MEDICINE AND HEALTH SCIENCE COLLEGE

NURSING DEPARTMENT

Medical Surgical Nursing I

Eye, Ear, Nose and Throat assessment and disorders

FOR 2nd NURSING STUDENTS

By: Haimanot. A (Bsc, Msc)

6/27/2022 PREPARED BY:H.A 1
Eye assessment and disorders
Learning objectives

At the end of this unit students will

 Describe brief anatomy and physiology of eye

 Able to perform eye assessment

 Describe common eye disorders in terms of

definition, etiology, C/M and diagnosis

 Manage patients with common eye disorders

ANATOMY AND PHYSIOLOGY OF THE EYE
ANATOMY AND PHYSIOLOGY…
 ANATOMY AND PHYSIOLOGY…
• The eye is the sensory organ of vision.

• It is well protected by the bony orbital cavity

surrounded with a cushion of fat.

• The eyelids further protect the eye from injury,

strong light and dust.

• The eyelashes curve outward filtering out dust

and dirt.
 ANATOMY AND PHYSIOLOGY…
The protection of the eye

A- Eye lid: It has the following parts

I. Skin-has three important features

 Thinnest-more elastic and mobile

 Little or no subcutaneous fat under the skin

makes it a good source of skin graft

 Extremely good blood supply that is why

wound heal well and quickly.
ii. Muscles
Orbicularis oculi muscle
• Important for closure of the eye lid
• Innervated by facial(cranial 7th) nerve
• Disorder is facial palsy difficult to close the eye
Levator palpebral
• Elevator of the eye lid
• Innervated by oculomotor nerve(CN 3rd)
• Disorder pytosis
Muscles…

Muller’s muscle

• Help to retract the upper eye lid

• Innervated by cervical sympathetic nerve

iii. Tarsal plates

- Are composed of dense fibrous tissue

- Keep the eye lids rigid and firm

-Contain meibomian glands-disorder is chalazion

Cont’d
B. Conjunctiva
• A thin mucous membrane lining the inner surface of
the eye lid and outer surface of the eye ball.

Parts Conjunctiva
I. Tarsal/pulpural Conjunctiva
- The part lining in the inner aspect of the eye lid.
- Firmly attached to the underlying tarsal plate.
- Which is highly pink- easily anemic identified
II. Bulbar Conjunctiva
- The part lining the eye ball.
- Loosely attached to the underlying sclera.
III. Fornix
-Part in which the tarsal and bulbar
conjunctivas are continuous.
C. Glands
 Glands of zeis and glands of Moll

 Both are modified sweat glands found on the

anterior margin of the eyelid

 Glands of zeis opens into the hair follicles at

the base of the eyelashes

 Glands of moll opens in a row near the base

of the eyelashes.
• The posterior lid margin is in close contact with
the globe

• Meibomian glands: Posteriorly located small

orifices of modified sebaceous glands
 Cont’d
D. Lacrimal apparatus
It consists of:
• Lacrimal gland
• Punctum
• Canaliculi
• Nasolacrimal sac
• Nasolacrimal duct
Cont’d
E. The globe/eye ball
 The globe is a visual organ which weighs 7.5gm
and an average diameter of 24mm.

Has three layers:

1. Outer layer/ fibrous/- sclera and cornea.

2. Middle layer/vascular/- iris, ciliary body,choroids

3. Inner layer/neural/- sensory retina and pigment

epithelium.
 Cont’d

 The globe/eye ball has three ocular

chambers
1. Anterior Chamber
2. Posterior Chamber
3. Vitreous Space
 Function of the parts of the eye
Parts Functions
Sclera Protects and supports the eye ball
Cornea Refracts light rays
Pupil Admits light
Choriod Absorbs stray light
Ciliary body Holds lens in place, Accommodation
Iris Regulates light entrance
Retina Contains sensory receptors for sight
Rods Makes white and black vision possible
Cones Makes color vision possible
Fovea centeralis Makes acute vision possible
Lens Refracts and focuses light rays
Humors Transmit light rays and support eye ball
Optic nerve Transmits impulse to brain
 Eye assessment
– History taking

– Testing vision

– Examining the eye

 History taking…

Current History

Impaired vision , pain , redness of the

eye , or double vision

Duration of illness

Associated systemic symptoms

 Ophthalmic History

 Trauma , surgery , or eye inflammation.

 Family history

 Refractive errors , cataract , glaucoma, retinal

detachment , retinal dystrophy , MD ,…

 Medical history

– DM , HTN , infectious diseases , rheumatic

disorders , skin diseases and surgery.
 Eye examination
 External examination

 Ocular motility  Slit-lamp

 Visual acuity  Visual field

 Refraction  Intraocular pressure

 Pupil function  Retinal examination

 Ophthalmoscope
 External examination

 Position and Alignment of the Eyes

 Inspect the eyebrows
 Inspection of the eyelids, Lacrimal
Apparatus.
 Palpation of the orbital rim.
 Inspect the conjunctiva and sclera…
Position and Alignment of the Eyes
• Stand in front of the patient and survey the eyes
for position and alignment with each other.
• If one or both eyes seem to protrude, assess
them from above.
• Inward or outward deviation of the eyes;
abnormal protrusion indicate Graves‘ disease or
ocular tumors.
 Assess Eyebrows

• Inspect the eyebrows

• Noting their quantity

and distribution

• Any scaliness of the

underlying skin
 Assess eyelids
• Normally, the upper 2mm of the iris is covered by
the upper lid
• When the eyes are fully open the upper eyelid
cover only the upper 3rd of the cornea
• Note the position of eye lids in relation to eyeballs
• Inspect any edema of the lids and lesions, color
of the lids, condition and direction of eyelashes
• Inspect adequacy with which the eye lids closed
 Eye lid Abnormalities
• Example: Blepharitis: An inflammation of the eye

lids along the lid margins

• Ectropion: When the margin of the lower lid is

turned outward, exposing the palpebral

conjunctiva

• Entropion: An inward turning of the lid-margin

Eye lid Abnormalities…
 Assess the Lacrimal Apparatus
• Briefly inspect the regions of the lacrimal gland
and lacrimal sac for swelling

• Look for excessive tearing or dryness of eyes

• Excessive tearing may be due to increased

production or impaired drainage of tears
 Assess the Lacrimal Apparatus…
• No swelling or redness should appear over areas of
the lacrimal gland.
• The puncta is visible without swelling or redness and
is turned slightly toward the eye.
• Use one finger and palpate just inside the lower
orbital rim
• No drainage should be noted from the puncta when
palpating the nasolacrimal duct.
Assess the Lacrimal Apparatus…
 Assess Conjunctiva and Sclera
• The normal sclera is opaque and white
• While examining, ask the patient to lookup as
you depress both lower lids with your thumbs,
exposing the sclera and conjunctiva
• Inspect for color, and not the vascular pattern
against the white sclera backgrounds
• Look for any nodules or swelling, discharge,
lesions
Conjunctiva and sclera…
 Assess Cornea, Iris and Lens
• Shine a light from the side across the cornea, and
check for smoothness and clarity
• This oblique view highlights any abnormal
irregularities in the corneal surface
• There should be no opacities (cloudiness) in the
cornea, or in the lens behind the pupil
• The iris normally appears flat, with a round regular
shape and even coloration
 Corneal light reflex
• Assess the parallel alignment of the eye axes
by shining a light towards the person‘s eyes

• Direct the person to stare straight ahead as

you hold the light about 30cm(12inches) away

• Note reflection of the light on the corneas; it

should be exactly the same spot on each eye
 Corneal light reflex…
• Abnormal- asymmetry of the light reflex indicates
deviation in alignment due to eye muscle
weakness or paralysis
 Test for the corneal Reflex
• The corneal reflex is controlled by cranial nerve V
(trigeminal) and nerve VII (facial).

• Take a sterile cotton ball and twist it into a very

thin strand. Using a lateral approach, gently touch
the cornea on the outer aspect of each eye.

• Confirm both eyes blink when either cornea is

touched
 Ocular motility test
 Used to test the extra ocular muscles

 The extra occular muscles help the eye ball to

move through all fields of gaze

 The movement of each eye is controlled by the

coordinated action of the six-muscles, the four
rectus and the two oblique muscles
• The four rectus muscles are

– Superior rectus, innervated by CN III

– Inferior rectus, innervated by cranial nerve III

– Medial rectus, innervated by cranial nerve III

– Lateral rectus, innervated by cranial nerve VI

• The two oblique muscles are

– Inferior oblique, innervated by CN III

– Superior oblique, innervated by CN IV

 Ocular motility test…
 Test for the nine cardinal directions of gaze
Ask the person to hold the head steady and to
follow the movement of your finger or pen only
with the eyes

Hold the object back about 12inches and move it

to each of the six positions, hold it momentarily,
then back to center. Progress clockwise
 Ocular motility test…
 Note for; speed, smoothness, range and
symmetry and unsteadiness of fixation.

A normal response is parallel tracking of the

object with both eyes

Failure to follow in certain direction indicates

weakness of an extra ocular muscle or CN
 Ocular motility test…
• For example if there is a third nerve palsy, the
condition called ptosis and abnormal eye
movement
• In Paresis of CN IV, the eye cannot look down
• In paresis of CN VI, the eye cannot look
laterally
• In paresis of CN III, eye points down and
outwards
 Ocular motility test…
• Nystagmus—an oscillating (shaking) movement
of the eye—may be associated with

– an inner ear disorder,

– multiple sclerosis,

– brain lesions, or

– narcotics use.
Ocular motility test…
 Perform cover test
• As you cover the eye, observe the
uncovered eye for movement.

• Now remove the opaque card and observe

the previously covered eye for any
movement
Perform cover test…
 Visual acuity
• VA: Is the eye's ability to detect fine details
and shapes

• A quantitative measure of the eye's ability

to see in-focus image at certain distance

• Is an important part of the eye examination

 Visual acuity…
• Visual acuity is measured using Snellen's chart

• Snellen's chart is a series of letters of varying

sizes and used to test distance vision

• Visual acuity is recorder according to the ratio

d/D or by using numbers, where

 Visual acuity…
– d: distance at which the letter are read by pt‘s

– D: distance at which the letters can be read

by normal eye

• The top letters of the Snellen's chart is visible to

the normal eye at 60 m and the subsequent
lines at 36, 24, 18, 12, 9, 6 and 5m respectively
 Visual acuity…

• Normal visual acuity = 20/20 or 6/6 vision

• Visual acuity of 20/200 or worse is

considered legally blind.
Snellen's chart
 Visual acuity test
• Light the chart well if possible

• Position the patient 20 feet or 6 m from the chart

• Patient who use glasses other than reading

glasses should wear

• Test both eye separately

• Ask the patient to cover one eye with card and

ask to read the letters
 Visual acuity test…
• A normal eye can read down at least the seven
line that is 6/6 or 20/20

• A patient who cannot read the largest letter

should be positioned closer to the chart with the
distance from it noted or the chart moved toward
the patient
• If the patient can not identify the largest letter
at 6m, use another methods to test VA

– Counting fingers; (CF)

– Hand movement

– Light perception

• Counting fingers; (CF): Hold a random

number of fingers and ask the patient to
count the numbers he/she sees.
 Visual acuity test…
• E.g. if the patient identifies the numbers of
fingers at 3 feet, then the examiner would
record the visual acuity as CF/3.

• If the patient is unable to count fingers, use

another method, i.e. Hand movement.

– Raise your hand up and down & move it side

to side and ask the patient in which direction
the hand is moving.
 Abnormality
• Vision of 20/200 means that at 20 feet the
patient can read that a person with normal
vision could read at 200 feet.

• The larger the second number, the worse

the vision.
 Refraction
• It is the determination of the ideal
correction of refractive error.

• Refractive error is an optical abnormality in

which the shape of the eye fails to bring
light into sharp focus on the retina,
resulting in blurred or distorted vision.
 Pupil function
• Inspect for size, shape & symmetry of the pupils

• Inspecting the pupils for PERRLA

– Pupils, Equal, Round, Reactive to Light &

Accommodation.

