Common Diseases of EENT

1. Common Diseases of EENT Assessment Disease: Eye, Ear, Nose, Throat Drug induced toxicities Pharmacotherapeutics yr4 October 2008 Thananan Rattanachotphanit

2. Objectives ??????????????????????????????????????????? ?? ?? ???? ?????????????????????????? ?? ?? ???? ????????? ??????????????????????????????????? ????????????????????????????? ?? ?? ?? ???? ???????????????????? ??????????????????????????????????????????????????????? ?? ?? ???? ?????????

3. ???????????????????? ?????????? ?????????????????? ????????? ?????????????????????? ??? ???????????? ?????????????????????? ??? ?????????????????????? ????????????????????????? ???????????????????????????????

4. Blepharitis Dry eyes Conjuctivitis Sty/hordelum Subconjuctival hemorrhage Glaucoma

5. Eye

6. ?????????????? ??: ???????????? ???????????? (optic nerve): ????????????????????? ?????????????????????: ???????????? ?????????????? 3 ???? ?????????????? ???????????? ?????????????

8. ?????????????? ???? fibrous layer ???? sclera (?????): ?????????????????????? ??????????? sclera ??? cornea (???????) ?????????????????????? ?????????????????????? ???????????????????????????????? ????????????????? ??????? (??????? ???? conjuntiva) ???????????????????????? ?????????? ???????? sclero-corneal junction / limbus ?????????????? trabecular meshwork ??? canal of Schalem Trabecular meshwork: ???? aqueous ??????????? canal of Schalemm ????????????????????? ??????????????????????????????? (14-16 mmHg)

9. ???????? uvea ?????????????????????????????? ???????? 3 ???? ??? ?????? (iris) ????????????????; ciliary body ????????????; Choroid ???????????? Iris: ????????????????????????????????? ???????????? 2 ????? ??? dilator papillae ??? sphincter papillae ????????????????????????????????????????? Dilator papillae: ???????????????????????????????? ?????????????????????? sympathetic ??????????????? ? ??????????????? ? ???????????? (mydriasis) Sphincter papillae: ???????????????????????????? ?????????????????????? parasympathetic ??????????????? ? ??????????????? ? ?????????????? (myosis) ????????????

10. Ciliary body ?? 2 ???? ??? ciliary process ??? ciliary muscle Ciliary process: ????? aqueous humor Ciliary muscle: ??????????????????????????????????????? Lens: ???????? ??????????????? ?????????????????? ???????????????????????????????????? ciliary body ???????????????? ????????????????????????????? ????????? Choroid ?????????????????????????????? ????????????????????? (retina) ?????????????????????: vitreous humor ????????? ????????????

11. ????????????? ???? (retina): ?????? ???????????????????? ??????????????????????? ??????????? ??????????????????????? (optic nerve) ????????????????????????????? ?????????? ???????? anterior cavity ????????? aqueous humor (?????????) ??????? ciliary body ?????????????????????????: Anterior chamber ?????????????????????????: Posterior chamber

12. ????????????? Aqueous humor ??????????? ciliary process ????????? posterior chamber ?????????????????? ??????? trabecular meshwork ???????????????? aqueous humor ?????????? canal of Schalemm ????????????????? ???????????????????????? 14-16 mmHg ??????????????????????????????? vitreous humor ??????????????????

13. ??????????????????? Topical Anesthetics Local anesthetics for injection Mydriatics & Cycloplegics Topical corticosteroids NSAIDS Anti-infective ophthalmic drugs Topical Antifungal Agents Topical Antiviral Agents

14. ??????????????????? Topical corticosteroids: ???????????????????????? allergic conjunctivitis, uveitis, episcleritis, scleritis, phlyctenulosis, superficial punctate keratitis, interstitial keratitis ?????????????????????????????????????????? relative potency of prednisolone to hydrocortisone is 4 times; of dexamethasone and betamethasone, 25 times) ?????????????????????????????????????????? ???? exacerbation of herpes simplex keratitis, fungal keratitis, cataract formation (unusual), and open-angle glaucoma (common)

