so chapter 50 is the very very last chapter of the text again make sure that you have all of your prototype drugs they are going to be on that very first page of the chapter which in this case is Page 810. so we're going to talk a little bit about the anatomy of the eye I can have a stream experience in dealing with uh and night conditions the anatomy of the eye the anterior the front part of the eye is the cavity filled with aqueous humor anterior contains anterior and posterior Chambers so even though posterior is usually the back the anterior part of the eye contains the front and the back chamber aqueous humor originates from the ciliary body of the posterior chamber that pulls through the pupil and the interior chamber trabecular network is connected to the canal or Slim and The Awkward humor drains from the anterior chamber to into the canal of schlem why does this all matter it's because when we have too much fluid in there or not enough we have different eye conditions so we're going to talk about those now glaucoma occurs when there's increased intraocular pressure so this is too much or too much pressure in the front part of the eye this leads to the optic nerve damage and visual field loss visual field mean if you're looking out and you're trying to read the eye chart or just looking around in the environment you have loss of depth usually you have loss of being able to see very far away this is the leading cause of preventable blindness often primary condition without any identiful level cost so you're not going to have a lot of symptoms of this disorder all of a sudden you're going to go into the eye doctor because you can't see and they're supposed to say whoa you've got glaucoma this is most frequently found in those over age 60 associated with genetic factors can be secondary however to certain conditions these are big ones eye trauma so we need pressure I need direct pressure to the eye diabetes and inflammation also Hemorrhage tumors and cataracts so patients that get cataracts removed they are constantly checking pressures to determine what's going on in that interior chamber of the eye and they have very very non-invasive options these days to check for pressure increases two types of glaucoma you can have closed or an open angle these are important to know the difference between them so mark this slide both are resulting from the buildup of obvious humor excessive production or blocked outflow so too much too much being formed or it's not able to drain so differences between the type is determined by how quickly it occurs and whether there is narrowing of the interior angle or not so how are we going to know if there's narrowing of the anterior angle you'll have to see an eye doctor you can't see this by looking at a patient you can't determine this by their symptoms you have to be able to see an eye doctor they have to do it in the very uh specific and inclusive exam and they're going to diagnose it with geometry this is a sister that ancient ocular ocular structure so anyone ever been to the eye doctor and they use that little pin and they put this little like rubber piece over the top of it and they just put it really really close to your eye or actually touch your eye and then they just tap it a couple of times what they're doing is checking your eye pressure and so that's called a tonopin let's talk about the specifics between the different ones closed angle glaucoma is also called acute or narrow angle glaucoma so remember closed is narrow um if you were to get this on a test closed angle is narrow angle as well it counts for about five percent of all glaucoma so very very low incidences it's usually unilateral it's caused by stress impact injury or medications what happens is the iris is pushed over the drainage area causing the angle to narrow and close remember this is not allowing the um the fluid the aqueous humor to drain out like it should this is a sudden cause of increased intraocular pressure patients can have a dull to severe eye pain very severe headache um they also can have nausea and vomiting with increased interocular pressure you can have nausea vomiting most common symptoms the patient's eye looks like it's bloodshot they can't find vision with Halos order of Irish can actually bulge out this is a very big medical emergency and it requires surgery so this isn't something you could wait in for an appointment for this is a medical emergency have to get to a surgeon immediately now can we do these types of surgeries at our emergency room nope not in the hospital usually you have to go to usually an outpatient surgery center some hospitals do have providers that can do this surgery in the hospital so it's very important to recognize this early on if you do have these symptoms they can check pressures in an emergency room so they would check the pressures and then they would find a provider that can do this surgery emergently any questions about closed or narrow angle glaucoma open angle glaucoma is the most common 9 of cases you usually bilaterally so the other one usually affects one eye this one usually affects both um simultaneously intraocular pressure or IOP develops slowly over years it's asymptomatic Iris does not cover the opening and it's treated with medications so we don't have surgery for open angle just for narrow angle and this one's treated with medications risk factors for glaucoma long-term use corticoids anti-hypertensives antihistamines antidepressants high blood pressure hypertension migraine headaches severe nearsightedness or far sightedness so severe changes in the eye meaning very strong strong glasses and normal aging process as well pharmacotherapy for glaucoma goal is to prevent damage the optic nerve by lowering the intraocular pressure when treatment begins you actually start treatment with the interoperative pressures between 21 and 30 or when you see signs of the optic nerve damage or visual fill changes so again you do need to have an eye exam to be able to determine if a patient has glaucoma combination therapy may be necessary