anatomy

1:posterior chamber
2:ora serrata
3:ciliary muscle
4:ciliary zonules
5:canal of Schlemm
6:pupil
7:anterior chamber
8:cornea
9:iris
10:lens cortex
11:lens nucleus
12:ciliary process
13:conjunctiva
14:inferior oblique muscle
15:inferior rectus muscle
16:medial rectus muscle
17:retinal arteries and veins
18:optic disc
19:dura mater
20:central retinal artery
21:central retinal vein
22:optic nerve
23:vorticose vein
24:bulbar sheath
25:macula
26:fovea
27:sclera
28:choroid
29:superior rectus muscle
30:retina
 As a conscious sense organ, the eye
allows vision. Rod and cone cells in
the retina allow conscious light perception
and vision including color differentiation
and the perception of depth. The human
eye can distinguish about 10 million colors.
 The posterior chamber
◦ a narrow chink behind the peripheral part of the
iris of the human eye, and in front of the
suspensory ligament of the lens and the ciliary
processes the Posterior Chamber consists of small
space directly posterior of the Iris but anterior to
the lens.
 Schlemm's canal, also known as canal of Schlemm
or the scleral venous sinus, is a circular channel in
the eye that collects aqueous humor from the
anterior chamber and delivers it into the
bloodstream.
 On the inside of the canal, nearest to the aqueous
humor, it is covered by the trabecular meshwork,
this region makes the greatest contribution to
outflow resistance of the aqueous humor.
 Named after Friedrich Schlemm (1795-1858), a
German anatomist.
 The pupil is a circular opening located in the
center of the iris of the eye that allows light
to enter the retina
 The anterior chamber is the fluid-filled

space inside the eye between the iris and

the cornea's innermost surface, the
endothelium.
 Aqueous humor is the fluid that fills the

anterior chamber.
 The cornea is the transparent front part of
the eye that covers the iris, pupil, and
anterior chamber. Together with the lens,
the cornea refracts light, accounting for
approximately two-thirds of the eye's total
optical power
 The iris is a membrane in the eye,
responsible for controlling the diameter and
size of the pupil and the amount of light
reaching the retina. "Eye color" is the color of
the iris, which can be green, blue, or brown.
In some cases it can be hazel (light brown).
In response to the amount of light entering
the eye, muscles attached to the iris expand
or contract the aperture at the center of the
iris, known as the pupil. The larger the pupil,
the more light can enter.
 The lens is a transparent, biconvex
structure in the eye that, along with the
cornea, helps to refract light to be focused
on the retina. The lens, by changing shape,
functions to change the focal distance of
the eye so that it can focus on objects at
various distances, thus allowing a sharp real
image of the object of interest to be formed
on the retina. This adjustment of the lens is
known as accommodation.
 retina is a light sensitive tissue lining the
inner surface of the eye. Light striking the
retina initiates a cascade of chemical and
electrical events that ultimately trigger
nerve impulses. These are sent to various
visual centers of the brain through the
fibers of the optic nerve.
 Rods provide black-and-white vision
 cones support daytime vision and the

perception of colour.
 The macula or macula lutea (from Latin
macula, "spot" + lutea, "yellow") is an oval-
shaped highly pigmented yellow spot near
the center of the retina of the human eye.
 Because the macula is yellow in colour it

absorbs excess light that enters the eye and

acts as natural sunglasses.
 Within the macula are the fovea and foveola

which contain a high density of cones

 The sclera, also known as the white of the
eye, is the opaque fibrous, protective, outer
layer of the eye containing collagen and
elastic fiber
 the conjunctiva is a thin layer covering the

sclera. Along with the vessels of the

conjunctiva, those of the sclera renders the
inflamed eye bright red.
 The choroid is the vascular layer containing
connective tissue, of the eye lying between
the retina and the sclera. In humans its
thickness is about 0.5 mm. The choroid
provides oxygen and nourishment to the
outer layers of the retina. Along with the
ciliary body and iris, the choroid forms the
uveal tract.
 The ciliary body is the circumferential tissue
inside the eye which secretes aqueous
humour
 theleading cause of
blindness in those 40 years or
older
 The earliest reference to cataracts can be
found in Hindu writings from the 5th
century BC
 The word Cataract comes from the Greek

word meaning “Waterfall”

