SPECIAL SENSES AUDIO-VISUAL DISTURBANCES

INTERNAL STRUCTURES OF THE EYE 1. EYEBALL ( 3 LAYERS OF THE EYEBALL) A.OUTER LAYER - fibrous coat that supports the eye a. SCLERAE - Tough, white connective tissue white of the eye - located anteriorly & posteriorly b. CORNEA - Transparent tissue through which light enters the eye. - Located anteriorly

sclera & the retina - it lines most of the sclera & is attached to the retina but can easily detach from the sclera - contains blood vessels that nourishes the retina b. CILIARY BODY - connects the choroid with the iris - secretes aqueous humor that helps give the eye its shape c. IRIS - the colored portion of the eye - extension of the ciliary body, located in front of the lens - it has a central opening called the pupil C. INNER LAYER (RETINA) - a thin, delicate structure in which the fibers of the optic nerve are distributed - bordered externally by the choroid & sclera and internally by the vitreous - contains blood vessels & photoreceptors (cones & rods) - light sensitive layer 2. FLUIDS OF THE EYE A. AQUEOUS HUMOR - Clear, watery fluid fills anterior & posterior chamber - produced by the ciliary processes, & the fluid drains in the Canal of Sclemm - serves as refracting medium & provides nutrients to lens & cornea - contributes to maintenance of IOP B. VITREOUS HUMOR - Clear, gelatinous/jell-like material that fill the posterior cavity of the eye - Maintains the form & shape of the eye - Provides additional physical support to the

B. MIDDLE LAYER a. CHOROID - a dark brown membrane located between the

Eye 3. EYE MUSCLES A. INTRINSIC MUSCLES: a. IRIS b. CILIARY BODY B. EXTRINSIC a. FOUR STRAIGHT RECTUS MUSCLE - superior, inferior, lateral & medial b. TWO OBLIQUE MUSCLES - superior & inferior 4. BLOOD VESSELS A. OPTHALMIC ARTERY - major artery supplying the structures in the eye B. OPTHALMIC VEINS - venous drainage occurs through vision 5. NERVE SUPPLY TO THE EYE A. CRANIAL NERVE II - Optic nerve (nerve of sight) B. CRANIAL NERVE V - Trigeminal (opthalmic) C. MOTOR NERVE ( CN III, CN IV, CN VI) - oculomotor, trochlear, abducens

occipital lobe, and fibers from the left half of each eye carry impulses to the left occipital lobe. From the OPTIC CHIASMA, the optic nerves continue, as optic tracts, to the cerebrum. Within the brain, visual impulses are interpreted as light

REFLEXES OF THE EYE A. LIGHT REFLEX - pupil becomes smaller when light is flashed in the eye B. ACCOMODATION REFLEX - pupil becomes smaller when gaze is shifted from distant to near object PHYSIOLOGY OF BINOCULAR VISION A. CONVERGENCE OF VISUAL AXES -coordinated movement of 2 eyes toward fixation of same near point B. REGULATION OF PUPIL SIZE -regulating amount of light entering eyes by changing pupil sizes C. REFRACTION OF LIGHT RAYS - rays are refracted or bent as they pass thru varying densities D. ACCOMMODATION a. near vision- ciliary muscle contract, lens bulges /convex b. distant vision- ciliary muscle relaxes, lens flattens ASSESSMENT OF VISION VISUAL ACUITY TEST - measures the clients distance & near vision SNELLEN CHART - simple tool to record visual acuity - the client stands 20 ft from the chart & covers 1 eye and uses the other eye to read the line that appears more

SENSORY PATHWAY FOR VISION - the ROD & CONE receptors, which are sensitive to light initiate nerve impulse messages which w/c travel over the optic nerves OPTIC CHIASMA is the crossing point for fibers from the medial halves of the retinae that in OPTIC CHIASMA, the optic nerve fibers from the medial halves of the retinae cross to the opposite side of the brain while from the lateral halves or the retinae remain uncrossed Thus fibers from the right half of each eye carry impulses to the brains right

clearly - this procedure is repeated for the other eye - the findings are recorded as a comparison between what the client can read at 20 ft and the no. of feet normally required by an individual to read the same line EXAMPLE: 20/50 - The client is able to read at 20 ft from the chart what a healthy eye can read at 50 ft CONFRONTATIONAL TEST - Performed to examine visual fields or peripheral vision - The examiner & the client sit facing each other - The test assumes that the examiner has normal peripheral vision EXTRAOCULAR MUSCLE FUNCTION - tests muscle function of the eyes - tests 6 cardinal positions of gaze 1. Clients right (lateral position) 2. Upward & right (temporal position) 3. Down & right 4. Clients left (lateral position) 5. Upward & left (temporal position) 6. Down & left - client holds head still & asked to move eyes & follow a small object - the examiner looks for any parallel movements of the eye or for NYSTAGMUS - an involuntary rhythmic rapid twitching of the eyeballs ASSESSMENT OF VISION COLOR VISION TEST - Tests for color vision which involve picking nos. or letters out of a complex & colorful picture

ISHIHARA CHART - consists of nos. that are composed of colored dots located within a circle of colored dots - client is asked to read the nos. on the chart - each eye is tested separately - the test is sensitive for the diagnosis of red/green blindness but not effective for the detection of the discrimination of blue PUPILS - Normal: round & of equal size - Increasing light causes pupillary constriction Decreasing light causes pupillary dilation - the client is asked to look straight ahead while the examiner quickly brings a beam of light ( penlight) in from the side & directs it onto the side - CONSENSUAL RESPONSE

DIAGNOSTIC TESTS FOR THE EYE 1. FLUORESCEIN ANGIOGRAPHY - detailed imaging & recording of ocular circulation by a series of photographs after administration of the dye PRE-OP NURSING CARE Assess for allergies & previous reactions to dyes Obtain informed consent A mydriatic medication is instilled in the eye 1 hr. before the test The dye is injected into the vein of the clients arm Inform client that the dye may cause the skin to appear yellow for several hrs. after the test & this is gradually eliminated through the urine

The client may experience N&V, sneezing, paresthesia of the tongue or pain at the injection site If hives appear, oral or IM antihistamines such as Diphenhydramine (Benadryl) are given as prescribed. POST-OP NURSING CARE Encourage rest. Encourage oral fluids. Remind the client that the yellow skin appearance will disappear Instruct the client that the urine will appear bright green until the dye is excreted Instruct the client to avoid direct sunlight for a few hrs after the test. Instruct the client that the photophobia will continue until pupil size returns to normal 2. COMPUTED TOMOGRAPHY - a beam of x-ray scans the skull & orbits of the eye - a cross-sectional image is formed by the use of a computer - contrast material is not usually administered NURSING CARE No special client preparation or followup care required Instruct the client that he or she will be positioned in a confined space & need to keep the head still during the procedure. 3. SLIT LAMP - allows examination of the anterior ocular structures under microscopic magnification - the client leans on a chin rest to stabilize the head while a narrow beam of light is aimed so that it illuminates only a narrow segment of the eye.

Explain the procedure to the client. Advise the client about the brightness of the light & the need to look forward at the point over the examiners ear

4. CORNEAL STAINING - installation of a topical dye into the conjunctival sac to outline the irregularities of the corneal surface that are not easily visible - the eye is viewed through a blue filter, and a bright green color indicates areas of non-intact corneal epithelium NURSING CARE If a client wears contact lenses, they must be removed The client is instructed to blink after the dye has been applied to distribute the dye evenly across the cornea 5. TONOMETRY - the test is primarily used to assess for an increase in IOP and potential glaucoma - NORMAL IOP: 8-21 mm Hg NURSING CARE Each eye is anesthetized. The client is asked to stare forward at a point above the examiners ear A flattened cone is brought in contact with the cornea The amount of pressure needed to flatten the cone is measured The client is instructed to avoid rubbing the eye following the examination if the eye has been anesthetized - the potential for scratching the cornea exists OPTHALMIC MEDICATIONS PARASYMPATHOLYTIC DRUGS - used pre-op or for eye examinations to produce mydriasis - C/I in clients with glaucoma because of the risk of increased IOP

