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Anatomy and Physiology of the Auditory System

The ear is divided into three major areas: External (Outer) Ear: Used for Hearing Composed of: 1. Auricle: What most people call the ear Shell-shaped structure surrounding the auditory canal opening 2. External Acoustic Meatus (Auditory Canal) Short, narrow chamber 1 inch long by inch wide carved into the temporal bone of the skull In its skin-lined walls are the ceruminous glands, which secrete waxy yellow cerumen or earwax, which provides a sticky trap for foreign bodies and repels insects. Sound waves entering the auditory canal eventually hit the tympanic membrane or eardrum, and cause it to vibrate. The canal ends at the eardrum, which separates the external from the middle ear. Middle Ear: Used for Hearing Also called tympanic cavity: Small, air-filled, mucosa-lined cavity within the temporal bone. It is flanked laterally by the eardrum and medially by a bony wall with two openings, the oval window and the inferior, membrane-covered round window. The pharyngotympanic (Auditory/Eustachian) Tube runs obliquely downward to link the middle ear cavity with throat, the mucosae lining the two regions are continous.Normally, the pharyngotympanic tube is flattened and closed, but swallowing or yawning can open it briefly to equalize the pressure in the middle ear cavity with the external, or atmospheric pressure. This is an important function because the eardrum does not vibrate freely unless the pressure on both of its surfaces is the same. When the pressures are unequal, the eardrum bulges inward or outward, causing hearing difficulty and some earaches. The tympanic cavity is spanned by the three smallest bones in the body, the ossicles, which transmit the vibratory motion of the eardrum to the fluids of the inner ear. These bones are named for their shape Hammer or Malleus Anvil or Incus Sitrrup or Stapes When the eardrum moves, the hammer moves with it and transfers the vibration to the anvil. The anvil passes the vibration on to the stirrup, which presses the oval window of the inner ear. The movement of the oval window sets the fluids of the inner ear into motion, eventually exciting the hearing receptors. Internal (Inner) Ear: Equilibrium and Hearing Maze of bony chambers called the bony, or osseus, labyrinth Location: Deep within the temporal bone behind the eye socket Three Subdivisions: Cochlea Vestibule : situated between the semicircular canals & cochlea Semicircular Canals

Mechanisms of Equilibrium: The equilibrium receptors of the inner ear, collectively called the vestibular apparatus, can be divided into two functional arms, one responsible for : Static Equilibrium Within the membrane sacs of the vestibule are receptors called maculae that are essential to our sense of static equilibrium. The maculae report on changes in the position of the head in space with respect to the pull of gravity when the body is not moving. Because they provide information on which way is up or down, they help us keep our head erect. Each macula is a patch of receptor (hair) cells with their hairs embedded in the otolithic hair membrane, a jellylike mass studded with otoliths, tiny stones made of calcium salts. As the hair moves, the otoliths roll in response to changes in the pull of gravity. This movement creates a pull on the gel, which in turn slides like a greased plate over the hair cells, bending their hairs. This event activates the hair cells, which send impulses along the vestibular nerve to the cerebellum of the brain, informing it of the position of the head in space. Dynamic Equilibrium Receptors are found in the semicircular canals. Respond to angular or rotator movements of the head. Semicircular canals is about inch or 1.3 cm around, are oriented in the three planes of space. Thus, regardless of which plane one moves in, there will be receptors to detect the movement. Ampulla, a swollen region at the base of each membranous semicircular canal, is a receptor region called crista ampullaris or simply crista, which consists of a tuft hair cells covered with a gelatinous cap called

the cupula. When your head moves in an arclike or angular direction, the endolymph in the canal lags behind. Then, as the cupula drags against the stationary endolymph, the cupula bends like a swinging door with the bodys motion, and the impulses are transmitted up the vestibular nerve to the cerebellum. Bending the cupula in the opposite direction reduces impulse generation.