 Until the mid 1700’s, it was thought that

cataract was formed by opaque material

flowing, like a waterfall into the eye
 The human lens is a
naturally clear
structure located
behind the iris and
supported by the
zonules
 The lens is
avascular-It does not
have a vascular
supply
 The basic lens
consists of a
central nucleus
surrounded by
the cortex
contained within
the lens capsule
 The lens is made mostly of water and
protein fibers
 The protein fibers are arranged in a
precise manner that makes the lens clear
and allows light to pass through without
interference
 With aging, the composition of the lens
undergoes changes and the structure of
the protein fibers breaks down
 Some of the fibers begin to clump
together, clouding areas of the lens, and
leading to the loss of transparency
 This loss of
transparency, or
opacity formation
is called Cataract
 Clouding of the lens is a normal part of
aging
 About half individuals older than 65 have

some degree of clouding of the lens

 According to one study, after age 75, 39%

of men, and 46% percent of women in the

U.S. have visually significant cataracts
 Cataracts produce a gradual, painless,
progressive loss of vision, and many
patients are unaware of vision problems
 Generally do not cause pain, or abnormal
tearing
 But as the clouding progresses, the cataract
eventually interferes with your vision
 Commonly affect distance vision
 Cause problems with glare
 In the early stages, stronger lighting and
eyeglasses can help deal with the vision
problems
 If impaired vision jeopardizes your normal
lifestyle, you might need surgery
 Patients often
describe trying to
look through a
fogged-up
window
 Clouded vision
can make it more
difficult to drive a
car, read, or see
details
 Blurred vision
 Increasing difficulty with vision at night
 Glare, especially at night
 Halos around lights
 The need for brighter light for reading
 Double vision in a single eye
 Fading or yellowing of colors
 Due to increase of
yellow-brown
pigment in the
lens, color
perception also is
affected
 These may also be symptoms of other eye
conditions, therefore it is important to see
your ophthalmologist annually, or if there is
a persistent change in vision
 Pain, redness, discharge, or irritation in the
eye are usually not signs or symptoms of a
cataract, but may be signs and symptoms
of other eye disorders
 A cataract isn't
dangerous to the eye
unless the cataract
becomes completely
white, a condition
known as an overripe
(hypermature) cataract
 This can cause
inflammation, eye pain
and headache
 A hypermature cataract
is extremely rare and
needs removal
 Responsible for nearly 10% of all visual
loss in children worldwide
 Approximately 0.03% of newborns have
some form of congenital cataract
 Most are not associated with additional
developmental problems
 Around one fifth of these patients have a
family history of congenital cataract but in
up to half of all cases there is no family
history
 In the case of a newborn infant, a cataract
causes the immature visual system to be
deprived of the stimulation needed for
normal development
 If left untreated, permanent visual loss

may occur
 Unilateral cataracts are more likely to

cause visual loss because of the

competition between the two eyes
 If the cataract is small there may be only
slight blurring of vision with near normal
visual development
 If the cataract is larger, or located more
posteriorly, it can effect visual
development
 In some cases this can lead to permanent
amblyopia (lazy eye)
 Without adequate stimulation central
vision can be permanently effected
 Outcome is very much dependent on
the type of cataract
 Some congenital cataracts impair

visual development only to a small

degree and may never require surgery
 If the cataract is only in one eye, there

is a strong tendency for the child to

prefer the healthy eye
◦ The eye affected by the cataract rarely
achieves normal vision, therefore removal of
the cataract is indicated
 Hereditary
◦ Autosomal dominant form most common
 Genetic and Metabolic Diseases
◦ Down syndrome
◦ Marfan’s syndrome
◦ Myotonic Dystrophy
 Maternal Infections
◦ Rubella, Syphilis, Toxoplasmosis, Varicella
 Ocular Anomalies
◦ Aniridia-Absence of iris at birth
 Toxic
◦ Corticosteroids, Radiation
 Trauma
 Exposure to sunlight (UV light)
 Smoking
 Diabetes
 Trauma (blunt or penetrating)
 Family history of cataracts
 Corticosteroid therapy
 Radiation exposure
 Electrical injury
 Myotonic dystrophy
 Uveitis- Ocular inflammation
 Everyone is at risk of developing cataracts
simply because age is the single greatest
risk factor
 By age 65 about half of all Americans have

