Clinical Skills · Assessment of the Head and Neck

Eyes

8 min read

On this page 9 sections

In 30 seconds
Why this matters
The college version
Eli explains
Worked example
Key takeaway
Check yourself
Study tools
Sources & references

In 30 seconds

The eyes are paired sensory organs that gather light and turn it into the neural signals that become vision. For nurses, the eye exam is about far more than "checking vision": it is a window into cranial nerve function, hydration and perfusion, and even systemic conditions that first show up in the eye, such as yellowing of the sclera or a change in eye movement. This topic covers the structures of the eye as they matter for assessment, the bedside techniques nurses use to screen vision and eye health, and how to document what you see so that changes over time are visible to the whole care team.

The nursing eye assessment is usually a screening exam: you inspect, test, and screen, then report abnormal findings so that a licensed provider can diagnose and treat. The techniques here are used across settings — admission exams, pre-surgical checks, school and community screenings, and routine outpatient visits — and the exact equipment, chart types, and protocols vary by facility, so always follow your program's and facility's procedures.

Why this matters

Safety: a person who cannot see well is at higher risk of falls, medication errors, and household injuries.
Neurological screening: the eye exam tests cranial nerves II, III, IV, and VI plus autonomic pupil responses — a quick way to detect changes in the nervous system.
Systemic clues: eye findings can be the first hint of a whole-body problem; a drooping eyelid or suddenly unequal pupils may signal a neurological emergency that needs immediate attention.
Quality of life: vision loss affects independence, driving, reading, and social connection; early screening and referral preserve function.
Communication: the ability to make eye contact, read facial expressions, and read printed materials is part of how people interact with the care team.

The college version

Core Concepts

External inspection

Begin with the structures you can see without instruments: eyelids, eyelashes, eyebrows, the lacrimal apparatus (the tear-producing and draining system at the inner corner of each eye), conjunctiva (the clear membrane over the sclera and the inner lids), sclera (the white of the eye), cornea, iris, and pupil. Inspect for symmetry, redness, swelling, discharge, lesions, or dryness. Ask about pain, itching, tearing, discharge, double vision, or changes in vision, and record what the person says in their own words.

Pupil assessment (PERRLA)

Using a penlight in a dimly lit room, check the pupils for Pupils Equal, Round, Reactive to Light and Accommodation (). Shine the light into one eye and watch that pupil constrict (direct response) and the other pupil constrict as well (); repeat on the other side. For , ask the person to look at a distant object, then at your finger held near their nose — the pupils should constrict and the eyes converge. Document pupil size in millimeters and the quality of the response, for example: "Pupils 3 mm, equal, round, briskly reactive to light; accommodation intact."

Visual acuity screening

Visual acuity is the sharpness of vision at a distance, usually screened with a placed 20 feet away. The top number is the distance between the person and the chart; the bottom number is the distance at which a person with typical vision could read the same line. For example, 20/40 means the person reads at 20 feet what a person with typical vision reads at 40 feet. Test one eye at a time (cover the other with an occluder or the person's hand), and near vision can be screened with a handheld card. People who wear glasses or contacts are usually tested with them on, and that is documented. Visual acuity screening is a screening test — it does not diagnose eye disease, and the chart used and pass/refer criteria follow facility policy.

Extraocular movements and visual fields

Extraocular movements test the six muscles that move each eye and the cranial nerves that control them (III, IV, VI). Ask the person to follow your finger or a penlight through six cardinal positions of gaze — up, down, left, right, and the two diagonals — and note whether the eyes move together smoothly, without (involuntary, jerky eye movement) or pain. The screens peripheral (side) vision: sit facing the person, have them cover one eye while you cover your opposite eye, and move your fingers from outside the field of view inward until the person sees them; both of you should notice the fingers at about the same time.

Special populations

Infants and children: the (the reddish-orange reflection seen through the pupil with an ophthalmoscope) is an important newborn and infant screening — a white or absent reflex is a finding to report immediately. Children's vision is screened at well-child visits, and crossed or wandering eyes should be evaluated early. Older adults commonly develop presbyopia (age-related difficulty focusing on near objects), cataracts, and dry eyes; ask about falls, night driving, and whether vision affects daily activities. Contact lens wearers need teaching about lens hygiene, and people with diabetes need regular eye examinations because eye problems can develop without symptoms — screening frequency follows current guidelines and the provider's recommendations.

