilateral or bilateral fixed and dilated pupils should be immediately reported to the physician or nurse practitioner: as the nurse you should stay with the client and complete a primary survey.<\/span>\r\n\r\n<span style=\"color: #000000\"><strong>Anisocoria<\/strong> (unequal pupil size) <strong>Figure 16<\/strong>, image below, does not require treatment unless it is new onset. Many clients have unequal pupil size, but new onset anisocoria may be of concern because it can be associated with neurological problems, stroke, infection, or eye trauma. Complete a focused assessment and report the findings to the physician or nurse practitioner.<\/span>\r\n\r\n<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/anisocoria-e1724550155374-300x161.jpg\" alt=\"\" width=\"300\" height=\"161\" class=\"wp-image-3331 size-medium aligncenter\" \/>\r\n\r\n<span style=\"color: #000000\"><strong>Figure 16<\/strong>: By Tair1978 - Own work,<\/span> <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\" target=\"_blank\" rel=\"noopener\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\" target=\"_blank\" rel=\"noopener\">Attribution-Share Alike 4.0 International<\/a> <span style=\"color: #000000\">license, from:<\/span> <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=82053909\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=82053909<\/a><span style=\"color: #000000\">).<\/span>\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<h2><span style=\"color: #000000\"><strong>Activity: Check Your Understanding<\/strong><\/span><\/h2>\r\n<div class=\"postbox h5p-sidebar\">\r\n<div class=\"h5p-action-bar-settings h5p-panel\">[h5p id=\"265\"]<\/div>\r\n<\/div>","rendered":"<p><span style=\"color: #000000\">The external eye assessment and anterior eyeball assessment includes assessing all visible eye-related structures: the area surrounding the eye, the eyelids, and the anterior eyeball. The assessment includes:<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"color: #000000\">General Inspection<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Pupillary light reflex and accommodation.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h2><span style=\"color: #000000\"><strong>General inspection<\/strong><\/span><\/h2>\n<p><span style=\"color: #000000\">This assessment should be done with the client looking straight ahead. Steps in the assessment include:<\/span><\/p>\n<ol start=\"1\">\n<li><span style=\"color: #000000\">Inspect for <strong>symmetry<\/strong> and <strong>placement<\/strong> of the eyebrows, eyes, eyelids, and <button class=\"glossary-term\" aria-describedby=\"2994-3356\">palpebral fissures<\/button>.<\/span><\/li>\n<\/ol>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"color: #000000\">Normally, the eye area is symmetrical, with the eyebrows and eyes at the same level on the left and right side. The upper eyelids should cross the <button class=\"glossary-term\" aria-describedby=\"2994-3357\">limbus<\/button> and sit above the pupil so that you can see some of the upper iris (i.e., iris above the pupil). The palpebral fissures should be equal bilaterally, and you should observe even distribution of eyelashes and eyebrow hair. Symmetry is a normal finding, but be aware that eye shape varies by ethnic background and can include eyes that are upward- or downward-turned, round, or almond-shaped, with a monolid or double eyelid.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Describe the appearance and location of any asymmetry such as eyelid drooping or retraction or unequal palpebral fissures. Describe any loss of eyelashes or loss of hair across eyebrows.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ol start=\"2\">\n<li><span style=\"color: #000000\">Inspect <strong>eyeball alignment<\/strong> in sockets.<\/span><\/li>\n<\/ol>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li>Normally, eyeballs are aligned in the eye socket and are not protruding or sunken. See <strong>Figure 6<\/strong>.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/figure-6-300x300.jpg\" alt=\"\" width=\"359\" height=\"359\" class=\"aligncenter wp-image-3314\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/figure-6-300x300.jpg 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/figure-6-150x150.jpg 150w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/figure-6-65x65.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/figure-6-225x225.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/figure-6-350x350.jpg 350w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/figure-6.jpg 512w\" sizes=\"auto, (max-width: 359px) 100vw, 359px\" \/><\/p>\n<p style=\"padding-left: 80px\"><span style=\"color: #000000\"><strong>Figure 6<\/strong>: Aligned eyeballs. (Photo by ABSOLUT on Unsplash:<\/span> <a href=\"https:\/\/unsplash.com\/photos\/ai-generated-portrait-of-a-model-looking-at-camera-with-red-lipstick-cmq6oysFais\" style=\"text-align: initial;font-size: 1em\" target=\"_blank\" rel=\"noopener\">weblink<\/a><span style=\"text-align: initial;font-size: 1em;color: #000000\">).