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Ear, eye and nose disorder updated pdfffff2

  1. 1. 1 By: Getenet D(BScN, MSc in MSN) LECTURER BDU-CHS, DEP’T OF NURSING FOR 2ND YEAR UNDERGRADUATE NURSING STUDENTS ,2012 E.C Ear Eye , disorder
  2. 2. External Otitis (Otitis Externa)  Refers to an inflammation of the external auditory canal.  Causes include water in the ear canal (swimmer's ear); trauma to the skin of the ear canal, permitting entrance of organisms into the tissues; and systemic conditions, such as vitamin deficiency.  Bacterial or fungal infections are most frequently encountered.
  3. 3. Otitis Externa …Contd  The most common bacterial pathogens associated with external otitis are Staphylococcus aureus and Pseudomonas species.  The most common fungus isolated in both normal and infected ears is Aspergillus.  External otitis is often caused by a dermatitis such as psoriasis, eczema, or seborrheic dermatitis.
  4. 4. Cont.…..  Even allergic reactions to hair spray, hair dye, and permanent wave lotions can cause dermatitis, which clears when the offending agent is removed.
  5. 5. Types OE  Chronic OE –longer duration (>6 weeks)  Eczematous OE –various dermatologic conditions (eg, atopic dermatitis , psoriasis, systemic lupus erythematosus) that may infect the EAC and cause OE  Necrotizing (malignant) OE – This is an infection that extends into the deeper tissues adjacent to the EAC; it primarily occurs in adult patients who are immunocompromised (eg, Dm AIDS) and is rarely described in children; it  Otomycosis - Infection of the ear canal secondary to fungus species such as Candida or Aspergillus 9
  6. 6. Pathophysiology  The processes involved in the development of OE can be divided into the following 4 categories:  Obstruction (eg, cerumen buildup, surfer’s exostosis, or a narrow or tortuous canal), resulting in water retention  Absence of cerumen, which may occur as a result of repeated water exposure or overcleaning the ear canal  Trauma  Alteration of the pH of the ear canal 10
  7. 7. Clinical Manifestations  Drainage from the ear - yellow, yellow-green, foul smelling, persistent  Ear pain - felt deep inside the ear and may get worse when moving head  Hearing loss  Itching of the ear or ear canal  Fever  Trouble swallowing  Weakness in the face  Voice loss
  8. 8. Diagnosis  Ear inspection:- the canal appears red and swollen in well-developed cases.  In fungal infections, hair like black spores may even be visible.  physical examination  Otoscope : narrowing of the ear canal from inflammation and the presence of drainage and debris.  Culture of the drainage 12
  9. 9. Medical Management • Relieving the discomfort. • Reducing the swelling of the ear canal. • Eradicating the infection. • Analgesics for the first 48 to 92 hours. • Antibiotics for infection and corticosteroid agents to soothe the inflamed tissues. • For fever, systemic antibiotics may be prescribed. • For fungal disorders, antifungal agents are prescribed.
  10. 10. Medical Management Cont.…..  If the tissues of the external canal are edematous, a wick should be inserted to keep the canal open so that liquid medications (e.g. antibiotic otic preparations) can be introduced.  These medications may be administered by dropper at room temperature.  Such medications usually combine antibiotic and corticosteroid agents to soothe the inflamed tissues.
  11. 11. Medical Management Cont.….  For cellulitis or fever, systemic antibiotics may be prescribed.  For fungal disorders, antifungal agents are prescribed.  First line Oxytetracycline hydrochloride + Polymyxin B sulphate + Hydrocortisone acetate, 2 drops 2-3 times daily  Alternatives  Cloxacillin, 500mg P.O., QID
  12. 12. IMPACTED CERUMEN  ear wax accumulates in ear canal leading to blockage and pressure on ear canal.  CAUSES  Use of hearing aids or ear plugs  Putting objects in the ear  Anatomical defect (which interferes in removal of wax) Older age 16
  13. 13. SIGNS AND SYMPTOMS 17  Tinnitus, Itching, Difficulty in hearing, Ear discharge, Odor coming from the ear  MANAGEMENT Irrigate the ear canal with irrigator. Instill antibiotic ear drops to prevent infection. Manual removal of wax. Wiping and clean the external ear by a cloth.
  14. 14. Foreign Bodies  Some objects are inserted intentionally into the ear by adults who may have been trying to clean the external canal or relieve itching or by children who introduce peas, beans, pebbles, toys, and beads.  Insects may also enter the ear canal.  In either case, the effects may range from no symptoms to profound pain and decreased hearing. 18
  15. 15. Foreign Bodies management  Removing a foreign body from the external auditory canal can be quite challenging.  The three standard methods for removing foreign bodies are the same as those for removing cerumen: irrigation, suction, and instrumentation.  The contraindications for irrigation are also the same. 19
  16. 16. Cont.…..  Foreign vegetable bodies and insects tend to swell; thus, irrigation is contraindicated.  Insect can be dislodged by instilling mineral oil, which will kill the insect and allow it to be removed.  In some circumstances, the foreign body may have to be extracted in the operating room with the patient under general anesthesia. 20
  17. 17. Malignant External Otitis  A more serious, although rare, external ear infection is malignant external otitis (temporal bone osteomyelitis).  This is a progressive, debilitating, and occasionally fatal infection of the external auditory canal, the surrounding tissue, and the base of the skull.  Pseudomonas aeruginosa is usually the infecting organism in patients with low resistance to infection. 21
  18. 18. Treatment  Successful treatment includes control of the diabetes, administration of antibiotics (usually intravenously), and aggressive local wound care.  Standard parenteral antibiotic treatment includes the combination of an antipseudomonal agent and an aminoglycoside, both of which have potentially serious side effects.  Because aminoglycosides are nephrotoxic and ototoxic, serum aminoglycoside levels and renal and auditory function must be monitored during therapy. 22
  19. 19. Conditions of the Middle Ear Tympanic Membrane Perforation  Perforation of the tympanic membrane is usually caused by infection or trauma.  Sources of trauma include skull fracture, explosive injury, or a severe blow to the ear.  Less frequently foreign objects (e.g., cotton-tipped applicators, bobby pins, keys) that have been pushed too far into the external auditory canal.
  20. 20. Cont.….  In addition to tympanic membrane perforation, injury to the ossicles and even the inner ear may result from this type of action.  Attempts by patients to clear the external auditory canal should be discouraged.  During infection, the tympanic membrane can rupture if the pressure in the middle ear exceeds the atmospheric pressure in the external auditory canal.
  21. 21. Medical Management  Although most tympanic membrane perforations heal spontaneously within weeks after rupture, some may take several months to heal.  Some perforations persist because scar tissue grows over the edges of the perforation, preventing extension of the epithelial cells across the margins and final healing.
  22. 22. Cont….  In the case of a head injury or temporal bone fracture, a patient is observed for evidence of cerebrospinal fluid otorrhea or rhinorrhea—a clear, watery drainage from the ear or nose, respectively.  While healing, the ear must be protected from water
  23. 23. Surgical Management  The decision to perform a tympanoplasty (surgical repair of the tympanic membrane) is usually based on the need to prevent potential infection from water entering the ear or the desire to improve the patient's hearing.
  24. 24. Acute Otitis Media  Ear infections can occur at any age; however, they are most commonly seen in children.  Approximately three out of four children experience an ear infection by the time they are 3 years of age.  Acute otitis media (AOM) is an acute infection of the middle ear, usually lasting less than 6 weeks.
  25. 25. Cause of Acute Otitis Media  Usually Streptococcus pneumoniae and Haemophilus influenzae which enter the middle ear after eustachian tube dysfunction caused by obstruction related to upper respiratory infections, inflammation of surrounding structures (e.g., sinusitis, adenoid hypertrophy), or allergic reactions (e.g., allergic rhinitis).
  26. 26. Bacteria responsible for acute otitis media  Streptococcus pneumonia 35%,  Haemophilus influenzae 25%,  Moraxella catarrhalis 15%.  Group A streptococci and Staphylococcus aureus may also be responsible. 32
  27. 27. Cont…..  Bacteria can enter the eustachian tube from contaminated secretions in the nasopharynx and the middle ear from a tympanic membrane perforation.  A purulent exudate is usually present in the middle ear, resulting in a conductive hearing loss.
  28. 28. Clinical Manifestations  The condition, usually unilateral in adults, may be accompanied by otalgia.  The pain is relieved after spontaneous perforation or therapeutic incision of the tympanic membrane.  Other symptoms may include drainage from the ear, fever, and hearing loss.
  29. 29. Cont….  On otoscopic examination, the external auditory canal appears normal.  The tympanic membrane is erythematous and often bulging.  Patients report no pain with movement of the auricle.
  30. 30. Risk factors  Age (younger than 12 months)  Chronic upper respiratory infections  Medical conditions that predispose to ear infections (Down syndrome, cystic fibrosis, cleft palate), and  Chronic exposure to secondhand cigarette smoke.
