ASSESSING CLIENTS WITH EYE DISORDERS

REVIEW OF ANATOMY AND PHYSIOLOGY The Eye and Vision = The eyes are complex structures, containing 70%
of the sensory receptors of the body. Each eye is a sphere measuring about 1 in (2.5cm) in diameter, surrounding and protected by a bony orbit and cushions of fat. The primary functions of the eye are to encode the patterns of light from the environment through photoreceptors and to carry the coded information from the eyes to the brain. The brain givs meaning to the coded information, allowing us to make sense of what we see. Both extraocular and intraocular structures are considered a part of the eye. Extraocular Structures = Extraocular or accessory structures of the eye are those portions of the eye outside the eyeball yet vital to its protection. These structures are the eyebrows, the eyelids, the eyelashes, the conjuctiva, the lacrimal apparatus, and the extrinsic eye muscles. The eyebrows are short, coarse hairs located above the eyes over the superior orbital ridges of the skull. The eye brows shade the eyes and keep perspiration away from them. The eyelids are thin, loose folds of skin covering the anterior eye. They protect the eye from foreign bodies, regulate the entry of light into the eye, and distribute tears by blinking. The eyelashes are short hairs that project from the top and bottom borders of the eyelids. When anything touches the eyelashes, the blinking reflex is initiated to protect the eyes from foreign objects. The conjunctiva is a thin, transparent membrane that lines the inner surfaces of the eyelids and also folds over the anterior surface of the eyeball. The palpebral conjuctiva lines the upper and lower eyelids, whereas the bulbar conjuctiva loosely covers the anterior sclera (the white part of the eye ). The conjuctiva is a mucous membrane that lubricates the eyes. The lacrimal apparatus is composed of the lacrimal gland, the puncta, the lacrimal sac, and the nasolacrimal duct. Together, these structures secrete, distribute, and drain tears to cleanse and moisten the eyes surface. The six extrinsic eye muscles control the movement of the eye, allowing it to follow a moving object. The muscles also help maintain the shape of the eyeball. INTRAOCULAR STRUCTURES = transmit visual images and maintain homeostasis of the inner eye. Those lying in the anterior portion of each eyeball are the sclera and the cornea (forming the outermost coat of the eye, call the fibrous tunic), the iris, the pupil, and the anterior cavity.The white sclera lines the outside of the eyeball. The functions of the sclera are to protect and give shape to the eyeball. The sclera gives way to the cornea over the iris and pupil. The cornea is transparent, avascular and very sensitive to touch. The cornea forms a window that allows light to enter the eye and is a part of its light-bending apparatus. When the cornea is touched, the eyelids blink and tears are secreted. The iris is a disc of muscles tissue surrounding the pupil and lying between the cornea and the lens. The iris gives the eye its color and regulates light entry by controlling the size of the pupil. The pupil is the dark center of the eye through which light enters. The pupil constricts when bring light enters the eye and when it is used for near vision; it dilates when light conditions are dim and when eye is used for far vision. In response to intense light, the pupil constricts rapidly in the papillary light reflex. The anterior cavity is made up of the anterior chamber (the space between the cornea and the iris) and the posterior chamber (the space between the iris and the lens). The anterior cavity is filled with a clear fluid called the aqueous humor. Aqueous humor is constantly formed and drained to maintain a relatively constant pressure of from 15-20 mm Hg in the eye. The Canal of Schlemm, a network of channels that circle the eye in the angle at the junction of the sclera and the cornea, is the drainage system for fluid moving between the anterior and posterior chambers. Aqueous humor provides nutrients and oxygen to the cornea and lens. The intraocular structures that lie in the internal chamber of the eye are the posterior cavity and vitreous humor, the lens, the ciliary body, the uvea, and the retina. The posterior cavity lies behind the lens. It is filled with a clear gelatinous substance called the vitreous humor. Vitreous humor supports the posterior surface of the lens, maintains the position of the retina, and transmits light. The lens is a biconvex, avascular, transparent structure located directly behind the pupil. It can change shape to focus and refract light onto the retina. The uvea, also called the vascular tunic, is the middle coat of the eyeball. This pigmented layer has three components: the iris, ciliary body, and choroid. The ciliary body encircles the lens, and along with the iris, regulates the amount of light reaching the retina by controlling the shape of the lens. Most of the uvea is made up of the choroids, which is pigmented and vascular. Blood vessels of the choroids nourish the other layers of the eyeball. Its pigmented areas absorb light, preventing it from scattering within the eyeball.

Rods allow for vision in dim light as well as for peripheral vision. Cones allow for vision in bright light and for the perception of color. The optic disk, a cream-colored round or oval area within the retina is the point at which the optic nerve enters the eye. The slight depression in the center of the optic disc is often called the physiologic cup. Located laterally to the optic disc is the macula, which is a darker area with no visible blood vessels. The macula contains primarily cones. The fovea centralis is a slight depression in the center of the macula that contains only cones and is a main receptor of detailed color vision

THE VISUAL PATHWAY

The optic nerves are cranial nerves formed of the axons of ganglion cells. The two optic nerves meet at the optic chiasma, which is just anterior to the pituitary gland in the brain. At the optic chiasma, axons from the medial half of each retina cross to the opposite side to form pairs of axons from each eye. These pairs continue as the left and right optic tracts. The crossing of the axons results in each optic tract carrying information from the lateral half of the retina of the left eye and the medial half of the retina of the right eye, whereas the right optic tract carries visual information from the lateral half of the retina of the right eye and the medial half of the retina of the left eye. The ganglion cell axons in the optic tracts travel to the thalamus and create synapses with neurons, forming pathways called optic radiation terminate in the visual cortex of the occipital lobe. Here the nerve impulses that originated in the retina are interpreted. The visual fields of each eye overlap considerably, and each eye sees a slightly different view. Because of this overlap and crossing of the axons, information from both eyes reaches each side of the visual cortex, which then fuses the information into one image. This fusion of images accounts for the ability to perceive depth; however, depth perception depends on visual input from two eyes that both focus well. Refraction is the bending of light rays as they pass from one medium to another medium of different optical density. As light rays pass through the eye, they are refracted at several points: as they enter the cornea, as they leave the cornea and enter the aqueous humor, as they enter the lens, and as they leave the lens and enter the vitreous humor. At the lens, the light is bent so that it converges at a single point on the retina. This focusing of the image is called accommodation. Because the lens is convex, the image projected onto the retina (the real image) is upside down and reversed from left to right. The real image coded as electric signals that are sent to the brain the brain decodes the image so that the person perceives it as it occurs in space. The eyes are best adapted to see distant objects. Both eyes fix on the same distant image and do not require any change in accommodation. For people with emmetropic (normal) vision, the distance from the viewed object at which the eyes require no accommodate the lens, constrict the pupils, and converge the eyeballs. Accommodation is accomplished by contraction of the ciliary muscles. This contraction reduces the tension on the lens capsule so that it bulges outward to increase the curvature. This change in shape also achieves a shorter focal length, another requirement for the focusing of close images on the retina. The closest point on which a person can focus is called the near point of vision; in young adults with normal vision this is usually 8-10 in. pupillary constriction helps eliminate most of the divergent light rays and sharpens focus. Convergence (the medial rotation of the eyeballs so that each is directed toward the viewed object) allows the focusing of the image on the retinal fovea of each eye. Assessment of the Eyes I. Health History A. Current Health Status 1. Problems 2. Corrective lenses B. Past Health Status 1. Lens change 2. Blurred vision 3. Spots, floaters, halos 4. Infections or inflammations of the eyes 5. Eye surgery or injury 6. Styes (hordeolums) 7. High blood pressure 8. Diabetes 9. Eye medications C. Family health status

Equipment Needed The retina is the innermost lining of the eyeball. It has an outer pigmented A Snellen Eye Chart or Pocket Vision Card layer and an inner neural layer. The outer layer, next to the choroids, serves An Ophthalmoscope as the link between visual stimuli and the brain. The transparent inner layer Visual Acuity is made up of millions of light receptors in structures called rods and cones.

