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COURSE OUTLINE
 Review of anatomy and physiology
 History to note when the patient comes to
the eye clinic
 Ophthalmic examination
 Eye tests
 Common visual defects
 Blindness
 Injuries/Foreign body: To remove foreign
body from conjunctiva and to remove
foreign body from the cornea

 Allergic reactions/inflammation
 uveitis
 sty
 conjunctivitis
 Trachoma
 Cataract
 Glaucoma
 Retinal disorders
 Tumors of the eye
4
VISION
Vision begins when light rays are
reflected off an object and enter the eyes
through the cornea, the transparent outer
covering of the eye. The cornea bends or
refracts the rays that pass through a
round hole called the pupil. The iris, or
colored portion of the eye that surrounds
the pupil, opens and closes (making the
pupil bigger or smaller) to regulate the
amount of light passing through.
6
The light rays then pass through the lens,
which actually changes shape so it can
further bend the rays and focus them on
the retina at the back of the eye. The
retina is a thin layer of tissue at the back
of the eye that contains millions of tiny
light-sensing nerve cells called rods and
cones, which are named for their distinct
shapes. Cones are concentrated in the
center of the retina, in an area called the
macula.
In bright light conditions, cones provide
clear, sharp central vision and detect
colors and fine details. Rods are
located outside the macula and extend
all the way to the outer edge of the
retina. They provide peripheral or side
vision. Rods also allow the eyes to
detect motion and help us see in dim
light and at night. These cells in the
retina convert the light into electrical
impulses. The optic nerve sends these
impulses to the brain where an image
is produced.
Functions of the various parts of the
eye
 Cornea: the clear front window of the eye. The
cornea transmits and focuses light into the eye.
 The sclera( white of the eye) helps to maintain the
shape of the eyeball and protects the intraocular
contents from trauma
 Iris: the colored part of the eye. The iris helps
regulate the amount of light that enters the eye.
 Lens: the transparent structure inside the eye that
focuses light rays onto the retina. It is avascular and
has no nerve or pain fibers. The lens enables focusing
for near vision and refocusing for distance vision. The
ability to focus and refocus is called
accommodation.
.
 Macula: a small area in the retina that
contains special light-sensitive cells. The
macula allows us to see fine details clearly.
 Optic Nerve: the nerve that connects the eye
to the brain. The optic nerve carries the
impulses formed by the retina to the brain,
which interprets them as images.
 Pupil: the dark center in the middle of the iris.
The pupil determines how much light is let into
the eye. It changes sizes to accommodate for
the amount of light that is available.
 Behind the cornea lies the anterior chamber,
filled with a continually replenished supply of
clear aqueous humor, which nourishes the
cornea
 Retina: the nerve layer that lines the back of the
eye. The retina senses light and creates impulses
that are sent through the optic nerve to the brain.
 Vitreous humor. : the clear, jelly-like substance
that fills the middle of the eye. helps maintain the
shape of the eye
 The uvea consists of the iris, the ciliary body, and
the choroid.
 conjunctiva, which is a thin, transparent, mucous
membrane that contains fine blood vessels
 choroid lies between the retina and the sclera. It
is a vascular tissue, supplying blood to the portion
of the sensory retina closest to it.
 Good visual acuity depends on a healthy,
functioning eyeball and an intact visual
pathway
 Promotion of Good Eye Health

 Dailywashing
 Avoiding irritants
 Using clean water and handkerchiefs
 Touching eyes with clean hands
 Good nutrition especially vitamin A
 Avoiding eye strain and self medication
 Clean home/safe working environment
 Regular eye check ups
 Screening early in children
Assessment of an ophthalmic
patient
Hx taking
 Is visual acuity diminished?
 Hx of blurred, double, or distorted vision?
 Presence of pain; is it sharp or dull; is it worse when
blinking?
 Are both eyes affected? •
 Is there a history of discharge• What is the duration of
the problem?
 • Is this a recurrence of a previous condition?, How has
the patient self-treated?
 Aggrevating factors? •presence of any systemic
diseases?
 medications are used in their treatment??
 Hx of ophthalmic surgery

 Observations to be
made
 Discharge and type
 Eye lashes-crusted
 Eye lids-swollen and tender
 Conjunctiva- white/pale, inflamed,
yellow..
 Cornea-normally transparent. May be
hazy or opaque
 Pupil-take note of shape and size
 photophobia
 Lacrimation
 Anterior chamber-aqueous humor may
be hazy
Physical examination
 Explain the assessment technique
 Use a room free of interruptions
 Sufficient light
 Place the patient on an upright position
 You should be able to visualize the
underlying structures
 Always compare left and right eyes
 Equipment
 Ophthalmoscope
 Pen light/torch
 Clean gloves
 Vision occluder
 Cotton tipped applicator
 Snell’s chart/E chart/pictorial chart
18
 Visual acuity
 Visualacuity is a measure of your central
vision, the ability to distinguish details and
shapes of objects.

Distant vision is tested with a chart with

differently sized letters read from a distance
of(20 feet) six metres away. Using the
Snellen’s chart.
 Someone who can read the second line of
letters up from the bottom is said to have 6/6
vision(20/20).
 Visual acuity is expressed as a fraction, the top
number (numerator) representing the distance
in meters the patient is from the chart (usually
6 meters) and the bottom (denominator)
indicating the distance at which the smallest
letters read by the patient, that should be read
by the normal eye. For example; if the patient
can only read VBDZ4 (12 METERS) on the
chart, his vision is recorded as V=6/12.
• The patient is positioned at the prescribed
distance, usually 20 feet, from the chart and is
asked to read the smallest line that he or she
can see
Snellen Chart
• each eye should be tested separately. If the
patient is unable to read the 20/20 line, he
or she is given a pinhole occluder and asked
to read again using the eye in question
• If the patient is unable to reads the top line
even from one metre,he/she is asked to
count fingers of the examiner and his vision
is recorded as e.g. count fingers 2 i.e. the
distance between you and the patient is 2
metres or count fingers face.
• Abbreviated as CF 2,CF 3 or at the face.
When the patient fails to count fingers,
the examiner moves his hand close to
the patients face. If he can appreciate
the hand movements, his visual acuity is
recorded as HM positive.
When the patient cant distinguish hand
movements, the examiner notes
whether the patient can perceive light.
 If yes, vision is recorded as PL positive, if
no,PL negativeNPL.
Visual fields(PERIMETRY)
The visual field refers to the total area in
which objects can be seen in the side
(peripheral) vision while you focus your
eyes on a central point.
 How it is done

Confrontation visual field exam: This is a

quick and basic check of the visual field.
The health care provider sits directly in
front of you. You will cover one eye, and
stare straight ahead with the other. You
will be asked to tell when you can see
the examiner's hand.
Manual perimetry
involves the use of moving (kinetic) or stationary
(static) stimuli or targets.
kinetic manual perimetry i.e Tangent screen or
Goldmann field exam: You will sit about 3 feet from a
screen with a target in the center. You will be asked to
stare at the center object and let the examiner know
when you can see an object that moves into your side
vision. This exam creates a map of your entire
peripheral vision.
OR
black felt material mounted on a wall that has a series
of concentric circles dissected by straight lines
emanating from the center. It tests the central 30
degrees of the visual field.
 Automated perimetry: uses stationary
targets.You sit in front of a concave dome and
stare at an object in the middle. You press a
button when you see small flashes of light in your
peripheral vision. Your responses help determine
if you have a defect in your visual field.
OR
a computer projects light randomly in different
areas of a hollow dome while the patient looks
through a telescopic opening and depresses a
button whenever he or she detects the light
stimulus.
THE EXTERNAL EYE
Include the eye brows, eye lids, lacrimal
apparatus, sclera and eye lashes
Structures are inspected and palpated
when the examiner and the patient are
at the same eye level sitted opposite
each other.
 Eye position
Symmetry of alignment
Eye brows
Eye lids and eye lashes: placement
and symmetry to r/o presence of
ptosis,edema,3rd cranial nerve disorders
and neuromuscular disorders. Check for
effective closure by asking the patient to
close the eyes. Confirm whether there is
entropion or ectropion
ptosis

