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Eye Anatomy

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Names of parts of the eye those are easy to see:
SCLERA - The sclera is the white part of the eye. It is the eyeball part of the eye.
IRIS - The iris is the brown color on the inside of the eye. Some times it may be blue
or green color, especially in Western people.
PUPIL - The pupil is the black hole that you see in the middle of the iris.
Names of the clear parts of the eye:
CONJUNCTIVA - The conjunctiva is a clear layer on top of the sclera. The conjunctiva
goes all the way around to the edge of the eyelid.
CORNEA - The cornea is a clear layer that is on top of the iris.
TEAR LAYER - The tear layer is on top of the cornea and conjunctiva.
LENS - The lens is inside the eye, behind the pupil.
Names of important parts around the eye:
EYELID - The eyelid is the skin that covers the eye when your eyes are
closed.
PUNCTUM - This is the name for the hole that is on the inside edge of the lower
eyelid, and on the inside edge of the lower eyelid, and on the
inside edge of the upper eyelid.
EYELASHES - The eyelashes are the hairs that are on the edge of the eyelids.
EYEBROW - The eyebrow is the row of hair that is above the orbit
ORBIT - The orbit is the hole in the head where the eye fits.
Names of parts you cannot see:
RETINA - The layer on the inside of the back of the eye.
OPTIC NERVE - The nerve that connects the eye to the brain.

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Purpose of Parts of the Eye


The SCLERA is ball of the eyeball. It is the basic structure of the eye and helps to
protect the parts of the eye that are inside the eyeball.
The IRIS is a round muscle that can become bigger or smaller. When the iris becomes
bigger of smaller, it is controlling the size of the pupil.
The PUPIL is only a hole, and the iris is what controls the size of the pupil. The pupil can
become larger to allow more light into the eye. The pupil can become smaller to allow less light
to come into the eye. If too much light comes into the eye, you are not comfortable. If not
enough light comes into the eye, you cannot see so well.
The CONJUNCTIVA provides a protective covering for the eyeball. The conjunctiva goes
all the way from the iris to the edge of the eyelids. You cannot loose something behind the eye
because the conjunctiva is in the way. The conjunctiva is a special layer with many blood
vessels that help to supply blood to parts of the eye.
The CORNEA is very special. You need a clear part on top of the iris and pupil so that
light can enter the eye and you can see. Injuries or infections to the cornea are very dangerous,
because if the cornea is not clear, light cannot get inside the eye and you cannot see.
The TEAR LAYER helps keep the eye wet. When the conjunctiva or the cornea
become dry, they become infected very easily.
The LENS is important for the eye to be able to change focus to keep the picture clear on
the retina. If the picture is not clear on the retina, we cannot see well. The lens also must stay
clear so that light can come inside the eye. If the lens is not clear, the light cannot reach the
inside of the eye and you cannot see.

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The EYELIDS help protect the eye and allow us to sleep. We have a reflex that causes
the eyelids to close when something comes close or the eye. The eyelids help spread the
normal tear layer around the eye.
The PUNCTUM is the small hole in each eyelid that helps the extra tears to drain out of
the eye.
The EYELASHERS and the EYEBROWS are there to help protect the eye. The eyelashes
and eyebrows help to keep dust, sweat and other things out of the eye.
The ORBIT is the hole where the eye is located. We have an orbit so that our eyes are a
little bit inside of our heads. This helps to protect the eyes from injuries and accidents.
The RETINA is a special nerve layer. The light comes into the eye and focuses on the
retina. This is the part of your eye that sees.
The OPTIC NERVE sends the picture from the retina to the seeing part of your brain.

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Eye Examination
Patient History
A good examination of the eye consists of three steps, and the examination should be done in
this order:
1. Patient History
2. Checking Vision
3. External Examination
As health workers you are already familiar that the patient history is important because it
can help you to identify the problem and help you to make a diagnosis and make the proper
treatment plan. The patient history always comes first. Even when you need to act quickly, such
as in the case of an accident or injury, you need to find out the cause of the accident before you
begin examination or treatment. The patient history for eye problems is about the same as the
patient history for other health problems. A basic outline for a patient history is as follows:
What is the problem/complaint?
How long have you had this problem?
Did it start suddenly or gradually?
What does the eye fell like (pain, itch, burning, sensitive to light, etc?)
Is there any change in vision?
Is the problem getting better or worse?
Did you try any medicine or treatment already? (What did you try?)
The patient history is about the same as a patient history for other health problems. One
important thing to remember about the eyes is that each eye is a separate patient and the history
for one eye may not be the same as the history as the other eye.
You want to record the reason that the person is coming for the eye examination in the
medical records. You also want to document any important information you get from the patient
history. You do not need to write down everything that the patient tells you, but you need to
make sure that your notes in the medical record have enough information that if another medic is
following up on your patient, they will understand what is going on.

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Checking Vision
To check vision you need to use an eye chart. There are many kinds of eye charts. Look
carefully at the eye chart that you have available to use. On the chart there will be instructions
about what distance to use. Most charts are made to be used at 6 meters. Some charts are
made to be used at 3 meters. Here are the important steps in checking vision.
Preparing
Chart must be placed at the proper distance, with good light and no glare. It is
best to put the chart about the same height as the eyes. If the chart is too close, it is too easy to
see the letters. It the chart is too far, it is too difficult to see the letters.
Instructing
Explain to the patient that you need to determine what the vision is like in each
eye. Instruct the patient to point their finger in the same direction as the E that you point to on
the chart. If the patient does not understand, you can bring them close to the chart and show
them how the E points in different directions.
Testing
Test the vision EYE BY EYE. Check the right eye first. Do not block the view of
the chart with your body or with your pen or pointing stick.
Recording
Record results eye by eye in the medical record. Write a large V with an R and
an L to indicate right and left eye. Put the best vision measured for the right eye next to the R.
Put the best vision measured with the left eye next to the L. The vision is the number next to the
smallest line that the patient can see clearly. To record the vision you can write like this:

R 20/50
L 20/30

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Eye Chart
Some charts will use different kinds of numbers for measuring vision. The charts used in
this program will use 20 measurements, which is the most common measurement for vision.
Some charts will use numbers like6/6, 6/12, 6/18 etc. or numbers like .9, .8, .5, etc. Some charts
will use English letters, numbers, letters from other languages, or pictures to measure vision.

Because you want to check the vision EYE BY EYE, the eye that you are not testing needs to be
covered. When checking vision, check the vision of the right eye first. To do this you must cover
the left eye. The patient can cover the left eye with their hand. Have them cover the eye with the
palm of their hand. They should not cover their eye with the fingers of their hand.

