Surgical Procedures

SURGICAL PROCEDURES
IRIDECTOMY
DEFINITION: An iridectomy is a procedure in eye surgery in which the surgeon removes a small, full-thickness piece of the iris, which is the colored circular membrane behind the cornea of the eye. An iridectomy is also known as a corectomy. In recent years, lasers have also been used to perform iridectomies. PURPOSE: Today, an iridectomy is most often performed to treat closed-angle glaucoma or melanoma of the iris. An iridectomy performed to treat glaucoma is sometimes called a peripheral iridectomy, because it removes a portion of the periphery or root of the iris. In some cases, an iridectomy is performed prior to cataract surgery in order to make it easier to remove the lens of the eye. This procedure is referred to as a preparatory iridectomy. DESCRIPTION: 1. Laser Iridectomy. A person who is at risk for an acute episode of closed-angle glaucoma or who has already had emergency medical treatment for an attack may be treated with a laser iridotomy to reduce the level of fluid pressure in the affected eye. The drawback of a laser iridotomy in treating closed-angle glaucoma is that the hole may not remain open, requiring repeated iridotomies, a laser iridectomy, or a surgical iridectomy. In addition, laser iridotomies have a higher rate of success when used preventively rather than after the patient has already had an acute attack. 2. Coventional Surgical Iridectomy. Melanoma of the iris is usually treated by surgical iridectomy to prevent the tumor from causing secondary closed-angle glaucoma and from spreading to other parts of the body. A surgical iridectomy is a more invasive procedure that requires an operating room . The patient lies on an operating table with a piece of sterile cloth placed around the eye. The procedure is usually done under general anesthesia. The surgeon uses a microscope and special miniature instruments to make an incision in the cornea and remove a section of the iris, usually at the 12 o'clock position. The incision in the cornea is self-sealing. NURSING RESPONSIBILITIES: 1. Patient education is important, since the majority of patient’s will recuperate at home without the aid of direct nursing supervision. 2. Written materials, audiovisual presentations, and formal education sessions in which questions and / or concerns can be addressed will alleviate anxiety associated with surgical event.

3. Allow the nurse to strengthen any postoperative instruction for the patient and family. 4. The patient should be well informed about the specific agents prescribed during the recovery period and notify the physician concerning any problems associated with the agents.

ENUCLEATION
DEFINITION: Enucleation is the surgical removal of the eyeball that leaves the eye muscles and remaining orbital contents intact. PURPOSE: Enucleation is performed to remove largesized eye tumors or as a result of traumatic injury when the eye cannot be preserved. In the case of tumors, the amount of radiation required to destroy a tumor of the eye may be too intense for the eye to bear. Within months to years, many patients who are treated with radiation for large ocular melanomas lose vision, develop glaucoma, and eventually have to undergo enucleation. The two types of eye tumors that may require enucleation are: 1. Intraocular eye melanoma. This is a rare form of cancer in which malignant cells are found in the part of the eye called the uvea, which contains cells called melanocytes that house pigments. When the melanocytes become cancerous, the cancer is called a melanoma. If the tumor reaches the iris and begins to grow, or if there are symptoms, enucleation may be indicated. 2. Retinoblastoma. Retinoblastoma is a malignant tumor of the retina. The retina is the thin layer of tissue that lines the back of the eye; it senses light and forms images. If the cancer occurs in one eye, treatment may consist of enucleation for large tumors when there is no expectation that useful vision can be preserved. If there is cancer in both eyes, treatment may involve enucleation of the eye with the larger tumor, and radiation therapy for the other eye. DESCRIPTION: Following anesthesia, the surgeon measures the dimensions of the eye globe, length of the optic nerve, and horizontal dimensions of the cornea. The surgeon then illuminates the globe of the eye before opening it. A dissecting microscope is used to detect major features and possible minute lesions. The eye is opened with a sharp razor blade by holding the globe with the left hand, cornea down against the cutting block, and holding the blade between the thumb and middle finger of the right hand. Enucleation proceeds with a sawing motion from back to front. The plane of section begins adjacent to the optic nerve and ends at the periphery of the cornea. The plane of section is

dependent on whether a lesion has been detected. If not, the globe is cut along a horizontal plane, using as surface landmarks the superior and inferior oblique insertions and the long postciliary vein. If a lesion has been found, the plane of section is modified so that the lesion is included in the slab RISK: Enucleation surgery is very safe; only rarely do patients experience major complications. Complications include the following: bleeding, infection, scarring, persistent swelling, pain, wound separation, and the need for additional surgery. Complications may also occur with the orbital implants routinely used with patients who have undergone enucleation. Among these is the risk of infection. NURSING CONSIDERATION: 1. Review the procedure with the patient and family members. 2. Describe postoperative expectations in detail. 3. Begin teaching preoperatively in care of enucleated eye socket and prosthesis. a. Inspecting the eye and lid b. Instilling medication c. Irrigating site to remove mucus d. Removing the prosthesis e. Using aseptic technique when performing procedures 4. Assess fear and anxiety associated with loss of body part. 5. Advise patient and family of support systems available, and make appropriate referrals. 6. Prepare the patient for surgery, and give preoperative medications as ordered. Postoperative Management and Nursing care 1. Instill medications, usually antibiotic and steroid ointments, to prevent infection. 2. Apply pressure/ice dressings as ordered to reduce swelling. 3. Irrigate conformer area to reduce mucus. 4. Cleanse eyelid to reduce chance of infection 5. Assist patient in adjusting to body image change. 6. Assist patient in adjusting to monocular vision— especially with loss of peripheral vision and depth perception. 7. Review that in 4 to 6 weeks after surgery, the patient will receive an ocular prosthesis. COMPLICATIONS: 1. Infection 2. Hemorrhage 3. Implant extrusion

Partial-thickness-lamellar  Fresh cornea is preferred tissue; it is removed from donor within 12 hours after death and used within 24 hours.  Special solutions for storage of fresh cornea are available, which may extend storage up to 3 days.  Cryopreservation is the care and handling of corneal graft by freezing to retain its transparency. Preoperative Management and Nursing Care: 1. Discuss psychological, cultural, and spiritual concerns with patient and health care personnel 2. Advise patient that the surgery is usually performed under local anesthesia and that he or she will be awake and must remain still during procedure. 3. Cleanse the face thoroughly with antibacterial solution as ordered. 4. Administer preoperative medications as ordered. Postoperative Management and Nursing Care 1. Assess for: a. Anxiety b. Security of the eye patch- patch helps protect the eye from disruption of sutures or injury due to increased inflammation. c. Level of discomfort d. Bladder and bowel Habits e. Activity 2. Administer medication as prescribed 3. Prevent infection- use aseptic technique with medication administration and dressing change. 4. Instruct patient to avoid touching dressing and eyes. Complications 1. Hemorrhage 2. Graft dislocation 3. Infection 4. Postoperative glaucoma 5. Graft rejection- may occur 10 to 14 postoperatively, signs and symptoms include decreased vision, ocular, irritation, corneal edema, red sclera.
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MASTOIDECTOMY
Removal of mastoid process of temporal bone 1. Simple- performed through the ear with a tympanoplasty. 2. Modified or radical- wide excision of the mastoid and diseased middle ear contents through an occipital incision. 3. Preoperative Management 4. Hearing function is fully evaluated. 5. Antibiotics are given to treat infection.

KERATOPLASTY OR CORNEAL TRANSPLANTATION
Description: The transplantation of a donor cornea, usually obtained at autopsy, to repair a corneal scar, burn deformity, or dystrophy. TYPES OF GRAFTS: 1. Full thickness (6.5-8mm)- most common

Postoperative management:

1. Antibiotics may be continued to prevent local and central nervous system infection. 2. Bed rest may be maintained for the first 24 hrs. or longer to decrease symptoms of nausea and vertigo 3. Analgesics, antiemetic’s, and antihistamines are given as needed 4. The patient is positioned to promote drainage but maintain some immobility. 5. Packing maybe removed up to 6 days postoperatively if prosthesis or graft procedure was performed. 6. Hearing will be reevaluated after edema has subsided and healing has occurred.

9. Instill solution drop by drop, then, allow it to flow into canal.This will allow the medicine to flow into the side of the canal before instilling the next drop. 10. Instruct the patient to maintain his position for 15-20 minutes after which time a cotton plug is place in the external ear. This position will insure the effective instillation of medicine. 11. Always have patient assume desired position comfortable to him/her. EXTERNAL AUDITORY CANAL IRRIGATION PURPOSE: Irrigation of the ear is the process of cleansing the external auditory canal of the patient. INDICATIONS: To relieve inflammation and congestion.It also aid in the removal or cerumen or foreign bodies from the external auditory canal. NURSING RESPONSIBILITIES: 1. Discuss with patient the process of treatment to be done. 2. Screen the unit for the privacy of the patient. 3. Take the tray to the beside, then wash hand to maintain cleanliness. 4. Place the patient from getting or a dorsal recumbent position with his/her head turned to the side to be irrigated. Note that the gravity causes irrigating solution to flow from ear to the basin. 5. Protect the patient from getting wet by way of adjusting rubber sheet and towel on the side to be irrigated. Put emesis basin on the towel. If the patient is able to help, he/she may be asked to hold the emesis basin. 6. Fill the bulb with solution. When an irrigating can is used, the level of the can must not be more than 6 inches above the ear level. 7. Pull the auricle to form a straight canal (If a child pull auricle down and back; if an adult up and back). This position will facilitate the flow of liquid. 8. Direct the stream of solution gently against the external canal wall, not against the tympanic membrane. Rotate the tip and maintain a continuous even flow of the solution. Minimum force must be used in administering the solution to avoid introducing infectious materials into the mastoid cells and prevent injury to the tympanic membrane. 9. Irrigate until the return flow of the solution is clear or until desired amount of solution has been used.