Anatomy and physiology of visual (eyes) The eye forms a visual image and projects it onto the sensory receptors (photoreceptors) of the retina. Accessory Structures The accessory structures of the eye include the: (1) eyebrows, (2) eyelids, (3) eyelashes, (4) conjunctiva, (5) lacrimal apparatus, and the (6) extrinsic eye muscles. Accessory Structures Eyebrows The eyebrows protect the eyes by (1) providing shade, and (2) they direct the movement of perspiration from the forehead away from the eyes. Eyelids (palpebrae) The eyelids, or palpebrae, (1) protect the eyes from foreign objects and (2) keep the eyes from drying by spreading lacrimal and other secretions and by covering the eyes. The inner surface of the eyelid is covered with a mucous membrane called the palpebral conjunctiva. Internally, the eyelids house the roots of the eyelashes and sebaceous glands. Large modified sebaceous glands of the eyelids are the Meibomian glands. The Meibomin glands proudce an oil-like secretion that functions to keep the eye moist. Upon blinking, the oily secretion spreads to the anterior surface of the eye where it slows evaporation. EYELASHES (1) protect the eyes from foreign objects and (2) help shade the eyes. CONJUNCTIVA The conjunctiva is a mucous membrane which covers (1) the inner aspect of the eyelid (palpebral conjunctiva) and (2) the anterior surface of the eye (ocular, or bulbar, conjunctiva) except the cornea. The conjunctiva is thin and transparent. Beneath the surface of the ocular conjunctiva, small blood vessels and the white portion of the eye (sclera) can be observed. The conjunctiva functions to (1) protect the eye by providing a site for sensory receptors(pain) and (2) produces lubricating mucus.

Lacrimal apparatus Each eye has a lacrimal apparatus. A lacrimal apparatus consists of the (1) lacrimal gland and (2) the structures which drain the secretions (tears) from the lacrimal apparatus. Each lacrimal gland is located superiorly and laterally to each eyeball. Lacrimal secretions (tears) from a lacrimal gland flow onto the upper conjunctiva through several small lacrimal ducts. Tears pass medially over the anterior surface of the eyeball and entertwo small openings (lacrimal puncta), one located at each medial margin of each eyelid. Each lacrimal punctum opens into a lacrimal canal, which drains into the lacrimal sac. Each lacrimal sac drains into a nasolacrimal duct, which enters the nasal cavity at the inferior nasal meatus (chamber under the bone called the inferior nasal concha. Extrinsic eye muscles

The six muscles which move the eyeball are called the extrinsic eye muscles. Four of the six muscles are named rectus muscles, and the two other muscles are named oblique muscles. The rectus muscles are further named by their position as the (1) superior rectus, (2) inferior rectus, (3) medial rectus, and (4) lateral rectus muscle, and the oblique muscles are named the (5) superior oblique and the (6) inferior oblique muscle Eye Movements

The medial and lateral rectus muscles function in eye movements in the horizontal plane. Because the medial and lateral rectus muscles are inserted along the horizontal axis of the eye, their contraction produces movement along the horizontal axis. The medial rectus muscle functions in eye adduction (movement of the eye toward nose) and the lateral rectus muscle function in eye abduction (movement of the eye away from nose). The remaining four muscles, the superior and inferiorrectus muscles and the superior and inferior oblique muscles, function in movement of the eye in the vertical plane moving the eye upward (elevation) and downward (depression). Because the superior and inferior rectus muscles are not inserted along the vertical axis of the eye, their contractions do not produce purely vertical movements (elevation and depression). When the eye is abducted, the superior and inferior rectus muscles exert the movements of elevation and depression, respectively. When the eye is fully adducted the superior and inferior oblique muscles exert the movements of depression and elevation, respectively. When the eye is in its forward position, all four muscles make contributions to elevation and depression. Structure of the Eyeball

The eyeball, which is mostly spherical in shape, is housed within and is protected by the bony orbit. Only a small portion of its anterior aspect is exposed to the external environment. Externally, the eye is surrounded by protective adipose tissue. Six muscles, the extrinsic muscles of the eye, control the movement of the eye. Internally, the eye is filled with fluids (humors) and is divided by the lens into an (1) anterior cavity (segment) - contains aqueous humor (2) posterior cavity (segment) - contains the vitreous humor (body). The wall of the eye consists of three layers (tunics). From outer to inner, they are the (1) fibrous tunic, the (2) vascular tunic, and the (3) sensory tunic. Structure of the Eyeball Wall of the Eye Fibrous tunic The fibrous tunic is the layer of tough dense connective tissue that surrounds the eye. The two components of the fibrous tunic are the sclera and the cornea. Vascular tunic The vascular tunic contains numerous blood vessels (vascular), pigments, and the intrinsic muscles of the eye. The components of the vascular tunic are the choroid, ciliary body, and iris. The intrinsic muscles of the eye describe the muscles found within the eye and include the muscles of the ciliary body, the ciliarymuscle, and the muscles of the iris. Neural tunic The neural tunic is the inner layer of the eye and is the retina.The retina consists of an inner neural layer and an outer pigmented layer. FIBROUS TUNIC