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Pinhole Test
Pinhole testing is another way to check vision. Pinhole testing is useful because it can
help you to decide if bad vision is due to needing eyeglasses, or if bad vision is due to a health
problem inside the eye. If the vision is normal, you do not need to do the pinhole test. Vision that
is 20/40 or better is normal. We do the pinhole vision test the same was that we do the regular
vision testing. The only difference is that we must put the pinhole in front of the eye that we are
checking.
If the vision is bad, the cause of the bad vision might be because the patient needs
eyeglasses, or might be because there is another problem with the eye. If there is a problem on
the outside of the eye, we can usually determine this from the external eye examination.
Sometimes there is a problem inside the eyeball, but we do not have special instruments to look
in side the eye. Doing the pinhole test in cases of bad vision can help us to decide if the patient
should be referred for eyeglasses or other problems.
If the vision improves when looking through the pinhole, then at least part of the problem
is because the patient needs eyeglasses. If the vision does not improve when looking through
the pinhole, then eyeglasses may not help and there may be another problem.
We write the results of the pinhole test the same way that we write the results of the
regular vision test, only we add the note pinhole under the V:
R 20/40
L 20/30
Pinhole
Even if you do not have an eye chart to check the vision, the pinhole test can be used. Have the
patient look through the pinhole and ask them if their vision is better with the pinhole, or better
without the pinhole.

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External Examination
After you have taken the patient history
and have checked the vision, you will
need to do an external examination of
the eyes. Before touching the patient
or the patientCs eye, you should always
wash your hands. Washing your hands
will help prevent the spread of infection.
You will actually start examining the eyes during the patient history. When you are
taking the patient history, sit or stand in front of the patient and look at the eyes. Do the eyes
appear normal and healthy as you sit or stand across from the patient during the patient history?
When you are ready to take a close look at the eyes, you will need to have good light. If
you have a good torch, you can examine the eyes by using the light of the torch. If you do not
have a good torch, you will need to use sunlight to examine the eyes. If you do not have a torch,
you will want to move the patient next to a window, a doorway, or take the patient outside in the
patient next to a window, a doorway, or take the patient outside in the sunlight to examine the
eye.
Another thing to remember about to external examination of the eye is to get close to the
eye. If you are one or two meters away from the patientCs eyes, you cannot see the details of the
eye well enough to know if they are normal or not. Do not be afraid to get very close to the
patients eye. The closer you are to the eye, the easier it is to see small details. What you want to
determine with the external examination is if the eye looks normal and healthy.
You want to look at each part of the eye carefully. You want to check to see if everything
looks normal or not normal. Start with the general appearance. Is there any redness. Swelling or
discharge around any parts of the eye?
Are the white parts of the eye white? Do the eyelids look normal and open and close
normally? Do the eyelashes look normal? The eyelashes should always point out, away from the
eye. Is there any crust or discharge around the eyelashes or at the edge of the eyelids?
Come closer to the eye and look at the cornea. Is the cornea clear? Is the cornea wet
and shiny? (Remember - a wet cornea is a happy cornea!) Do the iris and pupil look normal?
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The pupils should be round and the same size in both eyes. The pupil should respond to light by
getting smaller.
You also must look underneath the eyelids when you examine the eyes. It is easy to look
under the bottom eyelid. Just pull the bottom eyelid out and look carefully at the conjunctiva that
is on the inside of the bottom eyelid. To look under the top eyelid takes a little bit of practice.
Pull out gently on the middle of the top eyelid. Hold the eyelid by the eyelashes between your
first finger and your thumb. With your other hand, use a cotton bud, a small stick or a similar
object (such as a pen ) to help you turn the eyelid. Place the cotton bud in the center of the
eyelid, above where you are holding the eyelashes. After you have the cotton bud in place, pull
up with your hand that is holding the eyelashes.

Once the eyelid is up, you can keep it in place by using your finger or thumb. Hold the
lid up by the lashes, not by the conjunctiva in side the eyelid. You want to avoid holding up the
eyelid by the conjunctiva because you want to be able to see all of the conjunctiva and because
you want to avoid touching a conjunctiva that might be infected. Look very carefully at the
conjunctiva under the eyelid.

Wash your hands when you finish you examination


Write down your external examination results in the medical records. You may not always
be able to make a diagnosis, and that is OK. The important thing is to document what is NOT
normal about the eye or eyes. Be sure that you note if the problems you see are in one eye or in
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both eyes. You can abbreviate R for right eye and L for left eye. Your notes should be complete
enough that another health worker can understand the problem from reading the medical
records.

Examining Children
Examining the eyes of small children can be difficult. To examine small children, wrap
the child in a cloth or blanket. Have the mother hold the child on her lap, with the head of the
child on your lap.

A Normal Healthy Eye


1. The eyelids should open and close normal
2. The conjunctiva should be clear (on top of the sclera and underneath the eyelid)
3. The cornea should be clear and wet (a wet cornea is a happy cornea)
4. The pupil should be black
5. The eyelashes should point out
6. The vision should be good

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Trachoma
Cause of trachoma
Trachoma is an infection that occurs in the eyelid and is caused by the Chlamydia
organism which is closely related to bacteria. It is one of the leading causes of blindness in the
world. Trachoma spreads very easily from one person to another person.
There are many ways to spread the trachoma infection. We can reduce the amount of
trachoma and prevent the spread of the infection by learning how this infection is spread.
Discharge from the eye can carry the trachoma infection. If you have trachoma, you can rub
your eye with a cloth, and then another person rubs their eye with the cloth, the trachoma
infection can spread to the other personCs eye. If you rub your eye with your hand and then touch
another personCs hand, then the other person rubs their eye with their hand, the trachoma
infection can spread. Some types of flies like to land near the eye. These flies can spread the
trachoma infection from one eye to another personCs eye. People who play close together or
sleep close together can spread to trachoma infection easily by direct con tact or by bed cloths
such as sheets or pillows.

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Diagnosis of trachoma
Sometimes people with trachoma will have red eyes and may look like they have
conjunctivitis. Sometimes the eyes will be itchy and there may be mild watery discharge.
Sometimes there are no symptoms at all. The only way to know for sure is to look carefully
underneath the top eyelid. You must look underneath the top eyelid of any person who
complains about eye problems.

1. The first sign you will see in the trachoma infection is the presence of follicles, or small bumps
underneath the top eyelid. These small bumps are white or yellow. If you have five or more
follicles in the middle part of the top eyelid, you can make a diagnosis of trachoma. We can
abbreviate this stage of the trachoma infection as TF, for trachoma with follicles.

TF (Trachoma with Follicles


2. Another sign in some trachoma infections is redness or inflammation under to top eyelid.
Sometimes you will have inflammation and follicles together. The inflammation will make it
difficult to see the normal blood vessels under the top eyelid. If the inflammation prevents you
from seeing at least 50% (one half) of the normal blood vessels underneath the top eyelid, you a
diagnose trachoma. This stage of trachoma is abbreviated TI, for trachoma with inflammation.
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TI (Trachoma with Inflammation)


3. After a person has a trachoma infection for some time, the redness and the follicles will cause
scarring underneath the top eyelid. If you look underneath the top eyelid and you see white
areas where you cannot see the normal blood vessels, you have eyelid scarring. This scarring
may make it difficult to turn the eyelid over for examination. This scarring can also cause the
eyelashes to turn in and point towards the cornea. Anytime you see scarring under the top
eyelids, you must look very carefully at the eyelashes to see if they are turning in towards the
cornea. We can abbreviate this stage of trachoma as TS, for trachoma with scarring.