• Test the pupillary reaction to light

 Pupil function…
• Examples of abnormality:

– Miosis: refers to constriction of the pupils

(usually less than 3cm)

– Mydriasis: refers to dilation of the pupils

(usually greater than 5cm)

To test pupillary reaction
• First, dark the room and use a bright light (of the
instrument)
• Second, ask the patient to look in to the distance, and
shine a bright light obliquely in to each pupil in turn
 The pupillary reaction may be;
• Direct reaction: In which the pupillary constriction is
the same eye or
• Consensual: Pupilary constriction in opposite eye
 Accommodation test
• Ask the person to focus on a distance object,
then on near objects

• Instruct him to look alternately

• Normally the pupils should converge and

constricts symmetrically as the eyes focus on a
near objects
 Visual field test (confrontation)
• Used to assess the extent of the peripheral field.

To test visual field by confrontation

• Occlude one eye while fixated on the examiner's

eye with the non-occluded eye.

• Ask the patient to look with both eyes into your

eyes.
 Visual Fields by Confrontation…
• While you return the patient‘s gaze, place your
hands about 2 feet apart, lateral to the patient‘s
ears.

• Instruct the patient to point to your fingers as

soon as they are seen.

• Normally, a person sees both sets of fingers at

the same time. If so, fields are usually normal.
Visual field test…
 Ophthalmoscope examination
• This is an instrument that visualizes the
posterior structures of the retinal surface.
• To examine the patient by using ophthalmoscope:

– First, darken the room, then switch on the

ophthalmoscope light, and adjust it to the large
round beam of white light
– Second, turn the lens disc to "0" diopters (as
lens that neither converge nor diverges the
light rays).
– Diopter is a unit that measures the power of a
lens to converge or diverge light
Ophthalmoscope examination…
– Third, keep your index finger on the lens disc

so that you can focus the ophthalmoscope

– Use your right hand and right eye for pt's right

eye, left hand and left eye for the pt‘s left eye

– Inspect the optic disc for color and size ,

which is a yellowish orange to creamy pink

oval or round structure

Ophthalmoscope examination…
Ophthalmoscope examination…
Ophthalmoscope examination…
– Inspect the retina and identify the arteries and
veins

– Inspect the fovea and surrounding macula

• For example; MD of aging is an important

cause of poor central vision in elderly

• It takes many forms, including

hemorrhages, exudates, and cysts
Ophthalmoscope examination…
 Slit-lamp examination
 Table mounted microscope
with a special adjustable
illumination source
attached.
 Allow close inspection of
the anterior eye structures
and ocular adnexa.
 Intraocular pressure (IOP)

 (IOP) measured by Tonometry devices.

 The normal range is 10-21 mmHg.

 Retinal examination
 Fundus examination is an important part of
the general eye examination.
 Fully dilated pupil prior to ophthalmoscopy
examination is needed.
 A red reflex can be seen.
Amsler grid can be used for detection of
macular degeneration
Major symptoms of eye disease are:

– Disturbance of vision

– Discomfort or pain in the eye

– Eye discharge
 Eye disorders
– Refractive errors

– Disease of the eye lid

– Disease of the conjunctiva

– Disease of the cornea

– Disease of the lacrimal glands

– Disease of the lens

– Intraocular pressure disorders

 Refractive error
• RE: The shape of the eye does not bend
light correctly, resulting in a blurred image

• An optical abnormality in which the shape of

the eye fails to bring light into sharp focus on
the retina
 Refractive errors
– Hyperopia

– Myopia

– Astigmatism

– Presbyopia
 Hyperopia (far sightedness)
• Mechanism

– * Object focuses behind the retina

* Able to see only far objects

• Etiology

– * Genetic link

– Often when the eyeball is too short or the lens

can not become round enough (which is flat)
• Symptoms and signs

– * Blurred near vision

* Squinting
* Eye rubbing
* Headaches

• Diagnosis

– * Visual acuity test

– * Ophthalmoscope
 Hyperopia (far sightedness)…

•Treatment
–* Convex lens
 Myopia (near sightedness)
• Mechanism

– * Object focuses in front of the retina

* Able to see only close objects

• Etiology

– * Genetic link

– Long eyeball or thickened lens

 Myopia (near sightedness)…

• Symptoms and signs

– *Blurred far vision

– Squinting

– Eye rubbing

– Headaches

– Diagnosis: Visual V/A test and Ophthalmoscope

Myopia (near sightedness)…
 Cont’d

• Treatment
– *Concave lens
 Astigmatism
• Mechanism

– No point of focus of the light rays on the retina

– * Object is partially clear & other blurred

– * Abnormal shaped cornea

(egg shape instead of spherical)
Etiology

– * Genetic link
 Astigmatism…
• Symptoms and signs

– * Blurred vision (partially clear & other blurred)

– * Squinting

– * Eye rubbing

– Headache
Astigmatism…
• Diagnosis

– * Snellen visual acuity test

* Opthalmoscope

• Treatment

– * Artificial lens transplant

* Radial keratotomy
 Presbyopia
• Mechanism

– * Rigidity of the lens (old age)

– * Result of the natural aging process of the

lens where it becomes harder & less elastic.

– *Results in the inability to focus up close

– Hardening of natural lens causes light to

focus behind the retina _ poor near vision
 Presbyopia…
– Common close vision disorder as you age

– Also called aging eye condition

– Accommodation will be ineffective and the

person fails to do near work like reading.

– There is no difficulty of distant vision.

 Presbyopia…
• Etiology

– * Genetic link

• Symptoms and signs

– *Blurred near vision, squinting, eye

rubbing, headaches
 Presbyopia…
• Diagnosis

– * Snellen visual acuity test

* Opthalmoscope

• Treatment

– * Convex lens

– Lens transplant
Disorders of the eye lid and eye lashes

• Hordeolum • Ectropion

• Chalazion • Trichiasis

• Blepharitis • Edema

• Entropion
 Disorders of the eye lid
• Hordeolum (stye)
– *Inflammation of the hair follicle of the eye lid

– Infection of eye lid glands of zeis or mall

– Can be Internal or external

• Etiology

– * Staphylococcal infection
* Usually associated with blepharitis
 Internal Hordeolum
• It is secondary infection of meibomian glands
caused by staphylococcus

• It can be quite severe because the pus cannot

drain away easily

• Occasionally, the inflammation may spread to

the orbit, causing cellulitis

• More common in adolescent and young adult

 Internal Hordeolum…
• Clinical features

– Eyelid lump/swelling, pain

– Patient feels something in the eye

– Eyelid erythema & tenderness

– Visible or palpable, well-defined

subcutaneous nodule within the eyelid tarsus

– Enlarged preauricular lymph nodes

Internal Hordeolum…
 Internal Hordeolum…

• Non-pharmacological treatment

– Warm compresses; applied for 10

minutes twice daily for 2 to 4 weeks

– Incision and drainage if there is abscess

– Incision and curettage if not disappear

with other treatments
 Internal Hordeolum…
• Pharmacological treatment
– Cloxacillin 50mg/kg PO in four divided
doses for 7 days OR
– Ampicillin 50 mg/Kg PO in four divided
doses for 7 days
– *If the above management fails and if there
is an abscess referral for surgical drainage
 External Hordeolum (Stye)
• Acute small staphylococcal abscess of an
eyelash follicle and glands of Zeis

• Common in children and young adult

• Solitary or multiple and occasionally minute

abscesses may involve the entire lid margin

• In severe cases a mild Preseptal cellulitis may

be present
 External Hordeolum (Stye)…

• Symptoms and signs

– Painful swelling of eyelid margin of short

duration

– Visible or palpable, tender well-defined

nodule in the eyelid margin

• Investigations and diagnosis: Clinical

External Hordeolum (Stye)…
External Hordeolum (Stye)…
 External Hordeolum (Stye)…
• Non-pharmacological treatment
– Warm compresses, applied for 10
minutes twice daily for 2 to 4 weeks
– Epilation of the involved eyelashes
– Incision and curettage if other
treatments failed
 External Hordeolum (Stye)…
• Pharmacological treatment
– No pharmacological treatment is needed
most cases
– Tetracycline 1% ointment, single strip apply
BID to TID for 2 to 4 weeks OR
– Erythromycin 0.5% ointment, single strip
apply BID to TID for 2 to 4 weeks
 Chalazion (meibomian cyst)
• A chronic inflammatory lesion caused by
blockage of meibomian gland orifices

• Mechanism

– *Collection and stagnation of sebaceous

secretions fluid at the posterior eye lid

• Etiology

– * Blockage of meibomian gland

 Cont’d
• Symptoms and signs

– * Pea size cyst

* Painless slow swelling of inner part of eye lid
* May become infected.

– Patients with acne or dermatitis are at risk.

– May occur on either upper or lower eye lid

Chalazion (meibomian cyst)…
 Chalazion (meibomian cyst)…
• Diagnosis: * Visual Examination

• Treatment

_*Warm compression, massage & expression

– * Small ones may disappear spontaneously

after a month or two

Antibiotics if there is bacterial infections

*Large ones usually need surgical removal

 Blepharitis
• * Inflammation of the margins of the eye lids

• Common causes of external ocular irritation

• It is usually chronic and bilateral

• May be associated with conjunctivitis

/Blepharoconjunctivitis/

• Permanent cure is unlikely but control of

symptoms is usually possible
 Blepharitis…
• Types:

I. Staphylococcal (Ulcerative) Blepharitis

II. Seborrhoeic Blepharitis

III. Demodectic Blepharitis

 Staphylococcal (Ulcerative) Blepharitis
• Most common causes of blepharitis
• Usually caused by staphylococcus aureus
• It is more common in younger individuals

• Symptoms and signs…

– Irritation and burning to peak in the morning
and improve as the day progresses
– Foreign body sensation, itching, and crusting,
particularly upon awakening
 Ulcerative Blepharitis…
• Symptoms and signs…
– Hard, brittle fibrinous scales

– Hard, matted crusts surrounding individual

eyelash on the anterior eyelid margin

– Ulceration of anterior eyelid margin

– White lashes & loss of eyelashes (madarosis)

– Trichiasis can be seen in severe cases

Ulcerative Blepharitis…
Ulcerative Blepharitis…
 Ulcerative Blepharitis…
• Non-pharmacological treatment
– Eyelid hygiene
– Surgical correction of trichiasis

• Topical treatment
– Dexamethasone eye drop, 1 drop QID, for 3
to 6 weeks, then taper every 5 to 7 days OR
– Oxytetracycline+ Polymyxin B+Hydrocortisone
suspension TID/4 weeks OR
 Ulcerative Blepharitis…
• Topical treatment…

– Neomycin + Polymyxin B Sulphate +

Dexamethasone suspension BID/ 4 Wks OR

– Tetracycline 1% ointment, apply single strip

BID to TID, for 2 to 4 weeks OR

– Erythromycin 0.5% ointment, apply single

strip BID to TID, for 2 to 4 weeks
 Ulcerative Blepharitis…
• Systemic treatment (for recurrent cases)

– Doxycycline 100mg PO BID for 1 week, then

daily for at least 6 weeks OR

– Tetracycline 250mg PO QID for 6 weeks, then

tapered slowly OR

– Azithromycin 500 mg PO daily for 3 days, with

1-week 3 cycles
 Seborrhoeic Blepharitis
• The inflammation is located predominantly at the
anterior eyelid margin

• Meibomitis is a form of seborrheic blepharitis in

the posterior eyelid margin

• In one third patients there is aqueous tear

deficiency (dry eye)

• It may occur with staphylococcal blepharitis

 Seborrhoeic Blepharitis…
Symptoms and signs
• Chronic eyelid redness, burning, foreign body
sensation, itching

• Oily or greasy crusting, eye discharge

• Easily applicable eyelashes

• Dandruff-like flakes ―scurf randomly distribute

on and around eyelashes
Seborrhoeic Blepharitis…
 Seborrhoeic Blepharitis…
Non-pharmacological Treatment
• Eyelid hygiene, which includes

– Warm compression with clean towel for up to

10 minutes daily to TID

– Massaging or expression of meibomian gland

– Scrub: cleanliness of the eyelid margins to

remove keratinized cells and debris
Pharmacological Treatment
• Oxytetracycline + Polymyxin B +Hydrocortisone
suspension, apply 1 drop TID / 4 weeks OR

• Neomycin + Polymyxin B Sulphate +

Dexamethasone suspension TID / 4 weeks OR

• Tetracycline 1% ointment TID, for 2 to 4 wks OR

• Erythromycin 0.5% ointment, apply single strip

BID to TID, for 2 to 4 weeks
 Demodectic Blepharitis
• Caused by infestation of the eyelash follicles
with a mite

• Milder form of blepharitis, with little inflammation

• Can cause both anterior & posterior blepharitis

• Overpopulation or hypersensitivity to the mite

may lead to symptoms
 Demodectic Blepharitis…
• Clinical features

– Generally asymptomatic

– Waxy, cylindrical cuffs or ―sleeves around

the basis of the eyelashes

– Mites can be demonstrated under ×16 slit

lamp magnification

• Investigation and diagnosis: clinical

 Demodectic Blepharitis…
• Non-pharmacological treatment

– Eyelid hygiene to prevent reproduction

• Pharmacological treatment

– Ivermectin topical (1% cream) 2 times 1-

week apart OR Ivermectin oral two doses
of 200 µg/kg 1 week apart
 Entropion
• Mechanism

– Inversion of eye lid into eye

• Etiology

– Aging (course fibrous tissue)

 Entropion…
• Symptoms and signs

– Foreign body sensation, Tearing

– Itching, redness

– Continuous rubbing causes corneal ulcers

– Decreased visual acuity if not corrected

Entropion…
 Entropion…
• Diagnosis

– Visual examination

• Treatment

– Clean up on its own

– If not, minor surgery

 Ectropion
• Mechanism

– Outturned eye lids

• Etiology

– Elderly (weakness of eye lid muscles)

 Ectropion…

• Symptoms and signs

– Dryness of the exposed part of the eye

– Tears run down the cheeks

– If not treated can cause ulcers & damage

to cornea
 Ectropion…

•Rx- Minor surgery

 Trichiasis
• It is a condition in which the eye lashes grow in
wards and rub on the cornea.

