Ear, eye and nose disorder updated pdfffff2

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By: Getenet D(BScN, MSc in MSN)
LECTURER
BDU-CHS, DEP’T OF NURSING
FOR 2ND YEAR
UNDERGRADUATE NURSING
STUDENTS ,2012 E.C
Ear Eye , disorder

External Otitis (Otitis Externa)
 Refers to an inflammation of the external auditory
canal.
 Causes include water in the ear canal (swimmer's
ear); trauma to the skin of the ear canal, permitting
entrance of organisms into the tissues; and systemic
conditions, such as vitamin deficiency.
 Bacterial or fungal infections are most frequently
encountered.

Otitis Externa …Contd
 The most common bacterial pathogens associated with
external otitis are Staphylococcus aureus and
Pseudomonas species.
 The most common fungus isolated in both normal and
infected ears is Aspergillus.
 External otitis is often caused by a dermatitis such as
psoriasis, eczema, or seborrheic dermatitis.

Cont.…..
 Even allergic reactions to hair spray, hair dye,
and permanent wave lotions can cause
dermatitis, which clears when the offending
agent is removed.

Types OE
 Chronic OE –longer duration (>6 weeks)
 Eczematous OE –various dermatologic conditions (eg,
atopic dermatitis , psoriasis, systemic lupus
erythematosus) that may infect the EAC and cause OE
 Necrotizing (malignant) OE – This is an infection that
extends into the deeper tissues adjacent to the EAC; it
primarily occurs in adult patients who are
immunocompromised (eg, Dm AIDS) and is rarely
described in children; it
 Otomycosis - Infection of the ear canal secondary to
fungus species such as Candida or Aspergillus
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Pathophysiology
 The processes involved in the development of OE can
be divided into the following 4 categories:
 Obstruction (eg, cerumen buildup, surfer’s exostosis,
or a narrow or tortuous canal), resulting in water
retention
 Absence of cerumen, which may occur as a result of
repeated water exposure or overcleaning the ear canal
 Trauma
 Alteration of the pH of the ear canal
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Clinical Manifestations
 Drainage from the ear - yellow, yellow-green, foul
smelling, persistent
 Ear pain - felt deep inside the ear and may get worse
when moving head
 Hearing loss
 Itching of the ear or ear canal
 Fever
 Trouble swallowing
 Weakness in the face
 Voice loss

Diagnosis
 Ear inspection:- the canal appears red and
swollen in well-developed cases.
 In fungal infections, hair like black spores may
even be visible.
 physical examination
 Otoscope : narrowing of the ear canal from
inflammation and the presence of drainage and
debris.
 Culture of the drainage
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Medical Management
• Relieving the discomfort.
• Reducing the swelling of the ear canal.
• Eradicating the infection.
• Analgesics for the first 48 to 92 hours.
• Antibiotics for infection and corticosteroid agents to
soothe the inflamed tissues.
• For fever, systemic antibiotics may be prescribed.
• For fungal disorders, antifungal agents are prescribed.

Medical Management Cont.…..
 If the tissues of the external canal are edematous, a
wick should be inserted to keep the canal open
so that liquid medications (e.g. antibiotic otic
preparations) can be introduced.
 These medications may be administered by dropper
at room temperature.
 Such medications usually combine antibiotic and
corticosteroid agents to soothe the inflamed tissues.

Medical Management Cont.….
 For cellulitis or fever, systemic antibiotics may be
prescribed.
 For fungal disorders, antifungal agents are
prescribed.
 First line Oxytetracycline hydrochloride +
Polymyxin B sulphate + Hydrocortisone acetate, 2
drops 2-3 times daily
 Alternatives
 Cloxacillin, 500mg P.O., QID

IMPACTED CERUMEN
 ear wax accumulates in ear canal
leading to blockage and pressure
on ear canal.
 CAUSES
 Use of hearing aids or ear
plugs
 Putting objects in the ear
 Anatomical defect (which
interferes in removal of wax)
Older age
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SIGNS AND SYMPTOMS
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 Tinnitus, Itching, Difficulty in hearing, Ear
discharge, Odor coming from the ear
 MANAGEMENT
Irrigate the ear canal with irrigator.
Instill antibiotic ear drops to prevent
infection.
Manual removal of wax.
Wiping and clean the external ear by a
cloth.

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 peas, beans, pebbles, toys, and
beads.
 Insects may also enter the ear canal.
 In either case, the effects may range from no
symptoms to profound pain and decreased
hearing.
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Foreign Bodies management
 Removing a foreign body from the external auditory
canal can be quite challenging.
 The three standard methods for removing foreign
bodies are the same as those for removing cerumen:
irrigation, suction, and instrumentation.
 The contraindications for irrigation are also the same.
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Cont.…..
 Foreign vegetable bodies and insects tend to
swell; thus, irrigation is contraindicated.
 Insect can be dislodged by instilling mineral oil,
which will kill the insect and allow it to be removed.
 In some circumstances, the foreign body may have
to be extracted in the operating room with the
patient under general anesthesia.
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Malignant External Otitis
 A more serious, although rare, external ear infection is
malignant external otitis (temporal bone osteomyelitis).
 This is a progressive, debilitating, and occasionally fatal
infection of the external auditory canal, the surrounding
tissue, and the base of the skull.
 Pseudomonas aeruginosa is usually the infecting organism
in patients with low resistance to infection.
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Treatment
 Successful treatment includes control of the diabetes,
administration of antibiotics (usually intravenously), and
aggressive local wound care.
 Standard parenteral antibiotic treatment includes the
combination of an antipseudomonal agent and an
aminoglycoside, both of which have potentially serious side
effects.
 Because aminoglycosides are nephrotoxic and ototoxic,
serum aminoglycoside levels and renal and auditory
function must be monitored during therapy.
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Conditions of the Middle Ear
Tympanic Membrane Perforation
 Perforation of the tympanic membrane is usually
caused by infection or trauma.
 Sources of trauma include skull fracture, explosive
injury, or a severe blow to the ear.
 Less frequently foreign objects (e.g., cotton-tipped
applicators, bobby pins, keys) that have been pushed
too far into the external auditory canal.

Cont.….
 In addition to tympanic membrane perforation,
injury to the ossicles and even the inner ear may
result from this type of action.
 Attempts by patients to clear the external auditory
canal should be discouraged.
 During infection, the tympanic membrane can
rupture if the pressure in the middle ear exceeds
the atmospheric pressure in the external auditory
canal.

Medical Management
 Although most tympanic membrane perforations
heal spontaneously within weeks after rupture,
some may take several months to heal.
 Some perforations persist because scar tissue grows
over the edges of the perforation, preventing
extension of the epithelial cells across the margins
and final healing.

Cont….
 In the case of a head injury or temporal bone fracture, a
patient is observed for evidence of cerebrospinal fluid
otorrhea or rhinorrhea—a clear, watery drainage from
the ear or nose, respectively.
 While healing, the ear must be protected from water

Surgical Management
 The decision to perform a tympanoplasty (surgical
repair of the tympanic membrane) is usually based
on the need to prevent potential infection from
water entering the ear or the desire to improve the
patient's hearing.

Acute Otitis Media
 Ear infections can occur at any age; however, they are
most commonly seen in children.
 Approximately three out of four children experience
an ear infection by the time they are 3 years of age.
 Acute otitis media (AOM) is an acute infection of the
middle ear, usually lasting less than 6 weeks.

Cause of Acute Otitis Media
 Usually Streptococcus pneumoniae and Haemophilus
influenzae which enter the middle ear after eustachian
tube dysfunction caused by obstruction related to upper
respiratory infections, inflammation of surrounding
structures (e.g., sinusitis, adenoid hypertrophy), or allergic
reactions (e.g., allergic rhinitis).

Bacteria responsible for acute
otitis media
 Streptococcus pneumonia 35%,
 Haemophilus influenzae 25%,
 Moraxella catarrhalis 15%.
 Group A streptococci and Staphylococcus aureus
may also be responsible.
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Cont…..
 Bacteria can enter the eustachian tube from contaminated
secretions in the nasopharynx and the middle ear from a
tympanic membrane perforation.
 A purulent exudate is usually present in the middle ear,
resulting in a conductive hearing loss.

 The condition, usually unilateral in adults, may be
accompanied by otalgia.
 The pain is relieved after spontaneous perforation or
therapeutic incision of the tympanic membrane.
 Other symptoms may include drainage from the ear,
fever, and hearing loss.