The outer fibrous tunic consists of the (1) sclera and the (2) cornea. Sclera The sclera is the tough, opaque white portion of the eyeball formed by fibrous connective tissue. It completely surrounds the eyeball except for two locations: (1) anteriorly, where it merges with the cornea and (2) posteriorly, where it is pier ced by the optic nerve. The sclera functions in (1) providing an attachment site for the extrinsic muscles, (2) gives the eye shape, and (3) provides protection Cornea The cornea primarily functions in (1) allowing light into the eye, (2) in focusing (refraction) of light, and (3) protection. The cornea is formed from fibrous connective tissue and is continuous with the sclera, the corneal-scleral junction is called the limbus. The cornea is the transparent anterior window of the eyeball and is the eyes primary structure for focusing incoming light. The external surface of the cornea is lined with stratified squamous epithelium (not the conjunctiva). Numerous free nerve endings, which primarily function as pain receptors, are located in the corneal epithelium. Internally, the cornea is formed from layers of transparent collagen fibers, collectively called the stroma. VASCULAR TUNIC Identify the middle vascular tunic, which consists of the (1) choroid, (2) ciliary body, and (3) iris.

Choroid The choroid is the highly vascular posterior portion of the vascular tunic. Its numerous blood vessels (1) supply nutrients to the fibrous and sensory (retina) tunics, and (2) its pigments absorb light. Anteriorly, the choroid joins the ciliarybody near the anterior margin of the retina, the ora serrata.

Ciliary Body The ciliary body is a region of the vascular tunic anterior to the choroid. It consists of the (1) ciliary muscle and the (2) ciliary processes. Ciliary muscle The ciliary muscle is a ring of smooth muscle that functions in the regulation of the shape of the lens. The epithelial surface of the ciliary muscle is modified into folds called ciliary processes. Ciliary processes The ciliary processes are folds formed from the epithelium that covers the ciliary muscle. The ciliary processes (1) secrete the fluid (aqueous humor) of the anterior cavity (segment) and (2) provide attachment sites for the suspensory ligament, which attaches to the lens.

Suspensory Ligament The suspensory ligament extends from the ciliary processes to the lens. It consists of fibers that (1) provide for positioning of the lens and for (2) the transfer of tension produced by the ciliary muscle in the regulation of the shape of the lens. Iris and Pupil Iris The iris is the most anterior portion of the vascular tunic. The iris extends anteriorly from the ciliary body and divides the anterior cavity (segment) into the anterior (in front of iris) and posterior (behind the iris) chambers. The iris regulates the amount of light that enters the eye. Two groups of smooth muscle fibers, the dilator fibers and the sphincter (constrictor) fibers, control the diameter of the pupil, the central opening in the iris. The dilator fibers, which dilate, or increase the diameter of the pupil, are controlled by the sympathetic division of the autonomic nervous system (ANS). The sphincter (constrictor) fibers, which decrease the diameter of the pupil, are controlled by the parasympathetic division of the ANS. Pupil The pupil is the central opening in the iris SENSORY TUNIC (RETINA) The sensory tunic, or retina, is the inner tuni. The retina consists of the (1) inner neural (nervous) layer and an (2) outer pigmented layer. The neural layer of the retina consists of three major groups of cells. From outer to inner the cell layers are the (1) photoreceptors, (2) bipolar cells, and (3) the ganglion cells. c of the eye. Neural Layer Seven Layers A more detailed description of the retina divides the neural portion of the retina into seven layers. From outer to inner the layers are the (1) rods and cones, (2) outer nuclear layer, (3) outer plexiform layer, (4) inner nuclear layer, (5) inner plexiform layer, (6) ganglion cell layer, and (7) the layer of optic nerve fibers. Sensory Tunic Plexiform Layers The plexiform layers are regions that contain nerve fibrils (axons and dendrites) and synapses. Retina Outer Layer The outermost layer of the neural retina, the layer of rods and cones. This layer contains the light receptive elements of the photoreceptors that are either rod or cone shaped. The nuclei of the photoreceptors are located in the outer nuclear layer of the retina. The photoreceptors terminate with synapses to the bipolar cells in the outer plexiform layer. The rods do not respond to different wavelengths of light (color), thus, are only responsible for producing images without color (black and white). Rods also perform best under low light conditions. Cones function in color reception and perform best under higher light than allowed for rods. There are three varieties of cones, (1) red sensitive cones, (2) green sensitive cones,and (3) blue sensitive cones. Even though each cone is most sensitive in its named wavelength, overlapping sensitivity produces responses for the full color spectrum. Bipolar and Ganglion Cells Bipolar Cells Bipolar cells are neurons that have two processes associated with their cell body. Their receptive portions (dendrites) are found in the outer plexiform layer associated with the photoreceptors (and amacrine cells). The bipolar cells terminate with synapses to the ganglion cells in the inner plexiform layer. Ganglion Cells The receptive portion of the ganglion cells is in the inner plexiform layer where they synapse with bipolar cells (and horizontal cells). The axons of the ganglion cells form the layer called the ganglion nerve fibers (ganglion axons ) that converge at the optic disc to form the optic nerve. Macula Lutea The macula lutea is a region of the retina which contains only cones. An ophthalmoscopic view of the macula lutea reveals it to be a dark area lateral to the optic disc, the exit point of the optic nerve. Fovea Centralis The fovea centralis is a small pit located at the center of the macula lutea. In humans the fovea centralis contains only cones and is the area of most acute vision. The visual axis, the focal point of light through the eye, falls directly upon the fovea centralis. Optic Disc (Blind spot) The optic disc consists of axons of the ganglion cells (layer of nerve fibers) that converge and exit the eye as the optic nerve. The optic disc is called the blind spot because it does not contain photoreceptors (retina is absent at this location).