In cases of eye pain, injury, or visual loss, always check visual acuity before before proceeding with the rest of the exem or putting medications in your patients eyes. 1. Allow the patient to use their glasses or contact lens if available. You are interested in the patient's best corrected vision. 2. Position the patient 20 feet in front of the Snellen eye chart (or hold a Rosenbaum pocket card at a 14 inch "reading" distance). 3. Have the patient cover one eye at a time with a card. 4. Ask the patient to read progressively smaller letters until they can go no further. 5. Record the smallest line the patient read successfully 6. Repeat with the other eye. 7. Unexpected/unexplained loss of acuity is a sign of serious ocular pathology. Inspection 1. Observe the patient for ptosis, exophthalmos, lesions, deformities, or asymmetry. 2. Ask the patient to look up and pull down both lower eyelids to inspect the conjuntiva and sclera. 3. Next spread each eye open with your thumb and index finger. Ask the patient to look to each side and downward to expose the entire bulbar surface. 4. Note any discoloration, redness, discharge, or lesions. Note any deformity of the iris or lesion cornea. 5. If you suspect the patient has conjuntivitis, be sure to wash your hands immediately. Viral conjuntivitis is highly contagious - protect yourself! Visual Fields Screen Visual Fields by Confrontation 1. Stand two feet in front of the patient and have them look into your eyes. 2. Hold your hands to the side half way between you and the patient. 3. Wiggle the fingers on one hand. 4. Ask the patient to indicate which side they see your fingers move. 5. Repeat two or three times to test both temporal fields. 6. If an abnormality is suspected, test the four quadrants of each eye while asking the patient to cover the opposite eye with a card. Extraocular Muscles Corneal Reflections 1. Shine a light from directly in front of the patient. 2. The corneal reflections should be centered over the pupils. 3. Asymmetry suggests extraocular muscle pathology. Extraocular Movement 1. Stand or sit 3 to 6 feet in front of the patient. 2. Ask the patient to follow your finger with their eyes without moving their head. 3. Check gaze in the six cardinal directions using a cross or "H" pattern. 4. Check convergence by moving your finger toward the bridge of the patient's nose. Pupillary Reactions Light 1. Dim the room lights as necessary. 2. Ask the patient to look into the distance. 3. Shine a bright light obliquely into each pupil in turn. 4. Look for both the direct (same eye) and consensual (other eye) reactions. 5. Record pupil size in mm and any asymmetry or irregularity. Accommodation If the pupillary reactions to light are diminished or absent, check the reaction to accommodation (near reaction): [5] ++ 1. Hold your finger about 10cm from the patient's nose. 2. Ask them to alternate looking into the distance and at your finger. 3. Observe the pupillary response in each eye. Ophthalmoscopic Exam 1. Darken the room as much as possible. ++ 2. Adjust the ophthalmoscope so that the light is no brighter than necessary. Adjust the aperture to a plain white circle. Set the diopter dial to zero unless you have determined a better setting for your eyes. 3. Use your left hand and left eye to examine the patient's left eye. Use your right hand and right eye to examine the patient's right eye. Place your free hand on the patient's shoulder for better control. 4. Ask the patient to stare at a point on the wall or corner of the room. 5. Look through the ophthalmoscope and shine the light into the patient's eye from about two feet away. You should see the retina as a "red reflex." Follow the red color to move within a few inches of the patient's eye. 6. Adjust the diopter dial to bring the retina into focus. Find a blood vessel and follow it to the optic disk. Use this as a point of reference.

7. Inspect outward from the optic disk in at least four quadrants and note any abnormalities. 8. Move nasally from the disk to observe the macula. 9. Repeat for the other eye. Special Tests Upper Eyelid Eversion This procedure is performed when a foreign body is suspected. ++ 1. Ask the patient to look down. 2. Gently grasp the patient's upper eyelashes and pull them out and down. 3. Place the shaft of an applicator or tongue blade about 1 cm from the lid margin. 4. Pull the lid upward using the applicator as a fulcrum to turn the lid "inside out." Do not press down on the eye itself. 5. Pin the eyelid in this position by pressing the lashes against the eyebrow while you examine the palpebral conjuntiva. Ask the patient to blink several times to return the lid to normal. Notes 1. Visual acuity is reported as a pair of numbers (20/20) where the first number is how far the patient is from the chart and the second number is the distance from which the "normal" eye can read a line of letters. For example, 20/40 means that at 20 feet the patient can only read letters a "normal" person can read from twice that distance. 2. You may, instead of wiggling a finger, raise one or two fingers (unialterally or bilaterally) and have the patient state how many fingers (total, both sides) they see. To test for neglect, on some trials wiggle your right and left fingers simultaneously. The patient should see movement in both hands. 3. Additional Testing - Tests marked with (++) may be skipped unless an abnormality is suspected. 4. PERRLA is a common abbreviation that stands for "Pupils Equal Round Reactive to Light and Accommodation." The use of this term is so routine that it is often used incorrectly. If you did not specifically check the accommodation reaction use the term PERRLA. Pupils with a diminished response to light but a normal response to accommodation (ArgyllRobertson Pupils) are a sign of neurosyphilis. 5. Diopters are used to measure the power of a lens. The ophthalmoscope actually has a series of small lens of different strengths on a wheel (positive diopters are labeled in green, negative in red). When you focus on the retina you "dial-in" the correct number of diopters to compensate for both the patient's and your own vision. For example, if both you and your patient wear glasses with -2 diopter correction you should expect to set the dial to 2 with your glasses on or -4 with your glasses off. DIAGNOSTIC TESTS FOR THE EYE A. FLUORESCEIN ANGIOGRAPHY It is a detailed imaging and recording of ocular circulation by a series of photographs after administration of a dye. Preprocedure Interventions a. Assess client to allergies and previous reactions to dyes. b. Obtain informed consent c. A mydriatic medication, which causes pupil dilation, is instilled in the eye, 1 hour before the test. d. The dye is injected into a vein of the clients arm. e. Inform the client that the dye may cause the skin to appear yellow for several hours after the test and is eliminated gradually through the urine. f. The client may experience nausea, vomiting, sneezing, paresthesia of the tounge or pain at the injection site. g. If hives appear, orally or intramuscularly administered antihistamines such as diphenhydramine (Benadryl) are given as prescribed. Postoperative Interventions a. Encourage rest. b. Encourage fluid intake to assist in eliminating the dye from the clients system. c. Remind the client that the tallow skin appearance will disappear. d. Instruct the client that the urine will appear bright green until the dye is excreted. e. Instruct the client to avoid direct sunlight for a few hours after the test. f. Instruct the client that the photophobia will continue until pupil size returns to normal. B. COMPUTED TOMOGRAPHY It is a diagnostic test for the eye wherein there is a beam of x-rays scans the skull and orbits of the eye. A cross-sectional image is formed by the use of a computer and a contrast material is not usually administered. Nursing Interventions No special client preparation or follow- up care is required.

Instruct the client that he or she will be positioned in a confined space and will need to keep their heads still during the procedure. C. SLIT LAMP A slit lamp allows the examination of the anterior ocular structures under microscopic magnification. The client leans on a chin rest to stabilize the head while a narrowed beam of light is aimed so that it illuminates only a narrow segment of the eye. Nursing Interventions Explain the procedure to the client. Advise the client about the brightness of the light and the need to look forward at a point over the examiners ear. D. CORNEAL STAINING A topical dye is instilled into the conjunctival sac to outline irregularities of the corneal surface that are not easily visible. The eye is viewed to a blue filter, and a bright green color indicatesareas of a non intact corneal epithelium. Nursing Interventions If the client wears contact lenses, the lenses must be removed. The client is instructed to blink after the dye has been applied to distribute the dye evenly across the cornea.