  31. 31. Medical Management  With early and appropriate broad-spectrum antibiotic therapy, otitis media may resolve with no serious sequelae.  If drainage occurs, an antibiotic otic preparation is usually prescribed.  The condition may become subacute (lasting 3 weeks to 3 months), with persistent purulent discharge from the ear.  Rarely does permanent hearing loss occur.
  32. 32. Medical management  Amoxicillin for dosage based on age 10 ten days  Alternatives  Ampicillin  Parenteral:  N.B. Paracentisis should be carried out early if the tympanic membrane does not perforate spontaneously.  Antrotomy should be carried out early if it is indicated on clinical grounds. 38
  33. 33. Surgical Management  An incision in the tympanic membrane is known as myringotomy or tympanotomy.  The tympanic membrane is numbed with a local anesthetic such as phenol or by iontophoresis (ie, electrical current flows through a lidocaine-and-epinephrine solution to numb the ear canal and tympanic membrane).
  34. 34. Cont….  The procedure is painless and takes less than 15 minutes.  Under microscopic guidance, an incision is made through the tympanic membrane to relieve pressure and to drain serous or purulent fluid from the middle ear.
  35. 35. Chronic Otitis Media  Is the result of recurrent AOM causing irreversible tissue pathology and persistent perforation of the tympanic membrane.  Chronic infections of the middle ear damage the tympanic membrane, destroy the ossicles, and involve the mastoid.
  36. 36. Causes of Chronic Otitis Media  Late treatment of acute otitis media.  Inadequate or inappropriate antibiotic therapy.  Upper airway sepsis.  Lowered resistance, e.g. malnutrition, anemia, immunological impairment.  Particularly virulent infection, e.g. measles. 42
  37. 37. Clinical Manifestations  Discharge- mucopurulant,non foul smelling  Deafness  Earache  tympanic membrane perforation,  Tuning fork test:rinne-negative  Weber-lateralised to one side
  38. 38. Investigations  Culture and sensitivity  Examination under microscope  Pure tone audio gram: mild conductive loss between 20 to 30dB  X-ray of mastoid, neck lateral view 44
  39. 39. Medical management  First line  Amoxicillin, 500mg P.O., TID for 10-15 days  Augmentin
  40. 40. Serous Otitis Media  Serous otitis media (middle ear effusion) involves fluid, without evidence of active infection, in the middle ear.  In theory, this fluid results from a negative pressure in the middle ear caused by eustachian tube obstruction.  When this condition occurs in adults, an underlying cause for the eustachian tube dysfunction must be sought. 47
  41. 41. Cont…..  Middle ear effusion is frequently seen in patients after radiation therapy or barotrauma and in patients with eustachian tube dysfunction from a concurrent upper respiratory infection or allergy.  Barotrauma results from sudden pressure changes in the middle ear caused by changes in barometric pressure, as in scuba diving or airplane descent.  A carcinoma (eg, nasopharyngeal cancer) obstructing the eustachian tube should be ruled out in adults with persistent unilateral serous otitis media. 48
  42. 42. Clinical Manifestations  Hearing loss, fullness in the ear or a sensation of congestion, or popping and crackling noises, which occur as the eustachian tube attempts to open.  The tympanic membrane appears dull on otoscopy, and air bubbles may be visualized in the middle ear.  Usually, the audiogram shows a conductive hearing loss. 49
  43. 43. Management  Serous otitis media need not be treated medically unless infection (i.e.AOM) occurs.  If the hearing loss associated with middle ear effusion is significant, a myringotomy can be performed, and a tube may be placed to keep the middle ear ventilated.  Corticosteroids in small doses may decrease the edema of the eustachian tube in cases of barotrauma. 50
  44. 44. Cont….  A Valsalva maneuver which forcibly opens the eustachian tube by increasing nasopharyngeal pressure, may be cautiously performed.  This maneuver may cause worsening pain or perforation of the tympanic membrane. 51
  45. 45. Conditions of the Inner Ear  Disorders of balance are a major cause of falls of elderly people.  The term dizziness is used frequently by patients and health care providers to describe any altered sensation of orientation in space.  Vertigo is defined as the misperception or illusion of motion of the person or the surroundings. 72
  46. 46. Cont….  Most people with vertigo describe a spinning sensation or say they feel as though objects are moving around them.  Ataxia is a failure of muscular coordination and may be present in patients with vestibular disease.  Syncope, fainting, and loss of consciousness are not forms of vertigo and usually indicate disease in the cardiovascular system. 73
  47. 47. Cont….  Nystagmus is an involuntary rhythmic movement of the eyes.  Nystagmus occurs normally when a person watches a rapidly moving object (eg, through the side window of a moving car or train).  However, pathologically it is an ocular disorder associated with vestibular dysfunction.  Nystagmus can be horizontal, vertical, or rotary and can be caused by a disorder in the central or peripheral nervous system. 74
  48. 48. Motion Sickness  Motion sickness is a disturbance of equilibrium caused by constant motion.  For example, it can occur aboard a ship, while riding on a merry-go-round or swing, or in the back seat of a car. 75
  49. 49. Clinical Manifestations  The syndrome manifests itself in sweating, pallor, nausea, and vomiting caused by vestibular overstimulation.  These manifestations may persist for several hours after the stimulation stops. 76
  50. 50. Management  Over-the-counter antihistamines such as dimenhydrinate (Dramamine) or meclizine hydrochloride (Antivert) may provide some relief of nausea and vomiting by blocking the conduction of the vestibular pathway of the inner ear.  Anticholinergic medications, such as scopolamine patches, may also be effective because they antagonize the histamine response. These must be replaced every few days. 77
  51. 51. Cont…  Side effects such as dry mouth and drowsiness may occur.  Potentially hazardous activities such as driving a car or operating heavy machinery should be avoided if drowsiness occurs. 78
  52. 52. HEARING LOSS: Hearing loss also known as hearing impairment is partial or total inability to hear. It may occur in one or both ears. TYPES OF HEARING LOSS: • Conductive hearing loss: It usually results from an external ear disorders. Such as impacted Cerumen, or middle ear disorders, otitis media or otosclerosis.  In such conditions the efficient transmission of sound by air to inner ear is interrupted. 79
  53. 53. Types of hearing loss 2.Sensorineural hearing loss: It is a type of hearing loss, or deafness, in which the root cause lies in the inner ear or sensory organ (cochlea and associated structures) or the vestibulocochlear nerve (cranial nerve viii).  This is the most common type of permanent hearing loss. 3. Mixed hearing loss: Both conductive and sensorineural loss is present resulting from dysfunction of air and bone conduction. 80
  54. 54. 81
  55. 55. CLINICAL MANIFESTATIONS:  Tinnitus and increased inability to hear.  Student with hearing impairment will be inattentive and uninterested in class.  Speech deterioration. MANAGEMENT:  Removal of Cerumen by irrigation.  Removal of foreign bodies.  Treating the underlying cause.  for permanent or untreatable :Aural rehabilitation may be beneficial 82
  56. 56. Meniere’s Disease  Meniere's disease is an abnormal inner ear fluid balance caused by a malabsorption in the endolymphatic sac or a blockage in the endolymphatic duct.  Endolymphatic hydrops, a dilation in the endolymphatic space, develops, and either increased pressure in the system or rupture of the inner ear membrane occurs, producing symptoms of Meniere's disease.  More common in adults onset 40 years old 83
  57. 57. Meniere’s Disease……. 84
  58. 58. CAUSES:  Excessive endolymph in vestibular and semicircular canals of inner ear.  Viral infections  Allergies  Medications like Aspirin  Stress 85
  59. 59. Clinical Manifestations  Vertigo and dizziness  Tinnitus  Hearing loss or deafness  Fullness in both ears  Photophobia  Nausea and vomiting 86
  60. 60. Medical Management  Can be successfully treated with diet and medication.  Many patients can control their symptoms by adhering to a low-sodium (2000 mg/day) diet.  Psychological evaluation may be indicated if a patient is anxious, uncertain, fearful, or depressed. 87
  61. 61. Pharmacologic Therapy  Consists of antihistamines such as meclizine (Antivert), which suppress the vestibular system.  Tranquilizers such as diazepam (Valium) may be used in acute instances to help control vertigo.  Anti emetics such as promethazine (Phenergan) suppositories help control the nausea and vomiting and the vertigo because of their antihistamine effect. 88
  62. 62. Cont…….  Diuretic therapy (eg, hydrochlorothiazide) may relieve symptoms by lowering the pressure in the endolymphatic system.  Intake of foods containing potassium (eg, bananas, tomatoes, oranges) is necessary if the patient takes a diuretic that causes potassium loss. 89
