Assessment Tests (Special Tests) Visual Acuity – Used to determine vision. Most important part of an eye exam. Critical to assess pre-participation and immediately after injury. Assessed while wearing glasses or contacts for distance vision. Scored as a fraction of a standard for normal performance. Known as a Snellen Visual Acuity from a chart placed 20ft away. The numerator is the distance a normal person could read the same sized letters. Each eye is assessed independently by occluding (covering) the other eye. Children and no-readers use picture charts. In the absence of near vision cards (business cards, etc) can be used. When an injured player cannot see the largest letters, hold up fingers. Documentation is # of fingers at ___ distance (ft). If they cannot do that, wave the hand, documented as hand motion vision. If they cannot detect motion, any bright light source can be used. Documented as light perception vision. NOTE: Reduction in visual acuity in an injured eye is an ocular emergency. Pupilary Responses – Used to determine normal neural, iris, and ciliary body function. Pupilary reaction to light is normal. While the patient is looking into the distance, move a light in toward the eye from the side and shine directly onto the pupil. The speed (briskness) of contraction is noted. Examine each eye separately and compare. This is reactivity and responsiveness. Swing a light from the good to the injured eye, if the injured eye appears to dilate, this is known as afferent pupilary defect and may mean that a different amount of light is being transmitted through the optic nerve – serious. Larger pupils or unreactive pupils or no longer round pupils signals significant ocular trauma. A congenital large pupil on one side is called ansicoria. Eye Movement – Used to determine limitations of ocular movement from neural, muscular, and possibly bony conditions. Also called ocular motility. An inability to move into cardinal fields of gaze and indicates severe injury with possible bony or muscular pathology or entrapment. Have the patient follow your finger tip up, down, left, right, and oblique for both eyes together. Assess for smooth, uninterrupted movement. When the eyes do not move synchronously, patients usually complain of double vision (diplopia). Peripheral Vision – Used to determine neural or retinal detection of peripheral fields of vision. To test the right eye, sit in front of the patient 3 ft. away. Occlude the left eye and have them look at your left eye (examiner closes right eye). Hold up 1,2 or 3 fingers equidistant between the patient and you. You must be able to see your own fingers. Do this peripheral pattern in each cardinal field of vision. Eye Inspection – Used to determine lacerations, hematomas, forein bodies, shape and contours. Use a penlight (or normal flashlight). Retract the lower lid and have the patient look up. Retract the upper lid and have them look down. Visualize the conjunctiva, sclera and cornea. Visualize the fornices (posterior porti ons of the upper and lower conjunctiva where it overlaps the sclera and joins together. Any obscuring of the structures behind the cornea (iris or lens) is potentially a poor prognosis. If the eye is distorted or bleeding, discontinue palpation. Penetration or rupture of the eyeball should eliminate palpation examination. Ophthalmoscope – Used to determine red reflex and gross fundus examination. Turn on the scope and select a wide aperture (large oval light shown on your hand or the wall). Darken the room. Hold the handle of the scope in the right hand to examine the right eye. Put the index finger or middle finger on the lens selector wheel. Use the left hand to open the lids. Hold the scope against your right eye. Hold the scope against your right eye with the handle tilted laterally. Instruct the patient to look over your shoulder. Start from about 15” away and visualize a red-orange glow from inside the pupil (red reflex). Approach the eye from the lateral side at an angle of about 15 d. Move in toward the patient to view the optic disc, arteries, veins, and retina. To focus on various structures, turn the lens selector wheel. If the patient is myopic, a minus (red) lens will be used. The fundus or retina will appear as a yellow or pink background with blood vessels branching away from the optic disc. Follow vessels in four directions. Fluoresein Dye Test – When a corneal abrasion is suspected, fluorescein dye can be used to stain areas of the abrasion where the cornea and conjunctiva have lost epithelial surface layers. First wet