Ophthalmologists and opticians routinely examine the optic disc for pathology during eye examinations. The normal optic disc is observed as a white area with a slight depression called the optic cup. Also seen at the optic disc are the central artery and vein, two major blood vessels that vascularize a major portion of the retina by routing through the optic nerve. The outer retina (photoreceptors) receive most of their vascular supply from the choroid, and the inner retina (bipolar and ganglion cells) are vascularized by the central artery and vein. Segments and Chambers Anterior cavity (segment) The anterior cavity (segment) is the cavity anterior to the lens. It contains aqueous humor and is divided by the iris into the anterior and posterior chambers. Anterior chamber The anterior chamber is the division of the anterior cavity that is anterior to the iris (and posterior to the cornea). It contains aqueous humor. Posterior chamber The posterior chamber is the division of the anterior cavity that is posterior to the iris (and anterior to the lens). It contains aqueous humor. Posterior cavity (segment) The posterior cavity (segment) is the cavity located posterior to the lens. The posterior cavity contains the fluid called vitreous humor (body). Because the vitreous humor is firm and gelatinous, the term body is frequently used to replace humor (fluid). AQUEOUS HUMOR Location, production, and Reabsorption The aqueous humor is the fluid in the anterior cavity (segment). Aqueous humor is produced at the ciliaryprocesses by capillary filtration. From the ciliary process, the aqueous humor flows into the posterior chamber, then passes through the pupil into the anterior chamber. From the anterior chamber, aqueous humor enters into the scleral venous sinus (canal of Schlemm) at the inner junction of t he sclera and the cornea, then enters venous circulation. Lens The lens is a biconvex structure formed of layers of cells called lens fibers. The lens functions in the focusing of light onto the retina. The lens is attached to the suspensory ligament, which transfers tension from the ciliary muscle to the capsule of the lens. Contraction and relaxation of the ciliary muscle function in the regulation of the shape (curvature) of the lens. Changing the curvature of the lens changes its refraction (bending light), thus allowing focusing of light onto area of the retina of acute vision, the fovea centralis.

Diagnostic/ Laboratory Examinations for Disturbance in Visual Perception Direct Ophthalmoscopy A direct ophthalmoscope is a hand-held instrument with various plus and minus lenses. The lenses can be rotated into place, enabling the examiner to bring the cornea, lens, and retina into focus sequentially. The examiner holds the ophthalmoscope in the right hand and uses the right eye to examine the patients right eye. And switches to the left to examine the left eye. Indirect Ophthalmoscopy The indirect ophthalmoscope is an instrument commonly used by the ophthalmologist to see larger areas of the retina, although in an unmagnified state. Slit-Lamp Examination The slit-lamp is a binocular microscope mounted on a table. This instrument enables the user to examine the eye with magnification of 10 to 40 times the real image. The illumination can be varied from a broad to a narrow beam of light for different parts of the eye. Color vision Testing The ability to differentiate colors has a dramatic effect on the activities of the daily living (ADLs).