  63. 63. Surgical Management  Hearing loss, tinnitus, and aural fullness may continue, because the surgical treatment of Meniere's disease is aimed at eliminating the attacks of vertigo 90
  64. 64. Endolymphatic Sac Decompression  Endolymphatic sac decompression, or shunting, theoretically equalizes the pressure in the endolymphatic space.  A shunt or drain is inserted in the endolymphatic sac through a post auricular incision. 91
  65. 65. Middle and Inner Ear Perfusion  Ototoxic medications, such as streptomycin or gentamicin, can be administered to patients by infusion into the middle and inner ear.  The success rate for eliminating vertigo is about 85%, but the risk of significant hearing loss is high.  After the procedure, many patients have a period of imbalance that lasts several weeks. 92
  66. 66. Intraotologic Catheters  In an attempt to deliver medication directly to the inner ear, catheters are being developed to provide a conduit from the outer ear to the inner ear.  Medicinal fluids can be placed against the round window for a direct route to the inner ear fluids.  Potential uses of these catheters include treatment for sudden hearing loss and various disorders causing intractable vertigo. 93
  67. 67. Vestibular Nerve Sectioning  Vestibular nerve sectioning provides the greatest success rate (approximately 98%) in eliminating the attacks of vertigo. Cutting the nerve prevents the brain from receiving input from the semicircular canals. 94
  68. 68. Tinnitus  Tinnitus is a symptom of an underlying disorder of the ear that is associated with hearing loss.  The severity of tinnitus may range from mild to severe.  Patients describe tinnitus as a roaring, buzzing, or hissing sound in one or both ears.  Numerous factors may contribute to the development of tinnitus, including several ototoxic substances. 95
  69. 69. Tinnitus….  Underlying disorders that contribute to tinnitus may include thyroid disease, hyperlipidemia, vitamin B12 deficiency, psychological disorders (eg, depression, anxiety), fibromyalgia, otologic disorders (Ménière's disease, acoustic neuroma), and neurologic disorders (head injury, multiple sclerosis). 96
  70. 70. Labyrinthitis  Labyrinthitis, an inflammation of the inner ear, can be bacterial or viral in origin.  Bacterial labyrinthitis is rare because of antibiotic therapy, but it sometimes occurs as a complication of otitis media.  Viral labyrinthitis is a common diagnosis, but little is known about this disorder, which affects hearing and balance. 97
  71. 71. CAUSES:  Acute otitis media and meningitis  Viral infection, head injury and neoplasm of middle ear or VIII cranial nerve.  Alcoholism  Allergy  Upper respiratory tract infection 98
  72. 72. CAUSES Cont…..  The most common viral causes are mumps, rubella, rubeola, and influenza.  Viral illnesses of the upper respiratory tract and herpetiform disorders of the facial and acoustic nerves (ie, Ramsay Hunt syndrome) also cause labyrinthitis. 99
  73. 73. Clinical Manifestations  Extreme vertigo and dizziness  Labyrinthitis is characterized by a sudden onset of incapacitating vertigo, usually with nausea and vomiting, various degrees of hearing loss, and possibly tinnitus.  The first episode is usually the worst; subsequent attacks, which usually occur over a period of several weeks to months, are less severe. 100
  74. 74. Clinical Manifestations  Sensorineural hearing loss  Tinnitus  Otorrhea  Otalgia  Neck pain stiffness  Cognitive impairment like memory and thinking problems. 101
  75. 75. Management  Treatment of bacterial labyrinthitis includes IV antibiotic therapy, fluid replacement, and administration of an antihistamine (eg, meclizine) and antiemetic medications.  Treatment of viral labyrinthitis is based on the patient's symptoms. 102
  76. 76. Medical managment  Treat any gonorrheal infection in pregnancy.  Put tetracycline eye oint to new born with in 1hrs each  Eryhomyocine eye oint to new born with in 1hr each eye  Silver nitrate 1% eye drop to the new born with in 1hr each eye  Nursing managment  Bathing the head of the new born separating from other body parts  Apply the ointment as orderd. 103
  77. 77. SUMMARY  • Disorders of outer ear  Otitis externa  Impacted Cerumen  Furunculosis  Disorders of middle ear  Acute otitis media  Serous otitis media  Chronic otitis media  • Disorders of inner ear  Hearing loss  Meniere’s disease  Labyrinthitis 104
  78. 78. Eye Disorders Prepared By: Getenet D. (BSc, MSc) 105
  79. 79. Fun facts  Did you know that the average blink takes 1/3 of a second?  Seeing is so important that it takes up more than 50% of the brain’s functionality.  Newborns don’t shed tears, though they do know how to cry.  You blink about 15-20 times in a minute.  The most active muscles in your body are in your eyes.  Your eyes can get sunburned. 106
  80. 80. Fun facts  Blue eyed people are more tolerant of alcohol and less tolerant of the sun  If the human eye were a digital camera it would have 576 megapixels.  We spend about 10% of our wake time with our eyes closed.  An ostrich’s eye is bigger than its brain.  Chameleons can move their eyes in two directions at once.  A single scallop can possess over a hundred eyes 107
  81. 81. Fun facts  Your eyes contain around 107 million light sensitive cells.  Dolphins can sleep with one eye open.  Birds, cats and dogs have three eyelids.  Yes, you can sneeze with your eyes open and no, your eyes won’t fall out.  Ommatophobia is the fear of eyes.  The world’s most common eye colour is brown.  Dogs cannot distinguish between red and green. 108
  82. 82. Fun facts  The lifespan of the average eyelash is 5 months, the rest of your hair will last 2-4 years.  The eye has over 2 million moving parts.  Women to men crying ratio 50/10.  Source  The Canadian Association of Optometrists 109
  83. 83. Function of crying  Regulate their own emotion  Get support from others  Helps to relive pain  Enhance mood  Release chemicals that can reduce stress  aids sleep  Fight bacteria  Improve vision 110
  84. 84. Learning Objectives @ On completion of this chapter, the learner will be able to:  Identify significant eye structures and describe their functions.  Discuss clinical features, diagnostic assessment and examinations, medical or surgical management, and nursing management of ocular disorders.  Define low vision and blindness and differentiate between functional and visual impairment. Prepared By: Getenet D. (BSc, MSc in AHN) 111
  85. 85. Anatomy and Physiology 112
  86. 86. Prepared By: Getenet D. (BSc, MSc in AHN) 113
  87. 87. THE EYE BALL (GLOBE) HAS THREE LAYERS AND CAVITIES 1. The three layers (Coats) of eye ball: A) The fibrous (outer) layer -Cornea/sclera. a) Cornea transparent b) Sclera opaque representing the white appearance of the eye ball Function: -Along with the IOP, maintains the Shape, stability of the eye ball - Optical
  88. 88. THE EYE BALL (GLOBE)….. B) The vascular (Middle) layer -Iris/Ciliary body/Choroid--------Uveal tissues. -Brown to dark-brown in appearance. e.g. -The iris represent the brown appearing part behind the transparent cornea. Functions: -Nutrition for the inner layers of the eye ball. -Provide dark environment of the eye ball cavity to avoid image degradation. E.g. film developing
  89. 89. THE EYE BALL (GLOBE)….. C.Neuro Sensory (inner) layer -Retina/ RPE. Functions: -transducers the electromagnetic form of image to neuronal impulse to be dispatched to the brain.
  90. 90. THE THREE CAVITIES: A. Anterior chamber -Between the Cornea and anterior face of the Iris filled with the Aqueous-fluid. B. Posterior chamber: - Between the posterior face of the Iris and lens. Is also filled with the aqueous. *A and B communicate through the pupil. C. Vitreous cavity Between the Lens and retina Filled with Vitreous (jelly fluid)
  91. 91. Significance: 1. Aqueous from the ciliary body------P/C----Pupil---- A/C—Drainage channel----Episcleral vein---systemic circulation. 2. Balance between secretions and drainage--------Normal intraocular pressure (10-20mmHg) This make the eye ball a pressurized chamber Decreased drainage------Increased intraocular pressure (ocular hypertension) ---- (Resultant damage to optic nerve)----Glaucoma. Aqueous provide nutrient material to the avascular ocular structures such as the lens and the cornea.
  92. 92. THE LACRIMAL SYSTEM Has secretor and drainage part. 1. Secrotary system: Tear film is composed of three layers: -Oily/aqueous/Mucin layer a) Mucin: Goblet cells of conjunctiva. b) Oily: sebaceous mebomian gland, gland of zeiss and moli. c) Aqueous: Main lacrimal gland, glands of Kraus and wolfring. Main lacriaml gland is located at the anterior upper temporal aspect of orbit
  93. 93. Tear film function: Oily part: -Protect tear evaporation. Mucin layer: -Alter the hydrophobic corneal surface to Hydrophilic so that wetting is facilitated. Aqueous Part: -Provide nutritive and immunologic substances. General function: -Nutrition -Optical -Immunologic -Wash out tiny foreign bodies.
