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ΠThe eye is the organ of vision which is located in a cone
shaped cavity known as the orbit.
ΠIt is highly specialized & complex structure.
ΠIt visual data to the cerebral cortex for
interpreting visual images.
Π  have connections to the eyes. These
are;
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Î Rrain stem connections permit coordinated eye movement.
Î The eye ball is situated in the  #   
Î The eye ball is protected by: -
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Î  that supply nutrients & transmit
impulses to the brain are also present with in the orbit.
Î Organized are attached to the external
eye ball.


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 , their ducts
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m6 -These are sweat glands producing
sebum.
m Ô)*There are three muscles supplying the eyelid.
ü  )ü
Ú ü:- acrimal bone.
Ú  :- Deep in the facia around the lacrimal.
Ú  :- to close the eye lid & to screw up the eyes & facilitate tear
drainage.
Ú 

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Î )- skin of upper lid & tarsal plate.
Î )- to lift the upper lid.
Î

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£ This is smooth muscle.
£ ü:- evator palpebral superiors.
£  :-Tarsal plate.
£  :- provide extra elevation to the
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£ 

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ΠThe junction of the upper & lower eyelid is called
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Œ The inner, Ô   (contains the  !openings
that allow tears to drain into the upper portion of the lacrimal
system.
ΠThe elliptical space between open eye lid is called

  

Œ"   palpebral fissure = 8-11mm (More wide in female).
Œ¦.  palpebral fissure = 27 -  mm.
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  than lower eyelid.


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mIt is the thinnest of the body.
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mMeibomian gland orifice in a single row.
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÷ Its zones are: -
Ú 
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ball.
Ú  '  &
Ú It is extremely thin & transparent so that vessels are easily seen.
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Ú Covers the eye ball except the cornea.
Ú :- formed where bulbar & palpebral conjunctiva fold back over each
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ΠNumerous Excretory   emptying secretion to conjunctiva.
ΠMechanism of tear secretion is by: -
? Reflex - due to stimulation of trigeminal nerve.
? Ôsychogenic - central mechanism.


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? orause·s gland located in the eye lid.
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Upper & ower canaliculi (Common Canaliculi)

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? It is a highly elastic circular biconvex transparent
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suspensory ligament & enclosed with in a transparent
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the retina without adjustment of the lens or convergence of the
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Œ ëith aging, the ability of the eye to accommodate gradually
decreases because of increased rigidity of the lens
(Ôresbyopia).
ΠThe lens is tense able to change shape in response to visual
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? Requires using a metal, hand held instrument (the tormenter)
that rest on the anesthetized cornea. The result can be variable
but are a good estimate of IOÔ.
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? it is attached to a slit lamp to measure IOÔ.
? It is the most accurate form of measuring IOÔ.


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ΠIdentity the patient.
ΠCheck if the patient is wearing contact lenses, if so then remove
them before commencing the procedure.
ΠAdminister topical anaesthesia into both eyes.
ΠInstil fluorescein stain for accurate reading.
ΠInstruct the patient to look straight a head with both eyes wide
open- if necessary, the patient·s eyelids should be held apart by the
examiner with out pressure being applied to the eyeball.
ΠThe ton meter is brought into contact with the center of the
cornea .
Œ The IOÔ (in mm Hg) is found by multiplying the drum reading by
ten.


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ΠIt is employed by optometrists, use a puff of air blown against
the eye.
ΠIt is useful when contact with the cornea is not desired.
Π 
Œ A general determination of IOÔ can be made by applying gentle
finger pressure over the sclera of the closed eye.
ΠThe tips of both fore fingers are placed on the closed upper lid.
One finger gently presses inward while the adjacent finger
senses the amount of pressure exerted against it.


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ΠThe examiners then compare the tension felt or perceived in
the patient·s eye with the pressure in their own. This requires
practice.
ŒThe patient looks down wards, closing the eye.
Œpalpate the eye ball to assess the degree of hardness.
ŒNo accurate measurement can be taken but on eye with raised
pressure will feel harder than one with normal pressure.
ŒIt is a useful initial method of assessment, especially if none of
the specialized equipment needed for measuring IOÔ is
available.

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Π

? Are small pen like instruments that measure pressure
in a similar fashion to the applanation method.
: - ü = normal value is 1-2mmHg. Increased IOÔ is
the cardinal sign of glaucoma
4. Assisting the patient in measurement of refractive errors
Π6  
ΠDetermination of refractive errors.