15. ??????????????????? Topical ophthalmic corticosteroids: Hydrocortisone ointment, 0.5%, 0.12%, 0.125%, and 1% Prednisolone acetate suspension, 0.125% and 1% Prednisolone sodium phosphate solution, 0.125% and 1% Dexamethasone sodium phosphate suspension, 0.1%; ointment, 0.05% Medrysone suspension, 1% Fluorometholone suspension, 0.1% and 0.25%; ointment, 0.1% Rimexalone suspension, 1%

16. ??????????????????? Nonsteroidal anti-inflammatory agents (NSAIDS): Flurbiprofen 0.03%, and suprofen 1%: for inhibition of miosis during cataract surgery Ketorolac 0.5%: for use in seasonal allergic conjunctivitis Diclofenac and ketorolac: for postoperative inflammation following cataract surgery; for relief of pain & photophobia in patients undergoing laser corneal refractive surgery

17. ???????????????????

18. ??????????????????? Bacitracin: Ointment, 500 U/g, combinations with polymyxin B Polymyxin B: Ointment, 10,000 U/g; suspension, 10,000 U/mL. Erythromycin: ointment, 0.5% Neomycin: Solution, 2.5 and 5 mg/mL; ointment, 3.5–5 mg/g. Combinations with bacitracin and polymyxin B. Gentamicin: Solution, 3 mg/mL; ointment, 3 mg/g. Tobramycin: Solution, 3 mg/mL; ointment, 3 mg/g. Tetracyclines: Suspension, 10 mg/mL; ointment, 10 mg/g. Chloramphenicol: Solution, 5 and 10 mg/mL; ointment, 10 mg/g. Ciprofloxacin: Solution, 3 mg/mL Gatifloxacin: Solution, 3 mg/mL Moxifloxacin: Solution, 5 mg/mL Norfloxacin : Solution, 3 mg/mL Ofloxacin: Solution, 3 mg/mL Sulfacetamide Sodium: solution, 10%, 15%, and 30%; ointment, 10% Sulfisoxazole: solution, 4%; ointment, 4%.

19. ??????????????????? Topical Antifungal Agents: Natamycin Suspension, 5% Nystatin (not available in ophthalmic ointment form, but the dermatologic preparation (100,000 U/g) is not irritating to ocular tissues and can be used in the treatment of fungal infection of the eye) Amphotericin B (not available in ophthalmic ointment form. A solution (1.5–8 mg/mL of distilled water in 5% dextrose must be made up in the pharmacy from the powdered drug) Miconazole (1% solution is available in the form of IV preparation that may be instilled directly into the eye ) Fluconazole (0.2% parenteral preparation is available and may be instilled into the eye)

20. ??????????????????? Topical Antiviral Agents: Idoxuridine: solution, 0.1%; ointment, 0.5% Vidarabine: ointment, 3% Trifluridine: Solution, 1% Acyclovir: Tablet 200, 400, and 800 mg Ganciclovir: Intravitreal implant, 4.5 mg

21. ??????????????????? Topical antihistamines : Cromolyn Sodium: Solution, 4%: not useful in the treatment of acute symptoms. Ketotifen Fumarate: Solution, 0.025%:antihistamine and mast cell–stabilizing activity Lodoxamide Tromethamine: Solution, 0.1%:a mast cell stabilizer that inhibits type 1 immediate hypersensitivity reactions. Nedocromil Sodium: Solution, 2%: rapid onset of an antihistamine and true mast cell–stabilizing activity.

22. Topical antihistamines : Olapadine Hydrochloride: antihistamine and mast cell–stabilizing actions Levocabastine Hydrochloride: Suspension, 0.05%:is a selective, potent histamine H1-receptor antagonist. It is useful in reducing acute symptoms of allergic conjunctivitis. Emedastine Difumarate: Solution, 0.05% ???????????????????