  94. 94. DRAINAGE SYSTEM: Pumps and drain the tear to nasal cavity. Drainage canal: -Composed of Punctai, canaliculi, lacrimaL sac and NLD a) Puncta: -Small opening at medial end of each lids. b) Canaliculi: -Continuation of the puncta 2 mm vertical and 8mm horizontal coursing to lacriasml sac. c) Lacrimal sac: -Cystic structure on the lateral aspect of nasal bridge. d) Nasolacrimal duct: -cross the nasal bone to nasal cavity
  95. 95. Lacrimal pumping: Tear fluid drains from the surface of the eye through the draining system to nasal cavity. -depend on the potency of each segments of the drainage channel. -Is aided by a lacriaml pump mechanism. a) Normal lid apposition to the eye ball. b) Zipp like lid closure (orbicularis oculi muscle).
  96. 96. Failure lead to; Epihora: tearing due to drainage system failure. A) Pump failure. E.g. Facial palsy. B) Drainage canal obstruction. -Difference from tearing Tearing is due to irritative or emotional secretion of tear.
  97. 97. Red Eye  The red eye can be painful or is painless Or  It is accompanied with or without discharge Or  Accompanied by blurring of vision or not 124
  98. 98. What causes a red eye ? Dilatation of Conjunctiva blood vessels e.g. conjunctivitis  Episcleral blood vessels e.g. episcleritis  Scleral blood vessels e.g. scleritis Or  Accumulation of blood in the subconjunctival space i.e. Subconjunctival hemorrhage 125
  99. 99. causes a red eye…  Environmental causes of red, bloodshot eyes include:  Airborne allergens (causing eye allergies)  Smoke (fire-related, second-hand cigarette smoke, etc.)  Dry air (arid climates, airplane cabins, office buildings, etc.)  Airborne fumes (gasoline, solvents, etc.)  Chemical exposure (chlorine in swimming pools, etc.)  Overexposure to sunlight (without UV-blocking sunglasses) 126
  100. 100. causes a red eye…  Dry eyes  Eye allergies  Pink eye (conjunctivitis)  Contact lens wear  Digital eye strain 127
  101. 101. Serious eye conditions that can cause red eyes include:  Eye infections  Eye trauma or injury  Recent eye surgery (cosmetic eye surgery, etc.)  Uveitis  Acute glaucoma  Corneal ulcer 128
  102. 102. What causes a discharge in a red eye?  Exudation/transudation form conjunctival vessels  Due to over production of tears  Due to blockage of tear passages.  What causes visual loss in a red eye?  Corneal oedema/ulceration  Hazy anterior chamber ( Flare/cells)  Dilated pupil 129
  103. 103. What causes pain in a red eye ?  Pain is caused by irritation of the: Conjunctival nerves e.g dull ache in conjunctivitis  Corneal nerves: pain in corneal ulcer  Ciliary nerves: pain in scleritis, uveitis and angle closure glaucoma  It is important to remember that the orbit is surrounded by  air sinuses and inflammation of these is also an important cause of pain around the eyes 130
  104. 104. Causes of a painless red eye  Sub conjunctiva hemorrhage and Episcleritis are the two important causes of a painless red eye.  The other causes of a localised redness are:  Pterygium and  Pigencula 131
  105. 105. Refractive Errors  Refractive error is defective in the ability of the lens of the eye to focus an image accurately as occur in near sightedness and far sightedness.  Normal vision is called Emmeropia;  People with refractive errors focus images either in front or behind the retina and consequently don’t see close or far image clearly. Prepared By: Getenet D. (BSc, MSc in AHN) 132
  106. 106. Refractive Errors cont……  The normal visual acuity is 20/20 the visual acuity is expressed in a ratio that relates what a person with normal vision sees from a distances of 20 feet (6 metre)  Etiology  Hereditary Prepared By: Getenet D. (BSc, MSc in AHN) 133
  107. 107. Classification of refractive error A. Myopia usually occurs in people with elongated eyeballs.  Because of the excessive length of the eye, light rays focus at a point in the vitreous body before they reach the retina , the myopic eye can’t clearly see object in the distance since it has no way to reduce the excessive refractive power. Prepared By: Getenet D. (BSc, MSc in AHN) 134
  108. 108. Cont…. B. Hyperopia it results when the eye ball is shorter than normal, the causing, light rays to focus at theoretical point behind the retinal.  This type of image formation is due to insuffient reactive power to focus light on the retinal and short vision impaired. Prepared By: Getenet D. (BSc, MSc in AHN) 135
  109. 109. Cont…. C. Astigmation result from unequal curvature of the cornea.  The focus of rays is distorted, and the patient can’t focus horizontal and vertical rays on the retina at the same time vision is general distorted.  Either myopia or hyperopia may coexist with astigmation.  This disorder can’t be eliminated by accommodation but can generally be corrected by glasses grounded to neutrize the unequal curvature. Prepared By: Getenet D. (BSc, MSc in AHN) 136
  110. 110. Cont… D. Presbyopia - Is a form of farsightedness that occurs with aging people with presbyopia hold reading material further away to see it more clearly  Presbyopia is caused by the gradual loss of elasticity of the lens, which leads to a decreased ability to accommodate, or focus, for near vision by the ages 40 to 50 Prepared By: Getenet D. (BSc, MSc in AHN) 137
  111. 111. Prepared By: Getenet D. (BSc, MSc in AHN) 138
  112. 112. Clinical manifestation  Head ache  Blurred vision  Eye fatigue Prepared By: Getenet D. (BSc, MSc in AHN) 139
  113. 113. Diagnostic procedure  Snellen chart – to determine visual acuity  Placed 6 feet or 20 m away from patient  Normal visual acuity is expressed 20/20 feet  Gross examination as perception of light, hand motion and counting fingers of examiner Prepared By: Getenet D. (BSc, MSc in AHN) 140
  114. 114. Medical management  Refractive error is corrected with: - A. Eye glasses such as converging lens (convex lens) in hyperopia and diverging lens (concave lens) for myopia, these lenses bend light ray to compensate for clients refractive error. B. Contact lenses; they are small curved lenses, primary plastic, in shaped to fit the person's eye to correct refractive error or to enhance appearance Prepared By: Getenet D. (BSc, MSc in AHN) 141
  115. 115. Cont….  There are two forms of contact lenses float on the pre-corneal tear film and must be inserted, removed, cleaned and stored to prevent damage infection. 1. Hard contract lenses are gas- permeable last 15- 20 years with care 2. Soft contract lenses may require more frequent replacement usually every 1-3 years. Prepared By: Getenet D. (BSc, MSc in AHN) 142
  116. 116. Surgical management  Incisional radial keratotomy is a procedure that some times can correct refractive disorders under local anesthesia;  the cornea is reshaped by making surgical incision for myopia. Prepared By: Getenet D. (BSc, MSc in AHN) 143
  117. 117. Other management  Clean ,care, and safe guard contact lens and eye glasses  Teach patient how to remove, insert and care for visual aids 1. Clean eye glasses well daily or more with warm water & soap 2. Rinse the glasses well and dry with a soft, clean cloth.  Instruct for contact lenses care depends on its type hard or soft. Prepared By: Getenet D. (BSc, MSc in AHN) 144
  118. 118. Hordeolum  External hordeolem also known as sty  Sty is infection and inflammation of the superficial eye lid gland (moll gland a type oil gland) located at the edge of the eyelid  Etiology: it is caused by staphylococcus areus Prepared By: Getenet D. (BSc, MSc in AHN) 145
  119. 119. Hordeolum …… Prepared By: Getenet D. (BSc, MSc in AHN) 146
  120. 120. Clinical manifestation  Sub acute pain  Redness  Swelling of a localized area of the lid, tender  Red pustules externally or internally within the eyelid.  Diagnosis - The physical findings.  Culture of the exudates  Complication: chalazoin Prepared By: Getenet D. (BSc, MSc in AHN) 147
  121. 121. Medical and surgical management  Treatment with warm, moist compresses for 10-15 minutes 3-4 times a day to hasten healing process.  If no change after compress with in 48 hours may require incision and drainage in severe cases.  Apply the topical medications  Tetracycline .o.1% ointment 3-4 times a day.  Gentamycin o.3% ointment 2-3 times a day.  Chloramphenicol o.5% ointment 3-4 times days. Prepared By: Getenet D. (BSc, MSc in AHN) 148
  122. 122. Chalazoin  is a chronic granulomatous (cyst) of the meibomian gland localized swelling in the inner surface of the eye lid at the junction of the conjunctiva and lid margin.  Etiology Resulted from obstruction and retained secretion of the meibomian glands  Clinical pictures  Localized, painless swelling  As it grows, feels hard  Non tender, Small nodule in the eye lid on examination Prepared By: Getenet D. (BSc, MSc in AHN) 149
  123. 123. Chalazoin….. Prepared By: Getenet D. (BSc, MSc in AHN) 150
  124. 124. Chalazoin….. 151
  125. 125. Chalazoin…..Cont  Complication  The enlargement with in the eye lid affects visual acuity.  Secondary infection.  Diagnostic procedure: - Sign and symptoms  Distorted vision due to corneal compression & obscured pupil. Prepared By: Getenet D. (BSc, MSc in AHN) 152
  126. 126. Medical management  Uninfected chalazoin usually required treatment and disappear spontaneously within a few months.  Warm soaks and massage of the surrounded area to promote drainage.  Antibiotics therapy and corticosteroid drop or injection  Excision is indicated if the cyst is firm distort vision & infected. Prepared By: Getenet D. (BSc, MSc in AHN) 153
  127. 127. Blepharitis  Blepharitis is a chronic inflammation of the eyelid margins.  Etiology Seborrhae exess sebaceous(oil) ( non ulcerative) most common form. Staphylococcal infection. Both could also lead to the development of hordeola and chalazions. Prepared By: Getenet D. (BSc, MSc in AHN) 154
  128. 128. Blepharitis….. Prepared By: Getenet D. (BSc, MSc in AHN) 155
  129. 129. Clinical manifestations Eye irrtation Burning sensation Itching of the eye lid margin. Red - rimmed eyes Patchy flakes cling to eyelashes, visible about the lids Loss of lashes Development of white eye lashes Dilated blood vessels at the lid margin Prepared By: Getenet D. (BSc, MSc in AHN) 156
  130. 130. Medical treatment It includes:  Very careful cleaning of the lid margins daily /Bid using Cotton applicator, Non irritating shampoo, baby shampoo,water and mild friction.  Warm compress may be applied across each eyes  Using aseptic technique removing crusted matter with a wash cloth and apply topical antibiotics and steroids. Prepared By: Getenet D. (BSc, MSc in AHN) 157
  131. 131. Topical antibiotics ₢ TTC eye iont 1% 3-4 x a day. ₢ Gentamycine 0.3% 2-3/d ₢ Chloramphanicol 0.5% ointment 3-4 x a day ₢ Hydrocortisone 1.5% ointment 3-4x aday. ₢ Predonisolone acetate 0.125% solution 1drop q1 - 2hr ₢ Dexamethasone 0.1% solution or 0.5% oint 3-4 x.days Prepared By: Getenet D. (BSc, MSc in AHN) 158
  132. 132. What is conjunctivitis?  Conjunctivitis (―pink-eye‖) – is an inflammation of the conjunctiva due to a viral (Adenovirus), bacterial, or allergic  The most common ocular disease worldwide.  Characterized by a pink appearance (hence the common term pink eye) because of sub conjunctiva blood vessel congestion  inflammatory conditions like Stevens Johnson syndrome can cause it
  133. 133. Conjunctivitis……..  Causes:- chemicals, fungi, certain diseases,  contact lens wear(especially wearing lenses overnight).