the tip of the fluorescein strip with sterile saline. Touch the test strip to the lower lid conjunctiva (do not touch the eye globe). Have the patient blink to spread the dye. Darken the room. Use a cobalt blue light to illuminate the eye. Observe for bright yellowish-green marks that pinpoint the abrasion. Eye Lid Visualization – When foreign body sensations are present and persistent, the upper lid can be gently pulled away from the eyeball by grasping upper lid lashes and pull over the lower lid lashes. This can act as a brush against the upper eyelid. When the sensation still persists, the upper lid can be everted for direct inspection. Grasp the eyelid and have the patient look down, placing a cotton swab against the upper lid crease and then rotate the eyelid around the applicator to expose the upper lid conjunctival surface. A cotton-tipped applicator, cotton sponge, or cotton ball can be used to remove visible foreign bodies by lifting off the surface. Never touch the cornea and do not attempt to remove a foreign body from the cornea. Inadvertent pressure may push the object further in an penetrate the cornea. If these maneuvers fail, refer. Ear Visualization – Inspect the auricle noting size, shape, and symmetry. Note deformities or discoloration indicating trauma. Look for lesions or nodules. Observe for obvious discharge or odor (straw-colored fluid following head injury could be CFS – CFS may be in blood as well). Auricles and the mastoid area should be palpated for tenderness, swelling, and non-visible nodules. Hearing Exam – Gross detection of haring is determined by a patient’s responses to questions or directions. To distinguish between sensorineural and conductive hearing loss, Weber or Rine Tests are used. The Weber Test consists of holding a tuning fork at the base, tap lightly against the palm to start a vibration. Place the tuning fork at the vertex of the skull, then ask if sound is heard better on one or equally in both ears. Results are these: normal is equal sound heard in both ears; Conductive Loss is sound heard best in the impaired ear; Sensorineural Loss is sound only identified in the normal ear. For the Rine Test, hold the tuning fork at the base; tap it against the palm to start the vibration. Place the stem against the mastoid process, count the seconds to when sound is no longer heard, guickly place the sill vibrating fork ½ - 1” away from the ear. Ask the patient to say when sound is no longer heard and count the seconds. Compare the sounds with the other ear. Normal findings are these: air-conducted sound is usually heard twice as long as bone-conducted. For a Conduction Loss, the bone conducted sound is heard longer. For a Sensorineural Loss, the sound is reduced and heard longer through the air. Otoscope – Use the largest disposable speculum that comfortably fits. Usually the light in the otoscope is turned on by rotating a dial at the top of the handle. The patient should tip the head slightly to the opposite shoulder and avoid moving during the exam. Most of the time, the canal slopes inferiorly and forward toward the eyes. Straighten the canal by pulling up and back ob the pinna. Otitis externa is suspected if the patient experiences pain on this maneuver. Insert the otoscope with the speculum in place directed slightly down and forward about ½ inch into the canal. Use your little finger against the cheek to guard against inserting the speculum too far. The canal is lubricated with cerumen and this wax can build up in the external canal, sometimes impairing hearing and making the exam difficult. The skin in the canal should be smooth and somewhat pink or fleshy. Take note of scaling, increased redness, discharge, lesions, or foreign bodies. Reddened canals with discharge signifies inflammation or infection. Slowly move the otoscope in a circular direction in toward the tympanic membrane. The membrane should appear translucent and pearly gray in color. The malleus should be visible through the membrane. The membrane is concave by the pull of the malleus at the center (umbo). This allows a light reflex to be visible when observed through the otoscope. The tympanic membrane should be free from holes or breaks and should not be bulging or bloody. Redness of or around the tympanic membrane indicates infection in the middle ear, whereas white color may indicate pus behind the membrane. Nose Exam – Major non-traumatic conditions related to the nose are: nasal obstruction, drainage, facial pain or headache, epistaxis, and change in smell or taste. Thorough Hx is key to the