TYMPANOPLASTY
Reconstruction of diseased of deformed middle ear components: 1. Type I (myringoplasty)- purpose is close perforation by placing a graft over it in order to create a close middle ear to improve hearing and decrease risk of infection and cholesteatoma. Perforation is closed using one of the following.  Fascia from temporalis muscle  Vein grafts from hand or forearm  Epithelium from auditory canal (Eustachian tube) 2. Type II-V—suitable replacement (polyethylene, stainless wire, bone, cartilage) is used to maintain continuity of conduction sound pathway. The necessity of a two-stage procedure.

SPECIAL PROCEDURE
INSTILLATION OF OTIC SOLUTION
PURPOSE: This process is done to relieve pain in the patient’s ear.It will also soften hardened cerumen for easier cleansing. NURSING RESPONSIBILITIES: 3. Inform the patient of the treatment to be done to her/him.Then provide the patient privacy in the whole process. 4. Wash hands and take tray to the bedside. 5. Place patient in a dorsal recumbent position with the head turned to expose the ear to be treated. 6. Wipe the ear canal with a cotton applicator and discard it to the emesis basin. Removing discharge from canal before instillation will allow medicine to be introduced in canal more effectively. 7. Draw the required amount of medicine into the dropper. 8. Hold the auricle up and back to form a straight canal. This position will facilitate introduction of medicine into ear

HEARING AID DEVICE
PURPOSE: Recent technology can help most people with hearing loss understand speech better and achieve better communication.

INDICATION: 1. When the primary auditory cortex does not receive regular stimulation, this part of the brain loses cells which process sound. Cell loss increases as the degree of hearing loss increases. 2. Damage to the hair cells of the inner ear results in sensorineural hearing loss, which affects the ability to discriminate between sounds. This often manifests as a decreased ability to understand speech, and simply amplifying speech (as a hearing aid does) is often insufficient to improve speech perception. NURSING RESPONSIBILITIES: 1. Wipe aids regularly with a dry cloth or tissue. 2. Hearing aids should never be exposed to extreme heat. 3. Advice patient to keep them in the case provided when not wearing them. 4. Advice patient to keep your hearing aids away from pets. They like to chew them.

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Cryosurgery- a special technique in which a pencil-like instrument with metal tip is supercooled (-35°c), then is touched to the exposed lens, freezing to it so the lens is easily lifted out. Phacoemulsification

NURSING INTERVENTIONS: 1. Preparing the patient for surgery  Orient patient and explain procedures and plan of care to decrease anxiety. 2. Preventing Complications Postoperatively  Medicate for pain as prescribed to promote comfort  Administer medication to prevent nausea and vomiting as needed  Notify health care provider 3. Promoting Independence  Advise patient to increase activities as tolerated unless given restrictions by the surgeon  Instruct patient and family in proper eyedrop or ointment instillation

DISTURBANCES IN VISUAL PERCEPTION BLINDNESS
CATARACT
Clouding or opacity of the crystalline lens that impairs vision. PATHOPHYSIOLOGY AND ETIOLOGY: 1. Senile cataract- commonly occurs with aging 2. Congenital cataract- occurs at birth 3. Traumatic cataract- occurs after injury 4. Aphakia- absence of crystalline lens 5. Additional risk factors for cataract formation include diabetes; ultraviolet light exposure; high dose radiation; and drugs such as corticosteroids, phenothiazines, and some chemotherapy agents. CLINICAL MANIFESTATION: 1. Blurred or distorted vision 2. Glare from bright lights. 3. Gradual and painless loss of vision 4. Previously dark pupil may appear milky or white. DIAGNOSTIC EVALUATION: 1. Slit lamp examination- to provide magnification and visualize opacity of lens 2. Tonometry- to determine IOP and rule out other conditions 3. Direct and Indirect ophthalmoscopy to rule out retinal disease 4. Perimetry- to determine the scope of visual field. TREATMENT: 1. Intraocular Lens Transplantation 2. Surgical Procedures  Intraocapsular extraction  Extracapsular extraction

ACUTE (ANGLE-CLOSURE) GLAUCOMA
A condition in which an obstruction occurs at the access to the trabecular meshwork and canal of Schelmm. Intraocular pressure is normal when the anterior chamber angle is open, and glaucoma occurs when a significant portion of the angle is closed. Glaucoma is associated with progressive visual field loss and eventual blindness is allowed to progress. Tis is most often and acute painful condition not be confused with chronic open-angle glaucoma. PATHOPHYSIOLOGY AND ETIOLOGY: Mechanical blockage of anterior chamber angle results in accumulation of aqueous humor. CLINICAL MANIFESTATIONS: 1. Pain in and around eyes due to increased ocular pressure; may be transitory attacks. 2. Rainbow of color (halos) around lights 3. Vision becomes cloudy and blurred 4. Pupil mild-dilated and fixed 5. Nausea and vomiting may occur 6. Hazy appearing cornea due to corneal edema DIAGNOSTIC EVALUATION: 1. Tonometry- elevated IOP, usually greater than 50mm Hg. 2. Ocular examination may reveal a pale optic disk 3. Gonioscopy- to study angle of the anterior chamber of the eye. MEDICATIONS: 1. Parasympathomimetic drugs 2. Carbonic anhydrase inhibitor- restricts action of enzyme that is necessary to produce aqueous humor. 3. Beta blockers- may reduce production of aqueous humor or may facilitate outflow of aqueous humor. 4. Hyperosmotic agents- to reduce intraocular pressure by promoting diuresis.

SURGICAL PROCEDURES 1. Peripheral Iridectomy 2. Trabeculectomy 3. Laser iridectomy 4. Retinal cryopexy 5. Scleral buckling NURSING INTERVENTIONS: 1. Relieving Pain 2. Relieving Fear

TREATMENT: 1. Photocoagulation 2. Electrodiathermy 3. Cryosurgey 4. Retinal cryopexy 5. Scleral buckling

INFLAMMATORY DISTURBANCES
IRITIS
Iritis (i-RYE-tis) is inflammation that affects a part of your eye called the iris. The iris is the colored ring of tissue surrounding your pupil. It's part of the middle layer of the eye known as the uvea, which is why this condition is considered a type of uveitis (u-ve-Itis), or inflammation of the uvea. Because the iris is located at the front of the uvea, iritis is sometimes called anterior uveitis. CAUSE: Known causes of iritis include: 1. Injury to the eye 2. Infections 3. Genetic predisposition 4. Behcet's disease 5. Juvenile rheumatoid arthritis 6. Posterior uveitis SIGNS AND SYMPTOMS: 1. Eye redness, often seen as a bluish-pink color in the white of your eye (sclera) around the iris 2. Discomfort or achiness in the affected eye 3. Sensitivity to light (photophobia) 4. Blurred vision 5. Floating spots in your vision (eye floaters) DIAGNOSTIC TEST/ EXAMS: 1. External examination. During an external exam, your doctor may use a penlight to look at your pupils, observe the pattern of redness in your eye or eyes, and check for signs of discharge. 2. Visual acuity. Using an eye chart and other standard tests. 3. Slit-lamp examination. Using a special microscope with a light on it, your eye doctor views the inside of your eye looking for signs of iritis, including the presence of white blood cells or hazy protein deposits (flare). Glaucoma testing. During a glaucoma test, the pressure in your eyes (intraocular pressure) is measured. Elevated intraocular pressure indicates that you may have glaucoma. TREATMENT: 1. Most often, treatment for iritis involves: 2. Steroid eyedrops. Glucocorticoid medications, given as eyedrops, reduce inflammation associated with iritis. They work by stabilizing cell membranes in your eye and minimizing the circulation of white blood cells and other byproducts of the inflammatory process. 3. Dilating eyedrops. Cycloplegics are medicines that dilate your pupil. Given as eyedrops, they can reduce pain associated with iritis. Dilating

CHRONIC (OPEN-ANGLE) GLAUCOMA
Open angle glaucoma makes up 90% of primary glaucoma cases, and its incidence increases with age. Incidence with chronic open-angle--- 2% at age 40, 7% at age 70, 85 at age 80. PATHOPHYSIOLOGY AND ETIOLOGY: Degenerative changes occur in the trabecular meshwork and canal of Schlemm, causing microscopic obstruction. CLINICAL MANIFESTATIONS: 1. Mild, bilateral discomfort 2. Slowly developing impairment of peripheral vision 3. Progressive loss of visual field 4. Halos may be present around lights with increased ocular pressure. NURSING ASSESSMENT : 1. Assess frequency, duration, severity of visual symptoms. 2. Assess patient’s knowledge of disease process and anxiety about diagnosis 3. Assess patients motivation to participate in long term treatment. TREATMENT: 1. Laser trabeculoplasty 2. Iridencleisis 3. Cyclodiathermy 4. Cornealscleral Trephine

RETINAL DETACHMENT
Detachment of the sensory area of the retina (rods and cones) from the pigmented epithelium of the retina. A break in continuity of the retina may first occur from small degenerative holes and tears, which may lead to detachment. PATHOPHYSIOLOGY” Spontaneous detachment may occur due to degenerative changes in retina or vitreous. CLINICAL MANIFESTATION 1. Retinal detachment may occur slowly or rapidly, but without pain 2. The patient complains of flashes of light or blurred sooty vision due to stimulation of the retina by vitreous pull. 3. Delineated areas of vision may be blank DIAGNOSTIC EVALUATION: Indirect ophthalmoscopy shows gray or opaque retina.

eyedrops also protect you from developing adhesions underneath your iris, which can lead to potential complications, including glaucoma. 4. Antibiotic eyedrops. If your iritis is caused by a bacterial infection, your doctor will prescribe antibiotic eyedrops.