• Cause: _ Blepheritis

_ Trauma

_ Surgery to the lids

• Sign and symptoms: Foreign body sensation,

Tearing, Eye rubbing, corneal ulcer, redness
Trichiasis…
 Trichiasis…

• Rx: - Epilation

• Complications: Corneal abrasions /

ulceration and corneal Opacity

 Eye lid edema
 Is swelling of the eye lid due to abnormal

collection of fluid in the subcutaneous tissue.

 Can be two types

Inflammatory edema

Non-inflammatory edema
Eye lid edema…
Eye lid edema…
 Diseases of the conjunctiva

• Conjunctivitis

– Bacterial conjunctivitis

– Viral conjunctivitis

– Allergic conjunctivitis

• Trachoma
 Conjunctivitis (pink eye)
• * Is the inflammation of the conjunctiva

• * Most conjunctivitis is bilateral

• * Contagious‖ with contaminated hands,

washcloths

Etiology

– * Viral / bacterial
* Irritants (allergies, chemicals, UV light)
 Conjunctivitis (pink eye)…
Common symptoms and signs

• *Redness / swelling / itching, pus if infectious

• *Tearing when exposed to light

• Photophobia

• Eye discharge
 Conjunctivitis…
• Types

– Bacterial conjunctivitis

– Viral conjunctivitis

– Allergic conjunctivitis
 Bacterial conjunctivitis
• Is a bacterial infection of the conjunctiva usually
caused by Staph.auerus, streptococcus,…

• It can be acute or chronic and highly contagious

• Acute bacterial conjuctivitis is most common

– Caused by direct contact with secretions

– Usually self-limiting /about 60% resolve within

5 days without treatment/
Symptoms and signs

• Redness, burning /pain/ and discomfort

• Involvement is usually bilateral

• Stuck shut in the morning & Gumming of lashes

• Generalized conjunctival hyperemia & chemosis

• Muco-purulent eye discharge

• Palpable LNs in severe infections

• Visual acuity is not usually affected

 Acute bacterial conjunctivitis…
• Diagnosis: - Mostly clinical
• Gram stain, culture and sensitivity
Treatment
 Goal of treatment

Treat the infection

Prevent re-infection, transmission and

complications

 Non-pharmacological treatment

o Frequent cleaning of the eyelids and warm

compression
Treatment…
• Pharmacological treatment

 Topical antibiotics

– Chloramphenicol, 0.5 % solution 1 drop every

4 to 6 hours or 1% ointment single strip apply
BID to QID for 10 to 15 days OR

– Tetracycline 1% ointment, single strip apply

BID to QID for one to two weeks OR
• Treatment…
– Ciprofloxacin 0.3 % solution, 1 drop every 4 to
6 hours per day for one to two weeks OR

– Tobramycin 0.3% eye drop, 1 drop every 4 to

6 hours per day for one to two weeks

• Systemic antibiotics are required in cases of

severe infection (ceftriaxone, Augmentin,…)
 Acute bacterial conjunctivitis…
• Treatment…

– Quinolones (such as ciprofloxacin eye drop

should be reserved for resistant cases

– Don‘t use steroidal drugs

– In severe and complicated cases refer the pt.‘

-* Prevention- Personal hygiene

 Viral conjunctivitis
• It is viral infection of the conjunctiva

• Causes: -Adenovirus, Measles, Herpes Simplex

virus, Voricella

• Highly contagious and spread by:-

– Direct contact with the patient

– Contact with secretions or

– Contact with contaminated objects, surfaces

 Viral conjunctivitis…
• Clinical manifestations

– Red eye

– Chemosis (edema of the conjunctiva, severe)

– Itching, Photophobia

– Watery eye discharge

– Follicle may be present on the palpebral

conjunctiva
 Viral conjunctivitis…

Treatment

• Self limiting (within

7-10 days)

• Steroids if needed
 Allergic conjunctivitis
• Inflammation of the conjunctiva caused by
air born allergy contacting the eye.

• Hypersensitivity reactions upon exposure

to specific environmental antigens

• It is Type I, mediated by degranulation of

mast cells in response to action of IgE.
 Allergic conjunctivitis…
• *Clinical manifestations:

– Red eye, Severe chemosis

– Mucoid eye discharge

– Sinusitis may present

– Burning sensation & severe itching

– Photophobia and V/A is usually normal

 Allergic conjunctivitis…
• Treatment

– Betamethasone eye drop

– Hydrocortisone eye drop

– Cold compress
 Allergic conjunctivitis…
• There are various forms of allergic conjunctivitis

– Acute Allergic Conjunctivitis

– Perennial Allergic Conjunctivitis

– Seasonal Allergic Conjunctivitis

– Vernal Keratoconjunctivitis (VKC)

– Atopic Keratoconjunctivitis (AKC)

 Acute Allergic Conjunctivitis
• A common condition

• Acute reaction to an environmental

allergen (usually pollen)

• It is typically seen in younger children after

playing outside in spring or summer
 Acute Allergic Conjunctivitis…
• Symptoms and Signs

– Conjunctival swelling

– Acute itching and Watering

– Chemosis is the hallmark (frequently

dramatic and worrying to the child/ parents)

• Investigation and diagnosis: Clinical

 Acute Allergic Conjunctivitis…
Treatment
• Goal of treatment

– To relieve the symptom

• Non-pharmacological treatment

– Cold compress

• Pharmacological treatment

– Dexamethasone 0.1% BID to QID

Perennial /Seasonal Allergic Conjunctivitis
• Common subacute conditions

• Other atopic conditions (allergic rhinitis / asthma

 Symptoms and Signs
– Intense itching is a hallmark symptom, attacks
are usually short lived and episodic

– Eyelid edema

– Mucoid eye discharge, associated with

sneezing and nasal discharge

– Conjunctival hyperemia and chemosis

 Treatment
• Non-pharmacological treatment

– Identify and avoid the allergens

– Cold compresses

• Pharmacological treatment

– Artificial tears for mild symptomatic

– Mast cell stabilizer for long term use

 Treatment…

– Antihistamines for symptomatic

exacerbation

• Oral antihistamines for severe symptoms

 Vernal Keratoconjunctivitis (VKC)
• Recurrent bilateral disorder, IgE- and cell-
mediated immune mechanisms play roles

• Primarily affects boys and onset is generally

from about the age of 5 years onwards

• Mostly have personal or family history of atopy

• Often occurs on a seasonal basis

• There is remission by the late teens in 95%

 Symptoms and Signs
– Intense itching, lacrimation, photophobia

– Foreign body sensation, burning

– Thick mucoid discharge

– Increased blinking is common

– Conjunctival hyperemia and diffuse papillary

hypertrophy on tarsal plate (cobble stone)
 Treatment
• Non-pharmacological treatment
– Climatotherapy (use of air-conditioning
or relocation to cooler environment)
– Ice packs and frequent face washing
with cold water gives temporary relief
– Avoid eye rubbing, which is partly
responsible cause for corneal ectasia
 Treatment…
• Pharmacological treatment
– Mild: Topical antihistamine +/- NSAIDS
– Moderate: topical mast cell stabilizer +/-
NSAIDS
– Severe: Steroid +/- topical antihistamine +/-
NSAIDs +/- mast cell stabilizer
• Referral: In severe and complicated cases refer
to an ophthalmologist
 Atopic Keratoconjunctivitis (AKC)
• A rare bilateral disease that typically develops in
adulthood (peak incidence 30 to 50 years)

• Following a long history of atopic dermatitis

• Asthma is also extremely common in these pt‘s

• About 5% have suffered from childhood VKC

• Associated chronic staphylococcal blepharitis is

common
Atopic Keratoconjunctivitis (AKC)…
• Symptoms and Signs

– Symptoms similar to those of VKC, but are

frequently more severe and unremitting

– Discharge is generally more watery

– Eyelid erythema,dryness, scaling & thickening

– There may be keratinization of the lid margin

– Lid skin folds caused by persistent rubbing

 Treatment
• Non-pharmacological treatment

– Allergen avoidance

– Cold compress

– Lid hygiene for associated blepharitis

• Pharmacological treatment

– Vasoconstrictor: Tetrahydrozoline 0.05% or

Oxymetazoline 0.025% or 0.05%, 1 drop TID
 Treatment…
– Vasoconstrictors- antihistamine combination:
Naphazoline + Antazoline 0.025%+0.5% 1
drop TID

– Antihistamine: Levocabastine 0.05% or

Olopatadine 0.1%, 1 drop TID to QID

– Mast cell stabilizer: Cromolyn Sodium 4% or

Lodoxamide 0.1%, 1 drop TID to QID
 Treatment…

– NSAIDs: Diclofenac 0.1% or Ketorolac 0.5% 1

drop TID to QID

– Artificial tears, 1 drop 3 to 5 times per day

– Steroid: Dexamethasone 0.1% or

Prednisolone 0.25%, every 2 to 4 hours/ day
 Treatment…
– Steroid – antibiotics combination:
Dexamethasone + Chloramphenicol 0.1% +
0.5% or Dexamethasone + Tobramycin 0.1%
+ 0.3%, 1 drop every 2 to 4-hour

– Systemic: oral antihistamine may provide

symptomatic relief in some patients
 Trachoma
• It is a chronic infectious Keratoconjunctivitis
caused by Chlamydia trachomatis

• It is a Greek word meaning rough describing

surface appearance of the conjunctiva

• Primarily affects the superior and inferior

tarsal conjunctiva and cornea, also eyelids

• Superimposed bacterial infection is common.

 Trachoma…
• Very common disease in developing countries

• Globally 90% show sign of trachoma & some

areas 10% of those infected become blind.

• Trachoma tends to be found in dry rural areas,

where lack of water and bad living conditions
may facilitate the spread of the disease.
 Trachoma…
• Trachoma is related to poor hygiene, and

is a disease of poverty

• Important and major cause of avoidable /

preventable blindness in the world

Risk factors

 Poverty

 Poor hygiene

 Lack of water supply

 Age- common in children

 Environmental factors 4 Ds (Dust, Dry, Dirty,

Discharge).

