NEURO-SENSORY ANATOMY & PHYSIOLOGY

DISORDERS OF EYES

PART 2

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

cornea and accommodative • PALPEBRAL FISSURE

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

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

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 LACRIMAL APPARATUS (LACRIMAL
GLAND & ITS DUCTS AND PASSAGES)
ƒ Produces tears to
lubricate the eye &
moisten the cornea
ƒ Tears drain into
nasolacrimal duct
which empties into
nasal cavity
Layers of the Eyeball
1. OUTER LAYER - fibrous
coat that supports the
eye
A. SCLERAE
– Outer supporting layer
– Tough, white connective
tissue “white of the eye”
– located anteriorly &
posteriorly
B. CORNEA
– Transparent tissue
through which light enters
the eye.
– Located anteriorly
Layers of the Eyeball
2. MIDDLE LAYER –
vascular & pigmented
A. CHOROID
– a dark brown
membrane located
between the
sclera & the retina
– it lines most of the
sclera & is attached to
the retina but can easily
detach from the sclera
– contains blood vessels
that nourishes the
retina
– located posteriorly
Components of the Lacrimal
System
• Major lacrimal gland
– Produces the tears
• The puncta and tear
sac
– Collect the tears
• Nasolacrimal duct
– Empties the tears into
the nasal cavity
Layers of Tissue Forming the
Cornea
• An extremely thin outer
epithelial layer
– Continuous with the bulbar
conjunctiva
• A middle layer called the
substantia propria or stroma
– Composed of regularly
arranged collagen bundles
embedded in a
mucopolysaccharide matrix
• An inner endothelial layer
– Lies next to the aqueous
humor of the anterior
chamber
Layers of the Eyeball
2. MIDDLE LAYER (con’t)
B. CILIARY BODY
– connects the choroid
with the iris
– secretes aqueous
humor that helps give
the eye its shape
C. IRIS
– the colored portion of
the eye
– located in front of the
lens
– it has a central opening
called the pupil
2
 Layers of the Eyeball
3. INNER LAYER – contains
the blood vessels &
nervous tissue
A. RETINA
– a thin, delicate structure in
which the fibers of the optic
nerve are distributed
– bordered externally by the
choroid & sclera & internally
by the vitreous
– contains blood vessels &
photoreceptors
– light sensitive layer
– Receive visual images and
partially analyze them
– Transmit this modified
information to the brain
Types of Photoreceptors Present in
the Retina
1. CONES
– Specialized for fine
discrimination, central vision
& color vision
– capable of color
discrimination
– Functions at bright levels of
illumination
2. RODS
– More sensitive to light than
cones
– capable of black–
black–white
discrimination
– Aid in peripheral vision
– Functions at reduced levels
of illumination
Internal Structures of the Eyeball
1. FLUIDS OF THE EYE
A. AQUEOUS HUMOR
– Clear, watery fluid that
fills the anterior &
posterior chambers of
the eye
– produced by the ciliary
processes, & the fluid
drains in the Canal of
Sclemm
– The anterior chamber
lies between the cornea
& iris
– the posterior chamber
lies between the iris &
lens
Composition of the Neural
Retina
3 layers of neurons
– A posterior layer of
photoreceptors
– A middle layer of
bipolar cells
– An inner layer of
ganglion cells that
communicate with the
photoreceptors
Layers of the Eyeball
3. INNER LAYER (con
(con’’t.)
B. RETINAL BLOOD VESSELS
C. OPTIC NERVE
D. OPTIC DISK
– a creamy pink to white
depressed area in the retina
– the optic nerve enters & exits
the eyeball in this area
– Referred to as the “BLIND
SPOT”
SPOT”
– contains only nerve fibers
– lack photoreceptors
– insensitive to light
E. MACULA LUTEA
– Small, oval, yellowish pink
area located lateral &
temporal to the
optic disk
– 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
1. FLUIDS OF THE EYE
A. AQUEOUS HUMOR
(cont.)
– serves as refracting medium
Serves to maintain the
intraocular pressure
– Provides for the nutritive
needs of the lens and
posterior cornea
– Mediates the exchange of
respiratory gases
– Contains a low concentration
of protein and high
concentrations of ascorbic
acid, glucose & amino acids
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 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

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

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

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

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

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

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 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

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 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

