SPECIAL SENSES THE EYE I.

REVIEW OF ANATOMY AND PHYSIOLOGY

8. Iris - control how much light goes through the pupil (lets light enter the eye); highly vascular

Figure 1: External Structure of the Eye

Parts: 1. Eyeball or globe sits in a protective bony structure (orbit) surrounded on three sides by the sinuses: ethmoid (medially), frontal (superiorly), and maxillary (inferiorly) 2. Eyelids - protect the anterior portion of the eye. With every blink of the eyes, the lids wash the cornea and conjunctiva with tears. 3. Lacrimal glands produce tears (secreted in response to reflex or emotional stimuli) 4. Conjunctiva - a mucous membrane, provides a barrier to the external environment and nourishes the eye. The goblet cells of the conjunctiva secrete lubricating mucus. The bulbar conjunctiva covers the sclera, whereas the palpebral conjunctiva lines the inner surface of the upper and lower eyelids. The junction of the two portions is known as the fornix. 5. Sclera - helps to maintain the shape of the eyeball and protects the intraocular contents from trauma. The sclera may have a slightly bluish tinge in young children, a dull white color in adults, and a slightly yellowish color in the elderly. 6. Cornea - main refracting surface of the eye 7. Pupil part where light enters the eye. pupillary muscle and sphincter Its size is controlled by

Source: Brunner & Suddarths Textbook of Medical-Surgical Nursing (2009)

Figure 2: Internal Structure of the Eye

Source: Childrens Hospital Boston (www.childrenshospital.org)

9. Lens accomodation (focus & refocus); continues to grow throughout life, laying down fibers in concentric rings. This gradual thickening becomes evident in the fifth decade of life and eventually results in an increasingly dense core or nucleus, which can limit accommodative powers. 10. Vitreous humor filled with a clear, jelly-like material; forms two thirds of the eye's volume and gives the eye its shape (posterior to the lens); shrinks & shifts w/age 11. Anterior chamber - the space between the cornea and the iris. This space is filled with aqueous humor (a special transparent fluid rel. to IOP produced in ciliary body) that nourishes the eye (cornea) and keeps it healthy (open angle glaucoma) 12. Retina takes the light the eye receives and changes it into nerve signals to the brain Two important layers of the retina Retinal pigment epithelium (RPE) - A single layer of cells constitutes the RPE, and these cells have numerous functions, including the absorption of light. Sensory retina - contains the photoreceptor cells: Rods are mainly responsible for night vision whereas the cones provide the best vision for bright light, color vision, and fine detail. Cones are distributed ccfrn

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throughout the retina with their greatest concentration in the fovea. Rods are absent in the fovea 13. Macula - located roughly in the center of the retina; a small and highly sensitive part of the retina responsible for detailed central vision w/ the help of the fovea; allows us to appreciate detail and perform tasks that require central vision such reading. 14. Choroid - choroid provides oxygen and nourishment to the outer layers of the retina 15. Optic nerves FUNCTIONS A. Refraction Different curved structures & refractive media of the eye allow light to pass through the retina Each surfaces & media bends light differently to focus image on the retina Emmetropia - perfect refraction; normal refraction of light within the eye B. PUPILLARY CONSTRICTION Pupils controls the amount of light that enters the eye Increase light to one or both eyes both pupils constrict Constriction depends on the amount of light & how well the retina adapt to light changes MIOSIS pupillary constriction MYDRIASIS pupillary dilatation

If the patient reads all five letters from the 20/20 line with the right eye (OD) and three of the five letters on the 20/15 line with the left eye (OS), the examiner writes OD 20/20, OS 20/15-2, or VA 20/20, 20/15-2.