to achieve the goals drugs used for glaucoma decrease intraocular pressure by increasing the outflow so it's going to promote the aqueous humor to be coming out and reabsorbing it's going to decrease the formation of occasumor so it's either going to make it drain a little bit better or it's going to decrease the amount that you're actually producing now one good thing and I don't think this is listed here one Telltale sign by looking at a patient especially an older patient that does not have a glass extensions because they have the most gorgeous lashes and it's that's a side effect of the medication is you have very very long luscious lashes I know right if you have to use it you might as well have a good outcome there types of treatment prostaglandins they dilate the tradicular meshwork increase Oculus humor outflow Carbonic andrahydrase and hydrates sorry I can't talk today Inhibitors decrease production of the aqueous humor so again this top one pasta blandens is going to allow the office humor to drain a little bit better by dilating that trabricular Network or carbotic and hydrous Inhibitors are going to decrease the obvious humor production as osmotic diuretics are going to reduce the formulation formation of octa's humor so you're going to have less aqueous humor meant I excuse me many anti-glaucoma drugs affect the autonomic nervous system so what kind of symptoms are we going to see there autonomic nervous system what kind of response going back to our diagram you're going to have a fight or flight response beta adrenergic blockers The increased production of aqueous humor address effects bronchoconstriction dysrhythmias and hypotension Alpha 2 adrenergic agonists decreased production of aqueous humor non-selective Medics remember your sympathetic communicating your sympathetic nervous system myriadics myriadics there's other way you can say it they dilate the pupil to increase outflow may also increase intraocular pressure so it's important to recognize it may increase the blood pressure and heart rate when you use these it's actually going to dilate that pupil to help the fluid drain out the on consumer drain out you're going to see these used routinely when you get your eye exam or when you do a type of anterior segment surgery like cataract surgery these are rarely used for glaucoma and then osmotic diuretics reduce the formation of aqueous tumor as well so we're going to talk about the prostaglandin Prototype drug that's latanoprost mechanism of actions believed to reduce intraocular pressure by increasing that outflow of aqua's humor it treats open angle glaucoma remember that's the glaucoma it's allowing everything to drain adverse effects conjunctival edema tearing dryness burning pain irritation itching Sensations in the fore body and the eye um photophobia and or visual disturbances areas those eyelashes eyelashes on the treated eye May grow thicker and or darker they just have these really thick luscious dark lashes changes in pigmentation of the iris or tree and eye or periocular skin so you can have some changes with color in there the beta adrenergic blocker is timolol it reduces the formation of obvious humor to reduce elevated intraocular pressure in chronic acidity chronic open angle glaucoma adverse effects local burning sustaining upon installation sometimes if it burns a lot you'll use a topical anesthetic to numb things up first and then you'll use that there's work for glaucoma to determine history of certain conditions heart block bradycardia heart failure chronic obstructive pulmonary disease COPD establish a baseline of blood pressure and pulse use with use of beta blockers teach the patient how to check their pore to end the blood pressure so if we're doing teaching what would we expect to be teaching the patient so just someone who knows nothing about checking their bolts where do you want them to check their poles check the karate radial which fingers are you going to use to so the index in the middle finger do we want to use the thumb no we never want to use the thumb to check that now what about blood pressure how are we going to teach a patient to take their blood pressure if they have like a watch I guess they could do that it's not usually as accurate um you are wanting to do a cuff in the upper arm usually the left um you want to make sure that they do they're consistent at the same location um and so you do have wrist cuffs that you can use those aren't going to be as effective the arm cuffs are going to be a little bit more accurate yeah are the ones at Walmart they are to an extent so if you look at the the little uh there's usually going to be like a a thing a little card in the bathroom a little piece of paper that says how long you can use it over and over for accuracy since there's nobody that's checking it and calibrating it there'll be a little calibration paper or card in the back that usually says this is good for this many uses and a lot of patients don't know that and so it's really important to educate them you might want to switch it out if you're getting normal that's why you do a trend if you're getting normal normal readings all of a sudden you get an abnormal reading of course check it and then see your doctor just to validate but a lot of times it's because they're they're meters no longer calibrated okay so you want to review the normal heart rate and blood pressure parameters what would we think about as a normal heart rate for an adult 60 to 100 now we want to calculate also into effect that some patients who are very active may have a lower heart rate or somebody that is actually having some heart conditions can actually have a low heart rate as well if they need a pacemaker at least like that so it's it's very important to recognize if they do go out of those ranges they should seek their seed treatment from their medical provider now what about a blood pressure 120 over 80 is a pretty normal range again you really want to know what's going on with the patient what medications they're taking that can help them kind of understand