Cont….
 On otoscopic examination, the external auditory
canal appears normal.
 The tympanic membrane is erythematous and often
bulging.
 Patients report no pain with movement of the
auricle.

Risk factors
 Age (younger than 12 months)
 Chronic upper respiratory infections
 Medical conditions that predispose to ear infections
(Down syndrome, cystic fibrosis, cleft palate), and
 Chronic exposure to secondhand cigarette smoke.

Medical Management
 With early and appropriate broad-spectrum
antibiotic therapy, otitis media may resolve with no
serious sequelae.
 If drainage occurs, an antibiotic otic preparation is
usually prescribed.
 The condition may become subacute (lasting 3
weeks to 3 months), with persistent purulent
discharge from the ear.
 Rarely does permanent hearing loss occur.

Medical management
 Amoxicillin for dosage based on age 10 ten days
 Alternatives
 Ampicillin
 Parenteral:
 N.B. Paracentisis should be carried out early if the
tympanic membrane does not perforate spontaneously.
 Antrotomy should be carried out early if it is indicated
on clinical grounds.
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Surgical Management
 An incision in the tympanic membrane is known as
myringotomy or tympanotomy.
 The tympanic membrane is numbed with a local anesthetic
such as phenol or by iontophoresis (ie, electrical current flows
through a lidocaine-and-epinephrine solution to numb the ear
canal and tympanic membrane).

Cont….
 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.

Chronic Otitis Media
 Is the result of recurrent AOM 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.

Causes of Chronic Otitis Media
 Late treatment of acute otitis media.
 Inadequate or inappropriate antibiotic therapy.
 Upper airway sepsis.
 Lowered resistance, e.g. malnutrition, anemia,
immunological impairment.
 Particularly virulent infection, e.g. measles.
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 Discharge- mucopurulant,non
foul smelling
 Deafness
 Earache
 tympanic membrane perforation,
 Tuning fork test:rinne-negative
 Weber-lateralised to one side

Investigations
 Culture and sensitivity
 Examination under microscope
 Pure tone audio gram: mild conductive loss
between 20 to 30dB
 X-ray of mastoid, neck lateral view
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Medical management
 First line
 Amoxicillin, 500mg P.O., TID for 10-15 days
 Augmentin

Serous Otitis Media
 Serous otitis media (middle ear effusion) involves fluid,
without evidence of active infection, in the middle ear.
 In theory, this fluid results from a negative pressure in the
middle ear caused by eustachian tube obstruction.
 When this condition occurs in adults, an underlying cause
for the eustachian tube dysfunction must be sought.
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Cont…..
 Middle ear effusion is frequently seen in patients after
radiation therapy or barotrauma and in patients with
eustachian tube dysfunction from a concurrent upper
respiratory infection or allergy.
 Barotrauma results from sudden pressure changes in the
middle ear caused by changes in barometric pressure,
as in scuba diving or airplane descent.
 A carcinoma (eg, nasopharyngeal cancer) obstructing
the eustachian tube should be ruled out in adults with
persistent unilateral serous otitis media.
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 Hearing loss, fullness in the ear or a sensation of
congestion, or popping and crackling noises, which
occur as the eustachian tube attempts to open.
 The tympanic membrane appears dull on otoscopy,
and air bubbles may be visualized in the middle
ear.
 Usually, the audiogram shows a conductive hearing
loss.
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Management
 Serous otitis media need not be treated medically
unless infection (i.e.AOM) occurs.
 If the hearing loss associated with middle ear
effusion is significant, a myringotomy can be
performed, and a tube may be placed to keep the
middle ear ventilated.
 Corticosteroids in small doses may decrease the
edema of the eustachian tube in cases of
barotrauma.
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Cont….
 A Valsalva maneuver which forcibly opens the
eustachian tube by increasing nasopharyngeal
pressure, may be cautiously performed.
 This maneuver may cause worsening pain or
perforation of the tympanic membrane.
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Conditions of the Inner Ear
 Disorders of balance are a major cause of falls of
elderly people.
 The term dizziness is used frequently by patients
and health care providers to describe any altered
sensation of orientation in space.
 Vertigo is defined as the misperception or illusion of
motion of the person or the surroundings.
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Cont….
 Most people with vertigo describe a spinning
sensation or say they feel as though objects are
moving around them.
 Ataxia is a failure of muscular coordination and
may be present in patients with vestibular disease.
 Syncope, fainting, and loss of consciousness are not
forms of vertigo and usually indicate disease in the
cardiovascular system.
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Cont….
 Nystagmus is an involuntary rhythmic movement of
the eyes.
 Nystagmus occurs normally when a person watches
a rapidly moving object (eg, through the side
window of a moving car or train).
 However, pathologically it is an ocular disorder
associated with vestibular dysfunction.
 Nystagmus can be horizontal, vertical, or rotary
and can be caused by a disorder in the central or
peripheral nervous system.
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Motion Sickness
 Motion sickness is a disturbance of equilibrium
caused by constant motion.
 For example, it can occur aboard a ship, while
riding on a merry-go-round or swing, or in the back
seat of a car.
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 The syndrome manifests itself in sweating, pallor,
nausea, and vomiting caused by vestibular
overstimulation.
 These manifestations may persist for several hours
after the stimulation stops.
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Management
 Over-the-counter antihistamines such as dimenhydrinate
(Dramamine) or meclizine hydrochloride (Antivert) may
provide some relief of nausea and vomiting by blocking the
conduction of the vestibular pathway of the inner ear.
 Anticholinergic medications, such as scopolamine patches,
may also be effective because they antagonize the histamine
response. These must be replaced every few days.
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Cont…
 Side effects such as dry mouth and drowsiness may
occur.
 Potentially hazardous activities such as driving a car
or operating heavy machinery should be avoided if
drowsiness occurs.
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HEARING LOSS:
Hearing loss also known as hearing impairment is
partial or total inability to hear. It may occur in one or
both ears.
TYPES OF HEARING LOSS:
• Conductive hearing loss: It usually results from an
external ear disorders. Such as impacted Cerumen, or
middle ear disorders, otitis media or otosclerosis.
 In such conditions the efficient transmission of sound by
air to inner ear is interrupted.
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Types of hearing loss
2.Sensorineural hearing loss: It is a type of hearing loss,
or deafness, in which the root cause lies in the inner ear
or sensory organ (cochlea and associated structures) or
the vestibulocochlear nerve (cranial nerve viii).
 This is the most common type of permanent hearing
loss.
3. Mixed hearing loss: Both conductive and sensorineural
loss is present resulting from dysfunction of air and
bone conduction.
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CLINICAL MANIFESTATIONS:
 Tinnitus and increased inability to hear.
 Student with hearing impairment will be inattentive and
uninterested in class.
 Speech deterioration.
MANAGEMENT:
 Removal of Cerumen by irrigation.
 Removal of foreign bodies.
 Treating the underlying cause.
 for permanent or untreatable :Aural rehabilitation may
be beneficial
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Meniere’s Disease
 Meniere's disease is an abnormal inner ear fluid balance caused by a
malabsorption in the endolymphatic sac or a blockage in the
endolymphatic duct.
 Endolymphatic hydrops, a dilation in the endolymphatic space,
develops, and either increased pressure in the system or rupture of
the inner ear membrane occurs, producing symptoms of Meniere's
disease.
 More common in adults onset 40 years old
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CAUSES:
 Excessive endolymph in vestibular and
semicircular canals of inner ear.
 Viral infections
 Allergies
 Medications like Aspirin
 Stress
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 Vertigo and dizziness
 Tinnitus
 Hearing loss or deafness
 Fullness in both ears
 Photophobia
 Nausea and vomiting
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Medical Management
 Can be successfully treated with diet and
medication.
 Many patients can control their symptoms by
adhering to a low-sodium (2000 mg/day) diet.
 Psychological evaluation may be indicated if a
patient is anxious, uncertain, fearful, or depressed.
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Pharmacologic Therapy
 Consists of antihistamines such as meclizine
(Antivert), which suppress the vestibular system.
 Tranquilizers such as diazepam (Valium) may be
used in acute instances to help control vertigo.
 Anti emetics such as promethazine (Phenergan)
suppositories help control the nausea and vomiting
and the vertigo because of their antihistamine
effect.
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Cont…….
 Diuretic therapy (eg, hydrochlorothiazide) may relieve
symptoms by lowering the pressure in the endolymphatic
system.
 Intake of foods containing potassium (eg, bananas,
tomatoes, oranges) is necessary if the patient takes a
diuretic that causes potassium loss.
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Surgical Management
 Hearing loss, tinnitus, and aural fullness may continue,
because the surgical treatment of Meniere's disease is
aimed at eliminating the attacks of vertigo
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Endolymphatic Sac Decompression
 Endolymphatic sac decompression, or shunting,
theoretically equalizes the pressure in the
endolymphatic space.
 A shunt or drain is inserted in the endolymphatic sac
through a post auricular incision.
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Middle and Inner Ear Perfusion
 Ototoxic medications, such as streptomycin or
gentamicin, can be administered to patients by
infusion into the middle and inner ear.
 The success rate for eliminating vertigo is about
85%, but the risk of significant hearing loss is high.
 After the procedure, many patients have a period
of imbalance that lasts several weeks.
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Intraotologic Catheters
 In an attempt to deliver medication directly to the
inner ear, catheters are being developed to provide
a conduit from the outer ear to the inner ear.
 Medicinal fluids can be placed against the round
window for a direct route to the inner ear fluids.
 Potential uses of these catheters include treatment
for sudden hearing loss and various disorders
causing intractable vertigo.
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Vestibular Nerve Sectioning
 Vestibular nerve sectioning provides the greatest
success rate (approximately 98%) in eliminating the
attacks of vertigo. Cutting the nerve prevents the
brain from receiving input from the semicircular
canals.
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Tinnitus
 Tinnitus is a symptom of an underlying disorder of
the ear that is associated with hearing loss.
 The severity of tinnitus may range from mild to
severe.
 Patients describe tinnitus as a roaring, buzzing, or
hissing sound in one or both ears.
 Numerous factors may contribute to the
development of tinnitus, including several ototoxic
substances.
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Tinnitus….
 Underlying disorders that contribute to tinnitus may
include thyroid disease, hyperlipidemia, vitamin B12
deficiency, psychological disorders (eg, depression,
anxiety), fibromyalgia, otologic disorders (Ménière's
disease, acoustic neuroma), and neurologic disorders
(head injury, multiple sclerosis).
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Labyrinthitis
 Labyrinthitis, an inflammation of the inner ear, can
be bacterial or viral in origin.
 Bacterial labyrinthitis is rare because of antibiotic
therapy, but it sometimes occurs as a complication
of otitis media.
 Viral labyrinthitis is a common diagnosis, but little is
known about this disorder, which affects hearing
and balance.
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CAUSES:
 Acute otitis media and meningitis
 Viral infection, head injury and neoplasm of middle ear
or VIII cranial nerve.
 Alcoholism
 Allergy
 Upper respiratory tract infection
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CAUSES Cont…..
 The most common viral causes are mumps, rubella,
rubeola, and influenza.
 Viral illnesses of the upper respiratory tract and
herpetiform disorders of the facial and acoustic
nerves (ie, Ramsay Hunt syndrome) also cause
labyrinthitis.
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 Extreme vertigo and dizziness
 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.
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 Sensorineural hearing loss
 Tinnitus
 Otorrhea
 Otalgia
 Neck pain stiffness
 Cognitive impairment like memory and thinking
problems.
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Management
 Treatment of bacterial labyrinthitis includes IV
antibiotic therapy, fluid replacement, and
administration of an antihistamine (eg, meclizine)
and antiemetic medications.
 Treatment of viral labyrinthitis is based on the
patient's symptoms.
102