Ultrasonography uses the principle of sonar to study structures not directly visible high frequency sound waves are transmitted to a probe placed directly on the eyeball. As the sound waves bounce back off the various tissue components, they are collected by a receiver that amplifies them on an oscilloscope screen. Sound waves derived from the most distal structures arrive last, having travel the farthest. Ultrasonography may be used to evaluate tissue characteristics of a lesion as well as size and growth over time. It may also be used to measure axial length (distance from the cornea to the retina) in order to calculate the power for an intraocular lens implant in cataract surgery. L. OPTHALMODYNAMOMETRY Opthalmodyanamometry is a test that consists of exerting pressure on the sclera with a string plunger while observing the central retinal vessels emerging from the disc through an opthalmoscope. This instrument gives an approximate measurement of the relative pressures in the central retinal arteries and is an indirect method of assessing the carotid arterial flow on either sound.

M. ELECTRORETINOGRAPHY E. TONOMETRY This test is used primarily to assess for an increase of intraocular pressure An electrical potential exist between the cornea and retina of the eye. Because the retina is neurologic tissue, the normal retina is exhibit certain and potential glaucoma. Normal ocular pressure is 10- 21 mmHg. electrical responses when stimulated by light. Electroretinography (ERG) measures the normal change in electrical potential of the eye caused by a Nursing Interventions diffuse flash of light. For this test, electrodes incorporated into a contact Each dye is anesthetized. The client is instructed to stare forward at a point above the examiners lens are placed directly on the eye. Eye movements disrupt the values of the test, so the client must be able to fixate on a target while keeping the ear. eyes still. A normal ERG signifies functional integrity of the retina. Examples A flattened cone is brought contact with the cornea. of retinal diseases that may be th evaluated with ERG include retinitis The amount of pressure needed to flatten the cornea is measured. pigmentosa (progressive degeneration of photoreceptor cells), massive The client must instructed to avoid rubbing the eye following the ischemia, disseminated infection, or toxic effects from drugs or chemicals. examination if the eye has been anesthetized because the potential for scrubbing the cornea exists. N. VISUAL EVOKED RESPONSE F. FUNDUS PHOTOGRAPHY Visual evoked response (VER) is similar to ERG in that it also measures the electrical potential resulting from a visual stimulus. The entire visual Special retinal cameras are use to document fine details of the fundus for the study and future comparison. One of the most common applications is pathway from the retina to the cortex maybe evaluated in the examination the evaluation of insidious optic nerve changes in the clients with glaucoma. through the placement of electrodes on the scalp. Reduces speed of neuronal conduction, such as with demyelination, results in an abnormal Photographs are compared over time to identify subtle changes in the VER. Retina or optic nerve disease may be diagnosed by stimulating each clients with glaucoma. Photographs are compared over time to identify eye separately. subtle changes in disc shape and color. G. SPECULAR MIMOGRAPHY EYE DISORDERS

Specular mimography is a photographic technique used to count cells of the Degenerative Disorders corneal endothelium. A camera is focused on the endothelial layer, and the A. GLAUCOMA area is magnified 200 times; then the cell is counted. This layer of the cornea is one cell thick . cells in this layer do not reproduce but rather they Glaucoma includes a group of ocular disorders characterized by increase intraocular pressure, optic nerve atrophy and visual field loss. The individual expand to fill gaps in the endothelium. The number or lack of number, of response to intraocular pressure varies. Therefore, some people sustain cells may indicate healing potential. damage from relatively low pressures and others sustain no damage from H. EXOPTHALMOMETRY high pressure. The degree of increase pressure that cause ocular damage is not the same in every eye, and some individuals may tolerate a pressure The exopthalmometer is an instrument designed to measure the forward protrusion of the eye. This instrument provides a method of evaluating and for long periods of time that would rapidly blind another. recording the progression and regression of the prominence of the eye in Incidence disorders such as thyroid disease and tumors of the orbit. It is estimated that over 50,000 persons in the US are blind as a result of glaucoma. The incidence of glaucoma is about 1.5%, and in blacks, I. OPTHALMIC RADIOLOGY between the ages of 45 and 65, prevalence is at least five times that of the X-ray study, tomography, and CT scan are useful n the evaluation of orbital whites in the same age group. In most cases, blindeness can be prevented if treatment is began early. and intracranial conditions. Common abnormalities evaluated by these Glaucoma is called the sneak thief of sight because it strikes without methods include neoplasms, inflammatory masses, fractures and obvious symptoms. People with glaucoma are usually unaware of it until extraocular muscle enlargement associated with Graves eye disease. they have a serious loss of vision. In fact, about half of those who have Radiology is also useful in the detection of foreign bodies. glaucoma do not know it. Currently, that damage cannot be reversed. While there are usually no warning signs, some symptoms may occur in the J. MAGNETIC RESONANCE IMAGING later stages of the disease, such as a loss of peripheral vision, difficulty focusing on close work, seeing halos around lights, and frequent changes MRI has the advantage of not exposing the patient to ionizing radiation. Also, multidimensional views are possible without repositioning the patient. of prescription glasses. Unfortunately, though, once the vision is lost, it is This is used to image edema, areas of demyelination, and vascular lesions. gone forever. African Americans are at a higher risk of developing glaucoma than other However, the availability of MRI equipment is often lmited and the racial groups. Others at risk include: examination takes longer. MRI may also cause movement of a metallic Anyone with a close relative who has glaucoma; foreign body. Seniors; People with diabetes; K. ULTRASONOGRAPHY People taking steroid medications for extended periods of time.

Pathophysiology Intraocular pressure is determined by the rate of aqueous production in the cilliary body and the resistance to outflow aqueous from the eye. Increase intraocular pressure (usually greater that 23mm Hg) indicates the need for further evaluation. Intraocular pressure varies with diurnal cycles. (the highest pressure is usually on awakening) and position of the body (increase when lying down). Normal variation do not usually exceed 2-3 mm Hg. Intraocular pressure and blood pressure are independent of each pther but variations in the systemic blood pressure may be associate with corresponding variations in the intraocular pressures. Increase intraocular pressure may result from hyper production of aqueous or obstruction of the outflow. As aqueous fluid builds up in the eye, the increase pressure inhibits blood supply to the optic nerve and the retina. These delicate tissues become ischemic and gradually loss function. Etiology/ Risk Factors Many terms are used to describe the various types of glaucoma. The terms primary and secondary refer to whether the etiology is the disease alone or due to another condition. Acute and chronic refer to the onset and/ duration of the disorder. The terms open (wide) and closed (narrow) describe the width of the ngle between the cornea and the iris. Anatomically narrow anterior chamber angles predispose clients to an acute onset of angleclosure glaucoma. TYPES OF GLAUCOMA Primary Open-Angle Glaucoma Approximately 90% of primary glaucoma cases occur in clients with open angles. It is a multifunctional disorder that is often genetically determined, bilateral, ininsidious in onset, and slow to progress. Symptoms appear late when vision is impaired by damage to the optic nerve. Because there are no early warning symptoms, it is imperative that regular ophthalmic examinations include tonometry and assessment the optic nerve head (disc). This type of glaucoma is often referred t as the THIEF IN THE NIGHT because there are no early symptoms alerting the client that vision is being lost. The most common cause of chronic open angle glaucoma is degenerative change in the trabecular meshwork, resulting in the decrease outflow of aqueous humor.

non reactive. Slit lamp examination is used in open angle glaucoma to look for any secondary causes and associate findings. Intraocular pressure is measured at the slit lamp with the applanation tonometer. Gonioscopy is performed to determine the depth of the anterior chamber and to examine the entire circumference of the angle for any abnormal change in the filtering meshwork. Medical Management The goal of medical management is to facilitate the outflow of aqueous through remaining channels. This is achieved through the use of Topical miotics, which constricts the pupil and increase outflow ; Topical epinephrine, which also increase the outflow; Topical beta blockers or alpha adrenergics, which suppress the secretion of aqueous humor; and Oral carbonic anhydrase inhibitors, which also reduce the production of aqueous humor. When mediacal management is no longer effective, surgical intervention may be indicated. Surgical Management When maximum medical therapy has failed to halt the progression of visual field loss and optic nerve damage, surgical intervention is recommended. There are many procedures that are use to correct the aqueous outflow; however, there is no operation that is uniformly successful.

