Anatomy and Physiology

 The eye is the organ of vision which is located in a cone shaped cavity known as the orbit.
 It is highly specialized & complex structure.
 It receives & sends visual data to the cerebral cortex for interpreting visual images.
Seven cranial nerves have connections to the eyes.
For vision – CN II.
Eye movement – CN III, IV & VI.
Papillary reaction – CN III.
Eyelid elevation – CN III.
Eyelid closure – CN VII.
 Brain stem connections permit coordinated eye movement.
 The eye ball is situated in the bony socket or orbit.
 The eye ball is protected by:
Orbit.
Eyelids (Upper & lower)
 Nerves & blood vessels that supply nutrients
& transmit impulses to the brain are also present with in the orbit.
 Organized bands of muscles are attached to the external eye ball.
 Grey line;
 Where the skin joins palpebral conjunctivas.
 Glands:
 Meibomian gland;
 It is found with in the tarsal plate, their ducts opening through the palpebral
conjunctiva just behind the lashes.
 Produce sebaceous substance which creates the oily layer of the tear film.
 Glands of moll – These are sweat glands producing sebum.
 Muscles:-There are three muscles supplying the eyelid.
a. Orbicularis: Oculi
Origin:– Lacrimal bone.
Insertion:- Deep in the facia around the lacrimal.
Function:- to close the eye lid & to screw up the eyes & facilitate tear drainage.
Nerve supply:- Facial nerve (CN-VII).
Its paralysis cause lagophthalmos (Failure to close eye).
b.Levator palpebral superioris
Origin:– around apex of orbit.
Insertion:– skin of upper lid & tarsal plate.
Function:– to lift the upper lid.
Nerve supply:– Oculomotor (CN-III).
Its paralysis cause ptosis (dropping of eye lid).
c. Muller’s muscle
This is smooth muscle.
Origin: Levator palpebral superiors.
Insertion: Tarsal plate.
Function: provide extra elevation to the upper lid.
Nerve supply: Sympathetic nervous system.
 The junction of the upper & lower eyelid is called canthus/commisure.
 The outer, Lateral Canthus is on the lateral temporal aspect of the eye.
 The inner, Medial Canthus contains the Puncta, openings that allow tears to drain into the
upper portion of the lacrimal system.
 The elliptical space between open eye lid is called palpebral fissure.
Vertical palpebral fissure = 8-11mm (More wide in female).
Horizontal palpebral fissure = 27 – 30 mm.
Upper eye lid is more mobile than lower eyelid.
 Tarsus
It is called skeleton of the eyelid.
 Eyelids;
 It is skin without subcutaneous fat.
  It has 4 basic layers.
 From anterior to posterior the layers are:
 Skin & subcutaneous connective tissue
 Muscle
 Tarsus
 Conjunctiva.
 Conjunctiva
It is a thin, transparent, mucous membrane.
Its zones are: -
1. Palpebral conjunctiva:– forms inner layer of eyelid & reflects over eye ball.
2. Bulbar conjunctiva
-It is extremely thin & transparent so that vessels are easily seen.
-It is freely movable.
-Covers the eye ball except the cornea.
Fornices: formed where bulbar & palpebral conjunctiva fold back over each other.
 Lacrimal glands & Excretory System
 Lacrimal glands
 Location – Superiorly in a shallow depression of frontal bone.
It has 2 parts: -
 Orbital (lacrimal gland proper).
 Numerous Excretory ducts emptying secretion to conjunctiva.
 Mechanism of tear secretion is by: -
 Reflex – due to stimulation of trigeminal nerve.
 Psychogenic – central mechanism.
 Accessory glands
 Krause’s gland located in the eye lid.
 Meibomian gland
 Basal tear secretion is constant & under sympathetic nervous system control.

 Function of tear
- Refraction: to provide an optically
smooth surface to the cornea.
-Lubrication of the front of eye ball.
-Cleansing action by washing away dust
particles from the eye.
-Protection from infection by secreting the
enzyme lysozyme, immuno-proteins &
antimicrobial agents.
 Flow of tear is affected by:
- Blinking.

