University of La SaletteSantiago City

College of NursingEENT

Part 1 – EYES

An eye is a round-shaped organ that works with the brain to provide us with vision. The shape of the eye is maintained by the pressure of the aqueous humor.

The main function of the eye is to work with the brain to provide us with vision. The eye and brain translate light waves into a sensation we call vision.

A. External Structures of the Eye

Ocular Adnexa Are the accessory structures of the eyes that support and protect it.

Ocular Muscles Eyeball is moved by 6 ocular muscles, which are attached to the surface of the globe. 4 Rectus muscles – move eyes vertically & horizontally

(medial, lateral, superior, inferior) 2 Oblique muscles – rotate the eye in circular movements (superior, inferior)

Eyelids• elastic folds of skin that close to protect anterior eyeball.• Protect the eye from foreign particles. • distribute tears to prevent evaporation & drying of its surface.

Palpebral Fissure• elliptic space between the two open lids

Canthi • the corners of the fissure• Medial or Inner Canthus – next to the nose• Lateral or Outer Canthus – the outside corner

Meibomian Glands• are embedded in both upper and lower lids• oil secreting glands.

B. External Structures of the Eye

1. OUTER LAYER - fibrous coat that supports the eye SCLERAE - Tough, white connective tissue “white of the eye” - located anteriorly & posteriorly CORNEA - Transparent tissue through which light enters the eye. - Located anteriorly.

2. MIDDLE LAYER - second layer of the eyeball

- vascular & highly pigmented 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.CILIARY BODY - connects the choroid with the iris - secretes aqueous humor that helps give the eye its Shape. IRIS - the colored portion of the eye - located in front of the lens - it has a central opening called the pupil.

3. INNER LAYER (RETINA) - a thin, delicate structure in which the fibers of the optic nerve are distributed - bordered externally by the choroid & sclera and internally by the vitreous - contains blood vessels & photoreceptors (cones & rods) - light sensitive layer.

CONTAINS THE FOLLOWING STRUCTURES 1. CONES - Specialized for fine discrimination, central vision & color vision - Functions at bright levels of illumination 2. RODS - More sensitive to light than cones - Aid in peripheral vision - Functions at reduced levels of illumination.

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 - serves as refracting medium & provides nutrients to lens & cornea - contributes to maintenance of IOP VITREOUS HUMOR - Clear, gelatinous/jell-like material that fill the posterior cavity of the eye - Maintains the form & shape of the eye - Provides additional physical support to the eye - It is produced by the vitreous bodyVITREOUS BODY - contains a gelatinous substance that occupies the vitreous chamber which is the space between the lens & retina - transmits light & gives shape to the posterior eye.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” - contains only nerve fibers - lack photoreceptors - insensitive to light 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” which is an area where acute vision occursCANAL 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 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 retinaPUPILS - Control the amount of light that enters the eye & reaches the retina - Darkness produces dilation while light produces constriction.

EYE MUSCLES - Muscles do not work independently but work in conjunction with the muscle that produces the opposite movement.

A. RECTUS MUSCLES - Exert their pull when the eye turns temporally B. OBLIQUE MUSCLES - Exert their pull when the eye turns nasallyNERVES A. CRANIAL NERVE II - Optic nerve (nerve of sight) B. CRANIAL NERVE III - Oculomotor C. CRANIAL NERVE IV

- Trochlear D. CRANIAL NERVE VI

- Abducens

BLOOD VESSELS A. OPTHALMIC ARTERY - Major artery supplying the structures in the eye B. OPTHALMIC VEINS - Venous drainage occurs through vision

ASSESSMENT OF VISION

VISUAL ACUITY TEST - measures the client’s distance & near visionSNELLEN 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 EXTRAOCULAR MUSCLE FUNCTION - tests muscle function of the eyes - 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 eyeballsCOLOR VISION TEST - Tests for color vision which involve picking nos. or letters out of a complex & colorful pictureISHIHARA CHART - consists of nos. that are composed of colored dots located within a circle of colored dots - client is asked to read the nos. 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

PUPILS - Normal: round & of equal size - Increasing light causes pupillary constriction Decreasing light causes pupillary dilation - the client is asked to look straight ahead while the examiner quickly brings a beam of light ( penlight) in from the side & directs it onto the side. - Constriction of the eye is a direct response to the light shining into the eye; constriction of the opposite eye is known as CONSENSUAL RESPONSEFLUORESCEIN ANGIOGRAPHY - detailed imaging & recording of ocular circulation by a series of photographs after administration of the dyeCOMPUTED 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 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.TONOMETRY - the test is primarily used to assess for an increase in IOP and potential glaucoma - NORMAL IOP: 8-21 mm Hg