- MOT : Fly, Clothing, Finger

 Symptoms and Sign
• Mucopurulent discharge and Tearing

• Foreign body sensation, Trichiasis

• Eye lid edema, pain, red eye and photophobia

• Follicle (Whitish spots beneath the conjunctiva)

• Edematous and Thickened tarsal conjunctiva

• Upper tarsal conjunctiva scaring

• Corneal opacity and reduction in vision

Trachoma…
 Trachoma…
World Health Organization (WHO) Classification

• 5 stages of active trachoma

– Active trachoma with follicle (TF)

– Active trachoma with intense inflammation (TI)

– Trachomatous scarring (TS)

– Trachomatous trichiasis (TT)

– Corneal scarring (CO)

 Active trachoma with follicle (TF)

• At least 5 follicles in upper

tarsus, also some papilla

• Palpebral conjunctival blood

vessels are clearly visible

• Represent active moderate

infection, needs treatment
 Active trachoma with intense
inflammation (TI)
• Many follicles and papillae

• Palpebral conjunctival blood

vessels are almost obscured

• Represent active severe

infection, needs urgent Rx
 Trachomatous scarring (TS)

• White scars are present

on upper tarsus

• Represent prior/old

infection, now inactive

 Trachomatous trichiasis (TT)

• At least one eyelash

rubbing against the
cornea or prior epilation

• Likely to develop
progressive corneal
scarring, needs surgical
treatment
 Corneal opacity (CO)

• Corneal opacity
affecting central
cornea

• Visual loss from

previous trachoma,
now inactive
 Treatment and prevention
• 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
 Treatment and prevention…

• Goal of treatment

– Early Identification and treatment

– Prevent complications

• Non-pharmacological treatment

– Surgical correction of trichiasis (TT)

– Penetrating Keratoplasty if indicated (CO)

• Pharmacological treatment

I. Trachomatous inflammation follicular

 Topical treatment (effective, cheaper, minimal

systemic side effect)

– Tetracycline 1% ointment single strip apply

BID to QID for 6 weeks OR

– Erythromycin 0.5% ointment single strip apply

BID for 6 weeks

 Pharmacological treatment…

II. Trachomatous inflammation -intense (TI)

• Topical (see above under TF)

• Systemic treatment

– Azithromycin 1gm PO stat for adult and 20

mg/kg stat in children (―Magic bullet)

Disorders of the globe of the eye

• Keratitis • Macular degeneration

• Corneal abrasion or • Retinal detachment

ulcer • Uveitis
• Scleritis

• Cataract

• Glaucoma
 Keratitis
• It is inflammation and ulceration of the cornea

• From bacterial causes it is usually due to

staph-aureus, staph epidermidis, P.
aeruginosa, M. catarrhalis

• N.B. causative organism cannot be defined

reliably from the appearance of the ulcer
• Etiology

– * Herpes simplex virus (cold sores)

– * Bacteria & fungi

– * Trauma

– * Dry air or intense light (welding)

– lid abnormalities

– Immunosuppression
• Sign and symptoms

Pain- sharp and sever

Discharge and Red eye

Photophobia

Blurred vision

Corneal edema & Reduced corneal sensation

• Sign and symptoms…

 Cornea: - grayish to whitish infiltrate hazy with

loss of clarity and opacity of different degree.

 Keratitis…
• Diagnosis

– * Examination of cornea using slit lamp

– * Medical history

• Treatment

– *Eye patch to protect from photophobia

– *Gentamycin or ciprofloxacillin eye drop

frequently for bacterial keratitis
Rx for herpes Simplex (Herpetic) Keratitis
• Initial therapy

– Acyclovir 3% ointment 5 times per day OR

– Acyclovir 400 mg 5 times per day 10 to 14

days (immune-deficient, in children and sever)

• Maintenance therapy

– Acyclovir 400 mg PO BID, up to 1 to 2 years

• N.B. Avoid steroid use

 Corneal abrasion or ulcer
• Corneal ulcer: Loss of some of corneal

epithelium and surrounding inflammation

• Destruction of corneal tissue due to inflammation

• Corneal scar: is whitish opaque cornea, which is

the final result of inflammation.

 Corneal ulcer…
• Etiology

– * Foreign bodies
* Trauma (fingernail, contact lenses)

– Lid abnormalities

– Immunosuppression

– Dry eye
 Corneal abrasion or ulcer…
Symptoms and signs
– Pain
– Redness
– Tearing
– Something constantly in eye
– Whitish opaque cornea
– Vision impairment
Corneal abrasion or ulcer…
 Corneal abrasion or ulcer…
• Diagnosis

– * Visual examination

– * Fluorescien (stain) slit lamp examination

– *Tonometry (IOP)

– * Corneal ulcer scrape for microbiology

 Corneal abrasion or ulcer…
• Treatment
– * Remove foreign bodies

– * Eye wear for protection & promote hearing

– * Eye dressing to reduce movement

– Topical antibiotics for bacterial infection.

– Early referral to ophthalmological Rx center

 Scleritis
• Is inflammation of sclera

• Etiology

– Autoimmune disorders

– * Rheumatoid arthritis

– * Digestive disorders (crohn‘s)

 Scleritis…
• Symptoms and signs
– *Painful - typically a constant sever boring
pain that worsen at night or in the early
morning and radiate to the face and periorbital
region.

o Pain is sever enough to limit activity and often

prevent sleep.
• Symptoms and signs….
- *Intense redness

- Watering, photophobia

- Sclera edema and tenderness

- * Loss of vision (posterior sclera inflammation)

- * If untreated can lead to perforation or VI

Scleritis…
 Scleritis…
• Diagnosis

– * Ophthalmic examination
* Blood work to uncover underlying cause

• Treatment

– * Mild: Eye drops (antibiotics)

* Severe: Immunosupressive drugs
* Perforation: Surgery
 Iridocyclitis
• It is the Inflammation of iris and ciliary body

• It is an inflammation of anterior uveal tract

• Etiology

o Associated with systemic diseases (TB,

syphilis, sarcoidosis, rheumatoid arthritis)

o Infection but mostly idiopathic

• Sign and symptoms

– Painful red eye (Classically eye redness is

most marked adjacent to corneal margin)

– Photophobia

– Reduction of vision

– Watery discharge

– Cells in the anterior chamber and may be

hazy
• Sign and symptoms…

– Miosis (small pupil), may be irregular

– *Cornea is relatively clear

 Sign and symptoms…

Investigations and diagnosis

 Systemic work up - CBC, VDRL, RF, HIV, X-ray
Treatment
• Start with topical steroids

– E.g. dexamethasone eye drop QID.

• Atropine eye drop 1% BID to prevent adhesion

and to reduce pain OR

• Homatropine 5% or tropicamide eye drops BID

to QID
Treatment…
• Treat secondary glaucoma (Pilocarpine and
prostaglandins are contraindicated!)

• Treat the underlying systemic diseases

 Refer as soon as possible to ophthalmic center.

 Cataract
Definition

– *A congenital or acquired gradual deterioration

and opacity of the lens or lens capsule.

• The human lens is a naturally clear structure

located behind the iris and is avascular

– Leading cause of blindness in Ethiopia

– Age related cataract is the most common

 Cataract…
• Etiology

– * Familial or * congenital

– * Old age, Radiation

– * Trauma, Exposure to sunlight (UV light)

– * Drug toxicity (Steroids)

– * Uveitis

– * Systemic disease (Like diabetes mellitus)

 Pathogenesis
• The lens is made mostly of water & protein fibers

• The protein fibers are arranged in a precise

manner that makes the lens clear and allows
light to pass through without interference

• When light passes through the pupil, it is

focused by the lens to produce clear, sharp

images on the retina

 Pathogenesis…
• When this arrangement is disturbed in any way,

the transparency is lost

– With aging, the composition of the lens

undergoes changes and the structure of the
protein fibers breaks down

• This results in scattering of light, blurring, and

blocking of the image

 Pathogenesis…
• This loss of transparency, or opacity formation is
called Cataract.
Pathogenesis…
 Cataract…
• Sign and Symptoms
– Cloudy / white opaque area of the lens

– A gradual, painless, progressive loss of vision

– *Reduce visual acuity up to the level of LP

– Increasing difficulty with vision at night

– The need for brighter light for reading

– Double vision in a single eye (monocular)

 Cataract…
Diagnosis

• Clinical

• Visual examination

• Pen light of slit lamp

confirm cataract
• Treatment
– Cataract is most treatable cause of blindness

– Cataract Surgery (artificial lens replacement)

Cataract surgery is most frequently performed

• More than 95% of patients have improved

vision after surgery

– Eyeglass

– No pharmacological treatment for cataract

Cataract surgery…
 Glaucoma
• It is a group of diseases characterized by
progressive optic neuropathy and visual field loss

• Is increased intraocular pressure due to

blockage or increased production aqueous fluid

• A condition in which the intra ocular pressure is

sufficiently high to cause optic nerve damage
followed by visual field changes(blindness)
 Glaucoma…

• Usually bilateral, but may be unilateral or

asymmetrical (usually secondary)

• It is a major blinding disease worldwide and

the leading cause of irreversible blindness

– Glaucoma is often called ―a silent theft of

sight‖
 Glaucoma…
Risk factors

• Primary risk factor is elevated IOP (> 21 mm Hg)

• Advanced age

• Positive family history / race

• Refractive error

• Eye surgery or Trauma

• Inflammation and Overuse of steroids

 Pathogenesis
• Aqueous humor [produced by ciliary body] is a
clear liquid that fills the anterior and posterior
chamber of the eye.

• Normally, the pathway for aqueous humor is

wide and unobstructed and IOP = 10-21mmHg

• Any condition that causes blockage/increased

production of aqueous fluid leads to glaucoma
 Glaucoma…
Normal pathway for aqueous humor drainage
 Cont’d

In the normal eye, the pathway for aqueous humor to

flow to the canal of Schlemm is wide and unobstructed.
Pathogenesis…
 Classification
• Different types of glaucoma;

– Acute or Chronic

– Open or closed Angle Glaucoma

– Primary or Secondary

 Primary open angle is the commonest type in

Ethiopia
 Acute angle-closure glaucoma

• Acute attack usually occurs in one eye

• Without treatment, progress to permanent

damage and blindness, especially in old age

• Mechanism

– Complete blockage of aqueous humor

drainage system, usually due to trauma
Acute angle-closure glaucoma…

– The movement of fluid is impaired because

increased pressure in the posterior chamber
produces a forward bowing of the iris, which
narrows the canal of Schlemm.
 Symptoms and signs of ACAG
– Sudden onset severe eye pain and Redness,
Photophobia

– Markedly decreased vision

– Blurred vision ( smoke-filled room)

– Haloes ( rainbow around lights )

– Hemi-cranial headache

– Nausea & vomiting

 Symptoms and signs ACAG…

– Hazy or edematous cornea (elevated IOP)

– Mid-dilated non-reactive pupil

– Shallow anterior chamber

– Severely elevated IOP (50 to 80 mm Hg)

– Affected eye feels harder with finger palpation

* If untreated --> blindness
Symptoms and signs ACAG…
 Acute angle-closure glaucoma…
• Diagnosis

– * Goniolens (special lens to view the

opening)

– * Tonometry (pressure measure)

– Digital palpation to compare with other eye

– Ophthalmoscopy fundus examination

 Treatment of ACAG

• Goal of treatment

– Institute initial therapy and then refer to

hospital with ophthalmology unit

– To achieve immediate reduction in IOP

 Treatment of ACAG …
• Non-pharmacological treatment

– Supine position to encourage the lens to shift

posteriorly under the influence of gravity

– Laser peripheral iridectomy, if the attack not

broken medically

o *Iridectomy : creation of a hole in the iris

between the anterior and posterior chamber
• Pharmacological treatment (to reduce IOP)

– Acetazolamide 500mg PO (IV if IOP > 50 mm

Hg) stat, followed by 250mg 6 hourly PLUS

– Timolol 0.5% eye drops, instill 1 drop every 15

minutes 2x, then BID

– N.B. Where those above measures fail,

– Mannitol 1 to 2 g/kg as a 20% solution IV over

30 to 60 minutes
Chronic open-angle glaucoma
• *Increased IOP due to malfunction in eyes
aqueous humor drainage system
• The flow is obstructed at the trabecular meshwork.
• Can lead to optic nerve damage
• Etiology
• * Trauma
• * Overuse of steroids
• Symptoms and signs

– Mostly asymptomatic ( ―sight thief‖)

– * History of gradual loss of vision in the

affected eye or loss of visual field

– * If untreated - eventually complete vision loss

– Hard eye ball on digital palpation

– Cupping of optic disc on fundoscopy

– Elevated IOP
 Chronic open-angle glaucoma…

• Diagnosis

– * Tonometry measures intraocular

pressure (IOP)

