OPTHALMOLOGY 

❖ EXTERNAL LAYER  

  ❖ ANATOMY and PHYSIOLOGY OF THE EYE  ➢ fibrous coat that supports  

➢ The eye is 1 inch in diameter.   ➢ the eye 

➢ the eye is located in the anterior portion of the ➢ contains the SCLERAE 
orbit.  
o Tough, white connective tissue “white of the eye” 
➢ the orbit is the bony structure of the skull that
o Located anteriorly & posteriorly 
surrounds the eye and offers protection to the eye.  
The external layer contains the CORNEA 
➢ It is about 4 cm high, wide, and deep, and it is shaped
roughly like a four-sided pyramid, surrounded on three (Transparent tissue through which light enters the
sides by the sinuses.  eye. Contains more nerve endings)

❖ Eyelids  ❖ MIDDLE LAYER 

➢ Composed of thin elastic skin that covers striated and o Second layer of the eyeball is also known as the
smooth muscles ➢ It protects the anterior portion of UVEAL tract.
the eye 
o Highly vascular & pigmented 
➢ Eyelashes (lashes) 
➢ consists of the CHOROID 
➢ -one of the hairs that grow at the edge of the eyelid.  o A dark brown membrane located between the sclera
➢ They protect the eye from debris and perform same & the retina
function as whiskers do on cat and mouse  o The choroid lines most of the sclera and is attached to
the retina but can detach easily from the sclera.  
❖ EXTERNAL STRUCTURES 
o Composed of layers of blood vessels that nourishes
❖ Conjunctivae 
the retina    
➢ are thin transparent mucous membranes, and lines
❖ CILIARY BODY 
the posterior surface of each eyelid and is located over
the sclera. It is made of lymphoid tissue. Connects the choroid with the iris 

➢ It is typically subdivided into 3 parts:  Secretes aqueous humor that helps give the eye its
shape 
▪ Palpebral or Tarsal conjunctiva 
❖ IRIS 
➢ Fornix 
➢ The colored portion of the eye 
➢ Bulbar or Ocular conjunctiva  
➢ Located in front of the lens and has a central
❖ Lacrimal Apparatus 
opening called the pupil 
❖ (Lacrimal Gland and its Ducts and Passages) 
❖ INNER LAYER  
➢ Produces tears to lubricate the eye and moisten the
➢ consists of RETINA 
cornea
➢ A thin, delicate structure in which the fibers of the
➢ Tears drain into naso-lacrimal duct which empties
optic nerve are distributed 
into nasal cavity 
➢ Bordered externally by the choroid & sclera and
internally by the vitreous
❖ LAYERS OF THE EYE: 
➢ Contains blood vessels & photoreceptors called ➢ Contains a gelatinous substance that occupies the
cones & rods vitreous chamber which is the space between the lens &
retina 
➢ Light sensitive layer 
➢ Transmits light & gives shape to the posterior eye 
❖ CONTAINS THE FOLLOWING STRUCTURES 
❖ OPTIC DISK 
1. CONES 
➢ A creamy pink to white depressed area in the retina 
➢ Specialized for fine discrimination, central vision &
color vision ➢ The optic nerve enters & exits the eyeball in this
area 
➢ Functions at bright levels of illumination 
❖ Referred to as the “BLIND SPOT” 
2. RODS  
➢ contains only nerve fibers 
➢ More sensitive to light than cones 
➢ lack photoreceptor cells 
➢ responsible for peripheral vision and functions at
reduced levels of illumination  ➢ insensitive to light 
   ❖ MACULA LUTEA 
❖ FLUIDS OF THE EYE  ➢ Small, oval, yellowish pink area located lateral &
A. AQUEOUS HUMOR  temporal to the optic disk 

➢ Clear, watery fluid that fills the anterior & posterior ➢ The central depressed part of the macula is the
chambers of the eye  “FOVEA CENTRALIS” which is an area where acute vision
occurs 
➢ produced by the ciliary processes, & the fluid drains
in the Canal of Sclemm  ❖ CANAL OF SCHLEMM 

➢ The anterior chamber lies between the cornea & iris  ➢ a passageway that extends completely around the
eye 
➢ The posterior chamber lies between the iris & lens 
➢ permits fluid to drain out of the eye into the systemic
➢ Serves as refracting medium & provides nutrients to circulation so that a constant IOP is maintained  
lens & cornea
❖ LENS 
➢ Contributes to maintenance of IOP
➢ A transparent circular structure behind the iris & in
B. VITREOUS HUMOR  front of the vitreous body 
➢ Clear, gelatinous/jell-like material that fill the ➢ Bends rays of light so that the light falls on the retina 
posterior cavity of the eye 
❖ PUPILS 
➢ Maintains the form & shape of the eye 
➢ Control the amount of light that enters the eye &
➢ Provides additional physical support to the eye  reaches the retina ➢ Darkness produces dilation while
light produces constriction 
➢ It is produced by the vitreous body 

❖ VITREOUS BODY 
❖ BLOOD VESSELS 
   A. OPTHALMIC ARTERY  ✓ Fluorescein Angiography 

➢ Major artery supplying the structures in the eye  ❖ VISUAL ACUITY TEST 
 B. OPTHALMIC VEINS  ➢ -measures the client’s distance and near vision 
➢ Venous drainage occurs 1. Chart 