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ŒÔ (: - A pen torch is held at 1/m directly in front of
both eyes. The position of the reflection on each eye is then
compared.
ŒResults: - The results may be: -
ΠNormal Corneal reflections - symmetrical.
ΠAsymmetrical Corneal reflections.


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Π  )*It is carried out to detect the presence of a
squint, & should be used in conjunction with observation of
the corneal reflections.
Œ Ô (: - A penlight is held at ~ 1/m from the child. The
child must be looking at the height whilst the cover test is
carried out.
ΠIt is important to repeat the cover test using a detailed target,
e.g. a small picture on a tongue depressor, because same squints
are only present when looking at detailed objects. The caver test
should also be carried out at 6m where possible because other
squints are only present when looking into the distance, i.e.
intermittent squints.


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ΠCover one eye, watch for any movement of the uncovered
eye, remove the cover & repeat covering the other eye &
watching for any movement of uncovered eye.
ΠThe results may be: -
? No manifest squint.
? Manifest squint - right convergent squint (Fig 1.6)
? Manifest squint - right divergent squint (Fig 1.7)

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? The examiner sits in front of the patient & using a pen
torch, observes both eyes moving in all eight positions
of gaze.
ŒThis will include up, down, both sides & in all four corners,
always returning to the straight a head or primary position. The
patient·s head must be held still. Any muscle imbalance, over
action & under actions are then noted.


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ÎTuring inward of eyelids, usually
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 : - Contraction of the palpebral
conjunctiva following trauma or
disease to the eye lid or conjunctiva.
65)* Transverse lid surgery and suture.


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ŒIt is turning outwards of the eye
lids, usually the lower lids.
 : - caring of the lid or
conjunctiva
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 )- Measles
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Ú Red eye.
Ú Chemosis, if severe.
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Ú oeratitis .
Ú ëatery discharge & photophobia.
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m  ( is a highly contagious infectious
eye disease (Chlamydia Conjunctivitis) that
affects more than 5 million people world
wide and which may result in blindness.
mIt is the world's leading cause of preventable
blindness & primarily affects people in
Africa.


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 )* Chlamydia trachomatis
Ô  :-
' Direct Contact (with eye, nose, throat
secretion from the affected individual.
' Fomites (towel, hand kerchiefs, fingers,
wash clothes).
' Insect Vector (flies).

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? carring of eye lids.
? Entropion.
? Trichiasis.
? Corneal trauma & ulceration.
Ô5: - 6ood personal hygiene
- Tetracycline eye


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Ô  
Gp strategy;
Îurgery:- trichiasis and entropion.
Î Gntibiotic:- TTC (ointment apply TID for -4weeks.),
sulphonamides, erythromycin.
Î acial cleanness:- good hand and face washing practice.
Î pnvironmental changes:-address water shortage, eradicate
flies, avoid crowded, e.t.c.


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Πoeratitis is an inflammation of the cornea.
ΠCornea is susceptible to infection and injury because of its anterior
location and degree of exposure.
 
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 (exophtalmos, lagophtalmos) keratitis as a result of drying of
the cornea because of eye lids can not protect it adequately.
Î  &
Î    (staph.. aureus, strep.. pneumonia, pseudomonas
aergunosa).
Î " (herpes simplex, varicella zoster virus).
Î  (Candidia, aspergillus, cephalosporium).
Î    .
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Ú oeep the lid clean.
Ú Cool compresses.
Ú Monitor for sign of increased IOÔ.
Ú Acetaminophen 5mg 2tabs ÔRN.
Ú Cycloplegic & mydriatics to relieve pain & inflammation.

 
ŒCorneal car.
ŒRevascularization (new blood vessels formation) in the cornea.

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? Ôterygium is a triangular fibro-vascular connective tissue over the
growth of the intra-palpebral conjunctiva with extension to the
cornea.
? Usually occurring on the nasal side, but it can be temporal.
? It is thought to be an    phenomenon
caused by ultraviolet light.
 - unknown.

  : - people who live in hot, dry climates or
who work in the open air.
65
Ú urgical removal if pterygium encroaches on the visual axis or
causes significant discomfort.
Ú In -5 of cases it reoccurs after surgery.

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£ It is ulceration of cornea.
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£ Racteria;
£ taph.. aureus, strep.. pneumonia, pseudomonas aergunosa.
£ Fungus
£ Candidia, aspergillus.
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ΠIt is clouding or opacity of crystalline lens the impairs vision.
ΠThe lens is a delicate structure & any insult on it causes absorption of
water, resulting in the lens becoming opaque.
Œ According to ëHO, cataract is the leading cause of blindness in the
world (22).
 