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Surgery. Vitrectomy — surgery to remove some of the jelly-like material in your eye (vitreous) — may be necessary both for diagnosis and management of your uveitis. A small sample of the vitreous can help identify a specific cause of eye inflammation, such as a virus or bacterium.

UVEITIS
Uveitis is inflammation of the uvea, the vascular layer of the eye sandwiched between the retina and the white of the eye (sclera). The uvea extends toward the front of the eye and consists of the iris, choroid layer and ciliary body. The most common type of uveitis is an inflammation of the iris called iritis (anterior uveitis). CAUSE: 1. Autoimmune disorders, such as rheumatoid arthritis or ankylosing spondylitis 2. Inflammatory disorders, such as Crohn's disease or ulcerative colitis 3. Infections such as cat-scratch disease, herpes, syphilis, toxoplasmosis, tuberculosis or West Nile virus 4. Eye injury 5. Certain cancers, such as lymphoma, that have an indirect effect on the eye SIGNS AND SYMPTOMS: 1. Eye redness 2. Eye pain 3. Light sensitivity 4. Blurred vision 5. Dark, floating spots in your field of vision (floaters) 6. Decreased vision 7. Whitish area (hypopyon) inside the lower part of the colored area of the eye (iris) DIAGNOSTIC TEST/ EXAMS: 1. Complete eye exam and gather a thorough health history TREATMENT: 1. Anti-inflammatory medication. Your doctor may prescribe anti-inflammatory medication, such as a corticosteroid, to treat your uveitis. This medication may be given as eyedrops. Your doctor could also administer a corticosteroid by pill or by injection into the eye. For people with difficult-to-treat posterior uveitis, a device that's implanted in your eye may be an option. This device slowly releases corticosteroid medication into your eye for about 2 1/2 years. 2. Antibiotic or antiviral medication. If uveitis is caused by an infection, antibiotics, antiviral medications or other medicines may be given with or without corticosteroids to bring the infection under control. 3. Immunosuppressive or cytotoxic medication. Immunosuppressive or cytotoxic agents may become necessary if your uveitis responds poorly to corticosteroids or becomes severe enough to threaten your vision.

KERATITIS
Keratitis is an inflammation of the cornea — the clear, dome-shaped tissue on the front of your eye that covers the pupil and iris. Keratitis may or may not involve an infection. Noninfectious keratitis can be caused by a relatively minor injury, such as a fingernail scratch, or from wearing your contact lenses too long. Infectious keratitis can be caused by bacteria, viruses, fungi and parasites. CAUSE: 1. Eye Injury. 2. Contaminated contact lenses. 3. Viruses ( herpes virus and the virus that causes Chlamydia) 4. Contaminated water. SIGNS AND SYMPTOMS: 1. Eye redness 2. Eye pain 3. Excess tears or other discharge from your eye 4. Difficulty opening your eyelid because of pain or irritation 5. Blurred vision 6. Sensitivity to light (photophobia) 7. An itchy, burning or gritty feeling in your eye 8. Swelling around the eye 9. A feeling that something is in your eye DIAGNOSTIC TEST/ EXAMS: 1. Eye exam. Although it may be uncomfortable to open your eyes for the exam, it's important that an eye examination be done. The exam will include an effort to determine how well you can see (visual acuity), usually using standard eye charts. 2. Slit-lamp exam. The light from the slit lam allows your doctor to view these structures with high magnification to detect the character and extent of keratitis, as well as the effect it may have on other structures of the eye. 3. Laboratory analysis. Your doctor may take a sample of tears or some cells from your cornea for laboratory analysis to determine the cause of keratitis and how best to treat it. TREATMENT: 1. Noninfectious. Treatment of noninfectious keratitis varies depending on the cause. However, for uncomplicated cases in which, for example, keratitis is caused by a scratch or prolonged contact lens wear, a 24-hour eye patch and topical eye medications often may be all that's necessary. 2. Infectious. Treatment of infectious keratitis varies, depending on the cause of the infection.  Bacterial keratitis. For mild bacterial keratitis, antibacterial eyedrops may be all

you need to effectively treat the infection. If the infection is moderate to severe, you may need to take oral antibiotics to get rid of the infection. It may also be necessary to use corticosteroid eyedrops to reduce the inflammation of bacterial keratitis.  Fungal keratitis. Keratitis caused by fungi typically requires antifungal eyedrops and oral antifungal medication.  Viral keratitis. If a virus is causing the infection, antiviral eyedrops and oral antiviral medications may be effective. But these medications may not be able to eliminate the virus completely, and viral keratitis may come back in the future.  Acanthamoeba keratitis. Keratitis that's caused by the tiny parasite acanthamoeba can be difficult to treat. Antibiotic eye drops may be helpful, but some acanthamoeba infections are resistant to medication. Severe cases of acanthamoeba keratitis often require a corneal transplant (keratoplasty). 3. Surgery. If keratitis doesn't respond to medication, or if it causes permanent damage to the cornea that significantly impairs your vision, your doctor may recommend a corneal transplant.

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Examining your eyelids. Your doctor will carefully examine your eyelids and your eyes. He or she may use a special magnifying instrument during the examination.

BLEPHARITIS
Blepharitis (blef-uh-RI-tis) is inflammation that affects the eyelids. Blepharitis usually involves the part of the eyelid where the eyelashes grow. Blepharitis occurs when tiny oil glands located near the base of the eyelashes malfunction. This leads to inflamed, irritated and itchy eyelids. CAUSE: 1. Seborrheic dermatitis — dandruff of the scalp and eyebrows 2. A bacterial infection 3. Malfunctioning oil glands in your eyelid 4. Rosacea — a skin condition characterized by facial redness 5. Allergies, including allergic reactions to eye medications, contact lens solutions or eye makeup 6. Eyelash mites SIGNS AND SYMPTOMS: 1. Watery eyes 2. Red eyes 3. A gritty, burning sensation in the eye 4. Eyelids that appear greasy 5. Itchy eyelids 6. Red, swollen eyelids 7. Flaking of the skin around the eyes 8. Crusted eyelashes upon awakening 9. Sensitivity to light 10. Eyelashes that grow abnormally (misdirected eyelashes) 11. Loss of eyelashes DIAGNOSTIC TEST/ EXAMS

Swabbing skin for testing. In certain cases, your doctor may use a swab to collect a sample of the oil or crust that forms on your eyelid. This sample can be analyzed for bacteria, fungi or evidence of an allergy. TREATMENT: 1. Cleaning the affected area regularly. Cleaning your eyelids with a warm washcloth can help control signs and symptoms. Self-care measures may be the only treatment necessary for most cases of blepharitis. 2. Antibiotics. Eyedrops containing antibiotics applied to your eyelids may help control blepharitis caused by a bacterial infection. In certain cases, antibiotics are administered in cream, ointment or pill form. 3. Steroids eyedrops or ointments. Eyedrops or ointments containing steroids can help control inflammation in your eyes and your eyelids. 4. Artificial tears. Lubricating eyedrops or artificial tears, which are available over-the-counter, may help relieve dry eyes. 5. Treating underlying conditions. Blepharitis caused by seborrheic dermatitis, rosacea or other diseases may be controlled by treating the underlying disease.
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CONJUNCTIVITIS
Pink eye (conjunctivitis) is an inflammation or infection of the transparent membrane (conjunctiva) that lines your eyelid and part of your eyeball. Inflammation causes small blood vessels in the conjunctiva to become more prominent, which is what causes the pink or red cast to the whites of your eyes. CAUSE: 1. Viruses 2. Bacteria 3. Allergies 4. A chemical splash in the eye 5. A foreign object in the eye 6. In newborns, a blocked tear duct SIGNS AND SYMPTOMS: 1. Redness in one or both eyes 2. Itchiness in one or both eyes 3. A gritty feeling in one or both eyes 4. A discharge in one or both eyes that forms a crust during the night 5. Tearing DIAGNOSTIC TEST/ EXAMS: To determine whether you have pink eye, your doctor may examine your eyes. Your doctor may also take a sample of eye secretions from your conjunctiva for laboratory analysis to determine which form of infection you have and how best to treat it.

TREATMENT: 1. Treatment for bacterial conjunctivitis If your infection is bacterial, your doctor may prescribe antibiotic eyedrops as pink eye treatment, and the infection should go away within several days. Antibiotic eye ointment, in place of eyedrops, is sometimes prescribed for treating bacterial pink eye in children. An ointment is often easier to administer to an infant or young child than are eyedrops, though the ointment may blur vision for up to 20 minutes after application. 2. Treatment for viral conjunctivitis There is no treatment for most cases of viral conjunctivitis. Instead, the virus needs time to run its course — up to two or three weeks. Antiviral medications may be an option if your doctor determines that your viral conjunctivitis is caused by the herpes simplex virus. 3. Treatment for allergic conjunctivitis If the irritation is allergic conjunctivitis, your doctor may prescribe one of many different types of eyedrops for people with allergies. These may include antihistamines, decongestants, mast cell stabilizers, steroids and anti-inflammatory drops. You may also reduce the severity of your of allergic conjunctivitis symptoms by avoiding whatever causes your allergies, when possible. NURSING CARE: 1. Provide education on conjunctivitis and eye care. 2. Instruct the patient about hygiene eg. Washing of hands and not rubbing/touching eyes. 3. Reassure patient that the condition is selflimiting.