developed some degree of lens clouding

 Cataracts develop sooner in diabetic
patients than in non-diabetic patients
 This is caused by shifts in the glucose,
electrolyte, and water balance within the
lens
 Fluctuating vision and rapid shift to near
sightedness are symptoms of diabetes
 The most common
objective finding
associated with
cataracts is
decreased visual
acuity
 This is measured
with an office wall
chart or near-vision
card
 Acuity refers to the sharpness of vision or
how clearly you see an object
 In this test, your eye doctor checks to see
how well you read letters from across the
room
 Eyes are tested one at a time, while the
other eye is covered.
 Using the chart with progressively smaller
letters from top to bottom, to determine
the level of vision
 This is performed
by your doctor to
see if the
decrease in vision
is simply due for
need for new
glasses, or if there
is another process
at work that
accounts for the
decrease in visual
acuity
 SLE allows the
ophthalmologist to see
the structures of the eye
under magnification
 The microscope is called
a slit lamp because it
uses an intense slit of
light to illuminate your
cornea, iris, and lens
 These structures are
viewed in small sections
to detect any small
abnormalities
 Dilating drops are
placed in the eyes to
dilate the pupils wide
and provide a better
view to the back of the
eyes
 It allows the
ophthalmologist to
examine the lens for
signs of a cataract and,
if needed, determine
how dense the
clouding is
 It also allows for
examination of
the retina and the
optic nerve.
 Dilating drops
 
                    
usually keep your
pupils open for a
few hours before
their effect
gradually wears
off
When pupils are dilated, patients will have
difficulty focusing on close objects
 With your pupils open this wide, sunglasses

are helpful on a sunny day, and you may

need a driver to drive you home
 Cataract
 Retinal detachment
 Macular degeneration
 Diabetes mellitus
 Glaucoma
 Retinal artery occlusion
 Retinal detachment is often accompanied
by floaters, flashes of light, and loss of
peripheral vision, which is often described
as a gray curtain or shade covering all or
part of the visual field
 Risk factors include a history of previous

ocular trauma, nearsightedness, retinal

detachment in the fellow eye, or a family
history of retinal detachment
 Macular degeneration usually causes a
slow, progressive loss of central vision
 Symptoms of acute vision loss and

distortion result from leakage from

abnormal subretinal vessels
 Patients should be referred to a retina

specialist immediately
 Diabetic retinopathy may also contribute
to vision loss
 Findings include dot-and-blot

hemorrhages, microaneurysms, dilated

and tortuous vessels, and
neovascularization of the disk and retina
 Cataracts often obscure the fundus,

making assessment of diabetic

retinopathy difficult
 Open-angle glaucoma produces slow,
painless visual field loss that usually
begins peripherally
 Optic nerve damage and subsequent loss

of peripheral vision occur at normal as

well as elevated intraocular pressures
 With progressive optic nerve damage and

visual field loss, central vision is the last to

be affected
 Cataracts are the most treatable cause of
decreased vision in the United States
 For most patients, observation and
frequent eyeglass prescription changes
are sufficient
 When activities of daily living, such as
driving, reading, working, and self-care
are affected surgery should be discussed
 Cataract Surgery should be considered
when changes in eyeglasses no longer help,
quality of life is jeopardized, and cataract
removal is likely to have an impact on vision
 Make sure that eyeglasses or contact lenses
are the most accurate prescription possible
 Improve the lighting in your home with
more or brighter lamps
 When outside during the day, wear
sunglasses to reduce glare
 Limit night driving
 Think about how the cataract affects your
daily life
◦ Can you see to do your job and drive safely
◦ Do you have problems reading or watching
television?
◦ Is it difficult to cook, shop, climb stairs or take
medications?
◦ How active are you? Does lack of vision affect
your level of independence?
◦ Are you afraid you'll trip or fall or bump into
something?
 Sometimes a cataract should be removed
even if it doesn't cause major problems with
vision
◦ If it is preventing the treatment of another eye
problem, such as age-related macular
degeneration, diabetic retinopathy or retinal
detachment
 If you have cataracts in both eyes and
decide to have surgery, your eye doctor
typically removes the cataract in one eye at
a time
 This allows time for the first eye to heal

before the second eye surgery

 Cataract surgery is the most common operation
performed on patients over 65 years of age
 More than 95% of patients have improved vision
after surgery
 Benefits include improvement in uncorrected and
best-corrected visual acuity, improved
binocularity, depth perception, and increased
peripheral vision to enhance patients' ability to
drive, read, work, and manage their own
medications
 Advances in surgical technique and more
sophisticated technology have helped
make surgery a safe and effective
treatment for cataracts
 Prior to surgery, your eye doctor measures

the size and shape of your eye to

determine the proper lens implant power
 This measurement is made with a painless

