Unit III. Sensory disorders.pptx

Medical surgical II
Unit III. Sensory system disorders
Time allowed : 8 hrs
BY: Wondwossen Yimam (Msc.N)
March/2014
Alkan University College

Part I. Disorders of the ear
Assessment of the ear
1/ Inspection (for deformities, lesions, and discharge, as well as
size, symmetry, and angle of attachment to the head)
2/ Direct palpation (tenderness) direct palpation
3/ Otoscopic examination
- To examine the external auditory canal and tympanic
membrane
- The examiner looks for any discharge, inflammation, or foreign
body in the external auditory canal
- Tympanic membrane is pearly gray and is positioned obliquely
at the base of the canal.
- The presence of fluid, air bubbles, blood, or masses in the
middle ear also are noted
4/ Auditory acuity test
A/ Weber test B. Rinne test

Assessment of the ear---
5/ Whisper test
• To exclude one ear from the testing, the examiner
covers the untested ear with the palm of the hand
• Then the examiner whispers softly from a distance
of 0.3 or 0.6m (1 or 2 ft) from the unoccluded ear
and out of the patient’s sight
• Then,the patient with normal acuity can correctly
repeat what was whispered

Comparison of Weber & Rinne tests
Hearing status Weber test Rinne test
Normal hearing Sound is heard equally in
both ears
Air conduction is audible
longer than bone
conduction
Conductive hearing loss Sound best heard in
affected ear
Sound heard as long or
longer in affected ear
Sensorineural hearing loss Sound heard best in
normal hearing ear
Air conduction is audible
longer than bone
conduction in affected ear

Hearing loss
Conductive hearing loss
• Obstruction(cerumen impaction, otitis media, etc)
• Abnormal tympanic membrane findings
• Soft spoken
• Hears well in a noisy environment
• Lateralization to affected ear
RX:-
• Hearing aid
• Tympanoplasty (middle ear)/myringoplasty (eardrum)
Position the client flat with operative ear up for 12 hr
• Stapedectomy

Hearing loss
Sensori-neural hearing loss
• Tinnitus, & dizziness
• Loud spoken
• Hears poorly in a noisy environment
• Lateralization to unaffected ear
RX: Cochlear implant – electrodes are placed in the
inner ear and a computer is attached to the external
ear electronic impulses stimulate the nerve fibers

Assessment of the ear---
6/ Audiometric evaluation
Audiometry – An audiogram identifies if hearing loss is sensori-
neural and/or conductive ( The procedure take 10-15
minutes)
Audiometry (Pure-tone audiometry & speech audiometry)
• Pure-tone audiometry, in which the sound stimulus consists
of a pure or musical tone (the louder the tone before the
patient perceives it, the greater the hearing loss)
• Speech audiometry, in which the spoken word is used to
determine the ability to hear and discriminate sounds and
words
A. Frequency ( N= Perceive sounds 20 – 20000 HZ )
B. Pitch ( Ex. 100 HZ is low, 10,000HZ is high pitch)
C. Intensity(Loudness of sound) = The pressure exerted by sound

Quiz
Q.1
The client reports ringing in her ears and difficulty
hearing in loud environments. The Weber test
reveals lateralization to the unaffected ear.
The nurse should expect the audiogram to reveal
which type of hearing loss?
A. Sensorineural B. Conductive

A) Problems of the external ear
1. Cerumen impaction 2. Foreign bodies 3. External otitis
Cerumen impaction
• Cerumen normally accumulates in the external canal in
various amounts and colors
• Although wax does not usually need to be removed,
impaction occasionally occurs, causing otalgia, a
sensation of fullness or pain in the ear, with or without
a hearing loss
• Accumulation of cerumen is especially significant in the
geriatric population as a cause of hearing deficit.
Attempts to clear the external auditory canal with
matches, hairpins, and other implements are dangerous
because trauma to the skin, infection, and damage to
the tympanic membrane can occur

Cerumen impaction---
Mgt
Cerumen can be removed by:
 Irrigation
Suction, or
 Instrumentation

Foreign bodies
• Some objects are inserted intentionally into the ear
by adults who may have been trying to clean the
external canal or relieve itching or by children who
introduce the objects
• Other objects, such as insects, peas, beans, pebbles,
toys, and beads, may enter or be introduced into
the ear canal
• In either case, the effects may range from no
symptoms to profound pain and decreased hearing

Foreign bodies---
Mgt methods
 Irrigation, Suction , Instrumentation
• Foreign vegetable bodies and insects tend to swell;
thus, irrigation is contraindicated
• An insect can be dislodged by instilling mineral oil
• Attempts to remove any foreign body from the external
canal may be dangerous in unskilled hands
• The object may be pushed completely into the bony
portion of the canal, lacerating the skin and perforating
the tympanic membrane
• In difficult cases, the foreign body may have to be
extracted in the operating room with the patient under
general anesthesia

External otitis (otitis externa)
External otitis, or otitis externa, refers to an
inflammation of the external auditory canal
Causes
- Water in the ear canal
- Trauma to the skin of the ear canal
- Systemic conditions, such as vitamin deficiency and
endocrine disorders
- Bacterial(Staphylococcus aureus and Pseudomonas) or
fungal infections (Aspergillus)
- Dermatosis such as psoriasis, eczema, or seborrheic
dermatitis
- Allergic reactions to hair spray, hair dye, and permanent
wave lotions can cause dermatitis, which clears when
the offending agent is removed

External otitis (otitis externa)---
Clinical manifestations
• Pain, discharge from the external auditory canal,
aural tenderness, fever, cellulitis, lymphadenopathy,
pruritus and hearing loss or a feeling of fullness
• On otoscopic examination, the ear canal is
erythematous and edematous
• Discharge may be yellow or green and foul smelling
• In fungal infections, the hair like black spores may
even be visible

Medical management
• Analgesics for the first 48 to 92 hours
• If the tissues of the external canal are edematous, a
wick should be inserted to keep the canal open so
that liquid medications (EX. Burow’s solution
(Aluminum acetate - apply solutions as a compress
for 15 to 30 minutes BID or TID) , antibiotic
preparations) can be introduced
• For cellulitis or fever, systemic antibiotics may be
prescribed
• For fungal disorders, antifungal agents are
prescribed

Nursing management
• Teach patients not to clean the external auditory
canal with cotton-tipped applicators
• Teach to avoid swimming, and not to allow water to
enter the ear when shampooing or showering
• A cotton ball can be covered in a water-insoluble gel
such as petroleum jelly and placed in the ear as a
barrier to water contamination
• Infection can be prevented by using antiseptic otic
preparations after swimming (Ex. Swim Ear, Ear
Dry), unless there is a history of tympanic
membrane perforation or a current ear infection

