EYES

6 EXTRA OCULAR MUSCLES

1. Superior Rectus (upward)
2. Lateral Rectus (outward)
3. Inferior Oblique (upward & outward)
4. Superior Oblique (downward & outward)
5. Medial Rectus (inward)
6. Inferior Rectus (downward)
 LAYERS OF THE EYEBALL
1. Fibrous Tunic (outer layer)
a. Sclera
- tough outer layer; white=retracts light
b. Cornea
- transparent; bends or retracts entering light
2. Middle Layer (vascular tunic)
a. Choroid Black
- A very thin structure consisting of vascular network & many melanin containing pigment
cells.
b. Cilliary body
- Controls aqueous humor
- Continous with the anterior margin of choroid.
c. Iris
- Colored part of the eye
3. Inner Layer- (nervous tunic)-transmit light
a. Rods
- Receptors for dim or night
b. Cones
- Receptor for bright
- Color vision
CAVITIES OF THE EYE
1. Anterior Cavity (aqueous humor)
- Maintains the IOP
- nourishes the lens & cornea
- Transmit light rays
- Leaves the eye through trabecular meshwork and canal of schlemn
2. Posterior Cavity (vitreous cavity)
- Filled with clear gel-like substance
- maintains the shape of the eye
- Keeps retina attached to the choroid
- transmit light rays
Lens
- Transparent biconvex structure located directly behind the iris & pupil
- Retracts light rays to focus them on the retina
- Responsible for accommodation
Macula- Fovea Centralis
Orbit- bony part that contains the eyeball
VISUAL PATHWAY
Retina
Optic Nerve
Optic Chiasm
Optic Tract
Occipital Lobe
Diplopia- double vision
nursing mgt.= eye patch
pupil= 2-3mm.
Less than 2 mm= pinpoint pupil
Anisocoria= unequal pupil
PHYSICAL EXAMINATION
EYES
- Visual Activity/ Snellen’s Chart
- Visual Fields: Perimetry
- External Structures: Position/external structure of eyes, PERRLA
- Extra ocular movements
paralysis, Nystagmus
- Corneal Reflex
DIAGNOSTIC TEST
Snellen= visual acuity
Opthalmoscope= assess retinal problems
Biomicroscope/slitlamp= astigmatism, examine the anterior segment of the eye.
Tonometer= pressure of eyes
Ishihara Plate Test= color blindness, identify 3 colors
Cover/uncover Test= differentiate different types of strabismus.
PLANNING OF HEALTH PROMOTION
CARE OF THE EYES
Printed matter: 14’’ away
T.V.: 10-12 ft .away
Read with illumination 100-150 watts=light from behind

Teach about danger signals of visual disorder

- Persistent redness
- Continued pain and irritation especially after injury
- Children: crossing of eyes
- Blurred vision and/or spots before the eyes
- Growth on the eyes, opacities
- Continual discharge, crusting or tearing
PLANNING FOR HEALTH MAINTENANCE OR
RESTORATION
- Instillation of Eyedrops = lower conjuctiva. Just close eyes not squeeze
- Instillation of eye ointment= from inner to outer cantus
- Hot/cold compress
- Eye Irrigation= remove chemicals or secretions
- Massage the eyeball- in glaucoma
- Care of contact lens= do not wear when swimming
DISORDERS
- Injuries & Trauma
- Infections
- Cataract
- Glaucoma
- Detachment of retina
- Refractive errors
- Macular degeneration
EMERGENCY
- Treat the patient, leave the eye alone except in chemical injury . Flush eyes STAT
- Foreign Bodies= flush with H2O for 15 mins. while going to the Dr.

INFECTIONS: EYELID DISORDERS

BLEPHARITIS = inflammation of eyelid margins
= eyelashes fallout, burning and itching
HORDEOLUM= pustular infection of eyelash follicle
= painful, red, swelling of eyelid margin
= commonly caused by staphylococcus
CHALAZION = meibomian glands
= painless, slow-growing, hard, non tender round mass on the eyelid
DISORDERS OF THE CONJUNCTIVA, SCLERA &
CORNEA
CONJUNCTIVITIS = inflammation of conjunctiva
TRACHOMA = chlamydia trachomatis
= pustular infection of eyelash follicle
= painful, red, swelling eyelid margin
= staphylococcus
DRUGS: sulfonamides
tetracyclines
erythromycin
SCLERITIS/IRITIS= very red eye, painful to move