- Capillary attraction into the puncta

- Lacrimal pump by contraction of muscle
- Gravity

INTERNAL STRUCTURES of the EYES

Eye Ball- It is lined by 3 layers:
1. Outer protective layer
It is fibrous layer.
It consists:
A. Sclera
-It is the white part of the eye.
-Form outermost tissue of posterior & lateral (4/5)th aspects of eye ball.
-It is continuous anteriorly with cornea.
-Maintains the shape of the eye & gives attachment to extra ocular muscle
of eye.
B. Cornea
 -It is the anterior continuation of sclera.
-It is clear transparent & allow passage of light rays.
-It is convex anteriorly & is involved in refraction or bending light rays to
focus them on retina.
-It is highly sensitive.
2. Middle layer
It is Vascular organ.
It Consists:
A. Choroid
-Lines the posterior (5/6)th of inner surface of sclera.
-Highly vascularized.
-Light enters the eye through the pupil, stimulate the nerve endings in the
retina then is absorbed by the choroid.
-Deep chocolate brown in colour.
B. Ciliary body
- It is anterior continuation of the choroid & consists ciliary muscle &
secretary cells (producing aqueous humor).
-It gives attachment to suspensary ligament which, at its other end, is
attached to the lens.
- The ciliary muscle controls the shape of lens for focusing.
C. Iris
-It is the visible coloured part of the eye & extends anteriorly from the
ciliary body, lying behind the cornea in front of the lens.
-It divides the anterior segment of the eye into anterior & posterior
chambers which contain aqueous fluid secreted by ciliary body.
-In the center is an aperture, the pupil.
-The pupil varies in size depending upon the intensity of light.
-During bright light the pupil constrict, whereas dilate during dim light .
D. Lens
- It is a highly elastic circular biconvex transparent body, lying immediately
behind the pupil.
- It is suspended from the ciliary body by the suspensory ligament &
enclosed with in a transparent capsule.
- Its thickness is controlled by the ciliary muscle through suspensary
ligament.
-It bends light rays reflected by an object in front of eye.
3. Inner layer
A. Retina
- It is nervous tissue layer.
-Retina is especially adapted to be stimulated by light rays.
-Composed of several layers of nerve cell bodies.
-Rods & cones are layer highly sensitive to light.
Macula- It is an area of the retina situated to the temporal side of the optic disc.
-It contains a high concentration of cones.
-In its centre is the fovea centralis, a slight depression where only cones are
present.
B. Optic disc
-Contains no nerve cells, so the vision cannot take place here.
-This is known as the “blind spot”.
Structures inside the eye ball are
-Aqueous humour (fluid).
-Vitreous body.
 The anterior segment of the eye, i.e. the space between the cornea & the Lens, is incompletely
divided into anterior & posterior chambers by iris. Both chambers contain a clear aqueous fluid.
 Aqueous fluid
 It is secreted by ciliary gland.
  It passes in front of the lens, through the pupil into anterior chamber & returns to the
venous circulation in the angle between iris & cornea.
 Produced continuously & drained but the IOP remains fairly constant b/n 10 to 20 mm hg.
 An increase in pressure cause glaucoma.
 Vitreous body
 It is found behind the lens & filling the cavity of the eye ball.
 Soft, colourless, transparent, jelly like substance composed of 99% water.
 It maintains sufficient IOP to support the retina against the choroids & prevent the wall of
eye ball from collapsing.
 The eye keeps its shape because of IOP exerted by vitreous & aqueous fluid.
 Optic nerves = UNILATERAL BLINDNESS
 OPTIC TRACT = RIGHT HOMONYMOUS HEMIANOPSIA
 OPTIC CHIASM = BITEMPORAL HEMIANOPSIA
G
 The fibers of optic nerve originate in the retina of the eye.
 All the fibers converge to form the optic nerve about 0.5cm to the nasal side.
 It pierces the choroid & sclera to pass backwards & medially through the orbital cavity.
 Passes through optic foramen of sphenoid bone, backwards & medially to meet the nerve
from the other eye at the optic chiasma.
 Optic chiasma
 It is situated immediately in front of & above the pituitary gland in the sphenoid bone.
 In the optic chiasma the nerve fibers of the optic nerve from the nasal side of each retina
cross over to the opposite side.
 The fibers from temporal side do not cross.
Physiology of Sight
 Light reflects into the eyes by objects within the field of vision.
 A specific colour is perceived when only one wave length is reflected by the object & all the
others are absorbed.
E.g. an object appears red when only the red wave length is reflected.
 Objects appear white when all wavelengths are reflected & black when they are all
absorbed.
 In order to achieve clear vision light reflected from objects with in the visual field is focused
on the retina of both eyes.
 The processes involved in producing a clear image are refraction of the light rays, changing
the size of pupils & accommodation of the eyes.
Refraction of the light rays
 When light rays pass from a medium of one density to a medium of a different density they
are refracted or bent.
 Helps to focus light on retina.
 Lens: is the only structure in the eye that changes its refractive power.
 Light from distant objects needs least refraction & as the objects come closer, the
amount needed is increased (i.e. ciliary muscle contract).
 Size of the pupils: control the amount of light entering to the eye.
 If the pupils were dilated in a bright right, too much light would enter eye & damage
retina.
 The two muscles of iris, circular muscle fiber constriction causes pupil to constrict but
constriction of radiating muscle fiber dilate pupil
Accommodation of the eyes to light
 Close Vision
 In order to focus on near object i.e. with in 6 meters, the eye must make the following
adjustments.
 Constriction of the pupils.
 Convergence of the eye balls (Movement).
 If convergence is not complete there is double vision (diplopia).
 Changing the power of lens – the lens is thicker.
 Distant Vision
  Objects more than 6 meters away from the eyes are focused on the retina without
adjustment of the lens or convergence of the eyes.
 With aging, the ability of the eye to accommodate gradually decreases because of
increased rigidity of the lens (Presbyopia).
 The lens is tense able to change shape in response to visual challenge of focusing on near
objects.
OCULAR ASSESSMENT
1. Assisting the patient in measurement of visual acuity
The measurement of visual acuity records the acuteness of central vision for distance, and
near or reading vision.
Visual acuity: - is the most important function of eye and it should be performed first, so that
vision is assessed before actually touching the eye.
Distance Vision
It is tested at 6m as rays of light from this distance are nearly parallel.
If the patient wears glasses constantly, vision may be recorded with & without
glasses, but this must be noted on the record.
Each eye is tested and recorded separately, the other being covered with a card