2. Ishihara Test for color vision 3. Ophthalmoscopy (back part of the eye) cornea, lens, and retina into focus (Glaucoma) a. Direct hand-held b. Indirect uses a light source and binocular Size: Normal pupil diameter 3 & 5 mm Adult smaller pupil MYOPIA larger pupil HYPEROPIA smaller 4. Slit-lamp examination looks at structures that are at the front of the eye (eyelids, cornea, conjunctiva, sclera, and iris); for diagnosis of cataract & retinal detachment 5. Gonioscopy - visualizes the angle of the anterior chamber to identify abnormalities in appearance and measurements; a painless eye test that checks if the angle where the iris meets the cornea is open or closed, showing if either open angle or closed angle glaucoma is present 6. Tonometry - measures IOP (10-21mmHg) III. Common Disorders 1. CONJUNCTIVITIS inflammation of the conjunctiva characterized by a pink appearance of the sclera a. Bacterial conjunctivitis - acute onset of redness, burning, and discharge Acute type can develop into a chronic condition Chronic bacterial conjunctivitis is usually seen in patients with lacrimal duct obstruction b. Mild and viral conjunctivitis - self-limiting c. Immunologic or allergic conjunctivitis - a hypersensitivity reaction as a part of allergic rhinitis (hay fever), or it can be an independent allergic reaction d. Chemical conjunctivitis can be the result of medications, chlorine from swimming pools (more common during the summer), exposure to toxic fumes among industrial workers, or exposure to other irritants such as smoke, hair sprays, acids, and alkalis. ccfrn

C. ACCOMODATION Process of maintaining a clear visual image when the gaze is shifted from a distant to near object. The eye is able to adjust its focus by changing the curve of the lens Ability to focus & refocus Process of maintaining a clear visual image when the gaze is shifted from a distant to near object. The eye is able to adjust its focus by changing the curve of the lens II. DIAGNOSTICS 1. SNELLENS Chart test for visual acuity The visual acuity (VA) - recorded in the following way:

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General symptoms: may be unilateral or bilateral, but the infection usually starts in one eye and then spreads to the other eye by hand contact. Manifestations: *Edema *burning sensation *engorgement of the vessel *excessive tears *itching *watery discharge *Photophobia Diagnostics: Culture and Sensitivity Management *Nursing *Focus: LIMIT SPREAD OF DISEASE TO OTHER EYE AND PEOPLE instruct to avoid eye make up document amount color & type of drainage. Reinforce handwashing

Manifestations sees close up objects clearly, but objects in the distance are blurred Squinting the eyes needs to change glasses or contact lenses often Eyestrain Treatment easily corrected with biconcave lenses LASIK (Laser in situ kertomileusis) surgical procedure to change the shape of the cornea using a laser; reduces the need for glasses or contact lenses o Candidates for LASIK 1) 18 years old and above and in good health 2) Adhered to a stable vision prescription for at least a year 3) No other eye disease/s o Pre-operative preparation - Instruct the following to the client: 1) Stop wearing contact lenses prior to baseline evaluation a. Hard contacts = 4weeks b. Rigid contacts = 3weeks c. Soft contacts = 2weeks 2) No make-up or creams the day before surgery 3) Duration of surgery = 15-30 mins for both eyes o Post-operative management: 1) Wear the prescribed eyeshield 2) Client may experience itching, burning, light sensitivity blurry vision of the eyes 3) Follow-up after 24-48hrs 4) It may take 3-6months for vision to stabilize b. Hyperopia - a condition in which an image of a distant object becomes focused behind the retina, making objects up close appear out of focus Causes, incidence, and risk factors eyeball being too small or the focusing power being too weak Farsightedness is often present from birth family history Diagnostics: same as myopia

*Medical Management *Topical Antibiotics *Vasoconstrictor and corticosteroid eye drop

2. REFRACTIVE ERRORS a. Myopia - nearsightedness Occurs when the eye overrefracts the light Near vision is normal but poor distance vision image of a distant object becomes focused in front of the retina, making distant objects appear out of focus most common refractive error

