Вы находитесь на странице: 1из 38

NEURO-SENSORY ANATOMY & PHYSIOLOGY

DISORDERS OF EYES

PART 2

EXTERNAL STRUCTURES OF
The EYEBALL
THE EYE
y EYELIDS (PALPEBRAL) &
Description EYELASHES
– A hollow spherical structure – Protect the eye from foreign
particles
that functions in the y CONJUNCTIVA
reception of the light rays PALPEBRAL CONJUNCTIVA
Pink; lines inner surface of eyelids
that provide the stimuli for BULBAR CONJUNTIVA
vision White with small blood vessels, covers
anterior sclera
Mechanism of vision • PALPEBRAE
– Modified folds of skin that protect the
– The refractive surface of the eyeball
(bulbar)

cornea and accommodative • PALPEBRAL FISSURE


properties of the lens focus – The oval opening between the upper
and lower eyelids
the light signals from near • CANTHUS
and far objects on the – Found at the corners of the eye,
where the upper and lower lids meet
photoreceptors in the retina

EXTERNAL STRUCTURES OF
THE EYE (cont.)
• Tarsus (plate of
dense connective
tissue)
– Gives the lid its
shape
– Contains modified
sebaceous
glands, called
meibomian
glands, the ducts
of which open
onto the eyelid
margins

1
LACRIMAL APPARATUS (LACRIMAL Components of the Lacrimal
GLAND & ITS DUCTS AND PASSAGES) System
• Major lacrimal gland
ƒ Produces tears to
– Produces the tears
lubricate the eye &
• The puncta and tear
moisten the cornea sac
ƒ Tears drain into – Collect the tears
nasolacrimal duct • Nasolacrimal duct
which empties into – Empties the tears into
nasal cavity the nasal cavity

Layers of the Eyeball Layers of Tissue Forming the


1. OUTER LAYER - fibrous
Cornea
coat that supports the • An extremely thin outer
eye epithelial layer
A. SCLERAE – Continuous with the bulbar
– Outer supporting layer conjunctiva
– Tough, white connective • A middle layer called the
tissue “white of the eye” substantia propria or stroma
– located anteriorly & – Composed of regularly
posteriorly arranged collagen bundles
B. CORNEA embedded in a
mucopolysaccharide matrix
– Transparent tissue
through which light enters • An inner endothelial layer
the eye. – Lies next to the aqueous
– Located anteriorly humor of the anterior
chamber

Layers of the Eyeball Layers of the Eyeball


2. MIDDLE LAYER – 2. MIDDLE LAYER (con’t)
vascular & pigmented
A. CHOROID B. CILIARY BODY
– a dark brown – connects the choroid
membrane located with the iris
between the – secretes aqueous
sclera & the retina humor that helps give
– it lines most of the the eye its shape
sclera & is attached to C. IRIS
the retina but can easily
– the colored portion of
detach from the sclera
the eye
– contains blood vessels
– located in front of the
that nourishes the
lens
retina
– it has a central opening
– located posteriorly
called the pupil

2
Layers of the Eyeball Composition of the Neural
3. INNER LAYER – contains Retina
the blood vessels &
nervous tissue
3 layers of neurons
A. RETINA – A posterior layer of
– a thin, delicate structure in photoreceptors
which the fibers of the optic
nerve are distributed – A middle layer of
– bordered externally by the bipolar cells
choroid & sclera & internally
by the vitreous – An inner layer of
– contains blood vessels & ganglion cells that
photoreceptors
– light sensitive layer communicate with the
– Receive visual images and photoreceptors
partially analyze them
– Transmit this modified
information to the brain

Types of Photoreceptors Present in Layers of the Eyeball


the Retina
3. INNER LAYER (con
(con’’t.)
1. CONES
– Specialized for fine B. RETINAL BLOOD VESSELS
discrimination, central vision C. OPTIC NERVE
& color vision D. OPTIC DISK
– capable of color – a creamy pink to white
discrimination depressed area in the retina
– the optic nerve enters & exits
– Functions at bright levels of the eyeball in this area
illumination – Referred to as the “BLIND
SPOT”
SPOT”
2. RODS – contains only nerve fibers
– More sensitive to light than – lack photoreceptors
cones – insensitive to light
– capable of black–
black–white E. MACULA LUTEA
discrimination – Small, oval, yellowish pink
– Aid in peripheral vision area located lateral &
temporal to the
– Functions at reduced levels optic disk
of illumination – the central depressed part of
the macula is the “FOVEA
CENTRALIS”
CENTRALIS” which is an area
where acute vision occurs

Internal Structures of the Eyeball Internal Structures of the Eyeball


1. FLUIDS OF THE EYE
1. FLUIDS OF THE EYE
A. AQUEOUS HUMOR
– Clear, watery fluid that A. AQUEOUS HUMOR
fills the anterior & (cont.)
posterior chambers of – serves as refracting medium
the eye Serves to maintain the
– produced by the ciliary intraocular pressure
processes, & the fluid – Provides for the nutritive
drains in the Canal of needs of the lens and
Sclemm posterior cornea
– The anterior chamber – Mediates the exchange of
respiratory gases
lies between the cornea
& iris – Contains a low concentration
of protein and high
– the posterior chamber concentrations of ascorbic
lies between the iris & acid, glucose & amino acids
lens

3
Internal Structures of the Eyeball Vitreous Humor
1. FLUIDS OF THE EYE (cont.)
B. VITREOUS HUMOR • Definition
– Clear, gelatinous/gel-
gelatinous/gel-like
material that fill the posterior – A colorless, amorphous biologic gel that fills
cavity of the eye the posterior cavity of the eye
– Maintains the form & shape of
the eye
– Provides additional physical
• Composition
support to the eye – Approximately 99% water, some salts,
– It is produced by the vitreous
body glycoproteins, proteoglycans, and dispersed
2. VITREOUS BODY collagen fibrils
– contains a gelatinous
substance that occupies the
vitreous chamber which is the
• Location
space between the lens &
retina
– Attached to the ciliary body and the peripheral
– transmits light & gives shape to retina in the region of the ora serrata and to
the posterior eye
the periphery of the optic disk

Internal Structures of the Eyeball


Structure of the Lens
3. CANAL OF SCHLEMM
– a passageway that extends • The lens is an avascular,
completely around the eye transparent, biconvex body, the
– permits fluid to drain out of
the eye into the systemic posterior side of which is more
circulation so that a constant convex than the anterior side
IOP is maintained
• A thin, highly elastic lens capsule
4. LENS
is attached to the surrounding
– A transparent circular
structure behind the iris & in ciliary body by delicate
front of the suspensory radial ligaments
vitreous body called zonules, which hold the
– Bends rays of light so that
the light falls on the retina lens in place
5. PUPILS • When changing lens shape, the
– Control the amount of light tough elastic sclera acts as a bow,
that enters the eye & the zonule and the lens capsule
reaches the
retina act as the bowstring
– Darkness produces dilation
while light produces
constriction

Structure of the Lens (cont.)