their parameters as well if they're going out of range now determine factors that decrease compliance in sufficient Financial Resources lack of knowledge of the disease and we're again we're reviewing glaucoma nurse work lack of dexterity or skill to insert your eye drops so if patient has tremors do you think that they can instill their eye drop routinely in their eye no a lot of times you don't feel it or you can't feel it actually going in their eye where are we going to actually place it are we going to just put a drop right on top of the eye yeah the conjunctival sac so you'll again wash your hands pull your sack down and then put a drop inside the the conjunctable sock it's important to recognize a lot of patients tend to want to grab a tissue and just do this it's important to not allow them to just put direct pressure especially if you're using a numbing drop because you can actually press onto the eye and custody damage on those outer layers of the eye it's difficult to remember the dosing schedules so if they go to an eye physician a lot of times they'll give them a dosing schedule where they'll say okay today I want you to take this drop four times a day so when they give themselves their drop they have like a little bubble so it's just like a Scantron sheet where you just bubble in how many times you gave yourself the eye drops and allow the patient to an opportunity to verbalize their feelings and provide emotional support so drugs used to for eye exams again we talked about my geriatics dilate the people to allow better visualization causes photophobia it can increase the intraocular pressure and cause central nervous system effects cycloplegics or cause both dilation or relaxation of the ciliary muscle this can cause severe blood vision loss of near Vision in ankle closure glaucoma attacks so let's talk about cycloplegics for a minute so how do we see normally do you guys remember back to anatomy and physiology how are we able to see an image so we have our lens right the image is reflected and reflected upside down and then it's projected back to us through the lens usually through the muscle accommodation now a muscle accommodation if you think about when you can't see something you squint and you can see it a little better right as you get older how well does that work doesn't work for me anymore I can tell you that um not very well um so it's important to recognize there are some new uh lenses that they actually can implant in patient's eyes whether you have cataracts and you get your lens replaced or if you're doing um they usually call it an RNR well they'll take the lens out and put a new and replace the lens you can have it done uh prior to cataract surgery but it's diff usually have to pay out of pocket for it and it's a little bit expensive but they actually can accommodate those lenses can accommodate without including your muscles and so there's a lot of different Technologies they can use these days cycloplegics can cause severe blurred vision because it relaxes those muscles so it doesn't allow you to tense and move that lens however you need to so your near vision is decreased or lost and again full angle closure glaucoma attacks um it's not it's trapping that um that fluid in that anterior chamber and it's not allowing it to move anywhere so it's important to recognize um close your ankle close your glaucoma attacks you shouldn't use like cycloplegics unless the provider orders them usually you'll go to myriadics if you need to just dilate pupils to look drugs for irritation and dryness lubricate eye surface a lot of times people have changes in Vision because their outermost layer of their eye is dry so your epithelial cells on the very outer part of your eye is dry these medications should penetrate the specific area of the eye vasoconstrictors cycloplegics quadriatics and lubricate drops so they're going to penetrate the very specific area of the eye now the ear two major sensory functions so we're going to flip bases and the eyes and ears work together so that's why they're in the same chapter the ear two major sensory functions hearing and equilibrium imbalance three important structural areas there's the outer ear the middle ear and the inner ear so you just have three basic areas otitis is inflammation so you can have two different types of otitis otitis external is associated with water or swimmer's ears I don't know if you've ever had this but if you swim a lot you can have pain in the outer surface just right in the right outside of the canal as you're going into the ear now you can have a otitis medium associated with the upper respiratory infections allergies and the auditory tube irritation and then a match in the middle part of the ear or then you can have mastoiditis is in the inflammation of a mastoid sinus and the inner ear can result in hearing loss if they're untreated so a couple of different um infectious type of inflammation five diseases there pharmacotherapy for the ear antibiotics used to treat infections you can have topical ear drops for the external ear those are very relieving if it's just the external now you can have systemic for the middle and inner ear infections also extensive outer ear infections so it depends on the severity of what you're treating and then topical corticosteroid so many inflammation is present foreign you need to assess the Baseline hearing and auditory status symptoms I a current medical conditions obtain information regarding hypersensitivity hydrocortisone sulfate and polymyxin B many otic medications are contraindicated in the presence of a perforated ear drum see of course you don't want to be putting into anything into the ear drop point it is perforated and usually there's Associated drainage with that as well so it's not hard to know hypersensitivity eardrum perforation chlorofenacol is contraindicated side effects burning redness rash and swelling when instilling otic preparations cleanse the ear thoroughly remove wax or serumen through irrigation and warm to body temperature but not higher before installation