B) Problems of the middle ear
1/ Acute otitis media 2/ Chronic otitis media
3/ Mastoiditis 4/Otosclerosis
Acute otitis media
- An acute infection of the middle ear, usually lasting less
than 2 weeks
Causes
- Streptococcus pneumoniae, Haemophilus influenzae,
and Moraxella catarrhalis,r/t upper respiratory
infections (nasopharynx and the middle ear from a
tympanic membrane perforation)
- Inflammation of surrounding structures (Ex, sinusitis,
adenoid hypertrophy)
- Allergic reactions (Ex. Allergic rhinitis)

Acute otitis media---
• Fever ,decrease hearing, pain , pus draining from the
ear
• The patient reports no pain with movement of the
auricle. The tympanic membrane is erythematous and
often bulging
• Bulged & red ear drum (othoscopic examination)
• On otoscopic examination, the external auditory canal
appears normal
Medical management
• Oral Antibiotics / Amoxicillin/Erythromycin/
• Dry the ear by wicking
• Paracetamol for pain & fever

Acute otitis media---
Surgical management
– An incision in the tympanic membrane is known as
myringotomy or tympanotomy
– The procedure is painless and takes less than 15 minutes.
Under microscopic guidance, an incision is made through
the tympanic membrane to relieve pressure and to drain
serous or purulent fluid from the middle ear
– Normally, this procedure is unnecessary for treating acute
otitis media, but it may be performed if pain persists
– Myringotomy also allows the drainage to be analyzed (by
culture and sensitivity testing) so that the infecting organism
can be identified and appropriate antibiotic therapy
prescribed
– The incision heals within 24 to 72 hours

Chronic otitis media
Chronic otitis media is the result of repeated episodes of acute
otitis media causing irreversible tissue pathology and persistent
perforation of the tympanic membrane
• Chronic infections of the middle ear damage the tympanic
membrane, destroy the ossicles, and involve the mastoid
• Purulent discharge with offensive odor , Perforation of the ear
• Varying degrees of hearing loss, pain not common
• Otoscopic evaluation of the tympanic membrane may show a
perforation, and cholesteatoma can be identified as a white mass
behind the tympanic membrane or coming through to the
external canal from a perforation
• Cholesteatoma alone usually does not cause pain; however, if
treatment or surgery is delayed, the cholesteatoma may destroy
structures of the temporal bone
• In cases of cholesteatoma, audiometric tests often show a
conductive or mixed hearing loss

Chronic otitis media---
Medical Management
- Dry the ear by wicking, Treat fever & pain if present
- Instillation of antibiotic drops
- Systemic antibiotics usually not effective but a
single antibiotic dose is tried
Surgical management
1. Tympanoplasty
2. Ossiculoplasty
3. Mastoidectomy

Mastoiditis
• Inflammation of mastoid bone & cells
Cause: TB, & also as a complication of acute &
chronic otitis media
C/m: - Tender, swelling behind the ear, mastoid
process or tender on palpation
- Fever, pain, etc
Dx: By c/m & x-ray shows inflammation of the
mastoid hole
Rx:
• Antibiotics
• Anti pain
• Surgery / Mastoidectomy/

Otosclerosis
• Otosclerosis involves the stapes and is thought to result from the
formation of new, abnormal spongy bone, especially around the oval
window, with resulting fixation of the stapes
• The efficient transmission of sound is prevented because the stapes
cannot vibrate and carry the sound as conducted from the malleus
and incus to the inner ear
– Begins in adolescence -- Hereditary
More common in women , otosclerosis may be worsened by
pregnancy
* Conductive hearing loss or mixed hearing loss
* Bilateral hearing loss * Hears own voice well * Continuous tinnitus
• The condition can involve one or both ears and manifests as a
progressive conductive or mixed hearing loss.
• Otoscopic examination usually reveals a normal tympanic membrane
• Bone conduction is better than air conduction on Rinne testing
• The audiogram confirms conductive hearing loss or mixed loss,
especially in the low frequencies

Otosclerosis---
Medical Management
Treatment
• Hearing aid, reconstruct ossicles , & stapedectomy
• There is no known nonsurgical treatment for otosclerosis
• However, some physicians believe the use of Florical (a fluoride
supplement) can mature the abnormal spongy bone growth
Surgical management
• A stapedectomy, performed through the canal, involves removing
the stapes superstructure and part of the footplate and inserting a
tissue graft and suitable prosthesis
• Some surgeons elect to remove only a small part of the stapes
footplate (ie, stapedotomy)
• Regardless of the method used, the prosthesis bridges the gap
between the incus and the inner ear, providing better sound
conduction
• Stapes surgery is very successful in improving hearing. Balance
disturbance or true vertigo, which rarely occurs in other middle ear
surgical procedures, can occur for a short time after stapedectomy

Otosclerosis---
– Nursing management
• Operative ear up
• Ear plug for asepsis
• Treat N/V
• Safety measures
• Don’t dislodge prosthesis
–No cough, sneeze, blowing of nose, vomiting,
flying, lifting, showering
–If gets a cold: call MD

C. Problems of the inner ear
1/ Labyrinthitis 2/Ménière’s disease /syndrome/
Labyrinthitis
Is an inflammation of the inner ear
Causes
- Bacterial (complication of otitis media) or viral
(Ex. mumps, rubella, rubeola, and influenza) but
little is known about viral labyrinthitis
- Viral illnesses of the upper respiratory tract
Herpetiform disorders of the facial and acoustic
nerves (ie, Ramsay Hunt syndrome)

Labyrinthitis---
• Labyrinthitis is characterized by a sudden onset of
incapacitating vertigo, usually with nausea and
vomiting, various degrees of hearing loss, and possibly
tinnitus. The first episode is usually the worst;
subsequent attacks, which usually occur over a period
of several weeks to months, are less severe.
Management
- Intravenous antibiotic therapy
- Fluid replacement
- Vestibular suppressant (Ex. Meclizine 12.5–25 mg PO
every 6 hours as needed, and antiemetic medications-
Metoclopramide 10 mg (PO/IV) every 6–8 hours)
- Treatment of viral labyrinthitis is tailored to the patient’s
symptoms

Ménière’s disease /syndrome
• Ménière’s disease is an abnormal inner ear fluid balance
caused by a malabsorption in the endolymphatic sac.
• Edema and congestion in mucous membrane of cochlea and
semicircular canal
• An inner ear disorder that causes one to experience periods of
vertigo, dizziness, nausea, ear pressure, sensitivity to light and
tinnitus.
• Evidence indicates that many people with Ménière’s disease
may have a blockage in the endolymphatic duct. Regardless
of the cause, endolymphatic hydrops, a dilation in the
endolymphatic space, develops
• More common in adults, it has an average age of onset in
the 40s, with symptoms usually beginning between the ages
of 20 and 60 years. However, the disease has been reported
in children as young as age 4 years and in adults up to the
90s

Causes of meniere’s disease
• It is associated with a change in fluid volume in the
inner ear
• The membranous labyrinth, which is encased by
bone, is necessary for hearing and balance and is
filled with a fluid called endolymph
• An increase in endolymph, however, can cause the
membranous labyrinth to balloon or dilate, a
condition known as endolymphatic hydrops
• Reasonable possibilities are obstruction of
endolymphatic outflow at the endolymphatic duct
level, increased production of endolymph, or
reduced absorption of endolymph caused by a
dysfunctional endolymphatic sac