• The suspensory ligaments
and lens capsule are
normally under tension,
causing a flattened shape
for distant vision
• Contraction of the muscle
fibers of the ciliary body
produces a more spherical
or convex shape for near
vision

4
Pupillary Reflex
• Controls the size of
the pupil
• Is controlled by the
autonomic nervous
system
– The parasympathetic
nervous system
controls pupillary
constriction
– The sympathetic
nervous system
controls pupillary
dilation

Extraocular Eye Muscles Extraocular Eye Muscles and Their


- Muscles do not work Innervation
independently but
work in conjunction
• Innervated by three cranial nerves
with the muscle that – The abducens nerve (CN VI) innervates the
produces the lateral rectus
opposite movement
– The trochlear nerve (CN IV) innervates the
superior oblique
A. RECTUS MUSCLES
– Exert their pull when – The oculomotor nerve (CN III) innervates
the eye turns the remaining four muscles
temporarily
B. OBLIQUE MUSCLES
– Exert their pull when
the eye turns nasally

NERVES IN THE EYES BLOOD VESSELS OF THE EYES


A. OPTHALMIC
A. CRANIAL NERVE II
ARTERY
- Optic nerve (nerve of
sight) – Major artery
supplying the
B. CRANIAL NERVE III structures in the
- Oculomotor
eye
C. CRANIAL NERVE IV B. OPTHALMIC VEINS
- Trochlear – Venous drainage
occurs through
D. CRANIAL NERVE VI
- Abducens vision

5
Components of the Functions of
Vision
• Visual receptor function of the eyeball
• The optic nerve
• Visual pathways that carry and distribute
sensory information from the optic nerve to
the CNS
• Primary and visual association cortices
that translate the sensory signals into
visual images

ASSESSMENT OF VISION

ASSESSMENT OF VISION ASSESSMENT OF VISION


EXTERNAL EYE EXAMINATION
• External Eye • Ultrasonography
Examination • Color Fundus • Cranial nerve examination (i.e.
• Visual Acuity Photography Cranial nerves 2, 3,4, 5, 6, and 7)
• Color Vision • Fluorescein • Pupillary reflex (Direct &
• Amsler Grid Angiography Consensual pupillary reflexes)
• Direct and Indirect • Tonometry • Corneal reflex test
Opthalmoscopy • Gonioscopy • Direct Fundoscopy
• Slit-Lamp • Perimetry Testing • Confrontational Test
Examination

6
ASSESSMENT OF VISION ASSESSMENT OF VISION
• PUPILS CORNEA
– Normal:
Normal round & of equal size
– Increasing light causes
pupillary constriction
• Corneal Reflex
– Decreasing light causes – When cornea is
pupillary dilation
– the client is asked to look
touched with a wisp of
straight ahead while the clean cotton, blink
examiner quickly brings a
beam of light ( penlight) in response is normal
from the side & directs it onto
the side – Test cranial nerves 5
– Constriction of the eye is a &7
direct response to the light
shining into the eye (Direct
pupillary reflex); constriction of
the opposite eye is known as
Consensual pupillary reflex)

ASSESSMENT OF VISION ASSESSMENT OF VISION


• RETINA • CONFRONTATIONAL
TEST
– Performed to examine
visual fields or
peripheral vision
– The examiner & the
client sit facing each
other
– The test assumes that
the examiner has
normal peripheral vision

ASSESSMENT OF
ASSESSMENT OF VISION VISION
VISUAL ACUITY TEST
• EXTRAOCULAR MUSCLE - measures the client’s distance & near vision
FUNCTIONS and cranial nerve 2
– tests muscle function of the eyes - uses Snellen’s chart and Jaeger’s chart
and cranial nerves 3, 4 and 6.
– tests 6 cardinal positions of gaze SNELLEN CHART
• 1. Client’s right (lateral position)
- simple tool to record visual acuity
• 2. Upward & right (temporal position)
- the client stands 20 ft from the chart & covers
• 3. Down & right
1 eye and uses the other eye to read the line
• 4. Client’s left (lateral position) that appears more clearly
• 5. Upward & left (temporal position)
- this procedure is repeated for the other eye
• 6. Down & left
- the findings are recorded as a comparison
– client holds head still & asked to between what the client can read at 20 ft and
move eyes & follow a small object the no. of feet normally required by an
– the examiner looks for any parallel individual to read the same line
movements of the eye or for
nystagmus (an involuntary rhythmic
rapid twitching of the eyeballs) EXAMPLE: 20/50
- The client is able to read at 20 ft from the
chart what a healthy eye can read at 50 ft

7
ASSESSMENT OF VISION COMPUTERIZED FIELD ANALYSIS
• COLOR VISION TEST
– Tests for color vision which
involve picking nos. or letters
out of a complex & colorful
picture.
– Uses Ishihara Chart
• ISHIHARA CHART
– consists of nos. that are
composed of colored dots
located within a circle of
colored dots
– client is asked to read the
number or letter on the chart
– each eye is tested separately
– the test is sensitive for the
diagnosis of red/green
blindness but not effective for
the detection of the
discrimination of blue

Applanation Tonometry and


SLIT LAMP EXAMINATION
Gonioscopy
• SLIT LAMP
– allows examination of the anterior
ocular structures under
microscopic magnification
– the client leans on a chin rest to
stabilize the head while a narrow
beam of light is aimed so that it
illuminates only a narrow segment
of the eye.
• NURSING CARE
– Explain the procedure to the
client.
– Advise the client about the
brightness of the light & the need
to look forward at the point over
the examiner’s ear

Digital Fundus Photography and Digital Digital Fundus Photography and Digital
Fluorescein Angiography Fluorescein Angiography
• For evaluation of effects of diabetes and high blood
pressure etc on the retina of eyes. • FLUORESCEIN ANGIOGRAPHY
• Post-
Post-OP NURSING CARE
• FLUORESCEIN ANGIOGRAPHY
– detailed imaging & recording of ocular circulation – Encourage rest.
by a series of photographs after administration of – Encourage oral fluids.
the dye
– Remind the client that the yellow skin
• PRE-
PRE-OP NURSING CARE
appearance will disappear
– Assess for allergies & previous reactions to dyes
– Obtain informed consent – Instruct the client that the urine will appear
– A mydriatic medication is instilled in the eye 1 hr. bright green until the dye is excreted
before the test – Instruct the client to avoid direct sunlight for
– The dye is injected into the vein of the client’s arm a few hrs after the test.
– Inform client that the dye may cause the skin to
appear yellow for several hrs. after the test & this – Instruct the client that the photophobia will
is gradually eliminated through the urine continue until pupil size returns to normal
– The client may experience N&V, sneezing,
paresthesia of the tongue or pain at injection site
– If hives appear, oral or IM antihistamines such as
Diphenhydramine (Benadryl) are given as
prescribed.

8
AUTOREFRACTOMETER CORNEAL TOPOGRAPHY
• For computerized evaluation of corneal
• For computerized disorders
checking of spectacle
• CORNEAL STAINING
power. – installation of a topical dye into the
conjunctival sac to outline the
irregularities of the corneal surface that
are not easily visible
– the eye is viewed through a blue filter,
and a bright green color indicates areas
of non-intact corneal epithelium

• NURSING CARE
– If a client wears contact lenses, they must
be removed
– The client is instructed to blink after the
dye has been applied to distribute the dye
evenly across the cornea

YAG LASER TREATMENT EYE SURGERY


• For treatment of after • Eye operating
cataract and microscope
glaucoma • Phacoemulsification
without surgery machine
within few seconds

Infectious and Inflammatory


EYELIDS DISORDERS
Conditions
• Dry Eye Syndrome
Blepharitis
Hordeolum (Sty) • Conjunctivitis
Chalazion • Uveitis
Trichiasis • Orbital Cellulitis

9
HORDEOLUM CHALAZION
• Also called sty. • A small swelling of
• A boil on the edge of the the eyelid. It results
eyelid formed in the root from obstruction of
of an eyelash. the glands in the
• Treatment includes hot eyelid.
compresses and • It often requires
antibiotic eye medicines; surgery for correction.
• It occasionally requires
opening and drainage.

BLEPHARITIS
• Inflammatory, very LACRIMAL APPARATUS
contagious infection of the
eyelash and oil glands of the DISORDERS
eyelids.
• It is characterized by
swelling, redness, and crusts
of dried mucus on the lids.
Dacryoadenitis
• Ulcerative blepharitis is
caused by a bacteria
Dacryocystitis
infection. Keratoconjunctivitis sicca
• Nonulcerative blepharitis
may be caused by psoriasis,
seborrhea (dandruff), or an
allergic reaction.

Keratoconjunctivitis Sicca
CONJUNCTIVAL
• Dryness of the cornea
because of a lack of
DISORDERS
tear secretions.
• The corneal surface
appears dull and
Conjunctivitis
rough, and the eye Pinguecula
feels gritty and
irritated. Pterygium

10
CONJUNCTIVITIS CONJUNCTIVITIS - Types
• Definition
– An inflammation or infection of the
conjunctiva of the eye.
• Infectious
– Known as “PINK EYE” conjunctivitis
• Pathophysiology – Bacterial
conjunctivitis
– The severity varies by exposure and
cause. The etiologic agent comes in – Chlamydial
contact with and irritates the conjunctivitis
conjunctiva, setting up an inflammatory
response. Recurrent inflammation
– Opthalmia
leads to thickening of the conjunctival neonatorum
layer & lid margins. • Viral conjunctivitis
– Conjunctivitis is common and is easily
spread when bacterial or viral in nature • Allergic
– Manifests as pruritic eye with redness, conjunctivitis
edema, and discharge (RED).