held by the examiner.
Visual acuity is tested with an eye chart called snellen’s chart.
Snellen’s Chart test type
 Heavy black letters, numbers or symbols printed in black on a white background, are
arranged on a chart in grows of graded size, diminishing from above downwards. The
top letter can be read by the normal eye at a distance of 60m, and the following rows
should be read at 36, 24, 18, 12, 9, 6, 5, 4m respectively.
 The patient is seated 6m from the chart, which must be adequately lit, & asked to read
down to the smallest letter he can distinguish, using one eye at a time.
 Visual acuity is expressed as a fraction & abbreviated as VA.
 The numerator is the distance in meters at which a person (pt)can read a given line of
letters.
 The denominator is the distance at which a person with a normal average vision can
read the same line.
 If the patient cannot read the top letter at a distance of 1 meter, the examiner’s hand
is held at 0.9m, 0.6m or 0.3m a way against a dark background & the patient is asked
to count the number of fingers held up.
 If he answers correctly, record VA= CF (Count Fingers). For less visions the hand is
moved in front of the eye at 0.3m, record VA = HM (Hand movement).
 In the case of less vision, test for projection of light by shining a torch into the eye
from different directions to see if the patient can tell from which direction it comes if
he sees the light from which direction, it is noted as VA = PL(Perception of light). This
test is performed in the dark room. If no light is seen, record NO PL, which is total
blindness.
 A pinhole disk is used if the VA is less than 6/6, which may improve VA. If considerable
increase in vision is obtained, it may usually be assumed that there is no gross
abnormality, but a refractive error.
2. Assisting on ophthalmoscope Examination
 The internal eye is called the fundus & comprises the retina, optic disc, macula, &
retinal vessels.
 It can be visualized through an ophthalmoscope.
Ophthalmoscope is a hand-held instrument that projects light through a
prism & bends the light at 90 degrees, allowing the observer to
view the retina.
 The direct ophthalmoscope has several lenses arranged on a wheel. A lens may be
chosen by rotating the wheel with the index finger with out interrupting the
inspection.
 To a void a confrontation of noses, the right eye of the patient is examined with the
right eye of examiner
 The room is darkened to enhance papillary dilation.
  The direct ophthalmoscope has several lenses arranged on a wheel. A lens may be
chosen by rotating the wheel with the index finger with out interrupting the
inspection.
 To a void a confrontation of noses, the right eye of the patient is examined with the
right eye of examiner
 The room is darkened to enhance papillary dilation.
 Instruct the patient to hold the eyes still & focus on a real or imagined distant object.
 Grip the ophthalmoscope firmly in the hand, with the index finger resting on the lens
wheel.
 The head of the ophthalmoscope is braced with in the angle made by the eye brow &
the nose.
 The lens chosen for initial inspection should be the one labelled zero unless the
examiner is knowingly correcting his own defect in visual a acuity.
 An examiner who wears corrective lenses should become proficient in
ophthalmoscopy while wearing the lens.
 Lenses lobe led with a red numerals are for hyperopic (far sighted) patients & those
with a black numerals are for myopic (nearsighted) patients.
 The examiner stands approximately 37.5cm away & about 15 degrees to the side of
the patient’s gaze.
 When the light is focused on the pupil, the retina glows red (or orange) through
dilated pupil opening. This is called the red reflex.
 The examiner then moves closer to the patient. Placing a hand on the patient’s
forehead, the examiner rests his or her forehead on the hand & focuses through the
ophthalmoscope.
 Examining the fundus includes evaluating:
 The optic disc
 Its physiologic cup & Proportional size
 Retinal blood vessels
 Size
 Distribution
 Crossings & colour reflection
 Retinal characteristics
 General Colour
 Hemorrhagic
 Fluid
 Attachment
 Macular area
 Colour (darker red)
 Central reflection 
 Vitreous hum
 Colour
 Foreign bodies
3. Assisting in measurements of intraocular pressure
 Tonometry is a technique for measuring intra-ocular pressure (IOP) indirectly by
measuring the force necessary to flatten a 3.06mm diameter portion of the
corneal surface. The higher the IOP, the greater the force required.
 Methods of measuring IOP
 Digital.
 Golmann applanation tonometer.
 Schiotz (perkins applanation) tonometer.
 Pneumotonometer.
 Tonopen.
 Schiotz tonometry
 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 IOP.
 Goldmann applanation tonometry
  it is attached to a slit lamp to measure IOP.
 It is the most accurate form of measuring IOP. 
 Non contact tonometer (pneumotonometer)
 It is employed by optometrists, use a puff of air blown against the eye.
 It is useful when contact with the cornea is not desired.
 Digital
 A general determination of IOP can be made by applying gentle finger
pressure over the sclera of the closed eye.
 The 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.
 Tonopen
 Are small pen like instruments that measure pressure in a similar fashion to
the applanation method.
 NB: - IOP = normal value is 10-20mmHg. Increased IOP is the cardinal sign of
glaucoma
4. Assisting the patient in measurement of refractive errors
 Refraction
 Determination of refractive errors.
 Corneal Reflections
 Method: - A pen torch is held at 1/3m directly in front of both eyes.
The position of the reflection on each eye is then compared.
Results: - The results may be:
Normal Corneal reflections – symmetrical.
Asymmetrical Corneal reflections.
 Cover Test:-It is carried out to detect the presence of a squint, & should be
used in conjunction with observation of the corneal reflections.
REFRACTIVE ERRORS
RE is a pathological condition where parallel rays of light are not brought to focus on retina,
b/c of defect in the refractive media that is cornea and lens.
Refraction is the ability of the eye to bend light rays, so that they fall on the retina.
Refractive errors include:
Myopia (Short sightedness).
Hyperopia or hypermetropia (Long sightedness).
Astigmatism (asymmetric focus).
Presbyopia.
Aphakia.
1. Myopia or short sightedness
A short – sighted person has a long eyeball and the eye have excessive refracting power
(cornea and lens).
The light rays therefore come to a focus in front of the retina.
Can see near objects clearly.
Objects at a distance are blurred.
C/F = decreased distant vision.
Can be corrected by concave lens (minus), OR so that objects seen in the distance
are focused clearly on the retina. It bends light ray out ward.
2. Hyperopia or long sightedness
The eye has insufficient refractive power to focus light on the retina.
The rays of light entering the eye are focused behind the retina.
The individual can see distant object clearly, but close objects are blurred (C/M-Impairment