Causes of meniere’s disease---
• Ménière’s disease appears to be equally common in both
genders. The right and left ears are affected with equal
frequency; the disease occurs bilaterally in about 20% of
patients.
• About 20% of the patients have a positive family history for the
disease
• Herpes virus (HSV) antibodies are found more commonly in
Meniere's patients
• There is some recent pathologic data supporting a viral cause
• About one in three patients with Menieres disease have a first-
degree relative with Menieres disease
• About 60% of patients with Meniere's disease have serum
antibodies for inner ear proteins.
• About 10% of Meniere's patients have well documented
autoimmune disorders
• Some Meniere's patients show evidence for a change in their
immunity around the time of their attacks

Causes of meniere’s disease---
• 30% of patients with Meniere's disease have food allergy,
and suggested that allergy may play a role in three ways
that allergy may contribute:
• The sac may be the "target organ" of mediator released
from systemic inhalant or food reactions
• Deposition of circulating immune complex may produce
inflammation and interfere with the sac's filtering
capability;
• A predisposing viral infection may interact with allergies in
adulthood and cause the endolymphatic sac to
decompensate, resulting in endolymphatic hydrops
• There are clearly cases of post-traumatic Meniere's
syndrome

What are the symptoms?
• Episodic rotational vertigo (attacks of a spinning
sensation)
• Unilateral hearing loss
• Tinnitus (a roaring, buzzing, or ringing sound in the ear)
– Attacks at regular intervals, have dizziness, N/V,
unsteadiness on feet
– Tinnitus occurs during attack
• Sensation of fullness in the affected ear
• Usually occurs in 40-60 year old
• Men more than women
– Classic triads
• Progressive hearing loss with each attack
• Vertigo
• Tinnitus

Ménière’s disease /syndrome---
Assessment and diagnostic findings
• Vertigo. Typically, the patient reports that vertigo lasts
minutes to hours, possibly accompanied by nausea or
vomiting
• Patients also complain of diaphoresis and a persistent
feeling of imbalance or disequilibrium, which may last
for days
• They may complain of attacks that awaken them at
night. Between attacks, however, they usually feel well.
The hearing loss may fluctuate, with tinnitus and aural
pressure waxing and waning with changes in hearing.
• The tinnitus and feeling of aural pressure may occur
only during or before attacks, or they may be constant

Assessment and diagnostic findings---
• Findings of the physical examination are usually
normal, with the exception of the evaluation of cranial
nerve VIII.
• Sounds from a tuning fork (ie, Weber test) may
lateralize to the ear opposite the hearing loss, the one
affected with Ménière’s disease.
• An audiogram typically reveals a sensorineural hearing
loss in the affected ear. This can be in the form of a
“Pike’s Peak” pattern, which looks like a hill or
mountain, or it may show a sensori neural loss in the
low frequencies.
• As the disease progresses, the hearing loss increases.
The electronystagmogram may be normal or may show
reduced vestibular response. There is, however, no
absolute diagnostic test

Interventions
– Bed rest during acute phase
– Low sodium diet (sodium and fluid retention disrupts the
delicate balance between endolymph and perilymph in the
inner ear)
– Avoid alcohol, caffeine, tobacco
– Psychological evaluations
Medications
• Antihistamines – Meclizine
• To control vertigo - Diazepam
• Antiemetics - Promethazine
• Vasodilators
• Diuretics- HCT sometimes relieves symptoms by lowering the
pressure in the endolymphatic system
Surgical interventions
• Severing of acoustic nerve (8th cranial nerve)
• Labyrinthectomy

Managing ménière’s attack
• Lay down on a firm surface
• Stay motionless
• Keep eyes open and fixed on a stationary object
• Don’t drink water
• After spinning stops, get up slowly and sleep
Medications used between attacks
• Vestibular suppressants
• Calcium channel blockers
• Steroids (rarely)
• Immune suppressants

Surgical management
• Endolymphatic Sac Decompression
• Middle and Inner Ear Perfusion
• Intraotologic Catheters
• Vestibular Nerve Section

Content outlines
II. Eye disorders
• Diagnostic procedures of the eye
• Refractive errors of the eye
• Diseases of the eye lid
• Diseases of the conjunctivitis
• Diseases of the cornea
• Disorder of the lens
• Injuries of the eye
• Other conditions of the eye(Glaucoma)

Vision 2020 priority eye diseases
• Five major eye conditions
responsible for blindness -
--- in adults
Cataract
Glaucoma
Diabetic retinopathy
Trachoma
Onchocerciasis
---in children
• Vit A deficiency
• Xerophthalmia
• Trachoma
• Refractive errors
& low vision

Diagnostic procedures of the eye
1/ HX
2/ P/E
• Inspection
• Visual acuity
• Visual field (perimetry testing)
• Color vision
• Palpation
• Ophthalmoscope exam
• Gonioscopy (visualizes the
angle of the anterior chamber)

Diagnostic procedures of the eye---
 VA ---- CF --- HM --- LP
Visual Acuity
• Visual acuity is defined as the clarity or sharpness of
vision, which is the ability of the eye to see and
distinguish fine details
• The measurement of visual acuity records the
acuteness of central vision for distance, and near or
reading vision
• Visual acuity is an important factor for a variety of
everyday tasks, including reading text, recognizing
symbols, and performing assembly work
• Good visual acuity is very important when driving,
because it helps people recognize landmarks, avoid
obstacles, and read road signs
CF = Count Finger HM = Hand Movement LP = Light Perception

Visual acuity ---
o Is the most important function of eye and it
should be performed first, so that vision is
assessed before the actually touching of the eye
• It is tested at 6 meter as rays of light from this
distance are nearly parallel
• If the patient wears glasses constantly, vision may
be recorded with & without glasses, but this must
be noted on the record
• Each eye is tested and recorded separately, the
other being covered with a card held by the
examiner

Visual acuity---
Factors which affect acuity
 Environmental factors
 Lighting, crowding, position of chart
 Color, brightness, and contrast
 Visual behaviors
1. Central, eccentric
2. Stable, wandering, nystagmus, unsteady
3. Head or body movement
4. Squinting or shutting one eye
5. Use of glasses (peeking over glasses, viewing through bifocal
segment)
 Patient factors (Fatigue, fear, nervousness, eye movements,
motivation)
 Chart observation
1. Missing or skipping letters, & confusion of similar letters
2. Reading speed
3. Note any observation made by the patient (i.e. distortion,
hallucination, blurred areas)

Visual acuity ---
• Visual acuity record at 6metres or 3metres
VA = 6/6
• The Numerator represents the distance used and the
denominator the line read( i.e 6/6 represents reading the
line at 6 metres that should be read at 6 metres)
• The denominator is the distance at which a person with a
normal average vision can read the same line
• Young people can read better than 6/6 ,usually 6/5 or 6/4
• 6/12- 6/9 (> 0.5-0.67)(corrected or uncorrected ) in at
least one eye is the driving standard for an ordinary
licence + A visual field of >120 degrees (binocular )
• Optimal public vehicle licences(most states require people
to have a corrected visual acuity of 6/12 in at least one
eye before they can receive a driver’s license)
So = 2 Si