\u00a0<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Abnormal findings may include<\/span> <a href=\"https:\/\/www.nidirect.gov.uk\/conditions\/exophthalmos-bulging-eyes\" target=\"_blank\" rel=\"noopener\">protrusion of the eyeballs<\/a> <span style=\"color: #000000\">in which they bulge out of the socket (medical term: exophthalmos, also known as proptosis). This can be associated with eyelid retraction in which you can see visible sclera above the iris. The most common cause of this is <button class=\"glossary-term\" aria-describedby=\"2994-3358\">hyperthyroidism<\/button>. Another abnormal finding is<\/span> <a href=\"https:\/\/www.allaboutvision.com\/symptoms\/sunken-eyes-enophthalmos\/\" target=\"_blank\" rel=\"noopener\">sunken eyeballs<\/a> <span style=\"color: #000000\">(medical term: enophthalmos). This can be associated with age in which the client experiences atrophy around the eye, but it can also be associated with other conditions such as physical trauma.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><iframe loading=\"lazy\" id=\"oembed-1\" title=\"Inspection for Symmetry and Placement of the Eyebrows, Eyes, Eyelids, and Palpebral Fissures and In.\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/5DR6v19gHlM?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Video 1<\/strong>: Inspection for symmetry and placement of the eyebrows, eyes, eyelids, and palpebral fissures and inspection of eyeball alignment [0.43 seconds].<\/span><\/p>\n<div><\/div>\n<ol start=\"3\">\n<li><span style=\"color: #000000\">Inspect for <strong><button class=\"glossary-term\" aria-describedby=\"2994-129\">lesions<\/button><\/strong>, <strong>swelling<\/strong>, and <strong>discolouration<\/strong> (such as redness) of the eyelids and around the eyes.<\/span><\/li>\n<\/ol>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Normally, you will not observe lesions, swelling, or discolouration, but be aware that some lesions are normal. For example, freckles and nevi can be considered normal, but you should always use the ABCDE mnemonic to assess. <button class=\"glossary-term\" aria-describedby=\"2994-3359\">Lentigo\/lentigines<\/button> are caused by sun exposure and may appear on the face around the eyes. The area around the eyes is normally the same colour as the rest of the face, although the skin below the eyes may be a slightly darker shade.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">If present, describe the appearance and location of any lesions, swelling, and discolouration. Common lesions associated with swelling and redness include <button class=\"glossary-term\" aria-describedby=\"2994-3360\">hordeolum<\/button> and <button class=\"glossary-term\" aria-describedby=\"2994-3361\">chalazia<\/button>. Intraocular hemorrhage (bleeding in the eye) can be visualized in the sclera of the eye and caused by conditions such as physical injury or retinal detachment.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ol start=\"4\">\n<li><span style=\"color: #000000\">Inspect for any <strong>discharge<\/strong> associated with the eyes.<\/span><\/li>\n<\/ol>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Normally, you will observe no discharge, although a small amount of crust around the eyes (sometimes called \u201csleep\u201d) is normal after first waking up.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">If present, describe the colour (clear, purulent, sanguineous, serosanguineous), consistency (thin, thick, stringy), quantity (mild, moderate, severe), and location of discharge.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<div style=\"text-align: left\">\n<div>\n<p><iframe loading=\"lazy\" id=\"oembed-2\" title=\"Inspect for Lesions, Swelling, Discolouration and Discharge.\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/GQY0HHsFNrk?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<\/div>\n<p><span style=\"color: #000000\"><strong>Video 2<\/strong>: Inspect for lesions, swelling, discolouration and discharge. [0.27 seconds].<\/span><\/p>\n<\/div>\n<div><\/div>\n<ol start=\"5\">\n<li><span style=\"color: #000000\">Inspect the <strong>cornea<\/strong>, <strong>lens<\/strong>, and <strong>sclera<\/strong> on the anterior eyeball. It can be helpful to look directly at the eyeball from the front of the client and also look at the eyeball when standing at the side of the client while shining a penlight tangentially across the eyeball in order to better visualize the eyeball.<\/span><\/li>\n<\/ol>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Normally, the cornea are smooth and the lens and cornea are clear. The sclera may be white or may have a soft (muted) greyish-blue tone in clients with darker skin (see <strong>Figure 7<\/strong>). You may observe flat small brown specs (freckles) on some sclera (<strong>Figure 8<\/strong>), particularly in clients with darker skin tones.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Abnormal findings include corneal abrasions (scratches), which are often painful. The cornea and lens may be cloudy, sometimes having a milky appearance (<strong>Figure 9<\/strong>).<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Grey-eye-300x227.jpg\" alt=\"\" width=\"353\" height=\"267\" class=\"alignnone wp-image-3318\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Grey-eye-300x227.jpg 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Grey-eye-65x49.