TREATMENT: 1. First Aid Treatment  It is important to apply first-aid treatment immediately upon receiving an eye injury.  Seek emergency medical attention immediately.  Immediately apply ice or a cold compress for 15 minutes to reduce swelling and minimize pain. Do not press on the eye itself. Repeat every 1 to 2 hours for the first 48 hours.  If there is still tenderness after 48 hours, apply a warm compress every 1-2 hours.  For pain, take acetaminophen. Do not take aspirin or nonsteroidal anti-inflammatory medications like ibuprofen because these drugs can cause or increase bleeding. 2. Medical Treatment While many eye injuries are fairly minor and will heal within two weeks with basic first-aid, there is always the risk of more serious consequences, so you should still see an eye doctor immediately, even if you have no symptoms. This is especially urgent if a blow to the eye causes blood to appear in your eye, loss or change in vision, double vision, inability to move the eye normally, or severe pain in your eyeball. Depending on the extent of your injury, your doctor may provide further medical treatment.

HYPHEMA
Hyphema is blood in the front area of the eye. CAUSES: Hyphema is usually caused by trauma to the eye. Other causes of bleeding in the front chamber of the eye include: 1. Blood vessel abnormality 2. Cancer of the eye 3. Severe inflammation of the iris CLINICAL MANIFESTATIONS: 1. Bleeding in the front portion of the eye 2. Eye pain 3. Light sensitivity 4. Vision abnormalities EXAMS AND TESTS: 1. Eye examination 2. Intraocular pressure measurement (tonometry) 3. Ultrasound testing TREATMENT: 1. In some mild cases, no treatment is needed. The blood is absorbed in a few days. 2. The health care provider may recommend bed rest, eye patching, and sedation to reduce the likelihood of recurrent bleeding. 3. Eye drops to decrease the inflammation or lower the intraocular pressure may be used if needed.

EYE TRAUMA
BLUNT CONTUSION
An eye contusion is a bruise around the eye, commonly called a black eye. It may occur when a blow is sustained in or near the eye socket. If a bruise appears, it will usually do so within 24 hours of the injury. CAUSES: After being struck in the eye or nose, blood leaks into the area surrounding the eye. CLINICAL MANIFESTATIONS: A black and blue or purple mark will appear following the injury. There may also be redness, swelling, and tenderness or pain. Once it begins to heal, the contusion may turn yellow. EXAMS AND TEST: Eye contusions are diagnosed visually. Healthcare providers assume that the eye has been struck in some way or another. Most people are able to self-diagnose a contusion, but a doctor may confirm the diagnosis.

4. The ophthalmologist may need to remove the

blood, especially if the intraocular pressure is severely increased or the blood is slow to absorb again. You may need to stay in a hospital.

ORBITAL FRACTURE
A break in one of the bones that make up the orbit. Since the orbit is the seat of the globe (the eye), an orbital fracture can be a serious, sightthreatening break. CAUSES: 1. Sports injuries such as being struck by a ball in the face. 2. Being hit by a blunt object such a bat or fist 3. Automobile accidents 4. Striking you face on an objecty during a fall. CLINICAL MANIFESTATIONS: 1. Sunken eye (enophthalmos) 2. Altered sensation beneath the affected eye 3. Double vision, particularly with upward gaze TREATMENT Your treatment will depend on the severity and location of your injury. For a small, uncomplicated blowout fracture that does not affect the movement of your eye, your doctor may prescribe ice packs, decongestants and an antibiotic to prevent infection. You also may be told to rest for a few days and to avoid blowing your nose while the eye heals. If the fracture is more severe, your doctor will refer you to a plastic and reconstructive surgeon who specializes in treatment of eye injuries. This specialist will determine whether you need surgery to repair the broken bone. Surgery may be needed to: 1. Remove bone fragments 2. Free trapped eye muscles and eliminate double vision 3. Restore the normal architecture of the eye socket if your injured eye looks sunken in 4. Repair deformities of the eye rim that affect your appearance FOREIGN BODY A foreign body is an object in your eye that shouldn’t be there, such as wood chip, metal shaving, insect, or piece of glass. The common places to find a foreign body are under the eyelid or on the surface of your eye. CLINICAL MANIFESTATIONS: 1. Sharp pain in eye followed by burning and irritation 2. Feeling that there is something in the eye 3. Watery and red eye 4. Scratchy feeling when blinking 5. Blurred vision or loss of vision in the affected eye 6. Sensitivity to bright lights 7. Bleeding into the white of the eye (subconjunctival hemorrhage)

TREATMENT 1. Remove Foreign Body  Don't try to remove a large object or one that is deeply stuck in the eye. For small particles or something under the upper eyelid:  Clean around the eye with a wet washcloth if there are many particles.  Rinse the eye with a saline solution or clean water. Or place the affected side of the face in a pan of water; then have the person open and close the eye repeatedly to wash it out.  For something in the corner of the eye or under the lower lid:  If the object is under the lid, pull down the skin above the cheek bone.  Remove the item with the corner of a damp cloth or moistened cotton swab. 2. See a Health Care Provider  Get medical help if the person:  Still feels like there's something in the eye  Has abnormal sensation or pain or has changes in vision  Continues tearing after you wash out the eye  Has a cloudy spot on the cornea 3. Follow Up  The health care provider will examine the eye.  The person may be referred to an eye specialist.

REFRACTIVE ERRORS
HYPEROPIA
Hyperopia is better known as farsightedness. Patients with farsightedness generally see well at a distance, but have difficulty seeing clearly at a close range. Farsighted individuals often complain of eye strain, headaches or fatigue rather than blurry vision. In higher amounts, vision can be blurred at all distances CAUSES: By an imperfection in the eye (often when the eyeball is too short or the lens cannot become round enough), can be caused by sinus infections, injuries, migraines, aging or genetics TESTS AND EXAMS: Farsightedness is detected by a simple test called refraction. Young people are dilated during this test so they are unable to mask their farsightedness by accommodating their vision. TREATMENT: 1. Farsightedness is easily treated with glasses or contact lenses. 2. Refractive surgery is an option for adult patients who wish to see clearly without wearing glasses.

MYOPIA
Myopia is a condition of the eye where the light that comes in does not directly focus on the retina but in front of it. This causes the image that one sees when looking at a distant object to be out of focus but in focus when looking at a close object. CAUSES: Most nearsightedness (myopia) is caused by a natural change in the shape of the eyeball. This causes light to focus in front of the retina rather than directly on the retina. Nearsightedness is usually inherited. A child is likely to be nearsighted if one or both parents are nearsighted. TESTS AND EXAMS: A diagnosis of myopia is typically confirmed during an eye examination by an ophthalmologist, optometrist or orthoptist. Frequently an autorefractor or retinoscope is used to give an initial objective assessment of the refractive status of each eye, then aphoropter is used to subjectively refine the patient's eyeglass prescription. TREATMENT Eyeglasses, contact lenses, and refractive surgery are the primary options to treat the visual symptoms of those with myopia. Lens implants are now available offering an alternative to glasses or contact lenses for myopics for whom laser surgery is not an option. Orthokeratology is the practice of using special rigid contact lenses to flatten the cornea to reduce myopia. Occasionally,pinhole glasses are used by patients with low-level myopia. These work by reducing the blur circle formed on the retina, but their adverse effects on peripheral vision, contrast and brightness make them unsuitable in most situations

and the use of Jackson cross cylinders in a phoropter or trial frame may be used to subjectively refine those measurements 5. Another refraction technique that is rarely used involves the use of a stenopaic slit (a thin slit aperture) where the refraction is determined in specific meridians - this technique is particularly useful in cases where the patient has a high degree of astigmatism or in refracting patients with irregular astigmatism. TREATMENT: Astigmatism may be corrected with eyeglasses, contact lenses, or refractive surgery. Various considerations involving ocular health, refractive status, and lifestyle frequently determine whether one option may be better than another. In those with keratoconus, toric contact lenses often enable patients to achieve better visual acuities than eyeglasses. Once only available in a rigid gas-permeable form, toric lenses are now available also as soft lenses. If the astigmatism is caused by a problem such as deformation of the eyeball due to a chalazion, treating the underlying cause will resolve the astigmatism.

PEDIATRIC VISUAL DISTURBANCES
CONGENITAL CATARACT
A congenital cataract is clouding of the lens of the eye, that is present at birth. The lens of the eye is normally a clear structure, which focuses light received by the eye onto the retina. CAUSE: 1. Chondrodysplasia syndrome 2. Congenital rubella 3. Conradi syndrome 4. Down syndrome (trisomy 21) 5. Ectodermal dysplasia syndrome 6. Familial congenital cataracts 7. Galactosemia 8. Hallerman-Streiff syndrome 9. Lowe syndrome 10. Marinesco-Sjogren syndrome 11. Pierre-Robin syndrome 12. Trisomy 13 CLINICAL MANIFESTATIONS: 1. Cloudiness of the lens that looks like a white spot in an otherwise normally dark pupil -often obvious at birth without special viewing equipment 2. Failure of an infant to show visual awareness of the world around him or her (if cataracts present in both eyes) 3. Nystagmus (unusual rapid eye movements) DIAGNOSTIC TESTS: 1. To diagnose congenital cataract, the infant should have a complete eye examination by an ophthalmologist. The infant may also need to be examined by a pediatrician who is experienced in treating inherited disorders. Blood tests or x-rays may also be needed.