CONJUNCTIVITIS – CONJUNCTIVITIS –
Signs and Symptoms
Diagnostic Tests
• Infectious conjunctivitis
– Purulent drainage, lid swelling, • Smears and cultures of discharge are
moderate discomfort, redness of done to determine if viral or bacterial agent
conjunctiva
• Viral conjunctivitis
is present.
– Clear discharge, swollen preauricular • Conjunctival scrapings are used to rule out
node, tearing, redness, moderate inclusion conjunctivitis, trachoma, and
discomfort, light sensitivity
vernal conjunctivitis.
• Allergen or irritant • Vision, intraocular pressure, cornea, iris,
– Clear discharge, profuse tearing, pupil, and pupillary response are all
feeling of something in the eye, intense
itching (allergen), severe swelling of normal.
the lid, generalized redness of the eye,
moderate burning feeling

CONJUNCTIVITIS – CONJUNCTIVITIS –
Medical Treatment Nursing Interventions
• Drugs • Instruct in infection control measures such as good handwashing &
not sharing towels & washcloths
– Topical antiinfective drugs for bacterial cause; • Administer antibiotic or antiviral eye drops or ointment as Rx if
infection is present
topical antivirals for viral cause; topical • Administer antihistamines as Rx if an allergy is present
corticosteroids for allergens • Instruct the parents that the child should be kept home from school
or day care until antibiotic eye drops have been administered for 24
hrs
• General • Instruct in the use of cool compresses to lessen irritation & in
wearing dark glasses for photophobia
– Saline irrigation for discharge and comfort; • Instruct the child to avoid rubbing the eye to prevent injury
warm compresses for inflammation, cool • D/C use of contact lenses & to obtain new lenses to eliminate the
chance of re-infection
compresses for itching • Instruct the adolescent that eye make-up should be discarded &
replaced

11
CATARACTS
• Definition

LENS DISORDERS – an opacity or cloudiness of the lens


that distorts the image projected onto
the retina & that can progress to
blindness
• Pathophysiology
– Senile cataracts form as a result of a
chemical change in the gelatinous
Cataract lens protein encapsulated behind the
iris. As a result, the protein
coagulates, the lens gradually clouds,
and normal lens fibers swell and
migrate within the lens. Because of
these changes, a blurred image is
cast on the retina. If the condition
goes untreated, the opacity eventually
becomes complete and blindness
results.

CATARACTS CATARACTS
• Causes
– Cataracts are associated primarily with aging (senile • Types
cataracts) and chemical changes in lens proteins. – Aging process (Senile
Trauma, toxins, drugs, systemic disease (diabetes cataracts)
mellitus), and intraocular inflammation are also causes. – Inherited (Congenital
– Congenital cataracts, which are rare, are the result of cataracts)
inborn errors of metabolism, exposure of a first-
first-trimester – Injury (Traumatic cataracts)
fetus to rubella or toxins, and congenital anomalies.
– Can occur as a result of
– Cataracts are the third leading cause of blindness in the another eye disease
United States, and virtually everyone would develop (Secondary cataracts)
cataracts if they lived long enough.
– More than 60% of those over 65 years of age and 90%
of those over age 85 demonstrate lens opacities.

CATARACTS – Signs and Symptoms CATARACTS –


Diagnostic Tests
1. Progressive, painless blurring
& distortion of objects,
1. Snellen chart for
2. Gradual loss of vision.
Patient perceives that visual acuity
surroundings are dimmer 2. Ophthalmoscopy
3. Reduced visual acuity 3. Slit-lamp to
4. Glare from bright lights, establish the
5. Gray or white coloring on the degree of cataract
pupil (absence of red reflex) formation
6. Vision that is better in dim
light with pupil dilation

12
CATARACTS –
Medical Treatment
CATARACT SURGERY
- surgical removal of the lens, one eye at a
time. A lens implantation may be
performed at the time of surgical
procedure

1. EXTRACAPSULAR EXTRACTION
- the lens is lifted out without removing
the lens capsule
- may be performed with Phacoemulsion
PHACOEMULSION
- the lens is broken up by ultrasonic
vibrations & extracted
2. INTRACAPSULAR EXTRACTION
- the lens is removed within its capsule
through a small incision
3. PARTIAL IRIDECTOMY
- may be performed with lens extraction
to prevent acute secondary glaucoma
4. FOLLOW-
FOLLOW-UP LASER THERAPY
- to remove secondary membrane that
often forms

CATARACTS – CATARACTS –
Medical Treatment Nursing Interventions
1. Provide pre-operative care
• Pre-
Pre-op Drugs – Withhold aspirin therapy for 5-7 days, NSAIDS for 3-5 days and
– Topical anti-infective drugs Warfarin until PT of 1.5
– Mydriatic drugs – Dilating drops are administered every 10 minutes for 4 doses at least
1 hour before surgery
– Cycloplegics drug
– Implement measures to prevent increase intraocular pressure
– Hyperosmotic agents 2. Provide Post-operative care
• Post-
Post-op Drugs – POSITION: Place patient side lying on the UNAFFECTED side
– Corticosteroids – Administer pain medication, topical antibiotics and anti inflammatory
agents
– Mydriatics drugs
– Advise to wear glass x 24 hours or metal shield nightly x 1-4 weeks
• General – Clean eyes with single stroke from inner to outer canthus
– Lens implants (IOL) – Avoid lifting, pushing or pulling >15 pounds
– Corrective lenses (contact – Avoid prolonged stooping and bending. Assist in ambulation
lenses and eyeglasses) – Use side rails for safety and orient client to environment

CATARACTS –
Home Instructions
• Avoid eye straining
RETINAL DISORDERS
• Avoid rubbing or placing pressure on the eyes
• Avoid rapid movements, straining, sneezing, coughing, bending,
vomiting, or lifting objects over 5 lbs
• Teach measures to prevent constipation
• Wipe excess drainage or tearing with a sterile wet cotton ball from the Retinal Detachment
inner to the outward canthus
• Use an eye shield at bedtime
Retinal Vascular Disorder (CRVO and
• If an eye implant is not performed, the eye cannot accommodate & CRAO)
glasses must be worn at all times Macular Degeneration
• Cataract glasses act as magnifying glasses & replace central vision only
• Cataract glasses magnify, & objects appear closer therefore teach Diabetic Retinopathy
client to judge distance & climb stairs carefully Hypertensive Retinopathy
• Contact lenses provide sharp visual acuity but dexterity is needed to
insert them Retinoblastoma
• Contact the MD for any decrease in vision, severe eye pain or increase
in eye discharge

13
RETINAL DETACHMENT RETINAL DETACHMENT
• Definition • Causes
– a separation of the retina of the – Severe injury to the eye, as a bruise or
eye from the covering (choroid
(choroid)) penetrating wound, may be the cause, but in
in the back of the eye, most most cases retinal detachment is the result of
often resulting from a hole in internal changes in the vitreous chamber
the retina that allows the
linked to aging or, less often, to swelling of the
watery substance (vitreous
humor) to leak between the
inner eye.
choroid and the retina.
retina. – In most cases retinal detachment develops
– also occurs when both retinal slowly.
layers elevate away from the – Detachment often begins at the thin outer
choroid as a result of a tumor edge of the retina and reaches gradually
under the thicker, more central areas.

RETINAL DETACHMENT – RETINAL DETACHMENT –


Signs and Symptoms Signs and Symptoms
• SENSE OF CURTAIN IS BEING
• FLOATERS. The first symptom is often DRAWN. Detachment often begins at
the sudden appearance of many spots the thin outer edge of the retina and
floating loosely, hung in front of the reaches gradually under the thicker,
more central areas. The patient
affected eye. The patient may not seek senses a shadow that begins at the
help, because the number of spots side and grows in size, slowly edging
tends to decrease during the days and in on central sight.
weeks after the detachment. • DISTORTION OF VISION. As long as
the center of the retina is unaffected,
• FLASHES OF LIGHT. The patient may the sight, when the patient is looking
also notice a curious feeling of flashing straight ahead, is normal. When the
lights as the eye is moved. Because the center becomes affected, the eyesight
retina does not contain sense nerves is distorted, wavy, and unfocused. If
the detachment is not halted, total
that relay feelings of pain, the condition blindness of the eye will result. The
is painless. condition does not resolve itself.