OPTHALMIC MEDICATIONS

PARASYMPATHOLYTIC DRUGS - used pre-op or for eye examinations to produce mydriasis - C/I in clients with glaucoma because of the risk of increased IOPClassification MYDRIATICS

- dilate the pupils (mydriasis) CYCLOPLEGIA

- relax the ciliary muscles ANTICHOLINERGICS - block responses of the sphincter muscle in the ciliary body, producing mydriasis

Example:Atropine sulfate (Isopto-Atropine, Ocu-Tropine, Atropair, Atropisol)

Scopolamine hydrobromide (Isopto-Hyoscine)

Cyclopentolate hydrochloride (Cyclogyl, AK-Pentolate, Pentolair)

Homotropine hydrobromide (Isopto Homatrine, AK-Homatropine, Spectro-Homatrine)

Tropicamide (Mydriacyl, I-Picamide, Tropicacyl)

Phenylephrine hydrochloride (AK-Dilate, Dilatair, Mydfrin, Ocu-Phrin)

Nursing care: Assess for constipation & urinary retention 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 physician Instruct the client to wear sunglasses until the effects of the medication wear of Instruct to notify MD if blurring of vision, loss of sight, difficulty in breathing, sweating or flushing

occur Instruct the client to report eye pain to the physician

PARASYMPATHOMIMETICMiotics- 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 humor - used for chronic open-angle glaucoma or acute & chronic closed-angle Glaucoma

Example of miotic drugsAcethylcholine Cl (Miochol)

Carbachol (Miostat)

Pilocarpine HCl (Isopto Carpine, Pilocar)

Pilocarpine nitrate (Pilofrin, Liquifilm, Pilagan)

Echothiophate iodide (Phospholine iodide)

Demecarium bromide (Humorsol)

Isoflurophate (Floropryl)

Nursing Care: Assess breath sounds for rales & rhonchi

- cholinergic meds cause bronchospasms & increased bronchial secretions Maintain oral hygiene

- due to increased salivation Have Atropine sulfate available as antidote for Pilocarpine Instruct the client not to stop the meds suddenly 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

BETA-ADRENERGIC BLOCKING EYE MEDICATIONS- IOP by decreasing sympathetic impulses & decreasing aqueous humor production w/o

affecting accommodation or pupil size - Used to treat chronic open-angle glaucoma - C/I in the client with asthma EXAMPLES

• Betaxolol HCl (Betoptic)• Carteolol HCl (Ocupress)• Levobunolol HCl (Betagan)• Metipranolol (Optipranolol)• Timolol maleate (Timoptic)

Nursing Care• If the pulse is below 60 or if systolic BP is below 90 mm Hg, withhold the

medication & contact MD Instruct to change positions slowly to avoid orthostatic hypotension

ADRENERGIC EYE MEDICATIONS

Decrease the production of aqueous humor & lead to a decrease in IOP -Used to treat glaucoma

ADRENERGIC MEDICATIONS• Apraclonidine HCl (Iopidine)• Brimonidine tartrate (Alphagen)• Dipivefrin HCl (Propine)• Epinephrine borate (Epinal, Eppy)• Epinephrine HCl (Epifrin, Glaucon

CARBONIC ANHYDRASE MEDICATIONS

- Interfere with the production of carbonic acid which leads to decreased aqueous humor formation & decreased IOP - Used for long-term treatment of open-angle glaucoma - C/I in the client allergic to sulfonamides

EXAMPLES• ACETAZOLAMIDE ( DIAMOX)• DICHLORPHENHAMIDE (DARANIDE, ORATROL)• ETHOXYZOLAMIDE (CARDRASE, ETHAMIDE)• METHAZOLAMIDE (NEPTAZANE)

OSMOTIC MEDICATIONS Lower IOP Used in emergency treatment of acute closed-angle glaucoma Used pre-op & post-op to decrease vitreous humor volume

EXAMPLES• Glycerin (Glyrol, Osmoglyn)• Mannitol (Osmitrol)• Urea (Ureaphil)

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 blinkingEXAMPLES

• Hydroxypropyl methylcellulose (Lacril, Isopto Plain)• Petroleum-based ointment (Artificial Tears, Liquifilm Tears)