❖ EYE MUSCLES  a. Snellen Chart 

➢ Muscles do not work independently but work in b. Rosenbaum Chart 

conjunction with the muscle that produces the opposite
2. Count Fingers 
movement 
3. Hand Motion 
A. RECTUS MUSCLES 
4. Light Perception 
➢ Exert their pull when the eye turns temporarily 
5. No Light Perception 
B. OBLIQUE MUSCLES 
❖ VISUAL ACUITY 
➢ Exert their pull when the eye turns nasally 
➢ Measures the client’s distance & near vision 
❖ NERVES 
❖ SNELLEN CHART
A. CRANIAL NERVE II 
➢ simple tool to record visual acuity 
➢ Optic nerve (nerve of sight) 
➢ the client stands 20 ft from the chart & covers 1 eye
B. CRANIAL NERVE III 
and uses the other eye to read the line that appears
➢ Oculomotor  more clearly 

C. CRANIAL NERVE IV  ➢ if the client is able to do this accurately, the client
reads the next lower line.  
➢ Trochlear 
➢ the sequence is repeated until the client is unable to
D. CRANIAL NERVE VI 
identify correctly more than half of the characters on
➢ Abducens  the line.  

▪ How We See?  ➢ this procedure is repeated for the other eye 

❖ ASSESSMENT OF VISION  ➢ the findings are recorded as a comparison between

what the client can read at 20 ft and the no. of feet
✓ Visual Acuity  normally required by an individual to read the same
line  
✓ Refraction Test 
❖ EXAMPLE: 20/50 
✓ Visual Field Confrontation Test 

o DIAGNOSTIC TEST for the EYE  ➢ The client is able to read at 20 ft from the chart what
a healthy eye and read at 50 ft 
✓ IOP Measurement 
❖ Snellen Chart’s 
✓ Ophthalmoscopic Test 
❖ Rosenbaum Chart 
✓ Slit Lamp Examination 
❖ VISUAL ACUITY TEST 
✓ Corneal Staining 
2. Count Fingers 
➢ The examiner holds up a random number of fingers 1. Client’s right (lateral position) 
and asks the patient to count the number he or she
2. Upward & right (temporal position) 
sees. 
3. Down & right 
➢ Ex.  ▪ CF/3 
4. Client’s left (lateral position) 
3. Hand Motion 
5. Upward & left (temporal position) 
➢ The examiner raises one hand up and down or moves
it side to side and asks in which direction  6. Down & left 

➢ the hand is moving.  ➢ Client holds head still & asked to move eyes & follow
a small object
➢ Ex.  ▪ HM /1 ft 
➢ The examiner looks for any parallel movements of
❖ VISUAL ACUITY TEST  the eye or for nystagmus - an involuntary rhythmic
4. Light Perception  rapid twitching of the eyeballs 

➢ A patient who can perceive only light  ❖ COLOR VISION TEST 

5. No Light Perception  ➢ Tests for color vision which involve picking nos. or
letters out of a complex & colorful picture 
➢ A patient who cannot perceive light 
❖ ISHIHARA CHART 
❖ CONFRONTATIONAL TEST 
➢ Consists of nos. that are composed of colored dots
➢ Performed to examine visual fields or peripheral located within a circle of colored dots 
vision 
➢ Client is asked to read the nos. on the chart 
➢ The examiner & the client sit facing each other 
➢ Each eye is tested separately 
➢ the client is asked to look directly into the eyes of the
examiner throughout the test ➢ The test is sensitive for the diagnosis of red/green
blindness but not effective for the detection of the
➢ the examiner covers his right eye while the client discrimination of blue 
covers his left eye 
❖ COLOR VISION TEST 
➢ the examiner moves a finger from a nonvisible area
into the clients line of vision  ➢ Consensual Response 

➢ the examiner and client should see the object ❖ PUPILS 

at approximately the same time.   ➢ Normal: round & of equal size 
➢ when the client sees the object coming into the line
➢ Increasing light causes pupillary constriction 
of vision, the client informs the examiner.  
➢ Decreasing light causes pupillary dilation
➢ the procedure is repeated on the opposite eye. 
➢ The client is asked to look straight ahead while the
The test assumes that the examiner has normal
examiner quickly brings a beam of light (penlight) in
peripheral vision 
from the side & directs it onto the side 
✓ CONFRONTATIONAL TEST 
➢ Constriction of the eye is a direct response to the
✓ EXTRAOCULAR MUSCLE FUNCTION  light shining into the eye; constriction of the opposite
eye is known as CONSENSUAL RESPONSE 
Tests 6 cardinal position of gaze 
❖ DIAGNOSTIC TEST for the EYE: 
❖ Ophthalmoscope  1. Tonometry (Schiotz) 