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 RETINAL DETACHMENT
• Definition
– a separation of the retina of the
eye from the covering (choroid
(choroid))
in the back of the eye, most
often resulting from a hole in
the retina that allows the
watery substance (vitreous
humor) to leak between the
choroid and the retina.
retina.
– also occurs when both retinal
layers elevate away from the
choroid as a result of a tumor
RETINAL DETACHMENT –
Signs and Symptoms
• FLOATERS. The first symptom is often
the sudden appearance of many spots
floating loosely, hung in front of the
affected eye. The patient may not seek
help, because the number of spots
tends to decrease during the days and
weeks after the detachment.
• FLASHES OF LIGHT. The patient may
also notice a curious feeling of flashing
lights as the eye is moved. Because the
retina does not contain sense nerves
that relay feelings of pain, the condition
is painless.
RETINAL DETACHMENT –
Medical Treatment
• Surgery is often needed to repair the
hole and prevent the leakage of
vitreous humor that divides the
retina from its source of food, the
choroid. If the condition is found
early, when the hole is small and the
amount of vitreous humor lost is not
large, the retinal hole may be closed
by causing a scar to form on the
choroid and to join to the retina
around the hole. The scar may be
caused by heat, electric current, or
cold. The degree of restored sight
depends on the degree and length of
division. Maximum sight is gained
within 3 months after surgery.
Unless replaced, a detached retina
slowly dies after several years of
detachment. Blindness resulting
from retinal detachment cannot be
treated
RETINAL DETACHMENT
• Causes
– Severe injury to the eye, as a bruise or
penetrating wound, may be the cause, but in
most cases retinal detachment is the result of
internal changes in the vitreous chamber
linked to aging or, less often, to swelling of the
inner eye.
– In most cases retinal detachment develops
slowly.
– Detachment often begins at the thin outer
edge of the retina and reaches gradually
under the thicker, more central areas.
RETINAL DETACHMENT –
Signs and Symptoms
• SENSE OF CURTAIN IS BEING
DRAWN. Detachment often begins at
the thin outer edge of the retina and
reaches gradually under the thicker,
more central areas. The patient
senses a shadow that begins at the
side and grows in size, slowly edging
in on central sight.
• DISTORTION OF VISION. As long as
the center of the retina is unaffected,
the sight, when the patient is looking
straight ahead, is normal. When the
center becomes affected, the eyesight
is distorted, wavy, and unfocused. If
the detachment is not halted, total
blindness of the eye will result. The
condition does not resolve itself.
RETINAL DETACHMENT –
Medical Treatment
MEDICAL MANAGEMENT
- draining fluid from the subretinal space so that the retina can return to the
normal position
• SEALING RETINAL BREAKS BY CRYOSURGERY
- a cold probe applied to the sclera to stimulate an inflammatory response
leading to adhesions
• DIATHERMY
- the use of electrode needle & heat through the sclera to stimulate an
inflammatory response leading to adhesions
• LASER THERAPY
- to stimulate an inflammatory response to seal small retinal tears before
the detachment occurs
• SCLERAL BUCKLING
- to hold the choroid & retina together with a splint until scar tissue forms
closing the tear
• INSERTION OF A GAS OR SILICONE OIL
- to encourage attachment because these agents have a specific gravity less
than vitreous or air & can float against the retina
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 RETINAL DETACHMENT –
Nursing Intervention
• PRE - OPERATIVE NURSING CARE
– Provide bedrest
– Cover both eyes with patches to prevent further
detachment
– Speak to the client before approaching
– Position the client’s head as prescribed
– Protect the client from injury
– Avoid jerky head movements
– Minimize eye stress
– Prepare the client for surgical procedure as
prescribed
RETINAL DETACHMENT –
Nursing Intervention
• POST-
POST- OPERATIVE NURSING CARE (con
(con’’t.)
– Administer eye medications as prescribed
– Assist client with ADL
– Avoid sudden head movements or anything that
increases IOP
– Instruct the client to limit reading for 3-5 weeks
– Instruct client to avoid squinting, straining & constipation,
lifting heavy objects & bending from the waist
– Instruct the client to wear dark glasses during the day &
an eye patch at night
– Encourage follow-up care because of the danger of
recurrence or occurrence in the other eye
RETINAL VASCULAR DISORDERS
• Retinal Vein Occlusion
• A small percentage of cases recover some useful vision
either through the development of new anastomotic
channels or the canalization of the clot.
• A common complication is glaucoma which usually
appears 3 months after onset. The eye shows
neovascularization of the iris surface (rubeosis iridis) with
occasional hyphema or vitreous hemorrhage. The age,
for which reason the term hemorrhagic glaucoma has
been given.
• Recently, photocoagulation of the edematous retina has
shown promising results. Hemorrhagic glaucoma, once it
commences, is difficult to control medically and
eventually enucleation may be necessary to relieve the
pain.
RETINAL DETACHMENT –
Nursing Intervention
• POST-
POST- OPERATIVE NURSING CARE
– Maintain eye patches bilaterally as prescribed
– Monitor hemorrhage as prescribed
– Prevent N&V and monitor for restlessness which
can cause hemorrhage
– Monitor for sudden, sharp eye pain (notify the
MD stat)
– Encourage DBE but avoid coughing
– Provide bedrest for 1-2 days as prescribed
– If gas has been inserted, position as prescribed
on the abdomen & turn the head so unaffected
eye is down
RETINAL VASCULAR DISORDERS
• Retinal Vein Occlusion
• In elderly patients central vein thrombosis usually
arises from thrombosis by extension of an
arteriosclerotic process, considering that at the
region of the optic disk, the artery and vein share a
common adventitial coat. Endothelial proliferation
in a diabetic vessel is also a common cause. In
young individuals, a phlebitis may be con-sidered.
• Loss of vision is fairly rapid, though not as
instantaneous nor complete as in central artery
occlusion. The fundus will show venous
congestion and tortuousity and usually dark
coloration of the veins. Superficial retinal
hemorrhages of various sizes are present.
Because of the venous engorgement and retinal
hemorrhages, the condition has oftentimes been
called a "hot dog and catsup" fundus. The disc is
usually hyperemic with blurring of the margin
(Fig-ure 13.3).
RETINAL VASCULAR DISORDERS
• Retinal Artery Occlusion
• The usual causes of arterial obstruction are emboli from a cardiac
thrombus or general arteriosclerosis, thrombosis, or spasm.
• The outstanding symptom is marked blurring or complete loss of
vision if the main trunk of the artery is occluded. In arterial branch
occlusion, a defect in the visual field corresponding to the area
supplied by the arterial branch will be noticed. Usually the patient is
immediately aware of a branch occlusion of the temporal branches
as the macula is also involved producing impairment of central
vision.
• If ophthalmoscopy is done within a few hours after onset, the retinal
artery will be seen to be very much constricted. The optic disk is
pale and the rest of the eye ground is white in appearance because
of the opaque retina brought about by coagulation necrosis.
However, in the macular area the choroidal background still shines
through. This is commonly called the "cherry red" spot (Figure 13.2).
15
RETINAL VASCULAR DISORDERS
• Retinal Artery Occlusion
• Paracenthesis of the anterior chamber to produce rapid
softening of the eye, if done within 12-24 hours of onset,
may allow sufficient vasodilation of the retinal artery to
allow the embolus to pass inward into one of the
branches of the retinal artery and thus lessen the area of
retinal damage. Vascular dilation may also be done by
vasodilator drugs (amyl nitrate inhalation,. retrobulbar
acetylcholine or prescoline) 'or inhalation of carbon
dioxide (carbogen). A very simple procedure is to breathe
continuously into a paper bag thus inhaling the
accumulated CO2 that collects in the paper bag.
Diabetic retinopathy
• a disorder of the blood vessels in
the retina of the eye, resulting in
broken blood vessels in the eye.
• The disorder occurs most often in
patients with long-
long-term, poorly
controlled diabetes.
• Repeated bleeding may result in
partial or complete blindness.
• Treatment is to stop the bleeding of
damaged blood vessels by laser
beam (photocoagulation).
• All diabetics are advised to have
their eyes examined at least once a
year by physicians specializing in
diseases of the eye
(ophthalmologist).
• 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