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

TOPICAL ANESTHETICS FOR THE EYE -Produce corneal anesthesia Used for anesthesia for eye examinations, surgery, or to remove

foreign bodies from the eye EXAMPLES

• Proparacaine HCl (Ophthaine, Opthenic)• Tetracaine HCl (Pontocaine)

NURSING CARE• 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

ANTI-INFLAMMATORY EYE MEDICATIONSEXAMPLES

• Dexamethasone (Maxidex)• Diclofenac (Voltaren)• Flurbiprofen Na (Ocufen)• Suprofen (Profenal)• Ketorolac tromethamine (Acular)• Prednisone acetate (Predforte, Econopred)• Prednisolone Na phosphate (AK-Pred, Inflamase)• Rimaxolone (Vexol

ANTI-INFECTIVE EYE MEDICATIONS

ANTIBACTERIAL• Chloramphenicol (Chloromycetin, Chloroptic)• Ciprofloxacin hydrochloride (Cipro)• Erythromycin (Ilotycin)• Gentamicin sulfate (Garamycin, Genoptic)• Norfloxacin (Chibroxin)• Tobramycin (Nebcin, Tobrex)• Silver nitrate 1%

ANTIFUNGAL• Natamycin (Natacyn Opthalmic)

ANTIVIRAL• Idoxuridine (Herplex-Liquifilm)• Trifluridine (Viroptic)• Vidarabine (Vira-A Opthalmic)

DISORDERS OF THE EYE

A. LEGALLY BLIND

Anyone with vision worse than 20/200 that cannot be improved with corrective lenses is considered legally blind.

A legally blind person with vision of 20/200 has to be as close as 20 feet to identify objects that people with normal vision can spot from 200 feet.

Legal blindness is very common in older people because eyesight tends to worsen with time and age.

The leading causes of blindness are accidents, diabetes, glaucoma, and macular degeneration.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 • 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.

• People may use talking thermometers, enlarged or marked oven dials, talking watches, talking clocks, talking scales, talking calculators, talking compasses and other talking equipment.

• A small number of people employ guide dogs to assist in mobility.

General Care For Eye surgeries Preoperative CARE

If both eyes are to be covered after surgery, the patient needs to be oriented to the staff and the physical envinment prior to surgery

The child should practice having the eyes covered to decrease postoperative fear and restlessness

If both eyes are covered or if vision is greatly restricted, the call light should be placed within the reach of the patient

The preparation of the eye on the day of the surgery may include the instillation of combination of drugs into the eye at various intervals to dilate the pupil

POST OPERATIVE CARE General goal of Post operative care

o To prevento Increased IOPo Stress on the suture lineo Hemmorage into the anterior chmabe (hyphema)o Infection

Immediately after operative, the patiet must keep still the head still and try to avoid coughing, vomiting, sneezing or moving suddently

The patient should lie with unoperated side down to prevent pressure on the operated eye and to prevent possible contamination of the dressing with vomiting

A burning sensation about one hour after surgery usually means that the anesthethic is wearing off

The patient is instructed to avoid lifting the head or hips, straining at stolol or squeezing the eyelid

o If sneezing or coughinh occurs, the patient should follow through with open mouth

o If vomiting occurs, the eyelids should be kept openo Cough medicines and antiemetics can be givenb for cough and vomiting,

stool softener and laxatives for constipation To prevent stress on the suturebline, bending forward is avoided

o Sudden jerky movement may result in hemorrhage into the hyphema Side rails are placed on the bed immediately postoperatively and are kept on

while both eyes are covered or as long as necessary for protection The bedside table should be placed on the side of the unoperated eye so that the

patient can see it without excessive movement of the head Care is taken that the dressing is not looased or removed

o Bleeding and serous fluid should be minimalo Edema of the eyelids subside within 3 to 4 dayso The feeling of “something in the eye” 4 to 5 days post op usually is

because of sutures and is normalo Sensation of pressure within the eye ad sharp pain are quickly reported

to the surgeon. These indicate bleeding Supervision and assistance on ambulation should be given by the nurse to avoiding

sustain injury The patient is advised not to bend,or lift objects for several weeks post op, to prevent

increasing intraocular pressure

B. CATARACT- an opacity of the lens that distorts the image projected onto the retina & that can progress to blindness.- Intervention is indicated when visual acuity has been reduced to a level that the client finds to be unacceptable or adversely affecting lifestyle

Risk Factors Normal aging (90%) long-term exposure to ultraviolet light, exposure to radiation exposure to infrared radiation such as glassblowers, microwave radiation Drugs – Coticosteroids, Haloperidol, Miotics Denatured proteins can exhibit a wide range of characteristics, from loss of solubility to communal

aggregation.