➢ It is an instrument used to examine the external 2. Applanation Tonometry – measures the force
structures and the interior of the eye   required to flatten rather than indent a small area of the
central cornea and is more accurate
❖ Ophthalmoscopy 
➢ Tonometer is applied to an anesthetized cornea 
❖ Preparation 
➢ Normal: 10 – 21 mmHg 
✓ Darken room in order for the pupil to dilate 
➢ IOP increased in glaucoma 
✓ Hold the instrument with the right hand when
examining the right eye and the left hand when ❖ NURSING CARE 
checking the left eye 
✓ Each eye is anesthetized. 
✓ Ask client to look straight ahead at an object on the
✓ The client is asked to stare forward at a point above
wall ✓ Approach the client’s eye from about 12 inches
the examiner’s ear
to 15 inches away and 15 degrees lateral to the client’s
line of vision.   ✓ A flattened cone is brought in contact with the
cornea 
❖ Ophthalmoscopy 
✓ The amount of pressure needed to flatten the cone is
✓ As the instrument is directed at the pupil, a red glare measured
(red reflex) is seen in the pupil 
✓ The client is instructed to avoid rubbing the eye
✓ Absence of the red reflex may indicate opacity of the following the examination if the eye has been
lens ✓ The retina, optic disk, optic vessels, fundus and anesthetized due to the potential for scratching the
macula can be examined  cornea exists 
❖ Slit Lamp  ❖ Fluorescein Angiography 
➢ It allows examination of the anterior ocular ➢ -detailed imaging and recording of ocular circulation
structures under microscopic magnification  by a series of photographs after the administration of a
➢ The client leans on a chin rest to stabilize the head dye.  
while a narrowed beam of light is aimed so that it Procedure: 
illuminates only a narrow segment of the eye 
✓ Assess for allergies 
❖ Interventions  
✓ Secure consent 
✓ Explain the procedure to the client 
✓ Pre-op meds an hour before procedure (mydriatic
✓ Advise the client about the brightness of the light and medication causes pupil to dilate is instilled to the eyes
the need to look forward at the point of the examiner’s 1 hour before the test. 
ear. 
✓ Dye injected into a vein in client’s arm 
❖ TONOMETRY 
✓ Inform client that the dye may cause yellowish
➢ Measurement of intraocular pressure by means of discoloration on the skin for a couple of hours after the
placing a sensitive instrument (tonometer) directly on test 
the partially anesthetized eyeball 
✓ Inform the client that he may experience N&V,
sneezing, paresthesia of the tongue or pain at the
2 types: injection site 

Post-procedure 
✓ Encourage rest  ➢ is the passage of rays of light from an object through
the cornea, aqueous humor, lens and vitreous humor to
✓ Encourage increased oral fluids  the retina. 
✓ Inform client that urine may appear bright green  A. Normal: EMMETROPIA 
✓ Instruct to avoid direct sunlight for a few hours  ➢ Rays coming from an object at a distance of 6 meters
or more are brought to a focus on the retina by the
✓ Instruct that photophobia will continue until pupil
lens.  
size returns to normal 
B. Abnormal: AMETROPIA 
❖ Corneal Staining 
REFRACTIVE ERRORS 
➢ Procedure where a topical dye is instilled into the
conjunctival sac to outline irregularities of the corneal ❖ Near sightedness (myopia)  
surface that are not easily visible. The eye is viewed
through a blue filter and a bright green color indicates ➢ eye has an excessive refractive power to focus the
areas of non-intact corneal epithelium  light upon the retina. 

❖ Interventions  a. Ray of light coming from an object at a distance of

6meters or more are brought to a focus in front of the
✓ Contact lenses must be removed if client is wearing retina 
one
b. Correction: concave lens 
✓ Instruct client to blink once dye have been instilled in
❖ Farsightedness (hyperopia)  
order to distribute it evenly across the cornea 
➢ eye has insufficient refractive power to focus the
❖ REFRACTION TEST 
light upon the retina. 
❖ Snellen’s Chart reading with corrective lenses 
a. Ray of light coming from an object at a distance of
❖ Measures error of focus  6meters or more are brought to a focus at the back of
the retina 
❖ Myopia (nearsighted) 
b. Correction: convex lens 
❖ Hyperopia (farsighted) 
❖ S/s 
❖ Astigmatism (inability to focus horizontally and
vertically) ✓ frequent headache 

❖ NORMAL VISION & REFRACTIVE ERRORS  ✓ eye strain 

❖ Myopia  ❖ Accommodation

❖ Hyperopia  ➢ "In accommodation the focusing apparatus of the

eye adjusts to objects at different distances by means of
❖ Astigmatism   increasing the convexity of the lens (brought about by
contraction of ciliary muscles). 

Abnormal Condition 

❖ Presbyopia — the elasticity of the lens decreases

❖ NORMAL VISION & REFRACTIVE ERRORS  with increasing age; a person with presbyopia will read
❖ Vision  a paper at arm length and requires prescription lenses
to correct the problem. 

Curvature of Cornea 
A. Normal — equal curvature of cornea  ✓ Ophthalmic Medications 
B. Abnormal — ASTIGMATISM  ✓ Previously applied medications should be cleaned
away o also any drainage from the eye 
1. Uneven curvature of the cornea causing the patient
to be unable to focus horizontal and vertical rays on the ✓ Intended location is the conjunctiva  
retina at the same time. 2. Correction—cylinder lenses.  
✓ Poorly administered eye drops could result in loss of
Astigmatism- a vision condition that causes blurred medication through the tear duct 
vision due to the irregular shape of the cornea or
sometimes the curvature of the lens inside the eye. ✓ Poorly placed ointments may be distributed over
Presbyopia — the elasticity of the lens decreases with the eyelids and lashes  
increasing age; a person with presbyopia will read a
✓ Ophthalmic Medications 
paper at arm length and requires prescription lenses to
correct the problem.  ✓ Patient’s head should be tilted back 
❖ OPTHALMIC-MEDICATION  ✓ After administration, the patient should place a finger
ADMINISTRATION  in the corner of the eye, next to the nose to close the  