ΠFrom birth (congenital).
ΠAge (senile).
ΠEye injury (traumatic).
Πecondary to existing eye disease (e.g. uveitis).
ΠDrug like corticosteroids.
ΠCataract associated with systemic disease (DM, Hyperparathyroidism).
ΠUV light exposure.
ΠHigh dose of radiation therapy.

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ΠImmature cataract - part of the lens is opaque.
ΠMature cataract - the whole lens is opaque & may be swollen.
   
 
? Abnormal development of the eye.
? Metabolic disturbance.
? Rubella or malnutrition in first trimester of pregnancy.
-Ô
? Unable to see.
? white pupil (Unilateral or bilateral).
65)* Removing the cataract

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? Occur in patients over the age of 6 years.
? They result from sclerosis of the lens due to a degenerative
process.
? Usually bilateral.
? It is either;
ΠNuclear:-
Πaffects the central lens & takes on a brown color.
ΠThe patient sees better in dim light when pupil is dilated.
ΠCortical:-
ΠAffects the periphery of the lens & looks white.
ΠVision is usually better in bright light when the pupil is constricts.


D 
6 -Ô
Ú 6radual, progressive, and painless loss of vision.
Ú Double vision/blurred vision/
Ú Reduced light transmission.
Ú Rainbow/haloes/
Ú Ôrevious dark pupil appear milky or white.
5
£ Hx.
£ Ô/E.
£ Ophtalmoscopic exam.
£ lit lamp examination.


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Î  &
Î surgical removal of the lens usually done under local anesthesia.
Î IO (intraocular lens) are usually implanted at the time of
cataract extraction.
  
Ú 
 (
 
Ú Orient pt and explain the procedure and plan of care to
decrease anxiety.
Ú Instruct the pt not to touch to decrease contamination.
Ú Administer preoperative eye drops.


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?  
  &
? Administer medication as prescribed.
? Teach the pt to report sudden pain and restlessness with
increased pulse.
? Caution pt against coughing, sneezing, rapid movement,
bending.
? Encourage pt to wear shield at night to protect operated eye
fro injury while sleeping.


„ 
 
? It is an inflammation and swelling of sclera.
Etiology
£ Associated with connective tissue disorder like rheumatoid
arthritis.
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ΠUveal tract comprises the   
 
layer of the eye.
ΠIt is composed of three areas: -
ŒThe choroid.
ŒThe ciliary body.
ŒThe iris.
) - Uveitis is the inflammation of one or all structures of the
uveal tract.
ΠRecause the uvea contains    (  ( 
( ( and because it borders many other parts of
the eye, inflammation of this layer may ( 


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? Racteria ( TR).
? Virus (CMV, syphilis, herpes zoster and simplex).
? Fungi (toxoplasmosis, histoplasmosis, ocular
candidiasis).
? Chemical
? Trauma
? Allergy

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? Is the most common type.
? Is characterized by a history of pain, photophobia, blurring of
vision, & red eye.
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Ú Dilating drops (mydriasis) are instituted immediately to
prevent scar formation & adhesion to the lens (ynechiae),
which may cause glaucoma by impending aqueous outflow.
Ú ocal corticosteroids are used to decrease the inflammation.
Ú ëearing sunglasses.
Ú Analgesics.


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/   (  
Œ It is characterized by ´Floating spotsµ in the field of vision.
65) - Topical or injectable corticosteroids are used in severe
cases.
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ΠIs usually associated with some form of systemic disease, such as AID,
herpes simplex or zoster, tuberculosis.
-Ô
ΠDecreased or distorted vision.
Πeye redness & pain.
65 - ystemic corticosteroid.


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Uveitis generally categorized into two. These are;
1. Non-granulomatous
2. 6ranulomatous
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? It is a rare but devastating bilateral uveitis .
? Occurs after a latent period of days to years after a
penetrating injury to the uveal tract.
 - Unknown

  : - Allergy
-Ô
£ Inflammation of injured eye, followed by inflammation of the
unaffected (ympathetic) eye.


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ÔB
' Enucleation of the sightless eye within 1 days of injury is
usually recommended to reduce the risk of sympathetic
disease in the other eye.
  
? Rlindness after penetrating injury.
? Ôainful blind eyes that is unresponsive to the medical
treatment.
? Tumor of the eye.



„ 
  
? It is an inflammation of all tissue of the eye ball.
Etiology
£ Racteria.
£ Virus.
£ Fungus.
£ E.t.c«
£ Hx of recent intraocular operation.
£ Ôenetrating trauma.
£ Common in immune compromised pts, such as HIV/AID and
diabetes.