Medical managment
 Treat any gonorrheal infection in pregnancy.
 Put tetracycline eye oint to new born with in 1hrs each
 Eryhomyocine eye oint to new born with in 1hr each eye
 Silver nitrate 1% eye drop to the new born with in 1hr
each eye
 Nursing managment
 Bathing the head of the new born separating from other
body parts
 Apply the ointment as orderd.
103

SUMMARY
 • Disorders of outer ear
 Otitis externa
 Impacted Cerumen
 Furunculosis
 Disorders of middle ear
 Acute otitis media
 Serous otitis media
 Chronic otitis media
 • Disorders of inner ear
 Hearing loss
 Meniere’s disease
 Labyrinthitis
104

Eye Disorders
Prepared By: Getenet D. (BSc, MSc)
105

Fun facts
 Did you know that the average blink takes 1/3 of a
second?
 Seeing is so important that it takes up more than 50% of
the brain’s functionality.
 Newborns don’t shed tears, though they do know how to
cry.
 You blink about 15-20 times in a minute.
 The most active muscles in your body are in your eyes.
 Your eyes can get sunburned.
106

Fun facts
 Blue eyed people are more tolerant of alcohol and less
tolerant of the sun
 If the human eye were a digital camera it would have 576
megapixels.
 We spend about 10% of our wake time with our eyes
closed.
 An ostrich’s eye is bigger than its brain.
 Chameleons can move their eyes in two directions at once.
 A single scallop can possess over a hundred eyes
107

Fun facts
 Your eyes contain around 107 million light sensitive cells.
 Dolphins can sleep with one eye open.
 Birds, cats and dogs have three eyelids.
 Yes, you can sneeze with your eyes open and no, your
eyes won’t fall out.
 Ommatophobia is the fear of eyes.
 The world’s most common eye colour is brown.
 Dogs cannot distinguish between red and green.
108

Fun facts
 The lifespan of the average eyelash is 5 months, the
rest of your hair will last 2-4 years.
 The eye has over 2 million moving parts.
 Women to men crying ratio 50/10.
 Source
 The Canadian Association of Optometrists
109

Function of crying
 Regulate their own emotion
 Get support from others
 Helps to relive pain
 Enhance mood
 Release chemicals that can reduce stress
 aids sleep
 Fight bacteria
 Improve vision
110

Learning Objectives
@ On completion of this chapter, the learner will be
able to:
 Identify significant eye structures and describe their
functions.
 Discuss clinical features, diagnostic assessment and
examinations, medical or surgical management, and
nursing management of ocular disorders.
 Define low vision and blindness and differentiate
between functional and visual impairment.
Prepared By: Getenet D. (BSc, MSc in AHN)
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THE EYE BALL (GLOBE)
HAS THREE LAYERS AND CAVITIES
1. The three layers (Coats) of eye ball:
A) The fibrous (outer) layer
-Cornea/sclera.
a) Cornea transparent
b) Sclera opaque representing the white appearance of the
eye ball
Function:
-Along with the IOP, maintains the Shape, stability of the
eye ball
- Optical

THE EYE BALL (GLOBE)…..
B) The vascular (Middle) layer
-Iris/Ciliary body/Choroid--------Uveal tissues.
-Brown to dark-brown in appearance.
e.g. -The iris represent the brown appearing part
behind the transparent cornea.
Functions:
-Nutrition for the inner layers of the eye ball.
-Provide dark environment of the eye ball cavity
to avoid image degradation. E.g. film developing

THE EYE BALL (GLOBE)…..
C.Neuro Sensory (inner) layer
-Retina/ RPE.
Functions:
-transducers the electromagnetic form of image to
neuronal impulse to be dispatched to the brain.

THE THREE CAVITIES:
A. Anterior chamber
-Between the Cornea and anterior face of the Iris filled
with the Aqueous-fluid.
B. Posterior chamber:
- Between the posterior face of the Iris and lens. Is also
filled with the aqueous.
*A and B communicate through the pupil.
C. Vitreous cavity
Between the Lens and retina Filled with Vitreous (jelly
fluid)

Significance:
1. Aqueous from the ciliary body------P/C----Pupil----
A/C—Drainage channel----Episcleral vein---systemic
circulation.
2. Balance between secretions and drainage--------Normal
intraocular pressure (10-20mmHg)
This make the eye ball a pressurized chamber
Decreased drainage------Increased intraocular pressure
(ocular hypertension) ---- (Resultant damage to optic
nerve)----Glaucoma.
Aqueous provide nutrient material to the avascular ocular
structures such as the lens and the cornea.

THE LACRIMAL SYSTEM
Has secretor and drainage part.
1. Secrotary system:
Tear film is composed of three layers:
-Oily/aqueous/Mucin layer
a) Mucin: Goblet cells of conjunctiva.
b) Oily: sebaceous mebomian gland, gland of zeiss and moli.
c) Aqueous: Main lacrimal gland, glands of Kraus and wolfring.
Main lacriaml gland is located at the anterior upper temporal aspect of
orbit

Tear film function:
Oily part:
-Protect tear evaporation.
Mucin layer:
-Alter the hydrophobic corneal surface to Hydrophilic so
that wetting is facilitated.
Aqueous Part:
-Provide nutritive and immunologic substances.
General function:
-Nutrition
-Optical
-Immunologic
-Wash out tiny foreign bodies.