Laser Trabeculocospy The use of laser to create an opening in the trabecular meshwork is often indicated before filtration surgery is considered. The laser produces scars in the trabecular meshwork fibers. The tightened fibers allow increased outflow of aqueous. Intraocular pressure is reduced through improved outflow in about 80% of cases. Filtering Procedures Operative procedures such as trephination, thermal sclerostomy, or scleroctomy create an outflow channel from the anterior chamber to the subconjunctival space. These are called filtering procedures. Aqueous is absorbed through the conjunctival vessels. In about 25% of cases, the opening closes due to scar tissue formation, and reoperation is necessary. Ciliodestructive Procedures Angle- Closure Glaucoma When other surgical procedures have failed, cyclocryotherapy (application An acute attack of angle-closure glaucoma can develop only in an eye in of freezing tip) or cyclophotocoagulation may be used to damage the ciliary which the anterior chamber angle is anatomically narrow. The attack occurs body and decrease the production of aqueous. due to a sudden blockage of an anterior angle by the base of the iris. When the aqueous flow is obstructed, intraocular pressure becomes markedly ASSESSMENT elevated, causing severe pain and blurred vision or vision loss. Some client will see rainbow halos around lights, and some will experience nausea and Progressive loss of peripheral vision followed by loss of central vision vomiting. Elevated intraocular pressure (normal pressure is 10- 21 mmHg) Low Tension Glaucoma Vision worsening in the evening with difficulty adjusting to dark rooms Low-tension glaucoma resembles primary open-angle glaucoma. The angle Blurred vision is normal, the optic nerves are cupped and the visual fields show Halos around white lights characteristic glaucomatous effects. (peripheral vision deficits). These Frontal headaches changes, however, develop in the presence statistically normal intraocular Eye pain pressures. The etiology of low tensions glaucoma is not known. Although Photophobia the pressure readings are in the normal range, treatment is indicated to Lacrimation lower the pressure even further to avoid progressive optic nerve damage Progressive loss of central vision and visual field loss. NURSING INTERVENTIONS Acute Glaucoma Secondary Glaucoma Administer medications s prescribe to lower intraocular pressure. And Increase intraocular pressure may occur as a post operative complication. prepare the client for peripheral indectomy, which allows aqueous humor to Edematous tissue may inhibit the outflow of aqueous through the trabecular flow from the posterior to anterior chamber. meshwork. Delayed healing of corneal would edges may result in epithelial Chronic Glaucoma cell growth into the anterior chamber. Instruct the client on the importance of medications (miotics) to constrict Glaucoma may occur as a result of trauma. Lens displacement, the pupils, (carbonic anhydrase inhibitors) to decrease production of hemorrhage into the anterior chamber, laceration, and contusions can aqueous humor, and beta blockers to decrease the production of aqueous dirupt the flow pattern of aqueous humor. humor and intraocular pressure. Clinical Manifestations Instruct the client on the need for lifelong medication use and to avoid Clinical manifestations of glaucoma include: anticholinergic medications. 1. Increase intraocular pressure, Instruct the client to report eye pain, halos around the eyes, and changes in vision to the physician. 2. Cupping or indentation of the optic nerve head (disc) and Teach the client that when maximal medical therapy has failed to halt the 3. Visual field defects progression of visual field loss and optic nerve damage, surgery will be recommended. Diagnostic Assessment Prepare the client for trabeculoplasty as prescribed to facilitate aqueous An opthalmoscopic examination shows atrophy (pale color) and cupping (indentation) of the optic nerve head. The visual field examination is used to humor drainage and to allow drainage of aqueous humor into the conjunctival spaces b the creation of an opening. determine the extent of peripheral vision loss (see the section on visual fields). In chronic open angle glaucoma, a small crescent- shape scotoma (blind spot) appears early in the disease. In acute angle-closure glaucoma, B. CATARACT the fields demonstrate larger areas significant vision loss. Definition In clients with angle-closure glaucoma, a slit lamp examination may demonstrate an erythematous conjunctiva and corneal cloudiness. The anterior chamber aqueous may also appear turbid and the pupil may be

A cataract is a cloudy or opaque area (an area you cannot see through) in the lens of the eye. It is an opacity of the lens that distorts the image projected onto the retina and that can progress to blindness. Alternative Names Lens opacity Causes, incidence, and risk factors The lens of the eye is normally clear. If the lens becomes cloudy, the condition is known as a cataract. Rarely, cataracts may be present at or shortly after birth. These are called congenital cataracts. Adult cataracts usually develop with advancing age and may run in families. Cataracts develop more quickly in the presence of some environmental factors, such as smoking or exposure to other toxic substances. They may develop at any time after an eye injury. Metabolic diseases such as diabetes also greatly increase the risk for cataracts. Certain medications, such as cortisone, can also accelerate cataract formation. Congenital cataracts may be inherited. The gene for such cataracts is dominant (autosomal dominant inheritance), which means that the defective gene will cause the condition even if only one parent passes it along. I families where one parent carries the gene, there is a 50% chance in every pregnancy that the child will be affected. Congenital cataracts can also be caused by infections affecting the mother during pregnancy, such as rubella. They are also associated with metabolic disorders such as galactosemia. Risk factors include inherited metabolic diseases, a family history of cataracts, and maternal viral infection during pregnancy. Adult cataracts are generally associated with aging. They develop slowly and painlessly, and vision in the affected eye or eyes slowly gets worse. Visual problems may include the following changes: Difficulty seeing at night Seeing halos around lights Being sensitive to glare Vision problems associated with cataracts generally move towards decreased vision, even in daylight. Adult cataracts are classified as immature, mature, and hypermature. A lens that has some remaining clear areas is referred to as an immature cataract. A mature cataract is completely opaque. A hypermature cataract has a liquefied surface that leaks through the capsule, and may cause swelling and irritation of other structures in the eye. Most people develop some clouding of the lens after the age of 60. About 50% of people aged 65-74, and about 70% of those 75 and older, have cataracts that affect their vision. Most people with cataracts have similar changes in both eyes, although one eye may be worse than the other. Many people with this condition have only slight visual changes, and are not aware of their cataracts. Factors that may contribute to cataract development are low serum calcium levels, diabetes, long-term use of corticosteroids, and various inflammatory and metabolic disorders. Environmental causes include trauma, radiation exposure, and too much exposure to ultraviolet light (sunlight). Symptoms Cloudy, fuzzy, foggy, or filmy vision Loss of color intensity Frequent changes in eyeglass prescription The glare from bright lights causes vision problems at night, especially while driving Sensitivity to glare from lamps or the sun Halos around lights Double vision in one eye Decreased contrast sensitivity (the ability to see shades, or shapes against a background) Signs and tests Standard ophthalmic exam, including slit lamp examination Ultrasonography of the eye in preparation for cataract surgery Other tests that may be done (rarely) include: Glare test Contrast sensitivity test Potential vision test Specular microscopy of the cornea in preparation for cataract surgery