Causes, incidence, and risk factors affects males and females equally family history of Diagnostics Visual acuity: can easily read the Jaeger eye chart, but has trouble reading the Snellen eye chart Refraction test - to determine the correct prescription for glasses Slit-lamp exam of the structures at the front of the eyes Ishihara test Tests of the muscles that move the eyes

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Manifestations Aching eyes Blurred vision of close objects Crossed eyes (strabismus) in children Eye strain Headache while reading Treatment easily corrected with convex lenses LASIK c. Astigmatism - condition wherein the cornea is abnormally curved, causing vision to be out of focus; optical condition whereby the image is distorted (angular distortion) Causes, incidence, and risk factors The cause is unknown sometimes occurs after certain types of eye surgery (ie. cataract surgery) Diagnostics: refraction test retinoscopy - Children or others who cannot respond to a normal refraction test can have their refraction measured by a test that uses reflected light Symptoms difficulty in seeing fine details, either close up or from a distance the images seen may be blurry Treatment Mild astigmatism may not need to be corrected Glasses or contact lenses LASIK

Summary:

Colleen C. Flores, RN

Figure 3: Refractive Errors

Source: Childrens Hospital Boston (www.childrenshospital.org)

d. Presbyopia a condition in which the lens of the eye loses its ability to focus, making it difficult to see objects up close Causes, incidence, and risk factors age 45 and above Manifestations Decreased focusing ability for near objects Eyestrain Headache Diagnostics general eye examination Refraction test Visual acuity - Examination of the retina - Slit-lamp test

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Treatment NO CURE but it can be corrected with glasses or contact lenses (bifocals) With the use of contact lenses, some people choose to correct one eye for near and one eye for far vision (monovision); it eliminates the need for bifocals or reading glasses, but it can affect depth perception 3. BLINDNESS AND VISION LOSS Blindness is the inability to see; lack of vision loss of vision that cannot be corrected with glasses or contact lenses a. Partial blindness - very limited vision. b. Complete blindness - cannot see anything and do not see light c. Legal blindness - vision worse than 20/200 Causes, incidence, and risk factors leading causes of chronic blindness: a. cataract b. glaucoma c. age-related macular degeneration d. corneal opacities e. diabetic retinopathy f. eye conditions in children (e.g. caused by vitamin A deficiency) Accidents or injuries to the surface of the eye (ie. chemical burns or sports injuries) Diabetes Other causes: Blocked blood vessels; Complications of premature birth (retrolental fibroplasia); Complications of eye surgery; Lazy eye; Optic neuritis; stroke; tumors Manifestations: The type of partial vision loss may differ, depending on the cause: Cataracts - vision may be cloudy or fuzzy, and there may be problems seeing shapes Diabetes - vision may be blurred, there may be shadows or missing areas of vision, and difficulty seeing at night Glaucoma - there may be tunnel vision and blurry vision Macular degeneration - the side vision is normal but the central vision is slowly lost Management a. Home care - the kind of home assistance will depend on type of vision loss

b. Instruct the client and relatives to always keep certain items in the same drawer, cabinet, table, or counter space. c. Instruct client to learn to recognize the shape of certain items (ie. egg containers or cereal boxes) d. Instruct the client and relatives to use plastic rings to hold pairs of socks together, whether washing, drying, or storing them e. Client may learn Braille f. Instruct the relatives to use a phone with large numbers and instruct client to memorize the keypad g. Instruct the client to fold different types of paper money in a different way. For example, you can fold a $10 bill in half or double fold a $20 bill. h. If possible, learn to use a long white cane to help client get around on his own i. When walking with someone else's help, grasp their arm just above the elbow. Walk slightly behind them to follow their motions. j. Ensure safety of the client 4. CATARACT - an opacity of the lens that distorts the image projected to the retina; painless; of unknown cause Diagnostics 1. Snellen chart for visual acuity 2. ophthalmoscopy 3. slit-lamp Risk factors Aging, DM, Toxic factors, aging, family history Common Causes a. Age Related Cataract Lens water loss and fiber compaction b. Traumatic Cataract Blunt injury to the eye or head Penetrating eye injury Intraocular foreign body Radiation exposure, therapy Eye surgery Types: a. Senile Cataract - age-related cataracts are defined by their location in the lens: nuclear, cortical, and posterior subcapsular ccfrn

