1)	Fibrous Tunic

a)	cornea-.

b)	sclera-

2)	Vascular Tunic

a)	iris-

b)	ciliary body-

c)	choroid-

3)	Nervous Tunic

a)	retina-
b)	retinal pigment epithelium- Contains photoreceptors (rods and cones) Function- 

**The macula lutea is located in the center of the retina, composed mostly of cones. 
**The  fovea centralis is contained within the macula . Damage to the fovea reduces the 
   ability to see straight ahead. 
**Rods are not in the macula, but rather in the periphery of the retina. Damage to these 
  results in night blindness, however, visual acuity for objects straight ahead remains intact.  
An opacity or clouding of the lens that blocks the passage of light needed for vision.

Etiology is unknown, but it is known to form slowly with age. Can result from trauma, or 
exposure to poisons such as naphthalene.

blurred vision
double images
obliteration of parts of images
decreased perception of color
distorted images

**If cataract is not removed, vision will progressively deteriorate. The lens will enlarge 
causing increased intraocular pressure (IOP), resulting in Glaucoma. 

Surgical removal
Extracapsular extraction with implantation of intraocular lens (IOL)
Lens capsule is incised and lens cortex and nucleus are removed.
Small-incision phacoemulsification with posterior chamber IOL 
Fragmenting of lens nucleus with ultrasonic vibrations and aspiration of lens fragments.
Intracapsular extraction with implantation of anterior chamber IOL
Removal of entire intact lens.

When requiring cataract surgery in both eyes, several weeks are allowed to elapse between 

Most cataract operations are performed in outpatient settings. Patients are usually discharged
 within a few hours of surgery.

ADLs are resumed as the patient feels able.
Instruct on methods to prevent increased IOP
Do not sleep on operated side x 3-4 weeks
Do not bend over below waistline
Avoid heavy physical activity x 6 weeks
Avoid sneezing, coughing, straining, vomiting
Alert pt. that vision may not be "normal" immediately after surgery
Instruct pt. To call Dr. if
Redness of eye increases or eye pain is severe
Discharge from eye increases or changes color (to greenish)
Vision decreases

**Third leading cause of blindness, can damage the eye without the person being aware of it.
**Eye disease characterized by increased IOP associated with progressive loss of peripheral 

**Occurs when there is a buildup of IOP due to blockage of aqueous humor. Can progressively 
destroy the optic nerve.

Classified as 
Open-Angle Glaucoma-hereditary, most difficult to diagnose. Caused by a reduction in the 
outflow of aqueous humor, due to obstruction in trabecular meshwork. 

Symptoms-frequent change in eye glasses without any improvement in vision
   - inability of eyes to adjust to darkened rooms
   - loss of peripheral vision
   - rainbow colored rings around lights
   - persistent dull eye pain
   - headaches

ophthalmoscopy-eval of color and configuration of optic disc
perimetry-measurement of central field of vision


-Carbonic anhydrase inhibitors (Diamox) a diuretic used in conjunction with topical agents 
 (eye drops), reduces the amount of aqueous humor produced. Watch for signs of potassium 
-Miotic eye drops  (pilocarpine), these constrict the pupil and contract the ciliary muscle,  
 increasing the outflow of aqueous humor. Decrease visual acuity particularly when poorly
-Beta-adrenergic blocking agents (timolol maleate), used to lower IOP by decreasing the 
 formation of aqueous humor. Little effect on pupil size, does not cause blurred vision or night 

Indicated when conservative treatment fails
-Trabeculoplasty-application of laser beam on trabecular meshwork, changes the configuration 
  and leads to increased outflow of aqueous humor (OP)
-Trabeculectomy-an opening is made under a partial thickness scleral flap allowing aqueous 
 humor to flow into the subconjunctival spaces. (ON)

-reduction in IOP
 Closed-Angle Glaucoma- Outflow of aqueous humor is impaired due to narrowing of the angle
 between the iris and cornea	

   -severe pain
   -decreased vision
   -pupil enlarged and fixed
   -colored rings (halos) around lights
   -eye red
   -steamy cornea

-Same as open-angle glaucoma

-Osmotic Diuretics (Mannitol) a diuretic used parenterally or orally to withdraw fluid from the
  body, in turn, rapidly reducing the production of aqueous  humor in the eye, and the IOP. 
  Primarily used to treat acute attacks, or in preparation for surgery. Not for chronic use.
-Carbonic anhydrase inhibitors-(see open-angle glaucoma)
-Miotic eye drops-(see open-angle glaucoma)
-Laser iridotomy-attempts to lower IOP by directly damaging the ciliary bodies (Permanently). 
 This procedure frequently needs to be repeated and pts are  at risk for severe inflammation, 
 retinal detachments, hemorrhaging and phthisis.
-Peripheral iridectomy-performed to form a permanent connection between the anterior and 
 posterior chambers. This prevents the iris from occluding the anterior chamber. 
 This procedure is performed when laser treatment is unsuccessful.