If a cataract is not bothersome, then surgery is usually not necessary. Sometimes there is an additional eye problem that cannot be treated without first having cataract surgery. Cataract surgery consists of removing the lens of the eye and replacing it with an artificial lens. A cataract surgeon will discuss the options with the patient, and together they will decide which type of removal and lens replacement is best. LENS REMOVAL: There are 2 types of surgery that can be used to remove lenses that have a cataract. Extracapsular surgery consists of surgically removing the lens, but leaving the back half of the capsule (the outer covering of the lens) whole. Highfrequency sound waves (phacoemulsification) may be used to soften the lens to help removing it through a smaller cut. With extracapsular extraction, the lens is lifted out without removing the lens capsule; the procedure may be performed by phacoemulsification in which the lens is broken up by ultrasonic vibrations and is extracted. Intracapsular surgery involves surgically removing the entire lens, including the capsule. Today this procedure is done very rarely. In this procedure, lens is removed within capsule through a small incision. LENS REPLACEMENT: People who have cataract surgery are usually fitted with an artificial lens at the same time. The artificial lens is a synthetic (manufactured) disc called an intraocular lens. It is usually placed in the lens capsule inside the eye. Other options include contact lenses and cataract glasses. Surgery can be done in an outpatient center or hospital. Most people do not need to stay overnight in a hospital. The patient will need a friend or family member to assist with travel and home care after outpatient surgery. Follow-up care by the surgeon is important. NURSING INTERVENTIONS Preoperative Interventions Instruct the client regarding the postoperative measures to prevent or decrease intraocular pressure. Administer eye medications preoperatively, including mydriatics and cycloplegics as prescribed. Postoperative Interventions 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 to the unoperative side Use side rails for safety Assist with ambulation AGE RELATED MACULAR DEGENERATION Previously known as the senile macular degeneration, age related macular degeneration is an atrophic degenerative process that affects the macula and surrounding tissues, resulting in central visual deficits. Age related macular degeneration can be found in some degree to some adults over the age of 65. It is one of the most common causes of visual loss in the elderly. The exact etiology is unknown, but the incidence increases with each decade over 50. It may also be hereditary. Age- related macular degeneration falls into two categories: 1. Nonexudative 2. Exudative Both are usually bilateral and progressive. Also referred to as dry macular degeneration, nonexudative age related macular degeneration is characterized by atrophy and degeneration of the outer retina and underlying structures. Yellowish round spots called drusen may be seen in the retina and macula with an opthalmoscope. Drusen are deposits of amorphous material from the pigment epithelial cells of the retina. Overtime, these spots increase, enlarge and may calcify. At this, wet, exudative stage of age-related macular degeneration, Bruchs membrane, which lies just beneath the pigment epithelial cell layer of the retina, becomes compromised and this results in serous fluid leaks from the colloid with accompanying proliferation of choroidal blood vessels. A dome-shaped retinal pigment epithelium may be seen when examining the fundus. These leak produce a visual effect called tamorphopsia, which is the blurred, wavy distortion vision. The client may also notice blurred scotomo or decrease central visual acuity. Fundus photograpghy and angiography may be performed on a regular basis of documents and evaluate changes.

Treatment Management The only treatment for cataract is surgery to remove it. This is done when a There is no known means of medical treatment or prevention for age elated person cannot perform normal activities, even with glasses. For some people, changing glasses, getting stronger bifocals, or using a magnifying macular degeneration. Further damage from exudative macular degeneration sometimes may be arrested by the use of argon lens is helpful enough. Others choose to have cataract surgery. photocoagulation, even though laser bamage to the retina in this area

a. Myopia Myopia, or nearsightedness, is a condition in which the light rays come into focus in front of the retina. In this case the refractive power of the eye is too strong and a concave, or minus, lens is used to focus light rays on the ey. In most cases myopia is caused by an eyeball that is longer than normal, which may be a familial triat. Transient myopia may occur with the administration of a variety of medications (sulfonamides, acetozolamide, salicylates, and steroids) and has been associated with other disorders, such as influenza, typhoid fever, severe dehydration, and large intakes of C. RETINAL DETACHMENT Retinal detachment occurs when the layers of the retina separate because antacids. Correction is accomplished with eyeglasses or contact lenses. b. Hyperopia of the accumulation of fluid between them, or when both retinal layers The hyperopic, or farsighted, eye focuses light rays behind the eye, and elevate away from the choroid as a result of a tumor. Partial separation consequently the image that falls on the retina is blurred. Vision may be becomes complete if untreated. When detachment becomes complete, brought into focus by placing a convex, or plus, lens in front of the eye. The blindness occurs. lens supplies the magnifying power that the eye is lacking. Hyperopia may Assessment be caused by an eyeball that is shorter than normal or a cornea that has less curvature than normal. Because children have a greater ability to Flashes of lights accommodate, they are less often affected than adults. Demands for close Floaters work and reading usually bring on manifestations of headache or eye strain. Increase in blurred vision Correction is based on a persons age and individual needs and complaints. Sense of curtain being drawn c. Astigmatism Loss of a portion of the visual field Astigmatism is a refractive condition in which rays of light are not bent equally by the cornea in all direction so that a point of focus is not attained. Immediate Interventions In most instances, astigmatism is caused because the curvature of the Provide bed rest cornea is not perfectly spherical. This is the cause of poor vision for both Cover both eyes with patches to prevent further detachment distant and near objects. Astigmatism is corrected with cylindrical lenses. Speak to the client before approaching Surgical management Position the client head as prescribed The following are the three main types of refractive surgery and new Protect the client from injury Avoid jerky head movements procedure. Minimize eye stress Prepare the client for the surgical procedure as prescribed. Laser in situ keratomileusis (LASIK) is currently the most commonly used Surgical Procedures corrective surgery for nearsightedness in the United States. An extremely Draining fluid from the subretinal space so that the retina can return to thin layer of the cornea is peeled back for the laser reshaping on the middle the normal position. layer of the cornea and then put back in place. There is little postoperative Sealing retinal breaks by cryosurgery, a cold probe applied to the sclera, discomfort, rapid recovery of clear vision, and quick stabilization of to stimulate an inflammatory response leading to adhesions. refractive change. LASIK is performed in a surgeons office or samed-day Diathermy, the use of an electrode needle and heat through the sclera, to surgery center and does not require a hospital stay. It takes about 10-15 stimulate an inflammatory response. minutes per eye. It has a high success rate and low complication rate for Laser therapy to stimulate an inflammatory response, to seal small retinal low to moderate nearsightedness and may also be used to correct more tears before the detachment occurs. severe nearsightedness. Sclera buckling, to hold the choroid and retina together with a splint until Excimer laser photorefractive keratectomy (PRK) uses short-wavelenght, scar tissue forms closing the tear. high-energy ultraviolet radiation laser to reshape the corneal surface. In Insertion of gas or silicon oil to encourage attachment because these agents have a specific gravity less than vitreous or air and can float against PRK for myopia, the central cornea is flattened with the excimer laser. The same laser may be used to reshape the cornea by making the central the retina. curvature steeper to correct hyperopia. It may be used to correct nearsightedness and astigmatism at the same time. PRK is performed on Postoperative Interventions an outpatient basis in a surgeons office or same-day surgery center. The PRK procedure takes about 30 minutes, most of which is spent teaching the Maintain eye patches bilaterally as prescribed. client to hold the eye still. The actual treatment takes less than a minute. Monitor for hemorrhage. Recovery from PRK is longer and more painful than recovery from ether Prevent nausea and vomiting and monitor for restlessness, which can radial keratotomy (RK) or LASIK. Vision will be reduced for several days cause hemorrhage. after surgery. Monitor for sudden sharp eye pain and monitor the physician. Encourage deep breathing exercise but avoid coughing. Radial keratotomy (RK) involves making tiny cuts in the cornea, which Provide bed rest for 1-2 days and position the client as prescribed. flatten it and reduce nearsightedness. In people who have both astigmatism If gas has been inserted, position the client as prescribed on the and nearsightedness, the surgeon may make additional cutrs to flatten the abdomen and turn the head so unaffected eye is down. misshapen part of the cornea that is causing the astigmatism. RK is an Administer eye medications as prescribed. outpatient procedure. It is done under local or topical anesthesia in a Assist the client with activities of daily living. surgeons office or same day surgery center. Avoid sudden head movements or anything that increases intraocular pressure. Corneal ring implants are clear pieces of acrytic that can be surgically Instruct the client to limit reading for 3-5 weeks. implanted into the cornea. The implants are shaped like crescents or half Instruct the client to avoid squinting, straining and constipation, lifting circles. Two implants are used for each eye, and the implants are inserted heavy objects and bending from the waist. Instruct the client to wear dark glasses during the day and an eye patch along the sides of the cornea. Nursing management of the surgical client at night. Clients are assessed preoperatively for degree of myopia or astigmatism. Encourage follow-up care because of the danger of recurrence in the Clients with a severe case usually cannot achieve full correction. Surgery is other eye. performed on an out patient basis with local anesthesia. Eye protection is REFRACTIVE DISORDERS Light is bent (refracted) as it passes through the cornea and lens of the eye. used, such as goggles to prevent dry eyes. Vigorous activities, activities Refractive errors exist when light rays are not focused appropriately on the that cold get water in the eye, and eye makeup are to be avoided. The eye retina of the eye. Three basic abnormalities of refraction occur in the eye: 1) is treated with steroid eyed drops, and most clients report watering of the myopia 2) hyperopia, and 3) astigmatism. Optical correction is important to eyes and minimal pain. Refraction slowly stabilizes after surgery. There is a distinguish between visual loss caused by disease and visual loss caused period of adjustment during which visual acuity waxes and wanes. Reduced by refractive error. Refractometry is the measurement of refractive error and contrast sensitivity in night vision and daytime glare is common. Some should not be confused with refraction, the method used to determine which clients require re treatment for scarring that is unresponsive to topical steroids. lens or lenses (if any) will most benefit the client. Infectious and Inflammatory Conditions results in a blind spot. When the fovea is involved, central vision is lost and he only helpful measures are low-vision aids. The client with age-related macular degeneration is threatened with the loss of central vision. In order to evaluate change in vision, the client is taught to use an Amsler grid at home. The nurse may be able to assist the client to maximize remaining vision with low vision aids and community referral to a low vision specialist and low vision support groups.