30
 Examine the skin of the eyelids
In orbit palpate for
texture,firmness,mobility and integrity of
the underlying tissues
Eye balls: check for symmetry and
palpate for firmness. Ask the patient to
close the eyes and look down. Place the
tip of the index finger on the upper eye
lid over the sclera and palpate gently
Lacrimal apparatus: retract the upper
lid. Ask the client to look down for you to
visualize the lacrimal gland
Observe for any swelling and tenderness
The area between the lower lid and the
nose should be free from edema
Palpate the area over the lower orbit rim
near the inner cantus. There should be
no regurgitation of fluid from the sac on
palpation
 Conjunctiva and sclera
Colour changes such as ecchymosis
Texture vascularity
lesions
Thickness
Secretions
Foreign bodies
Normal colour is pink or light red
A normal sclera is opaque and white.
 Corneal reflex
Trigerminal nerve is responsible for this
Tell the client to open the eyes and look
straight ahead
Then a cotton tipped lubricator is
brought from the back and touch the
corneas simultaneously
Blinking and tearing indicate that the
fifth cranial nerve is intact
CORNEA
Should be even and smooth
In older adults, a thin greyish white ring
around the edge of the cornea called
arcus senellis may be seen
Abnormalities include irregularity,
cloudiness or opacity.
 Anterior chamber

Contains pupil. The room should be

darkened so that the pupils can be
examined.
Use a pen light or torch
It should be clear and transparent with
no shadow cast on the iris.
The iris should light up with oblique
lighting and should have a consistent
colour
Light inspects the pupil for size, shape
When you shine light on the eye, the
pupil should be black, round with smooth
borders and equal.
With light, both pupils should constrict
and vice versa.
PERRLA.-Pupil,Equal,Round,Regular,
Reactive to light and have effective
Accommodation
 Size of the pupil depends on
 Distance of the object
 Functionality of the nerves
 Use of medications that affect iris
contractility
 Intensity of light
 Pupil abnormality may be caused by
 Neurologic disease
 Intraocular inflammations
 Iris adhesions
 Systemic and ocular medications side effects
 observe for nystagmus (ie, oscillating movement
of the eyeball).
 The extraocular movements of the eyes -tested
by having the patient follow the examiner’s finger
or hand light through the six cardinal directions of
gaze (ie, up, down, right, left, and both diagonals).
This is especially impor-tant when screening
patients for ocular trauma or for neurologic
disorders.
40
 Superior oblique

Superior rectus The extra-ocular

muscle
responsible for
eye movement

Lateral rectus

Inferior rectus
Inferior oblique

Medial rectus muscle( not shown) is

responsible for opposing the movement of
the lateral rectus muscles.
INTERNAL EYE
 Istested using the ophthalmoscope
Diagnostic tests
Ophthalmoscopy
Is a test that allows a health professional
to see inside the fundus of the eye and
other structures using an
ophthalmoscope (or funduscope). It is
done as part of an eye examination and
may be done as part of a routine physical
examination. It is crucial in determining
the health of the retina and the vitreous
humor.
 Types
The direct ophthalmoscope is hand held
instrument with several lenses that can magnify up
to about 15 times. most commonly used during a
routine physical examination.
The examiner holds the ophthalmoscope in the
right hand and uses the right eye to examine the
patient’s right eye. The examiner switches to the
left hand and left eye when examining the patient’s
left eye. During this examination, the room should
be darkened, and the patient’s eye should be on the
same level as the examiner’s eye.
ct
Examiner should assess for:
Vasculature,optic nerve,cup,
health of fundus which should be
free from leisons,
Intraretinal haemorrhage, lipid
incase of hypercholestremia,
microaneurysms and
drusens(small, hyaline, globular
growth)
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An indirect ophthalmoscope. It produces a bright
and intense light. The light source is affixed with a
pair of binocular lenses, which are mounted on the
examiner’s head. The ophthalmoscope is used with
a hand-held, 20-diopter lens F.it allows a better
view of the fundus of the eye, and to see larger
areas of the retina
Slit-lamp ophthalmoscopy:. The slit lamp is a
binocular microscope mounted on a table. This
instrument enables the user to examine the eye with
magnification of 10 to 40 times the real image.By
varying the width and intensity of the light, the
anterior chamber can be examined for signs of
inflammation. Cataracts may be evaluated by
changing the angle of the light
Direct opthalmoscopy
Indirect opthalmoscopy

47
Slit-lamp ophthalmoscopy

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TONOMETRY
Measures intraocular pressure (IOP).
Normal pressure is 11-22 mm Hg
This test is used to check for glaucoma, an
eye disease that can cause blindness by
damaging the nerve in the back of the eye
(optic nerve). Damage to the optic nerve
may be caused by a buildup of fluid that
does not drain properly out of the eye.
measures IOP by recording the resistance
of your cornea to pressure (indentation).
Eye drops to numb the surface of your
eye are used.
uses a small probe to gently flatten part
of your cornea to measure eye pressure
and a microscope called a slit lamp to
look at your eye. The pressure in your
eye is measured by how much force is
needed to flatten your cornea.
51
GONIOSCOPY
visualizes the angle of the anterior
chamber to identify abnormalities in
appearance and measurements. The
gonioscope uses a refracting lens that
can be a direct or indirect lens. The
indirect lens views the mirror image of
the opposite anterior chamber angle
and can be used only with a slit lamp.
The direct gonioscopic lens gives a
direct view of the angle and its
structures
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COLOR VISION TESTING

 alteration in color vision is sometimes indicative of

conditions of the optic nerve,
 color vision testing is often performed in a neuro-
ophthalmologic workup. The most common color vision
test is performed using Ishihara polychromatic plates.
 These plates are bound together in a booklet. On each
plate of this booklet are dots of primary colors that are
integrated into a background of secondary colors. The
dots are arranged in simple patterns, such as numbers or
geometric shapes.
 Patients with diminished color vision may be unable to
identify the hidden shapes. Patients with central vision
conditions (eg, macular degeneration) have more
difficulty identifying colors than those with peripheral
vision conditions (eg, glaucoma) because central vision
identifies color.

53
 Ultrasonography
Lesions in the globe or the orbit may not be
directly visible and are evaluated by
ultrasonography. A probe placed against the
eye aims the beam of sound. High-frequency
sound waves emitted from a special
transmitter are bounced back from the lesion
and collected by a receiver that amplifies
and displays the sound waves on a special
screen.
Ultrasonography can be used to identify
orbital tumors, retinal detachment, and
changes in tissue composition
COLOR FUNDUS PHOTOGRAPHY
Technique used to detect and document
retinal lesions. The patient’s pupils are
widely dilated during the procedure,
and visual acuity is diminished for about
30 minutes due to retinal “bleaching”
by the intense flashing lights.
FLUORESCEIN ANGIOGRAPHY
 Evaluates clinically significant macular
edema, documents macular capillary
nonperfusion, and identifies retinal and
choroidal neovascularization
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 DROPS IN COMMON
USE
MAJOR GROUPS
◦ Mydriatics
◦ Miotics (antiglaucomas)
◦ Local anaesthetics-
◦ Anti-infectives.
◦ Anti-inflammatory
◦ Anti-septics
Mydriatics and cycloplegics
They dilate the pupil in diseases like iritis for
opthalmic examination of the fundus of the eye
and cycloplegics paralyse the ciliary muscles.
examples
 Atropine sulphate ½ - 2%
 Homatropine 2%
 Mydrilate
 Tropicamide

