Chapter 15

Disorders of the Eyes and Ears

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 Objectives (Eye):
• Describe the refractive disorders that impair vision
• Define strabismus, nystagmus, diplopia, ptosis
• Explain the eye infections discussed in lecture, their etiology, signs and symptoms
• Describe the pathophysiology of the increased intraocular pressure in glaucoma and explain how this
damages eye structures. List the signs and symptoms associated with each subtype of glaucoma.
• Explain the signs, symptoms and pathophysiology of macular degeneration
• Explain the pathophysiology of retinal detachment. Be familiar with the risk factors, signs and
symptoms for this disorder

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 Objectives (Ear):
• Explain the pathophysiology of Otitis Media
• List the signs/symptoms of Otitis Externa
• Explain the pathophysiology and characteristics of Meniere’s Disease
• Differentiate between Conductive and Sensorineural Deafness (etiologies and treatments)

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Disorders of the Ears

Infectious Ear Disorders

 Otitis Media
 Otitis Externa

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Otitis Media:

Otitis media is an inflammation or infection of

the middle ear cavity

Important Structural Anatomy:

• The mucosa of the middle ear cavity is
continuous with the mucosa lining the
nasopharynx.
• Usually the auditory tube (aka Eustachian tube)
is patent allowing fluid from the middle ear to
drain into the nasopharynx and allowing air to
freely enter the middle ear cavity from the
nasopharynx
• When the auditory tube is open there is equal
air pressures on both sides of the tympanic
membrane.

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Pathogenesis of Otitis Media:
• Mucosal congestion secondary to Upper Respiratory Infections or Allergies can lead to obstruction of the Auditory
Tube
• Obstruction of the Auditory tube leads to a buildup of fluid in the Middle Ear Cavity and the retained fluid can become
secondarily infected with bacteria
• Common bacterial causes of otitis media include Haemophilus influenza and pneumococcus

Normal
Tympanic Otitis
Membrane Media

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Otitis Media cont.

The auditory tubes in young children are more prone to becoming obstructed due to their shorter length and
more horizontal orientation

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Symptoms:
• Serous otitis media…i.e. when the fluid collecting in the middle ear cavity is still sterile is often asymptomatic
• However, once bacterial superinfection occurs and acute otitis media ensues, the child will usual complain of
• Severe pain (otalgia)
• Child is usually very distressed and pulling at the affected ear
• Feeling of fullness in the affected ear and
• Reduced hearing in the affected ear
• Fever and general malaise may be present
• Note: During an acute episode of Acute Otitis Media, the child will have a temporary conductive deafness in the affected
ear. This deafness will resolve after treatment of the infection.

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Diagnosis of Otitis Media:
Tympanostomy tube in place
Acute Otitis Medial can be diagnosed by visualizing the
inflamed bulging tympanic membrane with purulent fluid
often visible behind the bulging membrane (see photo on
previous slide)

Treatment:
• Antibiotics may need to be used if there is significant
bacterial superinfection, though the goal is to avoid use
of antibiotics whenever possible
• Decongestants and antihistamines are helpful to reduce
swelling and re-open the auditory tubes
• Ibuprofen and Tylenol are used for discomfort
• For children with recurrent ear infections a temporary
tube may be placed though the tympanic membrane
• The tube will allow equalization of pressures on both
sides of the membrane and allow fluid to drain.

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Otitis Externa:

Otitis externa is an inflammation or infection

of the External Auditory Canal

Important Structural Anatomy:

The External Auditory Canal is open to the air (and
water) and ends at the Tympanic Membrane.
Otitis Externa is often referred to as “Swimmer’s
Ear” as water can freely enter this canal as far as
the Tympanic Membrane when swimming and
showering.