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b. Nuclear cataract - associated with myopia (ie, nearsightedness), which worsens when the cataract progresses c. Cortical cataract - involves the anterior or posterior parts of the lens d. Posterior subcapsular cataracts - occur in front of the posterior capsule; the eye is increasingly sensitive to glare from bright light (eg, sunlight, headlights). Manifestations cataracts develop slowly and painlessly Mild clouding of the lens often occurs after age 60, but it may not cause any vision problems By age 75, most people have cataracts that affect their vision Visual changes: a. Being sensitive to glare b. Cloudy, fuzzy, foggy, or filmy vision c. Difficulty seeing at night or in dim light d. Double vision e. Loss of color intensity f. Problems seeing shapes against a background or the difference between shades of colors g. Seeing halos around lights Frequent changes in eyeglass prescription Management SURGERY ONLY CURE Better eyeglasses Better lighting Magnifying lenses Sunglasses Operative Measures: Cataract surgery- intracapsular extraction, extracapsular extraction, phaecoemulsification and lens replacement a. Intracapsular cataract extraction (ICCE) - involves the removal of the lens and the surrounding lens capsule in one piece; has a relatively high rate of complications due to the large incision required and pressure placed on the vitreous body. Disadvantages: large incision (>10mm); requires sutures; risk for retinal detachment & result in the loss of supportive structure for the intraocular lens implant b. Conventional extracapsular cataract extraction (ECCE) - involves manual expression of the lens through a small (usually 5-6mm or less) incision made in the cornea or sclera; self-sealing

c. Phacoemulsion used of sound waves to break cataractous lens into small pieces Preoperative care for cataract surgery 1) Teach about the nature, progression & treatment 2) Orient the client to the staff and physical environment if both eyes will be covered after surgery 3) Series of ophthalmic drugs are instilled to dilate pupils & for vasoconstriction (every 10 minutes for 4 doses at least 1 hour before surgery; additional dilating drops may be administered in the operating room 4) induce paralysis to prevent lens movement Post-operative care for cataract surgery POSITION: Place patient side lying on the UNAFFECTED side AVOID ACTIVITIES THAT INCREASE IOP: 1) bending from the waist 2) sneezing &coughing; blowing the nose 3) straining 4) Vomiting 5) wearing tight shirt collars 6) sexual intercourse Prevent accidental rubbing or poking of the eye (eyepatch); removed after the first follow-up appointment Advise to wear glass x 24 hours or metal shield nightly x 1-4 weeks Sunglasses should be worn while outdoors (eye is sensitive to light) Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days (use a clean, damp washcloth to remove slight morning eye discharge. Notify the surgeon if new floaters (ie, dots) in vision, flashing lights, decrease in vision, pain, or increase in redness occurs Patients may experience blurring of vision for several days to weeks. Vision gradually improves as the eye heals Administer pain medication, topical antibiotics and anti-inflammatory agents Complications for both ICCE and ECCE: 1) Pain early after surgery - IOP & hemorrhage 2) Infection yellow or greenish drainage 3) Bleeding into the anterior chamber 5. GLAUCOMA refers to a group of eye conditions that lead to damage to the optic nerve, the nerve that carries visual information from the eye to the brain ccfrn

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the drainage canals become clogged, blocked, or covered. Fluid cannot leave the eye even though new fluid is being produced in the posterior chamber. When the pressure becomes higher than the optic nerve can tolerate, damage to the optic nerve occurs.