TS (Trachoma with Scarring)


4. If there is enough scarring on the eyelid, the eyelashes turn in towards the cornea. We call this
condition trichiasis. Trichiasis means that some or all of the eyelashes are turning in toward the
eye instead of out. The eyelashes rub on the cornea whenever the person closes their eye. We
can abbreviate this stage of trachoma as TT, for trachoma trichiasis.

TT (Trichiasis)
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5. When the eyelashes are turned in (trichiasis), they rub on the cornea. This rubbing can lead to
a corneal opacity (scar). Where the cornea is scratched can easily become infected by bacteria
or viruses. The scars from trichiasis can cause vision loss because the cornea is not clear
anymore. Sometimes, if there is an infection in the scratched area of the cornea, the infection
may cause a scar and also cause vision loss. Vision loss from trachoma is due to damage and
scarring to the cornea. This is abbreviated CO, for trachoma with corneal opacity (scar on the
cornea).

Co (Corneal Opacity)

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Active Trachoma Infections


Follicles and Inflammation are both signs of active trachoma infection. The
Chlamydia organism is present when you see either trachoma with follicles (TF) or trachoma with
inflammation (TI). If you see follicles (TF) or inflammation under the top eyelid, you need to treat
with tetracycline ointment.
Tetracycline eye ointment is effective against active trachoma infections.
Terramycin ointment contains tetracycline, so Terramycin ointment is effective to use against
trachoma infection. The ointment should be used four times a day in both eyes until four tubes of
ointment are finished. Sometimes trachoma infections are very stubborn and need to be treated
a second time. It is a good idea to ask the patient to come back when the four tubes are finished
so that you can check again.
You need to review the instructions carefully with the patient (or mother of the
patient). They need to understand how many times to put the ointment in each day, how long to
use the ointment and the importance of good personal and family hygiene.
People can get infected with trachoma many times. Most active trachoma
infections are found in children. A child may have had trachoma infections many times and the
scarring slowly develops as they are adults, the trichiasis causing corneal scars when they are
older. It is possible to see scarring and corneal opacities in children and young adults, but
usually it will be older people.
When you find a patient with trachoma, you should ask to see all of the people
who live in the same house sot that you can also exam the others for trachoma. If you find
trachoma in a child, it is common to fine that some of the brothers and sisters also have
trachoma. If you have enough tetracycline ointment, it is a good idea to treat the entire family,
even if not all of them have trachoma.

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Inactive Trachoma Infections


If you do not see follicles or inflammation under the eyelid, you do not have an
active trachoma infection. Scarring (TS), trichiasis (TT) or corneal opacities (CO) are not active
trachoma infections. They are signs from trachoma infections from before. You do not need to
treat these stages with tetracycline ointment.
If you have only lid scarring (TS) then you need to monitor the patient every 4 -6 months.
The trichiasis can develop slowly, even if there are no longer active trachoma infections, so you
must check to see if trichiasis develops.
In all cases, you must look very close for trichiasis. Sometimes most of the
eyelashes are turned out normally and only a few are turned the eye and the patient already
pulled the eyelashes out. If you see any eyelashes turned in towards the eye, you need to pull
them out. The eyelashes will grow back in one or two weeks, so the eyelashes have to be pulled
out regularly to prevent damage to the cornea. As it may be difficult for the patient to come and
see you every week, it is good to teach a responsible family member how to remove the
eyelashes.
Because the trichiasis may have been scratching the cornea already, you should
give the patient with trichiasis, two tubes of tetracycline ointment to use. This will help prevent
infections to the cornea.
When they are removing the eyelashes regularly, there should be no danger to the cornea.
Patients with trichiasis must be counseled about the importance of continuing to
remove the eyelashes. If there is no corneal damage, removing the eyelashes regularly can
prevent corneal damage from happening. If there is a corneal opacity already, removing the
eyelashes will prevent the corneal damage from becoming worse.
You should also keep a list of all patients in your area that have trichiasis.
Sometimes it is possible to do surgery to repair the trichiasis. If an eye surgeon comes to your
area, you will then be prepared with names of patients for the doctor to look at for possible
surgery. With no eye surgery available, the patient must continue to remove the eyelashes that
turn in towards the eye,

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Removing Eyelashes
To pull out eyelashes, you need to have good light. If you do not have a good
torch, use sunlight. To be safe, you should have the patient lie down on a bench and keep
children and other people away who may disturb you. You do not want anyone to bump into you
when you are pulling the eyelashes.
To pull eyelashes out of the top eyelid, you will want the patient to look down so
that the cornea is safely out of the way when pulling the eyelashes. If you are pulling lashes from
the lower lid, you will want the patient to look up. With tweezers, pull from as near the base of the
eyelash as you can. It is better to put gently and steadily that it is to pull fast. If done well, the
patient will not feel anything. Tweezers with a wide tip generally are better to use than tweezers
with a small pointed tip.

Prevention of Trachoma
Trachoma is the leading cause of preventable blindness in the world. Trachoma
can be prevented by improving personal, family and community hygiene. Washing the hands
and face every day in very important in preventing trachoma. Families need to understand that
making sure the children wash hands and face every day will help prevent the spread of
trachoma. When you see trachoma in a child, you should suspect that the trachoma infection
might be in other children in the same house. You should ask to see all the brothers and sisters
of the child with trachoma so that you can treat all who are infected and give instructions
regarding improving hygiene.

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In areas where flies are a problem, the spread of trachoma infections can be
reduced by making sure that rubbish and trash is disposed of properly so that flies are not
attracted to the area. Flies are also attracted to animals such as cows and pigs, and latrines.
Animals should be kept away from the house and latrines should be built properly and used
properly so that flies are not attracted to the area.
People in your area may not understand that keeping clean is important in
preventing blindness. People also may not understand that eye infections in children can lead to
blindness later in life. You can help to educate the people in your community about this to help
prevent the spread of trachoma. All trachoma patients and the families of the trachoma patients
should have these things explained to them.
Trachoma is very common in small children. It would be a good idea to check all
of the school children twice a year. It would also be a good idea to check all children in the MCH
clinics twice a year. You will probably find more trachoma in the dry season than during the rainy
season. If you find a lot of trachoma in the school children, you may want to arrange with the
teacher to educate the children about the causes and prevention of trachoma.

Treatment of Trachoma
TF (Trachoma with follicles) and TI (Trachoma with inflammation)
1. Give four tubes of terramyacin ointment (tetracycline) to be used four times a day in
both eyes. Return to clinic after ointment finished for re evaluation. (May need
another round of treatment.)
2. Eyes and face to be washed four times a day (before putting in ointment). Discuss
importance of good hygiene with patient and family.
3. Examine all members of the family of the trachoma patient. Treat all with signs of
active trachoma infection, consider treating entire family if you have enough ointment,
even if signs of infection not present.