KERATITIS
Assessment: Pain
Photophobia
lacrimation
blepharospasm
↓ vision
DRUGS: Trifluridine
Idoxuridine
Adenine Arabinosid
CORNEAL ULCERATION
medical emergency
- May result to corneal perforation, scarring or intra ocular infection= permanent
impairment of vision
CAUSES: trauma
allergy
Vit. A Defficiency
bacterial, viral , fungal infection
Corneal Opacity
lack of corneal transparency due to inflammation, ulceration or injury
CORNEAL TRANSPLANTATION
repairs corneal opacity, perforation of corneal ulcer

Considerations:
- Donor eyes for the transplant should come from cadaver
- Ideally, donated eyes are transplanted immediately or removed from the body
w/in 24hrs. Of death.
- Cornea may still be viable w/in 12hrs. after death if the body is refrigerated 2-8
hrs.
- May be transplanted up to 48 hrs. after death if it is kept in a sterile container on
a piece of gauze soaked in NSS at 4°C
UVEAL TRACT DISORDERS
- Middle vascular layer of the eye contributing to the Retina’s blood supply. It is
composed of iris, ciliary body & choroid
UVEITIS
- inflammation of the uvea — the middle layer of the eye that consists of the iris,
ciliary body and choroid.Uveitis can have many causes, including eye injury and
inflammatory diseases.
- IRITIS=inflammation of the iris
- IRIDOCYCLITIS= inflammation of the iris & ciliary
- CHOROIDITIS= inflammation of the choroid
- CHOROIRENTINITIS= inflammation of the choroid & retina
CAUSES:
- Local or systemic disease
- Injury
- Unidentified factors
ASSESSMENT
- pain in the eyeball radiating to the forehead & temple.
- Blurred vision
- Photophobia
- Redness of eyes w/o purulent discharge
- Small pupil
- Lacrimation
COLLABORATIVE MNGMT.
MYDRIATICS (Atrophine Sulfate)
- To dilate pupils
- To prevent adhesion between the anterior capsule of the lens and iris
- To relieve pain and photophobia
- To reduce congestion
- To rest the iris & ciliary body
STEROIDS
DARK GLASSES
ANALGESICS
SYMPATHETIC OPTHALMIA
- A rare severe bilateral, granulomatous uveitis of unknown cause
- Occurs anytime from 10 days to several years following penetrating injury near
the ciliary body or following a retained foreign body.
- Leads to bilateral blindness
ASSESSMENT
- Inflammation of the injured or previously operated eye
- Photophobia
- Blurred vision
COLLABORATING MANAGEMENT
- ENUCLEATION
- Done if w/ perforation of sclera and ciliary body, vitreous humor loss, retinal
damage
- Removal of the eyeball
EVISCERATION
removal of the entire eyeball contents & cornea except the sclera.
EXENTERATION
removal of the eyelid, eyeball and orbital contents
STEROIDS
LOCAL ATROPHINE
RETINAL DISORDERS
RETINITIS
- Inflammation of the retina
- Often associated with diseases of the choroid
- Caused by bacteria, fungi, toxoplasmosis, cytomegalovirus
- Assessed through opthalmoscope
ASSESSMENT
- Reduced visual acuity
- Changes in the visual field
- Alterations in the shape of object
- Discomfort in the eyes
- photophobia
COLLABORATIVE MANAGEMENT
- Rest the eyes
- Protect eyes from light
- Atrophine sulfate
EXTRA OCULAR
STRABISMUS
involves a lack of coordination between the extra ocular muscles
eye deviation esotrophia
exotrophia
hyperterophia
hypotrophia
COLLABORATIVE MANAGEMENT
- Corrective eyeglasses
- Surgery
- Mini-tenotomy
General Pre-op Care
- Orient the client to the staff and environment if both eyes will be covered.
- If child, practice covering the eyes
- Administer mydriatics/cycloplegics
Isopto Atrophine, Ocu-Iropine, Atropine Sulfate
Cyclomydril, cyclogyl
scopolamine
mydriacyl
Post-Op Care
To prevent/relieve the following :
- Increase in IOP
- Stress on the suture site
- Hemorrhage into anterior chamber
- Infection
- Pain
A. Position the client on supine or turned to the unaffected side
B. Burning sensation is normal about one hour after surgery
C. Eye patch and eye shield (during the night 4 wks.) for 5-7 days
D. sensation of pressure w/in the eyes & sharp pain in the eyes
D. the client should be instructed to avoid the following to prevent increase IOP
- rubbing of eyes
- sudden jerky head movement
- sneezing, coughing
- nausea & vomiting
- straining at stool
- bending or stooping
- heavy lifting
- reading
- watching fast moving objects
E. Administer Miotics as prescribed:
- Carbotic (carbachol)
- Humorsol (Demecarium Bromide)
 - floropyl (Isoflurophate)
- Isopto Corpine (Pilocarpine HCL)
F. the feeling of “something in the eye”= 4-5 days is normal
CATARACT
- Opacity on the lens and its capsule which interferes with transparency
S/Sx:
- Dimness in visual acuity
- Rapid and marked corrections of refraction error
- Hazy vision= pathognomonic sign
Classifications :
- primary/senile
- Traumatic
- Congenital
- secondary
Treatment
Intracapsular Extraction=lens & capsule
Extracapsular Extraction= lens only
Cryoextraction= probe cooled to 0°C
Phacoemulsification= probe vibrates
Intra ocular lens=synthetic
EYE SURGERY
CARE PRE-OP
- orient to new environment
- eye antibiotics
- mydriatics if ordered= 1hr pre-op
CARE POST-OP
- re-orient patient to his surroundings
- prevent increase in IOP and stress on the suture line
ACTIVITIES THAT INCREASES IOP:
- coughing
- Brushing
- vomiting
- stooping
COMPLICATIONS:
A. Nausea & vomiting
=antiemetics
= cold compress
 B. Hemorrhage
= sudden pain of the eyes
C. Prolapse of the iris
= most common post-op complication
= can precipitate to glaucoma
HEALTH TEACHINGS
1-4 wks.: dark glasses or corrective lens
6-18/12wks: permanent lenses or contact lenses
Use one eye at a time unless with contact lens
Decrease peripheral vision
GLAUCOMA
↑ IOP
Progressive loss of peripheral vision
Cause: obstruction to circulation of aqueous humor
Types:
1. Chronic
simple, wider or open angle
Ex. Hereditary (thickening of trabecular meshwork)
Narrowing of Canal of Schlemm
2. Acute
narrow angle or close-angle
Ex: Infection (uveitis), injury or trauma
CHRONIC GLAUCOMA
S/Sx:
- loss of peripheral vision (TUNNEL VISION)= pathognomonic sign
- Difficulty in adjusting to darkness
- Failure to detect changes in color
- Headache, pain behind the eyeball
- Halos
- N/V
- Persistent dull eye pain in the morning
Mgt.
A. Conservative:
MIOTICS= pupillary constriction
draw iris smooth muscle away from the canal
given early AM