Types of cataracts;1. Senile Cataracts: age-related begin around age of 50 years

Classified into three:a. Cortical

-opacification found in the periphery of the lens-progree slowly, infrequenly involve the visual axis, often do not cause severe loss of vision

b. Nuclear sclerotic cataracts- progressive and hardening of the central lensc. Posterior subcapsular cataracts- occur centrally on the posterior lens capsule and cause visual loss early in their development because they lie directly on the visual axis

2. Traumatic: those associated with injury3. Congenital; Those associated at birth4. Secondary: Those which occur following other eye or systemioc diseases

ASSESSMENT Opaque or cloudy white pupil Gradual loss of vision Blurred vision or hazy vision Decreased color perception Vision that is better in dim light with pupil dilation Photophobia Absence of red reflex - reddish-orange reflection from the eye's retina that is observed when

using an ophthalmoscope.MEDICAL MANAGEMENT

No known medical treatment that either prevents or reduces cataract formation. OBJECTIVE: To remove the opacified lens.

EXTRACAPSULAR EXTRACTION – ECCE removing the lens & anterior portion of lens capsule, the posterior lens capsule is left intact. allow insertion of lens implant w/ fewer post-op complication.

INTRACAPSULAR EXTRACTION – ICCE removing the lens including the lens capsule.

PHACOEMULSION – 2 to 3 mm - the lens is broken up by ultrasonic vibrations & extracted.Cryoextraction: The cataract is lifted from the eye by a small probe that has been cooled to a temperature below zero and adheres to the wet surface of the cataract

PRE-OP NURSING CARE• Instruct measures to prevent or decrease IOP• Administer pre-op eye medications including mydriatics & cycloplegics as prescribed

POST-OP NURSING CARE• Elevate the head of the bed 30-45 degrees• Turn the client to the back or un-operative side• Position the client’s personal belongings on the un-operative side• Use side rails for safety.• Assist with ambulation.• Protective eye patch for 24 hours after surgery followed by eyeglasses worn during the

day and metal shield worn at night for 1 to 4 weeksCLIENT EDUCATION AFTER CATARACT SURGERY

• Avoid eye straining • 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 inner to the outward canthus• Use an eye shield at bedtime• Contact the MD for any decrease in vision, severe eye pain or increase in eye discharge.

*After removal of the lens, the patientis referred to as aphakic (without lens)Lens Replacement:

Intraocular lenses Lens implanted at the time of cataract extraction Held position either suture to the iris or by implanting it into the capsular sac Better binocular vision (ability of both eyes to focus on one subject and fuse the

two images into one) If an eye implant is not performed, the eye cannot accommodate &

glasses must be worn at all times

Note: Temporary glasses may be prescribed 1-4 weeks after surgery.USUALLY WITHIN 6-12 weeks healing has been sufficient for fitting of permanen glasses or contact lenses

Aphakic Eyeglasses Safest least expensive method Very thick lenses magnify object 25%,m making them appear closer than

they are actually are Cataract glasses act as magnifying glasses & replace central vision only Cataract glasses magnify, & objects appear closer therefore teach

client to judge distance & climb stairs carefully

Contact lenses Contact lenses provide sharp visual acuity and must have the manual

dexterity to handlethe lenses, cleaning, insertion of lenses, replacement of lenses and the dasnger of corneal abrasion

• If an eye implant is not performed, the eye cannot accommodate & glasses must be worn at all times

• Cataract glasses act as magnifying glasses & replace central vision only• Cataract glasses magnify, & objects appear closer therefore teach

client to judge distance & climb stairs carefully• Contact lenses provide sharp visual acuity but dexterity is needed to

insert them

C. GLAUCOMA Ocular condtions characterized by optic nerve damage that will lead to irreversible

blindness related to increased IOP due to congestion of aquuenous humor in the eye

Glaucoma is the second leading cause of blindness in the world, according to the World Health Organization.