lacrimal gently  
✓ Ophthalmic Medications  
o prevents loss of medication through tear duct 
✓ Must be at room temperature or body temperature  
✓ Patient should also keep the eyes closed for 1or 2
before application  
minutes after application  
✓ Should be stored according to package information  
✓ Ophthalmic Medications 
o reduces bacterial growth 
✓ When multiple drops of more than one medication
o ensures stability  are to be administered, the patient should wait 5
minutes  
✓ Considered sterile products 
between different medications 
o only preparations with preservatives can be  
o the first drop may be washed away 
repeatedly used  
o If an ointment and a drop are used together, the  
✓ Ophthalmic Medications 
drop is used first  
✓ Before application, patient should wash hands  
o wait 10 minutes before applying the ointment  
o prevents contamination of application site  
✓ Ophthalmic Medications 
✓ Tube or dropper should not touch the application
site  ✓ Ointments are generally applied at night 

o medication may become contaminated  o drug form of choice when extended contact with  

✓ Only sterile ophthalmic solutions or suspensions   the medication is desired 

should be used in the eye  o remind patient that some temporary blurring of vision
may occur after application 
o not preparations intended for other uses (e.g., otic) 
❖ INSTALLATION OF EYE DROPS  
✓ Some products are unit of use 
✓ MYDRIATICS, Cycloplegic & anticholinergic
o to be used for one administration only and then  
medications ✓ MYDRIATICS & Cycloplegic eye
discarded medications 
✓ ATROPINE TOXICITY  1. Contact can be removed after irrigation 

✓ SYSTEMIC REACTIONS OF ANTICHOLINERGICS  3. Immediate copious irrigation for at least 30 minutes 

✓ MYDRIATICS, Cycloplegic & anticholinergic 1. After 30 minutes of irrigation, close your eyes for 5
medications ✓ ANTI-INFECTIVE EYE MEDICATIONS  minutes

2. Test Eye pH (goal is neutral pH 7.0 to 7.3) 

✓ ANTI-INFLAMMATORY EYE MEDICATIONS 
1. Continue eye irrigation until Eye pH 7.0 to 7.3 (may
✓ TOPICAL ANESTHETICS FOR THE EYE 
require up to 10 liters of irrigant) 
✓ EYE LUBRICANTS  2. If pH paper not available, irrigate for a minimum of 2
✓ MIOTICS  liters irrigant over 30 minutes 

✓ OCUSERT SYSTEM  4. Adjunctive measures  

1. Consider sweeping medial and lateral canthus for

✓ BETA-ADRENERGIC BLOCKING EYE MEDICATIONS 
crystallized chemical 
✓ ADRENERGIC EYE MEDICATIONS 
1. Use moist swab to remove debris from Conjunctival
✓ CARBONIC ANHYDRASE MEDICATIONS fornices

✓ OSMOTIC MEDICATIONS  2. May be speed neutralization pf pH 

❖ OCULAR irrigation   ❖ Precautions 

❖ Indications  ➢ Never Use acid or based to neutralize chemical burn 

➢ Chemical Eye Injury  ❖ Efficacy 

❖ Equipment  ➢ Eye irrigation reduces risk of serious Eye Injury and

dramatically reduces healing times 
1. pH paper 

2. Eye irrigation fluid (Use option that is immediately

available) 1. Preferred irrigants (liter bag – may require
up to 10 liters) 1. Normal saline or 

2. Lactated ringers 

2. Alternatives if preferred agents are unavailable 

1. Sterile water 

2. Eyewash station or equivalent water supply 

3. Irrigation device (any clean device that can direct

irrigant flow to eye) 1. Intravenous tubing 

2. Nasal canula 

3. Morgan medi-flow lens  

❖ Technique  ❖ DISORDERS OF THE EYE 

1. Pre-treat with Topical Anesthetic (if available)  ❖ Infection of The Eyelid
2. Do not delay irrigation for contact removal  ❖ Chalazion 
➢ known as a meibomian gland lipogranuloma  ❖ Causes: 

➢ is a small lump in the eyelid caused by obstruction of ➢ a Staphylococcus aureus bacterial infection 
an oil producing or meibomian gland. Chalazia may
occur in the upper or lower lids.  ➢ blocking of an oil gland at the base of the eyelash. 

Signs & symptoms:  ➢ can be triggered by poor nutrition, sleep deprivation,

lack of hygiene or rubbing of the eyes 
✓ Painless lump within the lid that may slowly increase
in size ✓ redness  ➢ Sharing of washcloths or face towels

✓ swelling and soreness in some cases  ❖ Signs and Symptoms 

✓ Eyelid tenderness   ➢ The first sign of a stye is a small, yellowish spot at the
center of the bump that develops as pus expands in the
✓ Sensitivity to light   area.  