Risk Factors Age 50 and above; Race blacks; Family history; DM, HPN; Injuries Types 1) Open-angle - Usually bilateral, but one eye may be more severely affected than the other; the anterior chamber angle is open and appears normal 2) Closed-angle - Obstruction in aqueous humor outflow due to the complete or partial closure of the angle from the forward shift of the peripheral iris to the trabecula. The obstruction results in an increased IOP

Figure 4: Types of Glaucoma

Figure 3: Normal Aqueous Outflow

Source: www.berwickeye.com.au

Manifestations 1) IOP > 21, occular pain, HA, halos 2) Blurred vision 3) halos around the lights 4) Loss of peripheral vision (tunnel vision) 5) headache 6) discomfort around the eyes Management Surgical = prevent optic nerve damage 1) Laser iridotomy - an opening is made in the iris to eliminate the pupillary block; for narrow-angle glaucoma (CI: corneal edema) - Pilocarpine to prevent closure of the opening 2) Trabeculectomy filtering procedure to remove a part of the trabecular meshwork to drain the aqueous humor Pre-op care a) Check for consent b) oral or intravenous medication to help relax the client c) eye drops and an injection of anesthetic to numb eyes Post-op care a) eye patch covering with protective shield b) wear goggles during sleep for 1week ccfrn

Source: www.berwickeye.com.au

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c) eye drops for muscle relaxation, minimize scarring and inflammation 3) Selective Laser Trabeculoplasty - treats specific cells selectively, leaving untreated portions of the trabecular meshwork intact; used for the treatment of primary open angle glaucoma 4) Argon Laser Trabeculoplasty - laser beam opens the fluid channels of the eye, helping the drainage system work better; used for the treatment of primary open angle glaucoma 5) Neodymium: YAG laser cyclophotocoagulation (YAG CP) - a last resort procedure to save an eye from severe glaucoma damage not being managed by standard glaucoma surgery; destroys part of the ciliary body Pharmacologic - initial IOP target = 30% lower than the current pressure Table 1: Medications (Brunner and Suddarth, 2009) Nursing Medication Action Side Effects Responsibilities Increases aq. Fluid outflow Cholinergics by constriction Blurry vision (esp. Caution clients miotics of pupils & in the dark); in dimly lit (pilocarpine, opening of periorbital pain areas carbachol) trabecular meshwork Reduces aq. Eye redness; may Adrenergic Teach punctual Humor have systemic agonists occlusion to production & effects (ie. (dipivefrin, limit systemic increase palpitations, HPN, epinephrine effects outflow headache) -blockers (timolol, betaxolol) Carbonic anhydrase inhibitors (acetazolamide, methazolamide, dorzolamide topical form) Prostaglandin analogs (latanoprost) Decrease aq. Humor production Systemic effects (ie. bradycardia, hypotension) AE = anaphylactic reactions; depression; electrolyte loss; GI upset; impotence Conjunctival redness; possible rash CI: asthma, COPD,

6. Retinal detachment - separation of RPE from sensory layer Types a. Rhegmatogenous detachment - most common form; a hole or tear develops in the sensory retina, allowing some of the liquid vitreous to seep through the sensory retina and detach it from the RPE; This type of retinal detachment represents an emergency, and surgery is typically scheduled urgently (within 24 hours of diagnosis). Risk factors: myopia, aphakia after cataract surgery, trauma b. Traction retinal detachment from a pulling force on the retina; most common in the advanced stages of diabetic retinopathy Risk factors: diabetic retinopathy, vitreous hemorrhage, or the retinopathy of prematurity c. Exudative retinal detachments - the result of the production of a serous fluid under the retina from the choroid. Risk factors: conditions that disturb the blood-retinal barrier (ie. conditions that allow the build-up of fluid beneath the retina; inflammatory conditions such as Vogt-Koyanagi-Harada syndrome, collagen-vascular diseases, and posterior scleritis Other conditions: tumors of the eye (e.g.,choroidal melanoma), congenital abnormalities (e.g., Coat's syndrome), and nanophthalmos (extremely small eyes) Diagnostics Visual acuity testing Indirect opthalmoscopy Goldmann three-mirror examination Manifestations: Separation of the retina from the epithelium Onset : sudden and painless (no pain fibers at the retina) Photopsia Initial detachment is usually partial describe as the sensation of a curtain being pulled over part of the visual fields Bright flashes of light, especially in peripheral vision Blurred vision Floaters in the eye Shadow or blindness in a part of the visual field of one eye Management 1) Cryotherapy (freezing probe) - cause the same adhesions, or scarring, around the tear, thereby sealing the tear 2) Photocoagulation (laser) ccfrn