23. Blepharitis (??????????????) ???????????????????? (eyelids) Anterior blepharitis - Posterior blepharitis ????????????????????? (chronic condition) ??????????? tiny oil glands (????????????? base of the eyelashes) ???????????? Bacterial overgrowth ---- Leading to inflame, irritate and itchy eyelids

24. Signs & Symptoms Watery or red, swollen eyelids A gritty, burning sensation in the eye Itchy eyelids Flaking of the skin around the eyes Crusted eyelashes upon awakening Sensitivity to light Frothy tears Eyelashes that grow abnormally (misdirected eyelashes) Loss of eyelashes

25. Self-care ????????????????????????? 10 min. ????????????????????? ??????????????? 1-2 ??? ?????????????????????????????? ????????????????????????????????????? Medication Topical antibiotic ointment or cream In severe cases, eyedrops containing antibiotics and steroids Treat underlying cause such as dandruff or rosacea

26. Dry eyes (??????) ?????????????????????? tear film Tear film: a constant layer of fluid designed to remain stable between blinks, prevents dry eyes, allows eyes to maintain clear, comfortable vision Tear film has three basic layers: Oil (outer layer): it is produced by small glands on the edge of your eyelids (meibomian glands), contains fatty oils (lipids). Water (middle layer): it is produced by the tear glands (lacrimal glands), makes up about 90 percent of tears, mostly water with a little bit of salt. Mucus (inner layer): allows tears to spread evenly over the surface of your eyes

27. Tear gland

28. Causes of Dry Eyes An imbalance in the composition of tears Tear glands don't produce enough tears Tear glands damage due to inflammation or radiation Refractive eye surgeries such as laser-assisted in-situ keratomileusis (LASIK) (symptoms usually resolve after several months) Eyelid problems (Normal rate of blinking about 13 blinks each minute)

29. Causes of Dry Eyes Environmental factors: sun, wind, high altitude, a dry climate, hot blowing air and the dry air Tasks that require intense visual concentration: working at a computer Medical conditions such as diabetes, rheumatoid arthritis, lupus, scleroderma and Sjogren's syndrome Medications: diuretic, antihistamine, decongestant, tricyclic antidepressant

30. Treatment Aim: restoring a more normal tear film to minimize dryness, blurred vision, discomfort Determine which factors may be causing symptoms Medications: artificial tears (solution, ointment, gel), ocular emollient Mild dry eyes respond well to treatment with artificial tears. Severe dry eyes require more aggressive treatment such as the silicone plugs.

31. ??????????????????? Tear replacement & Lubricating agents: Artificial tears Ocular emollients Artificial tears: contains demulcent (high molecular weight compounds water-soluble polymers) which act like mucin: coat the surface of irritated mucous membranes wetting of the cornea & prevent drying of the affected tissue through increasing volume of fluid

32. ??????????????????? Artificial tears: Cellulose derivatives (common used and safe): carboxymethylcellulose, hydroxyethylcellulose, hydroxypropyl methylcellulose, methylcellulose Polyvinyl alcohol: lower viscosity than cellulose derivatives Povidone and dextran 70: transient stinging Gelatin: not be used as a single ingredient, can be added to another demulcent to raise the protein content of tears. 1-2 drops as needs (twice daily is sufficient) Instillation > 6 times a day may wash away natural tears & cause a rippled appearance on the ocular surface

33. ??????????????????? Ocular emollient: Ophthalmic ointment containing: lanolin, mineral oil, paraffin, petrolatum, white petrolatum, white ointment, white wax, yellow wax Soften tissue by forming an occlusive film on the eye surface Optimal time of use: Bedtime (because it may cause blur vision)

34. Conjunctivitis/ Pink eye (???????????????) An inflammation or infection of conjunctiva Small blood vessels in the conjunctiva become more prominent, resulting in a pink or red cast to the whites of eyes.

35. Causes Viruses Bacteria (Preschool-age children commonly develop both viral and bacterial conjunctivitis) Allergies Chemical splash in the eye Foreign object in the eye

36. Signs and symptoms Redness in one or both eyes Itchiness in one or both eyes Blurred vision and sensitivity to light A gritty feeling in one or both eyes A discharge in one or both eyes that forms a crust during the night Tearing

37. Viral and Bacterial Conjunctivitis Both may affect one or both eyes. Viral conjunctivitis: a watery or mucous discharge. Bacterial conjunctivitis: a thicker, yellow-green discharge and may be associated with a respiratory infection or with a sore throat. Viral and bacterial conjunctivitis are associated with colds. Adults and children alike can develop both of these types of pink eye. Bacterial conjunctivitis is more common in children than in adults. Someone with conjunctivitis may be contagious for seven to 14 days after signs and symptoms first appear.