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TS (Trachoma with scarring)
1. Ask patient to come to clinic each 4 - 6 months to check for trichiasis.
2. Ask patient to return to clinic right away if pain, itching in eyes.
TT (Trachoma with trichiasis) and CO (Coneal opacities from trachoma)
1. Pull all trichiasis eyelashes out. Show a responsible family member how to safely pull
out trichiasis eyelashes.
2. Explain to the patient and to the patients family the importance of keeping the
eyelashes pulled that are turning in.
3. Give eye ointment (2 tubes) to prevent infection of cornea. This is prevention in case
to trichiasis has scratched the cornea already. After the eyelashes are pulled every
week (or as needed) there should be no problem with cornea infections from
trichiasis.
4. Add patients name to your eye surgery list.
5. Ask the patient come to see you every few months or anytime there is pain or itching
of eyes so that you can rule out corneal scratches or infections and check to make
sure the patient is following instructions.

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Xerophthalmia
Vitamin A deficiency and Xerophthalmia
Your eyes and your body need vitamin a to stay healthy. Without vitamin A, you
can go blind or die. Vitamin A is also needed to help children grow. The eye is the only place
that you might see signs of vitamin A deficiency. It is possible to have vitamin A deficiency and
to look normal and healthy. Xerophthalmia is the name of the eye problems that are associated
with vitamin A deficiency.
Diagnosis of Xerophthalmia
Without vitamin A, you will not see very well at night. This is called night
blindness. Sometimes people will have a special way to say this, such as saying a person has
chicken eyes. Night blindness is often the first sign of xerophthalmia. A mother may notice that
her child is not very active and does not want to play like the other children as it is first starting to
get dark. If a mother reports this to you, assume vitamin A deficiency.
The next stage of xerophthalmia is dryness of the conjunctiva. The eye needs
vitamin A to stay wet. When there is not enough vitamin A, The tear layer will not be able to keep
the conjunctiva wet as usual. The conjunctiva and maybe the conjunctiva will also look old and
have a brown color. To diagnose this stage, you need to look carefully for an area of the
conjunctiva that does not stay wet after blinking.
BitotCs spots are the next sign you will see in xerophthalmia. BitotCs spots are
bubbles or foam on the conjunctiva. These spots will usually appear close to the cornea. They
might be white or gray or other colors. Sometimes you can remove part of the foam with a cotton
bud.

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Dryness of the cornea is the next stage of xerophthalmia. It is easy to see if the cornea becomes
dry as it does not reflect light well and does not look smooth.
If the cornea stays dry too long, it is in danger of getting infections from bacteria
or viruses. These infections are called corneal ulcers. If the cornea stays dry a long time, it can
start to become thin and develop holes. When the cornea becomes thin, we call this
keratomalacia. When there are corneal ulcers or keratomalacia, the eye can suffer permanent
vision loss.

When the cornea heals, there will be scarring on the cornea and it will not be
clear. The corneal scars are what cause blindness in vitamin A deficient eyes. Cornea scars are
permanent and are not a sign of active vitamin A deficiency.
The Stages of Xerophthalmia
1. Night Blindness
2. Conjunctival dryness (conjunctival xerosis)
3. BitotCs spots
4. Corneal dryness (corneal xerosis)
5. Corneal ulcer / keratomalacia
6. Corneal scarring

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Vitamin A deficiency can last a long time and slowly cause damage to the eye.
Sometimes there can be vitamin A deficiency and the eye shows only a little drying and maybe
no damage will occur. Sometimes when there is Vitamin A deficiency, if the child gets sick from
other causes, the eye signs can become rapidly worse and the eye can go blind in just a few
days.
Vitamin A deficiency can occur in anybody, but usually it will be in small children.
Most of the time those who suffer from vitamin A deficiency will be between one and six years
old. Most babies who are breast feeding will not have a problem with vitamin A deficiency as
breast milk contains vitamin A.

Treatment of Xerophthalmia
Treatment for Vitamin A Deficiency
All active forms of xerophthalmia, children age 1 year or more give
Day 1 200,000 IU
Day 2 200,000 IU
Day 8 200,000 IU
For child less than one year old (6 months - 12 months)
Day 1 100,000 IU
Day 2 100,000 IU
Day 8 100,000 IU
Children who are very sick (measles, severe diarrheas, respiratory tract
infections) and live in laces where xerophthalmia occurs, should be treated for xerophthalmia.
Children with corneal ulcer should also be treated for xeropthalmia, even if other signs of
xerophthalmia are not seen.
For treatment of women of reproductive age give
10,000 IU daily for two weeks
(or 25,000 IU once week) for 8 weeks

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This dose is recommended when the signs are night blindness, conjunctival
xerosis or BitotCs spots. If there is dryness of the cornea or evidence of corneal
ulcer/keratomalacia in women of reproductive age, the full treatment dose of 200,000 IU is highly
recommended, but this dose should only be given by a doctor.
All cases of corneal dryness should also be given 2 tubes of antibiotic eye
ointment to prevent the cornea from being infected. All patients seen with corneal
ulcers/keratomalacia must also be seen by the doctor. These patients must also be treated for
the corneal ulcer.

Prevention of Xerophthalmia
Children with vitamin A deficiency get sick easier than children who do not have
vitamin A deficiency. Of the children who are seriously ill, the children who have vitamin A
deficiency. This is especially true when the child is sick with measles, severe diarrheas or
respiratory tract infections. Preventing vitamin A deficiency not only keeps children from going
blind, but also keeps children healthier and helps children to be less likely to die from serious
illnesses.
Distributing vitamin A capsules to each child every six months is one way to
prevent vitamin A deficiency. This takes work and good record keeping. Even when vitamin A is
distributed this way, you need to be concerned about vitamin A deficiency. There are always
children absent when vitamin A is distributed and there may be new children in the area that you
do not know about.
Prevention for Vitamin A deficiency
Children 6 months to 1 year 100,000 IU every 4-6 months
Children 1 year and up
100,000 IU every 4-6 months
Newborn
50,000 IU at birth
Women child bearing age 200,000 IU within 1 month of birth
To avoid vitamin A deficiency in your camp or village, you need to encourage
people to eat green vegetables and orange or yellow fruit. These kinds of food are good sources
of vitamin A and should be eaten daily. Eggs and liver are also good sources of vitamin A.
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A child, who suffers from vitamin A deficiency and is then treated, can have
vitamin A deficiency again in the future. These children should be monitored closely. When you
find a child with vitamin A deficiency, you should examine the whole family. All those with signs
of xerophthalmia should be treated and all of those who do not have signs of xerophthalmia
should be given a preventive dose of vitamin A. The entire family should be counseled about
eating foods that contain vitamin A.

