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ASSESSMENT OF EYES

Tuesday, December 9, 2014

16:34

Visual Acuity

This is an essential part of the eye examination and a measure against which all
therapeutic outcomes are based.
The Snellen chart, which is composed of a series of progressively smaller rows of
letters, is used to test distance vision.
The fraction 20/20 is considered the standard of normal vision.
Most people can see the letters on the line designated as 20/20 from a distance
of 20 feet.
A person whose vision is 20/200 can see an object from 20 feet away that a
person with 20/20 vision can see from 200 feet away.
NOTE: ung first number ayun ung sayo, pero ung second number un ung sa
ibang tao. Meaning kapag 20/200 ikaw kailangan mong lumapit ng up to 20
feet para mabasa pero ung ibang tao nababasa nila un kahit 200 feet distance
Clients who wear corrective lenses other than for reading should have their vision
tested with the lens in place.

Confrontational test
The confrontational test is performed to examine visual fields or peripheral
vision.
The examiner and the client sit facing each other.
The client is asked to look directly into the eyes of the examiner throughout the
test.
The examiner covers his or her right eye while the client covers his or her left eye
(the client covers the eye directly opposite to the examiner's covered eye).
The examiner moves a finger from a nonvisible area into the client's line of vision.
The examiner and client should see the object at approximately the same time.
When the client sees the object coming into the line of vision, the client informs
the examiner.
The procedure is repeated on the opposite eye.
The test assumes that the examiner has normal peripheral vision.
Ishihara chart
The Ishihara chart consists of numbers composed of colored dots located within a
circle of colored dots.
The client is asked to read the numbers on the chart.
Each eye is tested separately.
Reading the numbers correctly indicates normal color vision
The test is sensitive for the diagnosis of red-green blindness but cannot detect
discrimination of blue.
Pupils
The pupils are round and of equal size.
Increasing light causes pupillary constriction.
Decreasing light causes pupillary dilation.

Constriction of both pupils is a normal response to direct light.

The client is asked to look straight ahead while the examiner quickly brings a
beam of light ( flashlight) in from the side and directs it onto the eye.
The constriction of the eye is a direct response to shining a light into that eye;
constriction of the opposite eye is known as a consensual response.

Sclera and cornea


Normal sclera color is white.

In a dark-skinned person, the sclera may normally appear yellow;


pigmented dots may be present.

A yellow color to the sclera may indicate jaundice or systemic problems.


The cornea is transparent, smooth, shiny, and bright.
Cloudy areas or specks on the cornea may be the result of an accident or eye
injury.

Ophthalmoscopy
The ophthalmoscope is an instrument used to examine the external structures
and the interior of the eye.
The room is darkened so that the pupil will dilate.
The instrument is held with the right hand when examining the right eye and
with the left hand when examining the left eye.
The client is asked to look straight ahead at an object on the wall.
The examiner should approach the client's eye from about 12 to 15 inches away
and 15 degrees lateral to the client's line of vision.
As the instrument is directed at the pupil, a red glare (red reflex) is seen in the
pupil.
The red reflex is the reflection of light on the vascular retina.
Absence of the red reflex may indicate opacity of the lens.
The retina, optic disk, optic vessels, fundus, and macula can be examined.
Tonometry
The test is used primarily to assess for an increase of intraocular pressure and
potential glaucoma.
Normal intraocular pressure is 10 to 21 mm Hg; intraocular pressure varies
throughout the day and is normally higher in the morning ( always document the
time of intraocular pressure measurement).

DISORDERS

Legally blind
The best visual acuity with corrective lenses in the better eye of 20/200 or less or
visual acuity of less than 20 degrees of the visual field in the better eye
NURSING INTERVENTIONS
When speaking to the client who has limited sight or is blind, the nurse uses a
normal tone of voice.
Alert the client when approaching.
Orient the client to the environment.
Use a focal point and provide further orientation to the environment from that
focal point.
Allow the client to touch objects in the room.
Use the clock placement of foods on the meal tray to orient the client.
Promote independence as much as is possible.
Provide radios, televisions, and clocks that give the time orally, or provide a
braille watch.

When ambulating, allow the client to grasp the nurse's arm at the elbow;
the nurse keeps his or her arm close to the body so that the client can
detect the direction of movement.
Instruct the client to remain one step behind the nurse when ambulating.