ultrasound test
 Cataract surgery is
typically an outpatient
procedure that takes less
than an hour
 Most people are awake
and need only local
anesthesia
 On rare occasions some
people may need
general anesthesia if
they have difficulty
laying flat or have
claustrophobia
 Two things happen
during cataract
surgery — the
clouded lens is
removed, and a clear
artificial lens is
implanted
 During
phacoemulsificati
on, phaco for
short, the
surgeon makes a
small incision,
where the cornea
meets the
conjunctiva
 The surgeon then
uses the probe,
which vibrates
with ultrasound
waves, to break
up (emulsify) the
cataract and
suction out the
fragments
 Once the cataract is
removed, a clear
artificial lens is
implanted to replace
the original clouded
lens
 This lens implant is
made of plastic, acrylic
or silicone and
becomes a permanent
part of the eye
 Some IOLs are rigid
plastic and implanted
through an incision that
requires several stitches
(sutures) to close
 However, many IOLs are
flexible, allowing a
smaller incision that
requires no stitches
 Patients usually go home the same day
 Patients are seen in the office the next day, the following
week, and then again after a month so that he or she can
check the healing progress
 It's normal to feel mild discomfort for a couple of days after
surgery
 You may wear an eye patch or protective shield the day of
surgery
 Your doctor may prescribe medications to prevent infection
and control eye pressure
 Patients are usually examined 1 day, 1
week and then one month after the surgery
date
 Vitreous Loss- 3.1%
 Vitreous Hemorrhage-0.3%
 Uveitis-1.8%
 Increased Eye Pressure- 1.2%
 Retinal Detachment- 0.7%
 Endophthalmitis- 0.13%
 Contact your doctor immediately if you
experience any of the following signs or
symptoms after cataract surgery:
◦ Vision loss
◦ Pain that persists despite the use of over-the-
counter pain medications
◦ A definite increase in eye redness
◦ Light flashes or multiple spots (floaters) in front
of the eye
◦ Nausea, vomiting or excessive coughing
 This condition occurs
when the back of the
lens capsule
eventually becomes
cloudy and blurs vision
 PCO can develop
months or years after
cataract surgery
 Occurs approx. 20%
percent of the time
 Treatment for PCO is simple and quick
 Laser capsulotomy is a quick, painless
outpatient procedure that usually takes less
than five minutes
 Capsulotomy means "cutting into the
capsule" and YAG is an abbreviation of
yttrium-aluminum-garnet, the type of laser
used for the procedure
 A technique in
which a laser
beam is used to
make a small
opening in the
clouded capsule
to let light pass
through
 Afterward, patients typically stay in the
doctor's office for about an hour to make
sure the eye pressure is not elevated
 In some people, particularly those who

have glaucoma or are extremely

nearsighted, YAG laser surgery can raise
eye pressure
 Other complications are rare but can

include swelling of the macula and a

detached retina
 Most cataracts occur with age and can't be
avoided altogether
 Regular eye exams remain the key to early

detection
 You can take steps to help slow or prevent

the development of cataracts

 Do not smoke
◦ Smoking produces free radicals, increasing
your risk of cataracts.
 Eat a balanced diet
◦ Include plenty of fruits and vegetables.
 Ultraviolet light protection since UV light
may contribute to the development of
cataracts
 Diabetes Control
 Researchers are continuing to explore new
ways to prevent and treat cataracts, such
as developing medications that would
reduce or eliminate the need for surgery
 Until then, cataract surgery is the method

to restore vision
 Sufficient rise in intraocular pressure to
cause visual damage
 Congenital Glaucoma
 Primary Glaucoma
 1- Open angle
 2- closed angle
 Secondary Glaucoma
 Absolute Glaucoma
 Features
 Buphthalmos
corneal diameter 12 mm < 1 yr
 Tears of descemet’s membrane
 Corneal haze
 Increased A/C depth
 Optic disc cupping
 Primary open angle glaucoma


Features
Virtually symptomless
frequent change of glasses
gross field defect (late stages)