INCREASED IOP
Glaucoma
GLAUCOMA - Causes
• Causes
– An increase in
intraocular pressure
that results from
abnormalities in the
balance between
aqueous production
and outflow
– Most common cause is
an interference with
aqueous outflow from
the anterior chamber,
rather overproduction
of aqueous humor
Angle-
Angle-closure (narrow-
(narrow-angle) vs.
Open-
Open-angle (wide-
(wide-angle) Glaucoma
• Open-angle (wide-angle)
Glaucoma
– Overproduction of aqueous
humor or blocking of the normal
flow of the watery fluid in the
space between the cornea and
lens of the eye (aqueous
humor).
• Angle-closure (narrow-
angle) Glaucoma
– happens if the pupil in an eye
with a narrow angle between
the iris and cornea opens too
wide and causes the folded iris
to block the flow of aqueous
humor.
GLAUCOMA
• Definition
– increased intraocular
pressure (IOP) resulting in a
condition that damages the
optic nerve & retina, and can
result in blindness
• Pathophysiology
– 1. Direct mechanismÆ
mechanismÆ
direct pressure damages
retina
– 2. Indirect mechanismÆ
mechanismÆ
high IOP compresses the
microcirculation in the optic
head resulting to nerve
injury and death
Classifications of Glaucoma
• Angle-
Angle-closure (narrow-
(narrow-angle) vs. open-
open-angle (wide-
(wide-
angle)
– Depends on location, circulation, and resorption
• Congenital vs. acquired condition
• Acute glaucoma (a(a rapid onset of IOP > 50-
50-70 mm
Hg) vs. Chronic glaucoma (a rapid onset of IOP >
50-
50-70 mm Hg)
• Primary vs. secondary disorder
– Primary: no evidence of preexisting ocular or systemic
disease
– Secondary: results from inflammatory processes
affecting the eye, tumors, or blood cells of trauma-
trauma-
produced hemorrhage
Symptoms of Congenital or
Infantile Glaucoma
• Excessive lacrimation and
photophobia
• Affected infants tend to be
fussy, have poor eating
habits, and rub their eyes
frequently
• Diffuse edema of the
cornea usually gives the
eye a grayish-
grayish-white
appearance
• Enlargement of the entire
globe (buphthalmos)
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
– When speaking to a client who has limited sight
or blind, the nurse uses a normal tone of voice
– Alert the client when approaching
– Orient the client to the environment
– Use a focal point & provide further orientation to
the environment from the 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 possible
• NURSING CARE (con
(con’’t.)
– Provide radios, TVs, & 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 used for the blind
client, which is differentiated from other canes by its
straight shape & 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