Aquenous Humor Flows in the anterior and posterior chamber of the eyes, nourishing the cornea and lens 90% of fluid flows out the anterior chamber, draining through the spongy trabecular

meshwork into the canal of schlemn and the episcleral veins 10% of fluids exits through the ciliary body into the suprachoridalspace and then drains

into the venous circulation of the ciliary body, choroid and sclera Outflow of aquenous humor depends on an intact drainage system and an open angle

( 45 degrees) between the iris and the cornea. IOP

Normal- 10-21 mmhg When A.H is inhibited from flowing out, the pressure builds up within the eye ( Increase IOP) Increase IOP----damages the optic nerve---blindness

Two theories regarding how IOP damages the optic nerve Direct mechanicasl theory

High IOP damages the retinal layer as it passess through the optic nerve head Indirect ischemic theory

High IOP compresses the microcirculation in the optic nerve head, resulting in cell injury and death

STAGES in the development of Glaucoma1. Initiating events

PF= illness, emotional stress, congenital narrow angles, long term corticosteroid, mydriatics

2. Structural altrertaion in the aquenous outflow system`

Tissue and cellular changes3.Functional alterations: :conditions such as increased IOP or impaired blood flow create functional changes4. Optic nerve damage: atrophy of the optic nerve is characterized by loss of nerve fibers and blood supply5. Visual loss: progressive loss of vision is characterized by visual field effect

Classification

Terms:Primary and secondary glaucoma refer whether the cause is the disease alone or another conditionAcute and chronic refer to the onset and duration of the disorderOpen ( wide) and closed ( narrow- describe the width of the angle between cornea and the iris .Narrower angle places the iris closer to the trabecular meshwork =impeded the outflow of A.H

Types of glaucoma:I. Primary Open-Angle Glaucoma – POAG Often referred to as “thief in the night”. The pressure in the eye slowly rises and the cornea adapts without swelling is the most common type of glaucoma. slow damage to the nerve in the back of the eye (optic nerve) causes gradual loss of eyesight. has been called simple glaucoma, chronic glaucoma, and wide-angle glaucoma.. The most common cause is degenerative change in the trabecular meshwork, resulting in

decrease outflow of aqueous humor. IOP= 30-50 mmhg

Risk Factors:a. Age. The risk for glaucoma increases rapidly after age 40.b. Race. Blacks are 4 times more likely than whites to have glaucoma.

c. Family history of glaucomad. Prior loss of vision in one eye from glaucomae. Diabetes. People with diabetes are also at risk for a type of secondary glaucoma where new

blood vessels grow into and block the drainage angle of the eye (trabecular meshwork).

II. Close – angle glaucoma An acute attack can develop only in an eye in which the anterior chamber angle is anatomically

narrow. Attack occurs due to sudden blockage of the anterior angle by the base of the iris. When Aqueous flow is obstructed >>> IOP becomes markedly elevated >>> severe pain &

blurred vision >>> Blindness This sudden rise in pressure can occur within a matter of hours and become very painful. If the

pressure rises high enough, the pain may become so intense that it can cause nausea and vomiting.

The eye becomes red, the cornea swells and clouds, and the patient may see haloes around lights and experience blurred vision.

IOP= 50-70 mmhg

Risk Factors:a. Race. People from East Asia or with East Asian ancestry, as well as Canadian, Alaskanb. Age. People over age 40 are at increased risk for closed-angle glaucoma. c. Sex. Older women are more likely than older men to develop closed-angle glaucoma. d. Birth defects - born with narrow drainage angles in the eyes.e. Physical injuries. Severe trauma, such as being hit in the eye, can result in increased eye

pressure. Injury can also dislocate the lens, closing the drainage angle.  f. Farsightedness, Family history, Having closed-angle glaucoma in one eye .

III. Congenital glaucoma is a rare form of glaucoma that is present in babies at birth. often caused by a birth defect that can cause abnormal development of structures in the

eye. usually diagnosed by the end of the first year of life. Glaucoma that develops between birth and age 3 is called infantile glaucoma. People between the ages of 3 and young adulthood can develop another type of developmental

glaucoma called juvenile glaucoma.Symptoms:

Watery eyes, sensitivity to light eyes that look cloudy Eyes look larger than normal Rubbing the eyes or keeping the eyes closed much of the time.

IV. Low-Tension Glaucoma Resembles Primary Open-Angle Glaucoma The angle is normal, optic nerves are cupped, & show peripheral vision deficits. IOP is within normal range. Treatment is indicated to lower the pressure even further, to avoid progressive optic nerve

damage and visual field loss.