Antibiotics
◦ Tetracycline 1%
◦ Gentamycin 0.3%
◦ Chloramphenicol 0.5%- 1%
◦ Neomycin
Antifungal- nyastatin, fluconazole
Antiviral- acyclovir 3%
Anti-inflammatories- hydrocortisone
0.5%,dexamethasone0.1%
 ANTIGLAUCOMA DRUGS

1.Miotics -are used to lower eye pressure in eyes with

glaucoma. They constrict the pupil for treatment of glaucoma
and after a cataract operation
Commonly Used Drugs
Pilocarpine (Isoptocarpine) 1%, 2%, 4%, 6% (Pilopine gel) 4%,
Ocusert
Carbachol 0.75%, 1.5%, 3%
Echothiophate (Phospholine Iodide) 0.06%, 0.12%, 0.25%
2.Sympathomimetic drugs(adrenergic)
Epinephrine 1% - in glaucoma, reduces intra-ocular pressure
by decreasing the rate of aqueous production
3.Hyperosmotic agents- Gylecerol(oral solution),
Iv Mannitol
4.Beta blockrers i.e timolol, levobunolol
 Antiseptics
◦ Albucid (sulphacetamide) 5- 30%
◦ Proflavine 1: 4000
◦ Silver nitrate 1%
Miscellaneous drops
Adrenaline 1:1000 – vasoconstrictor in operations
Antistin privine – for allergy
.
Castor oil
Paroleine (liquid paraffin) lubricants
Cod liver oil – for corneal ulcers
Artificial tears solutions
Diagnostic solutions – fluorescein dye

59
COMMON VISUAL DEFECTS
The most common are those of
refraction i.e. light rays entering the eye
are not bent at the correct angle and
therefore do not focus on the retina.
The refractive errors are:
◦ Myopia
◦ Hyperopia (Hypermetropia)
◦ Presbyopia

60
 Click icon to add picture

the.

Emmetropia/ NORMAL VISION. Parallel

rays of light enter the eye through the
cornea and are refracted to a precise
point on the retina(macula).
61
 HYPEROPIA
Farsightedness
is a defect of vision caused
by an imperfection in the
eye (often when the eyeball
is too short or the lens
cannot become round
enough), causing difficulty
focusing on near objects,
and in extreme cases
causing a sufferer to be
unable to focus on objects at
any distance
Corrected by convex lenses

Causes: sinus infections,

injuries, migraines, aging or 62
Click icon to add picture HYPEROPIA/
HYPERMETROPIA/LONG
SIGHTEDNESS. Lens is too
11
close to the retina. Light rays
converge at a point beyond
the retina

CORRECTED HYPEROPIA

Convex
lens

63
 MYOPIA
Nearsightedness
is a condition of the eye
where the light that comes
in does not directly focus
on the retina but infront of
it.
This causes the image that
one sees when looking at a
distant object to be out of
focus but in focus when
looking at a close object.
Corrected by Concave
lens
64
Click icon to add picture MYOPIA/SHORT-SIGHTEDNESS
Lens is too far away from the
retina. Light rays converge in
front before they reach the
retina.

CORRECTED MYOPIA

Biconcave
lens

65
 PRESBYOPIA
 As we grow older (above 40
years) our cilliary muscles
become less elastic and
cannot readily accommodate to
distant and near vision.( thus
occur when the elasticity of
the ciliary muscles is
reduced).
 Leads to failing vision of
near.
 This is known as presbyopia
(old sight). Bifocal glasses are
usually prescribed to allow for
two sets of lenses in one pair of
glasses, one set for viewing
distant objects and one for
seeing close objects (Near 66
ASTIGMATISM

Is a visual defect resulting from

◦ Uneven lens or
◦ Irregular curve of the cornea
Either prevents the horizontal and
vertical light rays from focusing at the
same point on the retina.
Treatment
◦ Prescription of contact lenses.
◦ Fitting of glasses with a cylinder correction,
so that light rays are brought into focus on
the retina

67
STRABISMUS (SQUINT/AMBLYOPIA
(crossedeye)failure of the eye to look in
the same direction at same time
Normally the axes of both eyes fall together on
the same point of the object being looked at. In
cases of strabismus they do not, as one eye is
directed away from this point. caused by
weakness of muscles of one eye.

68
NOTE: a child will not grow out of a
squint-the longer it is left the more
difficult it is to cure.
Causes
◦ Paralysis due to damage to the nerves
supplying the extrinsic muscles of the
eyeball.
◦ Mal-development or faulty insertion of one
group of muscles
◦ Cogenital, tumour
◦ Uncorrected refractive error
◦ Deflective vision in an eye(corneal
scar/congenital cataract).
◦ Eye strain( in prolonged exertion of the 69
Types
Esotropia- inward turning
Exotropia- outward turning
Hypertropia- upward turning
◦ . Treatment
◦ Covering of the normal eye to prevent double
vision and make the child use the lazy eye.
◦ Surgery to correct muscular deformity and
return them to single vision.
◦ Orthoptics (eye exercises) after surgery to
improve the affected eye in its function of
sight.
◦ Corrective spectacles for refractive error.
70
BLINDNESS
Def: the inability to see. The marked reduction in
visual field with varying degrees of visual
impairment.
The clinical definition of absolute blindness is
the absence of light perception. Legal blindness
is a condition of impaired vision in which an
individual has a VA that does not exceed
20/200 in the better eye or whose widest visual
field diameter is 20 degrees or less.
Blindness is defined by the World Health
Organization as vision in a person's best eye of
less than 20/500 or a visual field of less than 10
degrees
71
Causes
◦ Trauma of the eye
◦ Corneal ulcers/opacification
◦ Infectious (viral, bacterial, gonococcal)
◦ Cataracts, trachoma
◦ Glaucoma
◦ Retinal defects
◦ Dietary deficiency of vitamin A (might
blindness)
◦ Onchorcerciasis (from worm causing
river blindness)
◦ Age-related macular degeneration
◦ Diabetic retinopathy
◦ Childhood blindness 72
Predisposing factors
◦ Poor hygiene
◦ Poor sanitation
◦ Poverty (dietary)
Incidence
◦ 28 million world-wide and 6 % developed
countries
Prognosis
• Depends on cause and availability of medical
care.
Signs and symptoms
◦ Blurred vision
◦ Inability to identify objects
73
Prevention
◦ Promotion of good eye health
◦ Sufficient dietary intake of vitamin A
◦ Identifying and treating the cause e.g.
diabetes
◦ Surgery in indicated conditions
◦ Continuous visual assessment
◦ Referral for unexplained loss of vision
OTHER TYPES OF BLINDNESS
1. Daltonism (protanopia/red blindness)
◦ A defect in color vision in which a person
cannot distinguish between reds and greens.
The term used to refer to “color blindness”
in general. 74
2. Day blindness (Hemeralopia)
◦ Fairly good vision in poor light but poor
vision in good lighting. Congenital with poor
visual acuity and deflective color vision.
3. Night blindness (Nyctalopia)
◦Inability to see in dim light or at night due to a
disorder of the rods of the retina that are
responsible for vision in dim light. It can result
from a deficiency of vitamin A. if untreated, it
progresses to
•Xerophthalmia: (dry, thickened, wrinkled
cornea and conjunctiva), leading to
blindness.
•Keratomalacia: (soft cornea) which may
perforate. The condition is very serious and 75
A newly blind patient and his or her family
members (especially those who live with the
patient) undergo the various steps of grieving:
denial and shock, anger and protest,
restitution, loss resolution, and acceptance.
The ability to accept the changes that must
come with visual loss and willingness to adapt
to those changes influence the successful
rehabilitation of the patient who is blind.
Additional aspects to consider are value
changes, independence–dependence conflicts,
coping with stigma, and learning to function in
social settings without visual cues and
landmarks.