ASTIGMATISM
Astigmatism is an optical defect in which vision is blurred due to the inability of the optics of the eye to focus a point object into a sharp focused image on the retina. CAUSES: May be due to an irregular or toric curvature of the cornea or lens. Irregular astigmatism is often caused by a corneal scar or scattering in the crystalline lens and cannot be corrected by standard spectacle lenses, but can be corrected by contact lenses. Regular astigmatism arising from either the cornea or crystalline lens can be corrected by a toric lens. EXAMS AND TESTS: 1. A Snellen chart or other eye charts may initially reveal reduced visual acuity. 2. Akeratometer may be used to measure the curvature of the steepest and flattest meridians in the cornea's front surface. 3. Corneal topographymay also be used to obtain a more accurate representation of the cornea's shape. 4. An autorefractor or retinoscopy may provide an objective estimate of the eye's refractive error

A standard eye exam and slit-lamp examination are used to diagnose cataracts. Other diagnostic tests are rarely needed, except to rule out other possible causes of poor vision. TREATMENT: 1. If congenital cataracts are mild and do not affect vision, they may not need to be treated, especially if they are in both eyes. 2. Moderate to severe cataracts that affect vision, or a cataract that is in only one eye will need to be treated withcataract removal surgery. In most (noncongenital) cataract surgeries, an artificial intraocular lens (IOL) is inserted into the eye. The use of IOLs in infants is controversial. Without an IOL, the infant will need to wear a contact lens. 3. Patching to force the child to use the weaker eye is often needed to prevent amblyopia. 4. The infant may also need to be treated for the inherited disorder that is causing the cataracts.
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GLAUCOMA
Refers to a group of eye conditions that lead to damage to the optic nerve. This nerve carries visual information from the eye to the brain. In most cases, damage to the optic nerve is due to increased pressure in the eye, also known as intraocular pressure (IOP). CAUSES: There are many types of glaucoma and many theories about the causes of glaucoma. The exact cause is unknown. Although the disease is usually associated with an increase in the fluid pressure inside the eye, other theories include lack of adequate blood supply to the nerve. Open-angle (chronic) glaucoma is the most common type of glaucoma. 1. The cause is unknown. An increase in eye pressure occurs slowly over time. The pressure pushes on the optic nerve. 2. Open-angle glaucoma tends to run in families. Your risk is higher if you have a parent or grandparent with open-angle glaucoma. People of African descent are at particularly high risk for this disease. Angle-closure (acute) glaucoma occurs when the exit of the aqueous humor fluid is suddenly blocked. This causes a quick, severe, and painful rise in the pressure in the eye. 1. Angle-closure glaucoma is an emergency. This is very different from open-angle glaucoma, which painlessly and slowly damages vision. 2. If you have had acute glaucoma in one eye, you are at risk for an attack in the second eye, and your doctor is likely to recommend preventive treatment. 3. Dilating eye drops and certain medications may trigger an acute glaucoma attack. Congenital glaucoma is seen in babies. It often runs in families (is inherited). 1. It is present at birth.

It is caused by abnormal eye development. Secondary glaucoma is caused by: 1. Drugs such as corticosteroids 2. Eye diseases such as uveitis 3. Systemic diseases 4. Trauma CLINICAL MANIFESTATIONS: 1. Open-angle glaucoma  Most people have no symptoms  Once vision loss occurs, the damage is already severe  There is a slow loss of side (peripheral) vision (also called tunnel vision)  Advanced glaucoma can lead to blindness 2. Angle-closure glaucoma  Symptoms may come and go at first, or steadily become worse  Sudden, severe pain in one eye  Decreased or cloudy vision, often called "steamy" vision  Nausea and vomiting  Rainbow-like halos around lights  Red eye  Eye feels swollen 3. Congenital glaucoma  Symptoms are usually noticed when the child is a few months old  Cloudiness of the front of the eye  Enlargement of one eye or both eyes  Red eye  Sensitivity to light  Tearing DIAGNOSTIC TESTS: A complete eye exam is needed to diagnose glaucoma. You may be given eye drop to widen (dilate) your pupil. The eye doctor can look at the inside of the eye when the pupil is dilated. A test called (tonometry) is done to check eye pressure. However, eye pressure always changes. Eye pressure can be normal in some people with glaucoma. This is called normal-tension glaucoma. Your doctor will need to run other tests to confirm glaucoma. Some of the tests your doctor may do can include: 1. Using a special lens to look at the eye (gonioscopy) 2. Photographs or laser scanning images of the inside of the eye (optic nerve imaging) 3. Examination of the retina in the back of the eye 4. Slit lamp examination 5. Visual acuity 6. Visual field measurement
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TREATMENT: The goal of treatment is to reduce eye pressure. Treatment depends on the type of glaucoma that you have. Other treatments may involve:  Laser therapy called an iridotomy

Eye surgery if other treatments do not work Acute angle-closure attack is a medical emergency. Blindness will occur in a few days if it is not treated. If you have angle-closure glaucoma, you will receive:  Eye drops  Medicines to lower eye pressure, given by mouth and through a vein (by IV)

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2. Ptosis that is caused by a disease will improve if the disease is treated successfully. 3. Surgery can generally be done on an outpatient basis under local anesthesia which involves an operation to strengthen the muscle of the eyelid. 4. In children with ptosis, surgical correction may be necessary to prevent amblyopia. Surgical repair is usually very successful in restoring appearance and function.

PTOSIS
Is the medical term for drooping eyelids. It occurs when the upper eyelid droops to an abnormal level and covers part of the eye, restricting or obscuring vision. It can also occur at birth and can affect one or both eyes. Ptosis since birth can be congenital type and if it occurs after birth it is called acquired Ptosis. CAUSES: 1. Ptosis is due to an abnormality in the development of the muscles that elevate the upper lid. 2. Ptosis can also be caused by a malfunction of the nerves which control and activate the eyelid muscles or a problem with the nerve that sends messages to the muscle. 3. Old age is the most common cause of ptosis. The muscles that elevate the eyelid stretch and become thinned out and resulting in a loss of muscle tone and the inability to hold the upper lid in the proper position above the eye. 4. It can also be cause by injury or trauma to the eye as in an accident. 5. It may also be the result of diseases such as diabetes, tumors, inflammation, stroke, cancer or anerurysms. CLINICAL MANIFESTATIONS: 1. The primary symptoms of ptosis is a drooping eyelid of one or both eyes. 2. Children who are born with ptosis usually tilt their head back in an effort to see. 3. Difficulty in reading and while driving are common complaints. 4. Raising the entire brow with the muscles of the forehead and scalp may cause headaches and eyestrain as well. 5. Difficulty closing the eye completely. 6. There maybe increased watering of eyes. 7. Crossed or misaligned eye and sometimes double vision occurs. 8. Eye fatigue from straining to keep eyes open. DIAGNOSTIC TEST 1. A physical examination to determine the cause 2. Special tests may be done to evaluate suspected causes, such as myasthenia gravis TREATMENT: 1. Non-surgical modalities like the use of "crutch" glasses or special Scleral contact lenses to support the eyelid may also be used.

STRABISMUS
Is a condition in which the eyes are not properly aligned with each other. It typically involves a lack of coordination between the extraocular muscles, which prevents bringing the gaze of each eye to the same point in space and preventing proper binocular vision, which may adversely affect depth perception. CAUSES: 1. In most children with strabismus, the cause is unknown. In more than half of these cases, the problem is present at or shortly after birth (congenital strabismus). 2. Most of the time, the problem has to do with muscle control, and not with muscle strength. 3. Less often, problems with one of the nerves or muscles, or Graves' disease restriction may cause strabismus. Other disorders associated with strabismus include: 1. Brain and nerve disorders, such as traumatic brain injury, stroke, cerebral palsy, or Guillain-Barre syndrome 2. Diabetes (causes a condition known as acquired paralytic strabismus) 3. Damage to the retina in children who are born premature 4. Hemangioma near the eye during infancy 5. Injuries to the eye 6. Tumor in the brain or eye 7. Vision loss from any eye disease or injury CLINICAL MANIFESTATIONS: Symptoms of strabismus may be present all the time, or only when you are tired or sick. The eyes do not move together and may appear crossed at times. The other eye will appear turned out, up, or down from wherever the first eye is focused. Someone with strabismus may also have: 1. Depth perception loss 2. Double vision 3. Vision loss DIAGNOSTIC TEST A physical examination will include a detailed examination of the eyes. Tests will be done to determine how much the eyes are out of alignment. Eye tests include: 1. Corneal light reflex 2. Cover/uncover test 3. Retinal exam 4. Standard ophthalmic exam

5. Visual acuity A brain and nervous system (neurological) examination will also be performed. TREATMENT: 1. The first step in treating strabismus is to prescribe glasses, if needed. 2. Amblyopia or lazy eye must be treated first. A patch is placed over the better eye. This forces the weaker eye to work harder. 3. Your child may not like wearing a patch or eyeglasses. A patch forces the child to see through the weaker eye at first. However, it is very important to use the patch or eyeglasses as directed. 4. If the eyes still do not move correctly, eye muscle surgery may be needed. Different muscles in the eye will be made stronger or weaker. 5. Eye muscle repair surgery does not fix the poor vision of a lazy eye. A child may have to wear glasses after surgery. In general, the younger a child is when the surgery is done, the better the result. 6. Adults with mild strabismus that comes and goes may do well with glasses and eye muscle exercises to help keep the eyes straight. More severe forms of adult strabismus will need surgery to straighten the eyes. If strabismus has occurred because of vision loss, the vision loss will need to be corrected before strabismus surgery can be successful.

3. Follow-up examinations are determined based on the results of the first exam. Babies do not need another examination if the blood vessels in both retinas have completed normal development. 4. Parents should know what follow-up eye exams are needed before the baby leaves the nursery. TREATMENT:  Early treatment has been shown to improve a baby’s chances for normal vision. Treatment should start within 72 hours of the eye exam.  Some babies with “plus disease” need immediate treatment.  Treatment may include cryotherapy (freezing) to prevent the spread of abnormal blood vessels.  Laser therapy (photocoagulation) may be used to prevent complications of advanced ROP. The laser therapy stops the abnormal blood vessels from growing. It can be performed in the nursery using portable equipment. To be effective, it must be done before scarring and detachment occurs  Surgery is needed if the retina detaches. Surgical procedures continue to improve, but may not result in good vision.