✓ Increased tearing   ❖ Other stye symptoms may include: 

✓ Heaviness of the eyelid  ✓ A lump on the top or bottom eyelid 

✓ Signs of chalazion (meibomian cyst)  ✓ Localized swelling of the eyelid 

❖ Diagnosis:  ✓ Pain which becomes more intense if the pus ruptures

➢ Patients often request an examination after an ✓ Redness 

episode of pain and swelling of the lid. The doctor can
make the diagnosis during a simple examination of the ✓ Tenderness to touch 
eyelids.  ✓ Crusting of the eyelid margins 
❖ Treatment:  ✓ Burning in the eye 
➢ Topical antibiotic eye drops or ointment ✓ Droopiness of the eyelid 
(e.g.chloramphenicol or fusidic acid) 
✓ Scratchy sensation on the eyeball 
➢ disappear without further treatment within a few
months and virtually all will resorb within two years  ✓ Blurred vision 

➢ surgically removed using local anesthesia.  ✓ Mucous discharge in the eye 

Early stages chalazia may be treated at home with the ✓ Irritation of the eye [10] 
repeated use of warm compresses for 15 - 20 minutes
followed by several minutes of light lid massage.  ✓ Light sensitivity 

❖ Stye (Hordeolum)  ✓ Tearing 

➢ is an infection of the sebaceous glands of Zeiss at the ✓ Discomfort during blinking [11] 
base of the eyelashes, or an infection of the apocrine ✓ Sensation of a foreign body in the eye. 
sweat glands of Moll.
❖ Treatment 
➢ External styes form on the outside of the lids and can
be seen as small red bumps.   ➢ Styes can last from 1 to 2 weeks without treatment,
or as little as 4 days if treated properly. 
➢ bacterial invasion of the eyelash follicles usually
caused by staphylococci infection 

❖ Eyelid cysts 
➢ applying warm compresses on the affected eye, four ➢ Debris in the tear film, seen under magnification
to six times a day, for approximately 15 minutes. This (improved contrast with use of fluorescein drops).  
helps the drainage and fastens the curing process. 
➢ Gritty sensation of the eye. 
➢ patients may cleanse the affected eyelid with tap
water or with a mild, nonirritating soap or shampoo ❖ Seborrheic blepharitis 
(such as baby shampoo) to help clean crusted ➢ often associated with dandruff of the scalp or skin
discharge.   conditions like acne.  
➢ advised to not squeeze or puncture the stye  ➢ It can appear as greasy flakes or scales around the
➢ avoid eye makeup (e.g., eyeliner), lotions and base of the eyelashes and a mild redness of the eyelid.  
wearing contact lenses ➢ It may also result in a roughness of the normally
➢ Vibramycin, Oracea, Atridox and Adoxa- (antibiotics)  smooth tissue that lines the inside of the eyelid. 

➢ Pain relievers  ❖ Treatment: 

➢ Surgery is the last resort  ➢ Good eyelid hygiene and a regular cleaning routine
may control blepharitis  
❖ Blepharitis 
➢ This includes frequent scalp and face washing; warm
➢ is a chronic or long-term inflammation of the eyelids soaks of the eyelids; and eyelid scrubs.  
and eyelashes.  ➢ It affects people of all ages.  
➢ In cases where bacterial infection is a cause, eyelid
➢ Among the most common causes of blepharitis are hygiene may be combined with various antibiotics and
poor eyelid hygiene; excessive oil produced by the other medications.  ➢ Eyelid hygiene is especially
glands in the eyelid; a bacterial infection (often important upon awakening because debris can build up
staphylococcal); or an allergic reaction.  during sleep. 

➢ Blepharitis can appear as greasy flakes or scales ❖ Directions for A Warm Soak Of The Eyelids 
around the base of the eyelashes.
✓ Wash your hands thoroughly. 
➢ Staphylococcal blepharitis  
✓ Moisten a clean washcloth with warm water. 
❖ Complications of staphylococcal blepharitis 
✓ Close eyes and place washcloth on eyelids for about 5
❖ Signs and Symptoms:  minutes. ✓ Repeat several times daily. 

➢ Sandy, itchy eyes   ❖ Directions for An Eyelid Scrub 

➢ Red, burning and/or swollen eyelids   ➢ Wash your hands thoroughly.

➢ Mucous discharges and crusting or scaling  ➢ Mix warm water and a small amount of shampoo
that does not irritate the eye (baby shampoo) or use a
➢ Dandruff 
commercially prepared lid scrub solution recommended
➢ Loss of eyelashes and thickening of eyelid  by your optometrist. 

➢ Flaking of skin on the lids.   ➢ Close one eye and using a clean washcloth (a
different one for each eye), rub the solution back and
➢ Crusting at the lid margins, this is generally worst on forth across the eyelashes and the edge of the eyelid. 
waking.  ➢ Cysts at the lid margin (hordeolum).  
➢ Rinse with clear, cool water. 
➢ Red eye.  
➢ Repeat with the other eye. 
❖ Orbit - Inflammation 

❖ Orbital Cellulits frequently extends from adjacent

sinus infections, or periocular trauma. 

➢ A life and sight threatening emergency! Can extend

into the cavernous sinus, and brain. 

➢ Orbit - Inflammation 

❖ Signs and symptoms 

➢ sudden onset of fever  

❖ Proptosis 

➢ restricted eye movement 

➢ swelling and redness of the eye lids 

❖ Causes 

➢ previous sinusitis 

➢ infection of nearby structures 

➢ trauma  

➢ previous surgery 

❖ Prognosis and treatment 

➢ IV cefoxitin or ampicillin-sulbactam 

➢ Surgical decompression of the affected eye. 

➢ Abscess formation is another complication and may

require surgical drainage. 

