Evaluation of Eye
Pathologies
Orthopedic Assessment III – Head,
Spine, and Trunk with Lab
PET 5609C
Clinical Evaluation
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History:
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Location and Description of the Symptoms:
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Complaints of scratchiness or “something in the eye”
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Photophobia
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Foreign body
Displaced contact lens
Corneal Abrasion – painful scrape or scratch of the corneal
epithelium
Intolerance to light
Itching of the eye
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Chemosis – edema of the conjunctiva
 Allergies
Clinical Evaluation
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Photophobia – sensitivity to light
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Greater Risk: People with…
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Often a symptom of another
underlying problem:
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Lighter-colored eyes
Cataracts
Migraine headaches
Corneal abrasion
Uveitis
Meningitis
Retinal detachment
Contact lens irritations
Often accompanies:
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Albinism
Total color deficiency (seeing grey)
Botulism, rabies
Conjunctivitis, keratitis and iritis
Clinical Evaluation
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Mechanism of Injury:
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Striking Object:
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Size / Elastic properties
Basketball, baseball, golf
ball
Head, elbow, fist, finger
Chemicals / Foreign
Substances:
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Dirt and sand
Lime (playing field)
Mechanism of Injury
Size Relative
to the Orbit
Elastic
Property
Resulting Pathology
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
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Inspection of Periorbital
Area:
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Discoloration
Orbital Hematoma (black eye)
Gross deformity
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Immediate referral
Lacerations
Clinical Evaluation
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Inspection of the Globe:
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General Appearance:
How does it sit within the
orbit relative to uninvolved
side?
 Displaced:
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Medially, Inferiorly
Posteriorly
(Enophthalmos)
Anteriorly
(Exophthalmos)
Clinical Evaluation
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Inspection: Eyelids
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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
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Inspection: Cornea
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Crystal clear
Discoloration –
Referral to
ophthalmologist
Hyphema – collection
of blood within
anterior chamber of
eye
Clinical Evaluation
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Inspection: Conjunctiva
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Appearance should be
transparent (covers sclera)
Subconjunctival
Hematoma – leakage of
the superficial blood
vessels beneath the sclera
Examination
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Inferior portion – gently pull
down on the eyelid, patient
looks up
Upper portion – gently lift
upper eyelid, patient looks
down
Clinical Evaluation
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Inspection: Sclera
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Any abnormalities?
Appearance of black
object – may be inner
tissue of eye bulging
through a wound
Inspection: Iris
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Iritis – inflammation of
iris
Clinical Evaluation
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Inspection: Pupils
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Normally equal in size
and shape
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Anisocoria – unequal
pupil sizes
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Benign congenital
condition
Secondary to Brain
Trauma
Teardrop pupil
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Serious underlying
pathology (corneal
laceration, ruptured
globe)
Clinical Evaluation
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Palpation:
Do NOT palpate globe
 Superficial bony structures and soft tissue
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Orbital Margin (circumference of orbital rim)
 Frontal bone
 Nasal Bone
 Zygomatic bone
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Functional Testing
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Vision Assessment:
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Performed one eye than with both
eyes
Prescribed glasses/contacts worn
during assessment
Findings:
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Diplopia – double vision
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Can indicate orbital fracture, brain
trauma, damage to optic or cranial
nerves
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Blurred vision
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Loss of portions of visual field
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“A shade is being pulled over the
eye”
Can indicate a detached retina
Functional Testing
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Myopia:
Nearsightedness
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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
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Hypermetropia:
Farsightedness
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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
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Pupil Reaction to Light:
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Penlight - shine light into pupil for 1
sec. with opposite eye covered
Observe for pupil restriction and
dilation
Repeated on opposite eye
Positive Test:
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Pupil unresponsive to light
Pupil sluggish compared to opposite
side
Indicative of mechanical or
neurological deficit of iris
 Head Injury
Functional Testing
Functional Testing
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Inspection of Eyes – Head
Injury
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Eyes appearance
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Nystagmus – involuntary
cyclical movement
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Dazed, distant
Pressure on eyes’ motor nerves or
disruption of inner ear
Pupil Size
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Are they equal?
Unilaterally dilated pupil →
intracranial hemorrhage (pressure
on cranial nerve III)
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Anisocoria – unequal pupil size
(may be normal for athlete –
preparticipation exam)
Pupil Reaction to Light
Functional Testing
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Eye Motility Test:
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Eyes ability to perform complete sweep
of ROM (smooth and symmetrical)
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ATC stands in front of athlete and holds
finger 2 ft. from patient’s nose
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Evaluation Procedure:
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Patient focuses on finger and reports any
double vision
Finger moved ↑, ↓, →, ←
Finger moved through diagonal fields
Positive Test:
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Asymmetrical tracking
Double vision
Neurological Testing
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Cranial Nerve II – Optic
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Vision Assessment → Snellen’s
Chart
Cranial Nerve III –
Oculomotor
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Assessment:
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Cranial Nerve IV – Trochlear
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Assessment:
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Pupil reaction to light
Elevation of upper eyelid
Eye adduction and downward
rolling
Upward eye rolling
Cranial Nerve VI – Abducens
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Assessment:
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Lateral eye movement
Eye Pathologies
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Orbital Fractures:
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MOI: blow from an object
that is usually larger than the
orbit (frontal, zygomatic,
maxillary bone)
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↑ 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
Blow-up fracture – fx. of
orbital roof
Object striking the eye causes
the globe to expand downward,
rupturing the orbital floor.