of near vision).
Can be corrected by convex lens (plus) which bends light ray inward.
3. Astigmatism
It is a refractive error in which the light rays are spread over a diffuse area rather than
sharply focused on the retina.
 It results from unequal curvature of the cornea, causing horizontal and vertical rays to be
focused at two d/t pts on the retina, so that there is no point of focus of the light
rays on the retina.
C/F: - blurred vision, eye discomfort.
It can be hyperopic or myopic in relation to where the image falls.
Can be fix by astigmatasic lens
4. Presbyopia
It is a form of hyperopia that occurs as a normal process of aging usually around the age of
about 45 years.
As the lens ages and becomes less elastic , it loses its refractive power and the eye no longer
has the ability to accommodate for near vision.
The light rays therefore fall behind the retina before coming to a focus.
Can be corrected by convex lens.
5. Aphakia
It is the absence of crystalline lens.
The lens may be absent congenitally, cataract surgery, trauma.
Eye loses about 30% of its refractive power and no near vision.
Can be corrected by implanting intraocular lens.
External Ocular diseases
1. Hordeolum (Sty)
A Sty is an acute suppurative infection of superficial eye lid sebaceous glands.
Cause: - Staphylococcus aureus.
C/F: - Sub acute pain, redness, & swelling (edematous) of a localized area of the lid that may rapture.
- Stys are localized to the lid margins.
- small collection of pus in the form of an abscess.
Mgt:
- Worm, moist compresses for 10 to 15 minutes, three to four times a day, hastens the healing
process.
- If the condition doesn't begin to resolve with in 48 hours, incision & drainage may be indicated.
- Application of topical antibiotics.
- Analgesics.
2. Chalazion
- is a swelling of one of the meibomian/tarsal glands due to blockage of its duct.
- It is chronic condition.
- It is some times called internal hordeolum.
Cause: - Staphylococci are common causes if infected.
S/sx: -Localized, firm, painless swelling that develops over period of weeks.
-Palpation usually indicates small, painless nodule in the eye lid some distance from the lid
margin.
Management
Warm, moist compresses for 10 to 15 minutes, three to four times a day especially in the
early stage.
Massage & expression of the glandular secretions.
Antibiotic therapy (Chloramphenicol;- apply 3-4 x/d for 7-10 day, after the eye has been
steamed).
Corticosteroid drops/injection in to the chalazion lesion.
Incision is indicated if the chalazion grows larger enough to distort vision.
Nursing Care:
Instruct the patient to apply steam to the eye.
Instruct how to use drugs.
Instruct the pt. to clean eye lids by using worm water.
3. Blepharitis
It can be a cute or chronic inflammation of both eyelid margins.
It is usually bilateral.
It can take the form of:
 A. Staphylococcal blepharitis: It is usually ulcerative and more serous due to
involvement of the base of hair follicle. Permanent scaring can result. Caused by
staphylococcal chronic infection.
B. 2. Seborrehic blepharitis:- It is chronic and usually resistant to Rx, but the milder
case can respond to lid hygiene. Caused by Seborrhoea (excessive secretion of lipid
from meibomian glands).
It may be associated with dandruff, poor hygiene, eczema.
S/sx
Irritation of eye lids margins and red rimmed eyes with many scales or crusts on the
lid margin and eye lashes
Burning
Itching
Photophobia
Conjunctivitis may occur simultaneously
Mgt
Daily meticulous cleaning of the lid margins using cotton tipped applicator, with
dilute baby shampoo, 2x/day.
Warm Compresses.
Application of antibiotic ointment 2-3x/d.
Dandruff RX.
Stop using make up or change the brand used.
Improve hygiene.
Complication
Conjunctivitis.
Trichiasis.
Entropion or ectropion of lower lid.
Corneal Ulcer.
4.Trichiasis- It is a condition in which the eye lashes grow in wards & rub on the cornea.
Cause: - blepharitis
- Trauma or surgery to the lids.
Rx: - Epilation
Complication: - Corneal abrasions
- Corneal ulceration
- Corneal Opacity
- Vascularization of cornea
5. Entropion- Turing inward of eyelids, usually lower eye lids.
Cause: Contraction of the palpebral conjunctiva following trauma or disease to the eye lid
or conjunctiva.
Tx: - Transverse lid surgery and suture.
6. Ectropion
It is turning outwards of the eye lids, usually the lower lids.
Cause: Scaring of the lid or conjunctiva
- Paralysis of facial nerve.
Tx: Surgery
7. Ptosis
It is dropping of the upper eyelid.
Cause: - congenital.
- edema, tumor & scarring of eye lid
- Myasthenia gravis (Levator palpebral superioris).
- Paralysis of nerves supplying the upper lid.
Tx: - Treat underlying cause.
Disease of conjunctiva
1. Conjunctivitis- an inflammation of the conjunctiva.
It is the most common ocular disease world wide.
It is characterized by a pink appearance (hence the common term “pink eye”) because of
subcutaneous blood vessel hemorrhages.
Causes:
 1. Infections
A. Bacteria (Haemophilus influenza, staph aureus)
B. Virus (Adeno virus, HSV)
C. Chlamydial
D. Fungal
E. Parasitic
2. Immunologic (allergy); environmental allergens (e.g. pollens).
3. Irritant/toxic (Chemical, thermal, electrical).
4. Associated with systemic disorder.
Most conjunctivitis is bilateral; unilateral involvement suggests a toxic or
chemical origin.
2. Trachoma- is a highly contagious infectious eye disease (Chlamydia Conjunctivitis) that affects
more than 500 million people world wide and which may result in blindness.
It is the world's leading cause of preventable blindness & primarily affects people in Africa.
 Scaring of the inside of the eye lid.
 The eye lid turned inward and the lash rubs the eye ball.
 Scaring of the cornea.
 Irreversible corneal opacities and blindness.
Cause: Chlamydia trachomatis
Mode of transmission:
Direct Contact (with eye, nose, throat secretion from the affected individual.
Fomites (towel, hand kerchiefs, fingers, wash clothes).
Insect Vector (flies).
Complications:
Scarring of eye lids
Entropion
Trichiasis
Corneal trauma & ulceration
Mgt - Good personal hygiene
- Tetracycline eye
SAFE strategy;
Surgery:- trichiasis and entropion.
Antibiotic:- TTC (ointment apply TID for 3-4weeks.), sulphonamides, erythromycin.
Facial cleanness:- good hand and face washing practice.
Environmental changes:-address water shortage, eradicate flies, avoid crowded, e.t.c.
Disease of cornea – KERATITIS, CORNEAL ULCER, PTERYGIUM
1. Keratitis- is an inflammation of the cornea.
Causes:
-Exposure (exophthalmos/bulging eyes, lagophtalmos inability of the eyelids to
close) keratitis as a result of drying of the cornea because of eye lids can not protect it
adequately.
- Infections;
- Bacteria (staph.. aureus, strep.. pneumonia, pseudomonas aergunosa).
- Virus (herpes simplex, varicella zoster virus).
- Fungus (Candidia, aspergillus, cephalosporium).
- Parasitic organism.
Most of infections of cornea occur as a result of trauma or compromised systemic or
local defense mechanism.