Diagnosis
Ophthalmic exam
Field test
 Angle closure
 Acute
Very painful
Reduced vision
Nausea vomiting
Can be triggered by dilating drops
 Lens
 Intumescence
 Dislocation
 Phacolytic
 Trauma
 Uveitis
 Neovascular
 Blind
 Painful
 Treatment
 Enucleation
 Laser/Cryotherapy
 Absolute alcohol
 Medical
 Beta blockers (Timolol)
 Carbonic anhydraze inhibitors
Azopt and Trusopt
 Sympathomimetics
Propine and Apraclonidine
 Parasympathomimetics (pilocarpine)
 Prostaglandin Derivatives (Xalatan)
 Laser
 Surgical
◦Trabeculectomy
◦Trabeculoplasty
◦Sclerostomy
isa disorder of the eye in
which the retina peels
away from its underlying
layer of support tissue. It is
a medical emergency.
 flashes of light (photopsia) - very brief in the
extreme peripheral (outside of center) part of
vision
 a sudden increase in the number of floaters
 a ring of floaters or hairs just to the temporal side
of the central vision
 a slight feeling of heaviness in the eye
 Although most posterior vitreous detachments do
not progress to retinal detachments, those that do
produce the following symptoms:
 veil or curtain vision
 central visual loss
 Surgical:

◦ Scleral buckling
 Post op: must be in prone position
◦ Silicone Oil injection
Post op: must be in supine or low
fowler’s
◦ Cryopexy and Laser
Photocoagulation
 Consists of the auricle and EAM
 Skin-lined apparatus
 Approximately 2.5 cm in length
 Ends at tympanic membrane
 Auricle is mostly
skin-lined cartilage
 External auditory
meatus
◦ Cartilage: ~40%
◦ Bony: ~60%
◦ S-shaped
◦ Narrowest portion at
bony-cartilage
junction
 EAC is related to
various
contiguous
structures
◦ Tympanic
membrane
◦ Mastoid
◦ Glenoid fossa
◦ Cranial fossa
◦ Infratemporal fossa
 Innervation: cranial nerves V, VII, IX, X, and
greater auricular nerve
 Arterial supply: superficial temporal,

posterior and deep auricular branches

 Venous drainage: superficial temporal and

posterior auricular veins

 Lymphatics
 Squamous
epithelium
 Bony skin –
0.2mm
 Cartilage skin
◦ 0.5 to 1.0 mm
◦ Apopilosebaceous
unit
 Bacterial infection of external auditory canal
 Categorized by time course

◦ Acute
◦ Subacute
◦ Chronic
 “swimmer’s ear”
 Preinflammatory stage
 Acute inflammatory stage

◦ Mild
◦ Moderate
◦ Severe
 Edema of stratum corneum and plugging of
apopilosebaceous unit
 Symptoms: pruritus and sense of fullness
 Signs: mild edema
 Starts the itch/scratch cycle
 Progressive
infection
 Symptoms
◦ Pain
◦ Increased pruritus
 Signs
◦ Erythema
◦ Increasing edema
◦ Canal debris,
discharge
 Severe pain,
worse with ear
movement
 Signs
◦ Lumen obliteration
◦ Purulent otorrhea
◦ Involvement of
periauricular soft
tissue
 Most common pathogens: P. aeruginosa and
S. aureus
 Four principles

◦ Frequent canal cleaning

◦ Topical antibiotics
◦ Pain control
◦ Instructions for prevention
 Chronic inflammatory process
 Persistent symptoms (> 2 months)
 Bacterial, fungal, dermatological etiologies
 Unrelenting pruritus
 Mild discomfort
 Dryness of canal skin
 Asteatosis
 Dry, flaky skin
 Hypertrophied
skin
 Mucopurulent
otorrhea
(occasional)
 Similar to that of AOE
 Topical antibiotics, frequent cleanings
 Topical Steroids
 Surgical intervention
◦ Failure of medical treatment
◦ Goal is to enlarge and resurface the EAC
 In 1861 Prosper Meniere described a
syndrome characterized by deafness,
tinnitus, and episodic vertigo. He linked this
condition to a disorder of the inner ear.
 In 1938 Hallpike and Cairns described the

underlying pathology of Meniere’s disease

as being endolymphatic hydrops but the
precise etiology still remains elusive.
 Anatomical-  Viral-serum IgE to
abnormalities herpes simples virus
types I and II, Epstein-
 Genetic-autosomal
Barr virus and CMV
dominant  Vascular-associated
 Immunological- with migraines
 Metabolic-potassium
immune complex
intoxication
deposition
 Dilated membranous labyrinth
Normal membranous labyrinth in Meniere's disease (Hydrops)
In the US: 50% of patients have a positive family history.
The estimated prevalence is 150 cases per 100,000 population

