2 8.6 Inspection of Eyes

Begin the assessment by inspecting the eyes. The patient should demonstrate behavioral cues indicating effective vision during the assessment. Pupillary Response, Extraocular Movement, and Cranial Nerves (This will be covered during your NEUROLOGICAL Assessment Content and Lab)

Eye Inspection Assessment Method

1. General Inspection

Method: Begin by observing the patient’s eyes for symmetry, position, and overall appearance.

Normal Findings:

• Eyes are symmetric in size and position, and appropriately placed in orbits.
• No visible swelling, redness, or discharge.
• Eyes are aligned.

Abnormal Findings:

• Asymmetry in eye size or position (may indicate underlying pathology).
• Sunken eyes can indicate dehydration, protrusion of eyes (exophthalmos) can indicate thyroid disease.
• Swelling, redness, or discharge (could suggest infection, inflammation, or injury).
• Strabismus (eyes do not align when looking at an object).

2. Eyelids and Lashes

Method: Inspect the upper and lower eyelids for color, swelling, lesions, and the position of the eyelashes.

Normal Findings:

• Eyelids are smooth, with even coloration.
• Lashes are evenly distributed and curve outward with no redness or drainage at lid margin.
• Eyelids approximate when closed.
• Yellow plaque occurring on lids (xanthelasma) in older adults, no clinical significance.

Abnormal Findings:

• Redness, swelling, or lesions (may indicate infection like blepharitis or a stye).
• Lashes turning inward (entropion) or outward (ectropion).

3. Conjunctiva and Sclera

Method: Ask the patient to look up while gently pulling down the lower eyelid to expose the conjunctiva. Observe the color and clarity of the sclera.

Normal Findings:

• Conjunctiva is pink and moist.
• Sclera is white and clear.

Abnormal Findings:

• Conjunctiva appears red or pale (redness may indicate conjunctivitis, pale conjunctiva may suggest anemia).
• Sclera appears yellow (jaundice) or has visible blood vessels (subconjunctival hemorrhage).

4. Cornea and Lens

Method: Shine a light across the cornea and lens to assess their clarity.

Normal Findings:

• Cornea is clear and smooth.
• Lens is transparent.

Abnormal Findings:

• Corneal cloudiness or opacities (may indicate corneal scarring or keratitis).
• Lens opacities (cataracts).

5. Iris and Pupil

Method: Observe the color and shape of the iris. In a dimly lit room, shine a penlight into one pupil and observe the direct response (pupil constriction) and the consensual response (pupil constriction in the opposite eye).

Normal Findings:

• Iris color is consistent, with no irregularities.
• Pupils are round, equal in size (3-5 mm) (PER), and reactive to light (constrict in response to light) (RL).

Abnormal Findings:

• Irregular iris shape or color variations (may indicate trauma or congenital issues).
• Pupils are unequal (anisocoria), non-reactive, or dilated (could suggest neurological issues or drug effects).
• Miosis: Pupils are abnormally small (less than 2 mm) and may indicate opioid use, pontine hemorrhage, or other central nervous system disorders.
• Mydriasis: Pupils are abnormally large (greater than 5 mm) and may suggest drug use (stimulants), trauma, or neurological disorders.

6. Accommodation Reflex

Method: Ask the patient to focus on a distant object, then quickly shift their gaze to a near object (e.g., your finger held about 6 inches from their nose). Observe the pupils’ reaction.

Normal Findings:

• Pupils constrict when focusing on a near object (accommodation) (A).
• Pupils dilate when shifting focus back to a distant object.

Abnormal Findings:

• Failure to Constrict: Inability of the pupils to constrict when focusing on a near object may indicate a problem with the oculomotor nerve or conditions such as Adie’s pupil.
• Poor Accommodation: Difficulty in focusing on near objects can be a sign of presbyopia or neurological impairment.

When a patient is suspected of experiencing a neurological disease or injury, their pupils are assessed to ensure they are bilaterally equal, round (PER), and responsive to light (RL), and accommodation (A), commonly referred to as (PERRLA). Extraocular movement and other cranial nerves that affect vision hearing and balance may also be assessed. For more information about how to assess PERRLA, extraocular eye movement, and other cranial nerves, go to the Assessing Cranial Nerves section in the Neurological Assessment chapter.

7. Extraocular Muscles (EOM)

Method: Ask the patient to follow your finger or a penlight in an “H” pattern to test the six cardinal fields of gaze.

Normal Findings:

• Eyes move smoothly and symmetrically in all directions.
•  No nystagmus (involuntary eye movement).

Abnormal Findings:

• Limited eye movement in one or more directions (may suggest cranial nerve damage).
•  Presence of nystagmus.

8. Visual Acuity

Method: Test visual acuity using a Snellen chart (for distance vision) or a near vision card. In outpatient settings, near vision may be assessed using a prepared card or a newspaper. Color vision may be assessed using a book containing Ishihara plates.

Normal Findings:

• 20/20 vision (patient can read at 20 feet what a person with normal vision can read at 20 feet).

Abnormal Findings:

• Vision less than 20/20 (may require further evaluation for refractive errors).