OPTHALMIA NEONATORUM
Is a form of bacterial conjunctivitis contracted by newborns during delivery. The baby's eyes are contaminated during passage through the birth canal from a mother infected with either Neisseria gonorrhoeae or Chlamydia trachomatis. CAUSES: Neonatal conjunctivitis is most commonly caused by: 1. A blocked tear duct 2. Infection by bacteria or viruses, or irritation from antibiotic eyedrops containing silver nitrate (these are rarely used anymore) Bacteria that normally live in a woman's vagina may cause a milder form of neonatal conjunctivitis. However, an infection with other bacteria or viruses can be very serious. 1. The most common bacteria that can cause serious eye damage are gonorrhea and chlamydia, which can be passed from mother to child during birth. 2. The viruses that cause genital and oral herpes may also be passed to the baby during childbirth, and may lead to severe eye damage. Herpes eye infections are less common than those caused by gonorrhea and chlamydia. The mother may not have symptoms at the time of delivery. Yet she still may carry bacteria or viruses that can cause conjunctivitis in the newborn. CLINICAL MANIFESTATIONS:

RETROLENTAL FIBROPLASIA
Is abnormal blood vessel development in the retina of the eye in a premature infant. CAUSES: The blood vessels in the retina begin to develop three months after conception and finish development around the baby’s due date. When the baby is born early, the eye development is not completed. CLINICAL MANIFESTATIONS: 1. The symptoms include white pupils (leukocoria) 2. Abnormal eye movement (nystagmus) 3. Severe nearsightedness (myopia) 4. Crossed eyes (strabismus). 5. It is imperative to recovery that this disease is diagnosed and treated early, before severe scarring has developed and the retina has detached.

DIAGNOSTIC TESTS: 1. High-risk infants and those younger than 30 weeks gestation or born weighing fewer than 3 lbs should have retinal exams. 2. The first exam usually should be 4 - 9 weeks after birth, depending on the baby’s gestational age. Babies born at 27 weeks or later usually have their exam at 4 weeks of age. Those born earlier usually have exams later.

1. Infected newborn infants develop drainage from the eyes within 1 day to 2 weeks after birth. 2. The eyelids become puffy, red, and tender. 3. There may be watery, bloody, or thick pus-like drainage from the infant's eyes. DIAGNOSTIC TEST: The health care provider will perform an eye exam on the baby. If the eye does not appear normal, the following tests may be done: 1. Culture of the drainage from the eye to look for bacteria or viruses 2. Slit-lamp examination to look for damage to the surface of the eyeball TREATMENT: 1. Eye irritation that is caused by the eye drops given at birth should go away on its own. 2. For a blocked tear duct, gentle warm massage between the eye and nasal area may help. This is usually tried before starting antibiotics. If a blocked tear duct has not cleared up by the time the baby is a year old, surgery may be needed. 3. Antibiotics are often needed for eye infections caused by bacteria. Eye drops and ointments may also be used. Salt water eye drops may be used to remove sticky yellow drainage. Special antiviral eye drops or ointments are used for herpes infections of the eye.

DISTURBANCES IN AUDITORY PRECEPTION DEAFNESS
PRESBYCUSIS
Presbycusis is the loss of hearing that gradually occurs in most individuals as they grow older. Hearing loss is a common disorder associated with aging. About 30-35 percent of adults between the ages of 65 and 75 years have a hearing loss. It is estimated that 40-50 percent of people 75 and older have a hearing loss. The loss associated with presbycusis is usually greater for high-pitched sounds. CAUSE: 1. Heredity 2. Atherosclerosis 3. Dietary habits (increased intake of saturated fat) 4. Diabetes 5. Noise trauma 6. Smoking. 7. Hypertension 8. Ototoxic drugs SIGNS AND SYMPTOMS: 1. The speech of others seems mumbled or slurred. 2. High-pitched sounds such as "s" and "th" are difficult to hear and tell apart.

Conversations are difficult to understand, especially when there is background noise. 4. A man’s voice is easier to hear than the higher pitches of a woman’s voice. 5. Certain sounds seem annoying or overly loud. 6. Tinnitus (a ringing, roaring, or hissing sound in one or both ears) may also occur. DIAGNOSTIC TEST/ EXAMS: 1. General screening tests. Your doctor may ask you to cover one ear at a time to see how well you hear words spoken at various volumes and how you respond to other sounds. 2. Tuning fork tests. Tuning forks are twopronged, metal instruments that produce sounds when struck. Simple tests with tuning forks can help your doctor detect hearing loss. 3. Audiometer tests. During these more-thorough tests conducted by an audiologist, you wear earphones and hear sounds directed to one ear at a time. TREATMENT: 1. Hearing aids. If your hearing loss is due to damage to your inner ear, a hearing aid can help by making sounds stronger and easier for you to hear. 2. Avoid loud noises 3. Wear hearing protection devices. Wearing it when exposed to loud noise e.g. ear plugs 4. Speech reading training 5. Coping and Support. Advise friends and family members so they can take measures to improve communication e.g. talking clearly, facing the person when talking, minimize background noises during conversations etc.
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OTOSCLEROSIS
Otosclerosis is the abnormal growth of bone of the middle ear. This bone prevents structures within the ear from working properly and causes hearing loss. For some people with otosclerosis, the hearing loss may become severe. CAUSE: 1. Heredity 2. Hormonal changes associated with pregnancy. 3. Viral infections such as measles. SIGNS AND SYMPTOMS: 1. Hearing loss may occur slowly at first but continue to get worse. 2. You may hear better in noisy environments that quiet ones. 3. Ringing in the ears (tinnitus) may also occur. DIAGNOTIC TEST AND EXAMS: 1. A hearing test (audiometry /audiology) may help determine the severity of hearing loss. 2. A special imaging test of the head called a temporal-bone CT may be used to rule out other causes of hearing loss. TREATMENT: 1. Otosclerosis may slowly get worse. The condition may not require treatment until you having severe hearing problems.

Medications such as fluoride, calcium, or vitamin D may help to slow the hearing loss, but the benefits have not yet been proved. 3. A hearing aid may be used to treat the hearing loss. This will not cure or prevent hearing loss from getting worse, but may help relieve some of the symptoms. 4. Surgery to remove part of the ear (stapes) and replace it with a prosthesis can cure conductive hearing loss. A total replacement is called a stapedectomy. Sometimes a laser is used to make a hole in the stapes to allow placement of the prosthetic device. This is called a stapedotomy.
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MENIERE’S DISEASE
Meniere's disease is a disorder of the inner ear that causes spontaneous episodes of vertigo — a sensation of a spinning motion — along with fluctuating hearing loss, ringing in the ear (tinnitus), and sometimes a feeling of fullness or pressure in your ear. In most cases, Meniere's disease affects only one ear. People in their 40s and 50s are more likely than people in other age groups to develop Meniere's disease, but it can occur in anyone, even children. CAUSE: The cause of Meniere's disease isn't well understood. It appears to be the result of the abnormal volume or composition of fluid in the inner ear. Factors that alter the properties of inner ear fluid may help cause Meniere's disease. Scientists have proposed a number of potential causes or triggers, including: 1. Improper fluid drainage, perhaps because of a blockage or anatomic abnormality 2. Abnormal immune response 3. Allergies 4. Viral infection 5. Genetic predisposition 6. Head trauma SIGNS AND SYMPTOMS: 1. Recurring episodes of vertigo 2. Hearing loss 3. Tinnitus (perception of a ringing, buzzing, roaring, whistling or hissing sound in your ear) 4. Aural fullness DIAGNOSTIC TEST/ EXAMS: 1. Physical examination and medical history 2. Hearing assessment 3. Balance assessment  Electronystagmography (ENG). This test evaluates balance function by assessing eye movement.  Rotary-chair testing. Like an ENG, this measures inner ear function based on eye movement. In this case, stimulus to your inner ear is provided by movement of a special rotating chair precisely controlled by a computer.

Vestibular evoked myogenic potentials (VEMP) testing. VEMP testing measures the function of sensors in the vestibule of the inner ear that help you detect acceleration movement. Posturography. This computerized test reveals which part of the balance system — vision; inner ear function; or sensations from the skin, muscles, tendons and joints — you rely on the most and which parts may cause problems. 4. Tests to rule out other conditions:  Magnetic resonance imaging (MRI) Computerized tomography (CT Scan)  Auditory brainstem response audiometry TREATMENT: No cure exists for Meniere's disease, but a number of strategies may help you manage some symptoms. Research shows that most people with Meniere's disease respond to treatment, although long-term hearing loss is difficult to prevent. 1. Medications for vertigo  Motion sickness medications, such as meclizine (Antivert) or diazepam (Valium), may reduce the spinning sensation of vertigo and help control nausea and vomiting.  Anti-nausea medications, such as promethazine, may control nausea and vomiting during an episode of vertigo. 2. Noninvasive therapies and procedures 3. Rehabilitation 4. Hearing aid 5. Meniett device. Applies pulses of pressure to the ear canal through a ventilation tube. 6. Middle ear injections Medications injected into the middle ear, and then absorbed into the inner ear, may improve vertigo symptoms:  Gentamicin, an antibiotic that's toxic to your inner ear, reduces the balancing function of your ear, and your other ear assumes responsibility for balance.  Steroids, such as dexamethasone, also may help control vertigo attacks in some people. 7. Surgery If vertigo attacks associated with Meniere's disease are severe and debilitating and other treatments don't help, surgery may be an option. Procedures may include:  Endolymphatic sac procedures. The endolymphatic sac plays a role in regulating inner ear fluid levels. These surgical procedures may alleviate vertigo by decreasing fluid production or increasing fluid absorption. In endolymphatic sac decompression, a small portion of bone is removed from over the endolymphatic sac. In some cases, this procedure is coupled with the placement of a shunt, a tube that drains excess fluid from your inner ear.