NURSING CARE

- Mydriatics are C/I in cardiac dysrhythmias & cerebral atherosclerosis & should be used with caution in the elderly & in clients with prostatic hypertrophy, DM or parkinsonism MYDRIATICS, CYCLOPLEGIC & ANTICHOLINERGIC medications MYDRIATICS - dilate the pupils (mydriasis) CYCLOPLEGIA - relax the ciliary muscles ANTICHOLINERGICS - block responses of the sphincter muscle in the ciliary body, producing mydriasis Ex. Atropine sulfate (Isopto-Atropine, OcuTropine, Atropair, Atropisol) Scopolamine hydrobromide (IsoptoHyoscine) Cyclopentolate hydrochloride (Cyclogyl, AK-Pentolate, Pentolair) Homotropine hydrobromide (Isopto Homatrine, AK-Homatropine, SpectroHomatrine) Tropicamide (Mydriacyl, I-Picamide, Tropicacyl) Phenylephrine hydrochloride (AKDilate, Dilatair, Mydfrin, Ocu-Phrin) NURSING RESPONSIBILITIES Monitor for allergic reactions Assess for risk of injury Assess for constipation & urinary retention Instruct the client that a burning sensation may occur on installation Instruct the client not to drive or operate machine for 24 hrs after installation of the medication unless otherwise directed by the physician Instruct the client to wear sunglasses until the effects of the medication wear off Instruct to notify MD if blurring of vision, loss of sight, difficulty in breathing, sweating or flushing occurs Instruct the client to report eye pain to the physician

PARASYMPATHOMIMETIC A. GROUP I: MIOTIC CHOLINERGIC DRUGS - - reduce IOP by mimicking the action of acetylcholine - act directly on the myoneural junction & produce strong contractions of the iris ( miosis) & ciliary body musculature ( accommodation) B. GROUP II: CHOLINESTERASE INHIBITORS - reduce IOP by inhibiting the action of cholinesterase - action of this drug is difficult to reverse MIOTICS - reduce IOP by constricting the pupil & contracting the ciliary muscle, thereby increasing the blood flow to the retina & decreasing retinal damage & loss of vision - open the anterior chamber angle & increase the outflow of aqueous humor - used for chronic open-angle glaucoma or acute & chronic closed-angle glaucoma - used to achieve miosis during eye surgery - C/I in clients with retinal detachment, adhesions between the iris & lens, or inflammatory diseases - used with caution in clients with asthma, hypertension, corneal abrasion,hyperthyroidism, coronary vascular disease, urinary tract obstruction, GI obstruction, ulcer disease, parkinsonism, or bradycardia Ex. Acethylcholine Cl (Miochol) Carbachol (Miostat) Pilocarpine HCl (Isopto Carpine, Pilocar) Pilocarpine nitrate (Pilofrin, Liquifilm, Pilagan) Echothiophate iodide (Phospholine iodide)

 Demecarium bromide (Humorsol) Isoflurophate (Floropryl) NURSING CARE Assess V/S & risk of injury Assess the client for the degree of diminished vision Monitor for postural hypotension & instruct the client to change positions slowly Assess breath sounds for rales & rhonchi - cholinergic meds cause bronchospasms & increased bronchial secretions Maintain oral hygiene due to increased salivation Have Atropine sulfate available as antidote for Pilocarpine Instruct the client not to stop the meds suddenly Instruct to avoid activities such as driving while vision is impaired Instruct clients with glaucoma to read labels on OTC meds & to avoid Atropine-like meds Atropine increase IOP BETA-ADRENERGIC BLOCKING EYE MEDICATIONS - IOP by decreasing sympathetic impulses & decreasing aqueous humor production w/o affecting accommodation or pupil size - Used to treat chronic open-angle glaucoma - C/I in the client with asthma EX. Betaxolol HCl (Betoptic) Carteolol HCl (Ocupress) Levobunolol HCl (Betagan) Metipranolol (Optipranolol) Timolol maleate (Timoptic) NURSING CARE Monitor V/S before administering medication esp. BP & PR If the pulse is below 60 or if systolic BP is below 90 mm Hg, withhold the medication & contact MD Monitor for shortness of breath and I&O Assess for risk of injury

Instruct the client to notify MD if shortness of breath occurs Instruct not to D/C medication abruptly Instruct to change positions slowly to avoid orthostatic hypotension Instruct to avoid hazardous activities Instruct to avoid OTC meds without the MDs approval

ADRENERGIC EYE MEDICATIONS - Decrease the production of aqueous humor & lead to a decrease in IOP - Used to treat glaucoma ADRENERGIC MEDICATIONS Apraclonidine HCl (Iopidine) Brimonidine tartrate (Alphagen) Dipivefrin HCl (Propine) Epinephrine borate (Epinal, Eppy) Epinephrine HCl (Epifrin, Glaucon) CARBONIC ANHYDRASE MEDICATIONS - Interfere with the production of carbonic acid which leads to decreased aqueous humor formation & decreased IOP - Used for long-term treatment of openangle glaucoma - C/I in the client allergic to sulfonamides EX. ACETAZOLAMIDE ( DIAMOX) DICHLORPHENHAMIDE (DARANIDE, ORATROL) ETHOXYZOLAMIDE (CARDRASE, ETHAMIDE) METHAZOLAMIDE (NEPTAZANE) NURSING CARE Monitor V/S Assess visual acuity Assess for risk of injury Monitor I&O Monitor weight Maintain oral hygiene Monitor for lethargy, anorexia, drowsiness, polyuria, N/V Monitor electrolytes for hypokalemia Increase fluid intake unless C/I Advise the client to avoid prolonged exposure to sunlight

Encourage the client to use artificial tears for dry eyes Instruct not to D/C the medication abruptly Instruct to avoid hazardous activities while vision impaired

Be alert to allergic responses to the preservatives in the lubricants

OSMOTIC MEDICATIONS - Lower IOP - Used in emergency treatment of acute closedangle glaucoma - Used pre-op & post-op to decrease vitreous humor volume EXAMPLES Glycerin (Glyrol, Osmoglyn) Mannitol (Osmitrol) Urea (Ureaphil) NURSING CARE Assess V/S, visual acuity & risk for injury Monitor weight and I&O Monitor electrolytes Increase fluid intake unless C/I Monitor for changes in level of orientation EYE LUBRICANTS - Replace tears or add moisture to the eyes - Moisten contact lenses or an artificial eye - Protect the eyes during surgery or diagnostic procedures - Used for keratitis, during anesthesia or in a disorder that results in unconsciousness or decreased blinking EXAMPLES Hydroxypropyl methylcellulose (Lacril, Isopto Plain) Petroleum-based ointment (Artificial Tears, Liquifilm Tears) NURSING CARE Inform the client that burning may occur on installation

TOPICAL ANESTHETICS FOR THE EYE - Produce corneal anesthesia - Used for anesthesia for eye examinations, surgery, or to remove foreign bodies from the eye EXAMPLES Proparacaine HCl (Ophthaine, Opthenic) Tetracaine HCl (Pontocaine) NURSING CARE Assess for risk of injury Note that the medications should not be given to the client for home use & are not to be self-administered by the client Note that the blink reflex is temporarily lost & that the corneal epithelium needs to be protected Provide an eye patch to protect the eye from injury until the corneal reflex returns ANTI-INFECTIVE EYE MEDICATIONS ANTIBACTERIAL Chloramphenicol (Chloromycetin, Chloroptic) Ciprofloxacin hydrochloride (Cipro) Erythromycin (Ilotycin) Gentamicin sulfate (Garamycin, Genoptic) Norfloxacin (Chibroxin) Tobramycin (Nebcin, Tobrex) Silver nitrate 1% ANTIFUNGAL Natamycin (Natacyn Opthalmic) ANTIVIRAL Idoxuridine (Herplex-Liquifilm) Trifluridine (Viroptic) Vidarabine (Vira-A Opthalmic) NURSING CARE Assess for risk of injury Instruct the client in how to apply the eye medication Instruct the client to continue treatment as Rx Instruct the client to wash hands thoroughly & frequently

Advise the client that if improvement does not occur, notify the MD

ANTI-INFLAMMATORY EYE MEDICATIONS EXAMPLES Dexamethasone (Maxidex) Diclofenac (Voltaren) Flurbiprofen Na (Ocufen) Suprofen (Profenal) Ketorolac tromethamine (Acular) Prednisone acetate (Predforte, Econopred) Prednisolone Na phosphate (AK-Pred, Inflamase) Rimaxolone (Vexol)

Instruct the client in the use of the cane used for the blind client, which is differentiated from other canes by its straight shape & white color with red tip Instruct the client that the cane is held in the dominant hand several inches off the floor Instruct the client that the cane sweeps the ground where the clients foot will be placed next to determine the presence of obstacles

