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Evaluation of Eye

Pathologies
Orthopedic Assessment III – Head,
Spine, and Trunk with Lab
PET 5609C
Clinical Evaluation
 History:
 Location and Description of the Symptoms:
 Complaints of scratchiness or “something in the eye”
 Foreign body
 Displaced contact lens
 Corneal Abrasion – painful scrape or scratch of the corneal
epithelium
 Photophobia
 Intolerance to light
 Itching of the eye
 Chemosis – edema of the conjunctiva
 Allergies
Clinical Evaluation
 Photophobia – sensitivity to light
 Greater Risk: People with…
 Lighter-colored eyes
 Cataracts
 Migraine headaches
 Often a symptom of another
underlying problem:
 Corneal abrasion
 Uveitis
 Meningitis
 Retinal detachment
 Contact lens irritations
 Often accompanies:
 Albinism
 Total color deficiency (seeing grey)
 Botulism, rabies
 Conjunctivitis, keratitis and iritis
Clinical Evaluation
 Mechanism of Injury:
 Striking Object:
 Size / Elastic properties
 Basketball, baseball, golf
ball
 Head, elbow, fist, finger
 Chemicals / Foreign
Substances:
 Dirt and sand
 Lime (playing field)
Mechanism of Injury
Size Relative Elastic Resulting Pathology
to the Orbit Property
Larger Hard Orbital fracture, periorbital contusion

Larger Elastic Blow-out fracture, ruptured globe,


corneal abrasion, traumatic iritis,
periorbital contusion
Smaller Hard Ruptured globe, corneal abrasion,
corneal laceration, traumatic iritis

Smaller Elastic Ruptured globe, blow-out fracture,


corneal abrasion, traumatic iritis
Clinical Evaluation
 Inspection of Periorbital
Area:
 Discoloration
 Orbital Hematoma (black eye)
 Gross deformity
 Immediate referral
 Lacerations
Clinical Evaluation
 Inspection of the Globe:
 General Appearance:
 How does it sit within the
orbit relative to uninvolved
side?
 Displaced:
 Medially, Inferiorly
 Posteriorly
(Enophthalmos)
 Anteriorly
(Exophthalmos)
Clinical Evaluation
 Inspection: Eyelids
 Swelling
 Ecchymosis
 Lacerations
 Stye – infection of a ciliary
gland (form of sweat gland on
the eyelid) or sebaceous gland
(oil-secreting skin gland)
Clinical Evaluation
 Inspection: Cornea
 Crystal clear
 Discoloration –
Referral to
ophthalmologist
 Hyphema – collection
of blood within
anterior chamber of
eye
Clinical Evaluation
 Inspection: Conjunctiva
 Appearance should be
transparent (covers sclera)
 Subconjunctival
Hematoma – leakage of
the superficial blood
vessels beneath the sclera
 Examination
 Inferior portion – gently pull
down on the eyelid, patient
looks up
 Upper portion – gently lift
upper eyelid, patient looks
down
Clinical Evaluation
 Inspection: Sclera
 Any abnormalities?
 Appearance of black
object – may be inner
tissue of eye bulging
through a wound
 Inspection: Iris
 Iritis – inflammation of
iris
Clinical Evaluation
 Inspection: Pupils
 Normally equal in size
and shape
 Anisocoria – unequal
pupil sizes
 Benign congenital
condition
 Secondary to Brain
Trauma
 Teardrop pupil
 Serious underlying
pathology (corneal
laceration, ruptured
globe)
Clinical Evaluation
 Palpation:
 Do NOT palpate globe
 Superficial bony structures and soft tissue
 Orbital Margin (circumference of orbital rim)
 Frontal bone