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Vestibular nerve section. This procedure involves cutting the nerve that connects balance and movement sensors in your inner ear to the brain (vestibular nerve). This procedure usually corrects problems with vertigo while attempting to preserve hearing in the affected ear.  Labyrinthectomy. With this procedure, the surgeon removes a portion or all of the inner ear, thereby removing both balance and hearing function from the affected ear. This procedure is performed only if you already have near-total or total hearing loss in your affected ear. NURSING CARE: 1. Patient safety. 2. Ensure comfortable position. 3. Turn whole body when moving, avoid sudden movement of the head, avoid flickering lights and TV (makes symptoms worst), 4. Ambulatory assistance 5. Promote quite and dark room.

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EXAMS AND TESTS: 1. An examination of the eye with dilation of the pupil 2. A CT scan or MRI of the head to evaluate tumor and possible spread 3. An ultrasound of the eye (head and eye echoencephalogram) TREATMENT: Treatment options depend upon the size and location of the tumor. Small tumors may be treated by laser surgery. Radiation and chemotherapy may be needed if the tumor has spread beyond the eye. The eye may need to be removed if the tumor does not respond to other treatments. It is important to seek treatment from a physician with experience treating this rare type of tumor.

OCULAR MELANOMA
Melanoma of the eye is cancer that occurs in various parts of the eye. CAUSES: Melanoma is a very aggressive type of cancer that can spread rapidly. Melanoma of the eye can affect several parts of the eye, including the: 1. Choroid 2. Cilliary body 3. Conjunctiva 4. Eyelid 5. Iris 6. Orbit The choroid layer is the most likely location of melanoma in the eye. The cancer may only be in the eye, or it may spread (metastasize) to another location in the body, most commonly the liver. Melanoma can also begin on the skin or other organs in the body and spread to the eye. Excessive exposure to sunlight is an important risk factor. The occurrence of melanoma has greatly increased in recent decades. Fair-skinned and blueeyed people are most often affected. CLINICAL MANIFESTATIONS: 1. Bulging eyes 2. Change in iris color 3. Poor vision in one eye 4. Red, painful eye 5. Small defect on the iris or conjunctiva TESTS AND EXAMS An eye examination with an ophthalmoscope may reveal a single round or oval lump (tumor) in the eye. Tests may include: 1. Cranial CT scan to look for spread (metastasis) to the brain 2. Eye ultrasound 3. MRI of the head to look for metastasis to the brain 4. Skin biopsy if there is an affected area on the skin

NEOPLASTIC DISTURBANCES
RETINOBLASTOMA
Retinoblastoma is a malignant tumor (cancer) of the retina (part of the eye) that generally affects children under the age of 6. It is most commonly diagnosed in children aged 1 - 2 years. CAUSES Retinoblastoma occurs when a cell of the growing retina develops a mutation, causing it to grow out of control and become cancerous. Sometimes this mutation develops in a child whose family has never hadeye cancer, but other times the mutation is present in several family members. If the mutation runs in the family, there is a 50% chance that an affected person's children will also have the mutation. They will therefore have a high risk of developing retinoblastoma themselves. One or both eyes may be affected. A visible whiteness in the pupil may be present. Blindness can occur in the affected eye. The eyes may appear crossed. The tumor can spread to the eye socket through the optic nerve. It may also spread to the brain, lungs, and bones. This is a rare tumor, except in families that carry the RB gene mutation. CLINICAL MANIFESTATIONS: 1. A white glow in the eye that is often seen in photographs taken with a flash; instead of the typical "red eye" from the flash, the pupil may appear white or distorted. 2. White spots in the pupil 3. Crossed eyes 4. A red, painful eye 5. Poor vision 6. The iris may be a different color in each eye.

TREATMENT: Small melanomas may be treated with lasers, brachytherapy, or radiation therapy. Surgical removal of the eye (enucleation) may be necessary. Chemotherapy or biological therapy (interferon) are considered less effective therapies for melanoma involving the eye.

INFLAMMATORY DISTURBANCES
OTITIS EXTERNA
It is an inflammation of the outer ear and ear canal. Also known as "Swimmer's ear". CAUSE: 1. Swimming in polluted water is a common way to contract swimmer's ear, but it is also possible to contract swimmer's ear from water trapped in the ear canal after a shower, especially in a humid climate 2. Constriction of the ear canal from bone growth (Surfer's ear) can trap debris leading to infection 3. the use of objects such as cotton swabs or other small objects to clear the ear canal is enough to cause breaks in the skin, and allow the condition to develop. 4. Once the skin of the ear canal is inflamed, external otitis can be drastically enhanced by either scratching the ear canal with an object, or by allowing water to remain in the ear canal for any prolonged length of time. DIAGNOSIS: 1. Audiometric testing may reveal a partial hearing loss. Microscopic examination or culture and sensitiviy tests can be used to identify the causative organism and determine antibiotic treatment. In fungal otitis externa, removal of the growth reveals thick, red epithelium. 2. The diagnosis of external otitis is presumptive and return visits are required to fully examine the ear. Culture of the drainage may identify the bacteria or fungus causing infection, but is not part of the routine diagnostic evaluation. In severe cases of external otitis, there may be swelling of the lymph node(s) directly beneath the ear. TREATMENT: 1. Cleaning debris from the ear canal with suction and small cotton-tipped applicators under direct visualization through an ear speculum 2. Instilling antibiotic or anti-inflammatory drops-a combination of polymyxin B, neomycin, and hydrocortisone (Cortisporin Otic solution) to manage gram-negative and gram-positive organisms and to decrease inflammation 3. Inserting an ear wick or a piece of medicinesoaked cotton into the ear (when the canal is moderately or severely swollen) for 24 to 48 hours. 4. Administering analgesics as appropriate

5. Administering systemic antibiotics to combat systemic signs such as fever. Corticosteroids may be used with antibiotic drops. Surgery may be needed to excise and drain an abscess. For the patient with a fungal infection, treatment includes: 1. Cleaning the ear carefully 2. Applying a keratolytic or 2% salicylic acid in cream containing nystatin for candidal organisms 3. Instilling slightly acidic eardrops to create an unfavorable environment in the ear canal for most fungi as well as Pseudomonas. In chronic otitis externa, treatment involves: 1. Cleaning the ear and removing debris 2. Instilling antibiotic eardrops or applying antibiotic ointment or cream (neomycin, bacitracin, or polymyxin B, possibly combined with hydrocortisone). An ointment containing phenol, salicylic acid, precipitated sulfur, and petroleum jelly, which produces exfoliative and antipruritic effects, also may be used. For mild chronic otitis externa, treatment includes: 1. Instilling antibiotic eardrops once or twice weekly 2. Wearing specially fitted earplugs while showering, shampooing, or swimming.

ACUTE/ CHRONIC OTITIS MEDIA
Is inflammation of the middle ear, or a middle ear infection. It occurs in the area between the tympanic membrane and the inner ear, including a duct known as the eustachian tube. CAUSE: Otitis media is most commonly caused by infection with viral, bacterial, or fungal pathogens. The most common bacterial pathogen isStreptococcus pneumoniae.Others include Pseudomonas aeruginosa, nontypeable Haemophilus influenzae, and Moraxella catarrhalis. Among older adolescents and young adults, the most common cause of ear infections is Haemophilus influenzae. Viruses such asrespiratory syncytial virus (RSV) and those that cause the common cold may also result in otitis media by damaging the normal defenses of the epithelial cells in the upper respiratory tract. DIAGNOSIS Usually diagnosed via visualization of the tympanic membrane in combination with the appropriate clinical history. The use of a monocular otoscope and perhaps a tympanometer may not be able to distinguish bacterial versus viral etiology, especially if the canal is small and there is wax in the ear that obscures a clear view of the eardrum. Also, an upset child's crying can cause the eardrum to look inflamed due to distension of the small blood vessels on it, mimicking the redness associated with otitis media.

The occurrence, duration, or severity of symptoms is not predictive of an ear infection in the absence of examination of the eardrum TREATMENT: 1. Oral and topical analgesics are effective to treat the pain caused by otitis media. Oral agents include ibuprofen, paracetamol(acetaminophen ), and narcotics. Topical agents shown to be effective include antipyrine and benzocaine ear drops. Decongestants and antihistamines, either nasal or oral, are not recommended due to the lack of benefit and concerns regarding side effects 2. The first line antibiotic treatment, if warranted, is amoxicillin. If there is resistance, then amoxicillin-clavulanate or another penicillin derivative plus beta lactamase inhibitor is second line. While less than 7 days of antibiotics have less side effects more than seven days appear to be more effective. Among short-course antibiotics, longacting azithromycin was found more likely to be successful than short-acting alternatives 3. n chronic cases with effusions, insertion of tympanostomy tube (also called a "grommet") into the eardrum reduces recurrence rates in the 6 months after placementbut have little effect on long term hearing.Thus tubes are recommended in those who have more than 3 episodes of acute otitis media in 6 month or 4 in a year associated with an effusion. 4. There is an osteopathic manipulation technique called the Galbreath technique that can be done at home which is intended to improve drainage.The technique was evaluated in one randomized controlled clinical trial; one reviewer concluded that it was promising, but a 2010 evidence report found the evidence inconclusive.