38. Allergic conjunctivitis Affects both eyes. A response to an allergy-causing substance: pollen IgE triggers mast cells in the mucous lining of eyes and airways to release inflammatory substances Allergy symptoms: red or pink eyes, intense itching, tearing and inflammation of the eyes, sneezing and watery nasal discharge, swelling of conjunctiva

39. Treatment Viral conjunctivitis: ??????????????????? 3 ?????? ?????????????? ???????????? ?????? Symptomatic treatment Bacterial conjunctivitis: Antibiotic eyedrops/ ointment An ointment is often easier to administer to an infant or young child than are eyedrops.

40. Allergic conjunctivitis: Topical antihistamine Topical vasoconstrictor and antihistamines are advocated in Hay fever conjunctivitis Systematic antihistamine may be useful in prolonged atopic keratoconjunctivitis Topical corticosteroids are essential to the control of acute exacerbations

41. ??????????????????? Vasoconstrictive agents: ???????????????????????????????????? superficial vessels ??? conjunctiva ??????????????????????? Ephedrine 0.123% Naphazoline 0.012–0.1% Phenylephrine 0.12% Tetrahydrozoline 0.05–0.15% Astringent: Zinc sulphate 0.25% for relieve discomfort of minor eye irritation

42. Sty/ hordeolum (?????????) A red, painful lump filled with pus on the edge or inside of eyelid. Most sties disappear in just a few days. Cause: Bacterial infection (usually staphylococcus) Usually the bacterial infection develops near the root (follicle) of an eyelash. May have more than one sty

43. Signs and symptoms: A red lump similar to a pimple Swelling on eyelid Light sensitivity A scratchy sensation in eye Tearing Treatment: Topical antibiotic ointment To treat a pus-filled sty that won't rupture or burst on its own, doctor may choose to drain the sty to relieve pain and pressure.

44. Subconjunctival hemorrhage Blood vessel breaks underneath the conjunctiva, while conjunctiva cannot absorb the blood quickly Usually a harmless condition that disappears within 10 to 14 days (the blood will absorb within 10 to 14 days)

45. Risk factors People with DM or HT Medications: warfarin and aspirin It may be the result of a strong sneeze or cough causing a broken blood vessel. newborns, who may be subjected to pressure changes during delivery Treatment: No specific treatment Eyedrops or artificial tears to soothe any scratchy feeling

46. Glaucoma (??????) An increased ocular pressure and cause damaging optic nerve Optic nerve: A bundle of more than a million nerve fibers at the back of eye, carrying the images from the inside retina to brain.

47. Glaucoma occurs in several types Signs and symptoms vary depending on the type of glaucoma: open-angel glaucoma & angle-closure glaucoma Primary open-angle glaucoma: the most common form of glaucoma, develops gradually, giving no warning signs. Both open-angle and angle-closure glaucoma can be primary or secondary conditions. Glaucoma (??????)

48. Fluids inside eye help maintain the intraocular pressure: Vitreous fluid: fills the vitreous cavity at the back of eye, Aqueous humor: fills the anterior chamber at the front of eye. (It is continuously produced and circulated through the anterior chamber before draining out of eye)

49. Eyes' drainage system Aqueous humor exits eye through a drainage system located at the angle formed where the iris and the cornea meet. It passes through a sieve-like system of spongy tissue, called the trabecular meshwork, and drains into a channel, called Schlemm's canal. The fluid then merges into bloodstream. A healthy eye produces aqueous humor at the same rate that it drains fluid, thus maintaining a normal pressure.

50. Increase of ocular pressure due to : : trabecular meshwork becomes clogged : aqueous humor can't filter out of the eye at its normal rate It is often associated with gradual damage to the nerve fibers that make up the optic nerve.