V. Secondary Glaucoma Glaucoma may develop after an eye injury, after eye surgery, from the growth of an eye

tumor, or as a complication of a medical condition such as diabetes - cause new blood vessels to grow into the drainage angle of the eye.

Certain medicines : corticosteroids

Pigmentary glaucoma - is a form of secondary glaucoma caused by pigment granules being released from the back of the iris. These granules can block the drainage of aqueous humor.

Phacomorphic glaucoma - Cataract that causes swelling of the lens can cause glaucoma.

Primary Open-angle Glaucoma: Peripheral vision loss – objects to the side are ignored ( tunnel vision) Insiduous onset-generally no discomfort Patient may bump into other person in the street or fail to see passing vehicles, yet not realize

that the fault lies on their own vision The loss of peripheral vision ( TUNNEL VISION) CAN PROGRESS until the person is legally

blind, yet the person may be able to see well straight ahead Persistent dull eye pain in the morning Frequent changes of glasess, difficulty in adjusting to darkness, failure to detect changes in color

accuratelyAngle- closure Glaucoma:

Sudden, severe blurring of vision Severe eye pain Colored halos around lights Redness of the eye Nausea and vomiting

Diagnostic Assessment: Ophthalmoscopy - it is used to examine the area where the optic nerve leaves the eye (optic

disc). Damage to the optic nerve related to glaucoma can be diagnosed by ophthalmoscopy. Tonometry - measures the pressure in the eye (intraocular pressure, or IOP). Normal intraocular

pressure is usually between 10 and 21 millimeters of mercury (mm Hg). People with glaucoma sometimes have above-normal IOP.

Gonioscopy - is done to see if the drainage angle of the eye is closed or nearly closed. This helps your doctor see which type of glaucoma you have. Gonioscopy can also find scarring

or other damage to the drainage angle. Treat glaucoma. During gonioscopy, laser light can be pointed through a special lens at the

drainage angle. Laser treatment can decrease pressure in the eye and help control glaucoma. Check for birth defects that may cause glaucoma.

Nursing Care: Remove contact lenses Eyedrops are used to numb the eye so that you will not feel the lens touching your eye during this

painless examination. ask client to lie down or to sit in a chair & look straight ahead. A special lens is placed lightly on the front of the eye, and a narrow beam of bright light is pointed

into the eye. the drainage angle is checked & measured. The examination takes less than 5 minutes. If pupils were dilated, vision may be blurred for several hours after the test - (do not rub the eyes

for 20 minutes after the test, or until the medicine wears off).

Perimetry test (visual field testing) Measures all areas of eyesight, including peripheral vision. Regular perimetry tests can be used to see if treatment for glaucoma is preventing further vision

loss. It may take more than 45 minutes when both eyes are tested. To do the test, you sit and look inside a bowl-shaped instrument called a perimeter. While you

stare at the center of the bowl, lights flash. You press a button each time you see a flash. A computer records the spot of each flash and if you pressed the button when the light flashed in that spot.

At the end of the test, a printout shows if there are areas of your vision where you did not see the flashes of light.

Medical Management: OPEN ANGLE GLAUCOMAGOAL: to reduce IOP and keep it at a safe level

o Diet: no caffeine, low sodiumo Patient is advised to avoid fatigue or stress and to avoid drinking large quantities of fluidso Instruct the client the need for life-long medication useo Instruct the client to avoid anti-cholinergic medicationso Instruct the client to report eye pain, halos around eyes & changes of vision to the

physician

o Instruct the client that when maximal medical therapy has failed to halt the progression of visual field loss & optic nerve damage, surgery will be recommended

o Pharmocologic therapyTopical Miotics – Pilocarpine hydrochloride

o causes pupillary constriction to open canal of schlemmo constricts pupil & increase outflow

Topical epinephrine – also increase outflowTopical beta-blockers or alpha-adrenergics – Timolol Maleate

o Decreases production of aqueous humorOral carbonic anhydrase inhibitors – acetazolamide/Diamox

o Inhibits production of aqueous humor

When medical management is no longer effective, surgical intervention may be indicated.

Surgical Management:Laser Trabeculoplasty

Laser is used to create an opening in the trabecular meshwork to allow increased outflow of aqueous.

IOP is reduced in about 80% of cases. Effect of laser treatment decreases over time & procedure may need to be repeated. Tx with medications is usually continued.