Amsler Grid The Amsler grid is a test often used for patients with macular problems, such as macular degeneration. It consist of a geometric grid of identical squares with a central fixation point. The grid should be viewed by the patient wearing normal reading glasses. Each eye is tested separately. Ultrasonography Lesions in the globe or the orbit may not be directly visible and are evaluated by ultrasonography. Ultrasonography is a valuable diagnostic technique, especially when the view of the retina is obscured by opaque media such as cataract or hemorrhage. Ultrasonography can be use to identify orbital tremors, retinal detachment, vitreous hemorrhage , and changes in tissue composition with minimal discomfort for the patient. Optical Coherence Tomography Is a technology that involves low-coherence interferometry. Light is used to evaluate retinal and macular diseases as well as anterior segment conditions. The method is noninvasive and involves no physical contact with the eye. Color Fundus Photography Is used to detect and document retinal lesions. The patients pupil are widely dilated before the procedure. Flourescein Angiography Evaluates clinically significant macular edema, documents macular capillary nonperfusion, and identifies retinal and choroidal neovascularization (growth of abnormal new blood vessels) in age-related macular degeneration. Indocyanine Green Angiography Is used to evaluate abnormalities in the choroidal vasculature, conditions often seen in macular degeneration Indocyanine green dye is injected IV, and multiple images are captured using digital videoangiography over a period of 30s to 20min. Tonometry Measures IOP by determining the pressure necessary to indent or flatten (applanate) a small anterior area of the globe of the eye. Pressure is measured in millimeters of mercury (mm Hg) High readings indicate high pressure; low readings indicate low pressure. Perimetry Testing Evaluates the field of vision. A visual field is the area or extent of physical space visible to an eye in a given position. Its average extent is 65 degrees upward, 75 degrees downward, 60 degrees inward, and 95 degrees outward when the eye is in primary gaze. Diagnostic/ Laboratory Examinations for Disturbances in Auditory Perception Audiometry In detecting hearing loss, audiometry is the single most important diagnostic instrument. Audiometric testing is of two kinds: pure-tone audiometry, in which the sound stimulus consist of pure or musical tone and speech audiometry, in which the spoken word is used to determine the ability to hear and discriminate sounds and words. Tympanogram A Tympanogram, or impedance audiometry, measures middles ear muscle reflex to sound stimulate and compliance of the tympanic membrane by changing the air pressure in a sealed ear canal. Compliance is impaired with middle ear disease. Auditory Brain Stem Response Is a detachable electrical potential from the cranial nerve VIII and the ascending auditory pathways of the brainstem in response to sound stimulation. Electrodes are placed on the patients forehead. Electronystagmography Is the measurement and graphic recording of the changes in electrical potentials created by eye movements during spontaneous, positional, or calorically evoked nystagmus. Platform Posturography Is used to investigate postural control capabilities such as vertigo. It can be used to evaluate if the persons vertigo is becoming worse or to evaluate the persons response to treatment. Sinusoidal Harmonic Acceleration Sinusoidal harmonic acceleration, or a rotary chair, is used to assess the vestibulo-ocular system by analyzing compensatory eye movements in response to the clockwise and counterclockwise rotation of the chair.

Middle Ear Endoscopy With endoscopes with a very small diameters and acute angles, the ear can be examined by an endoscopist specializing in orlaryngology. Middle ear endoscopy is performed safely and effectively as an office procedure to evaluate suspected perilymphatic fistula and new-onset conductive hearing loss. RISK FACTORS FOR VISUAL DISORDERS : AGING Loss of lens transparency Clumping or aggregation of lens protein ( which leads to light scattering ) Accumulation of a yellow-brown pigment due to the breakdown of lens protein Decreased oxygen uptake Increase in sodium and calcium Decrease in levels of vitamin C, protein and glutathione ASSOCIATED OCULAR CONDITIONS Retinitis pigmentosa Myopia Retinal detachment and retinal surgery Infection (herpes zoster ) TOXIC FACTORS Corticosteriods, especially at high doses and in long-term use Alkaline chemical eye burns, poisoning Cigaratte smoking Calcium, copper,gold, silver and mercury, which tend to deposit in the pupillary area of the lens NUTRITIONAL FACTORS Reduced levels of antioxidants Poor nutrition Obesity