RETINAL DETACHMENT – RETINAL DETACHMENT –


Medical Treatment Medical Treatment
MEDICAL MANAGEMENT
• Surgery is often needed to repair the - draining fluid from the subretinal space so that the retina can return to the
hole and prevent the leakage of normal position
vitreous humor that divides the
retina from its source of food, the • SEALING RETINAL BREAKS BY CRYOSURGERY
choroid. If the condition is found - a cold probe applied to the sclera to stimulate an inflammatory response
early, when the hole is small and the
amount of vitreous humor lost is not leading to adhesions
large, the retinal hole may be closed • DIATHERMY
by causing a scar to form on the - the use of electrode needle & heat through the sclera to stimulate an
choroid and to join to the retina inflammatory response leading to adhesions
around the hole. The scar may be • LASER THERAPY
caused by heat, electric current, or - to stimulate an inflammatory response to seal small retinal tears before
cold. The degree of restored sight the detachment occurs
depends on the degree and length of • SCLERAL BUCKLING
division. Maximum sight is gained
within 3 months after surgery. - to hold the choroid & retina together with a splint until scar tissue forms
Unless replaced, a detached retina closing the tear
slowly dies after several years of • INSERTION OF A GAS OR SILICONE OIL
detachment. Blindness resulting - to encourage attachment because these agents have a specific gravity less
from retinal detachment cannot be than vitreous or air & can float against the retina
treated

14
RETINAL DETACHMENT – RETINAL DETACHMENT –
Nursing Intervention Nursing Intervention
• PRE - OPERATIVE NURSING CARE • POST-
POST- OPERATIVE NURSING CARE
– Provide bedrest – Maintain eye patches bilaterally as prescribed
– Cover both eyes with patches to prevent further – Monitor hemorrhage as prescribed
detachment – Prevent N&V and monitor for restlessness which
– Speak to the client before approaching can cause hemorrhage
– Position the client’s head as prescribed – Monitor for sudden, sharp eye pain (notify the
– Protect the client from injury MD stat)
– Avoid jerky head movements – Encourage DBE but avoid coughing
– Minimize eye stress – Provide bedrest for 1-2 days as prescribed
– Prepare the client for surgical procedure as – If gas has been inserted, position as prescribed
prescribed on the abdomen & turn the head so unaffected
eye is down

RETINAL DETACHMENT –
Nursing Intervention RETINAL VASCULAR DISORDERS
• Retinal Vein Occlusion
• POST-
POST- OPERATIVE NURSING CARE (con
(con’’t.) • In elderly patients central vein thrombosis usually
arises from thrombosis by extension of an
– Administer eye medications as prescribed arteriosclerotic process, considering that at the
– Assist client with ADL region of the optic disk, the artery and vein share a
common adventitial coat. Endothelial proliferation
– Avoid sudden head movements or anything that in a diabetic vessel is also a common cause. In
young individuals, a phlebitis may be con-sidered.
increases IOP • Loss of vision is fairly rapid, though not as
– Instruct the client to limit reading for 3-5 weeks instantaneous nor complete as in central artery
occlusion. The fundus will show venous
– Instruct client to avoid squinting, straining & constipation, congestion and tortuousity and usually dark
lifting heavy objects & bending from the waist coloration of the veins. Superficial retinal
hemorrhages of various sizes are present.
– Instruct the client to wear dark glasses during the day & Because of the venous engorgement and retinal
hemorrhages, the condition has oftentimes been
an eye patch at night called a "hot dog and catsup" fundus. The disc is
usually hyperemic with blurring of the margin
– Encourage follow-up care because of the danger of (Fig-ure 13.3).
recurrence or occurrence in the other eye

RETINAL VASCULAR DISORDERS RETINAL VASCULAR DISORDERS


• Retinal Vein Occlusion • Retinal Artery Occlusion
• A small percentage of cases recover some useful vision • The usual causes of arterial obstruction are emboli from a cardiac
either through the development of new anastomotic thrombus or general arteriosclerosis, thrombosis, or spasm.
channels or the canalization of the clot. • The outstanding symptom is marked blurring or complete loss of
• A common complication is glaucoma which usually vision if the main trunk of the artery is occluded. In arterial branch
appears 3 months after onset. The eye shows occlusion, a defect in the visual field corresponding to the area
supplied by the arterial branch will be noticed. Usually the patient is
neovascularization of the iris surface (rubeosis iridis) with immediately aware of a branch occlusion of the temporal branches
occasional hyphema or vitreous hemorrhage. The age, as the macula is also involved producing impairment of central
for which reason the term hemorrhagic glaucoma has vision.
been given. • If ophthalmoscopy is done within a few hours after onset, the retinal
• Recently, photocoagulation of the edematous retina has artery will be seen to be very much constricted. The optic disk is
shown promising results. Hemorrhagic glaucoma, once it pale and the rest of the eye ground is white in appearance because
commences, is difficult to control medically and of the opaque retina brought about by coagulation necrosis.
eventually enucleation may be necessary to relieve the However, in the macular area the choroidal background still shines
pain. through. This is commonly called the "cherry red" spot (Figure 13.2).

15
RETINAL VASCULAR DISORDERS Diabetic retinopathy
• a disorder of the blood vessels in
• Retinal Artery Occlusion the retina of the eye, resulting in
• Paracenthesis of the anterior chamber to produce rapid broken blood vessels in the eye.
• The disorder occurs most often in
softening of the eye, if done within 12-24 hours of onset, patients with long-
long-term, poorly
may allow sufficient vasodilation of the retinal artery to controlled diabetes.
allow the embolus to pass inward into one of the • Repeated bleeding may result in
partial or complete blindness.
branches of the retinal artery and thus lessen the area of • Treatment is to stop the bleeding of
retinal damage. Vascular dilation may also be done by damaged blood vessels by laser
beam (photocoagulation).
vasodilator drugs (amyl nitrate inhalation,. retrobulbar • All diabetics are advised to have
acetylcholine or prescoline) 'or inhalation of carbon their eyes examined at least once a
dioxide (carbogen). A very simple procedure is to breathe year by physicians specializing in
diseases of the eye
continuously into a paper bag thus inhaling the (ophthalmologist).
accumulated CO2 that collects in the paper bag. • The development of retinopathy
can be prevented or slowed by
controlling blood sugar levels and
blood pressure.

Retinitis Pigmentosa Papilledema


• a group of diseases, often • Swelling of the optic disc
hereditary, characterized by caused by high pressure
degeneration of both retinas, in the skull. The
beginning in childhood and coverings (sheaths) that
progressing to blindness by surround the optic nerves
middle age. are parallel to the
• Clinical signs include a membrane covering of
reduced range of vision, an the brain. Thus, high
inability to see in dim light, pressure is sent forward
loss of color of the retina, from the brain to the optic
degeneration of the central disc in the eye to cause
part of the retina, and the swelling.
eventually, vision is lost.

Optic Atrophy Types of Age Related Macular


Degeneration
• Wasting away of the optic disc in the
innermost part of the eye (retina),
caused by a breakdown of optic nerve
• ‘Dry” form
fibers.
• In primary optic atrophy, the disc is
– An atrophic non-exudative
white with sharp outer edges, and the
central depression is large. • “Wet” form
• In secondary atrophy the disc is gray,
its outer edges are blurred, and the – Exudative
depression is filled in.
• Optic atrophy may be caused by a
birth defect, swelling blockage of the
central retinal artery or internal carotid
artery, or by alcohol, arsenic, lead,
nicotine, or other poisons.
• Breakdown of the disc may be seen
with arteriosclerosis, diabetes,
glaucoma, hydrocephalus, anemia,
and different types of nervous system
disorders.