S/sx
- Sensation of foreign baby in the eye.
- Marked inflammation of glade (open space).
- Muco-purulent discharge with the eyelids stuck together on awakening.
- Ulceration.
- Hypoyon (Pus in the anterior chamber).
- Photophobia.
- Blurred vision.
 In advanced disease;
-Perforation of cornea.
- Extrusion of the iris.
- Endophthalmitis.
Diagnostics
-Identifying the ulcer by slit - lamp examination after instilling fluorescein drops to
demonstrate the shape & size of the ulcer under special light.
Mgt
- Patients with severe corneal infections are usually hospitalized to allow frequent
administration (every 30 minutes) of antimicrobial drops & regular examination.
- Keep the lid clean.
- Cold compresses.
- Monitor for sign of increased IOP.
- Acetaminophen 500mg 2tabs PRN.
- Cycloplegic & mydriatics to relieve pain & inflammation.
Complication
- Corneal Scar.
-Revascularization (new blood vessels formation) in the cornea.
2.Pterygium- 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 irritative and degenerative phenomenon caused by ultraviolet light.
Cause: unknown. But attributed to exposure to sunlight or UV light
Predisposing factors:
-People who live in hot, dry climates or who work in the open air.
Treatment
- Surgical removal if pterygium encroaches on the visual axis or causes significant
discomfort.
- In 30-50% of cases it reoccurs after surgery.
3. Corneal ulcer
- It is ulceration of cornea.
Etiology
Bacteria
-Staph.. aureus, strep.. pneumonia, pseudomonas aergunosa.
Fungus
- Candidia, aspergillus.
S/sx
Pain
Blurred vision
Photophobia
The ciliary vessel around the cornea will be dilated.
Diagnostics
History and physical examination
Culture and sensitivity.
Microscopic exam.
Mgt
Treat urgently.
Antibacterial
Gentamycin and ciprofloxacilin eye drops.
Antifungal
Natamycin and econazole eye drops.