– * Visual field test

– Ophthalmoscopy fundus examination

 Treatment of glaucoma
• Goal
– Early detection, control IOP & preserve vision

– Maintain the IOP to the safe level that does

not cause damage

– Halt progressive optic nerve head damage

and visual field loss

– Decrease the medication side effects

• Pharmacological treatment of glaucoma
– Medication that helps decrease aqueous
humor production or opens drainage system

• Beta adrenergic antagonist

• Prostaglandin analogues

• Adrenergic Agonists

• Para sympathomimetic

• Carbonic anhydrase inhibitors

 Pharmacological treatment of glaucoma…

Beta adrenergic antagonist

• Suppress aqueous humor production

– Timolol 0.25% or 0.5% eye drops, instill 1

drop BID

– Betaxolol 0.5% eye drops, instill 1 drop BID

 Pharmacological treatment of glaucoma…

Prostaglandin analogues

 Increase outflow through uveal pathway and

ciliary muscle

– Latanoprost 0.005% eye drops, 1 drop daily

– Alternative: Travoprost 0.004%

– NB. Currently prostaglandin analogue eye

drops are the first line, if available
 Pharmacological treatment of glaucoma…

Adrenergic Agonists

 Decrease production& increase out flow

– Brimonidine 2% eye drops,1 drop BID

– Apraclonidine eye drop, instill BID or TID

– NB. Use as second line if patient has

allergic reaction to prostaglandin analogue
 Pharmacological treatment of glaucoma…

Para sympathomimetic:

 Facilitation of aqueous outflow

– Pilocarpine, 2 and 4%, eye drops, 1 drop QID

– NB. Avoid use in uveitic glaucoma, and

primary open angle glaucoma (POAG) with
high myopia
 Pharmacological treatment of glaucoma…

Carbonic anhydrase inhibitors

 Suppression of aqueous humor production

– Acetazolamide 125 to 250mg, BID to QID or

– Methazolamide 50 to 100mg, BID to TID

– Dorzolamide 2% eye drop, 1 drop BID or TID

– Brinzolamide 1% eye drop, 1 drop BID to TID

 Pharmacological treatment of glaucoma…

• NB. oral preparations only used in cases of very

high IOP used for short period, due to side
effects
Non-pharmacological treatment of glaucoma

• Surgery

– Trabeculectomy

– Ridotomy or Iridectomy

– Tube-shunt implant

• Laser treatment: to open drainage

 Pterygium
• A triangular fibrovascular subepithelial ingrowth

of degenerative bulbar conjunctival tissue over

the limbus onto the cornea

• */Pterygium means wing/.

• It is vascular, thick and usually start nasally

• Common in dry, hot and dusty environment.

 Pterygium…
• The condition tends to run in families

• Symptoms and Signs

– Most small lesions are asymptomatic

– Patient complains slight cosmetic blemish

– Irritation of the eye.

– If it grows into the pupil, it will cause blindness

Pterygium…
 Pterygium…
Treatment

 Protection from sun with eye glass or hat.

 If irritated ,topical steroid

 Terracotril eye suspension BID.

 It needs surgical excision if pterygium

approaches on cornea by 3mm or more.

 Macular degeneration (MD)
• Macula is the area next to optic disc that
defines fine details at the center of visual field

• MD is disappearance of central vision due to

deterioration of pigment layer of retina
because of lack of enough blood supply to it

• Etiology: Age, Hemorrhage, Atherosclerosis

 Macular degeneration (MD)…
• Symptoms and signs

– * Fine detailed vision is impaired

* Sharp vision deterioration (reading)

* Peripheral vision is not affected

* Loss of central vision

 Macular degeneration…
• Diagnosis

– * Ophthalmoscopy

* Fluorescein angiography

* Patient history
 Macular degeneration…

Fundus photograph of a retina with soft, confluent

drusen from dry macular degeneration.
 Macular degeneration…

• Treatment

– * No known cure

* Laser photocoagulation

* Increase zinc in diet

* Strong magnifying glasses

 Retinal detachment

• MECHANISM

– * Elevation & detachment of the retina

from the choriod (partial or complete)

• ETIOLOGY

- Trauma
Retinal detachment…
 Retinal detachment…

• SYMPTOMS AND SIGNS

– * Visual floaters

– * Light flashes
* Dark/opaque shadow

– * If central retina is involved, could lead to

blindness
 Retinal detachment…
• Diagnosis

– * Ophthalmoscopy

• Treatment

– Pneumatic retiopexy

– Scleral buckle (placing silcon band around out

side the eye)

– Vitrectomy
Retinal detachment…
 Disease of the lacrimal apparatus

Dacryocystitis
• It is an inflammation of the lacrimal sac

• Usually secondary to obstruction of NLD

• Chronic tear stasis and retention leads to

bacterial infection, Staphylococcus,…

o May be associated Preseptal/orbital cellulitis

 Dacryocystitis…
• Fistula formation, lacrimal sac cyst or mucocele
can occur in chronic cases

• Clinically classified as acute and chronic

• Typical symptoms include highly inflamed ,

painful swelling on the surrounding area of the
lacrimal sac
Dacryocystitis…
 Acute Dacryocystitis…
Symptoms and Signs

 Pain, redness & swelling over the lacrimal sac

 Tearing and Mucoid or purulent discharge

 Erythematous, tenderness on nasal aspect of

lower eyelid

 Decompressing digitally over the mass drain

muciod or purulent discharge through punctum
Dacryocystitis…
 Acute Dacryocystitis…
• Non-pharmacological treatment

– Warm compresses and gentle massage to the

inner canthal region QID

– Incision and drainage of a pointing abscess

– Dacryocystorhinostomy (DCR) for chronic

Dacryocystitis
 Acute Dacryocystitis…
• Pharmacological treatment (Mild)

– Cloxacillin 500mg PO QID for 10 to 14 days

PLUS Chloramphenicol eye drop, 1 drop QID
for 10 to 15 days OR

– Amoxicillin/clavulanate 625mg PO BID for 10

to 14 days PLUS Gentamicin eye drop, 1
drop QID for 10 to 15 days
 Acute Dacryocystitis…
• Pharmacological treatment (Moderate to severe)
 Hospitalize and treat with IV medications
o Cephazolin 1gm IV TID for 10 to 14 days OR
o Cefuroxime 750mg IV TID for 10 to 14 days OR
o Clindamycin 300mg IV QID for 10 Lo 14 days
PLUS
o Gntamicint 2.0mg/kg IV loading dose, and then
1 mg/kg IV TID for 10 to 14 days
Objectives
 At the end of this lesson students be able to:
 Describe anatomy and physiology of ear

 Perform ear assessment using d/f techniques

 List and define the common ear disorders.

 Explain the pathophysiology, C/M and

diagnosis of common ear disorders.

 Treat and prevent common ear disorders.

 Anatomy of the ear
External ear

 Auricle, auditory canal

 Tympanic membrane

Middle ear

• Eustachian tube, ossicles

Inner ear

• Cochlea, Vestibule and Semi circular canals

Anatomy of the ear…
 Anatomy of the ear
• Auricle: Consists of movable cartilage and skin

 Tympanic membrane: Separates the external

and middle ear

Middle ear has three functions

 Conducts sound vibrations from the outer ear to

the inner ear.

 Protects inner ear by reducing sound amplitude

 Anatomy of the ear…
 Eustachian tube allows equalization of air pressure

on each side of the tympanic membrane and

prevents from rupture

• Inner ear : Contains sensory organs for hearing and

equilibrium

– Although the inner ear is not accessible to direct

examination, its functions can be assessed

Anatomy of the ear…
 Functions of the ears
• Hearing

• Balance and equilibrium

 Body balance is maintained by;

- Muscles and joints

- The eyes (visual system), and

-The labyrinth (vestibular system).

 These areas send their information about

equilibrium, or balance, to the brain for coordination
 Ear assessment
History taking
• Ask for any earache
• Infections , discharge
• Hearing loss
• Tinnitus , vertigo, etc.
Physical examination
Diagnostic assessment
 Physical examination of the Ear

• Inspection

• Palpitation

• Otoscopic examination

• Gross auditory acuity tests

 Physical examination of the Ear…
 Inspection
• Inspect each auricle and surrounding tissue for
deformities, lumps, discharge, size, symmetry,…

• Inspect the mastoid region for edema & abscess

– The auricle is displaced downwards and

outwards in mastoiditis

• Use an otoscope to inspect internal structures

 Physical examination of the Ear…

 Palpitation
• Assess the auricle, tragus and mastiod process
for tenderness

– Move the auricle up and down, press the tragus

and press firmly just behind the ear

• Movement of the auricle and tragus is painful

in acute otitis externa, mastoiditis
 Physical examination of the Ear…
 Otoscopic examination
• Use an otoscope with the largest ear speculum
that the canal will accommodate

• Inspect the ear canal and tympanic membrane

 Note for discharge, inflammation, redness,

mass or foreign body
Otoscopic examination…
 Otoscopic examination procedure
►Choose the largest speculum that fits the ear
canal of your patient

►Tilt the person‘s head slightly away from you

toward the opposite of the shoulder

►Pull pinna up and back on adult or older child to

straighten the canal

►Pull pinna down on infant/child under 3yrs

 Otoscopic examination procedure…
– N.B. Do not release traction on the ear until
you have finished the examination

►Hold the otoscope ‗upside down', it prevents

forceful insertion

►Stabilize the otoscope by resting the back of

your hand against the patient‘s temple area

►Insert the speculum slowly along the ear canal

 Otoscopic examination procedure…

►Watch the insertion, then put your eye up to the

otoscope

►You may need to rotate the otoscope slightly to

visualize the entire drum; do this gently

►In the external cannal note any redness,

swelling, lesions, foreign bodies, or discharge
Otoscopic examination procedure…
 Otoscopic examination procedure…
►Also inspect the ear drum: Normally the TM
appears as a grayish white, translucent
membrane set obliquely at the base of the canal

►Look the color and contour of the ear drum

– Red-bulging drum indicate acute otitis media

– Fluid, air bubbles, blood, or masses in the

middle ear can also be noted
Otoscopic examination…
 Physical examination of the Ear…
Evaluation of gross auditory acuity

– Whisper Test

– Weber Test

– Rinne Test
 Physical examination of the Ear…
• Whisper Test

– To estimate hearing, test one ear at a time

– Ask the patient to occlude one ear with a

finger or, better still, occlude it yourself

– Covers untested ear with palm of your hand to

make sure the patient does not read your lips
Whisper Test…

– Whispers softly from a distance of 1 or 2 feet

from the un-occluded ear and out of the
patient‘s sight.

– Choose numbers or other words with two

equally accented syllables, such as ―nine-
four‖ or ―baseball‖

• Normal: Ears—Acuity good to whispered voice

 Weber Test
• Is testing of hearing by using a tuning fork

• Tuning fork provide a simple, easy reliable

method of testing the hearing

• Used to test for lateralization of sound and helps

to distinguish between two basic types of
hearing loss

– Conductive and sensori-neural hearing loss.

Weber Test…

• Conductive hearing loss: results from problems

in the external or middle ear

• Sensorineural hearing loss: Result of problems

in the inner ear, cochlear nerve, or its central
connections in the brain
Weber Test…
• You need a quiet room and a tuning fork,
preferably of 512 Hz or possibly 1024 Hz.

– Forks with lower pitches may lead to

overestimating bone conduction

• Set the fork into light vibration by briskly stroking

it between thumb and index finger or by tapping
it on your knuckles.
Weber Test…

 Place the base of vibrating fork firmly on top of

the patient‘s head or on the mid-forehead.

 Ask where the patient hears it: on one or both

sides.

 Normally the sound is heard in the midline or

equally in both ears.
Weber Test…

– Place tuning fork on

patient‘s head

– Normally the sound

is heard equally in

both ears
Weber Test…

• If nothing is heard, try again, pressing the fork

more firmly on the head.

• In unilateral conductive hearing loss, sound is

heard in (lateralized to) the impaired ear.

• In unilateral sensori-neural hearing loss, sound

is heard in the good ear.
 Physical examination of the Ear…

 Rinne Test
• Used to compare air conduction (AC) and bone
conduction (BC)

 Place the base of a lightly vibrating tuning fork on

the mastoid bone, behind the ear and level with
the canal.
Rinne Test…

 When the patient can no longer hear the sound,

quickly place the fork close to the ear canal and
ascertain whether the sound can be heard again.