76
 ◦ Coping with social stigma
◦ Learning to communicate without visual clues
◦ Adherence to prescribed therapeutic regimens
The nurse’s role
1. Patient teaching – about self care
2. Skillful listening to patient’s needs & making
recommendations that are of real value to the
patient
3. Rehabilitation of the distressed patient
4. Patient support – in fear and correcting mis-
information
5. Patient care: treat with dignity, not pity. Things
should remain in the same position. Doors should
not be left half open. Rem: the sense of touch
becomes very important.
6. Collaboration with the physician in patient care.
77
7. Referral when patient is declared legally blind.
 Blindness-Nursing mgt
cntd…
Coping with blindness involves three types of
adaptation: emotional, physical, and social.
The emotional adjustment to blindness or
severe visual impairment determines the
success of the physical and social adjustments
of the patient.
Successful emotional adjustment means
acceptance of blindness or severe visual
impairment.
Promote coping effort. Effective coping may not
occur until the patient recognizes the
permanence of the blindness. Clinging to false
hopes of regaining vision hampers effective
adaptation to blindness
78
 Blindness- prognosis
The prognosis is dependent on its cause.
In patients with blindness due to optic-nerve
damage or a stroke, visual acuity can usually
not be restored.
Patients with long-standing retinal detachment
in general cannot be improved with surgical
repair of their detachment.
Patients who have corneal scarring or cataract
have a good prognosis if they are able to
access surgical care of their condition.

79
EYE TRAUMA
History: find out when it occurred, type of
injury, the injuring substance
Signs and symptoms.
◦ Hx of trauma - diplopia
◦ Photophobia - black eye
◦ Pain - Lacrimation
◦ Blurred vision
◦ Hyphema (blood in the anterior chamber)
O/E
Red or black eye
Laceration of cornea, sclera, or conjunctiva
± visible object
T ypes
Mechanical injuries
I. Retained extraocular foreign bodies
Manage by physician, a sterile local
anaesthesia is instilled into eye and
foreign body removed with swab
stick,hypodermic needle. after removal
antibiotic ointment is instilled and
patching eye for 24hrs
II. Blunt trauma
III. Penetrating and perforating injuries
IV. Penetrating injuries with retained
intraocular foreign bodies
81
NON MECHANICAL INJURIES
Chemical injuries
Causes
I. Agricultural accidents i.e
insectcides,fertilizers
II. Chemical laboratory accidents
III. Domestic accidents i.e
detergents, cosmetics
IV. Deliberate chemical attack
V. Chemical warfare injuries
82
 Management
At home
◦ Eye irrigation with sterile solution- water, normal
saline
◦ Medication- analgesic e.g.. paracetamol 1 gram stat
 Topical antibiotic – tetracycline 1 % eye ointment
 Steroids- terracorticcal drops (only if prescribed and
monitored)
 Tetanus toxoid
◦ Apply eye pad to both eyes
◦ Refer
Hospital
 Prepare for opthalmic examination
 If ordered –pre-op. care if indicated for penetrating eye
or corneal injuries. Eye swabbing using aseptic
CONDITIONS AFFECTING
CORNEA

84
CORNEAL ULCER
CORNEAL ULCERS
The condition results from a localized
infection of the cornea, similar to an
abscess.
Causes
 bacterial infection that invades the
cornea often following eye injury, trauma
or other damage.
 Contact lens wearers particularly are
susceptible to eye irritation that can lead
to a corneal ulcer. A contact lens may rub
against the eye's surface, creating slight
damage to the epithelium that may
enable bacteria to penetrate the eye. 86
 fungiand parasites, such as:
Fusarium,aspergillius,candida. These
fungi have been associated with fungal
keratitis outbreaks among contact lens
wearers who used a certain type of contact
lens.
Acanthamoeba. These common parasites
can enter the eye and cause Acanthamoeba
keratitis a very serious eye infection that
can result in permanent scarring of the
cornea and vision loss. Acanthamoeba
microorganisms are commonly found in tap
water, swimming pools, hot tubs and other
water sources.
 herpes simplex virus infection (ocular
herpes), which can damage exterior and
sometimes even deeper layers of the
eye's surface.
 severely dry eyes
 eye allergies
 widespread general infection.
 Immune system disorders and
 inflammatory diseases such as multiple
sclerosis and psoriasis
 Signs and symptoms
 pain
 red eye
 mild to severe discharge
reduced vision.
Treatment
◦ Local topical antibiotics- surface application
or sub-conjunctival injection
◦ Systemic antibiotics if infection spreads to
interior of the eye
◦ Fungal –antifungal drugs i.e fluconazole
◦ Viral- acyclovir, steroids
◦ Cauterization (diathermy) in chemical injury
If fungal and does not respond to antifungal
agents-local excision of cornea and corneal
grafting (keratoplasty) may be done.
KERATITIS
 Keratitis is a condition in which the
eye's cornea the front part of the eye,
becomes inflamed. The condition is often
marked by moderate to intense pain and
usually involves impaired eyesight. May
cause feelings of scratching each time
individual blinks eye.

91
 Signs and symptoms
Signs and symptoms
◦ Pain
◦ Excessive lacrimation (due reflex hyper lacrimation)
◦ Blurred vision
◦ Redness of eyes(occurs due to congestion of
circumcorneal vessels.)
◦ Photophobia, results from stimulation of nerve endings
◦ Swollen lids
On examination
◦ cloudy cornea
◦Signs of infection/inflammation

92
93
Management
Topical antifungal eye drops should be
used for a long period (6 to 8 weeks).
◦ These include; natamycin (5%) eye drops,
fluconazol (0.2%) eye drops, nystatin (3.5%)
eye ointment.
Systemic antifungal drugs may be
required for severe cases of fungal
keratitis.
Topical antibiotics as eye drops by day
and ointment at night.

94
Atropine eye ointment/drops should be
used to reduce pain from cilliary spasm
and to prevent the formation of
posterior synechiae.
It also increases the blood supply to
anterior uvea by relieving pressure on
the anterior cilliary arteries and so
brings more antibodies in the aqueous
humour.

95
 Systemic analgesics and anti-inflammatory
drugs such as paracetamol and ibuprofen
relieve the pain and decrease edema.
 Vitamins (A, B-complex and C) help in early
healing of ulcer.
 Local application of warm moist compresses
heat gives comfort, reduces pain and causes
vasodilatation.
 Dark goggles may be used to prevent
photophobia.
 Rest, good diet and fresh air may have a
soothing effect. 96
INFECTIONS OF THE EYE
Signs and symptoms ◦ local swelling e.g. if
– Discharge sty
– Pain ◦ Corneal destruction
– Photophobia
◦ Greyish membrane
– Redness of the conjunctiva
◦ Loss of
– Scars that make the eye opaque
vision(blindness)
Management
H/C( if uncomplicated)
– Tetracycline eye ointment 1% TDS
– Teach patient how to clean eyes, instill the ointment
– Give appointment date for check-up
In hospital (complicated)
– Prepare for eye examination
◦ Collect eye swab for culture and sensitivity Instill
prescribed medication.
97
INFLAMMATIONS OF THE EYE
CONJUCTIVITIS(pink eye)
This is inflammation of the conjunctiva, the
mucous membrane lining, the upper and lower
lids and covering the front of the eye.
Causes
◦ Infections
◦ Allergy
◦ Trauma
◦ Physical irritants
◦ Chemical injury
BACTERIAL CONJUNCTIVITIS
Causes
–Staphylococcus
–Streptococcus
– Pneumococcus
– Gonococcus (requires isolation)
– Haemophilus influenzae(koch-
weeks bacillus)

99
 –”
Signs and symptoms
Redness of the conjunctiva
Swelling of the conjunctiva
Itching and burning sensation
Photophobia
Purulent discharge with crusts of dried
exudates causing
A feeling of grittiness