 Nasal Bone

 Zygomatic bone
Functional Testing
 Vision Assessment:
 Performed one eye than with both
eyes
 Prescribed glasses/contacts worn
during assessment
 Findings:
 Diplopia – double vision
 Can indicate orbital fracture, brain
trauma, damage to optic or cranial
nerves
 Blurred vision
 Loss of portions of visual field
 “A shade is being pulled over the
eye”
 Can indicate a detached retina
Functional Testing
 Myopia:
Nearsightedness
 Light rays converge at a
point before reaching the
retina instead of focusing
on the retina
 Only the objects close to
the eyes are
distinguishable
 Distant objects hard to
see
 Most common vision
problem worldwide
Emmetropia - 20/20 Vision:
Ability to read the letters on the 20 ft line of an eye
chart when standing 20 ft from the chart
Functional Testing
 Hypermetropia:
Farsightedness
 Distant object
becomes focused
behind the retina
 Close objects appear
out of focus and may
cause headaches, eye
strain, and/or fatigue
 Squinting, eye
rubbing, difficulty in
reading
Functional Testing
 Pupil Reaction to Light:
 Penlight - shine light into pupil for 1
sec. with opposite eye covered
 Observe for pupil restriction and
dilation
 Repeated on opposite eye
 Positive Test:
 Pupil unresponsive to light
 Pupil sluggish compared to opposite
side
 Indicative of mechanical or
neurological deficit of iris
 Head Injury
Functional Testing
Functional Testing
 Inspection of Eyes – Head
Injury
 Eyes appearance
 Dazed, distant
 Nystagmus – involuntary
cyclical movement
 Pressure on eyes’ motor nerves or
disruption of inner ear
 Pupil Size
 Are they equal?
 Unilaterally dilated pupil →
intracranial hemorrhage (pressure
on cranial nerve III)
 Anisocoria – unequal pupil size
(may be normal for athlete –
preparticipation exam)
 Pupil Reaction to Light
Functional Testing
 Eye Motility Test:
 Eyes ability to perform complete sweep
of ROM (smooth and symmetrical)
 ATC stands in front of athlete and holds
finger 2 ft. from patient’s nose
 Evaluation Procedure:
 Patient focuses on finger and reports any
double vision
 Finger moved ↑, ↓, →, ←
 Finger moved through diagonal fields
 Positive Test:
 Asymmetrical tracking
 Double vision
Neurological Testing
 Cranial Nerve II – Optic
 Vision Assessment → Snellen’s
Chart
 Cranial Nerve III –
Oculomotor
 Assessment:
 Pupil reaction to light
 Elevation of upper eyelid
 Eye adduction and downward
rolling
 Cranial Nerve IV – Trochlear
 Assessment:
 Upward eye rolling
 Cranial Nerve VI – Abducens
 Assessment:
 Lateral eye movement
Eye Pathologies
 Orbital Fractures:
 MOI: blow from an object
that is usually larger than the
orbit (frontal, zygomatic,
maxillary bone)
 ↑ intraorbital pressure – orbital
bones break at weakest point
 Compression of inferior orbital
rim causes direct buckling of
the floor
 Blow-out fracture – fx. of
medial wall or floor Object striking the eye causes
 Blow-up fracture – fx. of the globe to expand downward,
rupturing the orbital floor.
orbital roof
Eye Pathologies
 Orbital Fractures:
 Inspection:
 Ecchymosis, swelling
 Eye may appear sunken
inferiorly or posteriorly into
the socket
 Eye may bulge outward or be
medially displaced
 Associated lacerations
 Palpation:
 Possible tenderness in
periorbital area
 Possible numbness in lateral
nose and cheek (infraorbital
nerve entrapment)
Eye Pathologies
 Orbital Fracture:
Functional Testing
 Vision:
 Diplopia
 Blurred vision