40’s and 50’s

Women>Men
 Periodic episodes
of rotatory vertigo
or dizziness
 Fluctuating,
progressive, low-
frequency hearing
loss
 Tinnitus
 Fullness/pressure
 The diagnosis of Meniere disease is made
based on a careful history and physical exam.
 If the work-up is normal and the classic

symptoms continue, the diagnosis of Meniere

disease is made.
 Most important part of the diagnosis
 Pattern of symptoms
 Association between hearing loss, tinnitus, and

vertigo
 Examination results vary, depending upon the phase
of disease. During remission, physical examination
findings may be completely normal, particularly if the
patient is symptom free.
 During an acute attack, the patient has severe
vertigo.
 Patients are sometimes diaphoretic and pale.
 Vital signs may show elevated blood pressure, pulse,
and respiration.
 Spontaneous nystagmus directed toward affected ear
is typical during an acute attack.
 The Romberg test
◦ shows significant instability and worsening when the
eyes are closed.
 The Weber tuning fork test
◦ lateralizes away from the affected ear.
 The Rinne test
◦ indicates that air conduction remains better than bone
conduction.
 Complete neurologic evaluation is important. New-onset
vertigo might be an early sign of stroke, migraine, or
brainstem compression that may require emergent
evaluation and care.
 No lab studies are specific for Meniere disease.
 A CBC, urinalysis, chemistry panel, and alcohol and
drug screening may be helpful if other causes are
considered.
 If an infectious cause is suspected, consider blood
cultures, urine culture, and a cerebral spinal fluid (CSF)
examination.
 Magnetic resonance imaging