10
Diagnosis
–Through opthalmoscopy
–Eye swab for culture and sensitivity
Management
– Isolation to prevent spread especially of
“pink eye” which is very infectious and
common among school children.
– Immediate treatment depending on
culture and sensitivity of the organism
causing the infection with;
• Ointments -tetracycline 1%
• Eye drops e.g. tetracortil, chloramphenicol
(chloromycetin) 10
 Management cont’
 Systemic antibiotics (especially
penicillin)
 Warm or cold moist compresses
 Irrigations with normal saline to remove
exudates and relieve itching and
burning
Follow-up on discharge
Health messages
– Use of clean, individualized items (face cloths
and towels)
– Hygiene –keeping eyes clean by washing 10
Viral conjunctivitis
 can be acute and chronic.
 The common causative organisms are
adenovirus and herpes simplex virus.
 The symptoms - extreme tearing, redness, foreign
body sensation, watery discharge, follicles are
prominent, Severe cases include
pseudomembranes
 It is usually preceded by symptoms of URTI.
 Corneal involvement causes extreme
photophobia. There is lid edema, ptosis,
conjunctival hyperemia ,
 These signs and symptoms vary from mild to
severe and may last for 2 weeks. tends to last
longer than bacterial conjunctivitis.
10
Inclusion conjunctivitis
affects sexually active young people who
have genital chlamydial infection.
Transmission is by oral- genital sex or
hand-to-eye transmission.
indirect transmission has been acquired
from inadequately chlorinated swimming
pools. The eye lesions usually appear a
week after exposure and may be
associated with a nonspecific urethritis or
cervicitis. The discharge is mucopurulent,
follicles are present, and there is
lymphadenopathy.
10
TRACHOMA
•It is a spefic type of chronic conjuctivitis
caused by chlamydia trachomatis.
•It is the greatest single cause of serious
and progressive loss of sight in the world,
often leading to blindness..
Transmission – Flies, Fingers, Formites
(towels etc)
Its occurrence is associated with poor
socioeconomic status,poor sanitation,&
hygiene,In Dry, Dusty & Dirty areas

10
 Trachoma
WHO Five stages of development of trachoma
I. Inflammation-follicular- beginning of
infection .five of more follicles appear on
inner surface(tarsal)of upper eye lid.
II. Trachomotous inflammation intense- eye
highly Infectious.there is pronounced
thickening or swelling of upper
tarsal(eyelid)
III. Eye lid scarring- repeated infections leads
to scarring of the upper inner
eyelid(tarsal).eyelid become distorted and
may turn inward(entropion) 10
iv. Trachomatous trichiasis(ingrown
eyelashes)- the scarred innerlining of
eyelid continue to deform causing eye
lashes to turn in and rub with the cornea
V. Corneal clouding(opacity)- cornea is
affected by inflammation and it is seen
under the eye lid. in turned eyelashes
leads to clouding of cornea

10
Corneal trauma due to cicatricial
entropion (the lid margins are turned in
by tarsal scarring).This also predisposes
to secondary bacterial and fungal corneal
infection and scarring.

10
Signs and symptoms
Acute stage
◦ Irritation of the eye lids and itching,
◦ swollen eye lids
◦ Very red eye with mucoid discharge
◦ Photophobia and eye pain
◦ Large follicles form in the conjunctiva, cornea and eyelids
giving a granular appearance, causing thickening and
congestion
◦ The corneal epithelium is infiltrated with
vascularization( development of capillaries) known as
trachomatous pannus.
◦ Papillae redish flat topped raised areas in conjuctiva
Later stage
 The lining of the eyelids and cornea becomes
scarred(herbets pits)
10

11
Management
Isolation of known cases
Antibiotic therapy to control the disease. 10 day
antibiotics to make individual Chlamydia free.
Topical therapy- Local 1%
tetracucline,1%erythromycin/ eye ointment for
6weeks
Systemic therapy- tetracycline or
erythromycin,doxycycline per oral,azithromycin
Combined topical and systemic therapy in very
severe cases
Expressing the contents of follicles
Surgeryin advanced stages i.e entropion caused by
chronic disease where lid surgery is effective in
everting the eye lid, correction of trichiasis to
prevent conjunctival scarring 11
Hygienic measures-
 health education on ocular hygiene.the
use of common towel should be
discouraged
Clean environment to reduce the fly
population
Frequent face washing: the flies are less
likely to be attracted to the child and the
infected person is less likely to spread
chlamydia by direct contact
Good water supply will reduce the
11
 Management
Saline irrigations to remove discharge
Warm compresses for 15 minutes 4
times a day
Care must be taken to prevent spread of
the infection to the other eye or other
people by using clean hands and
individualized items.
ALLERGIC CONJUNCTIVITIS
It is inflammation of conjuctiva due to
hypersensitivity reaction.
The patient usually has a history of an allergy
to pollens and other environmental allergens.
There is extreme itching, epiphora (ie,
excessive secretion of tears), severe
photophobia,stringlike mucoid
discharge,formations of papillae that have a
cobblestone appearance.
It is more common in children and young
adults. Most affected individuals have a
history of asthma or eczema.

11
management
Steroideye drops
Vasonstrictor ie naphalozine
Sodium chromoglycate
Non steroidal antiallergic drugs

11
UVEITIS
• The uveal tract comprises of , the iris, the cilliary
body, the choroid. Inflammation of the various parts
is called
– Iritis: usually unilateral, characterized by pain,
photophobia, blurring of vision, redness
(circumcorneal flush) and constricted pupil.
– Cyclitis (cilliary body)
– Choroiditis (choroid)
• Panuveitis involves the entire uveal tract.
Causes
– Exogenous: from without e.g.. in direct infection
from perforating injury i.e.. exogenous
uveitis(trauma,toxins,allergy)
– Endogenous: from within e.g. allergy through blood
stream i.e. endogenous uveitis.
 –As a reaction to other local eye diseases
e.g. scleritis
–Infective organisms- bacteria, viruses,
fungi, protozoa
–Non ineffective systemic diseasei.e dm,
rheumatoid athritis
Signs/symptoms
1. Iritis- blood vessels of the conjunctiva
around the cornea are inflamed
(circumcorneal flush).
The iris is inflamed, swollen and the pupil
small. This may lead to adhesions
between the posterior surface of the iris
and the lens causing contraction of the
2. Inflammatory cells appear in the
chamber, and if profuse, an exudate may
be seen with the naked eye.
3. Purulent discharge
4. Photophobia
5. Headache
6. Pain (if severe, may be a complication
into glaucoma)
7. Impaired vision
8. Choroiditis: inflammatory cells enter
the vitreous humour producing a cloudy
vision
Treatment
◦Of the systemic cause- if bacterial,
antibiotics etc.
◦Local treatment- atropine drops to
dilate the pupil and keep it dilated
◦Local and systemic corticosteroids
Prognosis
Non-granulomatous uveitis subsides
with treatment in a few weeks
though it takes a more acute course.
Granulomatous uveitis may last for
months or years – usually chronic
BLEPHARITIS
Def: inflammation of the eyelid edges.
Predisposing factors
– Seborrhea (excessive oiliness of the skin)
– Excessive dryness
– Poor hygiene
– allergies
DISEASES OF THE EYELID

12
classification
a)Ulcerative (staphylococcal infection). It
is a chronic staphylococcal infection of
lid margin.
Predisposing factors- chronic
conjuctivitis, hygenic conditions,chronic
eye infection and eye strain.
Signs and symptoms- yellow crust
formation at root of cilia,small ulcers
that bleed easly,irrritation,lacrimation
 ◦.
b) Seborrheic Blepharitis.
◦ Occurs in patients with seborrheic
dermatitis. It is characterized by oily skin
and flaking from the scalp or brows. There is
excessive lipid secretion on the eyelid
margins which are broken down by special
bacteria called Corynebacterium acnes. The
breakdown products will cause
inflammation of the eyelid margin.
Symptoms- redness and swelling of lid
margins,irritation,lashes fall out
frequently
CLINICAL FEATURES
Red eye.
Debris in the tear film, seen under
magnification (improved contrast with
use of fluorescein drops).
Gritty sensation of the eye.
Reduced vision.
Tears that are frothy or bubbly in
nature,
Eyelashes that grow abnormally,
Loss of eyelashes.
12
ct
Itchy eyelids
Redness of eyelids
Flaking of skin on the lids.
Crusting at the lid margins, this is
generally worse on waking.
Cysts at the lid margin
(hordeolum).