5. Alcohol abuse 6. A benign tumor of the middle ear 7. Certain medications taken in high doses  Furosemide (Lasix)  Aspirin  Some IV antibiotics  Phenytoin (Dilantin) at toxic levels 8. Benign paroxysmal positional vertigo: With this condition, small stones, or calcified particles, break off within the vestibule and bounce around. The particles trigger nerve impulses that the brain interprets as movement. 9. More serious causes of vertigo can mimic labyrinthitis, but these occur rarely.  Tumors at the base of the brain  Strokes or insufficient blood supply to the brainstem or the nerves surrounding the labyrinth DIAGNOSIS: 1. Your doctor may perform a Dix-Hallpike test, which can offer clues about the cause of vertigo. Your doctor may also look for signs of an ear infection, which can cause labyrinthitis. 2. Electronystagmogram, which uses electrodes to detect eye movements. It looks for characteristic eye movements that occur when the inner ear is stimulated. The pattern of eye movements can indicate the location of the cause of the vertigo, such as the inner ear or the central nervous system. 3. Imaging tests, such as computed tomography of the head and face (CT scan)or magnetic resonance imaging of the head (MRI), which may be done if the vertigo could be caused by a brain problem. 4. Hearing tests, although these tests are of limited use in finding the cause of vertigo. Hearing tests measure the ability of sound to reach the brain. A specific type of hearing test, called an auditory brain stem response (ABR) test, may be done to determine whether the nerve from the inner ear to the brain is working correctly TREATMENT: 1. Self-help techniques  Drink plenty of liquid, particularly water, to avoid becoming dehydrated. You should drink little and often.  In its early stages, labyrinthitis can make you feel constantly dizzy and it can give you severe vertigo. Therefore, you should rest in bed to avoid falling and injuring yourself. After a few days, the worst of these symptoms should have passed and you should no longer feel dizzy all the time. 2. Benzodiazepines reduce activity inside your central nervous system. This means that your brain is less likely to be affected by the abnormal signals that are coming from your vestibular system.

LABYRINTHITIS
Is an inflammation of the inner ear, and a form of unilateral vestibular dysfunction. CAUSE: 1. Often, the condition follows a viral illness such as a cold or the flu. Viruses, or your body's immune response to them, may cause inflammation that results in labyrinthitis. 2. Trauma or injury to your head or ear 3. Bacterial infections: If found in nearby structures such as your middle ear, such infections may cause the following:  Fluid to collect in the labyrinth (serous labyrinthitis)  Fluid to directly invade the labyrinth, causing pusproducing (suppurative) labyrinthitis 4. Allergies

3. Prochlorperazine is an antiemetic that can be used to effectively treat the symptoms of vertigo and dizziness. It may be considered as an alternative treatment if benzodiazepines are considered to be unsuitable for you 4. Corticosteroid medications, such as prednisolone, may be recommended if your symptoms are particularly severe. They are often effective at reducing inflammation levels 5. if your labyrinthitis is thought to be caused by a bacterial infection, you will be prescribed antibiotics. Depending on how serious the infection is this could either be antibiotic tablets or capsules (oral antibiotics) or antibiotic injections (intravenous antibiotics). 6. A number of antiviral medications are also available but these are usually much less effective than antibiotics and may have a limited effect in speeding up your recovery time. Therefore, your GP may feel that there is little benefit in prescribing antiviral medication.

OBSTRUCTIVE PROBLEMS
IMPACTED CERUMEN
Is an obstruction of the ear canal with wax (cerumen). CAUSES: Anything that affects the normal outward flow of cerumen may cause impaction. Cerumen impaction may be more common in men, elderly, and in people with mental health problems. It is not a sign that a person is not clean. The following factors may cause ear wax more likely to become impacted: 1. Advanced age wherein the ears tend to make drier cerumen. 2. Conditions that produce too much cerumen, such as keratosis and other skin diseases. 3. Narrow or abnormally shaped ear canals. 4. Wearing a hearing aid. 5. Incorrect use of cotton buds (swabs), or using needles, hair pins, or other objects to clean the ears. CLINICAL MANIFESTATIONS: 1. A feeling of fullness in the ear 2. Pain in the ear 3. Difficulty hearing, which may continue to worsen 4. Ringing in the ear (tinnitus) 5. A feeling of itchiness in the ear 6. Discharge from the ear 7. Odor coming from the ear 8. Dizziness DIAGNOSTIC TESTS: An exam with an otoscope (lighted instrument used to look in the ear) will reveal whether ear wax is present.

TREATMENT Most cases of ear wax blockage can be treated at home. The following can be used to soften the wax in the ear: 1. Baby oil 2. Commercial drops 3. Glycerin 4. Mineral oil Detergent drops such as hydrogen peroxide or carbamide peroxide may help remove the wax. Another method of removing wax is called irrigation. Use body-temperature water (cooler or warmer water may cause brief but severe dizziness or vertigo). With your head upright, straighten the ear canal by holding the outside ear and gently pulling upward. Use a syringe to gently direct a small stream of water against the ear canal wall next to the wax plug. Tip your head to allow the water to drain. You may need to repeat irrigation several times. Never irrigate the ear if the eardrum may not be intact. Irrigation with a ruptured eardrum may cause ear infection or acoustic trauma. Do not irrigate the ear with a jet irrigator designed for cleaning teeth (such as a WaterPik) because the force of the irrigation may damage the eardrum. After the wax is removed, dry the ear thoroughly. You may use a few drops of alcohol in the ear or a hair dryer set on low to help dry the ear. If you cannot remove the wax plug or irrigation causes discomfort, consult a health care provider, who may remove the wax by: 1. Repeating the irrigation attempts 2. Suctioning the ear canal 3. Using a small device called a curette Occasionally, the wax must be removed with the help of a microscope.

FOREIGN BODIES IN THE EAR CANAL
Is anything that gets stuck in your ear canal, other than earwax. Foreign bodies are usually trapped in the outer ear canal. The outer ear canal, or external auditory canal, is the tube from the opening of your ear to the eardrum. Many kinds of objects can get into the ear canal. Once an object is inside, it becomes difficult to remove because the size of the ear canal is small. CAUSES: 1. Insects 2. Plastic toys or beads 3. Cotton, paper 4. Organic material such as popcorn kernals or vegetable material 5. Small batteries (may be caustic!) CLINICAL MANIFESTATIONS: 1. Occasionally, a foreign body in the ear will go undetected and can cause an infectionin the ear. In this situation, you may notice ongoing infectious drainage from the ear.

Pain is the most common symptom. If the object is blocking most of the ear canal, you may experience a decrease in hearing on that side. 3. Additionally, irritation to the ear canal can also make you nauseated, which could cause you to vomit. 4. Bleeding is also common, especially if the object is sharp or if you try to remove it by sticking something else into your ear. 5. One of the most distressing experiences with this problem is having a live insect in the ear. The insect's movement can cause a buzzing in the ear and may be quite uncomfortable. Fortunately, dripping mineral oil into the affected ear will usually kill the insect. This is safe as long as you do not have a hole in your eardrum. DIAGNOSTIC TESTS: 1. Occasionally, an object is discovered accidentally when x-rays are taken for unrelated reasons. It is important to realize that many materials such as food, wood, and plastic will not be visible on a routine x-ray. 2. With good lighting, your caregiver will carefully check your ear using an otoscope. An otoscope is an instrument used to better see the inside of the ear. Your caregiver may also look for other problems, such as bleeding, infection, or injury. Your eardrum will also be checked for tears or holes. Your caregiver may also test your hearing. TREATMENT 1. Kill any live insects before attempting removal  Rubbing Alcohol or  Lidocaine 2% or  Mineral Oil 2. Use otoscope with operative head 3. Instruments and Methods  Micro Alligator Forceps: Remove graspable foreign body  Cerumen curettes  Suction catheter  Ear Irrigation (do not use if organic foreign body or button battery) 4. Other measures  Acetone dissolves styrofoam and super glue  Otic antibiotic drops indicated for concurrent Otitis Externa or ear canal trauma
2.

EAR TRAUMA
TYMPANIC MEMBRANE PERFORATION
Your tympanic membrane, or eardrum, is a stiff but movable oval membrane inside your ear. Your tympanic membrane separates your outer ear canal from your inner ear. A tympanic membrane perforation is a condition where your eardrum has a tear or hole in it.

CAUSE: 1. Changes in ear pressure 2. Direct trauma to your eardrum 3. Ear infection 4. Head trauma 5. Past ear surgery or procedure SIGNS AND SYMPTOMS: 1. Clear, mucoid (phlegm-like), thick and yellowish, or bloody ear discharge. 2. Hearing loss in your involved ear. 3. Pain in your involved ear. 4. Tinnitus (ringing or buzzing sound in your ear). 5. Vertigo (dizziness). DIAGNOSTIC TEST/ EXAMS: Tell your caregiver about any past ear infections and ear treatments you have had. Your caregiver may ask if you have history of trauma, such as accidents or assaults. He may also ask if you are involved in any water or contact sports, or if you fly often. Your caregiver may use a special tool called an otoscope to look inside your ear. An otoscope will allow your caregiver to see your eardrum and the size and location of the tear. Your caregiver will also be able to see if there is fluid or infection inside your ear. TREATMENT: 1. Surgery. You may need surgery to repair your eardrum and prevent future ear infections. This is done when the hole in your eardrum is large, or does not heal on its own. You may also need surgery if your hearing loss or ear discharge does not get better with medicine. Ask your caregiver for more information on the following:  Myringoplasty: This type of surgery uses a tissue graft to cover your torn eardrum. A tissue graft may be taken from your own body, another person, an animal, or is manmade. A procedure called a mastoidectomy may also be done with a myringoplasty. A mastoidectomy is removal of infected bone from behind your ear. A mastoidectomy may also help prevent your eardrum from breaking down.  Tympanoplasty: This surgery repairs your torn eardrum and any damage to your inner ear. A tympanoplasty also helps prevent chronic ear infections. The hole in your eardrum will be covered with a tissue graft. You may also need to have a mastoidectomy with your tympanoplasty surgery.