Inflammation and infection of eye structures are common. Eye infection is a haemophilus influenzae, and staphylococcus aureaus. It is manifested with an acute onset of redness, burning, and discharge. leading cause of blindness worldwide. Dry eye syndrome Dry eye syndrome, or keratoconjuctivitis sicca, is a deficiency in the production of any of the aquaeous, mucin, or lipid tear film components; lid surface abnormalities; or epithelial abnormalities related to systemic diseases (eg, thyroid disorders, Parkinsons disease), infection, injury, or complications of medications (eg. Antihistamines, oral contraceptives, phenothiazines) Clinical manifestations The most common complaint in dry eye syndrome is a scratchy or foreign body sensation. Other symptoms include itching, excessive mucus secretions, inability to produce tears, a burning sensation, redness, pain, and difficulty moving the lids. Assessment and diagnostic findings Slit-lamp examination shows an absent or interrupted tear meniscus at the lower lid margin, and the conjuctiva is thickened, edematous, and hyperemic and has lost its luster. A tear meniscus is the crescent-shaped edge of the tear film in the lower lid margin. Chronic dry eyes may result in chronic conjuctival and corneal irritation that can lead to corneal erosion, scarring, ulceration, thinning, or perforation that can seriously threaten vision. Secondary bacterial infection can occur. Management Management of dry eye syndrome requires the complete cooperation of the patient with a regimen that needs to be followed at home for a long period; otherwise, complete relief of symptoms is unlikely. Instillation of artificial tears during the day and an ointment at night is the usual regimen to hydrate and lubricate the eye and preserve a moist ocular surface. Antiinflammatory medications are also used, and moisture chambers (eg, moisture chamber spectacles, swim goggles) may provide additional relief. Patients may become hypersensitive to chemical preservatives such as benzalkonium chloride and themerosal. For these patients, preservative-free ophthalmic solutions are used. Management of the dry eye syndrome also includes the concurrent treatment of infections such as chronic blepharitis and acne rasacea, and treating the underlying systemic disease. Conjunctivitis Conjunctivitis (inflammation of the conjuctiva) is the most common ocular disease worldwide. It is characterized by a pink appearance (hence the common term pink eye) because of subconjuctival blood vessel congestion. Clinical manifestations General symptoms include foreign body sensation, scratching or burning sensation, itching, and photophobia. Conjunctivitis may be unilateral or bilateral, but the infection usually starts in one eye and then spreads to the other eye by hand contact. Assessment and Diagnostic Findings The four main clinical features important to evaluate are the type of discharge (watery, mucoid, purulent, or mucopurulent), type of conjuctival reaction (follicular or papillary), presence of pseudomembranes or true membranes, and presence or absence of lymphadenopathy (enlargement of the preauricular and submandibular lymph nodes where the eyelids drain). Pseudomembranes consist of coagulated exudates that adheres to the surface to the superficial layer of the ocnjuctiva, and moval results in bleeding. Follicles are multiple, slightly elevated lesions encircled by tiny blood vessels; they look like grains of rice. Papillae are hyperplastic conjuctival epithelium in numerous projections that are usually seen as a fine mosaic pattern under slit-lamp examination. Diagnosis is based on the distinctive characteristics of ocular signs, acute or chronic presentation, and identification of any precipitating events. Positive results of swab smear preparations and cutures confirm the diagnosis Types of conjunctivitis: 1. Microbial conjunctivitis Bacterial conjunctivitis can be acute or chronic. The acute type can develop into a chronic condition. Signs and symptoms can vary from mild to severe. Chronic bacterial conjunctivitis is usually seen in patients with lacrimal duct obstruction, chronic dacryocystitis, and chronic blepharitis. The most common causative microorganisms are streptococcus pneumoniae, 2. Viral conjunctivitis Viral conjunctivitis can be acute and chronic. The discharge is watery, and follicles are prominent. Severe cases include psudomemebranes. The common causative organisms are adenovirus and herpes simplex virus. Conjunctivitis caused by adenovirus is highly contagious. The condition isusually preceded by symptoms of upper respiratory infection. Corneal involvement causes extreme photophobia. Symptoms include extreme tearing, redness, and foreign body sensation that can involve one or both eyes. There is lid edema, ptosis, and conjuctiva hyperemia (dilation of the conjuctival blood vessels). These signs and symptoms vary from mild to sever and may last for 2 weeks.