Decrease aq. Humor production

CI: sulfa allergies electrolyte levels

Increases outflow

Instruct to report any SE

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3) Scleral Buckling - gently pushes the eye wall up against the retina Repair of the underlying structure A small piece of silicone is placed against the sclera & held in place by encircling band (a gas or silicone oil placed inside the eye can be used to promote retinal detachment (keeps the retina in contact with the choroids & sclera) 4) Vitrectomy to remove gel or scar tissue pulling on the retina, used for the largest tears and detachments (for tractional retinal detachments) Nursing Management Mainly client education and supportive care (comfort) If gas bubble is used prone or lateral position Inform of possible complications: Increased IOP Development of cataracts Post-op infections 7. Macular Degeneration - most common cause of visual loss in people older than age 60 Types a. Dry/Nonexudative - outer layers of the retina slowly break down; NO known treatment b. Wet/Exudative acute onset; proliferation of abnormal blood vessels growing under the retina (within the choroid) = choroidal neovascularization Manifestations Drusen (if outside the macula = asymptomatic) Gradual vision loss (central)

9. Intraocular Foreign Body Wash hands thoroughly before touching the eyes *Immediate copious flushing of the eye with water *if foreign body is lodged into the cornea, see a physician *avoid pressure on the eye, do not touch and rub *cover with dressing *consult an ophthalmologist immediately SPECIAL SENSES THE EAR

Figure 5: Structure of the Ear

Management Photodynamic therapy - a diode laser is used to treat the abnormal network of vessels using a dye (verteporfin) Pre-op care Instruct client to bring dark sunglasses, wide-brimmed hat, gloves, long-sleeved shirt; & slacks Post-op care Avoid bright lights or direct sunlight for 5days (ordinary indoor light is okay) 8. Trauma to the Eyes and related structures Penetrating eye injuries *Requires surgery Bed rest with BP for 1 to 2 days

Source: Brunner & Suddarths Textbook of Medical-Surgical Nursing (2008)

Structure: 3 Divisions 1. external ear 2. middle ear

3. inner ear

Parts EXTERNAL EAR - curved about 2.5 cm long in adult and ends at the tympanic membrane - attached to the head by skin and cartilage at about a 10 degree angle; adult - 1 to 1 inches (2.5 - 3.75 cm) - covered with skin that has many fine hairs, glands and nerve endings - develops in embryo at the same time as the kidneys and urinary tract. ccfrn

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1. Auricle or Pinna - composed of cartilage covered by skin; embedded in the temporal bone on both sides of the head at the level of the eyes 2. Tympanic membrane or ear drum - a thick transparent sheet of tissue providing a barrier between the external ear and the middle ear - Follicles and cerumen - protect the ear drum and middle ear MIDDLE EAR - begins at medial side of the ear drum that starts at the tympanic membrane 1. Ossicles of the middle ear (sound transmission) a. malleus hammer (most easily seen) b. incus anvil c. stapes - stirrups 2. eustachian tube -connects the middle ear to the nasopharynx; stabilizes the air pressure between the external atmosphere and middle ear INNER EAR - lies on the other side of the oval window 1. Semicircular canals - these are tubes made of cartilage that contains air cells and fluid; connected to sensory fibers of the vestibular portion of the 8th cranial nerve; the organs of equilibrium 2. Cochlea - the spiral organ of hearing essential for sound transmission and hearing 3. Vestibule a. Endolymph - a fluid similar to intracellular fluid b. Perilymph Assessment History Demographic data Family history and genetic risk - health problems causing changes of blood supply into the ear (heart diease, HPN, and DM) Personal history ear trauma ear surgery past infection excessive cerumen ear itch any invasive instrument routinely used to clean the ear type and pattern of ear hygiene exposure to loud and noise music air travel swimming habits and protection when swimming