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Otitis Externa:
The key difference between otitis media and otitis
externa therefore is the part of the ear that is
infected.
Pathogenesis/Etiology:
Otitis Externa usually occurs as a result of bacteria
being introduced into the ear:
• when swimming,
• cleaning the ears or
• wearing frequent ear plugs

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Symptoms of Otitis Externa:
• Initially there is usually itching and irritation in the external Otitis Externa
auditory canal
• Later, ear pain (may get very severe) develops and
• Purulent discharge drains from the canal
• There will be reduced hearing due to temporary reduction in
sound conduction through the canal
• Pain is aggravated by pulling on the pinna (this helps differentiate
otitis externa from otitis media

Treatment:
• Topical antibiotic ear drops
• Corticosteroid ear drops may be added to decrease swelling
• Later eardrops containing a dilute acetic acid may be used to
prevent recurrences
• Clients will be educated to avoid predisposing factors (keeping ears
dry… avoiding instrumentation etc.)

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Disorders of the Ears

Meniere’s Disease

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Meniere’s Syndrome:

Meniere’s Syndrome is an inner ear (labyrinthine) disorder

Usually it effects one ear and begins in otherwise healthy adults between 30 and 50 years of age

• Presents as acute attacks of extremely severe vertigo

• Each attack lasts minutes to hours
• There is associated tinnitus (tinnitus may persist after the vertigo attack has resolved)
• There is also an associated feeling of fullness in the ear during attacks
Pathophysiology:
Excessive endolymph accumulates within the labyrinth
This excess fluid would stretch the fragile membranes within the vestibule and cochlea
The acute episodes of vertigo are thought to occur when a small rupture occurs in the membrane holding the
endolymph.

Etiology:
The etiology is unknown

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Treatment of Meniere’s:
There is no specific treatment for Meniere’s
Medications such as meclizine (Bonine) can be used
for symptom relief during acute attacks

• The disorder has an unpredictable outcome with

a tendency for attacks to recur
• Acute episodes occur over several months,
usually followed by a period of relief
• There can be a lifelong tendency for cycles of
episodes to recur - but episodes can completely
stop occurring

Recurrent attacks can lead to damage to the hair

cells which can lead to impairment of hearing and
balance

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Disorders of the Ears

Deafness

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Causes of Hearing Loss:
Hearing loss has two main categories of etiology
• Conductive hearing loss and
• Sensorineural hearing loss

Conductive deafness occurs when sound is not transmitted (and amplified) through the external and middle ear
cavities.

Sensorineural deafness occurs when there is damage within the Organ of Corti or to the Cochlear section of the
Vestibulocochlear Nerve.

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Causes of Conductive deafness:
• Accumulation of wax in the external auditory canal
• Fluid in the middle ear (otitis media)
• Scar tissue on the tympanic membrane (make is stiffer
and reduces its ability to transmit vibrations to the
malleus)

Causes of Sensorineural deafness:

• Loud noise (even a single exposure to excessively loud
noise can permanently damage some hair cells)
• Ototoxic drugs (usually preceded by tinnitus)
• Presbycusis (age related hearing loss in elderly people,
usually due to a reduction in the number of hair cells
in the cochlea)
• Congenital deafness – may be due to infections
acquired in utero - such as rubella
• Note: Tinnitus which is a ringing or buzzing sound in
the ears if often associated with the early stages of
sensorineural deafness
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Treatment of Hearing Loss:
• If possible the cause of the reduced hearing is resolved…… such as impacted cerumen or otitis media
• Hearing aids can be helpful to amplify sound to stimulate the auditory nerve
• Cochlear implants – sound is picked up by an external microphone and bypasses many of the ear structures to
stimulate the cochlear nerve directly
• Profoundly deaf children can have excellent success with a cochlear implant provided it is implanted while they
are young (preferably aged 2 to 3)

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Refractive and Movement Disorders of the Eyes

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 Myopia (before and after correction)

Refractive Disorders in the Eye:

Myopia: (nearsightedness) The image is focused in front of the

retina. (as though the eyeball is too long)
• In this diagram the red line is indicating the line of focus for the
image in the uncorrected myopic eye.
• Note that the focal point is in front of the retina

After correction with a concave shaped lens note how the light rays
are now focused correctly on the retina

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Refractive disorders in the Eye cont: Hyperopia (before and after correction)

Hyperopia: (farsightedness) The image is focused behind the

retina. (as though the eyeball is too short)
• In this diagram the red line is indicating the line of focus for the
image in the uncorrected hyperopic (farsighted) eye.
• Note that the focal point is behind retina

After correction with a convex shaped lens note how the light rays
are now focused correctly on the retina

Presbyopia:
Note: Presbyopia refers to farsightedness associated with aging.
This is the condition that causes the need for reading glasses in
older people (usually over the age of forty)
This condition occurs as a result of age related loss of elasticity in
the lens.