➢ Orbital cellulitis is considered an ophthalmological

emergency

❖ Anatomy and Physiology of the EAR 

❖ EXTERNAL EAR 

➢ extends from the auricle through the external canal

to the tymphanic membrane or eardrum. 
➢ Embedded in the temporal bone bilaterally at the
level of the eyes. ➢ Includes the mastoid process which
is the bony ridge located over the temporal bone.  
➢ Collects sound. 
➢ Secretes cerumen which protects the tympanic
membrane.
b. The vestibular branch maintains balance and
equilibrium  
❖ HOW DO WE HEAR 
➢ Hearing with the outer ear. When the sound is made
outside the outer ear, the sound waves or vibrations
travel down- ossicles - amplify

❖ MIDDLE EAR  ❖ HEARING AND EQUILIBRIUM 

➢ Consists of the medial side of the tympanic 1. The external ear conducts sound waves to the middle
membrane ➢ Air filled chamber in temporal bone.  ear 2. The middle ear, also called the tympanic cavity,
conducts sound waves to the inner ear 
➢ Contains 3 auditory ossicles:  
3. The middle ear is filled with air which is kept at
a. Malleus   atmospheric pressure by the opening of the eustachian
tube 
b. Incus 
4. The inner ear contains sensory receptors for sound
c. Stapes 
and for equilibrium 5. The receptors in the inner ear
(Small bones) that transmit sound from the tympanic transmit sound waves and changes in body position to
membrane to the inner ear   the nerve impulses.  

❖ The tympanic membrane   ❖ INSPECTION OF THE EXTERNAL EAR 

a. Translucent and permits visualization of the middle ❖ Inspect for:  

ear
✓ • Size 
b. Separates the external ear from the middle ear  
✓ • Shape 
❖ Eustachian Tube  
✓ • Symmetry 
a. Bony Cartilaginous passageway between nasopharynx
and middle ear b. equalization of pressure on both sides ✓ • Landmarks • Color • Position • Deformity or Lesion 
of the tympanic membrane.  
❖ PALPATION 
❖ INNER EAR  Palpate auricles and mastoid area for:  
➢ Contains the semicircular canals, the cochlea, and ✓ Tenderness 
the distal end of the eighth cranial nerve. \ 
✓ Swelling 
➢ The semicircular canals contain fluid and hair cells
connected to sensory nerve fibers of the vestibular ✓ Nodules  
portion of the eighth cranial nerve. ➢ The inner ear
✓ Firmness 
maintains sense of balance or equilibrium.  ➢ The
cochlea is the spiral-shaped organ of hearing.  ❖ OTOSCOPIC EXAMINATION 

➢ The organ of Corti (within the cochlea) is the ➢ Provides illumination for examining the external
receptor and organ of hearing  auditory canal and tympanic membrane  
➢ Eighth cranial nerve  A) Have client sit comfortably with head tilted slightly
away from you 
a. The cochlear branch of the nerve transmits neuro
impulses from the cochlea to the brain where they are B) Use largest speculum that is comfortable  
interpreted as sound 
C) Grasp auricle and pull up, out, and back to straighten 4. Whispers non-sequential number (e.g. 3 5 7 ) for the
canal  client to  repeat. 

D) Hold instrument up   5. Normally the client will be able to hear and repeat
the number. 6. Repeat the procedure at the other ear 
E) Insert speculum gently down and forward into the
ear canal approximately 0.5 inches  ❖ Turning Fork Test
F) Do not touch inner portion of the canal wall with ➢ This test is useful in determining whether the client
speculum has a conductive hearing loss or a perceptive hearing
loss. There are 2 types of tuning fork test being
2) Inspect auditory canal noting: Cerumen Color Lesions
conducted 
Discharge or foreign bodies

3) Inspect the tympanic membrane for Landmarks Color ➢ WEBER TEST 

Perforations  ➢ Distinguishes between conductive and sensorineural
Inspect auditory canal noting: Cerumen Color Lesions hearing.
Discharge or foreign bodies 3) Inspect the tympanic
➢ 2) Place the vibrating fork on the middle of the
membrane  
client's head ➢ 3) Ask client if the sound is heard better
for Landmarks Color Perforations  in one ear or the same in both ears 

❖ TYMPHANIC MEMBRANE  ➢ Normal: hear sounds equally in both ears (No

Lateralization of sound)
➢ Color/shape-pearly grey, shiny, translucent, with no
bulging or retraction.  ➢ Conduction loss – Sound lateralizes to defective ear
(Heard louder on defective ear). 
2) Consistency - smooth. 
➢ Sensorineural loss – Sound lateralizes on better ear. 
3) Landmarks. 
❖ RINNE TEST 
a) Cone shaped light reflection of the otoscope light is
seen at 5:00 in the right ear and at 7:00 in the left ear.  ➢ Test compares air and bone conduction hearing. 
b) short process, malleus and umbo clearly visible.  ➢ Vibrating tuning fork placed on the mastoid process 
❖ EVALUATION OF GROSS AUDITORY ACUITY  b. Instruction client to inform the examiner when he no
longer hears the tuning fork sounding. 
➢ WHISPER TEST 
c. Position in the tuning fork in front of the client’s ear
➢ TURNING FORK TEST 
canal when he no longer hears it. 
➢ WEBER TEST 
➢ Normal: Sound should be heard when tuning fork is
➢ RINNE TEST  placed in front of the ear canal as air conduction< bone 