Filtering Procedures Goal is to create an outflow channel from the anterior chamber into the subconjunctival space.

Example: Trabeculectomy-remove the part of trabecular meshwrok to allow drainage of aqueous

humor into the conjuctival spacesSclerotomy- surgical incision of sclera Iridectomy- portion of the iris is excised to facilitate outflow of aquenuos humor

*25% of cases, the opening closes because of scar formationWays to prevent scar tissue formation

o Topical corticosteroid used post op –antiinflammtory action inhibits proliferation of fibroblast at the surgical site

o Injection subconjunctival of 5-FU, mitomycin and other anti-metabolitesCyclodestructive Procedure- destroying part of ciliary by cyclocryotherapy ( application of freezing tip) or cyclophotocoagulation

Medical Management: Close ANGLE GLAUCOMA• Treat as medical emergency• Maintain bed rest in quiet, darkened room, elevate head 30 degrees• Administer miotics eyedroips• Administer acetazolamide, glycerol orally as ordered• Assess patient;s ability to see• Prepare for eye examination as ordered• Avoid atropine preparation and other mydriatics as these drugs dilate pupils• Administer anti emetics as ordered for nausea• Provide diet as tolerated• Prepare for surgery if ordered

D. RETINAL DETACHMENT Occurs when 2 retinal layers separate because of either fluid accumulation or contraction of the

vitreous body. Most often occurs between ages 50-70. CAUSES:

sudden severe physical exertion,post cataract extraction,myopia, hemorrhage, & tumor

TYPES PARTIAL RETINAL DETACHMENT

- becomes complete if left untreated COMPLETE RETINAL DETACHMENT

- when detachment is complete, blindness may occur.

there is a hole or a tear in the retina. Fluid that normally fills the inside of the eye can go through these retinal holes or tears and get behind the retina. This separates the retina from the back of the eye, causing a detachment.

Retina is separated from the choroid >>> avascular necrosis >>> interrupts the transmission of visual images from retina to the brain >>> progressive loss of vision >>> COMPLETE BLINDNESS.

Clinical Manifestations: Shadow or curtain falling across the field of vision-part of detachment in the retina Painless – onset is usually sudden Black spots/Floaters- these are blood and retinal cells that are freed at the time of the tear and

cast shadows on the retina as they seem to drift about the eye Flashes of light –the light that enters the yes is not absorbed by the detached melanin epithelial

pigmentEp the patientDiagnostic Tests:

Ophthalmoscopy o used to evaluate the extent and source of detachment.o Areas of detachment appears bluish gray.

Immediate nursing care: to prevent further detachment Provide bedrest Cover both eyes with patches to prevent further detachment Speak to the client before approaching The head is positioned so that the retinal hole is in the lowest part of the eye ( dependent

position) Protect the client from injury Avoid jerky head movements Minimize eye stress Prepare the client for surgical procedure as prescribed

SURGERY - is required to repair detached retina.

GOAL: To place retina back in contact with the choroid and to seal accompanying holes & breaks.

Cryopexy Use of freezing probe or laser photocoagulation to seal the hole & stimulate adhesion formation.

Diathermy The use of electrode needle and heat through the sclera stimulate an inflammatory response

leading to adhesionsLaser therapy

To stimulate an inflammatriy response to seal small retinal tears before detachment occursSceral Buckling

Used to splint and hold the retina & choroid together. A silicone sponge implant is placed over the tear and held in place with an encircling band.

Pre op Nsg. Care: Place on activity restrictions based on the size & location of detachment. General anesthesia is used & pupil must be dilated before the operation.

Post op Nsg. Care: Observe eye patch for any drainage. Narcotics needed during first 24 hours. Nausea & vomiting may require management. IOP monitoring for first 24 hours. Resume regular diet & fluids as tolerated. Antibiotic-steroid combination drop Cycloplegic agents Redness & swelling of lids & conjunctiva should be expected. Clean eyes with warm tap water & clean wash cloth. Glasses worn during the day & eye shield should be worn at night. Avoid vigorous activities and heavy lifting. Healing takes place over weeks & months, vision may improve gradually. (Warm & cold

compress for comfort).

E. Macular Degeneration Is an atrophic degenerative process that affects the macula and surrounding tissues, resulting in

central visual deficits. Found in most adults over age 65. Incidence increases with each decade over 50. It may also be hereditary. There is no known medical treatment or prevention for age-related macular degeneration. Client may notice blurred scotoma or decreased central visual acuity.

