Eye assessment

Figure 7.2  

Figure 7.3  

Do first

Do not

  • If suspected or actual penetrating eye injury — do not put drops in eye
  • Do not give anaesthetic eye drops to take home
    • Numb eyes are easily damaged without person knowing it
    • Healing is slower and can lead to corneal ulcers

Ask

  • History of problem — one or both eyes, what happened (eg trauma/injury) and when, eg fast or slow onset
  • Problems with vision — near and distant, loss of sight, double or blurred vision, flashes of light, floaters (small moving objects in vision), haloes (fuzzy lights around objects)
  • Sore, scratchy, itchy, watery, pussy eyes
  • Hammering, grinding, welding, using air compressor or chemicals in last few days
  • Eye problems in past — injury, cataracts, eye surgery
  • Do they have glasses or contact lenses

Check both eyes

Use good light during examination and magnification if available — 2.5 magnification head loupes, ophthalmoscope, slit lamp, torch

  • Check near and distance vision (visual acuity)
  • Do eyes look straight or is one turned — squint, strabismus
  • Look at outside of eyelids and eyeball — oedema (swollen), erythema (red), sunken, pussy, teary, cuts and bruises
  • If eye too painful to examine properly — use 2 drops of topical local anaesthetic, eg tetracaine (amethocaine) or oxybuprocaine
    • Warn it will sting for a few seconds before numbing eye
    • Put on eye pads until local anaesthetic drops have worn off — try to leave on for 1–2 hours but at least 20 minutes 
  • Medical consult if
    • You can not examine eye properly — may need to send to hospital
    • Examination reveals abnormalities not covered by eye protocols, eg uncommon single red eye

Cornea (eye surface)

  • From about 30cm — shine a bright light all over cornea and watch for light reflection off the surface. Note if cornea is clear or cloudy
    • If defect — light reflex will be broken up and uneven
  • If you suspect abrasion (cut ) or defect or not sure — use fluorescein stain
    • Damage to eye surface shows up as a green patch
    • Serious injury to cornea may just look like a heavy fluorescein layer (green stain) — may need to put fluorescein stain in good eye to compare
    • Seen best with opthalmoscope blue light

Anterior eye

  • Check conjunctiva (covering over white of the eye) for redness, inflammation, foreign bodies
  • Check lower eyelid for any redness or discharge, eg pus
  • Check white of eye for redness or bleeding — subconjunctival haemorrhage
    • If you can't see the back edge of blood —  Figure 7.4 — may be skull fracture
    • If history suggests significant trauma — medical/specialist consult

Figure 7.4  

Anterior chamber 

  • Check for hyphema (layer of blood) or hypopyon (pus) — where blood or pus settles depends on the position head has been in
    • If person has been sitting or standing — settles on bottom of iris —  Figure 7.5
    • If person has been lying down, sleeping — settles on side of iris — Figure 7.6

Figure 7.5  

Figure 7.6  

Pupil tests

  • Ask person to look straight ahead into distance — shine bright test light into eye from below line of sight. Move light between eyes
  • Discourage person looking at the light — this will cause pupil constriction and confuse the results
  • Check size, shape and reaction to light 
    • Check for direct response — pupil with light shining in it constricts (quickly shrinks)
    • Check for consensual (involuntary) response — pupil without light shining in it shrinks the same amount at the same time as other pupil
  • Check for relative afferent pupillary defect
    • Shine light repeatedly from one eye to the other (swinging flashlight test). Count to 3 before swinging between eyes
    • Look at pupil response as light moves onto each eye — should be same for each pupil
    • If one pupil gets bigger rather than staying small — relative afferent pupil defect (RAPD) — optic nerve on this side not working properly
    • If RAPD not noted before — medical consult to find cause

Eye movements

  • Ask person to look up, down, left and right
    • Ask person if they get double vision while doing this
    • Watch to see if both eyes move in the same direction
  • In facial trauma difficulty looking up may mean cracks or an orbital blow-out fracture (breaks in bone around eye)

Upper eyelid

  • Evert eyelid — unless something penetrating eye
    • Look for subtarsal and non-penetrating foreign bodies (anything stuck to inside of eyelid or surface of eye)
    • Check for trachoma follicles or scarring

Supporting resources