16
GLAUCOMA
• Definition
– increased intraocular
pressure (IOP) resulting in a
condition that damages the
INCREASED IOP optic nerve & retina, and can
result in blindness
• Pathophysiology
– 1. Direct mechanismÆ
mechanismÆ
direct pressure damages
Glaucoma retina
– 2. Indirect mechanismÆ
mechanismÆ
high IOP compresses the
microcirculation in the optic
head resulting to nerve
injury and death

GLAUCOMA - Causes Classifications of Glaucoma


• Causes • Angle-
Angle-closure (narrow-
(narrow-angle) vs. open-
open-angle (wide-
(wide-
– An increase in angle)
intraocular pressure – Depends on location, circulation, and resorption
that results from • Congenital vs. acquired condition
abnormalities in the
balance between • Acute glaucoma (a(a rapid onset of IOP > 50-
50-70 mm
aqueous production Hg) vs. Chronic glaucoma (a rapid onset of IOP >
and outflow 50-
50-70 mm Hg)
– Most common cause is • Primary vs. secondary disorder
an interference with – Primary: no evidence of preexisting ocular or systemic
aqueous outflow from disease
the anterior chamber, – Secondary: results from inflammatory processes
rather overproduction affecting the eye, tumors, or blood cells of trauma-
trauma-
of aqueous humor produced hemorrhage

Angle-
Angle-closure (narrow-
(narrow-angle) vs. Symptoms of Congenital or
Open-
Open-angle (wide-
(wide-angle) Glaucoma Infantile Glaucoma
• Open-angle (wide-angle) • Excessive lacrimation and
Glaucoma photophobia
– Overproduction of aqueous • Affected infants tend to be
humor or blocking of the normal fussy, have poor eating
flow of the watery fluid in the
space between the cornea and habits, and rub their eyes
lens of the eye (aqueous frequently
humor). • Diffuse edema of the
• Angle-closure (narrow- cornea usually gives the
angle) Glaucoma eye a grayish-
grayish-white
– happens if the pupil in an eye appearance
with a narrow angle between • Enlargement of the entire
the iris and cornea opens too
wide and causes the folded iris globe (buphthalmos)
to block the flow of aqueous
humor.

17
GLAUCOMA – GLAUCOMA –
Signs and Symptoms Diagnostic Tests
• Progressive loss of peripheral 1. Tonometry to
vision (tunnel vision) followed by
a loss of central vision. measure the IOP
• Progressive loss of central vision 2. Ophthalmoscopy to
• Elevated IOP (Normal pressure is
10-
10-21 mm Hg) inspect the optic
• Blurred vision. Vision worsening nerve
in the evening with difficulty
adjusting to dark rooms 3. Gonioscopy to
• Blurred vision examine the angle
• Halos around white lights
• Frontal headaches 4. Perimetry to detect
• Photophobia visual field changes
• Increased lacrimation
• Discomfort in the eyes (red eyes)

GLAUCOMA – GLAUCOMA –
Medical Treatment Medical Treatment
Peripheral Iridectomy Laser Therapy
• NURSING CARE FOR ACUTE GLAUCOMA
– Treat as medical emergency
– Administer medications as prescribed to lower IOP
– Prepare the client for glaucoma surgery
• Allows aqueous humor to flow from the posterior to anterior
chamber
• Surgical management is laser trabeculoplasty, laser iridotomy,
filtering procedures, drainage implants or shunts

• NURSING CARE FOR CHRONIC GLAUCOMA


– Instruct the client the importance of medications
• MIoTICS:
MIoTICS: to constrict the pupils
• CARBONIC ANHYDRASE INHIBITORS: to decrease the
production of aqueous humor
• BETA-
BETA-BLOCKERS: to decrease the production of aqueous humor
& IOP
– Instruct the client the need for life-long medication use
– Instruct the client to wear a Medic-Alert bracelet

GLAUCOMA – GLAUCOMA –
Nursing Interventions Home Instructions
1. Teach patient about glaucoma care NURSING CARE FOR CHRONIC GLAUCOMA
2. Use of medications can slow the progression – Instruct the client to avoid anti-cholinergic medications
but not cure it – Instruct the client to report eye pain, halos around eyes &
– Information about instilling eye drops changes of vision to the physician
– Information as to the corrective SURGERY – Instruct the client that when maximal medical therapy has
to prevent irreversible blindness!!! failed to halt the progression of visual field loss & optic
nerve damage, surgery will be recommended
3. Reduce anxiety and Agitation – Prepare the client for TRABECULOPLASTY as
– Familiar, noise free, less stimulating prescribed
environment - to facilitate aqueous humor drainage
– Remain calm, and unhurried during agitation – Prepare client for TRABECULECTOMY as prescribed
attacks - allows drainage of aqueous humor into the conjunctival
spaces by the creation of an opening

18
NORMAL
REFRACTIVE ERRORS

• Hyperopia or
farsightedness
OPTICAL DEFECTS – The anterior-
anterior-posterior
dimension of the eyeball is
Hyperopia

too short, the image is


focused posterior to (behind)
the retina
Hyperopia • Myopia or
Myopia nearsightedness
Astigmatism – The anterior-
anterior-posterior Myopia

Presbyopia dimension of the eyeball is


too long, the focus point for
an infinitely distant target is
anterior to the retina

REFRACTIVE ERRORS LEGALLY BLIND


• Presbyopia • A person is legally
– Refers to changes in vision that
occur because of aging
blind if the best visual
– farsightedness caused by a loss of acuity with corrective
stretching of the lens of the eye.
The condition often occurs after lenses in the better
age 40. eye is 20/200 or less
• Astigmatism
– An abnormal condition of the eye
or a visual field of 20
in which the curve of the cornea is degrees or less in the
unequal. As a result, light rays
cannot be focused clearly. Vision better eye
is blurred and the eyes tire easily.
The condition usually can be
corrected with contact lenses or
eyeglasses

LEGALLY BLIND LEGALLY BLIND


• NURSING CARE • NURSING CARE (con
(con’’t.)
– Provide radios, TVs, & clocks that give the time orally or
– When speaking to a client who has limited sight provide a Braille watch.
or blind, the nurse uses a normal tone of voice – When ambulating, allow the client to grasp the nurse’s
– Alert the client when approaching arm at the elbow - the nurse keeps his or her arm close
to the body so that the client can detect the direction of
– Orient the client to the environment movement
– Use a focal point & provide further orientation to – Instruct the client to remain one step behind the nurse
the environment from the focal point when ambulating
– Instruct the client in the use of the cane used for the blind
– Allow the client to touch objects in the room client, which is differentiated from other canes by its
– Use the clock placement of foods on the meal straight shape & white color with red tip
tray to orient the client – Instruct the client that the cane is held in the dominant
hand several inches off the floor
– Promote independence as much as possible – Instruct the client that the cane sweeps the ground
where the client’s foot will be placed next

19
Disorders of Eye Movement
• Amblyopia
OCULAR MOTILITY – A condition of diminished vision in which no
DEFECTS detectable organic lesion of the eye is
present
• Strabismus
Strabismus – Any abnormality of eye coordination or
alignment that results in loss of binocular
Ambylopia vision
• Paralytic strabismus
• Non-paralytic strabismus

STRABISMUS –
STRABISMUS Signs and Symptoms
• called “SQUINT EYE”
EYE” or “LAZY • Amblyopia if not treated
EYE”
EYE”
• a condition in which the eyes are early
not aligned because of lack of • Permanent loss of vision if
muscle coordination of the
extraocular muscles not treated early
• most often results from muscle • Loss of binocular vision
imbalance or paralysis of
extraocular muscles, but may also • Impairment of depth
result from conditions such as perception
brain tumor, myasthenia gravis or
infection • Frequent headaches
• normal in young infant but should
not be present after about age 4 • Squints or tilts head to see
months

STRABISMUS –
Medical Treatment
• Corrective lenses as indicated
• Instruct the parents regarding
patching (occlusion therapy) of
the “good” eye
– to strengthen the weak eye
• Prepare for botulinum toxin
(Botox) injection into the eye
muscle
– produces temporary paralysis
– allows muscles opposite the
paralyzed muscle to strengthen the
eye