12
Management of blepharitis
A complete blepharitis cure may not
exist.
Good eyelid hygiene and prescription
medicine are often effective in managing
blepharitis.
1. The single most important treatment
principle is a daily routine of lid
margin hygiene.
- It involves:
Soften lid margin debris and oils: Apply a
warm wet compress to the lids -- such as a
washcloth with hot water -- for five to 10
minutes two to four times a day, to losen the
crusty deposits..
Mechanically remove lid margin debris:
After using the compresses, cleanse the
eyelids with a cotton applicator stick soaked
in a 4 to 1 mixture of water and baby
shampoo or an over-the-counter lid-cleansing
product. To wash away oily debris or scales at
the base of eyelashes.
Rinse eyelids with warm water and pad with
 cont. Gently and repeatedly rub along the lid
margins while the eyes are closed. Be careful to
avoid rubbing or scratching your eyes.
2. Limiting or stopping the use of eye
makeup, as its use will make lid hygiene
more difficult or reintroduce bacteria.
3. If the patient wears contact lenses,
he/she may have to temporarily discontinue
wearing them during treatment.
4. If the patient has dandruff, use of a
dandruff shampoo may help alleviate the
symptoms.
5.Lubricate eyes by over the counter
artificial tears
6. If bacterial infection is the cause, antibiotic
drops or ointment and other medications
may be prescribed along with eyelid hygiene
7.Depending on the degree of inflammation
of the lid margin, a combination of topical
antibiotic and steroid drops or ointments can
be prescribed.
8. If the blepharitis is secondary to acne
rosacea(redness due to chronic dilatation of
the subcutaneous capillaries which become
permanent with the formation of pustules in
the affected areas), treatment with oral
doxycycline together with lid-margin
hygiene routine may be prescribed.
9 . If the blepharitis is due to
allergy, identify and reduce the
exposure to the offending agent.
Prescription and over-the-counter
drop or oral antihistamines may
be used.
10. Recently, there has been some
evidence that oral omega-3 fatty
acids may be helpful in the
treatment of blepharitis.
13
Complications
Eyelash problems. Eyelashes fall out or
grow abnormally (misdirected eyelashes).
Eyelid skin problems. Scarring may occur
on eyelids in response to long-term
blepharitis.
Excess tearing or dry eyes. Abnormal oily
secretions and other debris shed from the
eyelid, such as flaking associated with
dandruff, can accumulate in the tear film —
the water, oil and mucus solution that forms
tears. Abnormal tear film interferes with the
healthy lubrication of the eyelids. This can
irritate the eyes and cause dry eyes or
excessive tearing.
Difficulty wearing contact lenses.
By affecting the amount of lubrication in
your eyes, wearing contact lenses may
be uncomfortable.
Sty: An infection that develops near the
base of the eyelashes. The result is a
painful lump on the edge (usually on the
outside part) of your eyelid. It is most
visible on the surface of the eyelid.
Chalazion: Occurs when there's a
blockage in one of the small oil glands
at the margin of the eyelid, just behind
the eyelashes. The gland can become
Chronic pink eye. Blepharitis can
lead to recurrent bouts of pink eye
(conjunctivitis).
Injury to the cornea. Constant
irritation from inflamed eyelids or
misdirected eyelashes may cause a
sore (ulcer) to develop on your cornea.
Insufficient tearing could predispose
you to a corneal infection.
STY (EXTERNAL HORDEOLUM)
Small painful lump in or outside the eye lid.affects
gland and follicles.it is an abcess filed with pus.
Cause: staphylococcal infection of a follicle of the
eyelash
Predisposing factors:
◦ General poor health
◦ Wearing of glasses
◦ Chronic phlebartis
◦ Habitual rubbing of eyes
Signs and symptoms
◦ Inflammation with redness, burning and itching of
the eyelids (blepharitis)
◦ Then a small pustule forms on the lid, becomes
swollen and red.
◦ Photophobia.
 – It is usually painful but very uncomfortable.
CHALAZIA (INTERNAL HORDEOLUM)
They are the infections of the meibomian
glands (cysts) of the small lubricating glands
around the edge of the eyelids due to retained
secretions often mistaken for stys, and cause
more pain.
Patient present with painless sweling in the lid
which is firm, non tender. when infected it
becomes very painful.
Treatment
STY
a) Warm moist compresses applied
regularly to help the sty to rupture
and drain.
b) Application of chloramphenicol
ointment.
c) Removal of eyelashes.
d) Avacuation of the pus
e) If they don’t rupture, surgical incision
13
CHALAZION

STYE
CHALAZIA OR CYSTS
– Warm moist compression
– Antibiotic ointments e.g. chloramphenicol
ointment BD and antiinflammatory drugs.
– Intraleisonal injection of long acting
steroids(triamcilone)
– Surgical treatment if they do not
clear(incision and curretage)
NOTE: frequent infections of the eyelids can
be symptomatic of diabetes mellitus
GLAUCOMA
 group of ocular conditions characterized by
optic nerve damage. The optic nerve damage is
related to the IOP caused by congestion of
aqueous humor in the eye.
 Damage to the optic nerve is caused by the
effects of raised ocular pressure acting at the
optic nerve head
 Independent ischaemia of the optic nerve is also
important
 Axon loss results in visual field defects and a
loss of visual acuity if the central visual field is
affected
Risk Factors
• Family history of glaucoma
• African American race
• Older age
• Diabetes
• Cardiovascular disease
• Migraine syndromes
• Nearsightedness (myopia)
• Eye trauma
• Prolonged use of topical or systemic
corticosteroids
14
Physiology of aqueous humour
 Intraocular pressure level depends on
the balance between production and
removal of aqueous humour.
 Aqueous is produced by secretion and
ultrafiltration from the cilliary processes
into the posterior chamber. It then
passes through the pupil into the
anterior chamber to leave the eye via
trabecular meshwork, schlemm’s canal
and the episcleral veins(conventional
pathway)
A small proportion of the aqueous(4%) drains
across the ciliary body into the supra-choroidal
space and into the venous circulation across
the sclera(uveoscleral pathway)
pathophsiology
 direct mechanical theory- high IOP damages
the retinal layer as it passes through the optic
nerve head.
 indirect mechanical theory- Raised
intraocular pressure causes ischaemia of the
nerve axons by reducing blood flow at the
optic nerve head through compressions of the
microcirculation in the optic nerve head,
resulting in cell injury and death(
Stages in development of glaucoma
pathophysiology
I. Initiating events: precipitating factorsi.e,
emotional stress, congenital narrow angles,
longterm use ofpupillary dilation).
II. Structural alterations in the aqueous outflow
system: due to tissue and cellular changes caused
by factors that affect aqueous humor dynamics
III. Functional alterations: conditions such as
increased IOP or impaired blood flow
IV. Optic nerve damage: atrophy of the optic nerve
is charac- terized by loss of nerve fibers and blood
supply
V. Visual loss: progressive loss of vision is
characterized by visual field defects.

