Burma Border Primary Eye Care Training Manual_English_ Update Mar 09.pdf

Border Eye Care Program

Primary Eye Cares Training Manual Page 1

Eye Anatomy



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.



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.



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.



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.



V

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



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.



V

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.



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?



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



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



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.



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.



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)



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)



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.



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,



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.



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.



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.



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.



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



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



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.



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



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.



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.

Distance

Vision

Pinhole

test

Pupil

reaction No Name Age Sex Address Diagnosis

R L R L R L



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



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.



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.



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



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



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.



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.



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.



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.



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



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



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.



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.



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.



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.



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



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.



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.



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.



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.



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.

Burma Border Primary Eye Care Training Manual_English_ Update Mar 09.pdf

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