Instruct the client in the use of the cane for the blind, which is differentiated from
other canes by its straight shape and white color with red tip.
Instruct the client that the cane is held in the dominant hand several inches off
the floor.
Instruct the client that the cane sweeps the ground where the client's foot will be
placed next to determine the presence of obstacles.

Cataract

is an opacity of the lens that distorts the image projected onto the retina and
that can progress to blindness.

Causes include the aging process (senile cataract), inherited (congenital


cataract), and injury (traumatic cataract s); cataract s also can result from
another eye disease (secondary cataract).
Intervention is indicated when visual acuity has been reduced to a level that
the client finds to be unacceptable or adversely affects his or her lifestyle.

ASSESSMENTS

Blurred v ision and decreased color perception are EARLY signs


Diplopia, reduced visual acuity, absence of the red reflex, and the presence of a
white pupil are LATE signs.
Loss of vision is gradual and painless

MEDICAL MANAGEMENT

No nonsurgical (medications, eyedrops, eyeglasses)


treatment cures cataracts or prevents age-related
cataracts.

In the early stages of cataract development, glasses, contact lenses, strong


bifocals, or magnifying lenses may improve vision.

SURGICAL MANAGEMENT

In general, if reduced vision from cataract does not interfere with normal
activities, surgery may not be needed.
In deciding when cataract surgery is to be performed, the patients functional and
visual status should be a primary
consideration.
Surgery is performed on an outpatient basis and usually takes less than 1 hour,
with the patient being discharged in 30 minutes or less afterward.
Although complications from cataract surgery are uncommon, they can have
significant effects on vision.
When both eyes have cataracts, one eye is treated first, with at least several
weeks, preferably months, separating the two procedures.
RATIONALE: Because cataract surgery is performed to improve visual
functioning, the delay for the other eye gives time for the patient and the
surgeon to evaluate whether the results from the first surgery are adequate to
preclude the need for a second operation. The delay also provides time for the f
irst eye to recover; if there are any complications, the surgeon may decide to
perform the second procedure differently.

POSTOPERATIVE INTERVENTION
Elevate the head of the bed 30 to 45 degrees.
Turn the client to the back or nonoperative side.
Maintain an eye patch as prescribed (usually for the first 24 hours adter the
surgery)
Orient the client to the environment.
Position the client's personal belongings to the nonoperative side.
Use side rails for safety.
Assist with ambulation.
HOME CARE
Advise the client to avoid the following activities, because these activities can
increase the IOP which can disrupt the sutures and can lead to Retrobulbar
hemorrhage

The nurse also explains that there should be minimal discomfort after surgery and
instructs the patient to take a mild analgesic agent, such as acetaminophen, as
needed. Antibiotic, anti-inflammatory, and corticosteroid eye drops or ointments
are prescribed postoperatively.
Advise the client to contact the physiciqn if the following is observed:

NURSING ALERT! If nausea occurs advised the client to call the physician
immediately as this is a sign of increase IOP
To prevent accidental rubbing or poking of the eye, the patient wears a protective
eye patch for 24 hours after surgery, followed by eyeglasses worn during the day
and a metal shield worn at night for 1 to 4 weeks.
Sunglasses should be worn while outdoors during the day because the eye is
sensitive to light.
Slight morning discharge, some redness, and a scratchy feeling may be expected
for a few days. A clean, damp washcloth may be used to remove slight morning
eye discharge.
Because cataract surgery increases the risk of retinal detachment, the patient
must know to notify the surgeon if new floaters (dots) in vision, flashing lights,
decrease in vision, pain, or increase in redness occurs.
The eye patch is removed after the first follow-up appointment.
The patient may experience blurring of vision for several days to weeks.
Vision gradually improves as the eye heals.
Vision is stabilized when the eye is completely healed, usually within 6 to 12
weeks.

Glaucoma
The term glaucomais used to refer to a group of ocular conditions characterized
by optic nerve damage due to increase IOP.