Snellen’s chart test type
• A Dutch ophthalmologist, Dr. Hermann Snellen
• The top letter can be read by the normal eye at a
distance of 60 m, and the following rows should be
read at 36, 24, 18, 12, 9, 6, 5, 4m respectively
• The patient is seated 6m from the chart, which must be
adequately lit, & asked to read down to the smallest
letter he can distinguish, using one eye at a time
• Visual acuity is expressed as a fraction & abbreviated as
VA
Example: - If the 8th line is read at a distance of 6m this is
VA 6/6. If same letters in the line are read but not all, it
is expressed as, for example, OD: 6/6 -2
• OD (Right eye) , OS (Left eye)& OU(Both eyes)

Snellen’s chart ---
• For vision less than 6/60 the distance between the
patient & the chart is reduced 1 meter at a time & the
vision is recorded accordingly as, for example, 5/60,
4/60, 3/60 ,2/60, 1/60
• If the patient is unable to see the letter “E” at any
distance, the examiner should determine if the patient
can count fingers (CF)
* If the patient cannot read the top letter at a distance of
1 meter, the examiner’s hand is held at 0.9m(3ft), 0.6m
or 0.3m a way against a dark background & the patient
is asked to count the number of fingers held up
• If he answers correctly, Ex, VA = CF/0.9m, etc
• For less visions the hand is moved in front of the eye at
0.3m, record VA = HM/0.3m

Snellen’s chart test ---
 In the case of less vision, test for projection of light
by shining a torch into the eye from different
directions to see if the patient can tell from which
direction it comes if he sees the light from which
direction, it is noted as VA = PL(Perception of light)
• Perception of light test is performed in the dark
room. If no light is seen, record VA=NO PL, which is
total blindness
• A pinhole disk is used if the VA is less than 6/6,
which may improve VA. If considerable increase in
vision is obtained, it may usually be assumed that
there is no gross abnormality, but a refractive error

Visual acuity---
• Good vision, VA = 0.4 - 1.0
(but, young adults: 20/16 – 20/12)
• Low vision , VA = 0.1 - 0.3
is defined as a best corrected visual acuity (BCVA) of 20/70 to
20/200
o Blindness VA = 0.02- 0.05
- Blindness is defined as a BCVA of 20/400 to no light perception
- The clinical definition of absolute blindness is the absence of
light perception
• Legal blindness is a condition of impaired vision in which an
individual has a BCVA that does not exceed 20/200 in the
better eye or whose widest visual field diameter is 200 or less
(WHO)
• Visual acuity of 20/200 or worse is considered as legally blind

Snellen’s E- chart Landolt’s rings

Snellen’s chart
6/60
6/30
6/21
6/15
6/12
6/9
6/7.5
6/6
Ft M
20 ft = 6 m

Tumbling E chart (Taylor , 1976)
6/60
6/36
6/24
6/18
6/12
6/9
6/6
6/5

Assisting on ophthalmoscope examination
• Examining the fundus includes evaluating: -
• The optic disc for: -
– Its physiologic CUP & proportional size
• The blood vessels for
– Size, distribution
– Crossings & colour reflection
• Retinal funds for: -
– General colour,hemorrhagic,fluid & attachment
• Macula & fovea centralis for: -
– Colour (darker red), central reflection
• The vitreous humor for: -
– Colour, foreign bodies

Assisting in measurements of intraocular pressure
• Tonometry is a technique for measuring intra-
ocular pressure (IOP) indirectly by measuring the
force necessary to flatten a 3.06 mm diameter
portion of the corneal surface
• The higher the IOP, the greater the force required
Methods of measuring IOP
• Digital
• Golmann applanation tonometer
• Schiotz (perkins applanation) tonometer
• Pneumotonometer
• Ton open

Intraocular pressure
Procedures
• Identity the patient
• Check if the patient is wearing contact lenses, if so then
remove them before commencing the procedure
remove them before commencing the procedure
• Administer topical anaesthesia into both eyes
• Instil fluoresce in stain for accurate reading
• Instruct the patient to look straight a head with both
eyes wide open- if necessary, the patient’s eyelids
should be held apart by the examiner with out pressure
being applied to the eyeball.
• The ton meter is brought into contact with the center
of the cornea
• The IOP (in mm Hg) is found by multiplying the drum
reading by ten

Slit lamp microscopy
• For examination of anterior segment, filtration
angles, & Measure IOP with applanation
tonometer.

Schiotz tonometer
• One of the method of measuring IOP

Applanation tonometer
• Using fluorecein and blue cobalt light
• Most accurate method of measuring IOP

Ocular movements
– The examiner sits in front of the patient & using a pen torch,
observes both eyes moving in all eight positions of gaze.
– This will include up, down, both sides & in all four corners, always
returning to the straight a head or primary position. The patient’s
head must be held still
– Any muscle imbalance, over action & under actions are then
noted
Color vision test
• Indicative of conditions of the optic nerve
– Ishihara polychromatic plates
Ex. Red/green/blue --- Blind
• Acquired color vision losses may be caused by medications (eg,
digitalis toxicity) or pathology such as cataracts

Refractive errors
Emmetropia (Normal refraction)
• Adequate correlation between axial length and
refractive power
• Parallel light rays fall on the retina (no
accommodation)
Ametropia (Refractive error) include:
• Mismatch between axial length and refractive power
• Parallel light rays don’t fall on the retina (no
accommodation)
– Nearsightedness (Myopia)
– Farsightedness (Hyperopia or hypermetropia )
– Astigmatism (Asymmetric focus)
– Presbyopia
– Anisometropia

Myopia or Short sight
A short – sighted person has a long eyeball. The light rays therefore come to
a focus in front of the retina
Etiology : Idiopatic, genetic link, long globe(axial myopia),diabetes, &
excessive refractive power
S&Sxs Blurred distance vision, eye rubbing, Headache (not common)
decreased distant vision
– Squinting in an attempt to improve uncorrected visual acuity when gazing into
the distance
– Amblyopia – uncorrected myopia > 10 D (Diopter)
Diagnosis * Snellen’s visual acuity test & * Ophthalmoscope
Mild myopia = < - 5 D
Moderate myopia = - 5, - 8D
Severe myopia = > - 8 D
Treatment
* Concave lens (Minus lens) = Diverging lens
* Bifocal glasses (for both distant & close objects)
* Radical keratotomy(Laser) - shallow incision in the cornea causing it to
flatten in desired area (could have significant complications)
= Clear lens extraction