14
Classification
1.Primary glaucoma
 Chronic open angle
 Acute and chronic closed angle
2.Congenital glaucoma
 Primary
 Rubella
 Secondary to other inherited ocular
diseases such as aniridia (Lack of part or
the whole iris)
3.Secondary glaucoma(causes)
Trauma
Ocular surgery
Associated with other ocular diseases
such as uveitis
Raised episcleral venous pressure
Steroid induced
Primary open angle glaucoma

 The drainage angle formed by the cornea

and iris remains open but trabecullar
meshwork is partially blocked that causes
increase in intaocular pressure damaging the
optic nerve
or
 In open angle glaucoma, the structure of the
trabecular meshwork appears normal but
offers an increased resistance to the outflow
of aqueous which results in an elevated
ocular pressure.
Causes of outflow obstruction
 Thickening and sclerosis of the
trabecular lamellae which reduces pore
size
 Reduction in the number of lining
trabecular cells
 Increased extracellular material in the
trabecular meshwork spaces
 Changes in the endothelial lining of the
canal schlemn.
 Signs and symptoms
• Usually progressive and asymptomatic
• Raised IOP
• headache
• Visual field defect
• Cupped optic disc
 Examination
 Requires full slit lamp
 Tonometer:The pressure is in the 22-40
range and in angle closure glaucoma the
pressure rises above 60mmHg
 To measure the thickness of the cornea
with a pachymeter
 Gonioscopy lens to examine the
iridocorneal angle
 Exclude other ocular diseases that may
be a secondary cause for glaucoma
 Examine optic disc and determine
whether it is pathologically cupped. In
normal eye, cup/disc ratio is less than
0.4. In this condition,the cup/disc ratio is
greater than 0.4
 Treatment
 Aimed at reducing intraocular pressure
 Medical treatment
 Prostaglandin analogues-increase passage of
aqueous through the uveoscleral pathway i.e
latanoprost, travoprost e.t.c
 Topical adrenergic beta-blockers suppress
aqueous secretion.1st choice i.e timolol
 Pilocarpine lower IOP by increasing aqueous
outflowb by opening spaces in trabecular
meshwork.
 Dorzolomade carbonic anyhydrase inhibitor
decrease aqueous secretion.
Laser trabeculectomy
 Laser burns are placed in the trabecular
meshwork to improve aqueous outflow
Surgical treatment
 Trabeculectomy relies on the creation of
a fistula between the anterior chamber
and the subconjuctival space.
Normal tension/low tension glaucoma

 Optic nerve become damaged even

though IOP is still in normal range. it may
be related to sensitive optic nerve or
reduced blood flow
 Glaucomatous field loss and cupping of
the optic disc occurs even though the
intraocular pressure is not raised.
 The optic nerve is unusually susceptible
to the intraocular pressure and/or has an
intrinsically reduced blood flow
Closed angle glaucoma
Results from increase in IOP due
to blokage of aqueous flow by
closure of a narrow angle
between iris and cornea(anterior
chamber).caused when iris
buldges foward.
TYPES
Acute, intermediate, chronic

15
causes
hypermetropic eye
Narrow angle of anterior chamber
Plateu iris configuration (iris
buldges foward)
Familly history
Old age >60yrs

15
pathophysiology
Pupil dilatation---increased
contact between lens and iris
preventing aqueous passing into
anterior chamber—physiological
iris bombe (foward bowing of
iris )due to pressure from continued
secretion of aqueous.----closure of
the angle blocks outflow ---------
synechiae (peripheral iris contact
leads to adhesions) –prolonged rise
in IOP.
15
management
Acetazolomide
Hyperosmotic agent
Pilocapine
Topicalsteroids
SURGERY
Peripheral iredectomy
trabulectomy

15
 Secondary glaucoma

 IOP rises due to blockage of the trabecular

meshwor
 The trabecular meshwork may be blocked by
 Blood following a blunt trauma
 Inflammatory cells(uveitis)
 Pigment from the iris
 Deposition of material produced by the
epithelium of the lens,iris,ciliary body in the
trabecular meshwork(pseudoexfolioative
glaucoma)
 Drugs increasing resistance of the meshwork
especially steroids
 Abnormal iris blood vessels may
obstruct the angle and cause the iris to
adhere to the peripheral cornea closing
the angle(rubeosis iridis)
 Large choroidal melanoma
 Cataract
 Uveitis may cause the iris to adhere to
the trabecular meshwork
 Congenital glaucoma
 Cause remains uncertain
 Iridocorneal angle may be
developmentally abnormal and covered
with a membrane which increases the
outflow resistance
 Clinical features
 Lacrimation,photophobia, buphthalmos
 CATARACT
 It’spartial/complete
opacification of the lens of the
eye
 The large majority of cataracts
occur in older subjects as a
result of cumulative exposure
to environmental and other
influences such as smoking,UV
radiation and elevated blood
sugar levels. This is refered to
as age related cataract.
 A smaller number are
associated with specific ocular
or systemic disease
 Some are congenital and may
be inherited
 risk factors
Ocular conditions
 Trauma
 Uveitis
 High myopia
 Retinal pigmentosa
 Retinal detatcment and surgery
 Prolonged use of Steroid eye drops
 Intraocular tumor
 Systemic diseases
cataract
 Diabetes
 Renal disorders
 Disorders related to lipid metabolism
 Hypocalcemia

Toxic factors
 prolonged use of Steroids
 Alcohol and cigarrete smoking
 Alkaline chemical eye burns, poisoning
 Calcium, copper deposits
Physical factors
 Excessive exposure to ionzing radiation
 Dehydration associated with chronic
diarrhea
 Blunt trauma, perforation of the lens with a
sharp object or foreign body, electric shock
Cogenital - Congenital rubella
others
 Family history
 Aging
 obesity

16
 Signs and symptoms
 Visual acuity is reduced
 Clouded,blurred or dim vision
 Fading or yellowing colors
 A cataract appears black against the red reflex
when the eye is examined with a direct
ophthalmoscope
 Double vision in a single eye
 Painless loss of vision
 Glaire and sentivity to light.
 Frequent changes in eye glasses
 In infants, cataract causes a failure of normal
visual development
 Treatment
Cataract surgery
 Involves gaining access to the lens
substance via a hole made in the anterior
part of the lens capsule, removal of most of
the lens fibers and epithelial cells and
insertion of a plastic lens implant of
appropriate optical power
 The implant is held in place within the
‘capsular bag’ and the thin, transparent
posterior capsule offers no obstruction to
light entering the eye
 Surgery is performed under local
anesthesia
Local anesthesia is infiltrated around the
globe and the lids or given topically. If
social circumstances allow, the patient
can attend as a day case.
 Complications of cataract
surgery
intraoperative
 Retro bulbar haemorhage, subconjuctivital
haemorrhage.
 Vitreous loss: If the posterior capsule is
damaged during the operation, the
vitreous gel may come forward into the
anterior chamber where it represents a
risk for glaucoma or may cause retinal
traction.
Early postoperative
 Iris prolapse: The iris may protrude
through the surgical incision in the
immediate postoperative period. It
appears as a dark area at the incision
site. The pupil is distorted. This requires
prompt surgical repair
 Endophthalmitis:Presents with a painful
red eye, reduced visual acuity and
collection of white cells in the anterior
chamber(hypopyon)
Late complications
 Cystoid macular edema
 Retinal detachment
 Opacification of posterior capsule
 If the fine nylon sutures are not removed after
surgery they may break in the following months
or years causing irritation and infection.
Late complications related to intraocular
lens implantation
 Malposition of the IOL, uveitis, Opacification of
the posterior capsule
 Read on preop and post op care
RETINAL DISORDERS
 The retina is composed of multiple
microscopic layers:
1. Inner sensory retina-rods and cons
2. Retinal pigment epithelium-the
basement membrane that joins the
retina and the choroid.
 Retinal detachment
 Is the separation of the retina from the
choroids and separation of the retinal
pigment epithelium from the sensory layer
Types of retinal detachment
1. Rhegmatogenous
Most common
A hole/tear develops in the sensory retina
allowing some of the vitreous to sip
through the sensory retina and separate
it from the retinal pigment epithelium
 CAUSES
 Myopia
 Aphakic patients
 Trauma
 Retinal degeneration
 Proliferative retinopathy i.e.
weakening/dying of the retina
especially in diabetes. Affects about 5-
10% of patients
 Age 40-60 years
 Secondary retinal detatchment