DISORDERS OF THE EYE LEGALLY BLIND - a person is legally blind if the best visual acuity with corrective lenses in the better eye is 20/200 or less or a visual field of 20 degrees or less in the better eye NURSING CARE When speaking to a client who has limited sight or blind, the nurse uses a normal tone of voice Alert the client when approaching Orient the client to the environment Use a focal point & provide further orientation to the environment from the focal point Allow the client to touch objects in the room Use the clock placement of foods on the meal tray to orient the client Promote independence as much as possible Provide radios, TVs, & clocks that give the time orally or provide a Braille watch. When ambulating, allow the client to grasp the nurses arm at the elbow Instruct the client to remain one step behind the nurse when ambulating

1. CATARACTS - an opacity of the lens that distorts the image projected onto the retina & that can progress to blindness - intervention is indicated when visual acuity has been reduced to a level that the client finds to be unacceptable or adversely affecting lifestyle CAUSES Aging process (Senile cataracts) Inherited (Congenital cataracts) Injury (Traumatic cataracts) Can occur as a result of another eye disease (Secondary cataracts) ASSESSMENT Opaque or cloudy white pupil Gradual loss of vision Blurred vision Decreased color perception Vision that is better in dim light with pupil dilation Photophobia Absence of red reflex MEDICAL MANAGEMENT - surgical removal of the lens, one eye at a time - a lens implantation may be performed at the time of surgical procedure EXTRACAPSULAR EXTRACTION - the lens is lifted out w/o removing the lens capsule - may be performed with Phacoemulsion PHACOEMULSIFICATION

- the lens is broken up by ultrasonic vibrations & extracted INTRACAPSULAR EXTRACTION - the lens is removed within its capsule through as small incision PRE-OP NURSING CARE Instruct measures to prevent or decrease IOP Administer pre-op eye medications including mydriatics & cycloplegics as prescribed POST-OP NURSING CARE Elevate the head of the bed 30-45 degrees Turn the client to the back or unoperative side Maintain an eye patch & orient the client to the environment Position the clients personal belongings on the un-operative side Use side rails for safety Assist with ambulation CLIENT EDUCATION AFTER CATARACT SURGERY Avoid eye straining Avoid rubbing or placing pressure on the eyes Avoid rapid movements, straining, sneezing, coughing, bending, vomiting, or lifting objects over 5 lbs Teach measures to prevent constipation Wipe excess drainage or tearing with a sterile wet cotton ball from the inner to the outward canthus Use an eye shield at bedtime If an eye implant is not performed, the eye cannot accommodate & glasses must be worn at all times Cataract glasses act as magnifying glasses & replace central vision only Cataract glasses magnify, & objects appear closer therefore teach client to judge distance & climb stairs carefully Contact lenses provide sharp visual acuity but dexterity is needed to insert them

Contact the MD for any decrease in vision, severe eye pain or increase in eye discharge

2. GLAUCOMA - increased IOP as a result of inadequate drainage of aqueous humor from the canal of Schlemm or over production of aqueous humor - the condition damages the optic nerve & can result in blindness TYPES A. ACUTE = a rapid onset of IOP > 50-7- mm Hg CLOSED-ANGLE/NARROW ANGLE GLAUCOMA - results from obstruction to outflow to aqueous humor B. CHRONIC = a slow progressive, gradual onset of IOP>30-50 mmHg CLOSED-ANGLE GLAUCOMA - follows an untreated attack of acute close-angled glaucoma OPEN-ANGLE GLAUCOMA - results from an overproduction or obstruction to the outflow of aqueous humor

ASSESSMENT Progressive loss of peripheral vision followed by a loss of central vision Elevated IOP (Normal pressure is 1021 mm Hg)

Vision worsening in the evening with difficulty adjusting to dark rooms Blurred vision Halos around white lights Frontal headaches Photophobia Increased lacrimation Progressive loss of central vision NURSING CARE FOR ACUTE GLAUCOMA Treat as medical emergency Administer medications as prescribed to lower IOP Prepare the client for peripheral iridectomy - allows aqueous humor to flow from the posterior to anterior chamber NURSING CARE FOR CHRONIC GLAUCOMA Instruct the client the importance of medications a. MIOTICS: to constrict the pupils b. CARBONIC ANHYDRASE INHIBITORS: to decrease the production of aqueous humor c. BETA-BLOCKERS: to decrease the production of aqueous humor & IOP Instruct the client the need for life-long medication use Instruct the client to wear a Medic-Alert bracelet Instruct the client to avoid anticholinergic medications Instruct the client to report eye pain, halos around eyes & changes of vision to the physician Instruct the client that when maximal medical therapy has failed to halt the progression of visual field loss & optic nerve damage, surgery will be recommended Prepare the client for TRABECULOPLASTY as prescribed to facilitate aqueous humor drainage Prepare client for TRABECULECTOMY as prescribed - allows drainage of aqueous humor into the

conjuctival spaces by the creation of an opening 3. RETINAL DETACHMENT - occurs when the layers of the retina separate because of accumulation of fluid between them - also occurs when both retinal layers elevate away from the choroid as a result of a tumor TYPES PARTIAL RETINAL DETACHMENT - becomes complete if left untreated COMPLETE RETINAL DETACHMENT - when detachment is complete, blindness may occur ASSESSMENT Flashes of light Floaters Increase in blurred vision Sense of curtain being drawn Loss of a portion of the visual field IMMEDIATE NURSING CARE Provide bedrest Cover both eyes with patches to prevent further detachment Speak to the client before approaching Position the clients head as prescribed Protect the client from injury Avoid jerky head movements Minimize eye stress Prepare the client for surgical procedure as prescribed MEDICAL MANAGEMENT - draining fluid from the subretinal space so that the retina can return to the normal position SEALING RETINAL BREAKS BY CRYOSURGERY - a cold probe applied to the sclera to stimulate an inflammatory response leading to adhesions DIATHERMY - the use of electrode needle & heat through the sclera to stimulate an inflammatory response leading to adhesions LASER THERAPY

- to stimulate an inflammatory response to seal small retinal tears before the detachment occurs SCLERAL BUCKLING - to hold the choroid & retina together with a splint until scar tissue forms closing the tear INSERTION OF A GAS OR SILICONE OIL - to encourage attachment because these agents have a specific gravity less than vitreous or air & can float against the retina POST-OP NURSING CARE Maintain eye patches bilaterally as prescribed Monitor hemorrhage as prescribed Prevent N&V and monitor for restlessness which can cause hemorrhage Monitor for sudden, sharp eye pain (notify the MD stat) Encourage DBE but avoid coughing Provide bed rest for 1-2 days as prescribed If gas has been inserted, position as prescribed on the abdomen & turn the head so unaffected eye is down Administer eye medications as prescribed Assist client with ADL Avoid sudden head movements or anything that increases IOP Instruct the client to limit reading for 3-5 weeks Instruct client to avoid squinting, straining & constipation, lifting heavy objects & bending from the waist Instruct the client to wear dark glasses during the day & an eye patch at night Encourage follow-up care because of the danger of recurrence or occurrence in the other eye 4. STRABISMUS - called SQUINT EYE or LAZY EYE - a condition in which the eyes are not aligned

because of lack of muscle coordination of the extraocular muscles - most often results from muscle imbalance or paralysis of extraocular muscles, but may also result from conditions such as brain tumor, myasthenia gravis or infection - normal in young infant but should not be present after about age 4 months ASSESSMENT Amblyopia if not treated early Permanent loss of vision if not treated early Loss of binocular vision Impairment of depth perception Frequent headaches Squints or tilts head to see NURSING CARE Corrective lenses as indicated Instruct the parents regarding patching (occlusion therapy) of the good eye ( to strengthen the weak eye) Prepare for botulinum toxin (Botox) injection into the eye muscle produces temporary paralysis allows muscles opposite the paralyzed muscle to strengthen the eye Inform the parents that the injection of botulinum toxin wears off in about 2 months & if successful, correction occurs Prepare for surgery to realign the weak muscles as Rx if nonsurgical interventions are unsuccessful Instruct the need for follow-up visits 5. CONJUNCTIVITIS - also known as PINK EYE - inflammation of the conjunctiva - usually caused by allergy, infection, or trauma TYPES BACTERIAL OR VIRAL CONJUNCTIVITIS - extremely contagious CHLAMYDIAL CONJUNCTIVITIS