Hyperopia or Long sight
– The rays of light entering the eye are focused behind the retina
– Impairment of near vision
Etiology
Genetic link, short globe, elderly, young children, insufficient
refractive power
S & Sxs
Blurred vision, Squinting, Eye rubbing, Headache, eye strain
Diagnosis Snellen visual acuity test & Ophthalmoscope
Treatment * Convex lens (Plus lens)
* Kerato refractive surgery
* Lensectomy with IO implant
Mild = + 2 - 3 Diopter
Moderate = + 3 - 5 D
Severe = > + 5 D

Astigmatism
• It results from unequal curvature of the cornea, so that there is no
point of focus of the light rays on the retina. Hard to see small
objects
• Parallel rays come to focus in 2 focal lines rather than a single
focal point
Etiology : Genetic link, not completely round eye
S&Sxs Blurred vision to all distances, Squinting, Eye rubbing, head
tilting and turning,headache, eye pain after reading
Diagnosis * Snellen’s visual acuity test & ophthalmoscope
RX : *Spherical lens with either concave or convex lenses
* Radial keratotomy , Artificial lens transplant
Mild = < 1 D
Moderate = 1-2 D
Severe = 2-3 D
Extreme = > 3 D
Amblyopia – Uncorrected astigmatism > 1.5 D
- Either hyperopia or myopia may co-exist with astigmatism

Presbyopia
Presbyopia (Aging eyes, rigidity of the lens)
• From the age of about 45 years, the lens in the eye no
longer has the ability to accommodate for near vision
(b/se of deposit of insoluble proteins in lens)
• The light rays therefore fall behind the retina before
coming to a focus. This is called presbyopia
S/Sx : Able to read at 40-50 cm, H/A, visual fatigue
Difficult to read fine print
RX: - Bifocal/trifocal glasses ( for reading)
- Convex lens or ‘Plus’ lens
- Lens transplant
1. Hard contact lens 2. Soft contact lens
- Progressive power glasses

Presbyopia
• Physiologic loss of accommodation in advancing
age
• Deposit of insoluble proteins in lens in advancing
age-->elasticity of lens progressively decrease--
>decrease accommodation
• Around 45 years of age , accommodation become
less than 3 D-->reading is possible at 40-50 cm--
>difficultly reading fine print , headache , visual
fatigue

Anisometropia
• Difference in refractive power between 2 eyes
• Refractive correction often leads to different image
sizes on the 2 retinas( aniseikonia)
• Aniseikonia depend on degree of refractive anomaly
and type of correction
• Closer to the site of refraction deficit the correction
is made-->less retinal image changes in size

Anisometropia
• Glasses : magnified or minified 2% per 1 D
• Contact lens : change less than glasses
• Tolerate aniseikonia ~ 5-8%
• Symptoms : usually congenital and often
asymptomatic
• Treatment
– Anisometropia > 4 D-->Contact lens
– Unilateral aphakia-->Contact lens or intraocular lens

Hordeolum (A stye)
A Stye is an infection of sebaceous glands of Zeis or
apocrine glands of Moll
• Glands of moll = Located near the base of the lashes
• Glands of zeis = Located in the margin of the eye lid
,service the eye lash & produce oil
Cause: - Staphylococcus auerus &usually associated with
blepharitis
C/F: * Pain/swelling/redness/pus
* Patient feels something in the eye
Mx: - Warm, moist compresses for 10 to 15 minutes,3- 4
times a day, hastens the healing process. - If the
condition doesn't begin to resolve with in 48 hours,
incision & drainage may be indicated.
- Application of topical antibiotics - Analgesics
Disease of the eye lid

Chalazion (meibomian cyst, internal hordeolum)
Chalazion is a swelling of one of the meibomian
glands(tarsal glands) due to blockage of its duct
- It is chronic condition
- Meibomian glands located b/n the cartilage &
conjunctiva of the eye lids
Cause: - Staphylococci are common causes if infected
C/F: * Localized, painless swelling that develops over
period of weeks
* Pea size cyst
* Painless slow swelling of the inner part of eye lid

Chalazion---
Mx: * Small ones usually disappear spontaneously after 1-2
month
* Large ones usually need surgical removal (Incision)
- Warm compresses, massage & expression of the glandular
secretions
- Antibiotic(doxycycline) therapy & corticosteroid drops
* Chloramphenicol;3-4 x/d for 7-10 day, after the eye has
been steamed
Nursing care
- Apply steam to the eye
- Instruct how to use drugs
- Clean eye lids by using warm water

Blepharitis
It can be a cute or chronic inflammation of the eyelid margins
- It is usually bilateral
Causes
* Ulcerative: staphy infection
* Nonulcerative: allergies, smoke, dust, chemicals, seborrhea, stye,
chalazion & acne rosacea
C/M: - Irritation of eye lids margins and red rimmed eyes are chief
- Burning Symptoms
- Itching
Mx: * Salt & water cleansing for 2 weeks
* If unsuccessful - local antibiotics or sulfonamide
- Warm compresses - Dandruff RX
- Stop using make up or change the brand used
- Improve hygiene
Complications
- Conjunctivitis - Trichiasis
- Entropion or ectropion of lower lid - Corneal ulcer

Trichiasis
• It is a condition in which the eye lashes grow in wards & rub
on the cornea
Cause: - Blepheritis - Trauma or surgery to the lids
Rx: - Epilation
Complications: - Corneal abrasions - Corneal ulceration
- Corneal opacity - Vacularization of cornea
Entropion (inversion of eye lid into eye)
- Turning inward of eyelids, usually lower eye lids
Cause: - * Aging (course fibrous tissue)
Symptoms and signs
* Foreign body sensation * Tearing / itching / redness
* Continuous rubbing causes conjunctivitis or corneal ulcers
* Decreased visual acuity if not corrected
Diagnosis * Visual examination
Treatment * Clean up on its own * If not, minor surgery

Ectropion (Outturned eye lids)
- It is turning outwards of the eye lids, usually the lower lids
Cause: - Elderly (weakness of eye lid muscles)
Symptoms and signs
* Dryness of the exposed part of the eye, * Tears run down the cheeks
* If not treated can cause ulcers and permanent damage to cornea
Diagnosis * Visual examination
Treatment * Minor surgery if doesn’t disappear
Ptosis (Blepharoptosis)
- It is dropping of the upper eyelid
-Weakness of eye muscle that raises eyelid (superior rectus, superior
oblique)
Etiology
* Familial * Trauma * Diabetes mellitus * Muscular dystrophy
* Myasthenia gravis * Brain tumors
Symptoms and signs “Drooping eye” Blocks vision
Diagnosis * Ophthalmic examination
Treatment * Surgery (strengthen muscles)
* Eye glasses with raised eyelid support * Treat underlying disease

Disease of the conjunctivitis
Conjunctivitis (Pink eye) an inflammation of the
conjunctiva
Etiology * Viral / bacterial * irritants (thermal,
chemicals, UV light)
- Immunologic (allergy) - Associated with systemic
disorder
Symptoms and signs
* Redness / swelling / itching * tearing when exposed
to light
* Pus if infectious * “contagious” with
contaminated hands, washcloths
* Most conjunctivitis is bilateral; unilateral
involvement suggests a toxic or chemical origin

