LECTURE SERIES NCM 104 BY: Richard Benedict S.

Roxas, RN, MD General Opthalmology Basics: OCULAR SYMPTOMATOLOGY: Objective Signs: 1. Redness of the ocular adnexae Inflammation, Allergy, or Physiological 2. Jaundice of the Eyeball Hepatitis, Inborn errors metabolism of bilirubin, Hemolysis etc. 3. Redness of the eyeball (Conjunctival/Ciliary), Congestion, Inflammation, Trauma 4. Crust, or Flakes Contact Dermatitis 5. Secretions a. Watery lacrimation, tearing (EPIPHORIA), crying, foreign bodies b. Discharges (Mucoid/Mucopurulent) Allergic conjunctivitis, Vitamin A deficiency 6. Lumps swellings, tumor, granuloma etc. Subjective Signs: 1. 2. 3. 4. 5. 6. Pain Foreign body, Inflammation, Trauma Itching, Burning Allergic, Inflammation, Foreign body Soreness or Tenderness Frontal or Temporal Headache Refractive errors, visual aura migraine Visual Disturbance General & Common symptom they visit physician Dizziness Swaying, whirling sensation (muscle palsy, disturbance vergence, visual field defects, or vestibular origin (cochlear), Hypertension 7. Poor Distant Vision Disturbance in ocular media (CORNEA, LENS, VITREOUS), DM, Retinal Detachment 8. Poor Near Vision Presbycusis 9. Spot in the Center spot on the center of visual field (macular diseases) 10. Day Blindness HEMARALOPIA (there was a formation corneal opacity at bright light), nuclear lens cataract 11. Night Blindness NYCTALOPIA (peripheral vision is contracted seen in optic atrophy, glaucoma, vitamin A deficiency) 12. Double Vision DIPLOPIA 13. Multiple Vision POLYPSIA 14. Distorted Vision METAMORPHOSIA (Astigmatism, Choroidal lesion, macular Disease)

15. Colored Vision CHROMATOPSIA (glaucoma, cataract, red vision, vitreous hemorrhage: (could be congenital X-linked Male 8% vs 0.4% Females) & acquired such as cataract & glaucoma) a. Yellow Vision Jaundice, Xanthopsia, Carbon Monoxide Poisoning b. White Vision seen in Digitalis Toxicity c. Blue Vision CYANOPSIA (after cataract extraction) d. Violet Vision IANTHENOPSIA (chorio retinal pathology) 16. Painful light (Photophobia) Seen in Inflammation conjunctivitis, mydriasis, Rabies 17. Flashes of Light PHOTOPSIA (Seeing Streaks of lights when eye is pressed, optic edema, retinal detachment) 18. Floaters Small dark particles floating in the air 19. BLINDNESS a. Total Blindness b. Gradual Progressive Blindness c. Partial Blindness Visual filed defect DIAGNOSTICS COMMONLY USED: 1. Direct Ophthalmoscopy uses Opthalmoscope device with battery & light (CORNIA, LENS, & RETINA, FUNDUS, ARTERIES, VESSELS, OPTIC NERVE) remember the room should be darkened, and on the sitting position both parties should be on eye level. 2. Indirect Ophthalmoscopy 3. Slit-Lamp Examination or BINOCULAR MICROSCOPE 4. Color Vision Testing (RED & GREEN TESTING) Polychromatic Plates 5. Amsler Grid used geometric lines grid to check macular degeneration, if pair of glasses are needed should wear it. 6. Ultrasonography, MRI Lesions in Globe or orbit, tumors, Retinal detachment etc. 7. Optical Coherence Tomography for macular diseases 8. Color Fundus Photography Retinal lesions (the pupil should be dilated that can make the visual acuity impairment for 30 min.) 9. Fluorescein Angiography Neovascularization check-ups in macular degeneration 10. Indocyanide Green Angiography evaluates choroidal vasculature that uses a per IV dye (INDOCYANIDE GREEN) 11. Tenometry (Schiotz) checks IOP (Applanation & Teno-Pen) 12. Perimetry Testing Evaluates Field of Vision