❖ 2 WAYS ON HOW WE HEAR SOUNDS 

❖ WATCHER’S TEST  ➢ AIR CONDUCTION- sounds, as transmitted by air 

❖ WHISPER TEST  ➢ -uses the apparatus of the ear (pinna, eardrum and
ossicles) to amplify and direct SOUNDS 
1. The examiner stands 2 ft. on the side of the ear to be
tested. 2. Instruct the client to occlude the ear canal of ➢ BONE CONDUCTION- through the mastoid 
the other ear. 3. The examiner then covers the mouth,
➢ via the MASTOID, bypasses some or all of these and
and using a soft-spoken voice, 
allows the sound to be transmitted directly to the
inner ear 
❖ WATCHER’S TEST  ➢ Spoken words is used to determine ability to hear
and discriminate sounds and words 
1. Ask the client to close the eyes. 
➢ The louder the sound perceived by the patient, the
2. Place a mechanical watch 1- 2 inches away the
greater the hearing loss 
client’s ear. 3. Ask the client if he hears anything 
❖ TYMPANOGRAM 
4. If the client says yes, the examiner should validate by
asking at what are you hearing and at what side.  ➢ also known as Impedance Audiometry
5. Repeat the procedure on the other ear. ➢ Measures middle ear muscle reflex to sound
6. Normally the client can identify the sound and at stimulation and compliance of tympanic membrane by
what side it was heard  changing the air pressure in sealed ear canal. 

❖ MIDDLE EAR ENDOSCOPY 

❖ COMMON NURSING INTERVENTION RELATED TO ➢ use of very small diameter endoscopes  

EARS
➢ done as an office procedure to evaluate suspected
1. Administration of ear drops  peri lymphatic fistula

➢ Medications of the ear should be warmed  ❖ How it is done? 

➢ Instruct patient to turn head  ➢ Tympanic membrane is anesthetized topically for 10

minutes
➢ After drops are instilled the head is kept tilted for a
few minutes ➢ External Auditory canal is irrigated with NSS 

2. Softening and removing Cerumen deposits  ➢ With aid of microscope a tympanotomy is created
with laser beam or myringotomy knife so that
➢ Daily instilling a few drops of hydrogen peroxide or endoscope can be inserted in middle ear. 
warmed glycerin
EXTERNAL EAR DISORDERS 
➢ Dose 2-3 days and then irrigate the ears  
❖ OTITIS EXTERNA 
3. Ear irrigation: 
➢ is an inflammation of the outer ear and ear canal.  
❖ DIAGNOSTIC EAR PROCEDURES 
➢ It maybe acute or chronic 
❖ AUDIOMETRY 
❖ COMMON BACTERIAL PATHOGENS 
➢ The single most important diagnostic instrument in
detecting hearing loss.  ➢ Pseudomonas 

➢ Patient wears earphones and signal to audiologist if ➢ Proteus vulgaris 

tone is heard.
➢ Streptococci 
➢ TYPES 
➢ Staphylococcus aerus 
1. Pure-Tone Audiometry 
➢ Aspergillus niger 
➢ uses musical tone 
➢ Candida Albicans 
➢ The louder the tone perceived by the patient, the
greater the hearing loss. ❖ CAUSED BY: 

2. Speech Audiometry   1. Excessive water exposure 

2. Cuts, abrasions in the lining of the ear canal  ❖ Chronic Otitis Externa: 
3. Harsh cleaning of the ear canal   ➢ Pruritus 
4. Foreign body in the ear canal   ➢ Scaling and skin thickening  
5. Lack of cerumen (ear wax  ➢ Aural discharge 
❖ PREDISPOSING FACTORS  ❖ DIAGNOSIS 
➢ Swimming in the contaminated water ❖ Physical Examination 
➢ Cleaning the ear canal with a cotton swab, bobby ❖ Otoscopy
pin, finger, or other foreign objects 
❖ In Acute Otitis Externa: 
➢ Regular use of earphones, earplugs or earmuffs 
➢ Swollen external ear canal 
➢ Chronic drainage from a perforated eardrum 
➢ Periauricular lymphadenopathy 
❖ TYPES 
❖ In Chronic Otitis Externa: 
1. Acute Otitis Externa  
➢ Thick red epithelium in the red canal 
➢ is an infection of the skin of the cartilaginous portion
of the ear canal with the involvement of the pinna and ❖ TREATMENT 
tympanic membrane 
❖ Acute Otitis Externa  
2. Chronic Otitis externa 
➢ Heat therapy to the periauricular region 
➢ inflammation of the skin lining the external ear
canal leading to the ear drum.   ➢ Analgesic 

➢ Can be caused by a number of problems including:   ➢ Instillation of antibiotic drops 