PHYSICAL FACTORS Dehydration associated with chronic diarrhrea, use of purgatives in anorexia nervosa, and use of hyperbaric oxygenation Blunt trauma, perforation of the lens with a sharp object or foreign body, electric shock Ultraviolet radiation in sunlight and x-ray SYSTEMIC DISEASES AND SYNDROMES Diabetes milletus Down syndrome Disorders related to lipid metabolism Musculoskeletal disorders RISK FACTORS FOR GLAUCOMA : Family history of glaucoma African- American race Older age Diabetes mellitus Cardiovacular disease Migraine syndromes Nearsightedness (myopia) Eye trauma Prolonged use of topical or systemic corticosteroids ASSESSMENT and SCREENING PROCEDURES : 1. 2. OCULAR HISTORY ViSUAL ACUITY

Visual acuity (VA) is acuteness or clearness of vision, which is dependent on the sharpness of the retinal focus within the eye and the sensitivity of the interpretative faculty of the brain.[1] Visual acuity is a measure of the spatial resolution of the visual processing system. VA is tested by requiring the person whose vision is being tested to identify characters (like letters and numbers) on a chart from a set distance. Chart characters are represented as black symbols against a white background (for maximumcontrast). The distance between the person's eyes and the testing chart is set at a sufficient distance to approximate infinity in the way the lens attempts to focus. Twenty feet, or six metres, is essentially infinity from an optical perspective.

20/20 vision is a term used to express normal visual acuity (the clarity or sharpness of vision) measured at a distance of 20 feet. If you have 20/20 vision, you can see clearly at 20 feet what should normally be seen at that distance. If you have 20/100 vision, it means that you must be as close as 20 feet to see what a person with normal vision can see at 100 feet.

EXTERNAL EYE EXAMINATION Commonly, the upper 2 mm of the iris are covered by the upper eyelid. The patient is examined for ptosis and for lid retraction. Sometimes the upper eyelid turns out, affecting the closure. The lid margins and lashes should have no edema, erythema, or lesions. The examiner looks for scaling or crusting, and the sclera is inspected. The normal sclera is opaque and white. Lesions on the conjunctiva, discharge, and tearing or blinking are noted. The room should be be darkened so that the pupils can be examined. The pupillary response is checked with a penlight to determine if the pupils are equally reactive and regular. A normal pupil is black. An irregular pupil may result from trauma, previous surgery, or a disease process. The patient eyes are observed in primary or direct gaze, and any head tilt is noted. A tilt may indicate cranial nerve palsy. The patient is asked to stare at a target; each eye is covered and uncovered quickly while the examiner looks for any shift in gaze. The examiner observes for nystagmus. The extra ocular movements of the eyes are tested by having the patients follow the examiners fi nger, pencil or a hand light through the six cardinal directions of gaze ( up, down,right,left,and both diagonals). This is especially important when screening patients for ocular trauma or for neurologic disorders.

Disturbances in Visual Perception Cataract A cataract is a lens opacity or cloudiness that leads to blurring of vision and eventual loss of sight. The opacity of the lens is caused by chemical changes in protein of the lens because of slow degenerative changes of age, injury, poison or intraocular infection. Cataracts rank behind only arthritis and heart disease as a leading cause of disability in older adults. Cataract is the leading cause of blindness in the world according to the World Health Organization (WHO)

Clinical Manifestations
Painless, blurry vision The person perceives that surroundings are dimmer Light scattering is common Experiences reduces contrast sensitivity, sensitivity to glare, and reduced visual acquity Myopic shift Astigmatism Monocular diplopia Color shift Brunescens Reduced light transmission

Glaucoma The term glaucoma is used to refer to a group of ocular conditions characterized by optic nerve damage. This nerve carries visual information from the eye to the brain. Damage to the optic nerve is due to increased pressure in the eye, also known as intraocular pressure (IOP). There is no cure for glaucoma but the disease can be controlled Classifications of Glaucoma: Acute (Narrow Angle or Close Angle) Eye disease that is characterized by suddenly impaired vision due to intraocular tension caused by an imbalance in production and excretion of aqueous humor. It is the result of an abnormal displacement of iris against the angle of the anterior chamber. Chronic (Simple, Wide Angle or Open Angle) Eye disease characterized impaired vision due to intraocular tension caused by an actual obstruction in the excretion of aqueous humor. It develops slowly, at first, symptoms may be absent. Permanent vision loss may occur before the individual is aware of having the disease. Clinical Manifestations
The first sign of glaucoma is often the loss of peripheral or side vision, which can go unnoticed until late in the disease.