51. Risk factors Age: Age is a large risk factor in the development of glaucoma, older than 60 is at increased risk of the disorder. (blacks: after age 40) Race: Blacks, Asian-Americans are at higher risk of angle-closure glaucoma FH of glaucoma Medical conditions: DM, high blood pressure or heart disease, hypothyroidism Prolonged corticosteroid use Physical injuries Nearsightedness Eye abnormalities

53. Primary open-angle glaucoma Chronic open-angle glaucoma ??????????????????? ????? ????????????????? (few or no symptoms until the condition reaches an advanced stage) ???????????????? ????????????????? vision loss ????????????? Drainage angle formed by the cornea and the iris remains open but the aqueous humor drains too slowly. This leads to fluid backup and a gradual build-up of pressure within eye. Damage to the optic nerve is so slow and painless Large portion of vision can be lost before aware of a problem

54. Angle-closure glaucoma ????????????? ?????????????????? ??????????? Drainage angle formed by the cornea and the iris closes or becomes blocked. Aqueous humor can't exit through the trabecular meshwork ? a build-up of fluid & increase ocular pressure An attack often happens in the evening or in a darkened room when the light is dim and pupils have become relatively dilated. Permanent vision loss can occur within a day of the attack ? Immediate medical attention !!!!

55. Angle-closure glaucoma Signs and Symptoms Blurred vision Halos around lights Reddening of the eye Severe eye pain Nausea and vomiting Age risk factor: When getting older, lens becomes larger, pushing iris forward and narrowing the space between the iris and the cornea.

56. Secondary glaucoma Causes: medical conditions, medications, physical injuries, and eye abnormalities or deformities Low-tension: Low-tension glaucoma is a poorly understood, though not uncommon, form of the disease. Eye pressure remains within the normal range, but the optic nerve is damaged nevertheless.

57. Screening and diagnosis Tonometry: Intraocular pressure (initial screening test for glaucoma) Open angle glaucoma: intraocular pressure >20 mmHg Close angel glaucoma: intraocular pressure 50-100 mmHg Test for optic nerve (????????????) damage Visual field test (????????) Gonioscopy ????????????

58. Treatment Glaucoma can't be cured & damage caused by the disease can't be reversed. Treatment aim: Reducing intraocular pressure by improving aqueous outflow, reducing the production of aqueous, or both. Treatment: Eyedrops, systemic medications, laser treatment, surgery, or a combination of treatments can prevent or slow further damage. Open-angle glaucoma: ????????????? Close-angel glaucoma: ?????????????????????????????????????????????????? ?????????????? laser treatment ???? surgery

59. Treatment of close-angle glaucoma Topical Beta-blocker 1 drop Carbonic anhydrase inhibitor ???? Acetazolamide 250 mg 2 tab. Osmotic agent ???? 50% glycerol 1-2 g/kg ???? 20% mannitol 1-2 gm/kg IV Topical steroid Miotic therapy: ????????????? ??? 2%-4% pilocarpine ???????????????????????? 1% pilocarpine 1 hr ????? ?????????????????? ?????????????????? ??????????????? : Topical steroid ????? 4 ?????, Acetazolamide, Topical Beta-blocker, Miotic drugs ?????????????????? ????????????????? ????????? ???? laser

60. Medications Beta blockers: reduce the production of aqueous humor Ex: Carteolol, Levobunolol, Timolol Alpha-adrenergic agents: reduce the production of aqueous humor Ex: Bromonidine Carbonic anhydrase inhibitors: reduce the amount of aqueous humor EX: Acetazolamide Prostaglandin analogues (hormone-like substances): increase the outflow of aqueous humor Ex: Bimatoprost, Latanoprost Parasympatheomimetic (Miotic): increase the outflow of aqueous humor Ex: Pilocarpine Epinephrine compounds: increase the outflow of aqueous humor

61. Drug used in glaucoma ????????????????????????????????????????????????????? tonometric ??????????????????? ?????????????????????????????? intraocular pressure ??????????????????????????? optic nerve ??? 1.???????????????? parasympathomimetics ???????? intraocular pressure ??????????? outflow of aqueous humor ??????? trabecular meshwork Direct-Acting Cholinergic (Parasympathomimetic) Drugs Pilocarpine Hydrochloride & Nitrate: Solution, 0.25%, 0.5–6%, 8%, and 10%; gel, 4%. Carbachol: Solution, 0.75%, 1.5%, 2.25%, and 3% Indirect-Acting Anticholinesterase Drugs Physostigmine Salicylate & Sulfate: Solution, 0.25%, and ointment, 0.25%