Use of Vitamin A
Anytime that you give vitamin A, you must document the DATE and the DOSE
given on the patientCs medical record. Before giving vitamin A, check the patientCs medical
record to see if vitamin A has been given recently. This is very important. Too much vitamin A
might be been approved by WHO as being safe.
When you treat for vitamin A deficiency, the eye signs such as dry conjunctiva
should usually disappear in a few weeks. Night blindness might even go away in a few days.
Sometimes BigotCs spots may go away go away more slowly, maybe months. Because it may
take for the signs of exophthalmia to go away after treatment, there is a chance that another
medic will see the patient, diagnose exophthalmia and decide to give vitamin A. If you did not
document your treatment with vitamin A or if the other medic does not check the medical record
carefully, there is a danger of giving too much vitamin A.
The strength of vitamin A is given in International Units (IU). Look carefully at the
label on your vitamin A bottle. Check the dose carefully. You must calculate your dose correctly.
Most of the border area uses 25,000 IU vitamin A capsules. There are some areas that have
50,000 IU tablets and some areas that have 20,000 IU capsules. In the future, we hope to have
200,000 IU vitamin A capsules. Much other strength is available.
If using 25,000 IU capsules, 8 capsules = 200,000 IU

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Cataracts
Cataract is the leading cause of blindness in the world. A cataract is cloudiness
in the lens inside the eye. When you get older, the lens becomes less clear. This happens
naturally because of age and age related cataracts are the most common type of cataracts.
Other factors such as exposure to sunlight, general health, history of smoking, diabetes, use of
drugs such as steroids, and dehydration can all help cataracts to develop in people who are not
yet old. Cataract can also develop after trauma. Occasionally, cataracts are present at birth.

The lens needs to be clear or light cannot pass through the eye to the retina. As
the cataract develops and the lens becomes cloudy, vision is reduced. In very severe cataracts,
the patient cannot see anything. To see a cataract, you have to look very carefully in the pupil.
The pupil should be black. If you see grey or white in the pupil, then you are probably seeing a
cataract.
Unfortunately, cataracts are not treatable with medicines. Surgery is the only
care for cataracts. It might be possible to delay the development of cataracts by eating well,
staying healthy, not smoking and avoiding sunlight exposure to the eyes by wearing wide
brimmed hats, glasses or sunglasses.

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Occasionally, eye surgeons visit the border area. For this reason, all clinics
should keep a register of all known cataract patients. If an eye surgeon visits your area, having a
register of the known cataract patients will save a lot of time, which will allow the surgeon more
time to do eye surgery and help more people.
Anytime you find a patient with a cataract, you need to note if the right eye, left
eye, or both eyes have cataracts. You need to check the vision on the eye chart and check the
vision again with the pinhole. You also need to check to see if the pupil responds to light. This
information will make it easier for the surgeon to decide which cases are good cases for cataract
surgery.
Below is a sample form which you can make in the back of your clinic book to
keep track of the cataract patients. Aside from the clinical information, you should also include
the name, age, sex and address of the patient so that the patient can be easily located if an eye
surgeon visits your area.
No

Name

Age Sex

Address

Diagnosis

Distance Pinhole Pupil


Vision
test reaction
R L R L R L

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Glaucoma
We are learning about glaucoma because
1. It is one of the leading causes of blindness in the world
2. We have seen a lot of cases of blind eyes from glaucoma on the border
This course if for advanced students and is not included in the primary eye care course because
1. The diagnosis of glaucoma can be very difficult
2. We do not have the drugs needed to treat glaucoma in the camps
3. Glaucoma is not preventable
The Learning Objectives for Reading this Lecture are
To know there are several types of glaucoma
To know the importance of the aqueous humour and the angle in glaucoma
To know what the normal range of pressure in the eye is
To know the basic cause of open angle glaucoma
To know the clinical signs and symptoms of open angle glaucoma
To know the basic cause of closed angle glaucoma
To know the clinical signs and symptoms of angle closure glaucoma
To know how to recognize an eye that is blind from glaucoma
After some clinical skills practice, you also should be able
To know how to check the angle of the eye with a torch
To know how to feel if an eye has normal pressure or very high pressure
To know if peripheral vision is present or absent
To know how to treat in basic treatment and planning for referral system

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Introduction to Glaucoma
Glaucoma is a word that is used to describe several different diseases of the eye. To make a
simplified statement, glaucoma is what happens when there is more pressure in side the eye
than the eye can tolerate safely.
In many cases, this means that the pressure in the eye is higher than normal. In few days, the
pressure in the eye is normal, but the eye cannot tolerate normal pressure. The most sensitive
area to pressure is the nerves at the optic nerve head. When there is damage to the optic nerve,
the eye will loose vision. If there is too much damage to the optic nerve the eye will become
blind.
Anatomy
To have a better understanding of glaucoma, we need to review some of the anatomy
and physiology of the eye. The aqueous humour is the fluid inside the eye that fills the anterior
chamber. The anterior chamber is the space between the lens and the cornea. The aqueous
comes into the eye through the ciliary body and is made from the clear serum of our blood. (See
drawings on the next page)
The eye makes new aqueous humour all of the time. We need fresh aqueous in the eye
because the aqueous provides nutrition to the lens and the inside layer of the cornea, which do
not have a blood supply. The pressure from the aqueous also helps to keep the shape of the
eye. If the eye were too soft, it would not keep its round shape and the optics of the eye would
not be correct.
The aqueous goes out of the eye through the Canal of Schlemn. This canal is all around
the eye and is located where the iris and the cornea and the conjunctiva meet. After going into
this canal, the aqueous re joins with our blood. We refer the place where the iris, cornea and
conjunctiva meet as the angle of the eye. If the angle is open, it means that there is enough
space between the iris and the cornea for the aqueous to reach the canal of Schlemn os it can
leave the eye.

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If the angle is closed, it means that there is not enough space for the aqueous to reach
the canal of Schlemn and the pressure in the eye increases. If there were not a place for the
aqueous to go out of the eye, we would soon have too much fluid in the eye, which causes an
increase in pressure. In the drawing below, you can see where the Canal of Schlemn is located.
We measure the pressure in the eye in millimeters of mercury (mm Hg). The range of pressure
that is considered normal for the eye is from about 10 mm Hg to about 22 mm Hg. The average
pressure in most people is often about 15 or 16 mm Hg. Pressure in the eye is measured with
instruments called tonometers.