– Here the ―U‖ of the fork should face forward,

thus maximizing its sound for the patient.

• Normally the sound is heard longer through air

than through bone (AC > BC).
Rinne Test…
Rinne Test…

• In conductive hearing loss, sound is heard

through bone as long as or longer than it is
through air (BC = AC or BC > AC)

• In sensorineural hearing loss air-conduction is

longer than bone-conduction
Comparison of Weber and Rinne test
 Ear assessment…
Diagnostic assessment

• Laboratory tests- Culture and sensitivity assays

for infection of external canal.

• Radiographic examinations

– Routine x-ray film of temporal bone.

 External ear disorders

– Cerumen (wax) impaction

– Foreign bodies

– External otitis
 Cerumen impaction

 Ear wax is mixture of secretions from sebaceous

and ceruminous glands, epithelial debris and dust

 Cerumen normally accumulates in the external

canal in various amounts and colors

 Ear wax is part of the body physiological defense

mechanisms and does not need to be removed
 Cerumen impaction…
 Although wax does not usually need to be
removed , impaction may occurs
 Cerumen impaction is excess accumulation of
ear wax in the auditory canal that prevents
transmission of sound wave to the middle ear
 Impaction is especially significant in the geriatric
population as a cause of hearing deficit
 Cerumen impaction…
 Clinical Features

Aural fullness / Sensation of fullness/

Itching and Otalgia

Decreased hearing

Occasionally tinnitus, vertigo

 Diagnosis: Otoscopy can reveal wax

obliterating the ear canal
Cerumen impaction…
 Cerumen impaction…
• Management

– Cerumenolytic drops like Hydrogen per

oxide, Olive oil (can soften the impaction)

– Syringing or manual irrigation

– Manual removal by an expert

• Suctioning, or Instrumentation
• Management…
• N.B: Syringing and manual irrigation should be
done by;

– Luke warm water (body temperature, 37

degree Celsius) and

– Whenever possible after the usage of

ceruminlytics for 2-3 days.

• Can soften the impaction for easy removal

Management…

• The only & rare complication of syringing is TMP

• Clearing the external auditory canal with

matches, hairpins, and others is dangerous

– Trauma to the skin, infection, and damage to

the tympanic membrane can occur

• NB: traumatic TMP usually heals by itself with

conservative management
 Cerumen impaction…

• Contraindications of ear irrigation

– Previous history of ear discharge

– Tympanic membrane perforation

– Previous history of ear surgery

– The only hearing ear

 Foreign bodies in the Ear
 It is intentional or unintentional introduction of
objects or matters into the ear canal
≈ Objects may be insects ,peas ,beans
,pebbles ,toys , and beads
 The majority of patients with foreign bodies in
the ear are children
 Objects may give rise to otitis externa by local
irritation of the epithelium of the mental walls
 Foreign bodies in the Ear…
• Clinical Features

 C/M may range from no symptom to profound

pain and decreased hearing

• Diagnosis

– Any suspicion for foreign body

– Foreign body detected on Otoscopic examination

 Managment
• Irrigation of the suspected ear with water if there
is no perforation of the tympanic membrane

– Cereals can be irrigated if fride, unfride

Cerails should not be irrigated because it get
swollen

– Ears with vegetable foreign bodies should not

be irrigated, since this may cause it to swell
 Management…
• Live insects can be killed rapidly by instilling
solutions like;

– Alcohol, 2% lidocaine (Xylocaine), and Olive

oil before removal is attempted

• Manual removal is another approach

– N.B. Foreign bodies that cannot be removed

by other methods may be removed manually
 Management…
– Attempts to remove any foreign body from the
external canal manually may be dangerous =
TMP

• In difficult cases, the foreign body may have to

be extracted in the operating room with G/A

 Management…
 N.B. Inorganic foreign body especially lithium
button battery should be removed urgently

If the foreign body is in the middle ear early

referral is advisable
 External otitis (otitis externa)

 Diffuse inflammation of the external auditory canal

 Which may also involve the pinna or the TM

 Causes
≠ Common causative agents being Pseudomonas
A., Staphylococcus aureus and others

≠ Fungal infections (Aspergillus) in the setting of

repeated antibiotic use
Risk factors
- Frequent Swimming (swimmer's ear)

- Trauma to the skin of the ear canal

- Rigorous ear cleaning

- Excessive use of air phone

- Underlying dermatological conditions such as

psoriasis, eczema, or seborrheic dermatitis

- Systemic conditions, such as vitamin deficiency

Clinical manifestations
– Pain and discharge from the external auditory
canal (may be foul smelling )
– Aural tenderness
– Fever, cellulitis, pruritus and hearing loss or a
feeling of fullness
– Posterior auricular lymphadenopathy
– On otoscopic examination, the ear canal is
erythematous and edematous
Medical management
 Analgesics for the first 48 to 92 hours

 Topical antibiotics

Ciprofloxacin 0.2% and dexamethasone 0.1%

otic suspension 2 – 3 drops BID for 02 weeks

Systemic antibiotics can be considered in

severe cases

For fungal disorders: antifungal agents

Nursing management

• Teach patients not to clean with cotton-tipped

applicators

• Teach to avoid swimming, and not to allow water

to enter the ear when showering

– A cotton ball can be used as a barrier

• Infection can be prevented by using antiseptic

otic preparations after swimming (Ex. Swim Ear)
 Middle ear disorders

 Tympanic Membrane Perforation

 Acute otitis media

 Chronic otitis media

 Mastoiditis

 Otosclerosis
 Tympanic Membrane Perforation

• TMP is usually caused by infection or trauma

– Skull fracture, explosive injury, severe blow to
the ear
– Foreign objects that have been pushed too far
into the external auditory canal
– During infection, TMP occurs if the pressure in
the middle ear exceeds pressure in the
external canal
Tympanic Membrane Perforation…
 Tympanic Membrane Perforation…
Clinical manifestation

– TMP with out infection are not painful

– Audible whistling sound during sneezing

– Decreased hearing.

– TMP with infection _ purulent discharge.

– Head injury – otorrhea.

Diagnosis: Otoscopic examination

 Management
• Mostly TMP heal spontaneously within weeks

• Some perforations persist because scar tissue

grows over the edges may prevent healing

• Protect the ear from water

• Tympanoplasty (surgical repair of the TM)

– Closing the perforation permanently improve

hearing and prevents infection
 Acute otitis media
 An acute infection of the middle ear, usually

lasting less than 6 weeks

o It is most common in children

o Rapid onset of signs and symptoms

o Mostly following URTIs

 Acute otitis media…

• Risk factors:

– Crowed conditions

– day care

– passive smoking

– bottle feeding

– low economy
 Acute otitis media…
Causes
• Usually caused by Streptococcus pneumoniae
• Other bacterias :- Haemophilus influenzae,
Moraxella catarrhalis, influenzae A and B,…
• Viral causes :- RSV, Rhinovirus, Adenovirus,…
• Inflammation of surrounding structures and
allergic reactions ( E.g. sinusitis, rhinitis )
 Pathophysiology

• The middle ear is separated from the outer ear

by the TM and drains into nasopharynx via the
Eustachian tubes

• Patency of the tube allows aeration of the middle

ear, but when obstructed, a vacuum develops
which can pull nasopharyngeal secretions into
the middle ear/middle ear effusion/.
 Pathophysiology…
• Fluid with in the middle ear then may be infected
with bacteria.
• This effusion also leads to complain of hearing
loss, sense of fullness in the ear, popping and
cracking noises
– Occurs as Eustachian tube attempts to open.
• TM : - appears dull, and air bubbles may be
visualized on otoscopy
Pathophysiology…
 Clinical manifestations
• Vary with the severity of the infection

• Usually unilateral in adults and associated with

otalgia.

– The pain is relieved after spontaneous

perforation or therapeutic incision of the TM

• Drainage from the ear, fever, and hearing loss

 Clinical manifestations…

• On otoscopic examination, the external auditory

canal appears normal but TM is erythematous

and bulging

• Patients report no pain with movement of the

auricle
 Diagnosis

• Otoscopic examination

– Bulging TM

– Yellow, white, or bright red color

– Opacification of eardrum

– Impaired visibility of ossicular land marks

– Squamous exudate
 Medical management
• AOM spontaneously resolves (40 - 60%)

• Non pharmacologic

– Advise on keeping the ear dry. I.e. apply

Vaseline soaked cotton during bathing

• Pharmacologic treatment

– Amoxicillin high dose 80-90 mg/kg/day PO

BID or TID for 10 days (Adult: 1000mg)
 Medical management…
• Alternative: Amoxicillin-clavulanate oral
suspension 90/6.4 mg/kg/day PO divided BID

• Second line drug: Ceftriaxone 50 mg/kg IV or IM

once daily x 3 days

• If beta-lactamase allergy: Azithromycin 10 mg/kg

PO STAT on day 1 and, 5 mg/kg /day for day 2-5

• Paracetamol 30-40mg/kg/24hrs QID for pain

 Surgical management

• An incision in the tympanic membrane is known

as myringotomy or tympanotomy

• Normally, is tympanotomy unnecessary for

treating AOM, but it may be performed if persists

• Myringotomy also allows the drainage to be

analyzed (culture and sensitivity)
 Chronic otitis media (COM)
• Chronic inflammation of middle ear characterized

by discharging ears for > 12 weeks (3 months)

• COM is the result of recurrent AOM causing

irreversible tissue pathology and TMP

• COM damage the tympanic membrane, destroy

the ossicles and involve the mastoid (mastoiditis)

 Clinical manifestations
• Symptoms may be minimal, with varying degrees

• Conductive hearing loss persistent or intermittent

• Constant or intermittent ear discharge

• Tympanic membrane perforation

• Pain is not usually experienced

• Otoscopy may show TMP & cholesteatoma

• Symptoms of complication: fever, headache,…

 Clinical manifestations…
• Cholesteatoma is an ingrowth of the skin of the

external layer of the eardrum into the middle ear

– It is generally caused by a chronic retraction

pocket of the TM, due to high negative pressure

• If not treated COM can cause chronic mastoiditis

and destruction of surrounding structures

Comparison of AOM and COM
Non pharmacologic treatment

• Instruct patients to keep the ear dry (Vaseline

gauze, dry it after showering)

• Aural toilet (together with topical antibiotics)

Pharmacologic treatment

• Ciprofloxacin ear drop, 0.3%, 5ml. 2 – 3 drops

twice daily for 02 weeks

• Culture directed systemic antibiotics for severity

 Chronic otitis media…
Surgical Management

• Surgical procedures, including tympanoplasty,

ossiculoplasty, and mastoidectomy

• The most common surgical procedure for

chronic otitis media is a tympanoplasty

 Chronic otitis media…
Prevention
• Cornerstone of therapy

• Promptly and appropriately treating AOM

• Strict water precautions for prevention and

management of recurrence

• Education on the risk factors like passive smoke

exposure, contaminated water, and malnutrition
 Mastoiditis

• Is a bacterial infection or Inflammation of

mastoid bone & cells

• It is serious infection that it can disseminate

in to brain and surrounding structures.

• Before the discovery of antibiotics, infections

of the mastoid were life-threatening
 Mastoiditis…
Causes

• Complication of AOM and COM

• Tuberculosis

Clinical manifestation

• Tender swelling behind the ear

• Fever, pain

• Erythematous and edematous post-auricular area

Diagnosis: C/m & x-ray shows inflamed mastoid bone

 Treatment
• Admission and IV antibiotics

– Vancomycin (15 mg/kg intravenously [IV]

every 6 hours; maximum 1 g per dose) OR

– Vancomycin PLUS Ceftazidime / cefepime 50

mg/kg per dose IV every 8 hours

– Anti pain like paracetamol, diclofenac,…

– Surgery / Mastoidectomy/
 Nursing interventions
 Relive pain and reduce anxiety
 Preventing infection
 Improving hearing and communication
 Assisted ambulation after surgery/balance
 Instruct to avoid heavy lifting, straining, exertion,
and nose blowing for 2-3wks post-op
o Prevents dislodging of TM graft or prosthesis .
 Otosclerosis

• It is formation of new, abnormal spongy bone,

especially around the oval window, with resulting
fixation of the stapes
• Prevents efficient transmission of sounds
– Stapes cannot vibrate and carry sound from
the malleus and incus to the inner ear
• Otosclerosis frequently hereditary
Otosclerosis…
 Clinical Manifestations
• Otosclerosis may involve one or both ears

• Progressive conductive or mixed hearing loss

• The patient may or may not complain of tinnitus

• Otoscopic examination usually reveals a normal

tympanic membrane

• Bone conduction is better than air conduction on

Rinne testing
 Management

• Hearing aids

• There is no known non-surgical treatment for

otosclerosis.