DISORDER OF THE AUDITORY SYSTEM

Ear disease causes significant discomfort and hearing loss. It also creates work loss and decreased productivity-- this increases as the persons communicative skills decrease when associated hearing loss increases. In children, developmental delays and academic failure my result due to manifestation of auditory problem if not properly treated. Ear Complications such as deafness, meningitis, brain abscesses, and facial nerve paralysis may also occur. Proper management of ear disease is critical and immediate attention is necessary. COMMON DISEASES AND DISORDER OF THE MIDDLE EAR Otitis Media (Middle Ear Infections) The basic underlying problem causing most forms of otitis is eustachian tube dysfunction. Most otitis occurs in patients whose eustachian tube, the tube between the nose and the middle ear the area behind the eardrum, does not work properly. When air cannot adequately get through this tube to the middle ear, the negative pressure created can "suck" fluid out of the lining of the middle ear/mastoid, filling the middle ear and mastoid air cells with fluid. A mild hearing loss usually accompanies the fluid. The hearing loss disappears when the fluid is gone as long as there are no other causes for the hearing loss. Three kinds of otitis can result from eustachian tube dysfunction. They are serous and secretory otitis, where fluid fills the middle ear and mastoid, acute otitis, where pus fills the middle ear and mastoid but its presence is of short duration, and chronic otitis, where pus fills the middle ear and mastoid and it has been present for months or years. Chronic otitis is associated with infection of the bone itself and thickening and polyp formation of the mucosal lining of the middle ear and mastoid. The highest incidence of otitis media occurs in preschool children and decreases gradually after age 6. The highest incidence occurs poor children, children in day care, and Native Americans. Additional factors that cause or aggravate otitis include the presence of enlarged adenoid tissue, lack of proper muscle in the back of the throat (as in those with a cleft palate), allergy, immune deficiencies, sudden change in atmospheric pressure (like poor pressurization in an airplane dropping from a high altitude), scarring or tumors in the nasopharynx, and abnormal cell function of the mucosa of the ear and nose. Diabetes does not increase the incidence of otitis, but can make it much more difficult to treat. Types of Otitis Media Serous otitis- where fairly clear fluid fills the middle ear and mastoid occurs with fairly sudden obstruction of the eustachian tube. A sudden descent of an airplane with poor pressurization or a bad cold are two of the most common causes of acute serous otitis media. Usually decongestants will clear the fluid or even bloods that can be sucked from the mucosa into the middle ear with wither of these processes. If the fluid does not clear within a few weeks, it is considered chronic serous otitis. Older people with poorly functioning eustachian tubes commonly have recurrent serous otitis and may require intermittent tube placement over many years. Hearing loss is present depending on the amount of fluid in the ear. The hearing loss usually resolves when the fluid is cleared out of the ear, either medically or surgically. Secretory otitis- where somewhat thicker fluid fills the middle ear and mastoid is common in small children and is often "outgrown" by the time they reach their teens. It is the most common disease process requiring the placement of PE tubes. This thicker fluid has components that are actually "secreted" by the mucous glands of the middle ear. There are actually tissue breakdown enzymes in this fluid; that, if left untreated, can gradually

eat away bone and cause chronic hearing loss/damage. Luckily, it generally lymphatic fluid becomes pus-like due to a build up of dead white blood cells and dead bacteria. This discharge from the middle ear can irritate the takes quite a while for these enzymes to cause damage to the ear, so Eustachian tube causing it to close. treating secretory otitis in children with medication for a few weeks or A blocked Eustachian tube is often what causes the pain of a middle ear months is safe. Leaving this kind of fluid in an ear for more than several infection. Pus builds up in the inner ear cavity with no where to go, putting months, however, places the ear tissues (including the tiny ear bones) at risk of damage or destruction by these enzymes. Not treating infections with pressure on the inner ear and the ear drum. If left without treatment, the pressure can be so great that it bursts the ear drum. The initial excruciating antibiotics at all places the ear structure at even higher risk of permanent pain of a burst eardrum is immediately compensated for by pain reduction damage/destruction by the fluid. Acute otitis- occurs when pus fills the middle ear. It is usually sudden in from the release of pressure. Whereas, prior to the burst eardrum, sleep was impossible, the pain relief from the pressure reduction allows the onset and is often associated with sudden obstruction of the eustachian sufferer to finally sleep. If the middle ear infection is cured on its own, the tube at the same time infections bacteria are present to cause the acute ruptured ear drum will also usually heal on its own, although sometimes otitis. Without antibiotic treatment, a true bacterial acute otitis is often surgery (tympanoplasty) is indicated if the rupture is extremely large. associated with sudden perforation of the eardrum, with profuse drainage Chronic Suppurative Otitis Media (CSOM) from the ear. Often the eardrum will spontaneously heal over after the infection has resolved, but a perforation can be left and damage to the middle ear and/or the inner ear can accompany the infection. The eardrum CSOM is the name given to a condition when there is an infection of the middle ear which fails to heal and is draining all the time. may be bright red or the creamy color of the fluid can sometimes be seen through the eardrum. It sometimes looks "soggy." Pain and fever may Glue Ear accompany an ear infection, but usually disappear rapidly if the eardrum perforates. Pain and fever are rarely present if there is a whole (perforation) There is a natural flow of fluids from the middle ear (the fluids keep the in the eardrum before the infection starts. The standard treatment of acute middle ear cavity moist) that migrate through the Eustachian tube to the back of the throat. A blocked Eustachian tube prevents air from reaching otitis media is oral antibiotics. Ear drops are added if the eardrum perforates. IV antibiotics are indicated for severe infections, if the mastoid the middle ear. When this happens the middle ear can fill up with the fluid that can becomes thick, like glue over time. This problem is called glue ear bone is also infected, or if the facial nerve becomes paralyzed as a or otitis media with effusion. The buildup of fluid in the middle ear reduces "complication" of the acute infections. Hearing loss is present but usually the movement of the eardrum and ossicles, and hearing is reduced. This goes away when the infection clears. Chronic otitis-occurs when chronic infection fills the middle ear space and condition is quite prevalent in children. Glue Ear is not a disorder in itself, it mastoid cavity. True chronic otitis media is almost always a form of chronic is just a visible symptom of a discharge of bacterial waste from the middle mastoiditis, where the bone of the mastoid cavity (the honeycombed bone ear. Note: Glue ear is sometimes confused by anxious parents with the normal behind the ear) is chronically infected along with the tissues of the middle discharge of wax from a child's ear canal. During an infant or child's growth, ear space. It is important to realize that antibiotics alone usually cannot there may be periods when ear wax is produced more copiously than remove infection from the bone; surgical removal of the infected bone is normal, causing wax to leak from the ear. usually necessary to accomplish this. Even IV antibiotics do not often How to tell the difference: eradicate a true bone infection, especially in the mastoid, which has its If the child has not had a fever then it is a normal wax discharge connection to the bacteria-filled nose through the eustachian tube. A cholesteatoma is a common additional finding along with chronic otitis and If the child has not complained of earache then it is a normal wax mastoiditis. A cholesteatoma is a skin sac that grows back into the middle discharge If the discharge does not have a really smelly odor then it is a normal wax ear or mastoid from the eardrum, creating a mass of skin and debris that discharge (there is a slight odor to normal wax, but nothing like that from keeps getting larger and larger over time, destroying anything in its path. The ear bones, the inner ear, the facial nerve (the nerve that makes all the waste bacteria from the middle ear) muscles of one side of your face work), and the brain next to the ear can all Predisposition factors for Otitis Media and Glue Ear be damaged or destroyed by either spreading infection or cholesteatoma. These diseases must be removed fore the safety of the ear, the head, and There are factors that can increase the risk of a child being susceptible to the brain. Infection or cholesteatoma involving the inner ear, facial nerve, or otitis media and glue ear: the brain requires immediate attention by an ear surgeon and often required being a male short length of breastfeeding immediate surgery. attendance at day care centers Symptoms of Middle Ear Infection parental smoking Earache wet climate Headache winter season Fever upper respiratory infection Discharge from the ear housing with mold Mild deafness allergies Difficulties in sleeping Symptoms of Glue Ear Loss of appetite. The causes of middle ear infection: A progressive head cold A thick liquid discharge from the ear that looks like liquid wax and is A viral sinus infection that spreads orange in color. An otitis externa infection left too long that spreads to the inner ear Ear aches Blowing the nose too hard, forcing sinal or eustachian material into the Headaches middle ear. Fever An opportunistic infection entering through a perforated eardrum Listlessness Treatments for Otitis Media They may be clumsy. With very small infants (1-3 years old), it might also Mild bacterial infections often clear up by themselves in a matter of days. take them longer to start to walk, speak or understand language. Over-the-counter painkillers can help alleviate the pain. Warm olive oil dripped in the ear can also soothe the pain as long as there is no ruptured Older children may be able to tell you if they cannot hear very well. Or you may notice that they say 'pardon' or 'what' a lot or that they turn the eardrum. Repeat every few hours. In more severe cases, antibiotics might be needed which usually includes television up loud. Glue ear also makes older children clumsy and dizzy. Treatment for Glue Ear an initial antibiotic shot, antibiotic pills and ear drops. In many cases of middle ear infection, the Eustachian tube is blocked and 1. Many children recover naturally from glue ear once the Eustachian tube opens. Doctors usually adopt a wait-and-see approach to begin with. Your can cause or at least contributes to a middle ear infection. A Eustachian child will normally be observed for about three months to see if they need tube can become blocked from any combination of the following: The body's inflammation reaction to an infection, swelling the Eustachian further treatment. If the eardrum has burst, it should heal over time approximately 3-6 weeks. tube to where it closes completely. 2. Self medication can be performed by means of an OTC pediatric oral A contributing factor can be the discharge of the dead bacteria and dead decongestant to thin the fluid in the ear and help it drain away. The main lymphocytes from the middle ear. The lymphatic system contains the white purpose of a decongestant is to dry the nasal passages so the Eustachian tube opens and the fluid drains into the throat. If that does not work you blood cells or lymphocytes which are the body's defense against foreign might want to try a small dose of an antihistamine such as Benadryl. Have objects such as bacteria. When the white blood cells kill bacteria, the