  134. 134. Conjunctivitis…  The conjunctiva can also become irritated by foreign bodies in the eye  And by indoor and outdoor air pollution caused, for example, by chemical vapors, fumes, smoke, or dust.
  135. 135. Bacterial conjunctivitis  Commonly caused by staphylococcus aurous  Streptococcus pneumonia  Chlamydia trachoma is commonly in adult  Highly contagious  Purulent discharge can help us to dx
  136. 136. Clinical Manifestations  Redness in the white of the eye or inner eyelid  Increased amount of tears  Thick yellow discharge that crusts over the eyelashes ,especially after sleep  Green or white discharge from the eye
  137. 137. CON…
  138. 138. Assessment and Diagnostic Findings  Type of discharge.  Type of conjunctival reaction.  Presence of membrane/ pseudo membrane.  Lymphadenopathy.
  139. 139. Laboratory investigation  Cultures.  Cytological investigations.  Detection of Chlamydia antigens.  Impression cytology ocular infection.  Polymerase chain reaction: small quantity of DNA for chlamydia trachomatis.
  140. 140. Kind of Discharge  Exudates plus debris plus mucus plus tears.  Serous; watery exudate in acute viral and acute allergic conjunctivitis.  Purulent; puss in severe acute bacterial conjunctivitis.  Muco purulent; puss plus mucus in mild bacterial conjunctivitis and Chlamydial conjunctivitis.
  141. 141. Treatment  Treatment Objective – Treat the infection ፣Prevent complications  Non Pharmacologic - Frequent cleaning of the eyelids and warm compression  Pharmacologic  First line Chloramphenicol, 1 drop every 4-6 hours OR single strip of ointment applied 24 times per day for 10-15 days.  Alternatives Tetracycline, single strip of ointment applied 2-4 times per day for 10-15 days.  OR Tobramicin, 1 drop every 4-6 hours per day for 10- 15 days. Dosage form: Eye drop, 0.3%
  142. 142. Prevention Personal hygiene
  143. 143. Viral Conjunctivitis  Viral conjunctivitis is caused by infection of the eye with a virus.  Can be caused by a number of different viruses, many of which may be associated with an upper respiratory tract infection, cold, or sore throat.  Usually begins in one eye and may progress to the second eye within days.
  144. 144. Viral Conjunctivitis…  Spreads easily and rapidly between people and can result in epidemics.  Is typically mild and usually clears up in 7-14 days without treatment and resolves without any long- term effects.  In some cases, it can take 2-3 weeks or more for viral conjunctivitis to completely clear up, depending on whether complications develop.
  145. 145. Causes 1. Severe adenoviral infection. 2. Ligneous conjunctivitis. 3. Gonococal conjunctivitis. 4. Stevens-Johnson syndrome.
  146. 146. Clinical manifestation  Photophobia  Pseudo membrane: Outside epithelium, Coagulated exudates adherent to the inflamed epithelium.  Can be easily pealed off.  Watery discharge  Lymphadenopathy
  147. 147. Treatment  Self limited  Cold compress  If the is any complication can use eye drop
  148. 148. Allergic conjunctivitis  Allergic conjunctivitis is caused by the body's reaction to certain substances to which it is allergic, such as pollen from trees, plants, grasses, and weeds; dust mites; molds; dander from animals; contact lenses and lens solution; and cosmetics.
  149. 149. Allergic conjunctivitis…  Allergic conjunctivitiets Cases are typically mild and can last as few as 2-3 days or up to 2-3 weeks.  Many cases improve in 2-5 days without treatment  However, topical antibiotics are often prescribed to treat the infection.
  150. 150. Allergic conjunctivitis…  Can occur year-round due to indoor allergens, such as dust mites and animal dander.  May result, in some people, from exposure to certain drugs and cosmetics.
  151. 151. Allergic conjunctivitis…  Clears up once the allergen or irritant is removed or after treatment with allergy medications.  Can occur when contact lenses are worn too long or not cleaned properly.
  152. 152. Sign and symptoms  Red eye  Sever itching both eye  Copious mucous discharge  blepharospasm,  blurred vision  And have purulent discharge through out the day that can be yellow ,white, green colour.
  153. 153. Diagnosis  Investigations – Clinical  Treatment  Dexamethasone  Prednisolone,
  154. 154. Nursing intervention  Practice good hygiene to control the spread of pink eye. For instance:  Don't touch your eyes with your hands.  Wash your hands often.  Use a clean towel and washcloth daily.  Don't share towels or washcloths.  Change your pillowcases often.  Throw away your eye cosmetics, such as mascara.  Don't share eye cosmetics or personal eye care items.
  155. 155. Trachoma  Is chronic chlamydial conjuctivitis found in hot, dry climate and It is an infecious disease that affects more than 500x106 people world wide  Trachoma is the world`s leading causes of preventable blindness and primary affects people in Africa , the middle east and Asia .  Etiology : Chlamydial trochomitis
  156. 156. Trachoma in Ethiopia 190
  157. 157. 191
  158. 158. 192
  159. 159. Prevalence of trachoma 193
  160. 160. 194
  161. 161. Transmission  personal contact (via hands, clothes or bedding) and by flies that have been in contact with discharge from the eyes or nose of an infected person. With repeated episodes of infection over many years, the eyelashes may be drawn in so that they rub on the surface of the eye, with pain and discomfort and permanent damage to the cornea. 195
  162. 162. Clinical manifestation  Feeling of foreign body ( mild itching & irritation )  Burnig sensatioon  Photophobia  Lacrimation  Little mucopurulent discharge  Follicles appear on the conjuctiva – in acute inflammation process  Follicles are tense, red  Thick lid and drooping  Trachomatous pannus ( Vascularized cornea )
  163. 163. Transmition of trachoma  direct contact.  The bacteria are also spread through shared blankets, pillows, and towels.  Certain conditions promote the spread of trachoma bacteria. These include: poor personal hygiene poor body waste and trash disposal insufficient water supply for washings close association with domestic animals
  164. 164. Investigation  The World Health Organization (WHO) has introduced a simple severity grading system for trachoma based on the presence or absence of five key signs: 1. Trachomatous Inflammation–Follicular (TF): The presence of five or more follicles in the upper tarsal conjunctiva. 2. Trachomatous Inflammation–Intense (TI): Pronounced inflammatory thickening of the tarsal conjunctiva that obscures more than half of the deep tarsal vessels. 3. Trachomatous Scarring (TS): The presence of scarring in the tarsal conjunctiva. 4. Trachomatous Trichiasis (TT): At least one eye lash rubs on the eye ball. 5. Corneal opacity (CO): Easily visible corneal opacity over the pupil.