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Ú It is bruising of the periorbital soft tissue.
-Ô
£ welling and discoloration of the tissue.
£ Rleeding in to the tissue and structure of the eye.
£ Ôain.
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Ú Reducing swelling and pain by applying cold and warm
compress.
Ú Refer for ophthalmologist ass·t.


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Î It is the presence of blood in the anterior chamber.
-Ô
£ Ôain.
£ Rlood in the anterior chamber.
£ Increase IOÔ.
Ô5
£ Usually spontaneously recovers.
£ If sever bed rest, and eye shield application.

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E. aceration/Ôerforation.
Ú It is cutting or penetration of soft tissue.
-Ô
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£ It is concussive injury to globe with tears in the ocular coat, usually the globe.
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Î It is the destruction of the eye tissue by chemical, thermal, and
ultraviolet ray.
A. Rurn of chemical agent that is caused by alkali or acids.
-Ô
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£ Consider as medical emergency.
£ Copious irrigation until ÔH is 7.
£ oeratoplasty for severe scaring.
£ Antibiotics.


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£ Ôain
£ Rurned skin
£ Rlisters
Ô5
m First aid-apply sterile dressing.
m Ôain control.
m eave fluid blebs intact.
m uture eyelid together to protect eye if perforation is possible.
m kin grafting with severe second and third degree burns.



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-Ô
Î Ôain
Î Foreign body sensation
Î acrimation
Î Ôhotophobia
Ô5
Ú Ôain relief.
Ú Rilateral patching with antibiotic ointment and cycloplegics.


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? 6 
 is a pathological rise in the intra ocular pressure
that causes damage to the various structure of the eye,
especially the optic nerve.
? It is the cause of blindness.
? There are four types of glaucoma. These are;
1. Congenital .
2. Closed angle (acute).
. Open angle (chronic)
4. econdary.


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1. Congenital glaucoma.
Ú It is a rare condition that occurs in infant and neonates
-Ô
? The diameter of the cornea increase in size.
? The cornea becomes edematous
5
? Tonometry exam-increase IOÔ.
Ô5
? Ô -Ôilocarpine drops, Acetazolamide tablet.
?  -6oniotomy-to incise the mesodermal membrane
in the angle of anterior chamber.


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/  
£ It accounts for 1 of the primary glaucoma.
p 
? Mechanical blockage of the anterior chamber angle.
-Ô
? A sudden severe pain in and around the eye.
? Nausea and vomiting
? Ôupil mid-dilated and fixed.
? Hazy appearing cornea due to corneal edema.
? A sudden elevation of IOÔ
5
? lit lamp exam nation.
? Tonometry examination.

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Ú Medical
l ower the IOÔ as quick as possible by medical means.
? Miotics- Used to constrict the pupil and contract the ciliary
muscle, thus the iris is drawn away from cornea; aqueous humor
may drain through lymph spaces (meshwork) ion to canal of
schlemm.
E.g. Ôilocarpine drops 2-4 every 5 minute fro an hour, and then
every hour for 12 hour topically.
? Carbonic anhydrase inhibitor-restricts action of the enzyme that
is necessary to produce aqueshumor.
E.g. Acetazolamide (diamox)25mg QID.


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? Hyperosmotic agents-reduce IOÔ by promoting diuresis.
E.g. Mannitol IV.
 
? Iridecomy- excision of a small portion of the iris where by AH
can bypass. This prevents the periphery of the iris blocking the
angle of the anterior chamber.
? Trabeculectomy-partial thickness sclera, resection with small
part of trabecular meshwork and iridectomy.
? aser iridotomy-multiple tiny laser incision to create openings
for AH flow.


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? Makes up 9 of primary glaucoma cases.
? Its incidences is increased with age.
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? Degenerative changes occur in the trabecular meshwork and canal
of schelmm.
6#  
? A6E.
? Familial history of glaucoma.
? Diabetes
? Hypertension


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-Ô
? Mild, bilateral discomfort (tired feeling in the eyes, foggy
vision).
? lowly developing impairment of peripheral vision with dilated
pupil.
? Ôrogressive loss of visual field.
? No pain or inflammation.
5
? Ôaleness of the optic disk.
? Optic nerve atrophy.
? Rise in IOÔ.


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Mgx
Medical
Ú Reduce the IOÔ by medication- the medication should be continued
for the rest of the patient life
? Ôilocarpine drops 2-4 QID.
? Adrenaline drops 1 RID.
? Timolol/Timoptol/ drops ).25-.5 RID.
urgical
? Iridencleisis- an opening is created b/n anterior chamber and
space beneath the conjunctiva; this by pass the blocked meshwork,
and AH is absorbed into conjunctival tissues.
? Cyclodiathermy/Cylocryotherapy-destruction of ciliary body with
a high frequency electrical current or supercooled probe.