vitiligo smoking vitamin B12 and folate deficiency ototoxic drugs

Diagnostics 1. Otoscope - Direct inspection of the ear 2. Audiometry - measurement of hearing acuity a. Pure tone - generated by an audiometer to determine hearing acuity Frequency - expressed in hertz Intensity - expressed in decibels Threshold - lowest level of intensity at which pure tones and speech are heard by a client b. Speech Audiometry - checks the clients ability to hear spoken words; measured through a microphone connected to an audiometer 3. Voice test - simple hearing acuity test 4. Rinne Test - compares air conduction from bone conduction 5. Webers Test - to assess bone conduction by testing the lateralization (sideward transmission) of sounds process 6. Electronystagmography (ENG) - a study used to clinically evaluate patients with dizziness, vertigo, or balance dysfunction; provides an objective assessment of the oculomotor and vestibular systems Treatment Modalities 1. Tympanoplasty - reconstructs the middle ear to improve hearing caused by conductive hearing loss; varies from simple reconstruction of the eardrum (myringoplasty) to replacement of the ossicles within the eardrum 2. Myringotomy - a surgical procedure where a small incision is made in the tympanic membrane (eardrum), typically in both ears. Small plastic tubes (typanostomy tubes), open at both ends, are then inserted into the incisions; allow fluid to drain out of the middle ear, which prevents pressure from building up 3. Ossiculoplasty - involves ossicular reconstruction 4. Stapedectomy - Surgical removal of the stape followed by replacement with prosthesis 5. Stapedotomy - Use of laser to create a hole in the footplate of the stapes and prosthesis is place in the hole 6. Labyrinthectomy - Surgical removal of the membranous labyrinth thru the oval window or thru the mastoid bone

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Common Disorders a. Otitis externa - Painful condition cause when irritating or infective agents (bacteria or fungi) come into contact with the skin of the external ear Manifestations: Pain, skin is red, swollen, and tender to touch Management: focused on reducing inflammation and promote comfort Topical or liquid otic antibiotics (Burows solution) Instillation of eardrops Analgesics for the 1st 48-92hrs b. Otitis media - acute infection of the middle ear, usually lasting less than 6 weeks Causative agents: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis Diagnostics a. assess for pain with or without movement of the external ear b. otoscopic examination c. cultures of drainage Manifestations vary with the severity - otalgia - ottorhea - erythematous tympanic membrane Management otic antibiotics analgesics antihistamines and decongestant myringotomy or tympanotomy c. Mastoiditis infection of mastoid cells by untreated otitis media; assess for the swelling behind the ear and pain with minimal movement of the tragus, pinna or the head - Mastoidectomy and myringotomy - IV antibiotics d. Impacted cerumen blockage within the ear canal as seen in the otoscope and treated by ear irrigation - unilateral - fever - hearing loss