Occasionally, intraocular pressure can rise to severe levels. In these cases, sudden eye pain, headache, blurred vision, or the appearance of halos around lights may occur. Seeing halos around lights Vision loss Redness in the eye Eye that looks hazy (particularly in infants) Nausea or vomiting Pain in the eye

Narrowing of vision (tunnel vision) Retinal Detachment Refers to the separation of the retinal pigment epithelium (RPE) from the sensory layer. Elevation of both retinal layers away from the choroid because of the presence of a tumor. Four type of retinal detachment: Rhegmatogenous detachment The most common form. In this condition, a hole or tear develops in the sensory retina, allowing some of the liquid vitreous to seep through the sensory retina and detach it from the RPE.

Traction retinal detachment A tension or pulling force is responsible for traction retinal detachment An ophthalmologist must ascertain all of the areas of retinal break and identify and release the scars or bands of fibrous material providing traction on the retina. A combination of rhegmatogenous and traction retinal detachment Patients can both have a combination of these two. Exudative retinal detachment Is the result of the production of a serous fluid under the retina from the choroid. Conditions such as uvietis and macular degeneration may cause the production of this serous fluid. Clinical Manifestations
Patients may report the sensation of a shade or curtain coming across the vision of one eye, cobwebs, Bright flashing lights, Or the sudden onset of great number of floaters. Patients do not complain of pain.

Retinopathy Refers to damage to the blood vessels of the retina. Some of the kinds of damage that your doctor may see in your retina are hypertensive retinopathy, a complication of high blood pressure (hypertension), and diabetic retinopathy, a complication of long-term diabetes. Retinopathy is usually a sign of another medical condition. Although several medical conditions (e.g., sickle cell disease, lupus) can cause retinopathy, the most common causes are diabetes and hypertension (high blood pressure). Clinical Manifestations
Early in diabetic retinopathy, there may be no symptoms at all. As the disease progresses, symptoms include: blurred vision fluctuating vision seeing floating spots blind spots changes in color perception sudden loss of vision double vision eye pain in advanced cases The earliest sign of diabetic retinopathy that your doctor may detect is the formation of microaneurysms - These are balloon outpouchings of small blood vessels in the retina that appear as tiny red dots at the back of the eye; they sometimes break, causing bleeding in the retina and cloudy vision. There may be no symptoms early in hypertensive retinopathy. However, as the condition progresses, symptoms include: headaches vision changes sudden loss of vision in one or both eyes double vision

Endophthalmitis Is an inflammatory condition of the intraocular cavities usually caused by infection. Noninfectious (sterile) endophthalmitis may result from various causes such as retained native lens material after an operation or from toxic agents. The 2 types of endophthalmitis: Endogenous endophthalmitis - results from the hematogenous spread of organisms from a distant source of infection (eg, endocarditis). Exogenous endophthalmitis - results from direct inoculation of an organism from the outside as a complication of ocular surgery, foreign bodies, and/or blunt or penetrating ocular trauma. Clinical Manifestations
progressive deterioration of vision light sensitivity pain and swelling around the eye

red eye Hypopyon

Panophthalmitis An inflammation of the inner eye which usually affects all the layers of the eyeball. The inflammation can also extend into tissue surrounding the eyeball. The infection can result from a penetrating injury to the eye, septicemia or can spread from pus-producing infection in another part of the body. Clinical Manifestations
Eye pain Ruptured eyeball Protruding eyeball Vision problems

Sympathetic Opthalmia Is a bilateral diffuse granulomatous uveitis (a kind of inflammation) of both eyes following trauma to one eye. The exact cause is unknown, but it is believed to be related to sensitivity to uveal pigment. The injured eye becomes inflamed first, and the other eye follows. Clinical Manifestations
White-yellow lesions called Dalen-Fuchs' nodules in the choroid (a blood-filled layer which provides oxygen and nutrients to the retina and lies between the retina and the sclera) Thickening of the uveal tract (middle layer of the eye). floating spots, reduced vision, pain in both eyes and increased sensitivity to light.

Uveitis Inflammation of the uveal tract can affect the iris, the ciliary body, or the choroid. The condition involves the middle layers of the eye, also called the uveal tract or uvea. Two types of uveitis: Nongranulomatous uveitis more common type of uveitis which manifests as an acute condition. The pupil is small or irregular, and vision is blurred. Granulomatous uveitis can have a more insidious onset and can involve any portion of the uveal tract. It tends to be chronic. Clinical Manifestations
Aching, painful eye(s) Red, bloodshot eye(s) Sensitivity to light (increased pain when eyes are exposed to light, called photophobia) Blurred, cloudy vision Floaters (random spots in the visual field) Disturbances in Auditory Perception