• One of two surgical procedures may be

performed, stapedectomy or stapedotomy

 Management…

• A stapedectomy involves removing the stapes

superstructure and part of the footplate and

inserting a tissue graft and a suitable prosthesis.

• *Stapes surgery is very successful (95% of

patients experience resolution of conductive

hearing loss)
 Nursing management
• Operative ear up
• Ear plug for asepsis
• Treat N/V
• Safety measures
• Don‘t dislodge prosthesis
– No cough, sneeze, blowing of nose, vomiting,
flying, lifting, showering
–If gets a cold: consult physicians
 Inner ear disorders

– Labyrinthitis

– Ménière‘s disease /syndrome/

– Tinnitus
 Labyrinthitis
• It is inflammation of the inner ear

• Can be viral or bacterial in origin

– Viral labyrinthitis is a common diagnosis

– Bacterial labyrinthitis is rare because of

antibiotic therapy

• Affects hearing and balance but little is known

about this disorder
Labyrinthitis…
Etiologies
• The most common viral causes are mumps,
rubella, and influenza

• Viral URTI and herpetiform disorders of the

facial and acoustic nerves also cause it

• It may occurs as a complication of AOM

– Infection can spread to the inner ear by

penetrating the oval or round window
Clinical Manifestations
• 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, occurring over a period of
several weeks to months, are less severe
Management
• Treatment of bacterial labyrinthitis includes :

– IV antibiotic therapy

– Fluid replacement

• Administration of an antihistamine and

antiemetic medications

 Treatment of viral labyrinthitis is based on the

patient's symptoms
 Ménière‘s disease /syndrome
• It is an abnormal inner ear fluid balance due to;

– Obstruction of endolymphatic outflow

– Increased production of endolymph, or

– Reduced absorption of endolymph

• It is associated with a change in fluid volume in

the inner ear

• Usually occurs in 40-60 year old

 Ménière‘s disease…
• Causes
– Mostly unknown

– Viral cause like HSV

– Autoimmune disorders

– Hereditary

– Post-traumatic

– Allergy
 Pathophysiology
• The membranous labyrinth is filled with a fluid
called endolymph

• An increase in endolymph causes dilation in the

endolymphatic space (endolymphatic hydrops)

• Endolymphatic hydrops causes increased

pressure in the system and rupture of the inner
ear membrane (Ménière‘s disease)
Ménière’s disease…
Ménière’s disease…
 Clinical manifestations
Classic triads :-

‾ Progressive unilateral hearing loss with attack

‾ Vertigo (attacks of a spinning sensation)

‾ Tinnitus (a roaring, buzzing, or ringing sound

in the ear) occurs during attack

Others:- Fullness, dizziness, N/V, unsteadiness

 Management
• Antihistamines –Meclizine

• To control vertigo -Diazepam

• Antiemetic-Promethazine

• Vasodilators

• Diuretics-HCT, lowering pressure

• Severing of acoustic nerve (8th cranial nerve)

• Labyrinthectomy
Management…
Endolymphatic Sac Decompression

Vestibular Nerve Sectioning

• Managing an attack
– Lay down on a firm surface

– Stay motionless

– Keep eyes open and fixed on a stationary

object

– Don‘t drink water

– After spinning stops, get up slowly and

– Sleep
Nursing interventions
– Bed rest during acute phase

– Low sodium diet

– Avoid alcohol, caffeine, tobacco

– Psychological evaluations
 Tinnitus
• An auditory meaningless perception in the
absence of external source of sound, related to
loss of stimuli to the central auditory pathways
 If meaning full perception in the absence of
external auditory sound is auditory hallucination
• It can occur on one or both sides of the head
• Mostly happens in the setting of Sensory Neural
Hearing Loss (SNHL)
 Tinnitus…
• Could be intermittent or persistent (> 6 month)

• Could be Primary or Idiopathic and Secondary

• Could be subjective or objective

• Could be pulsatile or non-pulsatile

• Could be caused by local or systemic disease

• Could affect the patient‗s quality of life and lead

mental health issues
 Tinnitus…
• The sounds can be expressed as the following
meaningless sounds
– Hissing, Roaring, Buzzing, Tingling sounds in
one or both ears
• Local causes
– It can have associated hearing impairment,
vertigo, aural fullness
– Any history of ototoxic drug intake
 Tinnitus…
• Systemic causes

– Psychogenic: Associated mental health

disturbances i.e sleep disturbance , emotional
disturbances , anxiety , anger , frustration

– Organic: History of Diabetic, Hypertension

and Dyslipidemia, neurologic disorders
 Tinnitus…
• Signs
– Otoscopy: Tympanic membrane Perforation,
Otorrhea, cerumen impaction, objective
peripheral vertigo

– Neurological examination

– Heart murmur, head and neck masses (carotid

bruits), and Vascular sounds
 Tinnitus…
• Investigation and diagnosis

– Tunning Fork test

– Audiometric evaluation (for hearing loss)

– Imaging Studies for underlying organic lesion

– Workup for systemic causes (CBC, VDRL,

thyroid function test, Doppler ultrasound, etc.)

 Treatment
• Avoid ototoxic medications

• Treat underlying cause if identified

• Provide counseling and if needed psychiatric

evaluation and treatment

• Recommend Hearing Aids for individuals with

hearing impairment

• Educate patient that there is no established cure

Objectives

 At the end of this lesson students be able to:

 Describe anatomy and physiology of nose

 List and define nose & throat disorders.

 Explain the pathophysiology, C/M and

diagnosis of nose & throat disorders..

 Treat and prevent common nose & throat

disorders
Anatomy of the nose and throat
 Anatomy and physiology…
• The mouth and throat =first part of digestive
system

– Functions: Ingestion, taste, preparing food for

digestion, & aiding in speech.

• The oral cavity is formed by lips, cheeks, hard

and soft palates, uvula, teeth , gums, tongue and
salivary glands.
 Anatomy and physiology…
• The arching roof of the mouth is the palate (hard
and soft palate)

– Anterior hard palate (whitish in color) and the

posterior soft palate (pink in color)

• Uvula is the free projection hanging down from

the middle of the soft palate.
Anatomy and physiology…
 Anatomy and physiology…
• The throat, or pharynx is the area behind the
mouth and nose.

– Behind the folds are the tonsils, each a mass

of lymphoid tissue.

• Tonsils has the same color as the surrounding

mucous membranes

• The posterior pharyngeal wall is seen behind

these structures.
 Anatomy and physiology…
Nose: Is the sensory organ for smell.

– Is divided medially by the septum

– Warms, moistens, and filters air

 Paranasal sinuses are air filled pockets within

the cranium that communicate with the nasal
cavity.
Anatomy and physiology…
 Anatomy and physiology…
• Two pairs of sinuses are accessible to

examination;

The frontal sinuses in the frontal bone

above and medial to the orbits and

The maxillary sinuses in the maxilla along

the sidewalls of the nasal cavity

 Anatomy and physiology…
• Others not accessible for
examination includes;

– Sphenoid and ethmoid

sinuses

– *Located deeper in the

skull over the nasal.
Anatomy and physiology…
 Nose and throat assessment

• Inspection

• Palpation

• Nasal speculum examination

 Inspection

• Inspect the anterior and inferior surface of the

nose for symmetry or deformity

• Inspect the inside of the nose and the inferior

and middle turbinate, the nasal septum and the
narrow nasal passage between them.
Nasal speculum examination
 Nasal speculum examination…
• Observe the nasal mucosa: The color and any
swelling, bleeding or exudates

– In rhinitis the mucosa is reddened swollen

• The nasal septum: Observe any deviation,

inflammation or perforation of the septum

– The lowest anterior portion of the septum is a

common source of epistaxis
 Inspection…
• Inspect the throat: using your light observe the
oval rough surfaced tonsils behind the anterior
tonsilar pillar.

– Their color is pinkish

– There should be no exudates on the tonsils.

 Inspection…
• Inspect the posterior pharyngeal wall by
depressing the tongue with a tongue blade.

– Push down half way back on the tongue.

– Note the posterior wall for color, exudates or

lesions.
Inspect the throat…
 Palpation
• Palpate the nasal bridge for tenderness

• Tenderness of the nasal tip suggests local

infection

• Test the patency of the nostrils

• Inspect and palpate the Para nasal sinus for

tenderness
Inspect and palpate the Para nasal sinus
 Nose and throat disorders

• Nasal obstruction • Sinusitis

• Epistaxis • Tonsillitis

• Deviated nasal • Peritonsillar abscess

septum • Pharyngitis

• Rhinitis • Laryngitis
 Nasal obstruction
 It is the blockage of passage of air through the
nostrils, frequently caused by:

‾ Deviation of the nasal septum

‾ Hypertrophy of the turbinate bones, or

‾ The pressure of nasal polyps (grapelike

swellings arising from the mucous membrane
of sinuses
 Nasal obstruction…
• Obstruction also may lead to a condition of
chronic infection (nasopharyngitis)

• Frequently, associated infection extends to the

sinuses of the nose.

• When sinusitis develops and the drainage from

these cavities is obstructed pain is experienced
Nasal obstruction…
 Management
• Removal of the obstruction
• Treat chronic infection if it exists
• Treatment of underlying allergy
• Endoscopic surgery to drain the nasal sinuses.
• If the cause is deviation of the septum (submucous
resection or septoplasty.
• Nasal polyps are removed by clipping them at their
base with a wire snare.
 Nursing interventions
• Most of these procedures are performed on an
outpatient basis.

• If hospitalized, elevates the head of the bed to

promote drainage and alleviate edema.

• Frequent oral hygiene to overcome dryness

caused by breathing through the mouth.
 Deviated nasal septum
• It is deviation of the nasal septum, which bisects
the nasal cavity and made up of cartilage& bone

• Although it is typically is asymptomatic, it can

cause nasal obstruction

– Increase the risk of sinusitis and epistaxis.

• It may be congenital or acquired caused by trauma

 Deviated nasal septum…
Signs and symptoms

• Drying, crusting nasal discharge

• Nasal bleeding

• Shortness of breath and difficulty breathing

through the nose

• Sinusitis and headache

 Deviated nasal septum…
Diagnosis
• Visual inspection of the nasal mucosa with a bright
light and nasal speculum.

Management
 Decongestants / E.g. xylomethazole, antihistamines,
to open the nasal airway

 Analgesics to relieve headache

 Septoplasty or sub mucous resection of the septum.

 Deviated nasal septum…
• Indications for surgery

– Nasal hemorrhage and an inability to pack the

nose because of deformity

– Recurrent sinusitis

– Snoring, shortness of breath, dry mouth,…

• Surgical complications:- hematoma, infection,

septal perforation and cosmetic deformity.
 Nursing interventions
 Oral hygiene care

 Elevate the head to 30 degree

 Administer analgesics as needed

 Encourage to expectorate oral secretions

 Administer oxygen using face tent

 Inform the patient to come back if sign of

complication (bleeding, fever, drainage,…)
 Rhino Sinusitis
• It is inflammation of mucosal membrane of the
nose and para-Nasal Sinuses

• Causes- Allergens, viral or bacterial

• Can be acute or chronic

• Acute rhinosinusitis may include viral, bacterial

and allergic rhinites
 Common cold (Viral rhinitis)
• Also known as Upper Respiratory Tract Infection
is a common acute illness

• Different viral strains may cause it

• Symptoms are self-limiting often lasting up to 10

days

• Transmission occurs through droplets

 Common cold (Viral rhinitis)…
Sign and Symptoms:

 Fever usually low grade

 Nasal congestion, Rhinorrhea

 Sneezing, Nasal itching, sore throat, general

malaise, headache and myalgia.