  165. 165. 10. Inflammatory Trachoma - Follicles (TF)
  166. 166. 11. Inflammatory Trachoma - Intense (TI)
  167. 167. 12. Conjunctival Scarring of Trachoma (TS)
  168. 168. 13. Trichiasis of Trachoma (TT)
  169. 169. 14. Corneal Opacity due to Trachoma (CO)
  170. 170. Can you place each of these pictures in the correct category?
  171. 171. Prevention and Treatment  The World Health Organization (WHO) advocates SAFE strategy. S = Surgery for complications (TT & CO) A = Antibiotics for active (inflammatory) trachoma (TT & TI) F = Face washing, particularly in children E = Environmental improvement including provision of clean water
  172. 172. Trachoma … ―To eliminate a disease, the critical step is knowing where it is – otherwise you are just shooting in the dark‖ Anthony Solomon, Medical Officer for Trachoma, WHO 207
  173. 173. Treatment of trachoma 1. Trachomatous Inflammation–Follicular (TF) First line Tetracycline, single strip of ointment applied BID for 6 weeks, OR asintermittent treatment BID for five consecutive days per month, OR QD for 10 consecutive days, each month for at least for six consecutive months. Alternative Erythromycin, single strip of ointment applied BID for 6 weeks 2.Trachomatous Inflammation – Intense (TI) Topical First line & Alternative (See under TF) PLUS Tetracycline, 250mg P.O., QID for 3 weeks (only for children over 7 years of age and adults). OR
  174. 174. 2.Trachomatous Inflammation – Intense (TI) …. Doxycycline, 100mg P.O., QD for 3 weeks (only for children over 7 years of age and adults). OR Erythromycin, 250mg P.O., QID for 3 weeks. For children of less than 25kg, 30mg/kg daily in 4 divided doses. N.B. Azithromycin is given as a single dose of 20mg/kg. It represents long acting macrolides which has shown very promising effects in the treatment of trachoma in clinical research. It is still a very expensive medicine. 209
  175. 175. Nursing managment  Teaching hygiene- Washing hands & face , Avoiding flies  Avoiding rubbing the eyes , using private wash cloths  Complication of trachoma  Cornea -Superficial keratitis  Cornea ulcer  Corneal opacity & perforation
  176. 176. Cont….  Eye lid complication  Trichiasis - an abnormal inversion of eye lashes  Ectopion - Turnig eye lid out ward ( eversion)  entropion - turnig eye lid inward to ward the eye  Ptosis - Abnormal upper eye lid droop
  177. 177. KERATITIS  Is an inflammation of the cornea, divided into two :-  Ulcerative keratitis  Nonulcerative keratitis caused due to cause of syphilis ,TB, congenitally  Types of ulcerative keretitiss  Corneal ulcer - lead to opcity of cornea  Phyctenular ulcer  Hypopyon ulcer severe form of ulcer with pus. Prepared By: Getenet D. (BSc, MSc in AHN) 212
  178. 178. Etiology  Trauma- as in wearing hard contact lense.  Bacterial ulcer – Frequent in contact lens users, Pseudomonas most common  Viral – Herpes (HSV) is a frequent etiology  Autoimmune, Syphilis, Fungal, ameobic, and many other types Prepared By: Getenet D. (BSc, MSc in AHN) 213
  179. 179. BACTERIIAL KERATIITIIS  COMMON PATHOGENS:  Neisseria gonorrhoeae  Corynebacterium diphtheriae  Listeria sp.  Haemophilus sp.  OTHER PAHTOGENS:  Produce keratitis only after loss of corneal epithelial integrity as in contact lens wear:  Pseudomonas aeruginosa 214
  180. 180. Clinical manifestation of keratitis  Localized pain  Sensation of foriegn body  Discomfortness - increased by blinking  Photophobia  Blurred vision  Tearing  Purulent discharge Prepared By: Getenet D. (BSc, MSc in AHN) 215
  181. 181. CLINICAL FEATURES:  Certain bacteria produce characteristic corneal response. 1- Staph. aureus and Strep. pneumoniae:  Oval, yellow-white, densely opaque stromal suppuration  clear cornea  Pseudomonas:  Mucopurulent exudate,  liquefactive necrosis  ground-glass adjacent stroma 216
  182. 182. KERATITIS ..... 217
  183. 183. Pseudomonas keratitis with hypopyon218
  184. 184. Advanced pseudomonas keratitis 219
  185. 185. Clinical manifestation for Fungal keratitis220 Fungal keratitis with hypopyon filamentous fungal keratitis
  186. 186. Complication Corneal opacity Panophthalmitis Prepared By: Getenet D. (BSc, MSc in AHN) 221
  187. 187. Medical management  Topical anesthetics  Tetracain Hydrochloride 0.5% solution 1-2drop for deeper anesthesia.  Prparacaine 0.5% solution 1-2drop q90 sec 3doses.  Benoxinate Hydrochloride 0.4% 1-2drop before Tonometry.  Mydriatics  Atropine sulfate 0.5-3% 1 drop solation Prepared By: Getenet D. (BSc, MSc in AHN) 222
  188. 188. Cont…. Antiboitics  Sulfacetamide sodium 10-20% solution Q 30 min or oint 3-4 times  Systematic antibotics in case of syphilis – Benzatine pen. 2.4 miu Im stat  Antiinflammation ointment - cortisone oint  Corneal transplantation for corneal scared tissue ( Keratoplasty ) Prepared By: Getenet D. (BSc, MSc in AHN) 223
  189. 189. Nursing Interventions  Frequent administration of antibiotic eye drops  Ophthalmic hygiene using aseptic principles  Removal of exudate that harbors of miccroobes  Temporarily removal of contract lense wearing  Patient education Prepared By: Getenet D. (BSc, MSc in AHN) 224
  190. 190. PTERYGIUM  A triangular fibrovascular connective tissue ( fold of conjuctiva ) over growth with extenstion to the cornea from the inner to the outer part of bulbar conjuctiva on the cornea , the apex is always to the cornea.  Etiology:- The exact cause is unknown,but it is thought to be an irritative and degenetative phenomenon by ultroviolent light and dust exposure Prepared By: Getenet D. (BSc, MSc in AHN) 225
  191. 191. Clinical manifestation  Visible tissue growth on the conjuctiva  Diagnostic procedures: P/E & clinical manifestation  Medical managment  Surgical removal. Prepared By: Getenet D. (BSc, MSc in AHN) 226
  192. 192. UVEITIS  Is the inflammation of all structures of the uveal truct such as iris, cilairy body and chorid.  Because the uvea contains many of the blood vessels that nuorish the eye and because it borders many other parts of the eye, inflammation of this layer may threaten vision. Prepared By: Getenet D. (BSc, MSc in AHN) 227
  193. 193. UVEITIS 228
  194. 194. Etiology  Allergens  Infections by microorganisms  Chemical  Trauma  Systemic disease such as diabetes, ulcerative colitis , AIDS, herpes zoster  Toxoplasmosis, TB Prepared By: Getenet D. (BSc, MSc in AHN) 229
  195. 195. Clinical manifestation  Pain  Photophobia  Blurning vision  Red eyes  Floating spots in the field of vision  Diagnosis  S/S  Slit light examination Prepared By: Getenet D. (BSc, MSc in AHN) 230
  196. 196. Clinical manifestation 231
  197. 197. Medical management  Oral or topical corticosteroids  Mydriatc (dilating) eye drops such as atropine  Antibiotic eye drops  Antipain  Sun glasses reduce the discomfort of photophobia Prepared By: Getenet D. (BSc, MSc in AHN) 232
  198. 198. Nursing management  Instruct the client on the medication regimen & drug administration  Stress complian since failure to follow may result is serious complication  Follow – up while the disorder is being treated  Complication  Glaucoma  Cataracts  Retinal detachment can occer 2o to uveitis Prepared By: Getenet D. (BSc, MSc in AHN) 233
  199. 199. Episcleritis  Inflammation of episcleral tissues.  Treatment: Usually self limiting and need no treatment  Steroids help but can lead to dependence 234
  200. 200. Causes  There is no apparent cause, but it can be associated with an underlying systemic inflammatory or rheumatologic condition such as rosacea, lupus or rheumatoid arthritis.  Typical symptoms include generalized or local redness of the eyes that may be accompanied by mild soreness or discomfort but no visual problems. 235
  201. 201. Diagnosis  Diagnosis of episcleritis is made clinically.  A work-up may be needed in some cases to uncover a possible underlying medical condition.  Treatment  Episcleritis generally clears without treatment, but topical or oral anti-inflammatory agents maybe prescribed to relieve pain or in chronic/recurrent cases. 236
  202. 202. CATARACT  Cataract is a condition in which the lens of the eye becomes apaque thus reducing the amount of light that reaches retina.  The lens of one or both eyes may be affected.  Etiology  Congenital  Injury to the lens  Secondary to other eye disorders or aging process  Patients with diabetes
  203. 203. Epidemiology 1. Cataracts remain the leading cause of blindness. 2. Age-related cataract is responsible for 48% of world blindness, which represents about 18 million people 3. Cataracts are also an important cause of low vision in both developed and developing countries.