 2.Traction retinal detachment

 Results from tension /pulling
 Patients who develop this type of
condition have developed a scar tissue
from diseases like vitreous hemorrhage,
retinopathy
 The hemorrhage and fibrous
proliferation associated with this
condition exerts a pulling force on the
delicate retina thus the separation of the
two membranes
3.Combined rhegmatogenous and
traction detachment
4.Exudative retinal detachment
Occurs due to retina being pulled away
from the choroids
Results from the production of a serous
fluid under the retina from the choroids
and this may be as a result of choroiditis
or macular degeneration
Predisposing factors to retinal detachment

 Age related macular degenerative changes

 Trauma
 Cataract extraction
 Severe myopia
 Previous retinal detachment in the other eye
 Family history of retinal detachment
 Spontaneous vitreous traction
 Diabetes
 Atrophy of the vitreous body
 Pathophysiology

 Retinal layers separate from the

choroids creating a subretinal space.
Vitreous fluid sips between layers
disrupting choroidal blood supply.
 Detachment may be partial causing
varying degrees of visual defect or total
causing blindness in the affected eye.
 Clinical manifestations
 Recurrent flashes of light and floating spots
 Progressive blurring of vision in the affected
eye followed by visual field defects which is
dependent on the area of detachment
 Sudden painless loss of vision
 Onset is sudden and because of this and
mode of presentation, patients appear
anxious and have fear of loss of vision
 Opthalmoscopy: Areas that are grey or an
opaque retina with either a hole, tear or
fault
Management
 Surgical repair to place the retina back
in contact with the choroids and to seal
the accompanying holes and tears
 Pre-operatively give mydriatic drugs to
dilate the pupils
Types of surgery
Sealing of retinal breaks by
photocaogulation, Cryopex
Bring the sclerochoroid and detactched
retina together- by scleral buckling
Pars palma virectomy- to cut the
vitroretinal traction bands

Readon propertive and postoperative

management
TUMORS OF THE EYE
• They may be benign or malignant, form
in or metastasize to the eye.
TYPES
1. Retinoblastoma: a congenital
malignant neoplasm found in children
and spreads easily to the brain
2. Melanoma: common in the iris and
choroid; grows slowly but metastasizes
to the liver and lungs.
RETINOBLASTOMA

 Malignant tumour of
early chilhood.
 Introcular tumour. Can
extend to the orbit &
CNS.
 Developes from
immature retinal cells.
 Most common malignant
ocular tumour in
children.

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RETINOBLASTOMA
Bilateral in 30% of all
cases.
Non-heritable in 60%
of cases.
Heritable in 40% of
cases.
Siblings of affected
child should be
examined.

184
Presentations of retinoblastoma

• Leukocoria - 60% • Secondary glaucoma

• Strabismus - 20%

• Anterior segment invasion • Orbital invasion

• Orbital inflammation
 RETINOBLASTOMA
TREATMENT:
Laser
photocoagulation
Cryotherapy
External beam
radiation
Chemotherapy
Enucleation (surgical
removal of the eye).in
advanced stage

186
Signs and symptoms
 Leukorrhea(In retinoblastoma, white pupillary
reflex (an abnormal white appearance of the
pupil which reflects light).
Severe pain,redness,watery and hazy cornea
Decreased vision
Strabismus
Retinal detachment
Headache
Visual disturbances
Nursing care
–Support client and family in coping with the
diagnosis
 – Observe for side effects of therapy, report and
attempt to alleviate them.
Post-operative care in Enucleation
–Maintain pressure dressings on the eye for 1-2
days to minimize hemorrhage.
–Administer prescribed analgesics for pain
–Monitor for signs of meningitis as a complication
(headache, neck stiffness etc.)
–Single eye vision-explain that this results in loss
of depth of perception (acuity) and activities
needing this should be performed cautiously.
–Support adaptation to changes in body image in
enucleation
–Explain that an artificial eye may be inserted
when healing is complete (6- 8weeks)
What is done if the child has tumor in
both eyes?
In these cases, generally the worse eye is
enucleated and the other eye is tried to
salvage by using other methods of treatment.
However, unfortunately in a few cases, both
eyes may have to be removed.
Why is early detection important?
The safer and less destructive procedures
may be taken when the tumor is in its early
stage. By detecting and treating the tumor
early, we may save the life, sight and eye of
the child.
 Nursing Management
Educate on proper eye care
◦ Hand wash
◦ Avoid rubbing
Rx as prescribed
Post-op
◦ Avoid valsalva maneuver
◦ Educate!!
Enucleation – pressure dress, artificial
eye
Support + family therapy

19
EYE SURGERY
Indications
◦ Intra-ocular foreign bodies
◦ Penetrating eye injuries
◦ Choroidal tears
◦ Hemorrhage
◦ Cataract
◦ Glaucoma
◦ Retinal detachment
◦ Tumors

19
 Pre-operative care
Orientation of the patient to his environment after
admission as his eyes may be bandaged after operation.
Pre-op. medications ordered e.g.. ophthalmic
ointments/drops to be given on time
Suppository (enema) if prescribed, to evacuate the
lower bowel to prevent straining immediately post-
op.
Clipping of eyes (if ordered)- petroleum jelly is
applied to the blades of blunt-pointed scissors so
that the eyelashes will adhere to the blade and not
fall into the eye.
Explanation for bandaging of both eyes post-op
i.e.., the unaffected eye is covered to keep the
patient from moving his eyes (i.e.. rest) during the
immediate post-op. period. 19
Continuation
Washing of eyes the evening before
surgery and a sterile pad applied over
the eye.
Respiratory infections or allergy that
may cause coughing, sneezing should be
notified to the surgeon. Surgery may
have to be post-poned as such violent
motions can cause hemorrhage/ rupture
of the surgical incision
Other general pre-op. care and as
ordered
19
 Post-operative care
Post-operative care
Gentleness is the key in all types of eye
surgery. All movements should be slow and
gentle
◦ The patient’s head must be firmly supported
when he is transferred form the operating table or
stretcher to his bed.
◦ Small pillows may be used on either side of his
head to support it in the supine position.
◦ Speech should always be soft before touching the
patient. Alert them when entering the room
because if he is sleeping. May be frightened and
move suddenly and violently when some-one
touches him. 19
◦ Uncooperative patients and children will need
someone in constant attendance to prevent
them pulling off the bandages.
◦ Nausea and subsequent vomiting may cause
severe damage to delicate suture lines. All
food and liquids should be withheld, surgeon
notified and an emetic drug ordered/given.
◦ Sudden pain in the eye may indicate
hemorrhage. Inform the surgeon immediately.
( glaucoma as a post-op. complication )
◦ External irrigation of the eye (there should be
no contact with the eyeball) or wet compresses
may be ordered to remove the exudates and
reduce swelling. Eyelids are cleaned with care.

19
Consult
◦ If the patient can be turned to one or both sides
◦ Whether he will remain flat supine or pillow
allowed, how high the head of the bed should be
elevated and
◦ Whether he can feed himself, or any restrictions on
fluid/food intake.
• If allowed out of bed, he must take care not to bang
his head or move too suddenly.
• All straining and lifting must be avoided
On discharge
Relatives and the patient should be encouraged to
follow these instructions at home during
convalescence so as not to endanger the success of
the surgery.
19
 MWISHO
AHSANTENI