20
STRABISMUS –
Medical Treatment (con
(con’’t.)
• Inform the parents that the
injection of botulinum toxin
wears off in about 2 months OCULAR INJURIES
& if successful, correction
will occur
• Prepare for surgery to
realign the weak muscles as
Rx if nonsurgical
interventions are
unsuccessful
• Instruct the need for follow-
up visits

HYPHEMA CONTUSION
• A bleeding into the anterior chamber of the
eye, usually caused by a injury (blow to the • bleeding into the soft tissue
eye). This condition usually resolves in 5-5-7
days as a result of an injury
• Glaucoma may result from recurrent bleeding • causes a black eye & the
• Bedrest is required. The patient should be
treated by an ophthalmologist who can decide discoloration disappears in
the need for removing the blood, and the approximately 10 days
need for medication.
• Encourage rest in semi-
semi-Fowler’
Fowler’s position • pain, photophobia, edema
• Avoid sudden eye movements for 3- 3-5 days to & diplopia may occur
decrease bleeding
• Administer cycloplegic eye drops as
• Place ice on the eye
prescribed - to place the eye at rest immediately
• Instruct in the use of eye shields or eye • Instruct the client to receive
patches as prescribed
• Instruct the client to restrict reading & an eye examination
watching TV

FOREIGN BODY PENETRATING OBJECT


• an object such as dust that enters the • an object such as dust that
eye
enters the eye
• Nursing Care
– Have the client look upward, expose • Nursing Care
the lower lid, wet a cotton- tipped – Never remove the object
applicator with sterile NSS & gently
twist the swab over the particle & because it may be holding
remove it ocular structures in place, the
– If the particle cannot be seen, have object must be removed by MD
the client look downward, place a – Cover the object with a cup
cotton applicator horizontally on the
outer surface of the upper eye lid, – Don’
Don’t allow the client to bend
grasp the lashes, & pull the upper lid – Don’
Don’t place pressure on the eye
outward & over the cotton applicator,
if the particle is seen, gently twist over – Client is to be seen by MD stat
it to remove

21
CHEMICAL BURNS
• an eye injury in which a corrosive
substance enters the eye
• Nursing Care
– Treatment should begin stat
NEURO-
– Flush the eyes at the site of injury with
water for at least 15-20 mins OPHTHALMOLOGY
– At the site of injury, obtain a small sample
of the chemical involved
– At the ER, the eyes is irrigated with NSS
or an opthalmic irrigation solution
Optic Nerve Disorders
– The solution is directed across the cornea CN 3,4 & 6 Disorders
& toward the lateral canthus
– Prepare for visual acuity assessment
Trigeminal Disorders
– Apply an antibiotic ointment as prescribed Facial Nerve Disorders
– Cover the eye with a patch as prescribed

Disorders of Neural Pathways


and Cortical Centers
• Visual field defects
– Retinal defects
• Disorders of the optic pathways
• Disorders of the Visual Cortex

22
Surgical Procedures and
Enucleation
OCULAR SURGERY • Orbital Surgeries
• Enucleation
• Ocular Protheses

ENUCLATION vs. EXENTERATION ENUCLATION vs. EXENTERATION


• ENUCLEATION
• Pre-Op Nursing Care
– removal of the entire eyeball – Provide emotional support to
the client
• EXENTERATION – Encourage the client to
– removal of the eyeball & verbalize feelings related to
surrounding tissues
loss
• Performed for the removal of • Post-Op Nursing Care
ocular tumors – Monitor V/S
• After the eye is removed, a ball
implant is inserted to provide a firm
– Assess pressure patch or
base for socket prosthesis & to dressing
facilitate the best cosmetic result – Report changes in V/S or the
• A prosthesis is fitted approximately presence of bright red
1 month after surgery drainage on the pressure
patch or dressing

23
ORGAN DONATION - DONOR ORGAN DONATION - RECIPIENT
• DONOR EYES • PRE-
PRE-OP CARE OF PATIENT
– Obtained from cadavers – Recipient may be told of the
– Must be enucleated soon after death tissue availability only several
due to rapid endothelial cell death hrs to 1 day before surgery
– Must be stored in a preserving – Assist in alleviating client
solution
anxiety
– Storage, handling & coordination of
donor tissue with surgeons – Assess for signs of eye
– is provided by a network of state eye infection
bank associations across The – Report the presence of any
country redness, watery or purulent
• CARE OF THE DECEASED CLIENT drainage or edema around the
AS A POTENTIAL EYE DONOR eyes to MD
– Discuss the option of eye donation – Instill antibiotic drops into the
with MD & family eyes as Rx to reduce the no. of
– Raise the head of the bed 30°
30° microorganisms present
– Instill antibiotic eye drops as RX – Administer IV fluids &
– Close the eyes & apply a small ice medications as Rx
pack to the closed eyes

ORGAN DONATION –
ORGAN DONATION - RECIPIENT
GRAFT REJECTION
• POST-
POST-OP CARE OF PATIENT
– Eye is covered with a pressure
patch and protective shield that • GRAFT REJECTION
are left in place until the next day
– Don’
Don’t remove or change the – Can occur at anytime
dressing without the MD’MD’s order
– Monitor V/S, LOC & assess
– Inform the client of signs
dressing of rejection
– Position the client on unoperative
side to reduce IOP – Signs include redness,
– Orient the client frequently swelling, decreased
– Monitor for complications of
bleeding, wound leakage, infection vision, & pain (RSDP)
& graft rejection
– Instruct the client in how to apply
– Treated with topical
the patch & eye shield steroids
– Instruct the client to wear the eye
shield at night for 1 month &
whenever around small children or
pets

INSTALLATION OF EYE DROPS

OPTHALMIC EYE DROPS


• Wash hands

AND •


Put on gloves
Check the name, strength, & expiration date of the medication
Instruct the client to tilt the head backward, open the eyes & look up
• Pull the lower lid down against the cheekbone

OTIC MEDICATIONS • Hold the bottle, gently rest the wrist of the hand on the client’s cheek
• Squeeze the bottle gently to allow the drop to fall into the conjunctival
sac
• Instruct the client to close the eyes gently & not to squeeze the eyes shut
• Wait 3-5 minutes before instilling another drop, if more than 1 is Rx
- to promote maximal absorption of the medication
• Don’t allow the medication bottle, dropper, or applicator to come in
contact with the eyeball

24
Installation of eye MYDRIATICS, Cycloplegic &
medications anticholinergic medications

EYE OINTMENTS MYDRIATICS


• Hold the ointment tube near, but not touching, the eye or - dilate the pupils (mydriasis)
eyelashes
• Squeeze a thin ribbon of ointment along the lining of the lower
CYCLOPLEGIA
conjunctival sac from the inner to the outer canthus - relax the ciliary muscles
• Instruct the client to close the eyes gently
• Instruct the client that vision may be blurred by the ointment
ANTICHOLINERGICS
- block responses of the sphincter muscle in the ciliary body,
producing mydriasis

MYDRIATICS & Cycloplegic eye


MYDRIATICS, Cycloplegic & medications
anticholinergic medications

- used pre-op or for eye examinations to produce mydriasis


EXAMPLES
- C/I in clients with glaucoma because of the risk of increased • Atropine sulfate (Isopto
(Isopto--Atropine, Ocu-
Ocu-Tropine,
Tropine, Atropair,
Atropair, Atropisol)
Atropisol)
IOP • Scopolamine hydrobromide (Isopto-
Isopto-Hyoscine)
Hyoscine)
- Mydriatics are C/I in cardiac dysrhythmias & cerebral • Cyclopentolate hydrochloride (Cyclogyl
(Cyclogyl,, AK-
AK-Pentolate,
Pentolate, Pentolair)
Pentolair)
atherosclerosis & should be used with caution in the elderly
• Homotropine hydrobromide (Isopto Homatrine,
Homatrine, AK- AK-Homatropine,
Homatropine,
and in clients with prostatic hypertrophy, diabetes mellitus or
Spectro-
Spectro-Homatrine)
Homatrine)
parkinsonism
• Tropicamide (Mydriacyl,
Mydriacyl, I-
I-Picamide,
Picamide, Tropicacyl)
Tropicacyl)
• Phenylephrine hydrochloride (AK-
(AK-Dilate, Dilatair,
Dilatair, Mydfrin,
Mydfrin, Ocu-
Ocu-Phrin)
Phrin)