e. Menieres Disease - over production or decreased reabsorption of endolymphatic fluid, causing a distortion of the entire inner canal system Three features: a. Tinnitus b. one sided sensorineural hearing loss c. Vertigo occurring in attacks that can last for several days Cause: unknown; but it often occurs with infections, allergic reaction, and fluid imbalances Incidence: a. occurs between 20 and 50 yrs old b. greater in men and in white individuals Manifestations: o headache o increasing tinnitus o feeling of fullness in the affected area Management: Goal: manage symptoms a. instruct client to make slow head movements to prevent worsening of the vertigo b. diet and lifestyle changes such as salt and fluid decrease c. advise clients to stop smoking d. drug therapy aims to control the vertigo and vomiting and restore normal balanced. - diuretics mild = triamterene and hydrochlorothiazide (Dyazide, Maxzide) - anti-vertigo = meclizine (Antivert) - nicotinic acid (vasodilator) - antihistamines (dyphenhydramine HCl) - anti emetics = chlorpromazine HCl, prochlorperazine (Compazine) - anti-anxiety = diazepam, alprazolam (Xanax) Surgical Management: a. LABYRINTHECTOMY the most radical procedure involves resection of the vestibular nerve or total removal of the labyrinth b. Transtympanic gentamicin treatment (chemical labyrinthectomy) a "low dose" variant is extremely effective

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6. Benign paroxysmal positional vertigo (BPPV) - develops when a small piece of bone-like calcium breaks free and floats within the tube of the inner ear Causes, incidence, and risk factors There are no major risk factors. However, the condition may partly run in families. A prior head injury (even a slight bump to the head) or an inner ear infection called labyrinthitis may make some people more likely to develop the condition. Diagnostics a. Dix-Hallpike maneuver b. ENG c. CT scan / MRI d. Hearing test e. Warming and cooling the inner ear with water (caloric stimulation) or air to test eye movements Manifestations Feeling of spinning or moving Nausea, vomiting hearing loss loss of balance Vision problems, such as a feeling that things are jumping or moving Management Epley's maneuver Medications: a. Antihistamines b. Anticholinergics c. Sedative-hypnotics To prevent symptoms from getting worse during episodes of vertigo, instruct client to avoid positions that trigger it. Instruct client to notify MD of weakness, slurred speech, or vision problems are experienced Complication: dehydration due to frequent vomiting References: Books Guyton, A. and Hall, J. (2006). Textbook on Medical Physiology, 11th ed. PA: Elsevier, Inc.

Porth, C.M. (2010). Essentials of Pathophysiology, 3rd ed. USA: Lippincott Williams & Wilkins. Smeltzer, S., et al (2009). Brunner and Suddarths Textbook on MedicalSurgical Nursing, 10th ed. USA: Lippincott Williams & Wilkins. Williams, L. S. and Hopper P. D. (2007). Understanding Medical-Surgical Nursing, 3rd ed. PA: F. A. Davis Company Internet Sources Childrens Hospital Boston - Harvard Medical School. (2011). Astigmatism, hyperopia, and myopia. Retrieved December 28, 2011 from http://web1.tch.harvard.edu/az/Site1517/mainpageS1517P0.html Eye Associates of Wilmington, P.A. (n.d.) Retrieved December 28, 2011 from http://www.wilmingtoneye.com/pdfs/Conventional_Glaucoma_ Surgery.pdf National Institutes of Health. (2011). Refractive errors. Retrieved December 28, 2011 from http://www.ncbi.nlm.nih.gov/pubmed health/PMH0002018/ Kasemsuwan, L., et al. (2007). Low Dose Transtympanic Gentamicin Treatment for Intractable Menieres Disease: A Prospective Study. Journal of the Medical Association of Thailand (90;2). Retreived December 28, 2011 from http://www.medassocthai.org/journal LasikEyeSurgery.org. (2010). Lasik eye surgery. Retrieved December 28, 2011 from http://www.lasikeyesurgery.org/ National Institutes of Health. (2011). Blindness. Retrieved December 28, 2011 from http://www.nlm.nih.gov/medlineplus/ency/article/ 003040.htm National Institutes of Health. (2011). Cataracts. Retrieved December 28, 2011 from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001996/ World Health Organization. (20111). Blindness. Retrieved December 28, 2011 from http://www.who.int/topics/blindness/en/

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