NORMAL PHYSIOLOGY
The eye normally produce fluid to nourish the cornea andlens. These fluilds are
known as the AQUEOUS HUMOR.
The Aqueous humor is produced by the cillary body.
These fluids will then drain through the TRABECULAR MESHWORK to th canal of
Schlemm and will then be reproduced by the cilliary body ( cycle sya kung baga)
GLAUCOMA PHYSIOLOGY
Open angle glaucoma
In this type of glaucoma, the production of aqueous humor is rapid and the the
cyle is slow.
This can lead to increase IOP
Pressure by the increase IOP impedes the microcirculation in the optic nerve
If the blood supply in the optic nerve is impeded by the pressure, this can lead to
gradual loss of vission.
Close angle glaucoma (pupillary block)
In this type of glaucoma, the production of the aqueous humor is normal,
however, the trabecular meshwork is block/obstructed due to thick iris
This can lead to increase IOP
Pressure by the increase IOP impedes the microcirculation in the optic nerve
If the blood supply in the optic nerve is impeded by the pressure, this can lead to
gradual loss of vission.
TYPES

MANIFESTATION

Open-Angle Glaucoma

Optic nerve damage


Visual field defects(loss of peripheral vission) IOP 21
mm Hg.
May have fluctuating IOPs.
Usually no symptoms but possible ocular pain,
headache, and halos.
NOTE: not that painful as compare to angle-
closure glaucoma

Angle-Closure ( Pupillary Rapidly progressive visual impairment,


Periocular pain
Block) Glaucoma
Conjunctival hyperemia, and congestion.
NOTE: Pain may be associated with nausea,
vomiting, bradycardia, and profuse sweating.
DIAGNOSTIC
Four major types of examinations are used in glaucoma evaluation, diagnosis, and
management:
Tonometry to measure the IOP
Ophthalmoscopy to inspect the optic nerve, gonioscopy to examine the filtration
angle of the anterior chamber, and perimetry to assess the visual fields. The
changes in the optic nerve related to glaucoma are pallor and cupping of the optic
nerve disc. The pallor of the optic nerve is caused by a lack of blood supply that
results from cellular destruction. Cupping is characterized by exaggerated
bending of the blood vessels as they cross the optic
MEDICAL MANAGEMENT
The aim of all glaucoma treatment is prevention of optic nerve damage.
Lifelong therapy is almost always necessary because glaucoma cannot be cured.
Treatment focuses on pharmacologic therapy, laser procedures, surgery, or a
combination of these approaches, all of which have potential complications and
side effects.
Although treatment cannot reverse optic nerve damage, further damage can be
controlled. The goal is to maintain an IOP within a range unlikely to cause further
damage.
PHARMACOLOGIC MANAGEMENT
MEDICATIO
N

ACTION

SIDE EFFECT

NURSING
INTERVENTION

Cholinergics
(miotics)
(pilocarpine,
carbachol)

Increases
Periorbital pain
Caution patients
Blurry vision
aqueous fluid
about diminished
Difficulty seeing in the dark
outflow by
vision in dimly lit
contracting the
areas.
Advise the client
ciliary muscle and
causing miosis
to qcoid complex
(constriction of
activitirs (driving,
the pupil) and
operating a
opening of
machine)
trabecular
meshwork

Adrenergic
agonists
(dipivefrin,
epinephrine)

Reduces
production of
aqueous humor
and increases
outflow

Eye redness and burning


Teach patients
Can have systemic effects,
punctal occlusion
including palpitations,
to limit systemic
elevated blood pressure,
effects ( Check
tremor, headaches, and
picture below)
anxiety

Beta-
blockers
(betaxolol,
timolol)

Decreases
aqueous humor
production

Can have systemic effects, Contraindicated in


including bradycardia,
patients with
exacerbation of pulmonary asthma, chronic
disease, and hypotension
obstructive
pulmonary
disease, second-
or third-degree
heart block,
bradycardia, or
cardiac failure
Teach patients
punctal occlusion
to limit systemic
effects.

Carbonic
anhydrase
inhibitors
(acetazolami
de,
methazolami
de,
dorzolamide)

Decreases

aqueous humor
production due its
diuretic effect

Oral medications

(acetazolamide and
methazolamide) associated

with serious side effects,


including anaphylactic
reactions, electrolyte loss,
depression, lethargy,
gastrointestinal upset,
impotence, and weight loss;
side effects of topical form
(dorzolamide) include
topical allergy

Do not administer
to patients with
sulfa allergies;
Monitor
electrolyte levels.