  204. 204. Classification of lens cataracts The most common are;- A. Senile B. Traumatic C. Congenital and D. Complication
  205. 205. I-Senile cataracts  Occurs in old age.  The client sees better in dimlight and also may see objects double or unclear.  There are 3 stages in senile cataract  First stage ( Immature stage ) opacity at the center / in periphery  Second stage ( mature stage ) lens becomes opaque and appear bluish white.  Third stage ( Hypermature ) The fluid of lens is less and the lens shrinks
  206. 206. II- Traumatic cataracts  Occurs after a perforating wound lens capsule or protrusion of the eye ball with out perforation.  The sub of the lens may protrude via the wound capsule and in the anterior chamber.
  207. 207. III- Complicated cataracts  It is due to local eye disease as perforated corneal ulccer iridocyclitis, choroiditis, glaucoma etc.  Opacity begins in the posterior capsule then progress until it involves the whole lens
  208. 208. IV- Congenital cataract  A lens opacity that occurs before or soon after birth. Causes : - Exposure to radiation in the first trimester - Drugs like corticosteroids - Intrauterine infections: TORCHES - Genetic and Hereditary problems. Morphologically it can be polar, nuclear or cortical, can be diffuse of localized opacity.
  209. 209. Clinical manifestation  Eariest symptom is seeing halo around light  Decreased visual acuity due to apacity  Difficulity of readinng  Changes in colour vision  Glaring of objects in bright light  On inspetion- a white or grey spot is visible behind the pupil
  210. 210. Subcapsular cataract Anterior Posterior
  211. 211. Cortical cataract
  212. 212. Diagnostic procedure  Ophthalmoscpic examination  Slit lamp Examination  Tonometry to determine IOP  Complication  Blindness
  213. 213. Management  Treatment the causes only  No medical treatment for cataracts it is treated surgical .  Surgical removal of the lens when clients describe their vision as unsatisfactory. The lens may be removed by  Removal of the lens within its capasule (Intracapsular Extraction )  Removal of lens leaving the posterior portion of its capsucle in position ( Extracapsular examination )
  214. 214. Cont….  Using ultrasound to break the lens in to minute particles that are then remove by aspiration throught a small incision ( Phacoemulification )  Vision may be restored after surgery by three methods  Contact Glasses  Wearing a contact lens  Insertion of intraocular lens
  215. 215. Nursing Management  Providing pre and post operative care of the client  Restrict patient from lying on the operative side, bending and lifting  Give antiemetic if nausea occur  Eyes are patched and dilating drugs are given to keep the client from squinting
  216. 216. GLAUCOMA  Is an abnormal condition of elevated pressure with in an eye due to an imbalance between the production and drainage aquoeous fluid.  When the drainage to channel of schlemm is obstructed , the anterior chamber become congested with fluid and intraoccurlar pressure ( IOP) rise if this pressure increases ,it leads to optic nerve atrophy and blidness. ,the normal IOP is 10- 21 mmHg
  217. 217. Etiology  Congenital at brith from family  Secondory glauloma- complication from  Occular trauma  Ophthalmic infection  Cataract surgery  Systemic or topical cotricostroids for long time
  218. 218. Classification of glaucoma based on cause 1. Primary glaucoma - due to unknown cause ,usually bilateral & hereditary 2. Secondary glaucoma - due to local disease in the eye. such as in the corneal - leucoma adherent  In the anterior chamber – hypopyon, lens disslocation  In the rirs- iritis iridocyclitis . It also classified as follows
  219. 219. Cont….  open -angle glaucoma - It is whether 1o or 2o  Angle - closure glaucoma : either it is primary acute /chronic or secondary  Combined -mechanism glaucoma  Developmental/ congenital glaucoma
  220. 220. Pathophysiology  Glaucoma can occur at any age but is most common after age of 35.  It is more prevalent among people who have a family history of the disorder.  Open angle glaucoma occur when structures in the drainage system( i.e trabecular meshwork and schlemm canal ) undergo degeneration and the exist channel for aqueous fluid become blocked.
  221. 221. Cont…..  Angle closure glaucoma occurs among people who have an anatomically narrow angle, at the juction where the iris meet the cornia, this structure deviation makes them vulnerable to angle closure when near by eye strucures protrude in to the anterior chamber and occlude draingle for aqueous fluid.
  222. 222. 264
  223. 223. Glaucoma
  224. 224. Diagnostic procedures  Tonometry - An instrument which measures IOP to identify glaucoma. normal IOP is <21 mmHg for 1 minute  Family history
  225. 225. Medical managment  Miotics such as  Carbachol 0.75-3% solution 1drop instilled in each eye which increases out flow  Pilocarpine 1-2 % solution in each eye q6-8 hr( which increases out flow )  Timolol maleate 0.25 - 0.5 % solution 1drop in each BlD reduce production
  226. 226. Cont….  Aqueous fluid reducers  Aectazalamide -250mg po oid  methezolamide 50- 100 mg po3xld .  Eserine sulfate 0.25% ointment3-4/d (increase out flow)  Mannitol IV in acute glaucoma  Which increase osmolarity of the plasma.1.5-2gm/kg 20% solution over 30-60min.  Analgestics -to reduced pain
  227. 227. Surgical managment It may be required when medication therapy is poorly in lowering IOP.  Laser surgery for glaucoma or surgical iridectomy ,laser trobeculo plasty  Laser traeculoplasty.
  228. 228. Nursing managment  Proving pre and post operative care  Keep water out of the eye  Instill antibiotic drops for 5 days .  Discontiue Corticostroids  Do not administer mydiratic drugs such as Atropine  Administer medication  Avoid vigorous activity and movement such as lifting ,strainig & bending for 1week.
  229. 229. Disorders of the nose and nasal cavity  Epistaxis Bleeding from inside the nose, either anterior nasal or posterior nasal.  Epi : from above  Staxis : drop by drop drip of fluid. Epistaxis is a sign, NOT a disease  It should never be treated as a harmless event. 272
  230. 230. Anatomical considerations  Nasal cavity: mucosa and turbinates are very vascular  Receives blood supply from branches of both internal and external carotid arteries.  Network of arteries : Kiesselbach’s plexus, woodruff’s plexus 273
  231. 231. 274
  232. 232. Epistaxis…….  Little’s area  Situated over the anteroinferior part of nasal septum, just above the vestibule  Caudal part of the nasal septum which has a rich submucosal arterial network(Kiesselbach’s plexus) by septal branches of anterior ethmoidal  sphenopalatine  superior labial  greater palatine 275
  233. 233. Epistaxis……. 276 • Little’s area is situated over the anteroinferior part of the nasal septum • Prone for drying (effect of inspired air ) and microtrauma by nose picking • Commonest site for epistaxis in children
  234. 234. Epistaxis…….  Retrocolumella vein  This vein runs vertically downwards behind the columella.  It crosses the floor of nose & joins venous plexus on the lateral wall of nose.  Common site of venous bleeding in young people 277
  235. 235. Epistaxis…….  Woodruff’s Area Vascular area situated over the posterior end of inferior turbinate  Sphenopalatine artery anastomoses with posterior pharyngeal artery  Posterior epistaxis occur 278
  236. 236. Epistaxis…….  Sites of epistaxis  Little’s Area (90%)  Above the level of middle turbinate  Below the level of middle turbinate  Posterior part of nasal cavity  Diffuse. ie : septum & lateral wall  Nasopharynx 279
  237. 237. Epistaxis……. 280
  238. 238. 281
  239. 239. Local causes of epistaxis……. I) congenital: hemangioma II) Infections :  Viral : Influenza, measles  Bacterial : (non-specific)- acute/ chronic rhinitis / sinusitis, artophic rhinitis (specific)-diphtheria, TB, syphilis, other  granulomas  Fungal : rhinosporidiosis, fungal  sinusitis  Parasites : maggots 282
  240. 240. Local causes of epistaxis…….  III) Trauma IV) Neoplastic : Benign : hemangioma V) Miscellaneous :  Deviated nasal septum, 283
  241. 241. Systemic causes of epistaxis…….  CVS  Hypertension  Atherosclerosis  Mitral stenosis  Pregnancy (HTN & hormonal)  Liver Cirrhosis  Vitamin K deficiency  Deficiency of factor ii, vii,ix and x 284
  242. 242. Systemic causes of Epistaxis…….  Hematological  Aplastic anaemia  Thrombocytopenia  Leukemia  Lymphoma  Agranulocytosis  Scurvy  Vitamin K deficiency 285
  243. 243. Systemic causes of Epistaxis…….  Renal disease  Chronic nephritis  Drugs  Salicylates  Analgesics  Anticoagulant  Mediastinal compression  Tumours of mediastinum raised venous pressure in the nose 286
  244. 244. Causes of Epistaxis…….  Acute general infection  Influenza  Measles  Chicken pox  Whooping cough  Vicarious menstruation  However generally the cause of epistaxis is idiopathic 287
  245. 245. How you can avoid nosebleeds:  Avoid vigorous nose-blowing and stuffing tissues  Discourage children from nose-picking, and keep their fingernails trimmed.  Use over-the-counter nasal saline sprays and topical nasal moisturizing gels.  Use a home humidifier to keep moisture in the air during winter months.  quitting tobacco smoke dries out the nasal mucosa and increases the risk for nosebleeds. 288
  246. 246. Steps to stop a nosebleed:  Gently blow your nose to clear any blood clots.  spray nasal decongestant 2–3 times into nose  Apply pinching pressure on nostrils for 5–10 minutes. Lean slightly forward  If the bleeding stops, avoid nose-blowing or strenuous activity for the remainder of the day,  Seek medical attention if the bleeding doesn’t stop after 30 minutes, if there is trouble breathing, have suffered severe nasal trauma or lost a significant amount of blood and feel weak.  Cold compress 289
  247. 247. Management of Epistaxis…….  cauterization, anterior packing, or both. Those with severe or recalcitrant bleeding may need posterior packing, arterial ligation, or embolization.  Pharmacotherapy plays only a supportive role in treating the patient with epistaxis. 290
  248. 248. Rhinitis 291 • Inflammation of the nasal mucosa. • Rhinitis is a group of disorders characterized by inflammation and irritation of the mucous membranes of the nose.