- is rare in older children & if diagnosed in a child who is not sexually active, the child should be assessed for possible sexual abuse ASSESSMENT Itching, burning or scratchy eyelids Redness Edema Discharge NURSING CARE Instruct in infection control measures such as good handwashing & not sharing towels & washcloths Administer antibiotic or antiviral eye drops or ointment as Rx if infection is present Administer antihistamines as Rx if an allergy is present Instruct the parents that the child should be kept home from school or day care until antibiotic eye drops have been administered for 24 hrs Instruct in the use of cool compresses to lessen irritation & in wearing dark glasses for photophobia Instruct the child to avoid rubbing the eye to prevent injury D/C use of contact lenses & to obtain new lenses to eliminate the chance of re-infection Instruct the adolescent that eye makeup should be discarded & replaced

EARS (Stirrup) EXTERNAL EAR - Embedded in the temporal bone bilaterally at the level of the eyes - Extends from the auricle through the external canal to the tympanic membrane or eardrum - Includes the mastoid process, a bony ridge located over the temporal bone A. AURICLE (PINNA) - Outer projection of ear composed of cartilage & covered by skin - collects sound waves B. EXTERNAL AUDITORY CANAL - Lined with skin - Glands secrete cerumen (wax) - provides protection - transmits sound waves to tympanic membrane C. TYMPANIC MEMBRANE (EARDRUM) - Located at the end of the external canal - Vibrates in response to sound & transmit vibrations to middle ear MIDDLE EAR - Consists of the medial side of the tympanic membrane - The tympanic membrane is a thick transparent sheet of tissue that provides a barrier between the external ear & the middle ear - The middle ear is protected from the inner ear by the round & the oval window membranes - The eustachian tube opens into the middle ear & allows for equalization of pressure on both sides of the tympanic membrane A. OSSICLES - Contains 3 small bones: Malleus (Hammer) Incus (Anvil)

Stapes

- Ossicles are set in motion by sound waves from malleus to the footplate of the stapes in the oval window B. EUSTACHIAN TUBE - Connects nasopharynx & middle ear - Equalizes pressure on both sides of eardrum INNER EAR - Contains the semi-circular canals, the cochlea & the distal end of the 8th cranial nerve - Maintains sense of balance & equilibrium A. SEMI-CIRCULAR CANALS - Contains fluid & hair cells connected to sensory nerve fibers of the vestibular portion of 8th cranial nerve B. COCHLEA - Spiral-shaped organ of hearing - Connects organ of Corti, receptor and organ for hearing - Transmits sound waves from the oval window & initiates nerve impulses carried by cranial nerve VIII (acoustic branch) to brain ( temporal lobe of cerebrum) th C. 8 CRANIAL NERVE 1. COCHLEAR BRANCH - transmits neuro-impulses from the cochlea to the brain where it is interpreted as sound 2. VESTIBULAR BRANCH - maintains balance & equilibrium HEARING & EQUILIBRIUM The external ear conducts sound waves to the middle ear The middle ear also called the tympanic cavity conducts sound waves to the inner ear

The middle ear is filled with air which is kept at atmospheric pressure by the opening of the Eustachian tube The inner ear contains sensory receptors for sound & forequilibrium The receptors in the inner ear transmit sound waves & changes in body position to the nerve impulses

ASSESSMENT OF THE EAR OTOSCOPIC EXAM GUIDELINES - the speculum is never blindly introduced into the external canal because of the risk of perforating the tympanic membrane - tilt the head slightly away & hold the otoscope upside down as if it were a large pen - this permits the examiners hand to lie against the head for support - pull the pinna up & back to straighten the external canal in an adult - visualize the external canal while slowly inserting the speculum NORMAL FINDINGS OF THE EXTERNAL CANAL Pink & intact without lesions Has various amounts of cerumen & fine little hairs NORMAL FINDINGS OF THE TYMPANIC MEMBRANE The tympanic membrane should be intact without perforations & free from lesions The tympanic membrane is transparent, opaque, pearly gray & slightly concave AUDITORY ASSESSMENT Sound is transmitted by air conduction & bone conduction Air is 2-3x longer than bone conduction CATEGORIES OF HEARING LOSS CONDUCTIVE HEARING LOSS

- due to any physical obstruction to the transmission of sound waves SENSORINEURAL HEARING LOSS - due to a defect in the organ of hearing, in the 8th cranial nerve, or in the brain itself MIXED CONDUCTIVE, SENSORINEURAL HEARING LOSS - results in profound hearing loss VOICE TEST Ask the client to block one external canal The examiner stands 1-2 ft away & quickly whispers a statement The client is asked to repeat the whispered statement Each ear is tested separately WATCH TEST A ticking watch is used to test the high-frequency sounds The examiner holds a ticking watch about 5 inches from each ear & asks the client if the ticking is heard. TUNING FORK TESTS A. WEBER TUNING FORK TEST CONDUCTIVE HEARING LOSS = the sound is heard in affected ear SENSORINEURAL HEARING LOSS= sound heard in the unaffected ear B. RINNE TUNING FORK TEST NORMAL RESULT: (+) RINNE TEST/ AC>BC CONDUCTIVE HEARING LOSS If the client is unable to hear the sound through the ear in front of the pinna, (-) RINNE TEST/ AC<BC VESTIBULAR ASSESSMENT OF THE EAR TEST FOR FALLING The examiner asks the client to stand with the feet together & arms hanging loosely at the sides & eyes closed The client normally remains erect with slight swaying ABNORMAL RESULT: (+) ROMBERG SIGN - presence of significant swaying TEST FOR PAST POINTING

 of

NORMAL TEST RESPONSE: - The client can easily return to the point

reference FINDINGS The client with vestibular function problem lacks a normal sense of position sense and is unable to return to the extended fingers to the point of reference, the fingers instead either goes to the right or left of the reference point GAZE NYSTAGMUS EVALUATION Examine the clients eyes as they look straight ahead, 30 degrees to each side, upward & downward FINDINGS - Any spontaneous nystagmus is a (+) result - ABNORMAL FINDING - a constant involuntary cyclic movement of the eyeball in any direction represents a problem with the vestibular system HALLPIKE MANEUVER Assesses for positional vertigo or induced dizziness The client assumes a supine position The head is rotated to one side for 1 minute FINDINGS (+) test result is presence of nystagmus after 5-10 sec - ABNORMAL FINDING - a constant involuntary cyclic movement of the eyeball in any direction represents a problem with the vestibular system DIAGNOSTIC TESTS FOR THE EAR TOMOGRAPHY - may be performed with or without contrast medium - assesses the mastoid, middle ear & inner ear structures - multiple x-rays of the head are done

NURSING CARE All jewelry are removed Lead eye shields are used to cover the cornea to diminish the radiation dose to the eyes The client must remain still in a supine position No follow-up care is required AUDIOMETRY - measures hearing acuity - uses 2 types: PURE TONE AUDIOMETRY & SPEECH AUDIOMETRY - after testing, audiogram patterns are depicted on a graph to determine the type & level of hearing loss PURE TONE AUDIOMETRY - used to identify problems with hearing, speech, music & other sounds in the environment SPEECH AUDIOMETRY - the clients ability to hear spoken words is measured NURSING CARE Inform the client regarding the procedure Instruct the client to identify the sounds as they are heard

ELECTRONYSTAGMOGRAPHY - evaluates spontaneous nystagmus - used to distinguish between normal nystagmus & either medication-induced nystagmus or nystagmus caused by a lesion in the central or peripheral vestibular pathway - records changing electrical fields with movement of the eye, as monitored by electrodes placed on the skin around the eye CALORIC TEST (BI-THERMAL TEST) - evaluate dizziness - Nystagmus, N/V or ataxia

- indicate a pathological condition of the labyrinth system, whereas a decreased response may indicate that the vestibular system is affected NURSING CARE Warm water causes a greater response than cold water Warm water caloric testing (irrigation) precedes cool water caloric testing (irrigation) The character & duration of the eye movements are measured The client must assume a supine position with eyes closed & head elevated to 30 degrees After the procedure, the client begins taking clear fluids slowly & cautiously because N & V may occur Assistance with ambulation may also be necessary following the procedure OTIC MEDICATIONS ADMINISTERING EAR DROPS ADULT Pull the pinna up & back to straighten the external canal to instill ear drops CHILD Pull the pinna down & back for infants & children younger than 3 years of age Pull the pinna up & back for children for children more than 3 years IRRIGATION OF THE EAR Irrigation of the ear needs to be prescribed by MD Ensure that there is direct visualization of the tympanic membrane Warm irrigating solution to 100 F solutions not close to the clients body temp will cause ear injury, nausea & vertigo Irrigation must be done gently to avoid damage to the eardrum When irrigating, dont direct irrigating solution directly toward the eardrum If perforation of the eardrum is suspected, irrigation is not done