Eye Pathologies
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Orbital Fractures:
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Inspection:
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Ecchymosis, swelling
Eye may appear sunken
inferiorly or posteriorly into
the socket
Eye may bulge outward or be
medially displaced
Associated lacerations
Palpation:
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Possible tenderness in
periorbital area
Possible numbness in lateral
nose and cheek (infraorbital
nerve entrapment)
Eye Pathologies
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Orbital Fracture:
Functional Testing
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Vision:
Diplopia
 Blurred vision
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Eye Motility:
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Limited ability to look
upward – entrapment of
the inferior rectus muscle
Eye Pathologies
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Orbital Fracture:
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Neurological Testing:
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Special Tests:
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Sensory testing of the cheek and
lateral nose (entrapment of
infraorbital nerve)
X-rays
CT scan
MRI
Special Note: Athlete should
refrain from blowing nose
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Air escapes nasal passage,
enters the orbit, and exits from
under the eyelid
Radiograph of blow out fracture
to the left orbit, with inferior
orbital contents herniating into
the maxillary antrum (arrow)
Eye Pathologies
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Corneal Abrasion –
Scratching of the eye
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MOI:
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External force striking
the eye
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Foreign object in eye
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Finger (poked 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
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Corneal Abrasion:
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Inspection:
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Tearing (attempt to wash particles from eye)
Conjunctival redness
Presence of foreign object
Functional Tests:
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Sensitivity to light
Blurred vision
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May be secondary to eye watering
Special Tests:
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Fluorescent strips and cobalt blue light
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Only cells suffering the abrasion will absorb the dye
Eye Pathologies
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Fluorescent Dye Test:
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Procedure:
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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
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Corneal Abrasion:
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Immediate Referral:
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Patch the eye
Refer to physician
Eye Pathologies
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Corneal Laceration:
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Partial – does NOT violate
the globe
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Similar signs/symptoms of
abrasion
Actual trauma may be
visible
Full-Thickness –
penetrates through the
cornea
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Aqueous humor may escape
the anterior chamber
Cornea may appear flat
Irregular shaped pupil
(teardrop distortion)
Eye Pathologies
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Iritis – inflammatory reaction within anterior
chamber; “Red Eye” appearance
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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
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Eye Pathologies
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Iritis: Symptoms
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Functional Testing:
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Pain
Photophobia
Blurred vision; headache
↑ tear production
Sluggishly reactive to light
Neurological Testing:
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Cranial Nerve III
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Pupil reaction to light
Note: Refer to
Ophthalmologist
Eye Pathologies
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Detached Retina:
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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:
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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
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Usually will separate without causing problems
If it pulls hard enough it can tear the retina
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Fluid may pass through the tear - lifting the retina off the back of the eye
Increased risk for retinal detachment:
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Nearsighted or family hx.
Previous cataract surgery or glaucoma
Previous retinal detachment (other eye)
Eye Pathologies
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Detached Retina:
Symptoms
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Flashing lights
New floaters
Description of a “Gray
curtain moving across field
of vision”
Treatment:
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Almost all patients with
retinal detachments require
surgery
Eye Pathologies
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Ruptured Globe:
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Most catastrophic injury to eye
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MOI:
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Severe blunt trauma (orbital rim dissipates little/no force)
Resulting rupture of cornea/sclera
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Contents are spilled
Inspection:
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Deformed globe / Deepened anterior chamber
Hyphema
Presence of black, coffee-ground like substance within
anterior chamber (spilled contents of globe)
Eye Pathologies
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Ruptured Globe:
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Treatment:
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Immediate
transportation to
hospital
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Cover eye with shield
Do NOT administer
any eye drops or allow
athlete to eat/drink
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Immediate surgery may
be needed
Eye Pathologies
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Conjunctivitis:
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Result of viral/bacterial infection of conjunctiva
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Onset/Description of Symptoms:
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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
1st thing in morning – eyelids may stick together
Itching, burning
Inspection:
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Discharge:
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Clear, watery – viral infection (Pink Eye)
Yellow or green – bacterial infection
Eye Pathologies
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Conjunctivitis:
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Functional Tests:
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Special Notes:
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Impaired vision
Highly contagious
Infected person – no
physical contact with other
athletes
Treatment:
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No contact lenses
Refer to physician
Eye Pathologies
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Foreign Bodies:
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Usually benign
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Clears once object is removed
Removal:
Flushed with saline or water
 Moistened cotton applicator may be used
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Do NOT use dry cotton
Instruct athlete to avoid rubbing the eye
Eye Pathologies
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Penetrating Eye Injuries:
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Do NOT attempt to
remove the object
Do NOT apply direct
pressure on the eye
Shield the eye
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If object is protruding far
from the eye, use a
paper/plastic cup to cover
Immediate transportation
to hospital
Eye Pathologies
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Chemical Burns:
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Rinse eye with large
amounts of saline
and/or water
Patch the eye
Transport immediately
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Eye Shields:
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Protection of the eye
for transport
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Athlete should be
instructed to close the
uninvolved eye or look
straight ahead
 Eyes move in unison
Contact Lens Removal
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Hard Lenses Removal:
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Open eyes wide
Laterally pull outer margin of
eyelids
Patient blinks, forcing lens out
Soft Lenses Removal:
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Patient looks up
Clean finger placed on inferior
edge of lens
Lens manipulated inferiorly and
laterally
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Pinch between fingers