Intraocular disease /Disorders of the Lens – CATARACT (CONGENITAL AND SENILE

CATARACT) DEGREE OF CATARACT: MATURE AND IMMATURE
1. Cataract- It is clouding or opacity of crystalline lens that impairs vision.
The lens is a delicate structure & any insult on it causes absorption of water, resulting in the
lens becoming opaque.
Causes
From birth (congenital).
Age (senile).
Eye injury (traumatic).
Secondary to existing eye disease (e.g. uveitis).
Drug like corticosteroids.
Cataract associated with systemic disease (DM, Hyperparathyroidism).
UV light exposure.
High dose of radiation therapy.
Degree of Cataract
Immature cataract – part of the lens is opaque.
Mature cataract – the whole lens is opaque & may be swollen.
Congenital Cataract
Cause
Abnormal development of the eye.
Metabolic disturbance.
Rubella or malnutrition in first trimester of pregnancy.
S/sx
Child is Unable to see.
white pupil (Unilateral or bilateral blindness).
Tx: - Removing the cataract. Old method: Extra Capsular Cataract Extraction (ECCE)
NEW VERSION: Phacoemulsification – cataract is being destroyed and replaced by
an artificial lens.
Senile Cataract
Occur in patients over the age of 60 years.
They result from sclerosis of the lens due to a degenerative process.
Usually bilateral.
It is either:
Nuclear: affects the central lens & takes on a brown color.
The patient sees better in dim light when pupil is dilated.
Cortical: Affects the periphery of the lens & looks white.
Vision is usually better in bright light when the pupil is constricts.
General S/sx
Gradual, progressive, and painless loss of vision.
Double vision/blurred vision/
Reduced light transmission.
Rainbow/haloes
Previous dark pupil appear milky or white.
Diagnostics
History and PE
Ophthalmoscopic exam.
Slit lamp examination.
Management
Surgery
Surgical removal of the lens usually done under local anesthesia.
IOL (intraocular lens) are usually implanted at the time of cataract
extraction.
Nursing intervention
Preparing the pt for surgery.
Orient patient and explain the procedure and plan of care to decrease
anxiety.
Instruct the pt not to touch to decrease contamination.
Administer preoperative eye drops.
Postoperative care:
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.
Diseases of sclera SCLERITIS,
1. Scleritis- It is an inflammation and swelling of sclera.
Etiology
- Associated with connective tissue disorder like rheumatoid arthritis.
S/sx
Severe pain.
The white part of the eye may appear red, swollen and a nodule which is painful in
touch.
Mgt
- Heavy immune suppression.
- Systemic corticosteroid and eye drops.
- Systemic NSAID’s and treating the underlying cause.
Disease of uveal tract (UVEITIS non-granulomatous, granulomatous – Acute anterior
uveitis/iritis, Intermediate uveitis, )

Non-granulomatous

1. Acute onset
2. Pain
3. Photophobia
4. Conjunctival ejection
5. Pupil will be small or irregular
6. Blurred vision
7.

1. Uveitis- is the inflammation of one or all structures of the uveal tract.

Uveal tract comprises the middle vascular pigmented layer of the eye.
It is composed of three areas: -
The choroid.
The ciliary body.
The iris.
Because the uvea contains many of the blood vessels that nourish the eye and because it
borders many other parts of the eye, inflammation of this layer may threaten vision.
Causes:
-Bacteria ( TB).
-Virus (CMV, syphilis, herpes zoster and simplex).
-Fungi (toxoplasmosis, histoplasmosis, ocular candidiasis).
- Chemical
- Trauma
- Allergy
1) Acute anterior uveitis (iritis)
- Is the most common type.
- Is characterized by a history of pain, photophobia, blurring of vision, & red eye.
Treatment:
- Dilating drops (mydriasis) are instituted immediately to prevent scar formation &
adhesion to the lens (Synechiae), which may cause glaucoma by impending
aqueous outflow.
- Local corticosteroids are used to decrease the inflammation.
- Wearing sunglasses.
- Analgesics.