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 Astigmatism
Refractive disorders in the Eye:
Astigmatism: (difficulty with depth perception)
• Astigmatism refers to irregular curvature in the cornea.
• This results in blurred vision and altered depth perception
• This can occur in addition to near or farsightedness

Treatment of Refractive disorders:

• Refractive disorders are corrected by using artificial lens to adjust refraction
(contact lens or spectacles)
• Astigmatism is usually corrected with special contact lens that conform to the
abnormal curvature (toric contact lens)
• In addition to corrective lens (contacts or spectacles) LASIK may be used to
correct Myopia, Hyperopia and/or Astigmatism.

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 Strabismus
Movement disorders in the Eye:

Strabismus: (cross eye) refers to deviation of

one eye …results in the symptom diplopia (i.e. double vision)
• Strabismus can be due to a neurologic defect – cranial nerve palsy or
• an abnormal external ocular muscle (weak or hypertonic muscle)

Nystagmus: Involuntary oscillating (jerking back and forth) movement of the eyes.
• This results from a neurologic cause (e.g. cerebellar lesions) or inner ear disorder (may occur with vertigo due
to cerebellar or inner ear dysfunction)

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Movement disorders in the Eye cont:

Diplopia (double vision):

• This can be due to trauma to cranial nerves- resulting in
paralysis of extraocular muscles
• Also can be due to stroke

Ptosis: (Droop of upper eyelid)

• May be seen secondary to problem with CN III
(oculomotor nerve)
• Myasthenia Gravis is commonly associated with ptosis

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Glaucoma

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Glaucoma:
• Glaucoma results from increased intraocular pressure caused
by an excessive accumulation of aqueous humor
• This can occur as a result of increased production or
decreased drainage
• Note: Glaucoma is the most common preventable cause of
loss of vision in developed countries

Pathophysiology:
• Increased pressure in anterior cavity is transmitted back to the
posterior cavity
• Pressure on retina and optic nerve causes ischemia and
atrophy of retina
• Changes are irreversible and can cause blindness

Symptoms
• Unfortunately early chronic glaucoma may be asymptomatic
• Reduced visual acuity
• Pain may occur but only if the IOP (intra- ocular pressure) is
greatly increased in the acute form 27
Acute (Narrow-Angle) Glaucoma:
• 10% of cases
• Angle between cornea and iris is decreased
• Iris is pushed forward and to side
• Outflow of aqueous humor is blocked
• Acute glaucoma can develop
• Sudden marked increase in IOP
• May be triggered by pupil dilation (e.g. drops used
to dilate eye for optometry retina check)
• Decongestants can also trigger an acute attack
• The decrease in the angle may have been caused
by aging, congenital abnormalities, or scar tissue
from trauma/infection

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Signs and Symptoms of Acute (Narrow-Angle) Glaucoma:
• May present acutely with sudden ocular pain
• Due to high acute development of high ocular pressure
• Other symptoms seen
• Halos around lights
• Red eye
• Decreased vision
• Fixed, mid-dilated pupil (see patient’s right eye in this picture)
• Nausea vomiting
• Acute Glaucoma is a Medical Emergency

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Treatment of Acute (Narrow-Angle) Glaucoma:
• Surgery:
• Iridotomy
• Laser trabeculoplasty
• May remove part of the iris

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Chronic (Open-Angle or Wide Angle) Glaucoma:
• This has a higher incidence after the age of 50 years
• 90% of glaucoma cases are secondary to this condition
• There is thickening of the trabecular network and blockage
of the Canal of Schlemm
• This interferes with the resorption of aqueous humor