DRAINAGE SYSTEM:
Pumps and drain the tear to nasal cavity.
Drainage canal:
-Composed of Punctai, canaliculi, lacrimaL sac and NLD
a) Puncta:
-Small opening at medial end of each lids.
b) Canaliculi:
-Continuation of the puncta 2 mm vertical and 8mm
horizontal coursing to lacriasml sac.
c) Lacrimal sac:
-Cystic structure on the lateral aspect of nasal bridge.
d) Nasolacrimal duct:
-cross the nasal bone to nasal cavity

Lacrimal pumping:
Tear fluid drains from the surface of the eye
through the draining system to nasal cavity.
-depend on the potency of each segments of the
drainage channel.
-Is aided by a lacriaml pump mechanism.
a) Normal lid apposition to the eye ball.
b) Zipp like lid closure (orbicularis oculi
muscle).

Failure lead to;
Epihora: tearing due to drainage system failure.
A) Pump failure. E.g. Facial palsy.
B) Drainage canal obstruction.
-Difference from tearing
Tearing is due to irritative or emotional secretion
of tear.

Red Eye
 The red eye can be painful or is
painless Or
 It is accompanied with or without
discharge
Or
 Accompanied by blurring of vision
or not
124

What causes a red eye ?
Dilatation of Conjunctiva blood vessels e.g.
conjunctivitis
 Episcleral blood vessels e.g. episcleritis
 Scleral blood vessels e.g. scleritis
Or
 Accumulation of blood in the subconjunctival
space i.e. Subconjunctival hemorrhage
125

causes a red eye…
 Environmental causes of red, bloodshot eyes include:
 Airborne allergens (causing eye allergies)
 Smoke (fire-related, second-hand cigarette smoke,
etc.)
 Dry air (arid climates, airplane cabins, office buildings,
etc.)
 Airborne fumes (gasoline, solvents, etc.)
 Chemical exposure (chlorine in swimming pools, etc.)
 Overexposure to sunlight (without UV-blocking
sunglasses)
126

causes a red eye…
 Dry eyes
 Eye allergies
 Pink eye (conjunctivitis)
 Contact lens wear
 Digital eye strain
127

Serious eye conditions that can cause red eyes
include:
 Eye infections
 Eye trauma or injury
 Recent eye surgery (cosmetic eye surgery, etc.)
 Uveitis
 Acute glaucoma
 Corneal ulcer
128

What causes a discharge in a red
eye?
 Exudation/transudation form conjunctival vessels
 Due to over production of tears
 Due to blockage of tear passages.
 What causes visual loss in a red
eye?
 Corneal oedema/ulceration
 Hazy anterior chamber ( Flare/cells)
 Dilated pupil
129

What causes pain in a red eye ?
 Pain is caused by irritation of the: Conjunctival nerves
e.g dull ache in conjunctivitis
 Corneal nerves: pain in corneal ulcer
 Ciliary nerves: pain in scleritis, uveitis and angle
closure glaucoma
 It is important to remember that the orbit is
surrounded by
 air sinuses and inflammation of these is also an
important cause of pain around the eyes
130

Causes of a painless red eye
 Sub conjunctiva hemorrhage and Episcleritis are the
two important causes of a painless red eye.
 The other causes of a localised redness are:
 Pterygium and
 Pigencula
131

Refractive Errors
 Refractive error is defective in the ability of the lens
of the eye to focus an image accurately as occur in
near sightedness and far sightedness.
 Normal vision is called Emmeropia;
 People with refractive errors focus images either in
front or behind the retina and consequently don’t
see close or far image clearly.
132

Refractive Errors cont……
 The normal visual acuity is 20/20 the visual acuity is
expressed in a ratio that relates what a person with
normal vision sees from a distances of 20 feet (6
metre)
 Etiology
 Hereditary
133

Classification of refractive error
A. Myopia usually occurs in people with elongated
eyeballs.
 Because of the excessive length of the eye, light rays focus
at a point in the vitreous body before they reach the retina ,
the myopic eye can’t clearly see object in the distance since
it has no way to reduce the excessive refractive power.
134

Cont….
B. Hyperopia it results when the eye ball is shorter than
normal, the causing, light rays to focus at theoretical
point behind the retinal.
 This type of image formation is due to insuffient reactive
power to focus light on the retinal and short vision
impaired.
135

Cont….
C. Astigmation result from unequal curvature of the
cornea.
 The focus of rays is distorted, and the patient can’t
focus horizontal and vertical rays on the retina at the
same time vision is general distorted.
 Either myopia or hyperopia may coexist with
astigmation.
 This disorder can’t be eliminated by accommodation but
can generally be corrected by glasses grounded to
neutrize the unequal curvature.
136

Cont…
D. Presbyopia - Is a form of farsightedness that
occurs with aging people with presbyopia hold
reading material further away to see it more
clearly
 Presbyopia is caused by the gradual loss of elasticity
of the lens, which leads to a decreased ability to
accommodate, or focus, for near vision by the ages 40
to 50
137

138

Clinical manifestation
 Head ache
 Blurred vision
 Eye fatigue
139

Diagnostic procedure
 Snellen chart – to determine visual acuity
 Placed 6 feet or 20 m away from patient
 Normal visual acuity is expressed 20/20 feet
 Gross examination as perception of light, hand
motion and counting fingers of examiner
140

Medical management
 Refractive error is corrected with: -
A. Eye glasses such as converging lens (convex lens) in
hyperopia and diverging lens (concave lens) for
myopia, these lenses bend light ray to compensate for
clients refractive error.
B. Contact lenses; they are small curved lenses, primary
plastic, in shaped to fit the person's eye to correct
refractive error or to enhance appearance
141

Cont….
 There are two forms of contact lenses float on the
pre-corneal tear film and must be inserted,
removed, cleaned and stored to prevent damage
infection.
1. Hard contract lenses are gas- permeable last 15-
20 years with care
2. Soft contract lenses may require more frequent
replacement usually every 1-3 years.
142

Surgical management
 Incisional radial keratotomy is a procedure that
some times can correct refractive disorders under
local anesthesia;
 the cornea is reshaped by making surgical incision
for myopia.
143

Other management
 Clean ,care, and safe guard contact lens and eye
glasses
 Teach patient how to remove, insert and care for
visual aids
1. Clean eye glasses well daily or more with warm
water & soap
2. Rinse the glasses well and dry with a soft, clean
cloth.
 Instruct for contact lenses care depends on its type
hard or soft.
144

Hordeolum
 External hordeolem also known as sty
 Sty is infection and inflammation of the superficial
eye lid gland (moll gland a type oil gland) located
at the edge of the eyelid
 Etiology: it is caused by staphylococcus areus
145

Hordeolum ……
146

 Sub acute pain
 Redness
 Swelling of a localized area of the lid, tender
 Red pustules externally or internally within the eyelid.
 Diagnosis - The physical findings.
 Culture of the exudates
 Complication: chalazoin
147

Medical and surgical management
 Treatment with warm, moist compresses for 10-15
minutes 3-4 times a day to hasten healing process.
 If no change after compress with in 48 hours may
require incision and drainage in severe cases.
 Apply the topical medications
 Tetracycline .o.1% ointment 3-4 times a day.
 Gentamycin o.3% ointment 2-3 times a day.
 Chloramphenicol o.5% ointment 3-4 times days.
148

Chalazoin
 is a chronic granulomatous (cyst) of the meibomian
gland localized swelling in the inner surface of the
eye lid at the junction of the conjunctiva and lid
margin.
 Etiology Resulted from obstruction and retained
secretion of the meibomian glands
 Clinical pictures
 Localized, painless swelling
 As it grows, feels hard
 Non tender, Small nodule in the eye lid on examination
149

Chalazoin…..
150

Chalazoin…..Cont
 Complication
 The enlargement with in the eye lid affects visual acuity.
 Secondary infection.
 Diagnostic procedure: - Sign and symptoms
 Distorted vision due to corneal compression &
obscured pupil.
152

Medical management
 Uninfected chalazoin usually required treatment and
disappear spontaneously within a few months.
 Warm soaks and massage of the surrounded area to promote
drainage.
 Antibiotics therapy and corticosteroid drop or injection
 Excision is indicated if the cyst is firm distort vision &
infected.
153