13. Visual Acuity (Snellens Chart Near Vision)

Pictures/Numbers/Letters, Jaeger Test card

RETINAL PATHOLOGY: RETINA Located in the innermost part of the eye and situated posteriorly with the optic nerve. 1. Visual Layer (PHOTORECEPTOR CONES, RODS) 2. Epithelial Layer anteriorly to the vitreous body FUNCTION OF THE RETNA: The Visual Layer a. RODS (Scotopic vision) night vision (influenced by vitamin A) (PERIPHERAL VISION) b. CONES (Photopic vision) daytime vision (PHOTORECEPTOR for color vision), located at the fovea centralis (ACUTE VISION) MULLER CELLS BLOOD SUPPLY: 1. CHRORIOCAPILLARIES 2. RETINAL ARTERIES storage of glucose (GLYCOGEN) that supplies the retina

SYMPTOMATOLOGY RELATED TO RETINAL PATHOLOGIES: 1. Visual Blurring (visual loss accompanied with macular damage) Impairement in the peripheral visual field 2. Photopsia FLASHES OF LIGHT (not the same with blow in the eye) or MOOREs LIGHTNING STREAKS 3. Sector Field Defects LOSS FIELD OF VISION , sensation of CURTAIN or FOG covering 4. Disturbance of the image shape & size METAMORPHOSIA (distorted), MACROPSIA (large image), MICROPSIA (small image) there are misalignment of the position of the visual fields 5. Nyctalopia Impairement vision at night (Vitamin A Deficiency)

READ SOMETHING ABOUT: DIABETIC RETINOPATHY

RETINAL DETACHMENT or RHEOMATOGENOUS RETINAL DETACHMENT: IS AN EMERGENCY Separation of the Retinal Epithelial layer to the Inner Sensory Layer. TYPES: a. PRIMARY (Idiopathic) usually associated with retinal tearing, or hole that leads to the inflow of vitreous fluid causing tension & pressure leads to breaking up detachment. b. SECONDARY caused by other than the retina or diseases caused the detachment (trauma, exudates (HARADA DISEASE) in the vitreous body, Tumors , etc)

SYMPTOMS: 1. Sensation of CURTAIN or SHADOW in part of the field of vision. (Affected retina only) 2. Sensations of flashes of light (PHOTOPSIA) Because of the mechanical separation stimulates in a way the Photoreceptors 3. Vision of Shower of black floaters caused by hemorrhage in the vitreous or retinal arteries. ( THESE SPOTS ARE THE EXACT SITE OF DAMAGE) 4. PAINLESS 5. SUDDEN (Can be accompanied with stressful event like HPN, TRAUMA, etc) DIAGNOSTICS: 1. OPTHALMOSCOPIC EXAM elevation of the retina and with wavy in-foldings, color grayish, Blood vessels are constricted. MANAGEMENT 1. Target the cause of damage if SECONDARY TYPE 2. SURGERY PROCEDURES: a. Scleral Buckle uses silicon band b. Pars Plana Vitrectomy uses vitrectomy instrument c. Pneumatic Retinoplexy Repair of Rhegmatogenous retinal detachment , least invasive 3. NURSING MANAGEMENT: a. Promoting SAFETY b. Promoting LESS FURTHER RETINAL DETACHMENT c. Promoting COMFORT d. Teaching about COMPLICATIONS 1. Increase IOP 2. Further Retinal Detachment