62. Drug used in glaucoma 2.Adrenergic (Sympathomimetic) Drugs; Nonspecific Epinephrine ?????????????????? outflow of aqueous humor ??????????????????? aqueous humor ??????????????????? long term use ?????????? ??????????? 12-72 ??. ??????????????? miosis S/E ??? local allergies ??????????? 25% ????????????? ??????????????? headache and heart palpitation ??????????????????? ?????????????????????????????? Epinephrine borate 0.5%, 1%, and 2% Epinephrine hydrochloride 0.25%, 0.5%, 1%, and 2% Dipivefrin hydrochloride 0.1%

63. Drug used in glaucoma 3. Adrenergic (Sympathomimetic) Drugs; Relatively Alpha 2–Specific Apraclonidine Hydrochloride: Solution, 0.5% and 1% Brimonidine Tartrate (Alphagan-P): Solution, 0.15% 4. Beta-Adrenergic Blocking (Sympatholytic) Drugs Timolol Maleate: Solution, 0.25% and 0.5%; gel, 0.25% and 0.5% Betaxolol Hydrochloride: Solution, 0.25% and 0.5%. Levobunolol Hydrochloride: Solution, 0.25% and 0.5% Metipranolol Hydrochloride: Solution, 0.3% Carteolol Hydrochloride: Solution, 1%

64. Drug used in glaucoma 5. Carbonic Anhydrase Inhibitors ??????????????? carbonic anhydrase ?? ciliary body ??????????????? aqueous ?????????????????????? 2 ??. ??????????????????? 4-6 ??. ??????????????????????????????????????????????? 20 ???? S/E: ????????????????????, gastric distress, diarrhea, exfoliative dermatitis, renal stone formation, shortness of breath, fatigue, acidosis, tingling of the extremities

65. Drug used in glaucoma 5. Carbonic Anhydrase Inhibitors Oral: Acetazolamide (Diamox): Tablets, 125 mg and 250 mg; give 125–250 mg two to four times a day Methazolamide: Tablets, 25 and 50 mg; 50–100 mg two or three times daily Dichlorphenamide: Tablets, 50 mg: usual maintenance dosage for glaucoma is 25–50 mg three or four times daily Topical: Dorzolamide Hydrochloride: Solution, 2% Brinzolamide Ophthalmic Suspension: Suspension, 1%

66. Drug used in glaucoma 6. Prostaglandin Analogs: ???????? intraocular pressure ??????????? outflow of aqueous humor ??????? uveoscleral pathway ???????? Adverse effects: increased brown pigmentation of the iris, conjunctival hyperemia, punctate epithelial keratopathy, and a foreign body sensation, ?????????????? ocular inflammation Latanoprost: Solution, 0.005% Travoprost: Solution, 0.004% Bimatoprost: Solution, 0.03% Unoprostone Isopropyl: Solution, 0.15%

67. Drug used in glaucoma 7. Hyperosmotic Agents: ????? intraocular pressure ???????????? plasma hypertonic ????????????? aqueous humor ????????????? acute (angle-closure) glaucoma ????????????? intraocular pressure ??????????????????

68. Drug used in glaucoma 7. Hyperosmotic Agents: Glycerin: orally as 50% solution with water, orange juice, or flavored normal saline solution over ice (1 mL of glycerin weighs 1.25 g) (Toxicity: Nausea, vomiting, and headache) Isosorbide: 45% solution Mannitol: 5–25% solution for injection (Problems with cardiovascular overload and pulmonary edema are more common with this agent because of the large fluid volumes required) Urea: 30% solution of lyophilized urea in invert sugar (Toxicity: Accidental extravasation at the injection site may cause local reactions ranging from mild irritation to tissue necrosis)

69. Cataract A clouding of clear lens of eye (Lens located behind the iris and the pupil) Most cataracts develop slowly and don't disturb eyesight early Interferes with vision.