Blepharitis
 Blepharitis is a chronic inflammation of the
eyelid margins.
 Etiology
Seborrhae exess sebaceous(oil) ( non
ulcerative) most common form.
Staphylococcal infection.
Both could also lead to the development
of hordeola and chalazions.
154

Blepharitis…..
155

Clinical manifestations
Eye irrtation
Burning sensation
Itching of the eye lid margin.
Red - rimmed eyes
Patchy flakes cling to eyelashes, visible about
the lids
Loss of lashes
Development of white eye lashes
Dilated blood vessels at the lid margin
156

Medical treatment
It includes:
 Very careful cleaning of the lid margins daily /Bid using
Cotton applicator, Non irritating shampoo, baby
shampoo,water and mild friction.
 Warm compress may be applied across each eyes
 Using aseptic technique removing crusted matter with a wash
cloth and apply topical antibiotics and steroids.
157

Topical antibiotics
₢ TTC eye iont 1% 3-4 x a day.
₢ Gentamycine 0.3% 2-3/d
₢ Chloramphanicol 0.5% ointment 3-4 x a day
₢ Hydrocortisone 1.5% ointment 3-4x aday.
₢ Predonisolone acetate 0.125% solution 1drop q1 -
2hr
₢ Dexamethasone 0.1% solution or 0.5% oint 3-4
x.days
158

What is conjunctivitis?
 Conjunctivitis (―pink-eye‖) – is an inflammation of the
conjunctiva due to a viral (Adenovirus), bacterial, or allergic
 The most common ocular disease worldwide.
 Characterized by a pink appearance (hence the common term
pink eye) because of sub conjunctiva blood vessel congestion
 inflammatory conditions like Stevens Johnson syndrome can
cause it

Conjunctivitis……..
 Causes:-
chemicals, fungi,
certain diseases,
 contact lens
wear(especially
wearing lenses
overnight).

Conjunctivitis…
 The conjunctiva can also become irritated by foreign
bodies in the eye
 And by indoor and outdoor air pollution caused, for
example, by chemical vapors, fumes, smoke, or dust.

Bacterial conjunctivitis
 Commonly caused by
staphylococcus aurous
 Streptococcus pneumonia
 Chlamydia trachoma is
commonly in adult
 Highly contagious
 Purulent discharge can help us to
dx

 Redness in the white of the eye or inner eyelid
 Increased amount of tears
 Thick yellow discharge that crusts over the eyelashes
,especially after sleep
 Green or white discharge from the eye

Assessment and Diagnostic Findings
 Type of discharge.
 Type of conjunctival
reaction.
 Presence of
membrane/ pseudo
membrane.
 Lymphadenopathy.

Laboratory investigation
 Cultures.
 Cytological investigations.
 Detection of Chlamydia antigens.
 Impression cytology ocular infection.
 Polymerase chain reaction: small quantity of DNA
for chlamydia trachomatis.

Kind of Discharge
 Exudates plus debris plus mucus plus tears.
 Serous; watery exudate in acute viral and acute
allergic conjunctivitis.
 Purulent; puss in severe acute bacterial conjunctivitis.
 Muco purulent; puss plus mucus in mild bacterial
conjunctivitis and Chlamydial conjunctivitis.

Treatment
 Treatment Objective – Treat the infection ፣Prevent
complications
 Non Pharmacologic - Frequent cleaning of the eyelids
and warm compression
 Pharmacologic
 First line Chloramphenicol, 1 drop every 4-6 hours OR
single strip of ointment applied 24 times per day for
10-15 days.
 Alternatives Tetracycline, single strip of ointment
applied 2-4 times per day for 10-15 days.
 OR Tobramicin, 1 drop every 4-6 hours per day for 10-
15 days. Dosage form: Eye drop, 0.3%

Viral Conjunctivitis
 Viral conjunctivitis is caused by infection of the
eye with a virus.
 Can be caused by a number of different viruses,
many of which may be associated with an upper
respiratory tract infection, cold, or sore throat.
 Usually begins in one eye and may progress to
the second eye within days.

Viral Conjunctivitis…
 Spreads easily and rapidly between people and can
result in epidemics.
 Is typically mild and usually clears up in 7-14 days
without treatment and resolves without any long-
term effects.
 In some cases, it can take 2-3 weeks or more for
viral conjunctivitis to completely clear up,
depending on whether complications develop.

Causes
1. Severe adenoviral infection.
2. Ligneous conjunctivitis.
3. Gonococal conjunctivitis.
4. Stevens-Johnson syndrome.

 Photophobia
 Pseudo membrane: Outside
epithelium, Coagulated
exudates adherent to the
inflamed epithelium.
 Can be easily pealed off.
 Watery discharge
 Lymphadenopathy

Treatment
 Self limited
 Cold compress
 If the is any complication can use eye drop

Allergic conjunctivitis
 Allergic conjunctivitis is caused by the body's
reaction to certain substances to which it is allergic,
such as pollen from trees, plants, grasses, and
weeds; dust mites; molds; dander from animals;
contact lenses and lens solution; and cosmetics.

Allergic conjunctivitis…
 Allergic conjunctivitiets Cases are typically mild
and can last as few as 2-3 days or up to 2-3 weeks.
 Many cases improve in 2-5 days without treatment
 However, topical antibiotics are often prescribed to
treat the infection.

 Can occur year-round due to indoor allergens, such
as dust mites and animal dander.
 May result, in some people, from exposure to
certain drugs and cosmetics.

 Clears up once the allergen or irritant is removed or
after treatment with allergy medications.
 Can occur when contact lenses are worn too long or
not cleaned properly.

Sign and symptoms
 Red eye
 Sever itching both eye
 Copious mucous
discharge
 blepharospasm,
 blurred vision
 And have purulent discharge
through out the day that can be
yellow ,white, green colour.

Diagnosis
 Investigations – Clinical
 Treatment
 Dexamethasone
 Prednisolone,

Nursing intervention
 Practice good hygiene to control the spread of pink
eye. For instance:
 Don't touch your eyes with your hands.
 Wash your hands often.
 Use a clean towel and washcloth daily.
 Don't share towels or washcloths.
 Change your pillowcases often.
 Throw away your eye cosmetics, such as mascara.
 Don't share eye cosmetics or personal eye care items.

Trachoma
 Is chronic chlamydial conjuctivitis found in hot, dry climate
and It is an infecious disease that affects more than 500x106
people world wide
 Trachoma is the world`s leading causes of preventable
blindness and primary affects people in Africa , the middle
east and Asia .
 Etiology : Chlamydial trochomitis

Transmission
 personal contact (via hands, clothes or bedding) and
by flies that have been in contact with discharge from
the eyes or nose of an infected person.
With repeated episodes of infection over many
years, the eyelashes may be drawn in so that
they rub on the surface of the eye, with pain
and discomfort and permanent damage to the
cornea.
195

 Feeling of foreign body ( mild itching & irritation )
 Burnig sensatioon
 Photophobia
 Lacrimation
 Little mucopurulent discharge
 Follicles appear on the conjuctiva – in acute inflammation
process
 Follicles are tense, red
 Thick lid and drooping
 Trachomatous pannus ( Vascularized cornea )

Transmition of trachoma
 direct contact.
 The bacteria are also spread through shared blankets,
pillows, and towels.
 Certain conditions promote the spread of trachoma
bacteria.
These include: poor personal hygiene
poor body waste and trash disposal
insufficient water supply for washings
close association with domestic animals

Investigation
 The World Health Organization (WHO) has introduced a
simple severity grading system for trachoma based on the
presence or absence of five key signs:
1. Trachomatous Inflammation–Follicular (TF): The presence of
five or more follicles in the upper tarsal conjunctiva.
2. Trachomatous Inflammation–Intense (TI): Pronounced
inflammatory thickening of the tarsal conjunctiva that obscures
more than half of the deep tarsal vessels.
3. Trachomatous Scarring (TS): The presence of scarring in the
tarsal conjunctiva.
4. Trachomatous Trichiasis (TT): At least one eye lash rubs on the
eye ball.
5. Corneal opacity (CO): Easily visible corneal opacity over the
pupil.

10. Inflammatory Trachoma - Follicles (TF)

11. Inflammatory Trachoma - Intense (TI)

12. Conjunctival Scarring of Trachoma (TS)

13. Trichiasis of Trachoma (TT)

14. Corneal Opacity due to Trachoma (CO)

Can you place each of these pictures in the correct category?