MEDICATIONS THAT AFFECT HEARING ANTIBIOTICS Amikacin (Amikin) Chloramphenicol - Chloromycetin - Chloroptic - Ophthoclor Erythromycin - E-Mycin - ERYC - Ery-Tab - PCE Dispertabs - Ilotycin Gentamicin (Garamycin) Streptomycin sulfate (Streptomycin) Tobramycin sulfate (Nebcin) Vancomycin (Vancocin) DIURETICS Acetazolamide (Diamox) Furosemide (Lasix) Ethacrynic acid (Edecrine) OTHERS Cisplatin (Platinol, Platinol-AQ) Nitrogen mustard Quinine (Quinamn) Quinidine - Cardioquin - Quinaglute - Quindex ANTI-INFECTIVE MEDICATIONS EXAMPLES Amoxicillin (Amoxil) Ampicillin trihydrate (Polycillin) Cefaclor (Ceclor) Clindamycin HCl (Cleocin) Trimethoprim (TMP) & Sulfamethaxazole (SMZ) Bactrim, Cotrim, Septra Erythromycin (Ilotycin, E-Mycin) Penicillin V potassium (Pen V) Loracarbef (Lorabid) Clarithromycin (Biaxin) Polymyxin B sulfate (Aerosporin) Tetracycline HCl (Achromycin) Acetic acid and Aluminum acetate (Otic Domeboro) ANTI-HISTAMINES & DECONGESTANTS - Produce vasoconstriction

- Stimulate the receptors of the respiratory mucosa - Reduce respiratory tissue hyperemia & edema to open obstructed eustachian tubes - Used for acute otitis media

SIDE EFFECTS Drowsiness Blurred vision Dry mucous membranes NURSING CARE Inform the client that drowsiness, blurred vision, & dry mouth may occur Instruct the client to increase fluid intake unless C/I & to suck on hard candy to alleviate dry mouth Instruct the client to avoid hazardous activities if drowsiness occurs EXAMPLES Tripolidine & pseudoephedrine (Actifed) Naphazoline HCl (Allerest, Albalon) Chlorpheniramine (Chlor-Trimeton, Teldrin) Brompheniramine (Bromphen, Dimetane) Terfenadine (Seldane) Clemastine (Tavist) Cetirizine (Zyrtec) Astemizole (Hismanal) LOCAL ANESTHETICS MEDICATION : Benzocaine (Americaine Otic; Tympagesic) SIDE EFFECTS Allergic reaction Irritation NURSING CARE Monitor for effectiveness if used for pain relief Assess for irritation or allergic reaction CERUMINOLYTIC MEDICATIONS EXAMPLES Carbamide peroxide (Debrox) Boric acid (Ear-Dry) NURSING CARE Instruct the client not to use drops more often than prescribed

Moisten a cotton plug with medication before insertion Keep the container tightly closed & away from moisture Avoid touching the ear with the dropper 30 minutes after installation, gently irrigate the ear as Rx with warm water using a rubber bulb ear syringe Irrigation may be done with hydrogen peroxide soln as Rx For chronic cerumen impaction, 1-2 gtts of mineral oil will soften the wax Instruct the client to notify MD if redness, pain or swelling persists

DISORDERS OF THE EAR 1. CONDUCTIVE HEARING LOSS - occurs when sound waves are blocked to the inner ear fibers because of external ear or middle ear disorders - disorders can often be corrected with no damage to hearing, or minimal permanent hearing loss CAUSES Any inflammatory process or obstruction of the external or middle ear Tumors Otosclerosis A build-up of scar tissue on the ossicles from previous middle ear surgery 2. SENSORINEURAL HEARING LOSS - a pathological process of the inner ear or of sensory fibers that lead to the cerebral cortex CAUSES Damage to the inner ear structures Damage to the cranial nerve VIII Prolonged exposure to loud noise Medications, trauma, infections, surgery Inherited disorders Metabolic & circulatory disorders

Menieres syndrome Diabetes mellitus Myxedema

3. MIXED HEARING LOSS - also known as conductive-sensorineural hearing loss - client has both sensorineural & conductive hearing loss SIGNS OF HEARING LOSS : GENERAL Frequently asking people to repeat statements Straining to hear Turning head or leaning forward to favor one ear Shouting in conversations Ringing in the ears Failing to respond when not looking in the direction of the sound Answering questions incorrectly Raising the volume of the television or radio Avoiding large groups Better understanding of speech when in small groups Withdrawing from social interactions FACILITATING COMMUNICATION Use of written words Provision of light in the room Getting the attention of the client before you begin to speak Facing the client when speaking Talking in a room without distracting noises Moving close to the client & speaking slowly & clearly Keeping hands & other objects away from the mouth when talking to the client Talking in lower tones, because shouting is not helpful Rephrasing sentences & repeating information Validating Reading lips Using sign language

Using telephone amplifiers Facing lights that are activated by ringing of the telephone or doorbell Specially trained dogs that help the client to be aware of sound & to alert the client of potential dangers COCHLEAR IMPLANTATION - used for sensorineural hearing loss - a small computer converts sound waves into electrical impulses - electrodes are placed by the internal ear with a computer device attached to the external ear - electronic impulses directly stimulate nerve fibers HEARING AIDS - used for the client with conductive hearing loss - can help the client with sensorineural loss, although it is not as effective - a difficulty that exists in its use is the amplification of background noise as well as voices CLIENT EDUCATION: HEARING AID Encourage to begin using the hearing aid slowly to develop an adjustment to the service Adjust the volume to a minimal hearing level to prevent feedback squeaking Teach the client to concentrate on the sounds that are to be heard & to filter out background noise Instruct the client to clean ear mold with mild soap & water Avoid excessive wetting of the hearing aid, and try to keep the hearing aid dry Clean the ear cannula of the hearing aid with a toothpick or pipe cleaner Turn off the hearing aid & remove the battery when not in use Keep extra batteries on hand Keep the hearing aid in a safe place Prevent hair sprays, oils, or other hair & face products from coming into contact with the receiver of the hearing aid

4. PRESBYCUSIS - associated with aging - leads to degeneration or atrophy of the ganglionic cells in the cochlea & a loss of elasticity of the basilar membranes - leads to compromise of the vascular supply to the inner ear with changes in several areas of the ear structure ASSESSMENT Hearing loss is gradual & bilateral Client states that he/she has no problem with hearing but cant understand what the words are Client thinks that the speaker is mumbling 5. EXTERNAL OTITIS - infective inflammatory or allergic responses involving the structure of the external auditory canal or the auricles - an irritating or infective agent comes into contact with epithelial layer of the external ear - this leads to either an allergic response or S/S of infection - the skin becomes red, swollen, & tender to touch on movement - the excessive swelling of the canal lead to conductive hearing loss due to obstruction - more common in children & termed as SWIMMERS EAR - occurs more often in hot, humid environments ASSESSMENT Pain Itching

Plugged feeling in the ear Redness & edema Exudate Hearing loss NURSING CARE Apply heat locally for 20 minutes 3x a day Encourage rest to assist in reducing pain Administer analgesics such as aspirin or acetaminophen (Tylenol) for the pain as prescribed Instruct the client that the ears should be kept clean & dry Instruct the client to use earplugs for swimming Instruct the client that cotton-tipped applicators should not be used to dry ear because their use can lead to trauma to the canal Instruct the client that irritating agents such as hair products or headphones should be discontinued