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Grey-eye-225x171.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Grey-eye-350x265.jpg 350w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Grey-eye.jpg 488w\" sizes=\"auto, (max-width: 353px) 100vw, 353px\" \/> <img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Blue-eye-300x266.jpg\" alt=\"\" width=\"297\" height=\"263\" class=\"alignnone wp-image-3319\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Blue-eye-300x266.jpg 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Blue-eye-65x58.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Blue-eye-225x200.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Blue-eye-350x311.jpg 350w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Blue-eye.jpg 410w\" sizes=\"auto, (max-width: 297px) 100vw, 297px\" \/><\/p>\n<p><span style=\"color: #000000\"><strong>Figure 7<\/strong>: Greyish-blue tone (left) and white tone (right) sclera.<\/span><\/p>\n<p><span style=\"color: #000000\"><strong>Image on left:<\/strong> Author: By Basile Morin &#8211; Own work,<\/span> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\" target=\"_blank\" rel=\"noopener\">CC BY-SA 4.0<\/a>, <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=105228490\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=105228490<\/a><\/p>\n<p><span style=\"color: #000000\"><strong>Image on right:<\/strong> Author:<\/span> <a href=\"https:\/\/en.wikipedia.org\/wiki\/User:8thstar\" target=\"_blank\" rel=\"noopener\">8thstar<\/a> at <a href=\"https:\/\/en.wikipedia.org\/wiki\/\" target=\"_blank\" rel=\"noopener\">English Wikipedia<\/a>, <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\" target=\"_blank\" rel=\"noopener\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\" target=\"_blank\" rel=\"noopener\">Attribution-Share Alike 3.0 Unported<\/a><span style=\"color: #000000\"> license,<\/span> <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=1944750\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=1944750<\/a><span style=\"color: #000000\">)<\/span><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Freckle-sclera-223x300.jpg\" alt=\"\" width=\"223\" height=\"300\" class=\"size-medium wp-image-3316 aligncenter\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Freckle-sclera-223x300.jpg 223w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Freckle-sclera-65x87.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Freckle-sclera-225x303.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Freckle-sclera-350x471.jpg 350w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Freckle-sclera.jpg 476w\" sizes=\"auto, (max-width: 223px) 100vw, 223px\" \/><\/p>\n<p><span style=\"color: #000000\"><strong>Figure 8<\/strong>: Freckle on sclera.<\/span><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Cloudy-cornea-300x221.jpg\" alt=\"\" width=\"300\" height=\"221\" class=\"size-medium wp-image-3317 aligncenter\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Cloudy-cornea-300x221.jpg 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Cloudy-cornea-65x48.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Cloudy-cornea-225x166.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Cloudy-cornea-350x258.jpg 350w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Cloudy-cornea.jpg 358w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/p>\n<p><span style=\"color: #000000\"><strong>Figure 9<\/strong>: Cloudy lens (probable diagnosis: cataract).<\/span><\/p>\n<p><span style=\"color: #000000\">(Author: Imrankabirhossain,<\/span> <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\" target=\"_blank\" rel=\"noopener\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\" target=\"_blank\" rel=\"noopener\">Attribution-Share Alike 4.0 International<\/a> <span style=\"color: #000000\">license, from:<\/span> <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Intumescent_cataract.jpg\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/wiki\/File:Intumescent_cataract.jpg<\/a><span style=\"color: #000000\">).<\/span><\/p>\n<p>&nbsp;<\/p>\n<ol start=\"6\">\n<li><span style=\"color: #000000\">Inspect the<strong> conjunctiva<\/strong> of the inside of lower and upper eyelids. Place the pads of your thumbs below the client\u2019s eyelids (on the orbital bone) and gently pull downward. Ask the client to look up towards the ceiling while inspecting the inner lower eyelid. Next, place the pads of your thumbs on the orbital bone above the eye and gently pull upward. Begin by inspecting the inner upper eyelid, and then ask the client to look to the right and then to the left while you inspect the outer and inner canthus.<\/span><\/li>\n<\/ol>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Normally, the conjunctiva is transparent with a slightly pink colour particularly over the area that covers the inside of the lower eyelids, visible blood vessels, and no lesions, swelling, or foreign bodies (<strong>Figure 10<\/strong>).<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Describe the location and appearance of any lesions, swelling, foreign bodies, or discolouration. See <strong>Figure<\/strong> <strong>11<\/strong> for an example of a melanoma.