Prevention and Treatment
 The World Health Organization (WHO) advocates
SAFE strategy.
S = Surgery for complications (TT & CO)
A = Antibiotics for active (inflammatory) trachoma (TT
& TI)
F = Face washing, particularly in children
E = Environmental improvement including provision of
clean water

Trachoma …
―To eliminate a disease, the critical step is knowing
where it is – otherwise you are just shooting in the
dark‖
Anthony Solomon, Medical Officer for Trachoma,
WHO
207

Treatment of trachoma
1. Trachomatous Inflammation–Follicular (TF)
First line Tetracycline, single strip of ointment applied BID
for 6 weeks, OR asintermittent treatment BID for five
consecutive days per month, OR QD for 10 consecutive
days, each month for at least for six consecutive months.
Alternative Erythromycin, single strip of ointment applied
BID for 6 weeks
2.Trachomatous Inflammation – Intense (TI)
Topical First line & Alternative (See under TF) PLUS
Tetracycline, 250mg P.O., QID for 3 weeks (only for
children over 7 years of age and adults). OR

2.Trachomatous Inflammation – Intense (TI) ….
Doxycycline, 100mg P.O., QD for 3 weeks (only for
children over 7 years of age and adults). OR
Erythromycin, 250mg P.O., QID for 3 weeks. For children
of less than 25kg, 30mg/kg daily in 4 divided doses.
N.B. Azithromycin is given as a single dose of 20mg/kg.
It represents long acting macrolides which has shown very
promising effects in the treatment of trachoma in clinical
research. It is still a very expensive medicine.
209

Nursing managment
 Teaching hygiene- Washing hands & face , Avoiding
flies
 Avoiding rubbing the eyes , using private wash
cloths
 Complication of trachoma
 Cornea -Superficial keratitis
 Cornea ulcer
 Corneal opacity & perforation

Cont….
 Eye lid complication
 Trichiasis - an abnormal inversion of eye lashes
 Ectopion - Turnig eye lid out ward ( eversion)
 entropion - turnig eye lid inward to ward the eye
 Ptosis - Abnormal upper eye lid droop

KERATITIS
 Is an inflammation of the cornea, divided into two :-
 Ulcerative keratitis
 Nonulcerative keratitis caused due to cause of syphilis
,TB, congenitally
 Types of ulcerative keretitiss
 Corneal ulcer - lead to opcity of cornea
 Phyctenular ulcer
 Hypopyon ulcer severe form of ulcer with pus.
212

Etiology
 Trauma- as in wearing hard contact lense.
 Bacterial ulcer – Frequent in contact lens users,
Pseudomonas most common
 Viral – Herpes (HSV) is a frequent etiology
 Autoimmune, Syphilis, Fungal, ameobic, and many
other types
213

BACTERIIAL KERATIITIIS
 COMMON PATHOGENS:
 Neisseria gonorrhoeae
 Corynebacterium diphtheriae
 Listeria sp.
 Haemophilus sp.
 OTHER PAHTOGENS:
 Produce keratitis only after loss of corneal epithelial
integrity as in contact lens wear:
 Pseudomonas aeruginosa
214

Clinical manifestation of keratitis
 Localized pain
 Sensation of foriegn body
 Discomfortness - increased by blinking
 Photophobia
 Blurred vision
 Tearing
 Purulent discharge
215

CLINICAL FEATURES:
 Certain bacteria produce characteristic corneal
response.
1- Staph. aureus and Strep. pneumoniae:
 Oval, yellow-white, densely opaque stromal suppuration
 clear cornea
 Pseudomonas:
 Mucopurulent exudate,
 liquefactive necrosis
 ground-glass adjacent stroma
216

Pseudomonas keratitis with
hypopyon218

Advanced pseudomonas keratitis
219

Clinical manifestation for Fungal
keratitis220
Fungal keratitis with hypopyon
filamentous fungal keratitis

Complication
Corneal opacity
Panophthalmitis
221

Medical management
 Topical anesthetics
 Tetracain Hydrochloride 0.5% solution 1-2drop for
deeper anesthesia.
 Prparacaine 0.5% solution 1-2drop q90 sec
3doses.
 Benoxinate Hydrochloride 0.4% 1-2drop before
Tonometry.
 Mydriatics
 Atropine sulfate 0.5-3% 1 drop solation
222

Cont….
Antiboitics
 Sulfacetamide sodium 10-20% solution Q 30 min or
oint 3-4 times
 Systematic antibotics in case of syphilis – Benzatine
pen. 2.4 miu Im stat
 Antiinflammation ointment - cortisone oint
 Corneal transplantation for corneal scared tissue (
Keratoplasty )
223

Nursing Interventions
 Frequent administration of antibiotic eye drops
 Ophthalmic hygiene using aseptic principles
 Removal of exudate that harbors of miccroobes
 Temporarily removal of contract lense wearing
 Patient education
224

PTERYGIUM
 A triangular fibrovascular connective tissue ( fold of
conjuctiva ) over growth with extenstion to the
cornea from the inner to the outer part of bulbar
conjuctiva on the cornea , the apex is always to the
cornea.
 Etiology:- The exact cause is unknown,but it is
thought to be an irritative and degenetative
phenomenon by ultroviolent light and dust exposure
225

 Visible tissue growth on
the conjuctiva
 Diagnostic procedures:
P/E & clinical
manifestation
 Medical managment
 Surgical removal.
226

UVEITIS
 Is the inflammation of all structures of the uveal truct
such as iris, cilairy body and chorid.
 Because the uvea contains many of the blood
vessels that nuorish the eye and because it borders
many other parts of the eye, inflammation of this
layer may threaten vision.
227

Etiology
 Allergens
 Infections by microorganisms
 Chemical
 Trauma
 Systemic disease such as diabetes, ulcerative colitis ,
AIDS, herpes zoster
 Toxoplasmosis, TB
229

 Pain
 Photophobia
 Blurning vision
 Red eyes
 Floating spots in the field of vision
 Diagnosis
 S/S
 Slit light examination
230

Medical management
 Oral or topical corticosteroids
 Mydriatc (dilating) eye drops such as atropine
 Antibiotic eye drops
 Antipain
 Sun glasses reduce the discomfort of photophobia
232

Nursing management
 Instruct the client on the medication regimen &
drug administration
 Stress complian since failure to follow may result is
serious complication
 Follow – up while the disorder is being treated
 Complication
 Glaucoma
 Cataracts
 Retinal detachment can occer
2o to uveitis
233

Episcleritis
 Inflammation of episcleral
tissues.
 Treatment: Usually self
limiting and need no
treatment
 Steroids help but can lead to
dependence
234

Causes
 There is no apparent cause, but it can be associated
with an underlying systemic inflammatory or
rheumatologic condition such as rosacea, lupus or
rheumatoid arthritis.
 Typical symptoms include generalized or local redness
of the eyes that may be accompanied by mild
soreness or discomfort but no visual problems.
235

Diagnosis
 Diagnosis of episcleritis is made clinically.
 A work-up may be needed in some cases to uncover a
possible underlying medical condition.
 Treatment
 Episcleritis generally clears without treatment, but
topical or oral anti-inflammatory agents maybe
prescribed to relieve pain or in chronic/recurrent cases.
236

CATARACT
 Cataract is a condition in which the lens of the eye
becomes apaque thus reducing the amount of light
that reaches retina.
 The lens of one or both eyes may be affected.
 Etiology
 Congenital
 Injury to the lens
 Secondary to other eye disorders or aging process
 Patients with diabetes

Epidemiology
1. Cataracts remain the
leading cause of
blindness.
2. Age-related cataract is
responsible for 48% of
world blindness, which
represents about 18 million
people
3. Cataracts are also an
important cause of low
vision in both developed
and developing countries.

Classification of lens cataracts
The most common are;-
A. Senile
B. Traumatic
C. Congenital and
D. Complication

I-Senile cataracts
 Occurs in old age.
 The client sees better in dimlight and also may see
objects double or unclear.
 There are 3 stages in senile cataract
 First stage ( Immature stage ) opacity at the center / in
periphery
 Second stage ( mature stage ) lens becomes opaque
and appear bluish white.
 Third stage ( Hypermature ) The fluid of lens is less
and the lens shrinks

II- Traumatic cataracts
 Occurs after a perforating wound lens capsule or
protrusion of the eye ball with out perforation.
 The sub of the lens may protrude via the wound
capsule and in the anterior chamber.