6. OTITIS MEDIA - infection of the middle ear occurring as a result of a blocked eustachian tube, which prevents drainage - a common complication of an acute respiratory infection ASSESSMENT Fever Irritability, restlessness & loss of appetite Rolling of head from side to side Pulling on or rubbing the ear Earache or pain Signs of hearing loss Purulent ear drainage Red, opaque, bulging or retracting tympanic membrane NURSING CARE Encourage oral fluids Teach the parents to feed infants in an upright position Instruct the child to avoid chewing during the acute period

chewing increases the pain Provide local heat & have the child lie with affected ear down Instruct the parents in the appropriate procedure to clean drainage from the ear with sterile cotton swabs Instruct in the administer of analgesics or antipyretics such as Acetaminophen (Tylenol) to decrease fever & pain Instruct the parents in the administration of prescribed antibiotics, emphasizing that the 10-14 day period is necessary to eradicate positive organisms Instruct the parents that screening for hearing loss may be necessary MYRINGOTOMY - temporary incision of tympanic membrane to decompress the membrane and promote drainage of effusion - insertion of tympanoplasty tubes in the middle ear to equalize pressure & keep the ears dry POST-OP NURSING CARE Keep the ears dry Earplugs should be worn during bathing, shampooing & swimming Diving & submerging under water are C/I Client education post myringotomy Avoid strenuous exercise Avoid rapid head movements, bouncing or bending Avoid straining on bowel movement Avoid drinking through a straw Avoid traveling by air Avoid forceful coughing Avoid contact with persons with colds Avoid washing hair, showering or getting the head wet for a week as Rx Instruct the client that if she/he needs to blow the nose, blow one side at a time with wide mouth open Instruct the client to keep ears dry by keeping a ball of cotton coated with petroleum jelly in the ear & to change cotton ball daily

Instruct the client to report excessive ear drainage to the physician

7. CHRONIC OTITIS MEDIA - a chronic infective, inflammatory, or allergic response involving the structure of the middle ear - surgical treatment is necessary to restore hearing - the type of surgery can vary & include a simple reconstruction of the tympanic membrane, a myringotomy, or replacement of the ossicles within the middle ear TYMPANOPLASTY - a reconstruction of the middle ear may be attempted to improve conductive hearing loss PRE-OP NURSING CARE Administer antibiotic ear drops as Rx Clear the ear of debris as Rx & irrigate ear with a solution of equal parts of vinegar & sterile H2Oas Rx Instruct to avoid persons with URTI Instruct client to obtain adequate rest, eat a balanced diet & drink adequate fluids Instruct in DBE & coughing but forceful coughing avoided. - increases pressure in the middle ear esp. post-op POST-OP NURSING CARE Inform client that initial hearing after surgery is diminished & hearing will improve after the ear canal packing is removed Keep dressing clean & dry Keep client flat with operative ear up for at least 12 hours Administer antibiotics as Rx Instruct the client that he/she may return to work in approximately 3 weeks post-op 8. OTOSCLEROSIS

- disease of the labyrinthine capsule of the middle ear that results in a bony overgrowth of the tissue surrounding the ossicles - causes the devt of irregular areas of new bone formation & causes fixation of the bones - stapes fixation leads to CONDUCTIVE HEARING LOSS - if it involves inner ear, SENSORINEURAL HEARING LOSS ASSESSMENT Slowly progressing conductive hearing loss Bilateral hearing loss A ringing or roaring type of constant tinnitus Loud sounds heard in the ear when chewing Pinkish discoloration (SCHWARTZS SIGN) of the tympanic membrane - indicates vascular changes in the ear (-) Rinne test Weber test shows lateralization of the sound to the ear with the most conductive hearing loss - it is not uncommon to have bilateral involvement, although hearing loss may be worse in one ear - nonsurgical intervention promotes the improvement of hearing through amplification - surgical intervention involves removal of the bony growth that is causing the hearing loss - a PARTIAL STAPEDECTOMY or COMPLETE STAPEDECTOMY WITH PROSTHESIS (FENESTRATION) may be surgically performed FENESTRATION

- removal of the stapes with a small hole drilled in the footplate & a prosthesis is connected between the incus & footplate - sounds cause the prosthesis to vibrate in the same manner as the stapes COMPLICATIONS: Complete hearing loss - Prolonged vertigo - Infection - Facial nerve damage PRE-OP NURSING CARE Instruct the client in measures to prevent middle ear or external ear infections Instruct the client to avoid excessive nose blowing Instruct not to clean the ear canal with cotton-tipped applicators Instruct the client to remove the hearing aid 2 weeks before surgery to ensure the integration of local tissue POST-OP NURSING CARE Inform the client that hearing is initially worse after the surgical procedure & no noticeable improvement in hearing may occur for as long as 6 weeks Inform the client that the Gelfoam ear packing interferes with hearing but is used to decrease bleeding Assist with ambulating during the first 1-2 days after surgery Provide side rails when the client is in bed Administer antibiotics & antivertiginous & pain meds as Rx Assess for facial nerve damage, weakness, changes in taste sensation, vertigo, nausea & vomiting Instruct to move head slowly when changing positions Instruct to avoid showering & getting the head & wound wet Instruct to refrain from using small objects to clean the external ear canal Instruct to avoid rapid, extreme changes in pressure caused by quick head movements, sneezing,nose blowing, straining & changes in altitude

Instruct to avoid changes in the middle ear pressure - it could dislodge the graft prosthesis

MENIERES SYNDROME - a syndrome also called ENDOLYMPHATIC HYDROPS (- refers to dilation of the endolympathic system by either overproduction or decreased reabsorption of endolymphatic fluid) - characterized by tinnitus, unilateral sensorineural hearing loss, & vertigo - symptoms occur in attacks & last for several days, & the client becomes totally incapacitated - initial hearing loss is reversible, but as the frequency of attacks continues, hearing loss becomes permanent - repeated damage to the cochlea caused by increased fluid pressure leads to the permanent hearing loss CAUSES Any factor that increases endolymphatic secretion in the labyrinth Viral & bacterial infections Allergic reactions Biochemical disturbances Vascular disturbances producing changes in the microcirculation in the labyrinth ASSESSMENT Feelings of fullness in the ear Tinnitus, as a continuous low-pitched roar or humming sound - is present most of the time but worsens just before & during severe attacks Hearing loss is worse during an attack Vertigo - periods of whirling which might cause the client to fall to the ground

- sometimes so intense that even when lying down, the client holds the bed or ground in an attempt to prevent the whirling Nausea & vomiting Nystagmus Severe headaches NON-SURGICAL MANAGEMENT Preventing injury during vertigo attacks Providing bed rest in a quiet environment Provide assistance with walking Instruct the client to move the head slowly - to prevent worsening of vertigo Initiate Na & fluid restrictions as Rx Instruct to avoid smoking Administer Nicotinic acid (Niacin) as Rx - promote vasodilating effect Administer antihistamines as Rx - reduce the production of histamine & inflammation Administer antiemetics as Rx Administer tranquilizers & sedatives as Rx - to calm client & allow rest, control the vertigo, N&V SURGICAL MANAGEMENT - performed when medical therapy is ineffective & the functional level of the client has decreased significantly ENDOLYMPHATIC DRAINAGE & INSERTION OF THE SHUNT - may be performed early in the course of the disease to assist with the drainage of excess fluids RESECTION OF THE VESTIBULAR NERVE LABYRINTHECTOMY - removal of the labyrinth may be performed POST-OP NURSING CARE

Assess packing & dressing on the ear Speak to the client on the side of the unaffected ear Perform neurological assessments Maintain side rails Assist with ambulating Encourage the use of bedside commode Administer antivertiginous& antiemetic medications as Rx

CERUMEN & FOREIGN BODIES CERUMEN/EAR WAX - the most common cause of impacted canals FOREIGN BODIES - can include vegetables, beads, pencil erasers & insects ASSESSMENT Sensation of fullness in the ear with or without hearing loss Pain, itching or bleeding CERUMEN NURSING CARE Removal of the wax by irrigation is a slow process Irrigation is C/I in clients with a hx of tympanic membrane perforation To soften cerumen, add 3 gtts of glycerin to the ear @ hs & 3 gtts of hydrogen peroxide BID After several days the ear is irrigated -50-70 ml of solution is the maximal amount a client can tolerate during an irrigation sitting FOREIGN BODIES NURSING CARE If the foreign matter is vegetable, irrigation is used with care Insects are killed before removal unless they can be coaxed out by flashlight or a humming noise Mineral oil or alcohol is instilled to suffocate the insect which is then removed with ear forceps Use small ear forceps to remove the object & avoid pushing the object farther into the canal & damaging the tympanic membrane