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/09\/Eye-1-300x261.jpg\" alt=\"\" width=\"400\" height=\"348\" class=\"aligncenter wp-image-3517\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/09\/Eye-1-300x261.jpg 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/09\/Eye-1-65x56.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/09\/Eye-1-225x196.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/09\/Eye-1-350x304.jpg 350w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/09\/Eye-1.jpg 450w\" sizes=\"auto, (max-width: 400px) 100vw, 400px\" \/><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"color: #000000\"><strong>Figure 10<\/strong>: Transparent conjunctiva with a slightly pink colour, visible blood vessels, no swelling or foreign bodies, small brown macule on right eye medial to the limbus, no other lesions.<\/span><\/p>\n<p><span style=\"color: #000000\">(By http:\/\/commons.wikimedia.org\/wiki\/User:Brazilianboy94 &#8211; Own work,<\/span> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\" target=\"_blank\" rel=\"noopener\">CC BY-SA 4.0<\/a>, <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=80905686\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=80905686<\/a>)<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Melanoma-blue-eye-300x209.jpg\" alt=\"\" width=\"300\" height=\"209\" class=\"size-medium wp-image-3321 aligncenter\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Melanoma-blue-eye-300x209.jpg 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Melanoma-blue-eye-65x45.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Melanoma-blue-eye-225x157.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Melanoma-blue-eye.jpg 322w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/p>\n<p><span style=\"color: #000000\"><strong>Figure 11<\/strong>: Melanoma.<\/span><\/p>\n<p><span style=\"color: #000000\">(Author: Jonathan Trobe,<\/span> <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\" target=\"_blank\" rel=\"noopener\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by\/3.0\/deed.en\" target=\"_blank\" rel=\"noopener\">Attribution 3.0 Unported<\/a> <span style=\"color: #000000\">license, from:<\/span> <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Iris_melanoma.jpg\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/wiki\/File:Iris_melanoma.jpg<\/a><span style=\"color: #000000\">).<\/span><\/p>\n<p>&nbsp;<\/p>\n<p><iframe loading=\"lazy\" id=\"oembed-3\" title=\"Inspect the Cornea, Lens, Sclera, and Conjunctiva.\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/xvqpJyt599s?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Video 3<\/strong>: Inspect the Cornea, Lens, Sclera, and Conjunctiva. [1.06].<\/span><\/p>\n<div><\/div>\n<ol start=\"7\">\n<li><span style=\"color: #000000\">Note the <strong>findings:<\/strong><\/span><\/li>\n<\/ol>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\"><strong>Normal findings<\/strong> might be documented as: \u201cEyebrows, eyes, eyelids, and palpebral fissures symmetrical. Even distribution of eyebrows and eyelids. Normal alignment of eyeballs with no protrusion or sunken eyeballs. No lesions, swelling, and discolouration of eyelids and around eyes. No eye discharge. Smooth cornea with no abrasions, lens and cornea are clear with white sclera and no lesions. Conjunctiva are transparent with a slightly pink colour, no lesions, swelling, or foreign bodies.\u201d<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">An <strong>abnormal finding<\/strong> might be documented as: \u201cDrooping left eyelid.\u201d<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<div class=\"textbox shaded\">\n<h2 style=\"text-align: center\"><span style=\"color: #000000\"><strong>Contextualizing Inclusivity<\/strong><\/span><\/h2>\n<p><span style=\"color: #000000\"><strong>Periorbital hyperpigmentation<\/strong> (sometimes referred to as \u201ccircles\u201d under the eyes) and puffiness (sometimes referred to as \u201cbags\u201d under the eyes) can be genetic, worsen with age (natural atrophy in which the skin begins to sag), and be influenced by other factors such as lack of sleep, allergies, dehydration, and fluid retention. The <strong>skin under the eyes<\/strong> is thin and transparent, so the underlying structures (vasculature) can create darkness under the eyes in which the pigmentation may vary in shades from brown, black, blue, and purple. People with darker skin often have hyperpigmentation around the eyes and darker circles under the eyes related to genetics, while the underlying structures may be more prominent in people with lighter skin.<\/span><\/p>\n<p><span style=\"color: #000000\"><strong>False Eyelashes <\/strong><span style=\"text-align: initial;background-color: initial;font-size: 1em\">were invented more than 100 years ago, but have become a more common cosmetic enhancement in the last 20 years. If a client wears false eyelashes, assess the eyelids for any signs of inflammation, as long-term use without breaks can block the glands and damage the follicles. Remember to use an <\/span><\/span><a href=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/part\/chapter-2\/\" style=\"text-align: initial;background-color: initial;font-size: 1em\" target=\"_blank\" rel=\"noopener\">inclusive<\/a><span style=\"text-align: initial;background-color: initial;font-size: 1em;color: #000000\"> assessment approach because false eyelashes are a gendered and racialized beauty trend that can lead to judgement and discrimination.