 CT scans
◦ reveal dehiscent superior
semicircular canals and/or
widened cochlear and vestibular
aqueducts
 Audiometry is particularly helpful to document
present hearing acuity and to detect future change.
-The patient may not notice a loss at specific
frequencies. Low-frequency or mixed low- and high-
frequency insufficiency may be observed.
- Typically, the lower frequencies are affected more
severely. This is due to preferential sensitivity of the
apex to the hydrops.
- Multiple hearing tests, which document fluctuating
hearing loss, are helpful in diagnosing Ménière.
 Medical therapy is both symptomatic (ie, acute
attacks) and prophylactic.
 If Ménière is due to a secondary cause (ie,
Ménière syndrome), primary first-line
management is the diagnosis and treatment of
the primary disease (eg, thyroid disease).
 Vestibulosuppressants (eg, meclizine)
decrease symptoms, but generally only mask
the vertigo by decreasing the brain's response
to vestibular input.
 Diuretics or diuretic-like medications (eg,
hydrochlorothiazide) actually decrease the fluid
pressure load in the inner ear. These medications
help prevent attacks but do not help once an
acute attack has started.
 Anti-inflammatory properties of steroids are helpful
in endolymphatic hydrops. This is probably due to
reduced endolymphatic pressure. Steroids
actually can reverse vertigo, tinnitus, and hearing
loss.
 Aminoglycosides are a class of antibiotics that were
discovered serendipitously to be preferentially toxic
to the vestibular end organ.
◦ Destruction of the vestibular end organ renders the
brain insensitive to the fluctuations in the inner ear
pressure during an acute Ménière attack.
◦ If given systemically, aminoglycosides affect both ears.
◦ Although these drugs can be used to treat extremely
severe bilateral Ménière disease, they leave the
patient with little or no balance function. The resulting
Dandy syndrome, a complete loss of inner ear
function, can be debilitating.
 During the quiescent phase, medical treatment of
Ménière disease is tailored to each patient.
Lifestyle and dietary changes are usually the first
step. Avoiding trigger substances (eg, caffeine)
alone may be sufficient. Smoking cessation also is
recommended.
 In an acutely vertiginous patient, management is
directed toward vertigo control.
◦ Intravenous (IV) or intramuscular (IM) diazepam
provides excellent vestibular suppression and
antinausea effects.
◦ Steroids can be given for anti-inflammatory effects in
the inner ear.
◦ IV fluid support can help prevent dehydration and
replaces electrolytes.
 Surgical Care:
◦ Surgical therapy for Ménière disease is reserved for
medical treatment failures and is otherwise controversial.
◦ Surgical procedures are divided into 2 major
classifications as follows:
 Destructive surgical procedures
Nondestructive surgical procedures
 Destructive surgical procedures
◦ Rationale to control vertigo: Endolymphatic hydrops
causes fluid pressure accumulation within the inner
ear, which causes temporary malfunction and misfiring
of the vestibular nerve. These abnormal signals cause
vertigo. Destruction of the inner ear and/or the
vestibular nerve prevents these abnormal signals. As
long as the opposite inner ear and vestibular
apparatus function normally, the brain eventually will
compensate for the loss of one labyrinth.
 Problems with destructive procedures:
◦ Destruction of one inner ear depends on the adequate
function of the opposite ear. Unfortunately, Ménière
disease can be bilateral (7-50%), in which case this
method is contraindicated. Since balance and hearing
are closely intertwined within the labyrinth, destruction
of the balance portion carries a high risk of hearing
loss. Note that destructive procedures are irreversible
and reserved for severe cases.
 Nondestructive surgical procedures:
◦ These are directed toward improving the
state of the inner ear. They are less invasive
than destructive procedures :
1. endolymphatic sac decompression or
shunt
2. vestibular nerve section
3. Labyrinthectomy
4. transtympanic medication perfusion.
 Endolymphatic sac decompression and/or shunt
◦ In theory, the endolymphatic sac procedure decreases
endolymph pressure accumulation by removing the
petrous bone, which encases the endolymph reservoir.
This procedure allows the reservoir sac to expand
more freely, thus dissipating pressure. A drain or valve
from the endolymphatic space to either the mastoid or
subarachnoid space can be inserted as another means
of further reducing pressure.
◦ Success rates (in terms of controlling vertigo and
stabilizing hearing acuity) with this procedure are
reported at 60-80%.
 Vestibular nerve section
◦ For patients with useful hearing in the affected ear,
sectioning the diseased vestibular nerve can be the
ultimate solution.
◦ Although the hearing and balance functions are housed
in one common chamber within the inner ear, their
neural connections to the brain separate into distinct
nerve bundles as they course through the internal
auditory canal.
◦ This anatomical separation allows balance function to
be isolated and ablated without affecting hearing
function.
 Labyrinthectomy
◦ This management option for Ménière disease has the
advantage of a high cure rate (>95%) and is useful in the
patient whose hearing on the diseased side has been
destroyed already by Ménière disease.
◦ Labyrinthectomy involves ablation of the diseased inner
ear organs.
◦ This procedure is less complex than vestibular nerve
section because labyrinthectomy does not require entry
into the cranial cavity.
◦ Labyrinthectomy is less invasive than vestibular nerve
section.
 This procedure carries less danger of cerebrospinal
fluid leak and meningitis since craniotomy is not
required.
 Like those who undergo vestibular nerve section,
patients require a few days of inpatient care.
 Accommodation to the surgical loss of one
vestibular apparatus usually takes weeks or months.
 Vestibular rehabilitation during this time period is
also helpful.
 Transtympanic perfusion of medication
◦ Medications for Ménière disease are applied through a
myringotomy within the middle ear cavity, where they
presumably are absorbed through the round window
membrane into the inner ear.
◦ Transtympanic perfusion is a relatively low-risk, simple
procedure that applies a high concentration of
medicine with minimal systemic effects.
 Diet:
◦ Dietary management is appropriate in patients not
severely affected; patients avoid substances that may
trigger or exacerbate fluid pressure buildup in the inner
ear.
◦ Similar to managing systemic hypertension, the goal
for Ménière disease is to reduce the total body fluid
volume. This, in turn, may reduce the inner ear fluid
volume.
◦ Since sodium seems to play a major role in fluid
retention within the inner ear, avoiding salt (eg, pizza,
preserved foods, smoked fish) is paramount.
 Consult with a nutritionist to establish a rigid
salt-restricted diet (1.5 g sodium per day).
 Avoiding other trigger substances (eg, caffeine,

nicotine, alcohol, high-carbohydrate substances,

high-cholesterol/triglyceride foods) also can
help.
 Note that many preserved and smoked foods

contain sodium nitrite, which can contribute to

high sodium content.
 Activity:
◦ Endolymphatic hydrops does not preclude regular
activity. Exercise is recommended in moderation.
◦ Because of the unpredictable nature of the disease,
balance-intensive, dangerous tasks (eg, especially
climbing ladders) should be avoided.
 Definition

◦ Otosclerosis is an abnormal
bone growth in the middle ear
that causes hearing loss.
 Causes:

◦ unknown
◦ Hereditary
◦ More common in Caucasians
◦ More common in females
 Symptoms

◦ Hearing loss
◦ Slow hearing loss that continues to
get worse
◦ Hearing may be better in noisy
environments than quiet areas.
◦ Ringing in the ears (tinnitus)
 Signs and tests
◦ A hearing test (audiometry
/audiology) may determine the
extent of hearing loss.
◦ Temporal-bone CT may be used
to distinguish otosclerosis from
other causes of hearing loss.
 Treatment