EAR CARE EAR PROTECTION Protecting and Caring For Your Ears The ears are delicate and irreplaceable instruments. Once hearing is damaged, it often can't be restored. So give your ears and your hearing the same level of care and attention as you do other vital parts of your body. General Nursing Care Tips Have your ears and hearing checked periodically Know the warning signs of hearing loss See a medical professional right away if you: - injure your ears, - experience ear pain, or - notice changes in your ears or sense of hearing Warning Signs of Hearing Loss Difficulty hearing conversations, especially in the presence of background noise Frequently asking others to repeat what theyve said Misunderstanding what people say Difficulty hearing on the telephone Requiring the TV or radio volume to be louder than others in the room prefer Feeling that people are mumbling when they are talking Difficulty hearing certain environmental sounds, such as birds chirping Agreeing or nodding your head during conversations when youre not sure whats been said Removing yourself from conversations because its too difficult to hear Reading lips so you can try to follow what people are saying Straining to hear or keep up with conversations Tinnitus Preventing Hearing Loss Avoid loud or prolonged exposure to noise. When you can't avoid noise, wear ear protection. If your ears produce excessive earwax, have your ears cleaned periodically by a health care professional. (Do not use cotton swabs, as you will lodge more earwax even

deeper into the ear canal than the small amount of wax you will remove.) Avoid ototoxic drugs. If taking one already, talk with your doctor and see if there's a less-ototoxic alternative. Stay healthy and be mindful of risk factors, such as hypertension. Noise Avoid exposure to loud noise. - best action: get rid of the noise or leave the noisy area. Follow this simple rule of thumb: if you need to shout to be heard over noise, it's potentially damaging When you cant avoid noise, always wear ear protection (earplugs or earmuffs) Be aware that repeated or prolonged exposure to lower noise levels may cause hearing damage Protect the ears of children who are too young to know the dangers that noise can pose Cleaning of Ears Clean ears with extra care. Wipe the outer ear with a washcloth or tissue. Never put anything into your ear thats smaller than an adult finger covered with a washcloth. Using cotton swabs or other small object may damage the sensitive structures of your inner ear Earwax is usually removed by the ears own cleaning mechanism. If there is build-up of excess earwax, have it removed by a physician or medical professional. Illness and Medications Reduce the risk of ear infections by treating upper respiratory tract infections promptly Some illnesses and medical conditions can affect hearing. If experiencing sudden hearing loss or persistent noise in your ears or head (tinnitus), have it seen by a health care provider/physician right away Illness and Medications Be aware that certain medications are ototoxic and may damage your hearing. Take medications only as directed, and refer to you health care provider/physician immediately if you experience unusual symptoms

Stop smoking. Some studies have found that adults who smoke are more likely to develop hearing loss than nonsmokers. Smoking can also aggravate existing conditions, such as tinnitus Blowing of the nose A study conducted by a team of researchers from the University of Virginia and the University of Aarhus in Denmark, revealed that blowing your nose may actually cause mucus to be propelled back into the sinus cavities. Also, blowing the nose creates a huge amount of pressure in the nose -- over seven times more pressure than is produced by sneezing or coughing. Proper blowing of the nose Blow your nose gently. Blowing too hard creates even more pressure that can force infectious mucus into your ears and sinuses. Avoid the "both-nostrils-open" blow. Instead ... Press a finger over one nostril. Gently blow the nose into a paper tissue thru the one open nostril. Switch your finger to close the opposite nostril, and repeat. Proper blowing of the nose Drink plenty of fluids. Makes it easier for mucus to be removed by blowing gently. Blowing your nose after taking a steamy shower can also help. Proper blowing of the nose Use paper tissues rather than cloth handkerchiefs. A used handkerchief is a breeding ground for germs -- and when you reuse it you're spreading those germs around your face and hands. Proper blowing of the nose Only use a paper tissue once, then throw it away. Minimizes the risk of putting germs back onto your face and hands. Wash your hands when you're finished, Microbes from your nose and tissue will be transferred to your fingers while you blow. Prevents spread of germs to other people or back to yourself. Ear Examination Includes an assessment of:

Hearing, and appearance of the ear Ear Examination Ear Examination History Look for classic symptoms of ear disease: deafness, tinnitus, discharge (otorrhia), pain (otalgia), and vertigo Previous ear surgery, or head injury Family history of deafness Systemic disease (for example stroke, multiple sclerosis, cardiovascular disease) Ototoxic drugs (antibiotics: gentamicin), diuretics, cytotoxics) Exposure to noise (pneumatic drill or shooting, for example) History of atopy and allergy in children Ear Examination Inspecting the External Ear Inspect the external ear before examination with an otoscope/auriscope. Swab any discharge, and remove any wax. Inspecting the External Ear Look for obvious signs of abnormality: Size and shape of pinna Extra cartilage tags/pre-auricular sinuses or pits Signs of trauma to pinna Suspicious skin lesions on the pinna including neoplasia Skin conditions of the pinna and external canal Infection/inflammation of external ear canal with discharge Signs/scars of previous surgery PALPATION OF THE EXTERNAL EAR Gently pull on the pinna to test for pain (If painful this may suggest external ear disease). Palpate for any lymph nodes (e.g. The parotid or postauricular nodes ~ this may also be suggestive of external ear disease) INSPECTION OF THE EXTERNAL AUDITORY MEATUS Examine the good ear first. With prior warning to the patient, gently pull the pinna upwards and outwards (Directly down and back in children). Inspecting the Ear Canal and Ear Drum Slowly insert the otoscope/auriscope, looking at the skin of the canal while entering. Check skin for normality or signs of inflammation. Inspecting the Ear Canal and Ear Drum

Look for wax or other obstructions (e.g. foreign bodies tips of cotton buds!) Ear wax Inspecting the Tympanic Membrane Move the otoscope in order to see several different views of the drum. Normal tympanic membrane should appear pearly grey, concave, & roughly circular (~1cm in diameter). Inspecting the Tympanic Membrane 1=Attic (pars flaccida) 2= Lateral process of malleus 3=Handle of malleus 4=End of the malleus 5=Light reflex Inspecting the Tympanic Membrane Look for signs of inflammation Acute otitis media Inspecting the Tympanic Membrane Look for signs of perforation. Perforation of ear drum Ear Examination Slowly retract the otoscope/auriscope from the ear. Change the speculum on the otoscope/auriscope and examine the other ear. Finally document what was seen in both ears, the condition of the tympanic membrane and the external auditory meatus Basic hearing tests Detailed hearing tests are usually performed in audiology clinics. A patient with normal hearing should hear equally as well in both ears. Tuning fork tests: Weber test and Rinne test Free field voice testing (whisper from 40 cm) Weber test The vibrating fork is placed anywhere on the midline of the patient's skull. The patient has to say where they hear the vibration. Interpretation of results is as follows: Normal hearing: vibration will be heard on the midline or equally in both ears Perceptive loss: sound is heard better by the intact ear Conductive loss: sound is heard better by the affected ear Weber Test Weber Test Rinne Test Should be performed on each ear in turn. The base of the fork is placed against the patient's mastoid process on one side.

When the patient can no longer hear the vibration, the tuning fork is placed next to their ear on the same side. Rinne Test Interpretation of results is as follows: If the sound is now heard, the Rinne test is positive, meaning that air conduction is better than bone conduction and there is: - no hearing loss - perceptive hearing loss. Conductive hearing loss may be diagnosed if the test is negative (i.e. bone conduction is better than air conduction) Rinne Test Rinne Test The whispered voice test Has the advantage of not needing any equipment. Patients are told that they will be asked to repeat three numbers. The examiner stands out of view of the patient (to prevent lip reading) while covering one of the patient's ears and rubbing the external auditory meatus with a gentle circular motion. This serves to mask sound input from the non-test ear. The examiner then fully exhales (which reduces voice volume) and standing 0.75 m (arm's length) from the ear being tested whispers 3 numbers. It is very important to pay attention to the loudness of the whispering. Failure to repeat 50% or more of the numbers on two trials is considered a fail and suggests a 30 dB+ hearing loss. Whispered voice test Stand 1-2 feet behind client so they can not read your lips. 2) Instruct client to place one finger on tragus of left ear to obscure sound. 3) Whisper word with 2 distinct syllables towards client's right ear. 4) Ask client to repeat word back. 5) Repeat test for left ear. 6) Client should correctly repeat 2 syllable word. The eye is like a camera. The external object is seen like the camera takes the picture of any object. The Eye Light enters the eye thru a small hole called the pupil and is focused on the retina, which is like a camera film. Iris (colored ring of the eye) controls the amount of light entering the eye; closes