\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 <\/span><\/p>\n<p><span style=\"color: #000000\"><span style=\"text-align: initial;background-color: initial;font-size: 1em\"><button class=\"glossary-term\" aria-describedby=\"2994-3325\">Ptosis<\/button><\/span><span style=\"text-align: initial;background-color: initial;font-size: 1em\">, when bilateral, is common with age due to muscle atrophy around the eye. It can also occur in children; if a child is born with it, the ptosis is typically congenital. Surgery may be considered, particularly if it affects vision.<\/span><\/span><\/p>\n<p><span style=\"color: #000000\">Note that <strong>eyebrows<\/strong> change with age: hormonal changes beginning in the 40s can lead to thinning eyebrows (particularly the outer third) in women and more bushy eyebrows and stray hairs in men.<\/span><\/p>\n<p><span style=\"color: #000000\"><strong>Dry eyes<\/strong> can affect people of all ages, but this condition is common in older adults and people experiencing menopause because the lacrimal apparatus production of tears is reduced. This condition can also be caused by adverse effects to medical treatment; it can lead to watery eyes, along with erythema and itchiness.<\/span><\/p>\n<p><span style=\"color: #000000\">Some clients may have an <strong>ocular prosthesis<\/strong> (an artificial eye, as shown in <strong>Figure 12<\/strong>). These are typically made of an acrylic material and customized for a person\u2019s eye socket. The quality of these vary, but many look quite real. In the province of Ontario (Canada), the costs are covered by OHIP (see<\/span> <a href=\"https:\/\/www.ontario.ca\/page\/artificial-eyes-and-facial-prosthetics\" target=\"_blank\" rel=\"noopener\">artificial eyes<\/a><span style=\"color: #000000\">). Explain to clients that prostheses must be removed and cleaned regularly and will require replacement after developmental changes, especially childhood growth spurts.<\/span><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Ocular-prosthesis-300x219.jpg\" alt=\"\" width=\"300\" height=\"219\" class=\"size-medium wp-image-3326 aligncenter\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Ocular-prosthesis-300x219.jpg 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Ocular-prosthesis-65x47.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Ocular-prosthesis-225x164.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Ocular-prosthesis.jpg 348w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/p>\n<div>\n<p><span style=\"color: #000000\"><strong>Figure 12<\/strong>: Ocular prosthesis.<\/span><\/p>\n<p><span style=\"color: #000000\">(By MalastiC, from<\/span> <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Colocaci%C3%B3n_Protesis_Ocular_4.jpg\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/wiki\/File:Colocaci%C3%B3n_Protesis_Ocular_4.jpg<\/a><span style=\"color: #000000\">, the<\/span> <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\" target=\"_blank\" rel=\"noopener\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\" target=\"_blank\" rel=\"noopener\">Attribution-Share Alike 4.0 International<\/a> <span style=\"color: #000000\">license.).<\/span><span style=\"background-color: initial;font-size: 1em;text-align: initial\">\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0<\/span><\/p>\n<\/div>\n<\/div>\n<div class=\"textbox textbox--learning-objectives\">\n<header class=\"textbox__header\">\n<h2 style=\"text-align: center\"><strong>Priorities of Care<\/strong><\/h2>\n<\/header>\n<div class=\"textbox__content\">\n<p><span style=\"color: #000000\">Report any abnormal findings to the physician or nurse practitioner.<\/span><\/p>\n<p><span style=\"color: #000000\">In certain cases, findings should be reported immediately:<\/span><\/p>\n<ul>\n<li><span style=\"color: #000000\"><strong>New onset\u00a0of drooping eyelid<\/strong> could be a potential sign of stroke. Conduct a primary survey and a focused neurological and eye assessment.<\/span><\/li>\n<li><span style=\"color: #000000\">If you\u00a0observe an<strong> intraocular hemorrhage<\/strong>, begin with a primary survey, followed by an eye assessment, and sometimes a brief scan of the neurological system.<\/span><\/li>\n<\/ul>\n<p><span style=\"color: #000000\">Loss of eyebrow hair or eyelashes is usually not a major concern. However, if the client is also experiencing thinning hair or hair loss on their scalp, along with other symptoms such as fatigue and weight change, you should investigate further.<\/span><\/p>\n<p><span style=\"color: #000000\">Eye hordeolum and chalazions may be treated by applying warm compresses. If they don\u2019t disappear within a few days, you should investigate further.