Acetazolamide= decrease aqueous production

potent carbonic anhydrase inhibitor

Fluid Restriction
B. Aggressive
Iridencleisis= a surgical procedure especially for relief of glaucoma in which a
small portion of the iris is implanted in a corneal incision to facilitate
drainage of aqueous humor.
Corneoscleral Trephening= formation of a drainage hole through the
corneoscleral junction into the anterior chamber to allow the outflow of
aqueous humor into the subconjunctival vasculature and lymphatics.
Trabeculectomy= A piece of tissue in the eye's drainage angle is removed to create
an opening. This new opening allows fluid (aqueous humour) to drain out of
the eye.
= for children only
Laser therapy to Meshwork
Trabeculectomy
- OPD
- 45-60 mins
- eyedrops anaesthetic—injectable
- Mitomycin-C=anticancer drug=prevents scarring=prevents
trabeculectomy to function long term
- blurry vision on the first 1-2 wks. is normal/ pain in the eye after surgery
- eyedrops (antibiotics& anti-inflammatory) a day after surgery
- avoid strenous activities—office work =2 wks., heavy work= 2mos. Or
.more
ACUTE ANGLE GLAUCOMA
Cause:
- pupillary dilation by mydriatics
- abnormal anterior displacement of iris
S/Sx:
- rapid onset of severe eye pain
- N/V
- blurred vision
- halos around light
- dilated pupils
Mgt.
Miotics
Diamox ( Acetazolamide)
Osmotic agent—glycerol
Surgery= Iridectomy
Nursing Care Surgery
Pre-op:
- explain that vision loss cannot be restored but further damage can be
prevented.
Post-op:
- Flat 24h
- turn to unoperative side
Long term care:
- Medical follow-up needed for life
- No fluid restriction—exercise permitted
no restriction on the use of the eyes