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

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

OCULAR SURGERY
ENUCLATION vs. EXENTERATION
• ENUCLEATION
– removal of the entire eyeball
• EXENTERATION
– removal of the eyeball &
surrounding tissues
• Performed for the removal of
ocular tumors
• After the eye is removed, a ball
implant is inserted to provide a firm
base for socket prosthesis & to
facilitate the best cosmetic result
• A prosthesis is fitted approximately
1 month after surgery
Surgical Procedures and
Enucleation
• Orbital Surgeries
• Enucleation
• Ocular Protheses
ENUCLATION vs. EXENTERATION
• Pre-Op Nursing Care
– Provide emotional support to
the client
– Encourage the client to
verbalize feelings related to
loss
• Post-Op Nursing Care
– Monitor V/S
– Assess pressure patch or
dressing
– Report changes in V/S or the
presence of bright red
drainage on the pressure
patch or dressing
23
 ORGAN DONATION - DONOR
• DONOR EYES
– Obtained from cadavers
– Must be enucleated soon after death
due to rapid endothelial cell death
– Must be stored in a preserving
solution
– Storage, handling & coordination of
donor tissue with surgeons
– is provided by a network of state eye
bank associations across The
country
• CARE OF THE DECEASED CLIENT
AS A POTENTIAL EYE DONOR
– Discuss the option of eye donation
with MD & family
– Raise the head of the bed 30°
30°
– Instill antibiotic eye drops as RX
– Close the eyes & apply a small ice
pack to the closed eyes
ORGAN DONATION - RECIPIENT
• POST-
POST-OP CARE OF PATIENT
– Eye is covered with a pressure
patch and protective shield that
are left in place until the next day
– Don’
Don’t remove or change the
dressing without the MD’MD’s order
– Monitor V/S, LOC & assess
dressing
– Position the client on unoperative
side to reduce IOP
– Orient the client frequently
– Monitor for complications of
bleeding, wound leakage, infection
& graft rejection
– Instruct the client in how to apply
the patch & eye shield
– Instruct the client to wear the eye
shield at night for 1 month &
whenever around small children or
pets
OPTHALMIC
AND
OTIC MEDICATIONS
ORGAN DONATION - RECIPIENT
• PRE-
PRE-OP CARE OF PATIENT
– Recipient may be told of the
tissue availability only several
hrs to 1 day before surgery
– Assist in alleviating client
anxiety
– Assess for signs of eye
infection
– Report the presence of any
redness, watery or purulent
drainage or edema around the
eyes to MD
– Instill antibiotic drops into the
eyes as Rx to reduce the no. of
microorganisms present
– Administer IV fluids &
medications as Rx
ORGAN DONATION –
GRAFT REJECTION
• GRAFT REJECTION
– Can occur at anytime
– Inform the client of signs
of rejection
– Signs include redness,
swelling, decreased
vision, & pain (RSDP)
– Treated with topical
steroids
INSTALLATION OF EYE DROPS
EYE DROPS
• Wash hands
•
•
•
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
• 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

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 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 clients with glaucoma to read labels on OTC meds & to avoid
Atropine-like meds
- Atropine increase IOP
• Instruct the client to check for the presence of the disk in the conjunctival
sac daily qHS & upon arising
• Since vision may change in the first few hours after the eye system is
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

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 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

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• diabetic retinopathy,

30
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 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

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 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

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

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