III- Complicated cataracts
 It is due to local eye disease as perforated corneal
ulccer iridocyclitis, choroiditis, glaucoma etc.
 Opacity begins in the posterior capsule then
progress until it involves the whole lens

IV- Congenital cataract
 A lens opacity that occurs before or soon after birth.
Causes :
- Exposure to radiation in the first trimester
- Drugs like corticosteroids
- Intrauterine infections: TORCHES
- Genetic and Hereditary problems.
Morphologically it can be polar, nuclear or cortical, can be
diffuse of localized opacity.

 Eariest symptom is seeing halo around light
 Decreased visual acuity due to apacity
 Difficulity of readinng
 Changes in colour vision
 Glaring of objects in bright light
 On inspetion- a white or grey spot is visible behind
the pupil

Subcapsular cataract
Anterior Posterior

Diagnostic procedure
 Ophthalmoscpic examination
 Slit lamp Examination
 Tonometry to determine IOP
 Complication
 Blindness

Management
 Treatment the causes only
 No medical treatment for cataracts it is treated
surgical .
 Surgical removal of the lens when clients describe
their vision as unsatisfactory. The lens may be
removed by
 Removal of the lens within its capasule (Intracapsular
Extraction )
 Removal of lens leaving the posterior portion of its
capsucle in position ( Extracapsular examination )

Cont….
 Using ultrasound to break the lens in to minute particles
that are then remove by aspiration throught a small
incision ( Phacoemulification )
 Vision may be restored after surgery by three
methods
 Contact Glasses
 Wearing a contact lens
 Insertion of intraocular lens

Nursing Management
 Providing pre and post operative care of the client
 Restrict patient from lying on the operative side,
bending and lifting
 Give antiemetic if nausea occur
 Eyes are patched and dilating drugs are given to keep
the client from squinting

GLAUCOMA
 Is an abnormal condition of elevated pressure with
in an eye due to an imbalance between the
production and drainage aquoeous fluid.
 When the drainage to channel of schlemm is
obstructed , the anterior chamber become
congested with fluid and intraoccurlar pressure (
IOP) rise if this pressure increases ,it leads to optic
nerve atrophy and blidness. ,the normal IOP is 10-
21 mmHg

Etiology
 Congenital at brith from family
 Secondory glauloma- complication from
 Occular trauma
 Ophthalmic infection
 Cataract surgery
 Systemic or topical cotricostroids for long time

Classification of glaucoma based
on cause
1. Primary glaucoma - due to unknown cause ,usually
bilateral & hereditary
2. Secondary glaucoma - due to local disease in the
eye. such as in the corneal - leucoma adherent
 In the anterior chamber – hypopyon, lens disslocation
 In the rirs- iritis iridocyclitis . It also classified as follows

Cont….
 open -angle glaucoma - It is whether 1o or 2o
 Angle - closure glaucoma : either it is primary acute
/chronic or secondary
 Combined -mechanism glaucoma
 Developmental/ congenital glaucoma

Pathophysiology
 Glaucoma can occur at any age but is most common
after age of 35.
 It is more prevalent among people who have a
family history of the disorder.
 Open angle glaucoma occur when structures in the
drainage system( i.e trabecular meshwork and
schlemm canal ) undergo degeneration and the
exist channel for aqueous fluid become blocked.

Cont…..
 Angle closure glaucoma occurs among people who
have an anatomically narrow angle, at the juction
where the iris meet the cornia, this structure
deviation makes them vulnerable to angle closure
when near by eye strucures protrude in to the
anterior chamber and occlude draingle for aqueous
fluid.

Diagnostic procedures
 Tonometry - An instrument which measures IOP to
identify glaucoma. normal IOP is <21 mmHg for 1
minute
 Family history

Medical managment
 Miotics such as
 Carbachol 0.75-3% solution 1drop instilled in each eye
which increases out flow
 Pilocarpine 1-2 % solution in each eye q6-8 hr( which
increases out flow )
 Timolol maleate 0.25 - 0.5 % solution 1drop in each
BlD reduce production

Cont….
 Aqueous fluid reducers
 Aectazalamide -250mg po oid
 methezolamide 50- 100 mg po3xld .
 Eserine sulfate 0.25% ointment3-4/d (increase out
flow)
 Mannitol IV in acute glaucoma
 Which increase osmolarity of the plasma.1.5-2gm/kg
20% solution over 30-60min.
 Analgestics -to reduced pain

Surgical managment
It may be required when medication therapy is poorly
in lowering IOP.
 Laser surgery for glaucoma or surgical iridectomy
,laser trobeculo plasty
 Laser traeculoplasty.

Nursing managment
 Proving pre and post operative care
 Keep water out of the eye
 Instill antibiotic drops for 5 days .
 Discontiue Corticostroids
 Do not administer mydiratic drugs such as Atropine
 Administer medication
 Avoid vigorous activity and movement such as lifting
,strainig & bending for 1week.

Disorders of the nose and nasal
cavity
 Epistaxis
Bleeding from inside the nose, either
anterior nasal or posterior nasal.
 Epi : from above
 Staxis : drop by drop drip of fluid.
Epistaxis is a sign, NOT a disease
 It should never be treated as a
harmless event.
272

Anatomical considerations
 Nasal cavity: mucosa and turbinates are very vascular
 Receives blood supply from branches of both internal
and external carotid arteries.
 Network of arteries : Kiesselbach’s plexus, woodruff’s
plexus
273

Epistaxis…….
 Little’s area
 Situated over the anteroinferior part of nasal septum, just
above the vestibule
 Caudal part of the nasal septum which has a rich
submucosal arterial network(Kiesselbach’s plexus) by
septal branches of
anterior ethmoidal
 sphenopalatine
 superior labial
 greater palatine
275

Epistaxis…….
276
• Little’s area is situated over
the anteroinferior part of the
nasal septum
• Prone for drying (effect of
inspired air ) and
microtrauma by nose
picking
• Commonest site for epistaxis
in children

Epistaxis…….
 Retrocolumella vein
 This vein runs vertically
downwards behind the
columella.
 It crosses the floor of nose
& joins venous plexus on
the lateral wall of nose.
 Common site of venous
bleeding in young people
277

Epistaxis…….
 Woodruff’s Area
Vascular area situated over the posterior end
of inferior turbinate
 Sphenopalatine artery anastomoses with
posterior pharyngeal artery
 Posterior epistaxis occur
278

Epistaxis…….
 Sites of epistaxis
 Little’s Area (90%)
 Above the level of middle turbinate
 Below the level of middle turbinate
 Posterior part of nasal cavity
 Diffuse. ie : septum & lateral wall
 Nasopharynx
279

Local causes of epistaxis…….
I) congenital: hemangioma
II) Infections :
 Viral : Influenza, measles
 Bacterial : (non-specific)- acute/ chronic rhinitis /
sinusitis, artophic rhinitis (specific)-diphtheria, TB,
syphilis, other
 granulomas
 Fungal : rhinosporidiosis, fungal
 sinusitis
 Parasites : maggots
282

Local causes of epistaxis…….
 III) Trauma
IV) Neoplastic :
Benign : hemangioma
V) Miscellaneous :
 Deviated nasal septum,
283

Systemic causes of epistaxis…….
 CVS
 Hypertension
 Atherosclerosis
 Mitral stenosis
 Pregnancy (HTN & hormonal)
 Liver Cirrhosis
 Vitamin K deficiency
 Deficiency of factor ii, vii,ix and x
284

Systemic causes of Epistaxis…….
 Hematological
 Aplastic anaemia
 Thrombocytopenia
 Leukemia
 Lymphoma
 Agranulocytosis
 Scurvy
 Vitamin K deficiency
285

Systemic causes of Epistaxis…….
 Renal disease
 Chronic nephritis
 Drugs
 Salicylates
 Analgesics
 Anticoagulant
 Mediastinal compression
 Tumours of mediastinum raised venous
pressure in the nose
286

Causes of Epistaxis…….
 Acute general infection
 Influenza
 Measles
 Chicken pox
 Whooping cough
 Vicarious menstruation
 However generally the cause of epistaxis is
idiopathic
287

How you can avoid nosebleeds:
 Avoid vigorous nose-blowing and stuffing tissues
 Discourage children from nose-picking, and keep
their fingernails trimmed.
 Use over-the-counter nasal saline sprays and
topical nasal moisturizing gels.
 Use a home humidifier to keep moisture in the air
during winter months.
 quitting tobacco smoke dries out the nasal mucosa
and increases the risk for nosebleeds.
288

Steps to stop a nosebleed:
 Gently blow your nose to clear any blood clots.
 spray nasal decongestant 2–3 times into nose
 Apply pinching pressure on nostrils for 5–10 minutes.
Lean slightly forward
 If the bleeding stops, avoid nose-blowing or strenuous
activity for the remainder of the day,
 Seek medical attention if the bleeding doesn’t stop
after 30 minutes, if there is trouble breathing, have
suffered severe nasal trauma or lost a significant
amount of blood and feel weak.
 Cold compress
289

Management of Epistaxis…….
 cauterization, anterior packing, or both. Those with
severe or recalcitrant bleeding may need posterior
packing, arterial ligation, or embolization.
 Pharmacotherapy plays only a supportive role in
treating the patient with epistaxis.
290

Rhinitis
291
• Inflammation of the
nasal mucosa.
• Rhinitis is a group of
disorders characterized
by inflammation and
irritation of the mucous
membranes of the nose.