Important guidelines for teaching the person with Glaucoma
Preventive Measures
Always have reserve bottle of eye drops
Carry eye drops when away from home
Carry ID for glaucoma and eye drops
Be aware of location of closest 24 hr drugstore
Medications are required for a lifetime
Know name, dosage, frequency and side effects of meds.
Know signs and symptoms which must be reported immediately to MD.
Eye pain 
Sudden change in vision
Halos around lights
**Occurs when the two retinal layers separate as a result of a full thickness break in the 
  sensory retina. This will result in liquefied vitreous humor passing through into the 
  subretinal space. 
**As the detachment extends, blindness can occur because the macula detaches.

Myopic degeneration					
**May follow sudden, severe physical exertion in a debilitated individual.
**May occur suddenly or develop over time.

-floating spots or opacities before the eyes (blood and cells freed at time of tear)
-flashes of light (vitreous traction on the retina)
-progressive loss of vision in one area (curtain drawn before eyes)

Based on ophthalmoscopic exam of retina
**Prevention is based on early detection.
High risk individuals
diabetic retinopathy
high degree of myopia

Surgical Procedures-goal is to seal off areas of tears
chorioretinitis-inflammatory reaction at the site of tear that produces adhesions 
between the edges of the break and the choroid diathermy-needlepoint electrodes used to 
produce an inflammatory reaction photocoagulation-laser beam used to close the retinal tear 
cryotherapy-subfreezing temperatures used to produce inflammatory reaction
scleral buckling-sclera and choroid are indented toward area of break
pneumatic retinopexy-intraocular injection of air or gas to tamponade the tear

**A disorder of the blood vessels of the retina which usually appears about 10 yrs after 
  onset of DM.
**Can be detected in 65% of persons with Type I diabetes for 15 yrs and in 60% of older
   persons with Type II diabetes. 
**Responsible for 10% of newly reported cases of  blindness each year.

Pathophysiology-tiny microaneurysms develop in the retinal capillary walls, retinal veins widen 
and become tortuous, small hemorrhages develop leaving small scars in those areas. 
Protein leaks, causing retinal edema, especially in the area of the macula. 

-tortuous vessels
-"fluffy wool" exudates on the retina
-new vessel formation
As disease progresses
-multiple  spots or "floaters"	
-increasing loss of vision

-fluorescein angiography

-Type I DM see ophthalmologist w/I 3yrs of dx., then yearly
-Type II DM at dx and yearly
-DM women who are pregnant should be examined during 1st trimester, then q3mo
Complications  -may lead to massive retinal hemorrhage and retinal detachment

-Photocoagulation-laser is directed on the retina, damaging and scarring 
 the peripheral retina in order to decrease the ischemia which induces neurovascularization.
-Vitrectomy-MD removes the opaque bloody fluid and replaces it with NS, the fibrous or scar
 tissue that could pull on the retina and cause detachment.

-Pt. teaching Re: 1) DM, 2) importance of regular eye exams
-Assessing ability to admin insulin if vision is impaired 

**A disease of the aging retina, cause is unknown

**Results from degenerative changes to the choriocapillaries or the retinal pigment epithelium.	

Exudative (wet) type-characterized by sudden growth of new vessels in the macular region. 
Vessels are fragile and leak blood and fluid that damages the macula by interfering with 
the blood supply.

Non-exudative (dry) type-most common, caused by degenerative processes other than 
neovascularization. Scattered round spots (drusen) appear in the macular region. 

-Central vision loss in one or both eyes
-decreased ability to distinguish colors

-Amsler grid-distorted lines, spots or areas totally missing

-No acceptable treatment for dry type
-Laser Rx. If no new vessels growing in the center of the macula.