exam. Always ask about the onset and duration of sx. For nasal obstruction, trauma or insidious onset; bilateral or unilateral; constant or intermittent is determined. As sessment of inspiratory and expiratory air flow are done by occluding one nostril at a time. Unilateral obstruction, may indicate an anatomical problem (deviated septum or polyp), whereas bilateral obstruction may be from a cold. If drainage is present, determine its characteristics (unilateral or bilateral; clear or discolored – clear indicates rhinitis either allergic or non-allergic; whereas yellow, green, or brown suggests bacterial or viral; straw-colored drainage following a head injury is associated with CSF; wear gloves). Facial pain and headache are associated with nasal or sinus disorders (differentiate from other causes – migraines, tension headaches, TMJ, dental disorders). For pain and swelling over the sinuses accompanied by purulent draina ge, suspect sinusitis. Examine the external nose, noting size, shape, and color. Ask the patient about changes in appearance or function. Look at the nose and face from behind and top to visualize linear or curved bone lines as well as depressions. The nares should be examined for discharge and unilateral flaring or narrowing. Palpation should be done for tenderness, swelling, masses, and displacement of bone or cartilage. Squeeze the nares together for a patency exam. Palpate the facial bones and sinuses (maxillary and frontal) – these are not usually tender and if so often indicate inflammation from infection or allergy. Trans-illumination – Sinuses may pass light through it walls. Use a penlite or otoscope in a darkened room. For the frontal sinuses, press the light medially against the supraorbital rim and look for a slight red glow just above the eye brow. For the maxillary sinus, press the light lateral to the nose beneath the medial aspect of the eye and have the patient open the mouth. The hard palate should be illuminated. When secretions are present, transmission is less or absent. Nasal Speculum Exam – To view the septum and turbinates, tilt the patient’s head slightly backward. The septum is normally pink, glistening, and thicker anteriorly. Look for discoloration, perforation, bleeding, crusting, and note differences such as polyps, holes, swelling, and abnormal coloring. The septum should be straight and close to the midline. The vestibule and turbinates are visualized with the patient’s head erect. The turbinates should be pink, moist, and free from lesions or discoloration. Mouth and Throat Exam – Always start with a visual inspection of the face, head and neck, noting symmetry and skin changes. Palpate lymph nodes bilaterally to detect enlargement and tenderness: anterior triangle neck chain, posterior triangle chain, subungal, periauricular, parotid, posterior auricular, facial, submandibular, and submental. Evaluate the lips with the mouth open and closed, noting texture, color and surface abnormalities. Ask the patient to open the mouth to visually examine the labial muscosa (inside lips and gums) as well as maxillary and mandibular vestibules, noting color, texture, and swelling of mucosa and gingivae. The buccal mucosa is observed from the labial commisure to the tonsilar pillar. Use a tongue depressor or gloved finger to pul the cheek away from the teeth, noting pigmentation, color, texture, mobility and other abnormalities. Cracking of the lips is indicative of dehydration. Inspect the mucosa for white or dark pigmented areas. Stensen’s duct looks like a small dimple opposite the second molar. Inspect the tongue for swelling, ulceration, coating, or variation in size, color, or texture. Ask the patient to stick out the tongue (CN XII), noting abnormal mobility or positioning. Grasp the tip of the tongue with sterile gauze and pull out more to visualize the lateral borders of the tongue. Then examine the ventral surface of the tongue and floor of the mouth. Ask the patient to tilt their head back, mouth open wide, and depress the tongue at the base with a tongue blade. Examine the hard and soft palate and oropharyngeal tissues. Movement of the soft palate is evaluate by asking the patient to say “ahhh” (CN IX, X). Continue inspecting the oropharynx: tonsilar pillars should be pink and blend in with the retropharyngeal wall. Hypertrophied or reddened tonsils that may be covered with exudate indicate a viral or bacterial infection. The posterior wall is normally pink and smooth. A yellowish film may indicate post-nasal drip. A gag reflex can be done to assess CN IX, X.