  249. 249. Classification rhinitis  A. Acute rhinitis  a. Non-allergic:  1. Infective:  Viral: Common cold (coryza or flu), rhinitis associated with influenza or other viral infections.  Bacterial: Usually occurs as a secondary infection following unresolved viral rhinitis. 2. Non-infective:  Vasomotor rhinitis.  Rhinitis due to chemical irritation 292
  250. 250. Classification rhinitis…… B. Allergic e.g. Hay fever. 293
  251. 251. B. Chronic rhinitis: a. Non-allergic: 1. Non-specific:  Chronic catarrhal rhinitis.  Chronic hypertrophic rhinitis.  Chronic atrophic rhinitis.  Rhinitis medicamentosa (drug-induced rhinitis). 2.Specific:  Scleroma.  Rare types: Syphilis, tuberculosis, lupus and, leprosy. b. Allergic: Perennial allergic rhinitis. 294
  252. 252. Causes Rhinitis  Rhinovirus.  Droplet infection.  reaction of the body’s immune system to an environmental trigger. The most common  environmental triggers include dust, molds, pollens, grasses, trees, and animals.  Both seasonal allergies and year-round allergies can cause allergic rhinitis. 295
  253. 253. Causes Rhinitis …..  nasal decongestants; foreign body.  allergens such as foods (eg, peanuts, walnuts, brazil nuts, wheat, shellfish, soy, cow’s milk, and eggs)  medications (eg, penicillin, sulfa medications, aspirin  The most common cause of nonallergic rhinitis is the common cold.  antihypertensive agents, such as angiotensin- converting enzyme (ACE) inhibitors and betablockers; “statins,” antidepressants; aspirin, antianxiety medications. 296
  254. 254. Clinical manifestation 1. Stage of invasion (few hours): Sneezing, burning sensation in the nasopharynx, nasal obstruction, and headache, Pruritis of nose 2. Stage of secretion (few days): Low grade fever, malaise, arthralgia, nasal obstruction, and profuse watery rhinorrhea. 3. Stage of resolution: Resolution within 5-7 days is the natural course of an uncomplicated disease. Symptoms lasting beyond 7 days, or worsening instead of improving suggest that secondary bacterial infection is being established. 297
  255. 255. Management 1. Supportive treatment: bed rest, analgesics, nasal decongestants (local i.e. drops and systemic), and occasionally steam inhalations. 2. Antibiotics should be reserved for treatment of secondary bacterial infections. 298
  256. 256. Management ……  Symptom relief:antihistamine/decongestant medications  Brompheniramine/pseudoephedrine (Dimetapp)  Cromolyn (NasalCrom), a mast cell stabilizer inhibits the release of histamine and other chemicals,  Use of saline nasal spray can act as a mild decongestant and can liquefy mucus to prevent crusting.  Two inhalations of intranasal ipratropium (Atrovent) can be administered in each nostril two to three times per day for symptomatic relief of rhinorrhea. 299
  257. 257. Management ……  intranasal corticosteroids may be used for severe congestion, and ophthalmic agents (cromolynophthalmic solution 4%) may be used to relieve irritation, itching, and redness of the eyes.  Newer allergy treatments include leukotriene modifiers (eg, montelukast [Singulair], zafirlukast[Accolate], zileuton [Zyflo]) 300
  258. 258. According to Ethiopian drug guiod line 2014 First line Chlorpheniramine, 4mg P.O., TID Alternative Cetrizine hydrochloride, 10mg P.O., daily PLUS Xylometazoline, adults; 2-3 drops of 1% solution 3-4 times a day 301
  259. 259. Sinusitis  Infection and inflammation of paranasal sinuses  TYPES  Acute – last less than 4 weeks  Chronic – more than a 3 months 302
  260. 260. Causes of sinusitis  Virus – Rhino virus, ECHO (enteric cyto pathogenic human organ) 28, Respiratory syncital virus  Bacteria – strepto. Pneumoniae, staph. pyogenes  Pollutants  Fungi  Respiratory infections  Nasal polyps  Fracture of sinus  Foreign bodies  Low immunity, smoking 303
  261. 261. CLINICAL FEATURES  Headache  Pain over maxillary antrum – suborbital region – it is aggravated by bending, walking or coughing  Facial pain or pressure  Runny nose  Sore throat, Loss of smell  Cough or congestion, Fever  Bad breath, Fatigue  Dental pain  Loss of vocal resonance 304
  262. 262. Chronic Sinusitis Symptoms  You may have these symptoms for 12 weeks or more:  A feeling of congestion or fullness in your face  A nasal obstruction or nasal blockage  Anosomia  Edema - sinus  Pus in the nasal cavity  Fever  Runny nose or discolored postnasal drainage  Cacosomia 305
  263. 263. DIAGNOSIS Sinusitis  H.C  PE  Blood test  Culture sensitivity test  X- ray  CT 306
  264. 264. Management of sinusitis  Prophylactic: good ventilation, proper humidity, vitamin diet, avoid flying and swimming, avoid smoking, treat cold  Medical: antibiotics – amoxicillin, local decongestants (ephedrine), steam inhalation, analgesics  Maxillary antral washout involves puncturing the sinus and flushing with saline to clear the mucus  Balloon sinuplasty: It uses a balloon over a wire catheter to dilate sinus passageways. The balloon is inflated with the goal of dilating the sinus openings, widening the walls of the sinus passageway and restoring normal drainage. 307
  265. 265. 308
  266. 266. 309
  267. 267. Nasal polyps …… 310
  268. 268. Nasal polyps …… 311
  269. 269. Etiology Nasal polyps ……  Inflammatory conditions of nasal mucosa  Rhinosinusitis  Disorders of ciliary motility  Kartagener’s syndrome  Abnormal composition of nasal mucus  Cystic fibrosis 312
  270. 270. 314
  271. 271. 316
  272. 272. Diagnosis of nasal polyps  Clinical examination  CT scan of paranasal sinuses  exclude neoplasia  plan surgery  Histological examination  especially in people >40 years 318
  273. 273. Treatment of nasal polyps  CONSERVATIVE  Antihistaminics & control of allergy may revert early polypoidal changes with oedematous mucosa to normal  Short course steroids in people who cannot tolerate antihistaminics or with asthma 319
  274. 274. SURGICAL management  Polypectomy  Intranasal ethmoidectomy  Extranasal ethmoidectomy  Transantral ethmoidectomy  Endoscopic sinus surgery 320
  275. 275. References  American Cancer Society. (2014). Cancer facts and figures. Atlanta: Author.  Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 11th edition.  Brunner & Suddarth’s Textbook of Medical-surgical Nursing. 2010, 12th Ed.  Medical-Surgical Nursing: Patient-Centered Collaborative Care, 2013, 7th edition
  276. 276. References  Lewis Direkson ,Heitkemper Bucher,medical surgical nursing assessment,9th edition  Sharon L. Lewis, Shannon Ruff Dirksen, Et Al .Medical- surgical Nursing: Assessment And Management Of Clinical Problems, 2014, Elsevier Inc. Ninth Edition  Wolters Kluwer,Incrideble medical surgical nursing practice,2012  Diseases of Ear, Nose and Throat & Head and Neck Surgery, 6th Edition, PL Dhingra, Elsevier
  277. 277. References  Kumar and klark’s.clinical medicine, 2009, Elsevier Limited. 7th edition.  Porth’s pathophysiology. Concepts of Altered Health States, 2014 ,9th edition.  Patricia Gonce Morton, critical care nursing A holistic approach, 2013, 10th edition.
  278. 278. GOD BLESS YOU !!

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