1. bacterial infection,   ➢ Cleaning of the ear 

2. a chronic skin disorder   ❖ TREATMENT 

3. Fungus   ❖ Chronic Otitis Externa  

4. chronic irritation   ➢ Cleaning of the ears 
5. chronic drainage from middle ear disease,   ➢ Supplemental therapy 
❖ SIGNS AND SYMPTOMS  ➢ Wearing specially fitted earplugs 
❖ Acute Otitis Externa:  ❖ PREVENTION 
➢ Moderate to severe pain  ✓ Decrease exposure to water 
➢ Fever  ✓ Do not insert instrument or scratch your ears 
➢ Foul-smelling aural discharge  ✓ A preventive ear drop solution  
➢ Regional cellulitis  ✓ Mineral oil ear drops  
➢ Partial hearing loss  ✓ NURSING INTERVENTION 
❖ SIGNS AND SYMPTOMS  ✓ Apply heat locally for 20 minutes 3x/day 
✓ Encourage rest   o Sensation of fullness or pain in the ear, with or
without hearing loss 
✓ Teach the client how to instill prescribed ear drops 
➢ Conductive hearing loss 
✓ Administer analgesics 
➢ Feeling of fullness in the affected ear  
✓ Instruct the client to keep the ears clean and dry  
➢ Ear noise (tinnitus)  
✓ Teach to avoid getting water in the affected ear until
fully healed ➢ Decreased hearing in the affected ear  

✓ Place two to three drops of a mixture of ❖ TYPES OF CERUMEN 

vinegar/isopropyl alcohol/water into your child's ear
❖ MANAGEMENT 
after the ears come in contact with water. ✓ Use ear
plugs for swimming or bathing  ❖ Irrigation- an initial therapy 

✓ Instruct the client that cotton-tipped applicators ➢ 2 gtts Domeboro otic gtts post irrigation 
should not be used to dry ears 
➢ Suction using a soft intravenous tubing (small
✓ Gapping earring puncture vacuum) ➢ Curette/forcep be use 
✓ Results from wearing heavy pierced earrings for a
long time or after an infection or as a reaction from the
earring or other impurities from the earring.  ❖ NURSING CARE 

✓ EAR RECONSTRUCTION  ✓ Routine assessment of the ear canal and cleaning as

necessary
❖ CERUMEN IMPACTION 
✓ Instruct not to insert hard objects in the ear canal
➢ CERUMEN IMPACTION 
✓ Stress the risk of impacting cerumen against the
➢ Earwax blockage occurs when earwax (cerumen) tympanic membrane when using cotton tipped swabs
accumulates in your ear and becomes too hard to wash (swabs may break and lodge in the canal) 
away naturally 
✓ If ear drops have been prescribed, teach how to instill
➢ CERUMEN   it. ✓ NURSING CARE 
➢ Smooth, yellow, brown ceruminal agent which helps ✓ Irrigation is C/I in clients with a hx of tympanic
in lubricating and cleaning your ears 
membrane perforation ✓ To soften cerumen, add 3 gtts
➢ Wax is secreted by the glands   of glycerin to the ear @ h.s. & 3 gtts of hydrogen
peroxide BID 
❖ CAUSES: 
✓ After several days the ear is irrigated 50-70 ml of
➢ Increase of cerumen production  solution is the maximal amount a client can tolerate
during an irrigation sitting 
➢ Often aggravated during an attempt to remove it
using cotton tipped swabs or hairpins but will just push ❖ FOREIGN BODY IN THE EAR 
wax deeper 
❖ FOREIGN BODY 
❖ SIGNS AND SYMPTOMS 
➢ refer to any object that is placed in the ear that is not
➢ Visible cerumen  meant to be there and could cause harm without
immediate medical 
➢ OTALGIA- EAR ACHE 
➢ Foreign bodies can either be in the ear lobe or in the
ear canal. 
➢ Some of the items that are commonly found in the ➢ a machine with suction to help pull the object out  
ear canal include the following: 
➢ cleaning the ear canal with water 
✓ food  
➢ DRIPPING MINERAL OIL 
✓ insects  
➢ After removal of the object, check for complications 
✓ toys  
❖ MANAGEMENT 
✓ buttons  
❖ Irrigation 
✓ pieces of crayon  
➢ may instill mineral oil or typical lidocaine drops
✓ small batteries   (insects)- contraindicated if there is TM perforation 

❖ INSECTS  ❖ Suction 

➢ Tick in external auditory canal  ➢ magnets are sometimes used if the object is metal 

✓ Insects in the ear canal  ❖ PREVENTION 

✓ Ant in the ear canal  ✓ Keep small, interesting, shiny objects out of children's
reach. 
✓ Seeds 
✓ Do not give children peanuts, popcorn, or gum until
✓ beans  age 7 as they are choking hazards until that time.  
✓ sand  ✓ Store batteries and throw out old ones in a place
❖ COMMON S/SX  where children can't each them 

✓ Pain   ✓ Teach children not to put things into body openings 

✓ Swelling   ❖ NURSING CARE 

✓ Discharge (if the object has been there for some time) ✓ If the foreign matter is vegetable, irrigation is used
with care
✓ Redness 
✓ If the foreign body is a battery, ear drops can cause
✓ deafness 
an electrical reaction
✓ Smaller children may be very fussy 
✓ Insects are killed before removal unless they can be
✓ bleeding  coaxed out by flashlight or a humming noise 

✓ Mineral oil or alcohol is instilled to suffocate the

insect which is then removed with ear forceps 

✓ Use small ear forceps to remove the object & avoid

❖ MANAGEMENT  pushing 
➢ The treatment for foreign bodies in the ear is prompt ✓ the object farther into the canal & damaging the
removal of the object by your child's physician  tympanic membrane
➢ instruments may be inserted in the ear  

➢ Alligator forceps  

➢ magnets are sometimes used if the object is metal