Bacterial conjunctivitis
Causative agents
- Gonococcus - Staph. auerus - Chlamydia
C/M: - Conjunctival injection, especially in the fornixes
where the blood supply is rich
- Hyperemia/rednes - Purulent discharge - Pain
Rx & nursing care
- Take swab from affected eye for culture & sensitivity if
severe
- Warm compress 3-4 times daily (10-15 min)
- Clean the eye using cooled, boiled water
- Chloramphenicol or tetracycline eye drop or paint 3x/d
for 3-5days

Neonatal conjunctivitis
Severe conjunctivitis occurring in a baby less than 28 days
old is a notifiable disease
Cause: - Gonococcus - Streptococcus - Chlamydia
C/M: - Severe discharge - Red, swollen eye lids -
Chamois
- Unilateral or bilateral infection
Rx: - Clean the eye
Conjunctivitis due to Gonorrhoea
 Give Ceftriaxone 50mg/kg IM in a single dose
 There is no need for antibiotic eye ointment
- Ceftriaxone 250 mg IM as a single dose to the mother;
- Ciprofloxacin 500 mg by mouth as a single dose to her
partner(s).

Neonatal conjunctivitis---
Conjunctivitis due to Chlamydia
 Give Erythromycin 50mg/kg QID by mouth for 14 days
 Apply 1% tetracycline ointment QID
• Erythromycin 500 mg by mouth four times daily for seven days
to the mother;
• Tetracycline 500 mg QID x 7d to her partner(s) OR Doxycycline
100 mg BID for 7d to her partner(s).
Conjunctivitis due to S. Aureus
 Apply 1% tetracycline ointment to the affected eye(s) QID for
five days.
 There is no need for systemic antibiotics
Complications: - Conjuctival Scarring - Chronic blepheritis
- Conjuctival ulceration & perforation
- Marginal corneal ulcer

Viral conjunctivitis
Causes: - Measles - Herpes simplex - Varicella
C/F
- Red eye
- Chemosis (edema of the conjunctiva, if severe)
- Follicle may be present on the palpebral conjunctiva
- Keratitis - Watery discharge & photophobia
Rx: - Self limiting (within 7-10 days)
- Steroid Rx
Allergic conjunctivitis
Causes: - Hay fever, Eczema
C/F: - Severe chemosis - Red eye - Watering eye
- Sinusitis may present - Photophobia
- Burning sensation & severe itching
Rx: - Betamethasone or hydrocortisone drop

Major Causes of Blindness Worldwide (in millions)
• Cataract 17.7
• Glaucoma 4.6
• Age-related macular
degeneration 3.2
• Corneal opacities 1.9
• Diabetic retinopathy 1.8
• Childhood blindness 1.4
• Trachoma 1.3
• Onchocerciasis 0.3
• Others 4.8

Trachoma(Sandy blight)
Trachoma: - is infectious disease caused by Chlamydia conjunctivitis
(serovars A, B, Ba and C)
- It is the world's leading cause of preventable blindness & primarily
affects people in Africa
• The national PR of active trachoma (either TF or TI) for children in
the age group 1-9 year is 40.14%
• Over 9 million 1-9 year old children live with active trachoma
• The highest prevalence is in Amhara (62.6%), Oromia (41.3%),
SNNP (33.2%), Tigray (26.5%), Somali (22.6%) and Gambella
(19.1%)
• The rural PR of active trachoma is almost fourfold compared to the
urban (42.5% rural Vs 10.7% urban)
• The national PR of trachomatous trichiasis (TT) is 3.1% with the
highest prevalence in Amhara regional state (5.2%)
• 1.3 million people 15 years and older have trachomatous trichiasis
• Trachomatous trichiasis is higher in females compared to males
(4.1% Vs 1.6%)

Trachoma---
Cause: - Chlamydia trachomatis (obligate intracellular bacterium)
Mode of transmissions (Ocular and nasal secretion of children)
• Direct contact such as touching infected eye secretions, touching
infected nasal or throat secretions
• Indirect contact such as touching contaminated items – Ex. towels,
sheets, blankets or clothing
• Flies that seek out the eyes
WHO classifies trachoma into the following 5 stages
FISTO stages------
TF = Trachomatous follicular - (follicles): > 5 follicles, at least 0.5mm in
size, on the 'flat' surface of the upper tarsal conjunctiva
TI = Trachomatous inflammation - (intense): inflammatory thickening of the
upper tarsal conjunctiva with more than half of the normal deep tarsal
vessels obscured
TS = Trachomatous scarring: scarring of the tarsal conjunctiva (fibrosis)
TT = Trachomatous trichiasis: at least one eyelash rubbing on the eyeball
or evidence of eyelash removal
CO = Corneal opacity: where at least part of the pupil is blurred or
obscured

Trachoma---
C/M
- Begin within 5 - 12 days following infection
- Up 3/4 of children with active trachoma exhibit no symptoms
• Eye irritation, redness and discharge (conjunctivitis)
• Swelling of the eyelids
• Scarring and distortion of the upper eyelid
• Eye lashes develop later that turn into the upper lid and then
rub on the cornea
• Abnormal growth of corneal blood vessels
• Opaque cornea (transparent membrane that covers the eye
surface).
• Lymphoid follicles become prominent whitish, yellow, or
grey elevations.
• Inflammatory thickening and hyperemia of the conjunctivae
are common, particularly under the tarsal plate.
- Red eye - Discharge - Keratitis
- Chemosis of bulbar connective - Blurring of vision

Trachoma---
Trachoma is diagnosed on clinical grounds when any of
the following are present:-
1. Five or more follicles >0.5 mm in diameter on tarsal
conjunctivae
2. Conjunctival scarring
3. Limbal follicles or Herbert pits
4. Corneal neovascularization and granulation tissue
formation
Complications
- Scarring of eye lids
- Entropion
- Trichiasis
- Corneal trauma & ulceration

Trachoma---
Mx: - The SAFE strategy
• Surgery for trichiasis
• Antibiotic therapy for TF/TI (Tetracycline 1% eye oint BID for
6wks or Tid for 3-4weeks to both eyes, but single dose
Azithromycin (20mg/kg, max. 1gm Po) is the antibiotic of
choice)
 Mass Rx with Azithromycin: Follicular trachoma ( in 1-9 % of
children from school) or PR > 10 % of total population
 Antibiotic must be given to all household members. In areas
where there is widespread infection, the whole community
may need to be treated. Treatment may need to be repeated
every 6 to 12 months
Azithromycin is C/I – for 1st trim pregnancy, & < 6 months old
 Facial cleanliness in young children &
• Environmental improvements such as latrine building and
improved access to water, house sanitation & safe disposal to
reduce transmission

Risk factors for trachoma---
• Inadequate personal hygiene, especially a dirty face
• Inadequate housing (about 50 per cent of the Northern
Territory’s Indigenous people don’t have proper homes)
• Crowded living conditions, such as having children share
the same bed
• Poor water supply (about one Indigenous person in six
doesn’t have a drinkable water supply in the Northern
Territory)
• Flies, which breed in human and animal feces
• Lack of education about the importance of environmental
cleanliness and personal hygiene, especially about facial
cleanliness in children
• Young age, since the infection is more common among
preschool children