NOTE: PUNCTUAL OCCLUSION to prevent systemic absorprion of optic medication

SURGICAL MANAGEMENT
In laser trabeculoplastyfor glaucoma, laser burns are applied to the inner surface
of the trabecular meshwork to open the intratrabecular spaces and widen the
canal of Schlemm, thereby promoting outflow of aqueous humor and decreasing
IOP. The procedure is indicated when IOP is inadequately controlled by
medications, and it is contraindicated when the trabecular meshwork cannot be
fully visualized because of narrow angles. (LASER TRABECULOPLASTY is for OPEN
ANGLE GLAUCOMA ONLY)
In laser iridotomy for pupillary block glaucoma, an opening is made in the iris
to eliminate the pupillary block. Laser iridotomy is contraindicated in patients
with corneal edema, which interferes with laser targeting and strength.
NURSING INTERVENTIONS
Instruct the client on the importance of medication. ( CHECK THE TABLE ABOVE)
Instruct the client of the need for lifelong medication use.
Instruct the client to wear a Medic Alert bracelet. Instruct the client to avoid
anticholinergic medications (atropine sulfate, this medication can cause
increase IOP by dilating the pupil)
Instruct the client to report eye pain, halos around the eyes, and changes in vision
to the physician.
Instruct the client that when maximal medical therapy has failed to halt the
progression of visual field loss and optic nerve damage, surgery will be
recommended.
Prepare the client for trabeculoplasty or laser iridectomy as prescribed to
facilitate aqueous humor drainage.
Retinal detachment
Detachment or separation of the retina from the epithelium
Retinal detachment occurs when the layers of the retina separate because of the
accumulation of fluid between them, or when both retinal layers elevate away
from the choroid as a result of a tumor.
Partial detachment becomes complete if untreated.
When detachment becomes complete, blindness occurs.

ASSESSMENTS
Flashes of light
Floaters or black spots (signs of bleeding)
Increase in blurred vision
Sense of a curtain being drawn over the eye
Loss of a portion of the visual field
IMMEDIATE INTERVENTIONS
Provide bed rest.
Cover both eyes with patches as prescribed to prevent further detachment.
Speak to the client before approaching.
Position the client's head as prescribed. If the detachment is on the right side
of the eye ball position the client's head on the right side also to prevent
further detachment
Protect the client from injury.
Avoid jerky head movements.
Minimize eye stress.
Prepare the client for a surgical procedure as prescribed. ( SCLERAL BUCKLING)

POSTOPERATIVE INTERVENTIONS
Maintain eye patches as prescribed.
Monitor for hemorrhage.
Prevent nausea and vomiting and monitor for restlessness, which can cause
hemorrhage
Monitor for sudden, sharp eye pain (notify the physician).
Encourage deep breathing but avoid coughing.
Provide bed rest for 1 to 2 days as prescribed.
Position the client as prescribed ( positioning depends on the location of the
detachment).
Administer eye medications as prescribed.
Assist the client with activities of daily living.
Avoid sudden head movements or anything that increases intraocular pressure.
Instruct the client to limit reading for 3 to 5 weeks.
Instruct the client to avoid squinting, straining and constipation, lifting
heavy objects, and bending from the waist.
Instruct the client to wear dark glasses during the day and an eye patch at night.
Encourage follow-up care because of the danger of recurrence or occurrence in
the other eye.
Contusion
Bleeding into the soft tissue as a result of an injury.
A contusion causes a black eye; the discoloration disappears in about 10 days.
Pain, photophobia, edema, and diplopia may occur.
INTERVENTIONS
Place ice on the eye immediately.
Instruct the client to receive a thorough eye examination.
Penetrating objects
An eye injury in which an object penetrates the eye
INTERVENTIONS
NEVER remove the object because it may be holding ocular structures in place;
the object must be removed by the physician.
Cover the object with a cup. Both eyes shouls be covered
Do not allow the client to bend over.
Do not place pressure on the eye.
Client is to be seen by a physician immediately.
X-rays and CT scans of the orbit are usually obtained.
Magnetic resonance imaging (MRI) is contraindicated because of the possibility
of metal-containing projectile movement during the procedure.
Chemical burn
An eye injury in which a caustic substance enters the eye
INTERVENTIONS
Treatment should begin immediately.

Flush the eyes at the scene of the injury with water for at least 15 to 20
minutes.
At the scene of the injury, obtain a sample of the chemical involved.
At the emergency room, the eye is irrigated with normal saline solution or an

ophthalmic irrigation solution for at least 10 minutes.


The solution is directed across the cornea and toward the lateral canthus.
Prepare for visual acuity assessment.
Apply an antibiotic ointment as prescribed.
Cover the eye with a patch as prescribed.