**CMV infection present in many individuals, only problematic when disease is evident

**Most common site for CMV disease in the HIV positive individual.

-blurred vision
-decreased vision
-may lead to blindness

-fundoscopic exam (one or many small white lesions "cotton wool spots" along vessels) 

-Gancyclovir (IV or PO) -anemia, phlebitis

-Foscarnet (IV) -renal failure, anemia

-Gancyclovir implants or intra orbitally		


Conductive Hearing Loss

Sensorineural Hearing Loss

Central Deafness

 Outer Ear
External otitis
- Pain
  Itching of ear canal


Foreign body-

Problems of tympanic membrane-Perforation-causes hearing loss. Some acute perforations 
will heal spontaneously. Myringoplasty-used if the perforation is only in the membrane with 
no other accompanying damage. Tympanoplasty is performed if 	the middle ear is involved. 
Post-op, don't blow nose, sneeze or cough with mouth open, avoid physical activity x1 week, 
keep ear dry x6 weeks (do not shampoo hair x1 week) avoid airplanes x1 week.

Middle ear
Infections-Otitis Media-. Throbbing pain, drainage, fever, bulging of the ear drum with possible 

Otosclerosis-hardening of the ear, (stapes), normal canal and ear drum, progressive 	
conductive hearing loss.

Trauma-to the tympanic membrane from a blast or blunt injury can cause a fracture or 
dislocation of the ossicle, facial nerve is also vulnerable.

Eustachian tube disorders-most common blockage due to enlarged adenoid tissue (children). 
In adults most common form of blockage is swelling during URI. Decongestants and a
ntihistamines are used to reduce swelling.

Inner ear
Infections-labyrinthitis, can be viral (most common) or bacterial

Tumors-acoustic neuroma of the eighth nerve, most common benign tumor, can sometimes 
spread out the ear canal into the Brainstem causing other problems
Balance disorders-Meniere's disease, characterized by a triad of symptoms, vertigo, 	
tinnitus and hearing loss. Affects CN VIII.



History- Onset 
- description and associated symptoms
- history of falls
- disability in relation to ADLs
- fears
- hearing acuity

Assessment-PE w/ emphasis on eyes, ears, thyroid, heart, lungs and Neuro exam
Diagnosis-audiometric testing, determine amt of hearing loss
   -magnetic resonance imaging, identify tumors, masses

Treatment-bed rest during attack
    -dimenhydrinate (Dramamine)
    -cyclizine hydrochloride (Marezine)
    -meclizine (Bonine, Antivert)
    -sedatives and hypnotics 

Nsg. Diagnosis-
Risk                  for injury falls
Fear		uncertainty of attacks
Anxiety		vertigo as threat to self concept
Fluid volume deficit	nausea, vomiting
Knowledge deficit	lack of exposure to information
-Move slowly, not turn head quickly

 Hearing Disorders-Sensorineural hearing loss most common inner-ear disorder. Factors that 
 affect the type and amt of hearing loss are:
-hereditary disease
-toxic substances
-noise-induced hearing loss
Noise-induced -major portion of hearing impairments among 35-65. Can be traumatic 
(sudden loud noise i.e. blast),over time from repeated injury from noise 
(major cause -industrial noise, firearms, second). Loss of higher frequencies.
Presbycusis- hearing loss associated with aging. More common after age 50. Hearing loss
of higher frequencies, accompanied by tinnitus.

Hearing aids-In-the-ear- for hearing loss of 25-65 dB; worn in ear concha
In-the-canal - for hearing loss of 25-50 dB; worn in ear canal
Postauricular- for hearing loss of 25-80 dB; worn behind the ear
All hearing aids consist of 1) microphone, 2) amplifier, 3) battery, and 4) receiver.

Care of hearing aid
1-turn off when not in use
2-open battery compartment at night to avoid draining the battery
3-keep extra battery available at all times
4-wash earmold frequently with mild soap and water with the use of pipe cleaner 
   to cleanse the cannula 
5-do not wear if ear infection


** A condition of deteriorating mentality, resulting in a loss of cognitive functioning. 

** Prevalence of dementia has been increasing due to increase in life expectancy.

Symptoms and behaviors
-short and long term memory impairment
-impaired abstract thinking
-impaired judgment
-personality changes

**There are three levels of dementia

Etiology- a complex of symptoms for which many causes have been identified. It develops as
 the result of two different types of processes.

Primary dementias- the result of  primary pathological changes taking place within the 
cerebral cortex.  Examples: Alzheimer's, multiinfarct dementia, Parkinson's dementia. 
They may also result from tumors of the nervous system or circulatory failure during 
cardiac arrest. 

Secondary dementias- result from factors external to the brain, such as drug interactions, 
metabolic disorders such as thyroid disease, or nutritional disorders that may be identified 
independently or in association with other conditions such as alcoholism, 

Delirium, a secondary dementia, characterized by acute onset of cognitive impairment, 
with change in LOC.