Prevention of trachoma
1. Good personal hygiene. Daily face washing/hand
washing
2. A good water supply near to the community
3. Ventilated pit latrines
4. Animals housed at a distance from community
homes
5. Health education

Disease of the cornea
Keratitis
Keratitis is inflammation and ulceration of the cornea. Cornea is
susceptible to infection and injury because of its anterior
location and degree of exposure
Cause: - infections (bacteria, virus, fungus, or parasitic
organism),trauma *& dry air or intense light (welding)
- Exposure keratitis as a result of drying of the cornea because
of eye lids can not protect it adequately
C/M
* Pain or numbness of the cornea * Decreased visual acuity
* Irritation * Tearing * Photophobia
* Mild conjunctivitis
In advanced disease
- Perforation of cornea
- Extrusion of the iris
- End-ophthalmitis

Keratitis---
Dx: - Identifying the ulcer by slit - lamp examination after
instilling fluoresce eye drops to demonstrate the shape
& size of the ulcer under special light
Mx: - Patients with severe corneal infections are usually
hospitalized to allow frequent administration (ever 30
minutes) of antimicrobial drops & regular examination
- Keep the lid clean - Cool compresses
- Monitor for sign of increased IOP
- Acetaminophen 500mg 2tabs PRN
- Cycloplegic & mydriatics to relieve pain & inflammation
- Eye patch to protect from photophobia
Complications
- Corneal Scar
- Revascularization (new blood vessels formation) in the
cornea

Corneal abrasion or ulcer
Etiology
* Foreign bodies
* Trauma (fingernail, contact lenses)
Symptoms and signs
* Pain / redness & tearing
* Something constantly in eye
* Vision impairment
Diagnosis
* Visual examination
* Fluorescien (stain)
Treatment
* Remove foreign bodies
* Eye wear for protection & promote hearing
* Eye dressing to reduce movement

Disorder of the lens - Cataract
A cataract is opacity of the lens
* The lens is a delicate structure & any insult on it causes
absorption of water, resulting in the lens becoming
opaque
Etiology: Familial, old age ( > 65), congenital, trauma,
smoking, drug toxicity (steroids), DM
Types of Cataract
1. Congenital 2. Senile 3. Traumatic 4. Secondary to
existing eye disease
5. Cataract associated with systemic disease (DM,
Hyperparathyroidism)
Degree of Cataract
- Immature cataract – Part of the lens is opaque
- Mature cataract – The whole lens is opaque & may be
swollen

Disorder of the lens - Cataract
Congenital cataract
Cause: - Rubella or malnutrition in the first trimester of
pregnancy
– Abnormal development of the eye
– Metabolic disturbance
C/M: Painless, glare & light sensitivity, Absent red reflex,
visible opacity, Reduce vision at night & bright light,
blurring of vision, photosensitivity
DX: - Pen light of slit lamp confers the presence of a
cataract
Rx:
- Intracapsular Phacoemulsification (involves breakage of
cataract then aspiration)
- Extracapsular Phacoemulsification (artificial lens
replacement)

Nursing care for cataract
• Dilating gtts Q.10 mins for four doses at least 1 hr before surgery
(Ex. Atropine = Mydriatic, cycloplegic)
(Ex. Phenylephrine = Mydriasis)
(Ex. Acetazolamide = decrease IOP, Mydriatic, cycloplegic)
• Antibiotic, NSAID, steroid :- to prevent POP infection &
inflammation
• Apply protective eye path/for 24 hrs?
• Vision will be established with in 6-12 wks
• Myopia or hypermyopia should be corrected after IOL
• Help to wear dark glass in bright light
• Avoid bending at waists, sneezing, coughing, straining,
vomiting(after OR), & head hyperflexion
• Avoid sexual intercourse, restrictive cloth, driving & rapid movt
• Eye glass for 1-4 wks( vision returns after 4-6 wks of surgery)
• Give steroid drops

Senile cataract
- Occur in patients over the age of 60 years
- They result from sclerosis of the lens due to a
degenerative process
- Usually bilateral
- It is either nuclear or cortical
Nuclear cataract
- Affects the central lens & takes on a brown color
• The patient sees better in dim light when pupil is
dilated
A cortical cataract
- Affects the periphery of the lens & looks white
* Vision is usually better in bright light when the pupil is
constricts.

Cataract---
- Medical mgt
Antioxidants(Vit A,C,E) to slow cataract progression
- Surgical mgt (ICCE/ECCE/
Cataract extraction (takes 1 hr at OPD)
• Intracapsular lens extraction – the entire lens(capsule,
cortex-in DM, nuclear-aging) is removed. Then intra –
ocular lens is implanted
- Indication: Subluxated cataract
- IOL inserted in front of the Iris (Anterior chamber)
• Extracapsular lens extraction – the anterior lens
capsule, the cortex & nucleus are removed
- Posterior capsule & zonular support are left intact
- Posterior chamber implants behind the iris

Injuries of the eye
Sympathetic ophthalmia
Sympathetic ophthalmia is an inflammatory condition created in the fellow
eye by the affected eye (without useful vision)
-The condition may become chronic and result in blindness (of the fellow eye)
- Is a rate but devastating bilateral uveitis
- Occurs after a latent period of days to years after a penetrating injury to the
uveal tract
Causes:- Unknown
Predisposing factor: - Allergy
C/M: - Inflammation of injured eye, followed by inflammation of the
unaffected (sympathetic) eye
MX: - Enucleation of the sightless eye within 10 days of injury is usually
recommended to reduce the risk of sympathetic disease in the other eye.
* Enucleation is complete surgical removal of the eyeball and part of the optic
nerve
Indication for enucleation: -
– Blindness after penetrating injury
– Painful blind eyes that is unresponsive to the medical treatment
– Tumor of the eye

Panophthalmitis
• An inflammation of the inner eye which usually affects all the layers of the
eyeball. The inflammation can also extend into tissue surrounding the
eyeball
1, Inflammation of eye and surrounding structures
2, Eye and surrounding structures are inflamed
3, Rapid progressive destruction of eye after trauma
4, Inflammation of all eye structures
Causes
• Penetrating injury to the eye, septicemia or can spread from pus-producing
infection in another part of the body
Symptoms of Panophthalmitis
• Eye pain, Ruptured eyeball
• Protruding eyeball
• Vision problems
Management
- Early detection
- Potent systemic antibiotics ( Penicillin + gentamycin+ Metronidazole)
- Anti inflammatory drugs
- Surgical interventions

Flow of Aqueous humor
• Aq.humor – - 90% ---- Trabecular meshwork ---
Canal of schlemn----- Episcleral veins ----
Aq.humor – - 10% --- Ciliary body ----Suprachoiroid
space --- Veinous circulation of choroid, sclera &
ciliary body