<\/span><\/p>\n<\/div>\n<\/div>\n<div>\n<h3><strong>Pupillary light reflex and accommodation<\/strong><\/h3>\n<p>The pupillary light reflex is used to assess the eye\u2019s response to light and innervation of CN II (optic) and CN III (oculomotor) while testing for accommodation assesses the eye\u2019s ability to accommodate for near objects and innervation of CN III (oculomotor). These assessments usually begin with the pupillary light reflex (<strong>Video 4<\/strong>) followed by accommodation (<strong>Video 5<\/strong>), as described below:<\/p>\n<ol>\n<li>To test <strong>pupillary light reflex<\/strong>, ask the client to look straight ahead at a distant point on the wall behind you (i.e., at the opposite end of the room) to slightly dilate the pupils. If possible, also reduce the lighting in the room to dilate the pupils.<\/li>\n<li>First, assess the pupils for shape, equality, and size.<\/li>\n<\/ol>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li style=\"font-weight: 400\">Normally, the pupils should be round, equal in size and shape, and sized 2 to 8 mm in diameter <strong>(Figure 13<\/strong>). Normal size will depend on the ambient lighting; for example, the diameters of normal pupils are smaller in a well-lit environment (2\u20134 mm) and bigger in a darker environment (4\u20138 mm).<\/li>\n<li style=\"font-weight: 400\">Abnormal findings may include pupils that are not round, are unequal in size and shape, or are smaller (<button class=\"glossary-term\" aria-describedby=\"2994-3362\">miosis<\/button>: <strong>Figure 14<\/strong>) or larger (<button class=\"glossary-term\" aria-describedby=\"2994-3363\">mydriasis<\/button>: <strong>Figure 15<\/strong>) than the normal size.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Normal-pupil-size-300x194.jpg\" alt=\"\" width=\"300\" height=\"194\" class=\"size-medium wp-image-3327 aligncenter\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Normal-pupil-size-300x194.jpg 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Normal-pupil-size-65x42.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Normal-pupil-size-225x146.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Normal-pupil-size-350x227.jpg 350w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Normal-pupil-size.jpg 426w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/p>\n<p><span style=\"color: #000000\"><strong>Figure 13<\/strong>: Normal pupil size.<\/span><\/p>\n<p><span style=\"color: #000000\">(By Biswarup Ganguly,<\/span> <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=10066382\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=10066382<\/a>, <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\" target=\"_blank\" rel=\"noopener\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/deed.en\" target=\"_blank\" rel=\"noopener\">Attribution-Share Alike 3.0 Unported<\/a> <span style=\"color: #000000\">license.)<\/span><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Miosis-eye-300x87.jpg\" alt=\"\" width=\"300\" height=\"87\" class=\"size-medium wp-image-3328 aligncenter\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Miosis-eye-300x87.jpg 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Miosis-eye-65x19.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Miosis-eye-225x65.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Miosis-eye-350x101.jpg 350w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Miosis-eye.jpg 624w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/p>\n<p><strong>Figure 14:<\/strong> Miosis.<\/p>\n<p>(By Thomas Bonini, from: <a href=\"https:\/\/commons.wikimedia.org\/wiki\/File:Miosis_caused_by_opium_consumption.jpg\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/wiki\/File:Miosis_caused_by_opium_consumption.jpg<\/a>, <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\" target=\"_blank\" rel=\"noopener\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/publicdomain\/zero\/1.0\/deed.en\" target=\"_blank\" rel=\"noopener\">CC0 1.0 Universal Public Domain Dedication<\/a><span style=\"color: #000000\">)<\/span><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Mydriasis-300x178.jpg\" alt=\"\" width=\"300\" height=\"178\" class=\"size-medium wp-image-3329 aligncenter\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Mydriasis-300x178.jpg 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Mydriasis-65x38.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Mydriasis-225x133.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Mydriasis-350x207.jpg 350w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/Mydriasis.jpg 436w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/p>\n<\/div>\n<div>\n<p><span style=\"color: #000000\"><strong>Figure 15<\/strong>: Mydriasis.<\/span><\/p>\n<p><span style=\"color: #000000\">(By Nutschig at the English-language Wikipedia,<\/span> <a href=\"http:\/\/creativecommons.org\/licenses\/by-sa\/3.0\/\" target=\"_blank\" rel=\"noopener\">CC BY-SA 3.0<\/a><span style=\"color: #000000\">,<\/span> <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=137216882\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=137216882<\/a><span style=\"color: #000000\">)<\/span><\/p>\n<\/div>\n<ol start=\"3\">\n<li><span style=\"color: #000000\">Ask the client to continue looking straight ahead at the distant point on the wall. Turn on your penlight and move it from the right side of the client to directly in front of their right eye. Shine the penlight on the eye, pause for 1\u20132 seconds, and then move the light back out to the side: the light should activate CN II to send a message to the brain, and then CN III should send a message to the pupillary muscles causing pupillary constriction.