2) Intermediate uveitis (Chronic cyclitis)

- It is characterized by “Floating spots” in the field of vision.
 Tx: Topical or injectable corticosteroids are used in severe cases.
3) Posterior uveitis (Inflammation affecting the choroid or retina)
- Is usually associated with some form of systemic disease, such as AIDS, herpes
simplex or zoster, tuberculosis.
S/sx
- Decreased or distorted vision.
- eye redness & pain.
Tx – Systemic corticosteroid.
--------------------
2. Sympathetic Ophthalmia- 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.
Cause – Unknown
Predisposing factor: Allergy
S/sx:
Inflammation of injured eye, followed by inflammation of the unaffected
(Sympathetic) eye.
Mgt:
- Enucleation of the sightless eye within 10 days of injury is usually recommended
to reduce the risk of sympathetic disease in the other eye.
- Indication for enucleation
- Blindness after penetrating injury.
- Painful blind eyes that is unresponsive to the medical treatment.
- Tumor of the eye.
Disease of the inner eye
1. Panophthalmitis-
It is an inflammation of all tissue of the eye ball.
Etiology
Bacteria.
Virus.
Fungus.
History of recent intraocular operation.
Penetrating trauma.
Common in immune compromised pts, such as HIV/AIDS and diabetes.
S/sx
- Severe pain.
- Loss of vision.
- Redness of conjunctiva and underlying episclera.
Mgt
- Medication (antimicrobial plus steroids)
- Topical.
- Subconjuctival.
- Intravitreally.
- Systemically, or in combination form.
- Surgery
- Enucleation.
Injuries to the eye
1. Trauma to the eye
A. Blunt contusion
It is bruising of the periorbital soft tissue.
S/sx
-Swelling and discoloration of the tissue.
- Bleeding in to the tissue and structure of the eye.
- Pain.
Mgt
- Reducing swelling and pain by applying cold and warm compress.
- Refer for ophthalmologist ass’t.
B. Hyphema
- It is the presence of blood in the anterior chamber.
S/sx
- Pain.
- Blood in the anterior chamber.
- Increase IOP.
Mgt
- Usually spontaneously recovers. Bed rest only.
- If sever bed rest, and eye shield application.
C. Orbital fracture
- It is fracture and dislocation of the wall of the orbit, orbital margin or both.
Cause: Injury on the cranial area.
S/sx
-Rhinorrhea fluid of on the nose
- Contusion
- Diplopia
Mgt
- May heal by itself, if no displacement or infringement on the other structure.
Surgery: if ther eis displacement, repair of the orbital floor.

D. Foreign body
- It is the presence of foreign material on the cornea or conjunctiva.
S/sx
-Severe pain with lacrimation
- Foreign body sensation
- Photophobia
- Redness
- Swelling
Mgt
-Consider a medical emergency.
-Removal of foreign body through irrigation, cotton tipped applicator.
- Surgical removal.
E. Laceration/Perforation.
- It is cutting or penetration of soft tissue.
S/sx
-Pain
-Bleeding
-Lacrimation
-Photophobia
Mgt
- Consider as medical emergency.
-Surgical repair- method of repair depends on the severity of injury.
- Antibiotics.
F. Ruptured globe
-It is concussive injury to globe with tears in the ocular coat, usually the globe.
S/sx
-Pain
- Altered IOP
- Limitation of gaze in field of rupture
- Hyphema
- hemorrhage
Mgt
- Consider as medical emergency.
- Surgical repair
- Antibiotics
- Steroids
- Enucleation
2.Burn of the eye
- It is the destruction of the eye tissue by chemical, thermal, and ultraviolet ray.
- Burn of chemical agent that is caused by alkali or acids.
S/sx
-Pain
- Burning
- Lacrimation
- Photophobia
Mgt
- Consider as medical emergency.
- Copious irrigation until PH is 7.
- Keratoplasty for severe scaring.
- Antibiotics.
B. Burns of thermal sources
S/sx
-Pain
- Burned skin
- Blisters
Mgt
- First aid-apply sterile dressing.
- Pain control.
- Leave fluid blebs intact.
- Suture eyelid together to protect eye if perforation is possible.
- Skin grafting with severe second and third degree burns.
C. Burn of UV source
S/sx
-Pain
- Foreign body sensation
- Lacrimation
- Photophobia
Mgt
- Pain relief.
-Bilateral patching with antibiotic ointment and cycloplegics.
Other eye condition
1. Glaucoma (Disorder of an aqueous Humor Circulation)
- Glaucoma 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;
A. Congenital
B. Closed angle (acute)
C. Open angle (chronic)
D. Secondary
A. Congenital glaucoma.
- It is a rare condition that occurs in infant and neonates
S/sx
- The diameter of the cornea increase in size.
- The cornea becomes edematous
Dx
- Tonometry exam-increase IOP.
Mgt
- Medical: Pilocarpine drops, Acetazolamide tablet.
- Surgical: Goniotomy-to incise the mesodermal membrane in the angle of anterior chamber.
B. Closed angle glaucoma
- It accounts for 10% of the primary glaucoma.
Etiology
Mechanical blockage of the anterior chamber angle.
 S/sx
-A sudden severe pain in and around the eye.
-Nausea and vomiting
-Pupil mid-dilated and fixed.
-Hazy appearing cornea due to corneal edema.
-A sudden elevation of IOP
Dx
-Slit lamp exam nation.
-Tonometry examination.
Mgt
-Medical- Lower the IOP as quick as possible by medical means.
A.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. Pilocarpine 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 aqueous humor.
E.g. Acetazolamide (diamox)250mg QID.
C. Open angle glaucoma
- Makes up 90% of primary glaucoma cases.
- Its incidences is increased with age.
Etiology
- Degenerative changes occur in the trabecular meshwork and canal of schelmm.
Risk factors
- AGE.
- Familial history of glaucoma.
- Diabetes
-Hypertension