Classification rhinitis
 A. Acute rhinitis
 a. Non-allergic:
 1. Infective:
 Viral: Common cold (coryza or flu), rhinitis
associated with influenza or other viral infections.
 Bacterial: Usually occurs as a secondary infection
following unresolved viral rhinitis.
2. Non-infective:
 Vasomotor rhinitis.
 Rhinitis due to chemical irritation
292

Classification rhinitis……
B. Allergic e.g. Hay fever.
293

B. Chronic rhinitis:
a. Non-allergic:
1. Non-specific:
 Chronic catarrhal rhinitis.
 Chronic hypertrophic rhinitis.
 Chronic atrophic rhinitis.
 Rhinitis medicamentosa (drug-induced rhinitis).
2.Specific:
 Scleroma.
 Rare types: Syphilis, tuberculosis, lupus and, leprosy.
b. Allergic: Perennial allergic rhinitis.
294

Causes Rhinitis
 Rhinovirus.
 Droplet infection.
 reaction of the body’s immune system to an
environmental trigger. The most common
 environmental triggers include dust, molds, pollens,
grasses, trees, and animals.
 Both seasonal allergies and year-round allergies can
cause allergic rhinitis.
295

Causes Rhinitis …..
 nasal decongestants; foreign body.
 allergens such as foods (eg, peanuts, walnuts, brazil
nuts, wheat, shellfish, soy, cow’s milk, and eggs)
 medications (eg, penicillin, sulfa medications, aspirin
 The most common cause of nonallergic rhinitis is the
common cold.
 antihypertensive agents, such as angiotensin-
converting enzyme (ACE) inhibitors and
betablockers; “statins,” antidepressants; aspirin,
antianxiety medications.
296

1. Stage of invasion (few hours): Sneezing, burning
sensation in the nasopharynx, nasal obstruction, and
headache, Pruritis of nose
2. Stage of secretion (few days): Low grade fever,
malaise, arthralgia, nasal obstruction, and profuse watery
rhinorrhea.
3. Stage of resolution: Resolution within 5-7 days is the
natural course of an uncomplicated disease. Symptoms
lasting beyond 7 days, or worsening instead of improving
suggest that secondary bacterial infection is being
established.
297

Management
1. Supportive treatment: bed rest, analgesics,
nasal decongestants (local i.e. drops and
systemic), and occasionally steam inhalations.
2. Antibiotics should be reserved for treatment of
secondary bacterial infections.
298

Management ……
 Symptom relief:antihistamine/decongestant medications
 Brompheniramine/pseudoephedrine (Dimetapp)
 Cromolyn (NasalCrom), a mast cell stabilizer inhibits the
release of histamine and other chemicals,
 Use of saline nasal spray can act as a mild decongestant
and can liquefy mucus to prevent crusting.
 Two inhalations of intranasal ipratropium (Atrovent) can
be administered in each nostril two to three times per day
for symptomatic relief of rhinorrhea.
299

Management ……
 intranasal corticosteroids may be used for severe
congestion, and ophthalmic agents (cromolynophthalmic
solution 4%) may be used to relieve irritation, itching,
and redness of the eyes.
 Newer allergy treatments include leukotriene modifiers
(eg, montelukast [Singulair], zafirlukast[Accolate],
zileuton [Zyflo])
300

According to Ethiopian drug guiod
line 2014
First line
Chlorpheniramine, 4mg P.O., TID
Alternative
Cetrizine hydrochloride, 10mg P.O., daily
PLUS
Xylometazoline,
adults; 2-3 drops of 1% solution 3-4 times a day
301

Sinusitis
 Infection and inflammation of paranasal sinuses
 TYPES
 Acute – last less than 4 weeks
 Chronic – more than a 3 months
302

Causes of sinusitis
 Virus – Rhino virus, ECHO (enteric cyto pathogenic human
organ) 28, Respiratory syncital virus
 Bacteria – strepto. Pneumoniae, staph. pyogenes
 Pollutants
 Fungi
 Respiratory infections
 Nasal polyps
 Fracture of sinus
 Foreign bodies
 Low immunity, smoking
303

CLINICAL FEATURES
 Headache
 Pain over maxillary antrum – suborbital region –
it is aggravated by bending, walking or coughing
 Facial pain or pressure
 Runny nose
 Sore throat, Loss of smell
 Cough or congestion, Fever
 Bad breath, Fatigue
 Dental pain
 Loss of vocal resonance
304

Chronic Sinusitis Symptoms
 You may have these symptoms for 12 weeks or
more:
 A feeling of congestion or fullness in your face
 A nasal obstruction or nasal blockage
 Anosomia
 Edema - sinus
 Pus in the nasal cavity
 Fever
 Runny nose or discolored postnasal drainage
 Cacosomia
305

DIAGNOSIS Sinusitis
 H.C
 PE
 Blood test
 Culture sensitivity test
 X- ray
 CT
306

Management of sinusitis
 Prophylactic: good ventilation, proper humidity,
vitamin diet, avoid flying and swimming, avoid
smoking, treat cold
 Medical: antibiotics – amoxicillin, local decongestants
(ephedrine), steam inhalation, analgesics
 Maxillary antral washout involves puncturing the sinus
and flushing with saline to clear the mucus
 Balloon sinuplasty: It uses a balloon over a wire catheter
to dilate sinus passageways. The balloon is inflated with
the goal of dilating the sinus openings, widening the
walls of the sinus passageway and restoring normal
drainage.
307

Etiology Nasal polyps ……
 Inflammatory conditions of nasal mucosa
 Rhinosinusitis
 Disorders of ciliary motility
 Kartagener’s syndrome
 Abnormal composition of nasal mucus
 Cystic fibrosis
312

Diagnosis of nasal polyps
 Clinical examination
 CT scan of paranasal sinuses
 exclude neoplasia
 plan surgery
 Histological examination
 especially in people >40 years
318

Treatment of nasal polyps
 CONSERVATIVE
 Antihistaminics & control of allergy
may revert early polypoidal changes with
oedematous mucosa to normal
 Short course steroids
in people who cannot tolerate
antihistaminics or with asthma
319

SURGICAL management
 Polypectomy
 Intranasal ethmoidectomy
 Extranasal ethmoidectomy
 Transantral ethmoidectomy
 Endoscopic sinus surgery
320

References
 American Cancer Society. (2014). Cancer facts and
figures. Atlanta: Author.
 Brunner & Suddarth's Textbook of Medical-Surgical Nursing,
11th edition.
 Brunner & Suddarth’s Textbook of Medical-surgical Nursing.
2010, 12th Ed.
 Medical-Surgical Nursing: Patient-Centered Collaborative Care,
2013, 7th edition

References
 Lewis Direkson ,Heitkemper Bucher,medical surgical
nursing assessment,9th edition
 Sharon L. Lewis, Shannon Ruff Dirksen, Et Al .Medical-
surgical Nursing: Assessment And Management Of Clinical
Problems, 2014, Elsevier Inc. Ninth Edition
 Wolters Kluwer,Incrideble medical surgical nursing
practice,2012
 Diseases of Ear, Nose and Throat & Head and Neck Surgery, 6th
Edition, PL Dhingra, Elsevier

References
 Kumar and klark’s.clinical medicine, 2009, Elsevier
Limited. 7th edition.
 Porth’s pathophysiology. Concepts of Altered Health
States, 2014 ,9th edition.
 Patricia Gonce Morton, critical care nursing A holistic
approach, 2013, 10th edition.

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