 Hearing loss Tinnitus Vertigo Throbbing pain as the middle and inner ear is subject to direct contact with the air Treatments for a Burst Eardrum If you have had a middle ear infection that pushed out the eardrum, then the throbbing pain has been greatly diminished. Wipe off the smelly pus with a damp cloth, and sit quietly with a warm compress on that side of the head. Antibiotics are usually prescribed, sometimes initially by injection, then a regimen orally three times a day for at least 7 days. If the perforation is very small and it does not heal after 2-3 weeks, an ENT may decide not to operate and allow nature to take its course and let the eardrum heal naturally. For a larger tear, an outpatient visit to the ENT will allow a small patch If your child has had glue ear over a few months and the eardrum has not (taken from under the skin behind the ear perhaps) to be attached (not completely covering the hole) over the hole to help it shrink and encourage burst and antibiotics have not worked, the other option is to have a small new skin growth. ventilation drain known as a grommet inserted into the ear drum. The Another technique an ENT may use to encourage healing is to add a grommet is made of either stainless steel or plastic. This procedure involves making a small hole in the eardrum and inserting the grommet through the chemical to the edges of the hole to stimulate growth and then place a thin paper patch on the eardrum to act as a base for skin growth over the hole. hole to keep it open. Initially fluid is sucked out of the middle ear through There are a variety of surgical techniques, but all basically place tissue this hole, then over a few months, the grommet lets air into the middle ear across the perforation allowing healing. The name of this procedure is space and lets fluid in the middle ear drain away. There are only simple called tympanoplasty or myringoplasty. Surgery is typically quite successful precautions to stop water getting into ear like swimming on the surface of in closing the perforation permanently, and improving hearing. the water only and not dive and you need to use earplugs or cotton wool with Vaseline to stop soap water getting into the ears when showering or If the opening is not too large, it may close and heal on its own. Failing that, washing hair. Plastic grommet to drain middle ear fluids an ENT specialist may close it with surgery or by covering it with a special material to keep the opening closed while it heals. Adenoidectomy You can usually help the symptoms by taking simple steps like wearing an It is a surgical treatment for glue ear which aimed to remove the adenoids. The ear plug or keeping the ear dry when you are having a bath or swimming. adenoids are located above the tonsils, at However, you may need an operation to repair the hole in the eardrum (tympanoplasty or myringoplasty). the back of the throat and are thought to Attico-antral assist the body in its defense against incoming bacteria and viruses by helping The attico-antral form of CSOM might also involve a hole in the the body to form antibodies. With ear eardrum usually in the upper part. This form of CSOM can be more of a infections, the adenoids often swell, usually due to an infection in the problem than the tubo-tympanic form because the eardrum sheds dead skin immediate area, in this case, the middle ear. which can build up and enter the middle ear. There are two major Tubo-Tympanic Otitis Media complications of the attico-antral variant of CSOM - Cholesteatomas and The tubo-tympanic form usually involves a perforation of the central part of Mastoid infections (Mastoiditis). the eardrum. This can be caused by infection, injury or surgery. Burst Eardrum (Perforation of eardrum, Rupture of the tympanic membrane) Symptoms of tympanic otitis media (triad) Hearing loss Discharge (which may come and go, and will become noticeable particularly if you get a cold or the ear gets wet) Tinnitus. Treatment of tympanic otitis media In the final stages of a middle ear infection, if the pressure becomes too Allowable sound exposure much, the eardrum may burst. This is actually a positive event if times controlled properly. The burst eardrum will immediately relieve the pressure in the middle ear and the accompanying earache will diminish. A smelly discharge (bacteria detritius from the middle ear) will spill out of the ear and can be sopped up with a wet rag or a tissue. your pharmacist recommend a child's dosage. If that treatment still doesn't work, see your family doctor or physician. They might prescribe stronger antihistamines or nasal steroids in the form of drops or sprays - both of which will help reduce the swelling of the Eustachian tube. 3. The second treatment is if there is a suspected infection. If the eardrum has burst, this is usually the case. Antibiotics are sometimes prescribed, often initially by injection, then a regimen orally three times a day for at least 7 days. In the past, antibiotics such as penicillin, erythrosine, or erythromycin were prescribed. However, in the last few decades, many in the general population have become immune to the effects of these antibiotics, and stronger ones are often prescribed. (The cause of immunity is often blamed on antibiotics fed to the food supply (chickens and beef) before they are brought to market). Surgical Treatments for Glue Ear Grommets-myringotomy

Causes of a burst eardrum External Causes of a Burst Eardrum - An external cause for a burst eardrum is a head trauma such as a blow to the ear or an object penetrating the ear canal and penetrating the eardrum. Usually, the larger the perforation, the greater the loss of hearing. The location of the perforation in the eardrum also affects the degree of hearing loss. If severe trauma (skull fracture) disrupts the bones in the middle ear which transmit sound or causes injury to the inner ear structures, the loss of hearing maybe quite severe. With a traumatic or explosive event, the loss of hearing can be great and tinnitus may be severe. Side effects of a perforated eardrum will definitely be excruciating pain. You will probably also suffer from vertigo and tinnitus Internal Causes of a Burst Eardrum- Perforated eardrums from internal causes are usually from middle ear infections or otitis Media. Detritus from the infection in the inner ear causes pressure to build in the middle ear cavity and if not relieved, the eardrum will burst outward. Symptoms of a burst eardrum from internal causes Sharp pain as the eardrum bursts, then initial pain relief. Pus discharge from the ear, and usually very smelly Bleeding from the ear

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Maximum Hours of Exposure Per 8-Hours Workday 24 hrs. 16 hrs. 12 hrs., 40 mins. 10 hrs., 04 mins. 8 hrs. 6 hrs., 21 mins. 5 hrs., 03 mins. 4 hrs. 3 hrs., 10 mins. 2 hrs., 31 mins. 2 hrs. 1 hr., 34 mins. 1 hr., 16 mins. 1 hr. 48 mins. 38 mins. 30 mins. 24 mins. 19 mins. 15 mins. 12 mins. 9 mins., 6 secs. 7 mins., 30 secs 3 mins., 45 secs 1 min., 52 secs 56 secs 28.07 secs 14.03 secs 7.01 secs 3.31 secs 1.45 secs .52 secs .26 secs .13 secs .06 secs