Common Confusions

Do Not Confuse	With	Difference
Direct pupil response	Consensual response	Direct: the pupil you shine the light into constricts. Consensual: the other pupil constricts too.
PERRLA (includes accommodation)	PERRL (accommodation not tested)	PERRLA includes near focusing; record what you actually tested.
20/20 vision	"Perfect" vision	20/20 is typical acuity at 20 feet; it says nothing about color vision, peripheral fields, or eye health.
Anisocoria (unequal pupils)	A pupil emergency	Mild lifelong inequality can be normal; a NEW difference, especially with other symptoms, is a red flag.
Visual acuity screening	Eye examination	Screening tests sharpness and refers; the provider's exam looks for disease.

Eli explains

The same idea, in plain words

Explain it like I’m 10

Your eyes are like a pair of cameras connected to your brain. The nurse shines a light into them to check that the "shutters" (pupils) close properly, asks you to read letters on a chart to see how sharp your vision is, and has you follow a finger to make sure the camera lenses move together smoothly. If any part of the camera is not working, the nurse notices and tells the doctor so it can be checked further.

Worked example

Mr. Alvarez, 78, is admitted after a fall at home. During the head-to-toe assessment you examine his eyes. He tells you he stopped driving at night because "the lights bother my eyes," and he reads the 20/60 line on the Snellen chart with glasses on. His pupils are 4 mm, equal, round, and briskly reactive; extraocular movements are smooth; confrontation fields are full. You document these findings, note that his acuity is reduced even with glasses, and add vision to his fall-risk plan: you make sure the call light and personal items are within reach, the room is well lit, and you report the acuity result to the provider, who decides whether a referral for a full eye examination is appropriate. Notice what you did: you screened, documented objectively, connected the finding to safety, educated, and referred — you did not diagnose his eye condition.

Key takeaways

Assessment order: inspect the external eye, then test pupils, acuity, extraocular movements, and visual fields — and always compare one eye with the other.
PERRLA is a description of pupil findings, not a diagnosis — an abnormal finding means "report and follow up," not "name the disease."
Document pupil size in mm and describe reactivity (brisk, sluggish, or nonreactive).
The consensual response means shining light in one eye constricts both pupils — the pathway involves cranial nerve II (sensory) and cranial nerve III (motor).
Visual acuity is tested one eye at a time; document whether corrective lenses were worn.
Sudden vision loss, sudden double vision, a suddenly dilated pupil, or severe eye pain are urgent findings — notify the provider immediately.
Use person-first language and ask about vision problems in the person's own words; do not assume that a person who "looks fine" sees fine.
Scope note: nurses screen and educate; diagnosing eye disease and prescribing treatment are provider responsibilities, and the exact exam components vary by setting and institutional policy.

Check yourself

6 review questions from the chapter. Try each one, then open the answer.

What does PERRLA stand for, and what do you check at each step?
Show answer
Pupils equal, round, reactive to light and accommodation: check size and shape, shine a light in each eye (direct and consensual responses), then test near focusing.
A patient reads the 20/100 line on the Snellen chart. What do the two numbers mean?
Show answer
The patient reads at 20 feet what a person with typical vision reads at 100 feet — vision is reduced at distance.
You shine your penlight into the patient's right eye and both pupils constrict. Which response is direct, and which is consensual?
Show answer
The right pupil constricting is the direct response; the left pupil constricting is the consensual response.
List the six cardinal positions of gaze and the cranial nerves they test.
Show answer
Up, down, left, right, and the two diagonals — testing cranial nerves III, IV, and VI.
What is the red reflex, and why is it important in newborns?
Show answer
The reddish-orange reflection seen through the pupil; a white or absent reflex in an infant is an urgent finding to report.
A patient reports sudden vision loss in one eye. What should you do?
Show answer
Treat it as urgent: notify the provider immediately, keep the patient safe, and document the onset and details. (Educational note: always follow facility protocol for urgent findings.)

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Study tools & related lessonsKey vocabulary · Related

Key vocabulary

Snellen chart: Wall chart of letters or symbols used to test distance vision from 20 feet
PERRLA: Shorthand for "pupils equal, round, reactive to light and accommodation"
Consensual response: Constriction of the pupil in the opposite eye when light shines in one eye
Accommodation: Pupil constriction and eye convergence when focusing on a near object
Anisocoria: Unequal pupil size
Nystagmus: Involuntary, jerky movement of the eyes
Red reflex: Reddish-orange glow seen through the pupil with an ophthalmoscope
Confrontation test: Peripheral (side) vision screening by comparing the person's field with your own

Sources & references

openstax.org — Clinical Nursing Skills

This lesson was adapted from the open educational references above; their licenses and attributions are preserved. See Copyright & Licensing.

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