◦ A hearing aid may be used to

treat the hearing loss.
◦ Surgery: Stapedectomy -
replacement of the stapes with
a prosthesis
 To reduce the risk of complications after surgery:
◦ Do not blow your nose for 1 week after surgery.
◦ Avoid people with respiratory or other infections.
◦ Avoid bending, lifting, or straining, which may cause
dizziness.
◦ Avoid loud noises or sudden pressure changes such as
scuba diving, flying, or driving in the mountains until
healed.
◦ If surgery is unsuccessful, total hearing loss may occur.
Treatment then involves developing skills to cope with
deafness, including use of hearing aids and visual cues.
 Surgery Complications
◦ Complete deafness
◦ Infection, dizziness, pain, or
blood clot in the ear after
surgery
 Definition
◦ Tonsillitis is inflammation of the tonsils.
 Causes:

◦ Infection of tonsils, pharynx,

and surrounding regions
 Commonly by: Group A beta-
hemolytic Streptococci
 Symptoms

◦ Difficulty swallowing
◦ Ear pain
◦ Fever, chills
◦ Headache
◦ Sore throat - lasts longer than 48 hours and
may be severe
◦ Tenderness of the jaw and throat
◦ Voice changes, loss of voice
 Signs and tests
◦ Inspection of tonsils by use of
tongue depressor
 Teststhat may be done
include:
◦ Rapid strep test
◦ Throat swab culture
 Treatment

◦ Antibiotic therapy
 Per orem
 Must be taken throughout the entire
regimen
Intramuscular injection
Usually given in 1 shot
◦ Surgery: tonsillectomy
 Complications
◦ Blocked airway from swollen tonsils
◦ Dehydration from difficulty swallowing fluids
◦ Kidney failure
◦ Peritonsillar abscess or abscess in other
parts of the throat
◦ Post-streptococcal glomerulonephritis
◦ Rheumatic fever and related cardiovascular
disorders
 Surgical removal of tonsils
 The tonsillectomy has been practiced for 2000
years, with varying popularity over the
centuries. The procedure is first mentioned in
"Hindu medicine" about 1000 BC; roughly a
millennium later the Roman aristocrat Celcus
(25 AD – 50 AD) described a procedure
whereby using the finger (or a blunt hook if
necessary), the tonsil was separated from the
neighboring tissue prior to being cut out.
 Pre operative phase
 Ensure a signed informed consent, &

CP clearance
 NPO 8-12 hrs prior to procedure
 Give pre meds as ordered
 Monitor for untoward signs and

symptoms
 Refer to the medical team
 Accomplish pre-op checklist
 Intra operative phase
 Prepare the sterile field and equipment
 Proper skin preparation
 Application of safety straps
 Proper positioning

◦ Supine with cushion behind the shoulders to

hyperextend the neck
 Sterile draping
 Ensure safety- keep side rails up
 Ensure patent airway, oxygen therapy, DBE
 Orient to time, person, and place
 Assess LOC periodically
 Close monitoring of vital signs – v/s q15mins
 Positioning – supine with head turned to the side
 Give due medications and IV’s as prescribed
 Watch out for dyspnea, hemmorrhage (common
sign is frequent swallowing)
 The visually impaired are individuals with
no sense of sight.
 The other senses compensate for the lack of

sight.
 Focus on their strengths, not their

weaknesses
 Involve the family and significant other in

the care and treatment.

 Provide a safe environment
◦ Sharp objects must kept away
◦ Heating devices must be secured
◦ Non slip surfaces and ramps must be provided
◦ Furniture must not be moved often
◦ Identify yourself when approaching them
◦ Ask for permission when touching them
 Speak in a normal tone
 Refer to special education for specific needs

such as:
◦ Walking canes
◦ Guide dogs
◦ The use of braile
 The hearing impaired are persons with no
sense of hearing
 In the absence of hearing other senses may

compensate for its loss (especially sight).

 Involve the family and significant other in

the care and treatment of the patient

 Alternative communication methods must

be explored
 Refer to proper resources for education of

the patient and family. E.g. sign language

 Speak to them normally, there is no need to
shout
 If the patient still has a functioning ear,

speak in to it as much as possible

 Accentuate speech with hand gestures
 Articulate speech well and not too fast for

them to read lips

 Do not cover your mouth when speaking to
them
 Do not chew gum or speak with anything in

our mouth when communicating with them

 Always face the patient when talking to

them
 Sounds of household items like the

telephone or doorbell maybe fitted with

lights for them to have a visual cue.