If there is only a slight increase in the pressure of the eye, the patient may not have any
symptoms at all. If there is a mild increase in the pressure of the eye, there can be swelling of
the cornea tissue. This may cause the patient to experience halos around lights at night. This
may be the only symptom in some glaucoma patients. A halo around lights is like looking at the
moon on a night where there are a few clouds around the moon.
In some types of Glaucoma, there is a big increase in the pressure. If there is a big
increase in the pressure of the eye, the patient will usually feel pain or even severe pain around
the eye. There will be clinical signs when the pressure in the eye is very high.
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If the pressure is too high for too long, the optic nerve head becomes affected. The
pressure can cause direct damage to the nerve and can also affect the flow of the blood vessels
that are inside the optic nerve. The optic nerve head contains approximately one million verves.
These nerves are attached to the retina and damage to these nerves will affect vision. Once
damage has occurred to the optic nerve, it is usually permanent and cannot be repaired.
Although there are several types of glaucoma, we will start by only talking about the two
most common types of glaucoma. The most common types of Glaucoma are primary open angle
glaucoma and primary angle closure glaucoma.
Primary Open Angle Glaucoma
This type of glaucoma is called open angle glaucoma because the angle is open and
there is enough space for the aqueous to go out of the eye through the Canal of Schlemn. The
problem here is that the eye is making too much aqueous. Even though the aqueous is going out
of the eye at a normal rate, too much new aqueous is coming into the eye, causing an increase in
the pressure of the eye.
Most of the time in open angle glaucoma, the increase in the pressure in the eye is not
big. The pressure in the eye of people with open angle glaucoma is usually between 24-30
mmHg.
Because the increase in pressure is not high, the patient may not have any symptoms or
may only have mild symptoms that they do not notice. Seeing halos around lights at night is
maybe the most common symptom for people with open angle glaucoma in the early stages.
Over time, this increase in pressure is enough to cause damage to the optic nerve. The
increase in pressure is not enough for the patient to feel any thing is wrong. Many people who
have chronic open angle occur slowly, the patient does not notice that they are loosing vision,
until late in the disease process.
In the late stages of open angle glaucoma, the patient will start to loose a large part of
their visual field. The visual field is not the same as visual acuity. We measure visual acuity we
check how well the patient sees on the eye chart. The visual field is how much and how far out
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you can see some thing to your eye, you are using your visual field. The amount of visual field
you have is how far you can notice something to your side, when your eyes are looking straight
ahead. If you are normal, you can look straight ahead and your eye will notice if something is
moving on your side. As the open angle glaucoma progress over time, the peripheral vision will
slowly start to disappear. Patients with late stage glaucoma can only see something when they
look straight at it. They will not see something off to the side.
Primary open angle glaucoma is often genetic. It is not unusual to find primary open
angle glaucoma in several people in the same family. Most of the time, this type of glaucoma
usually starts when the patient is meddle aged (about 40 years old) but in some cases might
start when the patient is younger. Primary open angle glaucoma is a chronic condition and does
not go away.
The rate of glaucoma is different in each population and we donCt know the true rate of
open angle glaucoma on the border. In many other populations, the rate of open angle
glaucoma is very small in young adults, but starts to in crease after age 40. In most populations
the rate for open angle glaucoma for those above 40 is around 1-2%
Eye drops and/or surgery is needed to treat open angle glaucoma. The patient is
controlled with treatment but is not cured.
Primary Angle Closure Glaucoma
Primary angle closure glaucoma is also sometimes called acute angle closure glaucoma
or just angle closure glaucoma. In angle closure glaucoma the angle is closed and the aqueous
cannot leave the eye. Asian eyes are more likely to have this type of glaucoma then other people
are. This is probably due to genetics and the shape of the angle in the Asian eye.
The eye may be nearly normal most of the time, open enough to let the aqueous go out of
the eye, but on some occasions, the angle will close completely. When the angle closes
completely, the pressure in the eye build up very fast. This is painful and the patient will
complain about a very bad pain around the eye. They may come with a cloth held over their eye
because they are also sensitive to the sunlight. Sometimes the pain is bad enough that they will
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be vomiting. The patient may have a history of having this sort of pain before. If they do report a
history of the same kind of pain, the angle has probably bee closed before.
Because the pressure in the eye builds up very high, this type of glaucoma can blind a
patient very quickly, even in a few days time. When the angle is completely closed the pressure
in the eye may bee 50 mmHg, 60 mmHg or even higher. The pressure may be high enough that
the eye will feel more hard compared to the normal eye.
If the pressure is high enough, you might be able to notice that the cornea is not 100%
clear, or not as clear as the other eye. The pupil may look stuck and will not react to light very
well or may not react to light at all. By using your torch, you will also be able to see the angle is
closed.
Often the angle will b closed in one eye, but the other eye is also in danger of having
angle closure. In some patients, the angle only partially closes and some aqueous can leave the
eye but the pressure still becomes higher than normal. These patients may complain a little bit
about pain around the eye and the pressure may be in the 30-40 mmHg range. Over time this
partially closed angle can also blind the eye.
Angle closure glaucoma is not rare on the border. You will probably see angle closure
glaucoma sometime if you continue to work in the eye clinics.
The Blind Eye from Glaucoma
Many of you have already seen blind eyes from glaucoma. Eyes that are blind from
glaucoma do not react to light. When you check the pupils with your torch, you see no
constriction of the pupil and the pupil is a bit larger than normal or mid-dilated.
This is the main reason why you need to check the pupil on all patients who have
cataracts. If you have a patient with a very ripe cataract and the pupil reacts to light by getting
smaller, cataract surgery will probably help them to see. If you have a patient with a very ripe
cataract and they cannot see anything and the pupil is about half dilated and does not react to
the light at all, then cataract surgery will not help because if the pupil does not work, the optic
nerve is dead. In our population, this will almost always mean that the patient has glaucoma.
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When the eye is blind from glaucoma already, nothing can help the eye to see again. If
the eye has lost vision (a little or a lot) due to glaucoma, you cannot repair the lost vision, but with
treatment you can prevent more vision from being lost.
Problems in Diagnosing and Treating Glaucoma on the Border
To make a true diagnosis of open angle glaucoma requires instruments to measure the
visual field AND a tonometer to measure the pressure in the eye, AND a good look at the optic
nerve head and retina inside the eye. It also takes a lot of experience. Because of this, it will be
difficult for us to be sure about our diagnosis of open angle glaucoma in the camps and on the
border.
Treatment is also difficult as the drops needed are not available in the camps. Our
tetracycline ointment is NOT useful in the treatment of glaucoma. Routine follow up is needed
and even with drops sometimes surgery is needed. Sometimes the surgery also does not control
the pressure in the eye. Even in the developed industrial countries, glaucoma blinds may people
every year.
Diagnosis for acute angle closure glaucoma can be done clinically. Treatment is needed
immediately or the patient may go blind. At this time we donCt have the drugs needed to treat
acute angle closure in the camps, but if you learn well, we may try to provide them in the future.
Helpful Clinical Tests for Diagnosis
1. Evaluating the Angle of the Eye
We can use a good torch to evaluate the angle of the eye to see if it is open or closed.
To do this, we need to hold the penlight so that it is perpendicular to the line of sight. The light
from the torch needs to shine across the plane of the iris. The best way to do this is to sit or
stand right in front of the patient. Have the patient look straight ahead (right at your eyes or at
your nose). Hold the torch several centimeters away from the eye, but level with the eye as seen
in the drawing below.

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What you want to look at is the amount of shadow you see on the iris on the other side of
the pupil from the torch (as seen in the drawing above). The top example, you have no shadow
and the angle is completely open. In the second (middle drawing) example, you have a small
amount of shadow; the angle is open, but not 100% open. On the bottom drawing example, the
shadow covers most of the iris on the inside of the pupil. If the shadow is touching the pupil,
then the angle is closed. Below are two photographs of angles. Can you tell which one is open
and which one is almost closed?

The photo above on the left is an open angle. The white line shows you where the
shadow is. See how there is very little shadow on the iris on the opposite side that the light is
coming from. The photo above on the right is an angle that is closed or almost closed. The
white line showing the shadow almost touches the pupil. If the shadow does come to the pupil,
the angle is closed.