Menieres disease Is an abnormal inner ear fluid balance caused by a malabsorption in the endolymphatic sac or a blockage in the endolymphatic duct. Endolymphatic hydrops, dilation in the endolymphatic space, develops and either increased pressure in the system or rupture of the inner ear membrane occurs, producing symptoms of Menieres disease. Clinical Manifestations
Fluctuating, progressive sensorineural hearing loss Tinnitus or roaring sound A feeling of pressure or fullness in the ear An episodic, incapacitating vertigo, often accompanied by nausea and vomiting These symptoms range in severity from minor nuisance to extreme disability, especially if the attacks of vertigo are severe. At the onset of the disease, perhaps only one or two of the symptoms are manifested. Two subsets of the disease: Cochlear Menieres disease recognized as a fluctuating, progressive sensorineural hearing loss associated with tinnitus and aural pressure in the absence of vestibular symptoms or findings. Vestibular Menieres disease characterized as the occurrence of episiodic vertigo associated with aural pressure but no cochlear symptoms.

Otitis media Otitis" means inflammation of the ear, and "media" means middle which simply means inflammation of the middle ear. This inflammation often begins with infections that cause sore throats, colds or other respiratory problems, and spreads to the middle ear. Infections can be caused by viruses or bacteria, and can be acute or chronic. Two classifications: Acute otitis media - is usually of rapid onset and short duration. is typically associated with fluid accumulation in the middle ear together with signs or symptoms of ear infection; a bulging eardrum usually accompanied by pain, or a perforated eardrum, often with drainage of purulent material (pus, also termed suppurative otitis media). Fever can be present. Chronic otitis media - is a persistent inflammation of the middle ear, typically for a minimum of a month. This is in distinction to an acute ear infection (acute otitis media) that usually lasts only several weeks. Following an acute infection, fluid (an effusion) may remain behind the ear drum (tympanic membrane) for up to three months before resolving. - Chronic otitis media may develop after a prolonged period of time with fluid (effusion) or negative pressure behind the eardrum (tympanic membrane). Chronic otitis media can cause ongoing damage to the middle ear and eardrum, and there may be continuing drainage through a hole in the eardrum.

- Chronic otitis media often starts painlessly without fever. Ear pressure or popping can be persistent for months. Sometimes a subtle loss of hearing can be due to chronic otitis media. Clinical Manifestations
earache a high temperature (fever) of 38C (100.4F) or higher being sick lack of energy slight deafness pulling, tugging or rubbing their ear irritability poor feeding restlessness at night coughing a runny nose diarrhea unresponsiveness to quiet sounds or other signs of difficulty hearing, such as sitting too close to the television or inattentiveness

loss of balance Tympanosclerosis is a condition in which there is calcification of tissue in the eardrum and middle ear. If extensive, it may affect hearing. Tympanosclerosis may be classified as: Myringosclerosis - involving only the tympanic membrane. Intratympanic tympanosclerosis - involving other middle ear sites: the ossicular chain or, rarely, the mastoid cavity. Clinical Manifestations
significant hearing loss or chalky, white patches on the middle ear or temporal membrane

Acoustic neuroma is a benign tumor that develops on the nerve that connects the ear to the brain. This nerve is called the vestibular cochlear nerve. It is behind the ear right under the brain. The tumor usually grows slowly. As it grows, it presses against the hearing and balance nerves. Clinical Manifestations
Common symptoms include: Abnormal feeling of movement (vertigo) Hearing loss in the affected ear that makes it hard to hear conversations Ringing (tinnitus) in the affected ear Less common symptoms include: Difficulty understanding speech Dizziness Headache Loss of balance Numbness in the face or one ear Pain in the face or one ear Weakness of the face

Sensorineural hearing loss Was reffered to asnerver deafness in the past. is a type of hearing loss in which the root cause lies in the vestibulocochlear nerve (Cranial nerve VIII), the inner ear, or central processing centers of the brain. Sensorineural hearing loss can be mild, moderate, or severe, including total deafness. Clinical Manifestations
Symptoms of hearing loss may include: Certain sounds seem too loud Difficulty following conversations when two or more people are talking Difficulty hearing in noisy areas Hard to tell high-pitched sounds (such as "s" or "th") from one another Less trouble hearing men's voices than women's voices Problems hearing when there is background noise Voices that sound mumbled or slurred Other symptoms include: Feeling of being off-balance or dizzy (more common with Meniere's disease and acoustic neuroma) Pressure in the ear (in fluid behind the eardrum) Ringing or buzzing sound in the ears (tinnitus)