<\/span><\/li>\n<\/ol>\n<p style=\"padding-left: 40px\"><span style=\"color: #000000\">When pausing the light on the eye, observe the client\u2019s right eye and left eye for pupillary constriction. If necessary, perform this procedure twice so that you can focus on the right eye (for direct response: meaning the pupil of the eye on the side where the light is introduced constricts), and then focus on the left eye (for consensual response: meaning the pupil of the opposite eye where the light is introduced also constricts). Repeat this step for the left eye and observe direct and consensual responses. Also note the size of the pupil afterwards: it should return to the same size as before the light was introduced.<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Normally, you should see a direct response and a consensual response of both eyes. Normal constriction is often described as prompt or brisk, meaning it happens right away. Normally, when you remove the light, pupils will return to the same size\/shape they had before you introduced the light.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Abnormal findings include no direct and\/or consensual response (response is absent and pupils do not constrict), or when pupillary constriction is sluggish (slow).<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><iframe loading=\"lazy\" id=\"oembed-4\" title=\"Pupillary Light Reflex\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/_T8CwTx7uzU?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p><strong>Video 4<\/strong>: Pupillary light reflex test. [0.25 seconds].<\/p>\n<ol start=\"4\">\n<li><span style=\"color: #000000\">To test<strong> accommodation<\/strong>, first ask the client to stare straight ahead at a distant point on the far wall and if possible, have the lights dimmed to dilate the pupils. While they are staring straight ahead, explain that you are going to move your index finger (or your penlight turned off) in front of their nose and slowly bring it closer to their nose. Ask them to shift their gaze from looking at the distant point on the wall to your finger and stay focused on your finger. Next, place your index finger in front of their nose (about 20\u201330cm from the tip of their nose and slowly move it closer so that it is about 8 cm from the tip of their nose).<\/span><\/li>\n<\/ol>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"color: #000000\">Normally, the client should shift their gaze to your finger (convergence of the eyes inward) accompanied by pupillary constriction.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">Abnormal findings include inability to shift eyes simultaneously and lack of pupillary constriction.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><iframe loading=\"lazy\" id=\"oembed-5\" title=\"Testing for Accommodation.\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/KZdHjUwiOFM?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p><span style=\"color: #000000\"><strong>Video 5:<\/strong> Testing for accommodation. [0.37 seconds].<\/span><\/p>\n<ol start=\"5\">\n<li><span style=\"color: #000000\">Note the findings:<\/span><\/li>\n<\/ol>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\"><strong>Normal findings<\/strong> might be documented as: \u201cPupils round, 3 millimetres, and equal in size. Prompt, direct and consensual light reflex noted bilaterally. When testing for accommodation: pupillary constriction and convergence of eyes noted.\u201d (In some institutions, this is sometimes noted as PERRLA: pupils equal, round, and reactive to light and accommodation.)<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\"><strong>Abnormal findings<\/strong> might be documented as: \u201cNo direct or consensual light reflex noted bilaterally.\u201d<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<div class=\"textbox shaded\">\n<h2 style=\"text-align: center\"><span style=\"color: #000000\"><strong>Contextualizing Inclusivity<\/strong><\/span><\/h2>\n<p><span style=\"color: #000000\">It can be difficult to evaluate the pupil size and pupillary constriction in clients with dark irises. If necessary, ask them to look up while doing the assessment; this can help. Alternatively, use a second penlight and shine the light tangentially to highlight the iris without causing an unintentional pupillary reflex.<\/span><\/p>\n<\/div>\n<div>\n<div class=\"textbox textbox--learning-objectives\">\n<header class=\"textbox__header\">\n<h2 style=\"text-align: center\">Prioritizing Care<\/h2>\n<\/header>\n<div class=\"textbox__content\">\n<p><span style=\"color: #000000\">One serious finding is a<strong> \u201cblown\u201d <\/strong><strong>pupil<\/strong>: the pupil is dilated and also fixed and unresponsive. This condition resembles mydriasis, as shown above in <strong>Figure 15<\/strong>; it is often associated with brain herniation, meaning the brain tissue shifts due to increased intracranial pressure. Brain herniation can be related to various pathophysiological processes such as brain trauma, stroke, aneurysm, or tumour. New onset of unilateral or bilateral fixed and dilated pupils should be immediately reported to the physician or nurse practitioner: as the nurse you should stay with the client and complete a primary survey.