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Signs and symptoms of Chronic (Open-Angle or Wide Angle)
Glaucoma
• Has insidious onset – no acute attacks
• Painless
• Picked up by routine screening
• The increase in pressure causes corneal edema – interferes
with light refraction and can get blurring of vision an halos
• Gradual visual field loss – initially peripheral vision is lost.
This pattern of visual loss is often referred to as “Tunnel
Vision”

Treatment:
• Eye drops to decrease production of aqueous humor
• Eye drops to constrict the pupil
• Laser trabeculectomy (this procedure deepens the anterior
chamber …. Increasing the drainage of aqueous humor

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Infectious Eye Disorders

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Eye Infections:

Hordeolum: (Stye)
• A hordeolum is an infection involving meibomian or sebaceous
glands around the hair follicles on either eyelid
• Usually staphylococcal
• Swollen red mass forms on the eyelid
• Purulent drainage occurs

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Eye Infections:

Conjunctivitis: (pink eye)

Note: the conjunctiva lines the inside of the eyelids and
continues to cover the sclera (does not encroach on the
cornea)
• Conjunctivitis is a superficial inflammation or infection
of conjunctiva with redness, itching, and excessive
tearing
• +/- purulent discharge or swelling
Etiologies:
Infectious agents
• Bacteria
• Contact lens are a frequent source of infection
• Viruses
• Associated with the common cold viruses

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Conjunctivitis Etiology cont:
• Bacterial causes – more purulent discharge
• Staphylococcus aureus
• Frequently occurs in children
• Sclera and eyelid appear red; purulent
discharge
• Spread by fingers or contaminated towels
• Occurs with contact lens use
• Contaminated makeup etc.
• Antibiotics are used to treat and prevent
damage to the cornea

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Keratitis:
• Keratitis refers to inflammation of the cornea
• Severe pain an photophobia
• Important: There is real risk of ulceration of cornea with
scar tissue formation and resultant loss of vision

Etiology of Keratitis: Corneal abrasion seen with Fluorescein

• May be due to trauma for example corneal abrasion due
to contact lens (fluorescein stain will show defect in the
cornea
• Chemical irritation
• Viral infection – Herpes Simplex
• Infection from contact lens (pseudomonas)

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Degenerative Eye Disorders

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 Cataract
Cataracts:
• A cataract is an opacity in the normally clear LENS
• This will interfere with passage of light trough the lens
and therefore will impact vision
• Associated with age related degeneration but can be
accelerated in diabetes
• Excessive exposure to sunlight increases the risk

Symptoms / Treatment
• Blurred vision – progressive
• Night driving is especially difficult
• When this becomes severe enough to interfere
with functional vision the lens can be removed
and replaced with an artificial lens

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Detached retina:
Pathophysiology:
Retinal Detachment is an acute emergency
• Retina tears away from the underlying choroid
• Tear allows vitreous humor to flow behind the retina
• Therefore an increasing portion of the retina is lifted away from the
choroid
• Retinal ischemia develops
• Can lead to irreversible loss of receptors (rods and cones)

Signs and Symptoms:

• There is no pain or discomfort
• However, the visual field will contain areas of blackness (scotomas)

Risk Factors:
• Severe myopia
• Trauma
• Older age Scotoma

Treatment:
• Will involve surgical reattachment of the retina by the opthalmologist
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Macular Degeneration: fovea
Age-related macular degeneration (AMD) is a common
cause of visual loss in older people
Note: The macula is the area of sharpest vision in the retina

Etiology:
• Unknown
• However, a combination of these genetic and environmental
factors increase the risk
• Age
• Caucasian
• Female
• Smoker
• Diet poor in vegetables
• Excessive exposure to UV light

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Macular Degeneration:
Two main Types:
• Dry or atrophic (90%)
• More common – deposits from in retinal pigment cells
• Wet or exudative (10%)
• Neovascularization
With both types there is interference with transfer of nutrients from
the choroid to the retina

Symptoms:
• No pain
• Central vision becomes blurred and is gradually lost

Treatment:
• Changes are irreversible
• For the wet subtype laser surgery may have a role to destroy new
blood vessels (new drugs are under development to slow the
neovascularization
• For the more common dry subtype a nutrition assessment is done
to ensure that vitamin and mineral intake is adequate.

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