S/sx
- Mild, bilateral discomfort (tired feeling in the eyes, foggy vision).
- Slowly developing impairment of peripheral vision with dilated pupil.
- Progressive loss of visual field.
- No pain or inflammation.
Dx
- Paleness of the optic disk.
- Optic nerve atrophy.
- Rise in IOP.
Mgt
Medical
- Reduce the IOP by medication- the medication should be continued for
the rest of the patient life
- Pilocarpine drops 2-4% QID.
- Adrenaline drops 1% BID.
- Timolol/Timoptol/ drops ).25-0.5% BID.
Surgical
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.
D. Secondary glaucoma.
It is a type of glaucoma caused by a specific causes or pathologies.
Etiology
Hemorrhage.
Corticosteroid use.
 Uveitis.
Mgt
Treat the cause.
2.Strabismus/Squint
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.
Effects of squint
In adults
Double vision/diplopia/.
Abnormal head posture.
In children
Ambylopia/lazy eye/.
S/sx
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.
Testing the ocular movements.
There are six extra ocular muscle, and each one produces most of the movement in
the particular direction.
Mgt
In children
-Try to correct any refractive errors and ambylopia before straightening the
squint surgically.
- Patching the good eye.
-Surgical correction by either weakening, straightening or realigning the
extra ocular muscles
In adults
Cosmetic surgery is the only treatment.
3. Diabetic Retinopathy
- Caused by damage to or occlusion of the blood vessels those nourish the retina. Weakened
blood vessels become hyper-permeable & leak, causing micro-hemorrhages, retinal swelling, or
exuadative deposits.
- Progressive retinal ischemia stimulates the formation of new blood vessels
(neovascularization).

4. Retinal detachment
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.
Causes: - The neural retina can be either pulled, pushes or floated off the underlying epithelial layer

Pulled off : by vitreous traction

Which occurs when new blood vessels have grow in to the vitreous.
Pushed off: lesion behind the retina
Floated off: iif a tear or hole appears in a retina. Rhegmatagenaus (tear induced) detachment.
C/F: -
- History of floating or flashing lights or both. The floaters are perceived as tiny dark spots or
cobwebs.
- Spreading shadow or curtain moving across the field of vision, resulting in blurred vision &
loss of visual field as the retina separates
- Decreased central acuity or lass or central vision
- Flashing lights (photopia).
Patients with Neurologic Problems

Rapid Neuro Assessment

Glasgow Coma Scale

Localizes pain – when u pinch the patient, hulagon.
Withdraws to pain – mahulag hulag kay indi nya bal an kung din ang pain.
Trapezius Squeeze – kung magwinaras lang sa, withdraws.
Level of consciousness.

Lethargic
Stuporous
Coma

Decerebration – dysfunction of brainstem.

FUNCTIONS OF EACH CRANIAL NERVES AND WHERE IT IS LOCATED

Above the pituitary gland

Occippital lobe

Facial nerve: near the tagus of ear

Glossopharyngeal –
Vagus nerve – swallowing

Brain disorders
Migraine – due to dilation of cerebral vessels
Trigeminal – sensation ophthalmic
Maxillary – sensation of the face
Movement is covered by facial

Triggers

Estrogen is involved in dilation of vessels, other meds causes dilation

NSAIDs
Beta blockers such as Inderal

Seizures

Corpuscallostomy – corpus callosum removal

MENINGITIS
CLEAR COLORLESS.- NORMAL/ VIRAL
CLOUDY – BACTERIAL
PINK – ORANGE – TRAUMATIC
>05 VIRAL
LESS THAN 50 BACTERIAL BECAUSE BASTERIA CONSUMES GLUCOSE

CEFTRIAXONE

PNEUMOCOCCAL = PENICILLIN

CUSHING’S TRIAD

LUMBAR PUNCTURE DIAGNOSTIC OF CHOICE