MYDRIATICS, Cycloplegic & ATROPINE TOXICITY


anticholinergic medications
9 Dry mouth
9 Blurred vision
9 Photophobia
SIDE EFFECTS 9 Tachycardia
9 Fever
9 Tachycardia 9 Urinary retention
9 Photophobia 9 Constipation
9 Conjunctivitis 9 Headache, brow pain
9 Dermatitis 9 Confusion
9 Hallucinations, delirium
9 Coma
9 Worsening of narrow-angled glaucoma

25
SYSTEMIC REACTIONS OF MYDRIATICS, Cycloplegic &
ANTICHOLINERGICS anticholinergic medications
9 Dry mouth & skin
9 Fever NURSING CARE
9 Thirst • Monitor for allergic reactions
• Assess for risk of injury
9 Confusion • Assess for constipation & urinary retention
9 Hyperactivity • Instruct the client that a burning sensation may occur on
installation
• Instruct the client not to drive or operate machine for 24 hrs after
installation of the medication unless otherwise directed by the
ALPHA-
ALPHA-ADRENERGIC BLOCKER physician
• Instruct the client to wear sunglasses until the effects of the
- example Dapiprazole hydrochoride (Rev-
(Rev-Eyes) medication wear off
- used to counteract mydriasis • Instruct to notify MD if blurring of vision, loss of sight, difficulty in
breathing, sweating or flushing occurs
• Instruct the client to report eye pain to the physician

ANTI-INFECTIVE ANTI-
ANTI-INFECTIVE EYE MEDICATIONS
EYE MEDICATIONS ANTIBACTERIAL
• Chloramphenicol (Chloromycetin, Chloroptic)
• Ciprofloxacin hydrochloride (Cipro)
- Kill or inhibit the growth of bacteria, fungi, & viruses
• Erythromycin (Ilotycin)
SIDE EFFECTS • Gentamicin sulfate (Garamycin, Genoptic)
• Norfloxacin (Chibroxin)
9 Superinfection
9 Global irritation • Tobramycin (Nebcin, Tobrex)
• Silver nitrate 1%
NURSING CARE
• Assess for risk of injury ANTIFUNGAL
• Natamycin (Natacyn Opthalmic)
• Instruct the client in how to apply the eye medication
• Instruct the client to continue treatment as Rx ANTIVIRAL
• Instruct the client to wash hands thoroughly & frequently • Idoxuridine (Herplex-Liquifilm)
• Advise the client that if improvement does not occur, notify the MD • Trifluridine (Viroptic)
• Vidarabine (Vira-A Opthalmic)

ANTI-
ANTI-INFLAMMATORY EYE ANTI-
ANTI-INFLAMMATORY EYE
MEDICATIONS
- Control inflammation, thereby reducing vision loss & scarring
MEDICATIONS
- Used for uveitis, allergic conditions, & inflammation of the conjunctiva,
cornea, & lids

SIDE EFFECTS EXAMPLES


9 Cataracts • Dexamethasone (Maxidex)
9 Increased IOP
9 Impaired healing • Diclofenac (Voltaren)
9 Masking S/S of infection • Flurbiprofen Na (Ocufen)
NURSING CARE • Suprofen (Profenal)
• Assess for risk of injury • Ketorolac tromethamine (Acular)
• Instruct the client in how to apply the eye medication
• Prednisone acetate (Predforte, Econopred)
• Instruct the client to continue treatment as Rx
• Prednisolone Na phosphate (AK-Pred, Inflamase)
• Instruct the client to wash hands thoroughly & frequently
• Rimaxolone (Vexol)
• Advise the client that if improvement does not occur, notify the MD
• Note that dexamethasone (Maxidex) should not be used for eye abrasions
& wounds

26
TOPICAL ANESTHETICS
FOR THE EYE TOPICAL ANESTHETICS
- Produce corneal anesthesia FOR THE EYE
- Used for anesthesia for eye examinations, for surgery, or to remove
foreign bodies from the eye

SIDE EFFECTS EXAMPLES


9 Temporary stinging or burning of the eye
9 Temporary loss of corneal reflex • Proparacaine HCl (Ophthaine, Opthenic)
NURSING CARE • Tetracaine HCl (Pontocaine)
• Assess for risk of injury
• Note that the medications should not be given to the client for home use &
are not to be self-administered by the client
• Note that the blink reflex is temporarily lost & that the corneal epithelium
needs to be protected
• Provide an eye patch to protect the eye from injury until the corneal reflex
returns

EYE LUBRICANTS
EYE
LUBRICANTS
- Replace tears or add moisture to the eyes
- Moisten contact lenses or an artificial eye
- Protect the eyes during surgery or diagnostic procedures
- Used for keratitis, during anesthesia or in a disorder that results in
unconsciousness or decreased blinking EXAMPLES
SIDE EFFECTS • Hydroxypropyl methylcellulose (Lacril, Isopto Plain)
9 Burning in installation • Petroleum-based ointment (Artificial Tears, Liquifilm Tears)
9 Discomfort or pain in installation

NURSING CARE
• Inform the client that burning may occur on installation
• Be alert to allergic responses to the preservatives in the lubricants

MIOTICS
MIOTICS
- reduce IOP by constricting the pupil & contracting the ciliary muscle,
thereby increasing the blood flow to the retina & decreasing retinal
damage & loss of vision
- open the anterior chamber angle & increase the outflow of aqueous
MIOTIC CHOLINERGIC MEDS
humor - reduce IOP by mimicking the action of acetylcholine
- used for chronic open-angle glaucoma or acute & chronic closed-angle
glaucoma MIOTIC ACETYLCHOLINE
- used to achieve miosis during eye surgery
- C/I in clients with retinal detachment, adhesions between the iris & INHIBITORS MEDS
lens, or inflammatory diseases - reduce IOP by inhibiting the action of cholinesterase
- used with caution in clients with asthma, hypertension, corneal
abrasion,hyperthyroidism, coronary vascular disease, urinary tract
obstruction, GI obstruction, ulcer disease, parkinsonism, or
bradycardia

27
MIOTICS MIOTICS
SIDE EFFECTS SYSTEMIC EFFECTS
9 Myopia 9 Flushing
9 Headache
9
9
Diaphoresis
GI upset & diarrhea
EXAMPLES
9 Eye pain 9 Frequent urination
• Acethylcholine Cl (Miochol)
9 Decreased vision in poor light 9 Increased salivation
9 Local irritation 9 Muscle weakness • Carbachol (Miostat)
9 Respiratory difficulty • Pilocarpine HCl (Isopto Carpine, Pilocar)
• Pilocarpine nitrate (Pilofrin, Liquifilm, Pilagan)
TOXICITY • Echothiophate iodide (Phospholine iodide)
9 Vertigo & syncope
9 Bradycardia • Demecarium bromide (Humorsol)
9 Hypotension • Isoflurophate (Floropryl)
9 Cardiac dysrhythmias
9 Tremors
9 Seizures

MIOTICS OCUSERT
NURSING CARE -
SYSTEM
It’s a thin eye wafer (disk) impregnated with time-release Pilocarpine
• Assess V/S & risk of injury - Devised to overcome the frequent application of Pilocarpine
• Assess the client for the degree of diminished vision - Placed in the upper or lower cul-de-sac of the eye
• Monitor S/E & toxic effects - Pilocarpine is released over 1 wk & disk is replaced every 7 days
• Monitor for postural hypotension & instruct the client to change positions - Drawbacks of its use include sudden leakage of Pilocarpine, migration
slowly of the system over the cornea, & unnoticed loss of the system
• Assess breath sounds for rales & rhonchi
- cholinergic meds cause bronchospasms & increased bronchial secretions NURSING CARE
• Maintain oral hygiene • Assess the client’s ability to insert the medication disk
- due to increased salivation • Store the medication in the refrigerator
• Have Atropine sulfate available as antidote for Pilocarpine • Instruct the client to discard damage or contaminated disks
• Instruct the client regarding the correct administration of eye meds • Inform the client that temporary stinging is expected but to notify MD if
• Instruct the client not to stop the meds suddenly blurred vision or brow pain occurs