 As it illness progresses, cough usually appears

• Non pharmacologic management

– Bed Rest, Adequate Hydration, Steam

– Increasing intake of vitamin C

• Pharmacologic management

– Symptomatic Rx: Paracetamol or NSAID

– Topical decongestants, Oral Antihistamines

– N.B: Avoid usage of antibiotics

 Acute bacterial rhinosinusitis
• Non-resolving acute viral rhinosinusitis with 10

days or worsening of symptoms after 5 days

• 2% of acute viral rhinosinusitis can complicate

with bacterial rhinosinusitis.

• Causes: Haemophilus influenza, Streptococcus

pneumococcus and Moraxella catarrhalis

 Acute bacterial rhinosinusitis…
• Clinical Features

– Purulent nasal discharge

– Anosmia, hyposmia

– High grade fever, malaise

– Sinus tenderness, maxillary dental pain

– Nasal obstruction

– Pressure/ Fullness in the face

 Treatment
• Non pharmacologic

– Nasal Saline Irrigation, Steam inhalation

• Pharmacologic

– Amoxicillin 1000 mg P.O., TID for 7days

– Amoxicillin-Clavulanate 875/125 PO BID / 7 days

– Azithromycin, children; 200mg/5ml P.O., daily for

3 days adults; 500mg P.O., daily for 3 days
 Allergic Rhinitis
• IgE mediated inflammatory response of the
nasal mucous membrane after exposure to
allergens

• Can be seasonal or chronic and perennial

• Can occur with other auto immune diseases

 Allergic Rhinitis…
• Clinical features
– Itching of the nose, eye, ear and throat

– Nasal obstruction, sneezing attacks

– A clear watery nasal discharge

– Watery eye discharge and red eye

– Darkening and puffiness of the lower eye lids

– Allergic crease across the nasal bridge

Allergic Rhinitis…
 Management
• Non pharmacologic

– Avoid exposure to Known allergens

– Nasal saline / Salt water Irrigation

• Pharmacologic (symptomatic management)

– Xylometazolinee, adults; 1% 2 to 3 drops 2-3

times into each nostril daily

– Cetirizine, adults; 10mg tab P.O., daily

 Management…
• Dexchlorpheniramine maleate, 6mg PO BID
Syrup for adults OR

• Momethasone Furate; Adults and Adolescents >

12 years: 2 sprays in each nostril once daily for
a period of one month
 Epistaxis
• Epistaxis is bleeding from the nose

• It is a common complaint

• It is rarely life threatening

• It can be classified as mild, recurrent or

sever/persistent
 Epistaxis…
• It can also be classified based on the cause as
local and systemic

• The local causes can be classified as anterior

and posterior

• 90% of the local case is anterior

 Epistaxis…
• Risk factors for epistaxis

– Digital manipulation of the nose

– Drug abusing (nasal sniffers)

– Acute rhinitis (common cold)

– Excessive use of nasal spray

– Smoking can cause nasal dryness

 Epistaxis…
Clinical features

• Symptom

– Anterior nasal bleeding or posterior nasal

bleeding from the throat

– If the bleeding is severe it can cause shock

• Sign

– Look for bleeding in the anterior nasal septum

 Epistaxis…
– Look for signs of systemic bleeding like
gingival bleeding, joint bleeding, petechia
rash, subconjunctival hemorrhage

– Blood vomiting in the case sever posterior

nasal bleeding due to swallowing

• Investigations : CBC, coagulation profile, liver

function test
Epistaxis…
 Managment
• For sever persistent epistaxis

– Resuscitation

– Stop/localize the bleeding

– Pinching the anterior aspect of the nose for 15

minutes.

– Cold compression over the major neck vessels

– Position the head forward (Tilt forward)

 Management…
– If not responding, apply cautery (silver nitrate
(Silver Nitrate + Potassium Nitrate, apply to
mucous membranes 2-3 times/week for 2-3
weeks) or electronic cautery),

– If not responding to cautery applies anterior

nasal packing

– Nasal packing can be Vaseline gauze

 Management…
– If the anterior nasal packing is not working,
the posterior nasal packing can be applied

• The posterior nasal packing can be inflation

of balloon or folly catheter.

– If no response with this, refer for surgery

• N.B. embolization or surgical ligation of the

offending vessels may be needed in sever case
 Management…

• Oral antibiotic for the prevention of toxic shock

syndrome among immunocompromised hosts,
diabetes mellitus, and advanced age

– Amoxicillin 250 – 500mg P.O TID 7 – 10 days

– Alternative; Amoxicillin/Clavulanate 625mg

P.O BID for 7-10 days
 Foreign bodies in the nose
• Common complaint in emergency department,
usually found in children in the 2 – 3 year age
groups and adults with mental disabilities.

• Usually the insertion is done while playing by

themselves, when left alone

• Foreign bodies can be classified as either

inorganic or organic
 Foreign bodies in the nose…
• Inorganic materials are typically plastic or metal
(e.g. beads, toys)

• Organic foreign bodies include food (peas,

beans, nuts), rubber, wood, sponges,…

• Button batteries (causes liqufactive necrosis)

• Magnetic NFB, living NFB (Larvea and worm)

• Most foreign bodies are right sided

 Clinical presentations
• Unilateral purulent • New onset snoring
rhinorrhea (common) • Chronic sinusitis
• Unilateral nasal • Unilateral facial
obstruction swelling
• Epistaxis • Sneezing
• Pain • Rhinolith
• Irritation
 Foreign bodies in the nose…
• Investigations

– Anterior rhinoscopy

– X-ray if you suspect radiopic foreign body

• Treatment: Non pharmacologic

– Remove the foreign body

– Prevent complications
 Removal techniques for NFBs
• Forced exhalation by occluding unaffected nose
• Mother‘s kissing; Provide a puff of forced exhalation
to the child mouth
• Direct instrumentation
• Hooked probs
• Ballon catheter (5-8 Fr)
• Suction
• Magnet, irrigation, posterior displacement
 Sinusitis
 It is Inflammation of mucosa of the sinuses

 Usually caused by infecting organisms:

• Streptococcus pneumonia , Haemophilus ,

influenza , and Moraxella , catarrhalis.

 Predisposing factors: allergies, frequent colds,

nasal obstruction

 Can be Acute or chronic

 Pathophysiology
• Normally sinuses are air filled cavities used for
resonation of sound
• Viral or bacterial infection of the nasal cavities
causes sinus tract obstruction
• Nasal congestion, caused by inflammation,
edema, and transudation of fluid, leads to
obstruction of the sinus cavities.
 Sinusitis…
Sign and Symptoms
• Facial pain or pressure over the affected sinus

• Nasal obstruction, fatigue, Poor appetite

• Purulent nasal discharge, fever, headache, a

decreased sense of smell, eyelid edema, or
facial congestion or fullness

• Ear pain & fullness, dental pain, cough,…

Sinusitis…
Treatment
• The goals of treatment is to treat the infection,
shrink the nasal mucosa, and relieve pain

– Humidified air; fluids

– Semi-Fowlers position

– Heated mist and saline irrigation also may be

effective for opening blocked passages
 Sinusitis…
Medications:
• Decongestants such as oxymetazoline
• Analgesics
• Antihistamines like Asprin
• Expectorants/ e.g Guaifenesin
• Antibiotics

Surgical interventions: Remove obstruction

 Acute tonsillitis
• Inflammation & enlargement of the tonsil tissue

• The commonest causes are viral

– Less likely; beta-Streptococci, Staphylococci,

Streptococcus Pneumoniae and Haemophilus

• It is very common up to the age of 15 years.

Risk factors: - URTI, Lowered immunity, Pollution

 Clinical features
– Low/high grade fever and possibly chills,
especially in children

– Persistent pain in the oropharynx or Naso

pharynx /Sore throat/

– Pain on swallowing /dysphagia/

– Opening the mouth is often difficult and

painful if it is complicated
 Clinical features…
– Systemic symptoms like headache and
marked feeling of malaise, chills, and rigor
– Inflamed and reddened enlarged tonsils
– Exudates are apparent in bacterial tonsillitis
– Tender cervical lymphadenopathy
• Diagnostic investigations
– History , P/E, Culture, CBC and ESR
 Acute tonsillitis…
Grading of tonsil enlargement:-

• 1+ = Visible

• 2+ = Halfway between tonsillar pillars and uvula

• 3+ = Touching the uvula

• 4+ = Touching each other.

Acute tonsillitis…
 Medical management
 Management is conservative for viral cases

 For bacterial tonsillitis

• First line : Amoxicillin 500mg PO TID for 10 days

• Cephalexin 500 mg PO BID x 10 days OR

• Amxoicillin – Clavulanate: 875/125 mg PO BID x

10 days) OR

• Benz. Penicillin 2.4Million IU IM divide stat

 Nursing interventions
– Analgesics such as paracetamol 1gm PO as

needed

– Tepid sponge

– Bed rest and soft diet

– Warm saline gargles

 Acute tonsillitis…
Complications:
– Peritonsillar abscess

– Paraphayrengial abscess

– Retropharyngeal abscess

– Septicemia

– Acute otitis media

– Chronic tonsillitis
 Peritonsillar abscess
• Collection of pus outside the tonsillar capsule

• Inadequately treated acute or chronic tonsillitis

can spread to the surrounding tissue and form

abscess

• It is usually unilateral
 Clinical features
• Severe pain such that the patient often refuses
to eat

• The head is held over to the diseased side, and

rapid head movements are avoided

• The patient has sialorrhea and oral fetor

• Swelling of the regional lymph nodes

 Clinical features…
• Fever with high temperatures of 39°C to 40°C
and general condition deteriorates rapidly

• Redness, and protrusion of the tonsil, the faucial

arch, the palate and the uvula

• Marked tenderness of the tonsillar area

Peritonsillar abscess…
• Treatment of peritonsillar abscess
– Drainage of the absccess and tosnillectomy

– Antibiotic, Oral hygiene

• Systemic complication
– Septicemia

– Rheumatic heart disease

– Post streptococcal plomerulonephritis

 Pharyngitis
Definition:- It is a febrile inflammation of the throat

Causative agent:-Viral organism 70%

- Group A streptococcus (most common)

Clinical features

–Red pharyngeal membrane & tonsil

–Enlarged & tender cervical lymph nodes

–Fever, malaise, & sore throat

Pharyngitis…
 Pharyngitis…
Diagnosis

• Clinical sign & symptoms

Differential diagnosis

• Tonsillitis , -Laryngitis ,-Diphtheria

Complications

• Otitis Media , Mastoditis, Meningitis

 Pharyngitis…
Medical treatment for bacterial causes

– Amoxacillin 500mg PO TID for 10 days

– Ampicillin 500mg PO QID for10 days or

– Erythromycin 500mg PO QID for 10days

 Pharyngitis…
Nursing Interventions
• Instruct bed rest during febrile stage of illness

• Liquid or soft diet during acute stage

• Warm saline gargles or irrigation to reduce

spasm in the pharyngeal muscle

• Acetaminophen 500mg 2 tabs at 6 hour interval

• Mouth care can be given

 Laryngitis
• It is an inflammation of the larynx often occurs
as a result of voice abuse, exposure to dust,
chemicals, smoke, & other pollutant.

Etiology:

• Almost always virus

• Bacterial invasion may be secondary

 Laryngitis…
Risk factors:

– URTI , Vocal misuse and over use

– Irritation /smoking, alcohol/ Seasonal changes

– Iatrogenic / intubations & laryngeal surgery /

– Usually associated with rhinitis or pharyngitis.

– It is common in winter & is easily transmitted

 Laryngitis…

Clinical manifestations
• Hoarseness or complete loss of voice

• Severe cough

• Pain occurs in severe cases

• Stridor may be present in children

• Edema, exudates, congestion

Laryngitis…
 Laryngitis…

Potential complications
• Sepsis

• Peritonsillar abscess

• Otitis Media

• Sinusitis
 Laryngitis…

Medical management
–Resting the voice

–Avoid smoking

–Bed rest

–Inhaling cool steam or aerosol

–Treat secondary bacterial infection

Nursing interventions
• Clearing airway and Voice rest

• Humidifying the environment /inhaling steam/

• Give analgesics

• Promoting communication

• Encouraging fluid intake

• Patient teaching –treatment regimen, prevention

• Monitor & manage potential complications

THANK
YOU‼