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When you see a normal open angle, it does not mean that the angle has always been
open. When you see a normal open angle is does not mean that the angle will always be open in
the future.
2. Checking the pressure of the Eye
If we do not have a tonometer we can still get a general idea if the pressure in the eye is
normal (or near normal) or if the pressure in the eye is very high. To do this we ask the patient to
close their eyes.

We then use the first fingers or the middle fingers of each hand to feel the eye
thought the closed eyelid. You can rest your third and fourth fingers on the forehead just above
the eye. You can also rest our thumbs on the cheek of the patient, just below the eye. Feel with
the fingers of both hands. Do not be afraid to press a little bit hard on the eye to get a good feel.
Compare the right eye to the left eye of the patient. This will not allow you to measure the
pressure in the eye accurately, but it might give you an idea if the pressure in the eye is near
normal or very high.
You should practice this several times on normal eyes, so that you will have an idea what
the pressure in a normal eye feels like. If you know what the pressure in the normal eye will feel
like, it will make it easier for you to feel when the pressure in the eye is very high.
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Sometimes you might have tonometer available to check the pressure in the eye.
Checking the pressure in one examination only is not enough to make a diagnosis of open angle
glaucoma. It is easy to make a mistake when checking the pressure. The pressure in the eye
goes up and down a little bit during every day. In angle closure glaucoma, you will find a very
high pressure in the eye.
One of the more common instruments that we have
available for checking the pressure (Shiotz tonometer) is
not as accurate as instruments that require an office setting
to use. Also, in some cases, the eye with normal pressure
can suffer from glaucoma, thus we cannot diagnose by
only measuring the pressure.
It takes a bit of practice to be able to use the Shiotz tonometer well. You
must put anesthetic drops in the eye before you do this test. After the
cornea is anaesthetized, you place the instrument on the centre of the
cornea, straight up and down. To do this, you need to have the patient
laying flat and looking straight up in the air. The tonometer is placed
gently on the cornea and the reading is taken.
In cases of Angle Closure Glaucoma, the pressure in the eye will be very high, often in
the 40 or 50 or 60 mmHg range or even higher. In Open angle Glaucoma, the pressure in the
eye may only be a little bit above normal, maybe 25 to 30 or 35 mmHg. Checking the pressure of
the eye can help you to make a diagnosis of primary open angle glaucoma, but pressure that is
above normal, does not mean that there is glaucoma.
3. Checking the Visual Fields
Most of the time, by the time a patient notices that the peripheral vision is gone; there
already has been a lot of damage to the optic nerve. With a special instrument, we can test the
visual fields very carefully to check for loss of peripheral vision and other forms of vision loss that
occur in glaucoma. These visual field testers are not available to us in the field. In the field there
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is no way for us to check about the peripheral vision and other forms of visual field loss very
accurately.
We can get a very rough idea if there has been severe vision field loss already or not. To
do this you stand right in front of a patient. You will test eye by eye so ask them to close or cover
one eye. Ask them to look right at your nose with the eye that is open. You ask them NOT to
move their eye and to look only at your nose. While they are looking at your nose, you put out
your arm to where your hand is near the side of their head. You can move you finger and ask the
patient if they see your finger moving or not. Make sure they keep looking straight ahead at your
nose. They will be using the side of their vision to see your finger. If the peripheral vision is
normal, they should be able to see about 90 degrees ort from the line of sight on the ear side of
their eye. The normal patient will see less than that on the nose side, because the nose gets in
the way! This test can be difficult to do, so you will have to have someone with experience show
you how to do the test and you will have to practice.
4. Evaluating the Optic Nerve Head
To be able to detect glaucoma by viewing the optic nerve and nerve fiber layer requires a
LOT of experience and expertise. To properly assess the optic nerve and the nerve fiber layer
requires special instruments that allow us to look into the patientCs eye with both of our eyes so
that we can see with depth perception. These instruments are not readily available on the
border. A direct ophthalmoscope is not good enough to notice very early changes in the optic
nerve head from glaucoma damage. If we can see damage to the optic nerve head with a direct
ophthalmoscope, there is going to be some damage present to the visual field of that eye. If we
can see damage to the optic nerve head with a direct ophthalmoscope, the glaucoma has
probably been present for quite a while.
TREATMENT OF GLAUCOMA
Glaucoma is a common eye disease in which the Intraocular Pressure (IOP) rises higher
than the normal level of 22 mmHg. This raised pressure damages the Optic Nerve which leads
to loss of vision. The amount of vision lost depends on how high the pressure rises and for how
long it is raised. The higher the pressure and the longer it is raised the more the damage. The
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lost vision can NEVER be regained. Treatment is to lower the pressure to STOP FURTHER
VISUAL LOSS.
The eye produces Aqueous Fluid in the Ciliary body which drains through the Drainage
Angle. If the Drainage angle is blocked the IOP rises as the Aqueous fluid cannot drain out.
There are 2 common types of GLAUCOMS depending on whether the drainage angle is
blocked internally by silting up or externally by the iris.
1. OPEN ANGLE GLAUCOMA
Is where the drainage angle looks open on gonioscopy and is just silted up
The pressure rises above the normal of 22 mm but rarely goes above 35 mm. It causes slow,
gradual loss of peripheral visual field.
2. CLOSES ANGLE GLAUCOMA
This type of glaucoma is often produced as the lens becomes bigger with age pushing
the iris forward. This type of glaucoma causes very high pressures, often as high as 50 or 60
mm. It may be very painful and causes VERY FAST VISUAL LOSS. Patients may lose vision in
just a few weeks if untreated
CLOSED ANGLE GLAUCOMA IS VERY COMMON ON; THE BORDER and as it is so
serious anyone who you find with raised pressure should be treated as having CLOSED ANGLE
GLAUCOMA. This treatment will also work with OPEN ANGLE GLAUCOMA so you donCt have to
worry about deciding which type it is.
TREATMENTS AVAILABLE
DIAMOX tablets work by stopping the body producing aqueous fluid so the pressure falls
PILOCARPINE eye drops have 2 actions.
Firstly it constricts the pupil pulling the iris away from the drainage angle which will open it so the
IOP falls.
Secondly it makes the aqueous drain better out of the angle by widening the pores in the angle.
Both these actions lower the intraocular pressure.
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Pilocarpine will not work when the pressure is above 40 mm which is why you must give the
Diamox first to lower the pressure.
TREATMENT PROTOCOL
Give 2 tablets of DIAMOX 250 mg by mouth.
One hour later start Pilocarpine 2% eye drops 4 times a day to both eyes.
1 day later check the pressure again.
If the pressure has fallen below 20 mm then continue with Pilocarpine 2 % eye drops 4 times a
day until seen by the ophthalmologist.
Check pressure 3 days later.
If pressure still above 20 mm then continue with the Pilocarpine 2 % eye drops 4 times a day and
give Diamox 250 mg 4 times a day until seen by ophthalmologist.
When seen by the ophthalmologist these patients will all need some operation, a P.I, a
trabeculectomy or a cataract extraction.