Other conditions of the eye
Glaucoma
Glaucoma: is a group of ocular conditions characterized by optic
nerve damage or characterized by elevated IOP associated
with optic cupping and visual field loss. The normal range of
IOP is 10 – 24mmHg (>21mmHg,or 2.8 Kpa)
- Glaucoma is often called “a silent thief of sight” because most
patients are unaware of that have the disease until they
experience visual change and vision loss
- It is more prevalent > 40 years of age
- A leading cause of irreversible visual loss
There is no cure for glaucoma, but research continues
S&SXs
• Blurred vision, difficulty on focus
• Difficulty adjusting eyes on low lighting
• Loss of peripheral vision , “Halos” around light
• Aching around eyes and headache associated with raised IOP
(> 24mmHg)

I/ Open-angle glaucoma (most common)
• Usually bilateral, but one eye may be more severely affected
than the other
A/ Chronic open-angle glaucoma (COAG,90%)
- Anterior chamber angle is open & normal, angle b/n iris and
sclera is normal
Etiology:- Old age, trauma, steroids, DM, myopia, CVA, infection,
tumor,
S&SXs: Optic nerve damage (pallor, cupping), visual field
defects, IOP >21 mm Hg. May have fluctuating IOPs
-No symptoms but possible ocular pain, headache, and halos.
DX:- Gonioscopy, Tonometry, Perimetry, & Opthalmoscopy
RX: Decrease IOP 20% - 50%. Additional topical and oral agents
added as necessary
• If medical treatment is unsuccessful, laser trabeculoplasty (LT)
can provide a 20 % drop in intraocular pressure. - Glaucoma
filtering surgery if continued optic nerve damage despite
medication therapy and LT

I/ Open-angle glaucoma (most common)
B/ Ocular hypertension
S&SXs: elevated IOP without disc or field
abnormality. The patient may be observed
periodically as a glaucoma suspect
RX: Lower IOP by at least 20%
C/ Normal tension glaucoma
S&SXs: IOP ≤ 21 mm Hg. Optic nerve damage,
visual field defects
RX: Similar to COAG, however, the best
management for normal tension glaucoma
management is yet to be established
Goal is to lower the IOP by at least 30%

II/ Angle-closure (pupillary block) glaucomas
• Obstruction in aqueous humor outflow due to the
complete or partial closure of the angle from the
forward shift of the peripheral iris to the trabecula. The
obstruction results in an increased IOP
A/ Acute angle-closure glaucoma (AACG,10 %)
S&SXs: Rapidly progressive visual impairment, periocular
pain, conjunctival hyperemia, and congestion. Pain may
be associated with nausea, vomiting, bradycardia, and
profuse sweating. -Reduced central visual acuity,
severely elevated IOP, corneal edema. Pupil is vertically
oval, fixed in a semidilated position, and unreactive to
light and accommodation
- Sudden vision loss in 48- 72 hrs, IOP >30 mmHg angle
b/n iris and sclera decreases

II/ Angle-closure (pupillary block) glaucomas
Acute angle-closure glaucoma ---
RX: Ocular emergency; administration of
hyperosmotics, azetazolamide, and topical ocular
hypotensive agents, such as pilocarpine and beta-
blockers (betaxolol).
Possible laser incision in the iris (iridotomy) to release
blocked aqueous and reduce IOP. Other eye is also
treated with pilocarpine eye drops and/or surgical
management to avoid a similar spontaneous attack.
- Avoid caffeine

Angle-closure (pupillary block) glaucoma---
B/ Subacute angle-closure glaucoma
S&SXs: Transient blurring of vision, halos around lights;
temporal headaches and/or ocular pain; pupil may be semi-
dilated.
RX: Prophylactic peripheral laser iridotomy. -Can lead to acute
or chronic angle-closure glaucoma if untreated.
C/ Chronic angle-closure glaucoma
S&SXs: Progression of glaucomatous cupping and significant
visual field loss; IOP may be normal or elevated; ocular pain
and headache.
RX: Management similar to that for COAG: includes laser
iridotomy and medications.
Diagnostic procedures
• Tonometry: Goldmann applanation tonometer, Perkins
tonometer and Tonopen, Pneuma-tonometer, Schiotz
tonometer.

General mgt for glaucoma
Medical treatment
1/ Suppression of aqueous humor production
A. Beta-adrenergic blocking agents (Timolol 0.5% 1gtt once/d, betaxolol)
B. Alpha-adrenergic agonist (Epinephrine dilates pupil) CI for angle closure
glaucoma
C. Systemic carbonic anhydrase inhibitors (Acetazolamide 200 mg po TID )
2/ Facilitation of aqueous outflow
- Parasympathetic agents= Cholinergics (miotics) (Ex. Pilocarpine 2%
2gttsTID)
= Increase out flow of aq.humor by affecting ciliary muscle contraction &
pupil constriction ---- Allowing flow through a larger opening b/n the iris
& trabecular meshwork
3/ Reduction of vitreous volume
-Hyper osmotic agents (oral glycerin, IV urea, or mannitol)
4/ Occular steroids Ex. Prednisolone actate
5/ Prostaglandin analog
Latanoprost --- Increases uveo-scleral outflow

General mgt for glaucoma /National/
 Open angle glaucoma (chronic)
First line ß-blocker
• Timolol 0r Betaxolol 0.25%, 0.5% , instil 1 gtt BID.
N.B. If there is no response despite adequate adherence to
the above medicines : ADD
Prostaglandin analogues
• Latanoprost, 0.005%, ophthalmic drops, instil 1 drop daily
Alpha Agonist
• Brimonidine 0.15–0.2%, ophthalmic drops, instill 1 drop 12
hourly.
Parasympathomimetic agent:-
• Pilocarpine, 2-6%, ophthalmic drops, instil 1 drop 6 hourly
Carbonic anhydrase inhibitors:-
• Acetazolamide, oral, 250mg 6 hourly

General mgt for glaucoma/National/---
Angle closure glaucoma (acute)
• Acetazolamide, oral, 500mg immediately as a
single dose, Followed by 250mg 6 hourly. PLUS
• Timolol, 0.25–0.5%,drops, instill 1 drop 12 hourly.
N.B. Where those measures fail, for short-term
use only:
• Mannitol, IV, 1.5–2 g/kg as a 20% solution over
30–60 minutes. OR
• Glycerol, oral, 1 g/kg of 50 % solution as a single
dose immediately.

Surgical treatment for glaucoma
Peripheral iridotomy & iridectomy – for pupilary block
glaucoma
Laser trabecloplasty: burn via a goniolens to trabecular
meshwork
Glaucoma drainage surgery: To drain Aq.hum from anterior
chamber to sub-conjunctival space in to a bleb, there by
passing normal drainage structure --- For chronic glaucoma
Nursing management
• Ensure compliance to treatment
• Check IOP 1-2 hrs postoperatively
• Cover eye with a patch & protective shield
• Pt should report severe pain/ nausea– Hemorrhage
• Age > 40 years annual examination of IOP

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