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? It is a type of glaucoma caused by a specific causes or
pathologies.
p 
? Hemorrhage.
? Corticosteroid use.
? Uveitis.
Ô5
? Treat the cause.



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? It is the situation where by the two eyes are looking in
different directions.
Etiology
? Disorder of vision.
? Disorder of the eye movement secondary in the abnormality
on the muscle that controls the movement.
p 8
? In adults
? Double vision/diplopia/.
? Abnormal head posture.
(
? Ambylopia/lazy eye/.


D 
-Ô
Ú The corneal light reflex.
? This is the best and simplest test of squint.
? If the two eyes are straight, then the two corneal light reflexes
are central and symmetrical, but if one eye squints, then the
reflex deviates from the center of the cornea.
Ú Testing the ocular movements.
? There are six extra ocular muscle, and each one produces most
of the movement in the particular direction.


D 
Ô5
(
? Try to correct any refractive errors and ambylopia before
straightening the squint surgically.
? Ôatching the good eye.
? urgical correction by either weakening, straightening or
realigning the extra ocular muscles
  
? Cosmetic surgery is the only treatment.

 
 „-. 
ΠIs a frequent complication of DM.
ΠOccur after 2years of having DM.
ΠCaused by damage to or occlusion of the blood vessels those
nourish the retina. ëeakened blood vessels become hyper-
permeable & leak, causing micro-hemorrhages, retinal swelling, or
exuadative deposits.
Œ Ôrogressive retinal ischemia stimulates the formation of new blood
vessels (neovascularization).
ΠThese new vessels are fragile & may rapture, causing sub retinal
hemorrhage or bleeding. The vitreous body also, they may form
fibro vascular bands that contract, resulting in traction &
subsequent retinal detachment.
ΠThere  of diabetic retinopathy.

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(
ΠOccurs in most diabetics about 2years after the onset of the
disease.
ΠHas no symptom until macula is involved.
-Ô) - The fundus has dots (Micro - Aneurysms), blots (mall
hemorrhage), & hard waxy exudates (leakages of lipids from
the hemorrhaging blood vessels.
Œ Ô 
( 
ŒIt is main cause of visual impairment in non insulin dependent
DM.

 
D 
   
( 
ΠOccurs in eyes with background retinopathy only.
C/M: - The retina is ischemic which causes;
? Cotton wool spot
? Dilation, beading, looping of blood vessels
? Arteriole narrowing
? arge dark blot hemorrhage
  
( 
ΠIs the main cause of visual impairment in IDDM.
G  
(
ΠIt is the end result of uncontrolled proliferative retinopathy &
results in blindness.

 
D 
6  -Ô   
( &
ŒIf fluid collects at the macula, the patient notices blurred central
vision.
ŒVitreous hemorrhage in cloudy or hazy vision of sudden onset.
Mgx
Πaser photocoagulation surgery is useful. An intense beam of
laser light is used to seal of leaking blood vessels & destroy
abnormal new ones.
ΠControl DM.

 
 .
? Retinal detachment occurs when there is a separation of the
neuro-sensory retina from the underlying pigment
epithelium layer of the retina.
? Neurosensery retina contains: - rods & cones.

 
D 
 ) - The neural retina can be either pulled, pushes or
floated off the underlying epithelial layer
Î : - by vitreous traction, which occurs when new
blood vessels have grow in to the vitreous.
ΠThis condition con be caused by;
ΠDM.
ΠRetinal hemorrhage .
ΠVitreous hemorrhage.
Î (ff: - A lesion behind the retina . such as choroidal tumors,
hemorrhage, choroiditis & retinopathies
Î   :- If a tear or hole appears in the retina, subretinal fluid
or vitreous fluid enters the hole, floating the neural layer off the
epithelial layer. Rhegmatagenaus ( tear - induced ) detachment - is
most common type.


D 
  (   &
? congenital malformation
? Metabolic disorders
? Vascular disease
? Neoplasm
? trauma
? Degenerative changes

D 
-) - History of floating or flashing lights or both. The
floaters are perceived as tiny dark spots or cobwebs.
Πpreading shadow or curtain moving across the field of
vision, resulting in blurred vision & loss of visual field as the
retina separates
ΠDecreased central acuity or lass or central vision
ΠFlashing lights (photopia).


2