70. Light passes through the cornea and the pupil to the lens. lens focuses this light, producing clear, sharp images on the retina As a cataract develops, the lens becomes clouded, which scatters the light and prevents a sharply defined image from reaching your retina. As a result, your vision becomes blurred.

71. Cataract It isn't dangerous unless it becomes completely white, a condition known as an overripe (hypermature) cataract. A cataract can develop in one or both eyes. (Most cases, it tend to develop symmetrically in both eyes.)

72. Risk factors Age: single greatest risk factor Some people are born with cataracts or develop them during childhood (result of the mother having contracted German measles (rubella) during pregnancy) Diabetes Family history of cataracts Previous eye injury or inflammation Previous eye surgery Prolonged use of corticosteroids Excessive exposure to sunlight Exposure to ionizing radiation Smoking

73. Signs and symptoms Clouded, blurred or dim vision Increasing difficulty with vision at night Sensitivity to light and glare Halos around lights The need for brighter light for reading and other activities Frequent changes in eyeglass or contact lens prescription Double vision in a single eye

74. Screening and diagnosis Visual acuity test: sharpness of vision or how clearly you see an object. Slit-lamp examination. A slit lamp allows doctor to see the structures at the front of eye under magnification. Retinal examination: Ophthalmoscope for examination lens for signs of a cataract Treatment: Cataract removal is one of the safest, most effective. Most common surgical procedures are replacing the lens with a clear lens implant.

75. Diabetes retinopathy Retinopathy: ??????????????? blood vessels (capillaries) ???????? retina High blood sugar levels Two types (usually affecting both eyes similarly): Non-proliferative diabetic retinopathy (NPDR) Proliferative diabetic retinopathy (PDR)

76. Retinopathy

77. Signs and symptoms "Spiders," "cobwebs" or tiny specks floating in your vision Dark streaks or a red film that blocks vision Vision loss or blurred vision A dark or empty spot in the center of your vision Poor night vision Difficulty adjusting from bright light to dim light The National Eye Institute: A comprehensive dilated eye exam at least once a year.

78. Treatment Two main treatments: -Photocoagulation (Laser treatment) -Vitrectomy (???????????????)

79. Sjogren's syndrome Autoimmune disorder Often accompanies other autoimmune disorders such as RA, Lupus ?? inflammation of connective tissues. mucous membranes & moisture-secreting glands of eyes & mouth ??????????????????? ??????????????????????????? ????????????? Difficult to Dx because signs & symptoms are similar to those caused by other diseases and can vary from person to person.

80. Signs & Symptoms Dry eyes, Dry mouth Dental cavities Fatigue Enlarged parotid glands Difficulty swallowing or chewing Change in sense of taste Hoarseness Oral yeast infections, such as candidiasis Skin rashes or dry skin Vaginal dryness Dry cough that doesn't produce sputum Joint pain, swelling and stiffness

81. Risk factors Having a rheumatic disease Being female Being a certain age (older than 40) Having a family history

82. Corneal ulcer Bacterial keratitis (P. aeruginosa, Pneumococcus, Moraxella): Topical ATBs: fluoroquinolones such as cipofloxacin, ofloxacin, norfloxacin Fungal Keratitis: Topical natamycin, amphotericin are the most commonly used, oral imidazoles may by helpful. Herpes simplex keratitis: Topical antivirals alone are insufficient, Oral acyclovir, 200-400 mg 5 times/day may be helpful Herpes zoster ophthalmicus: High dose oral acyclovir (800 mg 5 times/day), valacyclovir (1 g 3 times/day), or famciclovir (250-500 mg 3 times/day) start within 72 hrs

83. Uveitis (Intraocular inflammation) Anterior uveitis: Topical corticosteroids Occasionally, periocular corticosteroid injections or systemic corticosteroid may be required Posterior uveitis: Systemic or intravitreal corticosteroid, occasionally systemic immunosuppression such as azathioprine, tacrolimu, cyclosporin or mycophenolate

84. ??????????????????? Topical Anesthetics: ?????????????????? : tonometry, removal of foreign bodies or sutures, gonioscopy, conjunctival scraping, minor surgical operations on the cornea and conjunctiva Proparacaine Hydrochloride: Solution, 0.5% Tetracaine Hydrochloride: Solution, 0.5%, and ointment, 0.5% Benoxinate Hydrochloride: Solution, 0.4% ????????????????????????????????????????????????????????? corneal ???????????????? ocular disease ????????????