RETINAL DETACHMENT
- Fluid accumulation
- Tumor
Cause:
- Myopic degeneration
- Trauma
- Hemorrhage
- Aphakia
S/Sx:
- Floating spots
- Curtain—veil like vision=pathognomonic sign
- Casts shadows in the retina
- Bright flashes of light
- Progressive constriction of vision in 1 eye
Mgt.:
Conservative
- In bed with eyes covered
- Photocoagulation– small burn to retina
- Cryotherapy– cold probe to freeze retina.
Surgical:
Scleral Buckling= sealing and reattaching the retina

Nursing Care:
Post-op
- Cover eyes
- area of detachment dependent
- mydriatics
- Discharge instructions= no strenuous activities for 6 weeks.
REFRACTIVE ERRORS
Refraction= bending of light rays
Accommodation= near/far vision
Adaptation= ability to see light from darkness

Common Errors
- Myopia
- Hyperopia
- Presbyopia
- astigmatism
MYOPIA
- Near sighted
- Long AP dimension of the eyeball
- Light rays focus in front of the retina
- Good vision for concave lenses
HYPEROPIA
- Far sighted
- Eyeball AP dimension too short
- Light rays focus behind the retina
- Good vision for far distances
- Convex lenses
PRESBYOPIA
- Farsightedness of old age
- Gradual loss of accommodation
- Loss of lens elasticity
- Inability to read w/o holding the material more than 13 “., from the eye
- Bifocal lenses
ASTIGMATISM
- Assymetry or irregular curvature of the cornea
- Cylindrical lenses
- Vision 20/200
REHABILITATION OF BLIND EYE
- Orient to the environment
- Promote independence
- May have a guide dog or use cane
- When approaching talk before touching
- Talk to the patient frequently
- Do not change location of objects without describing the change
- Promote safety
- Advise about gifts for blind person—suggest gifts that appeal to senses other than
vision
MACULAR DEGENERATION
- A loss of vision in the center of the visual field (macula) because of damage to
retina
- Difficult or impossible to read or recognize faces
DRUGS
- Anti-angiogenics or Anti-Vascular Endothelial Growth Factor= 1-2x/month
S/Sx.:
- Visual acuity drastically decreasing
- Blurred vision
- Centraled Scotomas= pathognomonic sign
Diagnostics:
- Amsler Grid
- Flourescein Angiography = allows for the identification & localization of abnormal
vascular processes.
Nursing Intervention:
- Orient with the environment
- increasing carotenoids, lutein zeaxanthin
- Products with Omega-3
EARS
External Ear
- Auricle/Pinna
- External Auditory Meatus/Canal
- Tympanic Membrane
Middle Ear
- Ausicles: Malleous, Incus, Staps
- Eustachian tube
- Mastoid
- Windows: oval & round
Inner
- Organ of Corti—Cochlea—Hear
Vestibular Apparatus
- Balance
- 3 semicircular canals
- Saccule & utricle
Anatomy/Physiology of Ear
1. Sound waves to tympanic membrane
2. Ossicles in motion
3. Vibration from stapes to oval window
4. Cochlea: Organ of Corti
5. Temporal lobe: cranial nerve 8
AUDITORY ASSESSMENT
External Ear Examination
- Inspection & palpation of auricle
- Visualization: straighten the auditory canal
Normal Eardrum= shiny
pearly gray in color
slightly conical
Hearing Test
- Test for acuteness or degree of deafness
- Whisper or spoken voice test
Audiometer:
- Pure tone= measure loudness in decibel
- Speech= ability to understand and discriminate
Watch Tick Test
Tuning Fork Test = test to localize cause of deafness
- Schwabach’s
- Rinne’s
- Weber’s
SCHWABACH’S TEST
- Bone conduction vs hearing loss
- Tuning fork @ patient’s mastoid until the patient hears no sound
- TF is transferred to examiner’s ear
- Normal=no sound heard
- Abn= sensorineural hearing loss
RINNE’S TEST
- Sound heard better: air vs bone
- N= +: air conduction is better
- -Abn= negative: bone conduction better= conductive hearing loss
WEBER’S TEST
- TF top midline of the head
- Sound heard: normal ear vs. affected ear
- Better in affected ear: conductive
- Better in normal ear: sensori neural
TEST FOR VESTIBULAR FUNCTION
Caloric test (occulo vestibular test)
- - check direction of the nystagmus
- COWS= cold opposite: warm side of stimulated ear
Rotation (Barany) test
- Rotating chair
- Nystagmus is opposite to the direction of the rotation
HEALTH PROMOTION
Ear Protection
- Noise over 10 decibels is potentially damaging to hearing
- Most common & important type of occupational hearing is caused by loud noise.
General Ear Care
- Ear is self cleaning
- Cerumen- lubricant: traps dirt
- Keep eyes, mouth open while blowing the nose
- Cleanse the external ear reached by vision
Nursing Intervention
Ear Drops
- Warm
- After administration head should remain tilted
Softening & Removing Impacted Cerumen
- Few drops of hydrogen peroxide
- Irrigate the ear
Ear Irrigation
- To clean the external canal
- Removed impacted cerumen
- Caloric tests
- Apply antiseptic soln’s.
SYMPTOMS OF EAR DISEASES
Deafness
- Hearing loss may be mild or severe
- Conductive or sensori-neural or mixed types
- Child= otitis media
- Adult= presbycusis
Pain
- children=otitis media, Adult= otitis externa
- From the ear itself
Discharge
- May be mucoid, purulent or bloody
- Common cause= otitis externa/media
Vertigo
- Form of diziness= spinning sensation
- Vestibular system is diseased
Tinnitus
- Noise in the ear, high pitched whistle to the clanging of bells or recognizable
scratches of music
COMMON EAR PROBLEMS
1. Otosclerosis
- Normal bone is replaced by spongy bone
- Ankylosis of the foorplate of the stapes
ASSESSMENT
- Gradual hearing loss
- Difficulty hearing a whisper
Paracusis: hear better in loud environment
Rinne’s Test: bone conduction better
Planning & Implementation
- Hearing aid
Surgery= is the primary form of treatment
- Stapedectomy
- Stapes mobilization operation
- Febestration operation= new window is created
DIFFERENT TYPES OF EAR SURGERIES
Myringoplasty= closure of tympanic membrane
Tympanoplasty= closure of perforated in tympanic membrane, middle ear is involved
Ossiculoplasty= ossicular construction
Stapedectomy= use of laser to create a hole and prosthesis is placed in the hole
Labyrinthectomy= removal of the membranous labyrinth through the oval window.