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Conjunctivitis
The most common type of eye infection is conjunctivitis People will often say pink
eye or red eye. It is not always possible to know if conjunctivitis is caused by bacteria or a
virus or an allergy. Whenever you see a patient with conjunctivitis, be sure to look under the
eyelid for signs of trachoma. Trachoma and conjunctivitis can occur together.
Conjunctivitis caused by bacteria will respond well to the ointment and get better
in a few days. Bacterial conjunctivitis will often have a pus discharge.

Conjunctivitis caused by virus cannot be treated and the eye will have to get
better by itself. Viral conjunctivitis will ofte3n have a watery discharge. The ointment will make
the eye feel better and will prevent a secondary bacterial infection. Viral conjunctivitis will usually
take about a week to get better.

Conjunctivitis from allergies will feel better when using ointment, but the ointment
will not treat the allergy. Allergic conjunctivitis will often have a ropey or stringy discharge. The
allergy problems in the eye can be reduced by washing the eyes carefully. Allergic conjunctivitis
will often be worse during certain times of the year. It is usually not possible to determine what
the eye is allergic to.

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Because you cannot know what causes the conjunctivitis, you can treat all types
of conjunctivitis with eye ointment such as terramycin. The patient should use the ointment four
times a day until two tubes are finished. The patient should also be instructed to wash the eyes
every time they use the ointment. Many kinds of conjunctivitis are very easily spread from one
person to another person, so the patient must also be warned to wash their hands frequently,
and warned not to share towels and cloth used to wipe the face with other people.

Eyelid Infections
Stye
One type of eyelid infection is usually called a stye and looks like a bump on the
eyelid. The stye may come up on the outside of the eyelid or on the inside of the eyelid.
Sometimes this is an infection and can be treated with ointment. These styes develop quickly
and are often painful. Sometimes the stye is chronic, and will not go away with treatment. The
chronic stye may feel hard, like a stone. It may last for many months. It is possible to remove the
stone with surgery.
To treat a stye, have the patient use Terramycin ointment four times a day on the
stye and on the edge of the eyelid until two tubes are finished. The patient should also wash
carefully around the eyes each time before applying the ointment. Hot compresses may help
speed up the healing of a stye. Hot compresses can be used many times a day.

Blepharitis
Sometimes the edge of the eyelid will become infected. The edge of the lid, near
the lashes will look very red. Sometimes you will notice crust on the eyelashes. This is a
stubborn type of infection that may come and go many times. The patient should use Terramycin
ointment four times a day on the edge of the eyelids. The patient also needs to wash at the edge
of the eyelids, at least four times a day.
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Treating Eye Infections


Basic treatment for eye infections
1. Antibiotic ointment (Terramycin) to be used four times a day until two tubes finished.
2. Patient to wash around eyes each time before using ointment
3. Hot compresses help reduce swelling in eye infections.
4. Patient to return if eye not better after treatment is finished.
5. Serious infections and infections not responding to treatment should be referred

NEVER PATCH AND INFECTED EYE

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Eye Injuries
When there has been an injury to the eye, your goal is to prevent infection. The
injury may have caused some damage to the eye, but often, an infection to the site of the injury
causes the most damage. When somebody comes to you with an eye injury, your first concern is
to clean the eye well. Your next concern is to make sure that there are no foreign bodies present.
Foreign bodies often stick to the cornea or to the conjunctiva underneath the eyelid. Always look
under the eyelids, both the top and bottom eyelids.

To remove something that is stuck to the cornea or conjunctiva:


First try to rinse the foreign body away by washing with clean water or normal
saline solution. If this does not remove the foreign body, you can use the eyelid of the patient to
try to remove. If this does not work, you can use a cotton bud to remove the foreign body. Be
very gentle.

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Scratches and abrasions on cornea:
Cornea injuries are very painful. Patching the eye helps to keep the eyelid from
blinking so there is less pain. Patching also helps the cornea to heal faster. Some small
scratches may not need patching. Most scratches or abrasions usually need patching for one
night only. Large scratches may need patching for 3 or 4 days. The patch needs to be removed
every day and the cornea re evaluated. If you see any evidence of infection to the cornea,
patching must be stopped and the patient must be referred to the doctor. Each time you put on
a patch, apply a lot of antibiotic eye ointment first.
Because the cornea is clear, it is difficult to see scratches and abrasions on the
cornea. Sometimes you will need to use pain as a guideline. If there is only mild pain and the
patient can tolerate walking around in the sunlight and doing ordinary activities, you may not
need to patch. Antibiotic eye ointment should still be applied to the eye to prevent infections. If
the pain is very severe, you should patch the eye. Make sure the eye is clean, there are no
foreign bodies and that you have applied ointment before you patch the eye. If the pain is very
severing, you might want to give paracetamol.
Instructions for Eye Injuries
1. Clean the eye carefully with normal saline or clean water
2. Examine carefully and remove anything that is stuck on the eye or under eyelids.
3. Apply large amount of antibiotic ointment
4. If cornea is scratched and is very painful, apply a patch for overnight
5. Re - evaluate patient the next day

Very serious eye injuries should be referred. If you need to move the patient to
another location, you should place a shield over the eye to prevent additional injuries to the eye
during transportation.

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Making Eye Patching


D. EYE PATCHES should be used when there is damage to the cornea. Avoid its use when eye
is infected but not injured. They MUST be used with an antibiotic. To make an eye patch:
1. Put a layer of thick cotton between 2 pieces of gauze. Cut into an oval shape. Use an oval
cardboard pattern 1.5 x 2.5 inches (4 cm. x 6.5 cm.)
2. The eye patch should be big enough to cover the eye but small enough not to include the
eyebrows or the cheeks.
3. Avoid touching the side of the eye patch that will come in contact with the eye.
4. Cover the eye with the eye patch and put two pieces of plaster over it diagonally. Make sure
you put the plaster on with enough pressure to keep the eye from opening and closing under the
eye patch.

2.

1.

3.

4.

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Making Eye Shields


C. EYE SHIELDS should be used to prevent further trauma to the eye after surgery, for example,
while the patient is sleeping. To make an eye shield:
1. cut a cardboard into a circular piece about 5 inches (12 cm) in diameter.
2. Cut out a key hole from this piece as shown below.
3. Make into a cone by stapling or taping the cut ends together.
4. When positioning the eye shield use two pieces of tape from the forehead diagonally with
lower ends towards the ear.
5. When placing the eye shield make sure that it is secure enough to protect the eye from
bumps and hits. It should rest on the eyebrow and cheekbone to avoid any direct pressure
on eye.

1.

2.

3.

4.

5.
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Making Eye Charts

You can photocopy or trace the letters of an eye chart. You can also draw your
own letters. The E in the eye chart is square. The height of the E is the same size as the width of
the E. The size of each arm and space between the arms is 1/5 of the size of the E. Here are
letter measurements for a 6 meter chart:
Letter size
E size
arm/space size
20/200
9.0 cm.
1.8 cm.
20/100
4.25 cm.
0.85 cm.
20/50
2.25 cm.
0.45 cm.
20/30
1.25 cm.
0.25 cm.
20/20
0.9 cm.
0.18 cm.
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