85. ??????????????????? Local anesthetics for injection: ???????????????????? Longer acting agents ???? bupivacaine ??? etidocaine ????????????????? local anesthetics ???????????????????????????????? ?????????? hyaluronidase ???????????????????????????????????? ???????????? onset ????????????? Injectable anesthetics ?????????????????????????????????????????????????? cardiac arrhythmias Lidocaine Hydrochloride Procaine Hydrochloride Solution, 1%, 2%, and 10%. Mepivacaine Hydrochloride: Solution, 1%, 1.5%, 2%, and 3% Bupivacaine Hydrochloride (duration 6–10 hours): Solution, 0.25%, 0.5%, and 0.75% Etidocaine Hydrochloride (duration 4–8 hours): Solution, 1% and 1.5%

86. ??????????????????? Mydriatics and cycloplegics: ??????? pupil ????????????????????? ophthalmoscopy ????? paralysis of muscle accommodation ????????? pupil ??? paralysis of muscle accommodation ?? uveitis ??????????????????????????????????????????????????????????? narrow anterior chamber angles ?????????????????????????????????? angle-closure glaucoma

87. ??????????????????? Mydriatics (Sympathomimetics): Phenylephrine Hydrochloride: Solution, 0.12%, 2.5%, and 10% Cycloplegics (Parasympatholytics): Atropine Sulfate: Solution, 0.5–3%; ointment, 0.5% and 1% Scopolamine Hydrobromide: Solution, 0.25% Homatropine Hydrobromide: Solution, 2% and 5% Cyclopentolate Hydrochloride: Solution, 0.5%, 1%, and 2% Tropicamide

88. ??????????????????? Corneal dehydrating agents: ??????? corneal edema ????? tear film ?????? hypertonic ??? corneal tissues Create an osmotic gradient that draw fluid from the cornea Ex: Anhydrous glycerin solution Hypertonic sodium chloride 2% and 5% ointment and solution

89. Instruction for use of eye drop Wash the hand thoroughly with an antibacterial soap. Tilt head back and gently pull lower lid forward to create a pouch. Instill one drop into the pocket without touching the eyelid or lashes with eyedropper or bottle tip Wait a few second, then bring the lid forward, lookdown, and gently lift the lower lid up until it touches the upper lid. Release the lid and keep the eye closed without blinking or squeezing for 1-2 min. Apply gentle pressure over the puncta (opening of tear duct at the inner corner of the eye) for 2 min. to minimize systemic absorption and to prevent drainage of solution from the intended area.

90. Instructions for use of ophthalmic ointments,gels Wash the hand thoroughly with an antibacterial soap. Without touching the tip of the tube, remove the cap form the ointment or gel container. Tilt head slightly backward. With one finger, pull the eyelid down to form a pouch Squeezing the tube carefully to avoid touching it to the eye, apply the recommended amount of ointment or gel to the pouch inside of eyelid. Release eyelid and close the eye, keeping it closed for 1-2 min. While eye is closed, distribute the medication by moving the eye.

91. ????????? (Eye irrigation) Loose foreign material in the eye Eyewash or eye lotion Sterile isotonic solution: boric acid, sodium borate, sodium chloride, purified water (packaged with eyecup (11-12 ml)) How to irrigate: Rinse eyecup with clean water or eyewash before use Eyewash is placed in the cup until it is half filled Patient bends over until the periorbital area is surrounded by the rim of eyecup Open eye and tilts the head back until the eyecup bath ocular tissue Eyeball must be rotated to ensure through bathing Alternatively way, hold the head over a sink, holding eyewash at angle slightly away from the eyes, solution will stream across the surface of eye.

92. Contact lens Major types of lenses: 1) Rigid (gas-permeable): more durable and easier to care but more difficult to tolerate 2) Soft Soft lenses are also available for extended wear Disposable soft lenses to avoid necessity for lens cleaning, and sterilization are available for daily or extended wear. Contact lens care: cleaning and sterilization, removal of protein deposits.