EAR SURGERY
Pre-op Care:
- Hair shampoo
Inform Client:
- Head still during surgery
- Post-op= get out of bed w/ assistance,
- Avoid nose blowing until 1 week.
Post-OP
Promote comfort and safety
- 24H bed rest
- lie on unopperated side
- No t.v. or fast moving objects
- Pain reliever
- Gradual ambulation with assitance
- Blow nose with 1 side at a time
- Change cotton ball in ear daily
- Do not shampoo hair for 1 week
- Avoid high altitude for 1 week
Psychological Well-being
- Slushing with-in the ear= report to the doctor
Complication
- Facial nerve involvement
- Facial paralysis
- Inability to show teeth
- Bacterial meningitis=report s/sx.
- Bleeding
Discharge Planning
- Discharged w/ dressing
- Avoid sudden head movement
- No elevators
- Avoid people with URTI
MENIERE'S DISEASE
- Chronic
- Increase endolymphatic disease
Assessment
- Tinnitus
- Unilateral hearing loss
- Vertigo
Planning
- Conservative: palliative
Bed rests
Meds: Sedative: phenobarbital
antihistamine
LOW SALT DIET
Surgery
- Delayed after client’s hearing below serviceable level
- Deconstruction of labyrinth
- Decompression of endolymphatic sac
- Suctioning of vestibular nerve
- Cryosurgery of the labyrinth
Types of Hearing Loss
CONDUCTIVE
- Damage to the conduction system (Vestibule)
- Hearing aid is useful
SENSORINEURAL
Damage to:
- Organ of Corti
- Cochlear Nerve
- Acoustic branch of auditory nerve
ASSESSMENT
- irritable/hypersensitive
- Difficulty ff. directions
- Complains people mumbling
- Turns up volume on t.v.
- Asks for repetition
- Assumes questions inappropriately
- Complains ringing of ears
- Dominates conversation
Communicating w/ hearing –impairment
- Avoid use of gestures w/o speech
- Speak distinctly/close to the client
- Use short phrases
- Do not whisper w/ someone in front of a hearing impaired client.
- Do not smile, do not chew gum or cover mouth while talking.
Sound Amplication
Hearing Aids: Post-auricular
Body-type
In-ear Model