 Eye Motility:
 Limited ability to look
upward – entrapment of
the inferior rectus muscle
Eye Pathologies
 Orbital Fracture:
 Neurological Testing:
 Sensory testing of the cheek and
lateral nose (entrapment of
infraorbital nerve)
 Special Tests:
 X-rays
 CT scan
 MRI
 Special Note: Athlete should
refrain from blowing nose Radiograph of blow out fracture
 Air escapes nasal passage, to the left orbit, with inferior
enters the orbit, and exits from orbital contents herniating into
under the eyelid the maxillary antrum (arrow)
Eye Pathologies
 Corneal Abrasion –
Scratching of the eye
 MOI:
 External force striking
the eye
 Finger (poked in eye)
 Foreign object in eye
 Sand, dirt, paint chip
 Contact lenses – wearing
longer than
recommended
 Athlete reports feeling of
“something in the eye” Note: Under normal conditions,
the abrasion is not visible to the
unaided eye.
Eye Pathologies
 Corneal Abrasion:
 Inspection:
 Tearing (attempt to wash particles from eye)
 Conjunctival redness
 Presence of foreign object
 Functional Tests:
 Sensitivity to light
 Blurred vision
 May be secondary to eye watering
 Special Tests:
 Fluorescent strips and cobalt blue light
 Only cells suffering the abrasion will absorb the dye
Eye Pathologies
 Fluorescent Dye Test:
 Procedure:
 Soak the fluorescent strip
with saline
 Lightly tough the strip to
the conjunctiva of the
lower eyelid (hold for a
few seconds)
 Have patient blink a few
times – will spread the
dye
 Darken room, use cobalt
blue light
Eye Pathologies
 Corneal Abrasion:
 Immediate Referral:
 Patch the eye
 Refer to physician
Eye Pathologies
 Corneal Laceration:
 Partial – does NOT violate
the globe
 Similar signs/symptoms of
abrasion
 Actual trauma may be
visible
 Full-Thickness –
penetrates through the
cornea
 Aqueous humor may escape
the anterior chamber
 Cornea may appear flat
 Irregular shaped pupil
(teardrop distortion)
Eye Pathologies
 Iritis – inflammatory reaction within anterior
chamber; “Red Eye” appearance
 MOI:
 Blunt trauma (traumatic iritis)
 Nontraumatic iritis – frequently associated with
certain systemic diseases (tuberculosis, inflammatory
bowel disease, psoriasis)
 Infectious causes – Lyme disease, TB, syphilis,
herpes simplex
Eye Pathologies
 Iritis: Symptoms
 Pain
 Photophobia
 Blurred vision; headache
 ↑ tear production
 Functional Testing:
 Sluggishly reactive to light
 Neurological Testing:
 Cranial Nerve III
 Pupil reaction to light
 Note: Refer to
Ophthalmologist
Eye Pathologies
 Detached Retina:
 Anatomy review: Retina - nerve layer at the back of your eye (senses
light and sends images to your brain)
 Does not work when detached; almost always causes blindness if left
untreated
 MOI:
 Jarring force to the head
 Aging Process - As we age, the vitreous (clear gel that fills the eye) can
pull away from its attachment to the retina at the back of the eye
 Usually will separate without causing problems
 If it pulls hard enough it can tear the retina
 Fluid may pass through the tear - lifting the retina off the back of the eye
 Increased risk for retinal detachment:
 Nearsighted or family hx.
 Previous cataract surgery or glaucoma
 Previous retinal detachment (other eye)
Eye Pathologies
 Detached Retina:
Symptoms
 Flashing lights
 New floaters
 Description of a “Gray
curtain moving across field
of vision”
 Treatment:
 Almost all patients with
retinal detachments require
surgery
Eye Pathologies
 Ruptured Globe:
 Most catastrophic injury to eye
 MOI:
 Severe blunt trauma (orbital rim dissipates little/no force)
 Resulting rupture of cornea/sclera
 Contents are spilled
 Inspection:
 Deformed globe / Deepened anterior chamber
 Hyphema
 Presence of black, coffee-ground like substance within
anterior chamber (spilled contents of globe)
Eye Pathologies
 Ruptured Globe:
 Treatment:
 Immediate
transportation to
hospital
 Cover eye with shield
 Do NOT administer
any eye drops or allow
athlete to eat/drink
 Immediate surgery may
be needed
Eye Pathologies
 Conjunctivitis:
 Result of viral/bacterial infection of conjunctiva
 Inflammatory causes such as chemicals, fumes, dust, and debris
 Allergies
 Injuries
 Oral genital contact with someone who might be infected with a
sexually transmitted disease (STD) such as chlamydia,
gonorrhea, or herpes
 Onset/Description of Symptoms:
 1st thing in morning – eyelids may stick together
 Itching, burning
 Inspection:
 Discharge:
 Clear, watery – viral infection (Pink Eye)
 Yellow or green – bacterial infection
Eye Pathologies
 Conjunctivitis:
 Functional Tests:
 Impaired vision
 Special Notes:
 Highly contagious
 Infected person – no
physical contact with other
athletes
 Treatment:
 No contact lenses
 Refer to physician
Eye Pathologies
 Foreign Bodies:
 Usually benign
 Clears once object is removed
 Removal:
 Flushed with saline or water
 Moistened cotton applicator may be used
 Do NOT use dry cotton
 Instruct athlete to avoid rubbing the eye
Eye Pathologies
 Penetrating Eye Injuries:
 Do NOT attempt to
remove the object
 Do NOT apply direct
pressure on the eye
 Shield the eye
 If object is protruding far
from the eye, use a
paper/plastic cup to cover
 Immediate transportation
to hospital
Eye Pathologies
 Chemical Burns:  Eye Shields:
 Rinse eye with large  Protection of the eye
amounts of saline for transport
and/or water  Athlete should be
 Patch the eye instructed to close the
uninvolved eye or look
 Transport immediately straight ahead
 Eyes move in unison
Contact Lens Removal
 Hard Lenses Removal:
 Open eyes wide
 Laterally pull outer margin of
eyelids
 Patient blinks, forcing lens out
 Soft Lenses Removal:
 Patient looks up
 Clean finger placed on inferior
edge of lens
 Lens manipulated inferiorly and
laterally
 Pinch between fingers