when light is bright and opens when light is dim. Sclera: the tough white sheet that covers the outside of the eye The Eye Eye also has a focusing lens, which focuses images from different distances on the retina. The Eye Ciliary muscles in ciliary body control the focusing of lens automatically. Image formed on the retina is transmitted to brain by optic nerve. The image is finally perceived by brain. Three Layers of the Eyeball Sclera: outer fibrous layer, helps keep the shape of the eye Choroid: middle blood rich layer supplying nutrition to the eye structures Retina: inner colored (pigmented) nerve layer of the eye. Eye Care Practitioners Eye Care Practitioners Ophthalmologist a medical doctor who specializes in eye care. Optometrist optometric doctor trained to provide refractive correction and diagnose/treat common issues. Ophthalmic medical practitioner Similar to an optometrist (in the UK). Oculist Older term for either an ophthalmologist or optometrist. Ocularist specializes in the fabrication and fitting of ocular prostheses for people who have lost eyes due to trauma or illness. Optician also called Optical Dispenser specializes in the fabrication and fitting of spectacles. Prescription for the spectacles must be supplied by an ophthalmologist or optometrist. Orthoptist specializes in ocular motility, which is the movement of the eye controlled by the extraocular muscles. Vision therapist work with patients that require therapy, such as low vision patients.

Ophthalmic medical personnel popularly called "OMP" is a collective term for allied health personnel in ophthalmology. often used to refer to non-specialized personnel (unlike ocularists or opticians).

photophobia (iridocyclitis, Iritis)

Keratitis Glaucoma Eye Health Promotion Nutrition Ensure proper intake of nutrients necessary for optimum vision health in the daily diet Ensure intake of different vitamins, minerals, and herbal supplements shown by research as essential for good vision health and the prevention of potentially blinding vision conditions Vitamin A absolutely essential for eye and vision health. required by the retina for its proper functions recommended for those with poor night vision Helps eyes adjust to light changes Moistens the eyes, which can enhance visual acuity has been shown to prevent the forming of cataracts helps prevent blindness from macular degeneration Sources: sweet potatoes, carrots, mangoes, spinach, and cantaloupe, yellow squash. Vitamin C - An antioxidant Linked to the prevention of cataracts One study has shown that taking 300 to 600 mg supplemental vitamin C reduced cataract risk by 70 percent, delay of macular degeneration, and eye pressure reduction in glaucoma patients. Sources: orange juice, citrus fruits and broccoli, cauliflower, cabbage, and strawberries. Vitamin E Use as an antioxidant Helps protect against cataracts and age-related macular degeneration. A clinical study has showed that taking vitamin E can cut the risk of developing cataracts in half. Another study also showed that the combination of vitamins C and E had a protective effect against UV rays.

Danger signs of Visual Disorders for referral loss or distortion of central vision, or marked difference of acuity between eyes sudden loss of peripheral vision flashes of light or floaters (ischemia), sudden cobweb or stringy floaters (detachment) curtain across eyes (ischemia) halos about lights (glaucoma) intermittent dimming of vision strabismus cornea > 11 mm in newborn (congenital glaucoma) red eye with Red Eye Danger Signs Red Eye Danger Signs blurred vision (keratitis, glaucoma, Iritis) ciliary flush - perilimbal conjunctival injection (Iritis) corneal opacification or epithelial disruption (bacterial keratitis) abnormal pupil: nonreactive, small/irregular. (glaucoma, iridocyclitis, Iritis) proptosis Iritis Proptosis Also called Exophthalmos forward displacement of the eye in the orbit. caused by swelling of the soft tissues or bones of the orbit. Causes: inflammation, infection and tumor, hyperthyroidism CONTINUED :Red Eye Danger Signs increased intraocular pressure colored halos (acute angle-closure glaucoma) pain (glaucoma, Iritis, bacterial keratitis) Aus sign: sharp pain in covered (red) eye when uncovered eye is illuminated (Iritis)

Sources: wheat germ, dark green leafy vegetables (such as spinach), sweet potatoes, avocado, asparagus Zinc Our eyes actually contain the greatest concentration of zinc in our body. an essential element required for the conversion of beta-carotene into vitamin A. Sources: Oysters, red meat and poultry Chromium plays a large role in muscle contraction including eye muscles low levels of chromium are a major risk factor for increased intraocular pressure Sources: beef, liver, eggs, chicken, oysters, wheat germ, green peppers, broccoli, apples, bananas, and spinach. Glutathione An amino acid that protects the tissues surrounding the lens of the eyes Helps prevent cataracts, glaucoma, retinal disease, and diabetic blindness. Sources: garlic, eggs, asparagus, and onions, watermelon, asparagus, and grapefruits. Lutein and zeaxanthin Accumulate within the retina and imbue a yellow pigment that helps protect the eye Protects photoreceptors of the retina from light damage Act like sunglass filters to protect the eye Lower the risk of cataracts and macular degeneration Are also antioxidants Sources: dark, leafy greens , corn, oranges, papaya and squash. Ginkgo Biloba Increases blood flow to the retina. Can slow retinal deterioration which results in an increase of visual acuity. Prevention of Eye Injury Protect your eyes from the sun. Ultraviolet radiation can harm your eyes. Use a wide-brim hat and UVabsorbing eyewear to protect your eyes from harmful effects of the sun.

Eyewear should provide 99 to 100 percent of UV-A and UV-B protection. Prevention of Eye Injury Regular eyeglasses do not provide enough safety protection. Protect your eyes with proper safety glasses. Injuries can be prevented if proper eye protection is used at home, in the workplace and playing sports. Use appropriate lighting. Proper lighting can help improve safety at home and prevent eye injuries. Prevention of Eye Injury Keep your children safe. - Pay special attention to where sharp items are placed. - Items such as cosmetics, kitchen utensils and desk supplies can cause eye damage. - Avoid flying or projectile toys and any with sharp points and dangerous edges. Visit eye doctor (ophthalmologist) regularly. Recommended regular eye exam at least every 2 years. - Early detection of problems is key to treatment and prevention. Specific Prevention of Eye Injury At home or outside: Wash your hands after using household chemicals. Wear chemical safety goggles when using hazardous solvents and detergents, and do not mix cleaning agents around or near a child. Specific Prevention of Eye Injury At home or outside: Turn spray nozzles away from your face and the faces of others. Read and follow directions when opening bottle-tops (such as wine, carbonated beverages). Read and follow directions when playing games and operating equipment. Specific Prevention of Eye Injury At home or outside: Provide lights and handrails to improve safety on stairs.

Keep paints, pesticides and fertilizers properly stored in a secure area. Be sure to wear recommended protective goggles, helmets, and safety gear during the appropriate activities. Use guards on all power equipment. Protect eyes from the sun with either by a wind-brimmed hat or by wearing ultraviolet (UV)-protective sunglasses Never look directly at the sun (especially during an eclipse). Specific Prevention of Eye Injury At play: Recommended protective eyewear should be worn during the appropriate sports and recreational activities. A helmet with a polycarbonate face mask or wire shield should be worn during the appropriate sports. Fireworks should be handled with care and only be used by adults. Appropriate protective eyewear should be worn during sporting and recreational activities. Protective eyewear should be worn when using lawnmowers, as debris may be projected into the air. At school, it is important to wear protective eye wear when performing science or lab experiments. Prevention of Eye Strain Most common symptoms of eye strain, which may be attributed to prolonged computer screen or tv viewing. Symptoms may include:

Position the video display terminal (VDT) slightly further away than where you normally hold reading material. Position the top of the VDT screen at or slightly below eye level. Place all reference material as close to the screen as possible to minimize head and eye movements and focusing changes. Minimize lighting reflections and glare. Keep the VDT screen clean and dustfree. Schedule periodic rest breaks to avoid eye fatigue. Keep the eyes lubricated (by blinking) to prevent them from drying out. Keep the VDT screen in proper focus. Consult ophthalmologist - some individuals who normally do not need glasses may need corrective lenses for computer work.

red, watery, irritated eyes tired, aching, or heavy eyelids problems with focusing muscle spasms of the eye or eye headache

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backache Symptoms of eye strain are often relieved by: - resting the eyes - changing the work environment - wearing the proper glasses. - Using proper lighting when using a computer Prevention of Eye Strain when Using a Computer