• Instruct to avoid activities such as driving while vision is impaired • Instruct the client to check for the presence of the disk in the conjunctival
sac daily qHS & upon arising
• Instruct clients with glaucoma to read labels on OTC meds & to avoid
Atropine-like meds • Since vision may change in the first few hours after the eye system is
- Atropine increase IOP inserted, instruct the client to replace the disk at bedtime

BETA-
BETA-ADRENERGIC
BLOCKING EYE
MEDICATIONS BETA-
BETA-ADRENERGIC
- Reduce IOP by decreasing sympathetic impulses & decreasing BLOCKING EYE MEDICATIONS
aqueous humor production without affecting accommodation or
pupil size
- Used to treat chronic open-angle glaucoma
- C/I in the client with asthma
EXAMPLES
- systemic absorption can cause increased airway resistance
• Betaxolol HCl (Betoptic)
- Used with caution in the client receiving oral beta-blockers
• Carteolol HCl (Ocupress)
SIDE EFFECTS • Levobunolol HCl (Betagan)
9 Ocular irritation
• Metipranolol (Optipranolol)
9 Visual disturbances • Timolol maleate (Timoptic)
9 Bradycardia
9 Hypotension
9 Bronchospasm

28
BETA-
BETA-ADRENERGIC ADRENERGIC EYE
BLOCKING EYE MEDICATIONS
MEDICATIONS
NURSING CARE - Decrease the production of aqueous humor & lead to a decrease in
• Monitor V/S before administering medication esp. BP & PR IOP
• If the pulse is below 60 or if systolic BP is below 90 mm Hg, withhold the - Used to treat glaucoma
medication & contact MD
• Monitor for shortness of breath and I&O
ADRENERGIC MEDICATIONS
• Assess for risk of injury
• Instruct the client to notify MD if shortness of breath occurs • Apraclonidine HCl (Iopidine)
• Instruct not to D/C medication abruptly • Brimonidine tartrate (Alphagen)
• Instruct to change positions slowly to avoid orthostatic hypotension • Dipivefrin HCl (Propine)
• Instruct to avoid hazardous activities • Epinephrine borate (Epinal, Eppy)
• Instruct to avoid OTC meds without the MD’s approval • Epinephrine HCl (Epifrin, Glaucon)

CARBONIC ANHYDRASE CARBONIC ANHYDRASE


MEDICATIONS MEDICATIONS
- Interfere with the production of carbonic acid which leads to NURSING CARE
decreased aqueous humor formation & decreased IOP
• Monitor V/S
- Used for long-term treatment of open-angle glaucoma
• Assess visual acuity
- C/I in the client allergic to sulfonamides • Assess for risk of injury
• Monitor I&O
SIDE EFFECTS • Monitor weight
9 Appetite loss • Maintain oral hygiene
9 GI upset • Monitor for side effects such as lethargy, anorexia, drowsiness, polyuria,
9 Paresthesias in the fingers, toes & face nausea, & vomiting
9 Polyuria • Monitor electrolytes for hypokalemia
9 Hypokalemia • Increase fluid intake unless C/I
9 Renal calculi • Advise the client to avoid prolonged exposure to sunlight
9 Photosensitivity • Encourage the client to use artificial tears for dry eyes
9 Lethargy & drowsiness • Instruct not to D/C the medication abruptly
9 Depression • Instruct to avoid hazardous activities while vision is impaired

OSMOTIC MEDICATIONS
- Lower IOP
OSMOTIC EYE
- Used in emergency treatment of acute closed-angle glaucoma
- Used pre-op & post-op to decrease vitreous humor volume MEDICATIONS
SIDE EFFECTS
9 Heache
9
9
Nausea, vomiting, diarrhea
Disorientation EXAMPLES
9 Electrolyte imbalance
• Glycerin (Glyrol, Osmoglyn)
NURSING CARE • Mannitol (Osmitrol)
• Assess V/S, visual acuity & risk for injury
• Urea (Ureaphil)
• Monitor weight and I&O
• Monitor electrolytes
• Increase fluid intake unless C/I
• Monitor for changes in level of orientation

29
• diabetic retinopathy,

30
31
32
33
Chapter 58
Assessment and
Management of Patients
With Eye and Vision

34
Impaired Vision

• Refractive Errors
– emmetropia, myopia, hyperopia, and
astigmatism
• Low Vision and Blindness
– magnification and image
enhancement
– multiple-unit artificial retinal chipset
(MARC)

Orbital and Ocular Trauma


• Orbital Trauma
– Soft tissue injury and hemorrhage
– Fractures
– Foreign bodies
• Ocular Trauma
– Penetrating injuries and contusions
– Intraocular foreign bodies
– Ocular burns

Commonly Used Ocular


Orbital and Ocular Tumors
Medications
• Benign Tumors of the Orbit,
Eyelids, and Conjunctiva • Topical • Corticosteroids
• Malignant Tumors of the Orbit, Anesthetics and Nonsteroidal
Eyelids, and Conjunctiva • Mydriatics and Anti-
• Malignant Tumors of the Globe: Cycloplegics Inflammatory
Ocular Melanoma • Medications to Drugs
Treat Glaucoma • Antiallergy
• Anti-Infectives Medications
O l I i

35
DISORDERS AUDIO-VISUAL
OF THE EYE DISTURBANCES

Risk factors of eye


disorders

9 AGING PROCESS
9 CONGENITAL
9 DIABETES MELLITUS
9 HEREDITARY
9 MEDICATIONS
9 TRAUMA

COMPUTERIZED FIELD ANALYSIS DIAGNOSTIC TESTS FOR THE EYE

COMPUTED TOMOGRAPHY
- a beam of x-ray scans the skull & orbits of the eye
- a cross-sectional image is formed by the use of a computer
- contrast material is not usually administered

NURSING CARE
• No special client preparation or follow-up care required
• Instruct the client that he or she will be positioned in a confined
space & need to keep the head still during the procedure

36
DIAGNOSTIC TESTS FOR THE EYE

TONOMETRY CORNEAL DISORDERS


- the test is primarily used to assess for an increase in IOP and
potential glaucoma
- NORMAL IOP: IOP 8-21 mm Hg

NURSING CARE Corneal Ulcer


• Each eye is anesthetized. Keratitis
• The client is asked to stare forward at a point above the examiner’s Corneal Opacities
ear Arcus senilis
• A flattened cone is brought in contact with the cornea Keratoconus
• The amount of pressure needed to flatten the cone is measured
Keratomalacia
• The client is instructed to avoid rubbing the eye following the
examination if the eye has been anesthetized
- the potential for scratching the cornea exists

Corneal Disorders
Corneal Disorders
• Refractive Surgeries
• Corneal Dystrophies – Radial keratotomy (RK), Laser
• Keratoconus vision correction photorefractive
keratectomy (PRK)
• Corneal Surgeries
– Laser-assisted in situ
–Phototherapeutic Keratectomy
keratomileusis (LASIK)
–Keratoplasty

Disorders of the Cornea


• Corneal trauma VITREOUS DISORDERS
• Keratitis
• Herpes simplex keratitis
• Abnormal corneal deposits Vitreous Liquefaction & Detachment
• Arcus senilis Vitreous Opacities
Vitreous Bands and Membranes

37
Retinal Disorders
RETINAL DISORDERS
• Retinal Detachment
• Retinal Vascular Disorders
Retinal Detachment – Central Retinal Vein Occlusion
Retinal Vascular Disorder (CRVO and
CRAO) – Branch Retinal Vein Occlusion
Macular Degeneration
Diabetic Retinopathy – Central Retinal Artery Occlusion
Hypertensive Retinopathy • Macular Degeneration
Retinoblastoma

RETINOPATHIES
Ocular Consequences of
Systemic Disease • Diabetic retinopathy
• Hypertensive retinopathy
• Atherosclerosis of retinal vessels
• Diabetic Retinopathy
• Retinopathy of prematurity
• Cytomegalovirus Retinitis
• Hypertension-Related Eye
Changes

RETINAL VASCULAR DISORDERS


• Macular Degeneration

38