<\/span><\/p>\n<p><span style=\"color: #000000\"><strong>Anisocoria<\/strong> (unequal pupil size) <strong>Figure 16<\/strong>, image below, does not require treatment unless it is new onset. Many clients have unequal pupil size, but new onset anisocoria may be of concern because it can be associated with neurological problems, stroke, infection, or eye trauma. Complete a focused assessment and report the findings to the physician or nurse practitioner.<\/span><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/anisocoria-e1724550155374-300x161.jpg\" alt=\"\" width=\"300\" height=\"161\" class=\"wp-image-3331 size-medium aligncenter\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/anisocoria-e1724550155374-300x161.jpg 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/anisocoria-e1724550155374-65x35.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/anisocoria-e1724550155374-225x120.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/anisocoria-e1724550155374-350x187.jpg 350w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/08\/anisocoria-e1724550155374.jpg 413w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/p>\n<p><span style=\"color: #000000\"><strong>Figure 16<\/strong>: By Tair1978 &#8211; Own work,<\/span> <a href=\"https:\/\/en.wikipedia.org\/wiki\/en:Creative_Commons\" target=\"_blank\" rel=\"noopener\">Creative Commons<\/a> <a href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/deed.en\" target=\"_blank\" rel=\"noopener\">Attribution-Share Alike 4.0 International<\/a> <span style=\"color: #000000\">license, from:<\/span> <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=82053909\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=82053909<\/a><span style=\"color: #000000\">).<\/span><\/p>\n<\/div>\n<\/div>\n<\/div>\n<h2><span style=\"color: #000000\"><strong>Activity: Check Your Understanding<\/strong><\/span><\/h2>\n<div class=\"postbox h5p-sidebar\">\n<div class=\"h5p-action-bar-settings h5p-panel\">\n<div id=\"h5p-265\">\n<div class=\"h5p-iframe-wrapper\"><iframe id=\"h5p-iframe-265\" class=\"h5p-iframe\" data-content-id=\"265\" style=\"height:1px\" src=\"about:blank\" frameBorder=\"0\" scrolling=\"no\" title=\"External Eye Assessment and Anterior Eyeball Assessment HP5\"><\/iframe><\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"glossary\"><div class=\"glossary__tooltip\" id=\"2994-3356\" hidden><p>are the opening\/space between the upper and lower eyelids.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"2994-3357\" hidden><p>refers to the border between the cornea and the sclera, looks like a darker ring around the iris.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"2994-3358\" hidden><p>is a disease involving an overactive thyroid gland leading to high levels of thyroid hormone in the blood.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"2994-129\" hidden><p>A general term referring to an abnormal appearance or growth.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"2994-3359\" hidden><p>are flat, irregular shaped macula that are slightly darker than the client's normal skin colour and found on sun-exposed areas of the body.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"2994-3360\" hidden><p>are small, red, and painful bumps on the eyelid often caused by bacterial infections (commonly called styes).<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"2994-3361\" hidden><p>small red and swollen bumps, sometimes painful, caused by blocked oil glands that clog up.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"2994-3325\" hidden><p>refers to the drooping of the upper eyelid over the eye.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"2994-3362\" hidden><p>refers to excessive constriction of pupil.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"2994-3363\" hidden><p>refers to excessive dilation of the pupil.<\/p>\n<\/div><\/div>","protected":false},"author":34,"menu_order":6,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-2994","chapter","type-chapter","status-publish","hentry"],"part":1653,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/2994","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/users\/34"}],"version-history":[{"count":54,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/2994\/revisions"}],"predecessor-version":[{"id":3975,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/2994\/revisions\/3975"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/parts\/1653"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/2994\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/media?parent=2994"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapter-type?post=2994"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/contributor?post=2994"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/license?post=2994"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}