3. Endophthlmitis 4. Cataract & Glaucoma

LENS PATHOLOGIES 1. 2. OPACITY OF THE LENS (CATARACT) Opacity of the lens accompanied with visual impairement May occur in any place in the eye ANATOMICAL SITES: a. Nuclear b. Cortical c. Posterior Capsular d. Anterior Capsular e. Subcapsular 3. CLASSIFICATION OF CATARACT: a. AGE OF ONSET (Congenital, Senile, Infantile) b. SITE OF OPACITY (Nuclear, Cortical, Etc) c. MATURITY OF OPACITY (Incipient, Immature, Mature, Hypermature) d. DESCRIPTION (Punctate, Lamellar, Coralliform) 4. CAUSES OF CATARACT: a. Developmental (Congenital,Senile, Inherited, Maternal-illness related) b. Metabolic (Diabetic, Deficiency of Vitamin, Hyperthyroidism, Hypocalcemia) c. Osmotic d. Complicated (Uveitis, Rubella, Toxoplasmosis, Retinal detachment, Radiation Exposure in the Head) e. Toxic (Poisons, Corticosteroids, Miotic) f. Traumatic

SYMPTOMS: 1. CLOWDINESS OF VISION 2. Monoocular Diplopia 3. Distortion of Images (SECOND SIGHT makes to remove the eye glasses able to read news paper prints on PRESBYOPTIC Elderly) there are changes in the index refraction of the cataractous lens MANAGEMENT: 1. Control & Treat the underlying cause 2. SURGERY Remove the Cataract a. Discission

b. c. d. e. f. g.

Needling Capsulectomy Phacoemulcification Lensectomy Intracapsular Cataract Extraction Extracapsular Cataract Extraction Absence of Crystalline lens must wear APHAKIC GLASSES

APHAKIC PATIENT

3. NURSING MANAGEMENT: a. Providing Preoperative Care b. Providing Postoperative Care c. SELF CARE TEACHING STRATEGIES (home care checklist) OCULAR MOTILITY 3 Pairs Types of Extraocular Muscles that connects with GLOBE/EYE BALL 1. 2 Horizontal Rectus Muscles (Lateral, Medial) 2. 2 Vertical Rectus Muscles (Superior, Inferior) 3. 2 Oblique Muscles (Superior & Inferior) CN III (OCULOMOTOR NERVE) ALL MUSCLES (NOT LATERAL RECTUS) IV (TROCHLEAR) SUPERIOR OBLIQUE CN VI (ABDUCENS) LATERAL RECTUS ONLY 2 CILIARY ARTERIES SUPPLY EACH MUSCLES (1 only in Lateral Rectus) CN

OCULAR MOVEMENTS: 1. 2. 3. 4. 5. 6. ABDUCTION MEDIAL RECTUS ADDUCTION LATERAL RECTUS ELEVATION SUPERIOR RECTUS DEPRESSION INFERIOR RECTUS EXTORTION INFERIOR OBLIQUE + MEDIAL RECTUS INTORTION SUPERIOR OBLIQUE + MEDIAL RECTUS ORTHOPHORIA NORMAL MUSCLE BALANCE (no deviation) OCULAR DEVIATION (STRABISMUS)

Disorders Related to Motility Problems:

1. Heterophoria failure of fusion mechanism that alignment of both eye parallel is not achieved 2. Esotropia Most common (congenital, errors in vision ) 3. Paralytic or Non-comitant strabismus (Infectious cause)

EFFECTS of DEVIATIONS: 1. Position of the eyeball are not aligned that could disfigure appearance 2. Vision are not aligned & can cause double vision lead to accidents Diagnostics: 1. 2. 3. 4. Visual Acuity (E-chart & or Picture Chart) Prism Reflex test Hirschberg Test Ambyoscope

Treatment: 1. Correction of Causative Factor (Trauma, Infections) Paralytic Type 2. Covering 1 eye prevents diplopia 3. Surgery Correcting the paralyzed muscle (HUMMELSHEIM OPERATION) OCULAR THERAPEUTICS: COLOR CODING on the Caps: Blue White Yellow Green Red Antimicrobials Steroids Anesthetic Miotic Mydriatic

Difference Between Solution & Ointment Topical Medications a. b. c. d. Diffusion Rate: Ointment has slower effect, while Solution has rapid effect Effectivity Rate: Ointment has prolonged action , while shorter in solution Time Duration: Ointment 6 8 hours, while Solution has 1-3 hours Visual Disturbance: Produces visual disturbance in ointment , while none in solution