** Most common form of dementia accounts for 60-80% of all dementia cases
** Not a normal process of aging.
** In 1907 ,Alois Alzheimer published the autopsy findings from the brain of a 55 yo woman, 
who died after suffering from progressive dementia. Her brain had the following pathological 
-neurofibrillary tangles- abnormal nerve cells filled with tangles of fibers 	
-neuritic plaques- a cluster of degenerating nerve endings in the cerebral cortex. 
These occur in large concentrations in the area of the brain associated with learning and 
memory (hippocampus, band of Broca, frontal, parietal and occipital lobes)
Many neurotransmitters are deficient in Alzheimer's patients.
There are relatively few signs and symptoms and diagnosis is usually one of exclusion.

Associated risk factors-age

-family history

-parental age

-head injuries

-potassium channel dysfunction

-environmental factors

    -a slow, insidious onset
    -loss of sense of smell at an early age
    -lack of specific, focal neurological signs until later stages, when rigidity, slowing of 
     movement and abnormal gait may occur
    -deterioration in all areas of cognitive functioning with changes in personality,  mood,  
     and behaviors.
    -as the disease progresses, pts loose control over bowel and bladder, then swallowing
    -eventually, loss of all memory (global memory loss) and aphasia 

Diagnosis-by exclusion

Treatment-No cure.
    -Protection of dignity
    -Preservation of  functional status
    -Promotion of quality of life


**Frequently presents with symptoms characteristic of irreversible dementia, sometimes called 

** A mood disorder presenting with marked vegetative symptoms and acute confusion that 
   mimic the chronic cognitive disorder (dementia)

** The development of significant or persistent depressive symptoms is not the normal 
   emotional state of the majority of older persons.

** Some studies indicate that 15% of elderly living at home have significant symptoms, 
   with a higher prevalence rate in institutions. 
** Many times is treatable

** Suicide attempts are more likely to be successful in the elderly than younger persons. 

**Significant differences between depression and dementia
   - patient history 
   - patient's expression of symptoms to others
   - past personal or family history of depression
   - feelings of worthlessness, hopelessness
   - rapid onset frequently associated with a life event or situation
   - patient is aware of memory loss

symptoms- depressed mood most of the time
    - diminished interest or pleasure in all or most activities
    - significant wt. loss or gain
    - insomnia or hypersomnia
    - fatigue
    - feelings of worthlessness
    - difficulty making decisions
    - psychomotor agitation or retardation
    - recurrent thoughts of death
    - memory loss
    - confusion

      - Observe for any sudden or progressive change in appearance, speech, movement 
         or behavior
      - assess changes in cognitive functioning, complaints of memory loss, or difficulty 
      - physical status, drug regimens, nutritional status and use of substances is investigated 	
       (R/O infection, thyroid disease, cancer, medications)
      - follow-up on somatic diseases and identify if treatable or emotional


** Often described as acute brain syndrome, or acute confusional states

** 30-50% of elderly patients experience an episode of delirium during hospitalization.

** Approximately 25% of cognitively intact elderly patients developed delirium within 1 month 
   of admission.

Etiology-vascular insufficiency
 -electrolyte imbalance
 -post surgical/ICU psychosis
 -nutritional deficiencies
 -medications (toxicities, withdrawal)

Symptoms-easily distracted with the need to have questions repeated
    -rambling, incoherent speech
    -decreased LOC, difficulty arousing or staying awake
    -illusions or hallucinations
    -disorientation to person, place or time
    -memory impaired
    -disturbance in sleep-wake cycle
    -changes in psychomotor behavior: increased or decreased
    -features fluctuate and develop over a short period of time

Treatment-physiological support
    -review of medications
    -environmental support re-orientation
    -protection from injury

Short Portable Mental Status Questionnaire (SPMSQ) (Pfeiffer, 1975)
Mini-Mental State Exam (MMSE) (Folstein, Folstein & McHugh, 1975)
Cognitive Capacity Screening Examination (CCSE) (Jacobs, Bernhard, Delgado & Strain, 1977)
**All used to show the existence of organic brain disorder

**A behavioral syndrome that can appear as an isolated symptom or with other CNS 
   complications of AIDS

**Typically, motor problems precede other cognitive problems

Symptoms- Cognitive
    -memory loss
    -impaired concentration
    -mental slowing (less verbal)
    -disoriented x3
    -recent memory loss
    -easily distracted
    -apathy, withdrawal, depressed
    -agitation, confusion
    -unsteady gait
    -leg weakness
    -loss of coordination
    -ataxic gait 

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