Amsler Grid a simple device to test the early and progressive effects of age-related macular degeneration. patients can test their own vision by posting the grid on the refrigerator or somewhere else at

home. Then patients can report any changes they detect.

F. Diabetic Retinopathy A progressive disorder of the retina characterized by microscopic damage to the retinal vessels. As a result of inadequate blood supply , sections of the retina deteriorate & vision is permanently

lost. All diabetics are prone to develop retinopathy. Clients who have had diabetes for 15-20 years have an 80-90% chance of developing

retinopathy.Clinical Manifestations:

Gradual or sudden loss of vision Floaters or shadows

Management: tight control of diabetes. tight control of diabetes. avoiding smoking, keeping regular appointments with your doctor and the eye specialist. Community referrals for rehabilitation & low vision aids.

Eye infection

Conjunctivitis Conjunctivitis is an inflammation or infection of the conjunctiva.

Three types:A. Infectious – commonly known as “Pink eye.”B. Allergic

C. ChemicalClinical manifestation:

o Hyperemia – rednesso Tearing & exudationo Psuedoptosis – drooping of the upper lido Sandy or scratchy feeling in the eyes o Blurred vision

It is important to prevent spreading conjunctivitis. If contagious, measures can be taken to prevent spreading conjunctivitis to others.

Keep your hands away from your eyes; Thoroughly wash hands before and after applying eye medications; Do not share towels, washcloths, cosmetics or eye drops with others; Seek treatment promptly.

Infectious conjunctivitis treated with antibiotic eye drops and/or ointment.

Allergic conjunctivitis avoid contact with any animal if it causes an allergic reaction.

Chemical conjunctivitis Wear swimming goggles if chlorinated water irritates your eyes.

Blepharitis Is a common chronic bilateral inflammation of the eyelid margins. Signs & Symptoms:

itching & burning of the eyes.red eyelid margins,scales or granulations along lashes.

In view of the long-term nature of the condition, strict lid hygiene is necessary. The following regimen may be useful:

Fill a small glass with warm water. Add three drops of baby shampoo. Take a clean cotton ball and soak it in the solution. While the eyes are closed, gently scrub both eyelids for two minutes . Rinse with cool tap water. Gently dry with a clean towel. Use medications as directed. Infected blepharitis may be treated with antibiotic ophthalmic ointment.

Hordeolum “Stye” – is an infection of the glands of the eyelids. Caused by staphylococcus infections. Signs & Symptoms:

redness & pain; localized swelling; may be filled with purulent material. Management:

Warm compressAntibioticsIncision & drainage as indicated.

Chalazion Is a sterile chronic granulomatous inflammation of a meibomian gland. “Meibomian Cysts” Usually characterized by painless localized swelling along the lid margin without redness. If large enough to distort vision or to be a cosmetic blemish, it may be surgically excised.

Extraocular Muscle Disorrders

Strabismus : called “SQUINT EYE” or “LAZY EYE” -a condition in which the eyes are not aligned because of lack of muscle coordination of the extraocular muscles - most often results from muscle imbalance or paralysis of extraocular muscles, but may also result from conditions such as brain tumor, myasthenia gravis or infection - normal in young infant but should not be present after about age 4 months

ASSESSMENT Amblyopia if not treated early Permanent loss of vision if not treated early Loss of binocular vision Impairment of depth perception Frequent headaches Squints or tilts head to see

Medical Management:• 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

• Inform the parents that the injection of botulinum toxin wears off in about 2 months & 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- the presence of blood in the anterior chamber - occurs as a result of injury - condition usually resolves in 5-7 daysNURSING CARE

• Encourage rest in semi-Fowler’s position• Avoid sudden eye movements for 3-5 days to decrease bleeding• Administer cycloplegic eye drops as prescribed

- to place the eye at rest• Instruct in the use of eye shields or eye patches as prescribed• Instruct the client to restrict reading & watching TV

Trauma to the eye and related structure

CONTUSIONS - bleeding into the soft tissue as a result of an injury - causes a black eye & the discoloration disappears in approximately 10 days - pain, photophobia, edema & diplopia may occurNURSING CARE

• Place ice on the eye immediately• Instruct the client to receive an eye examination

Intraocular FOREIGN BODIES- an object such as dust that enters the eye

NURSING CARE Wash hands thoroughly before touching the eye• 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

If foreign body is lodged into the cornea, do not attempt to remove it, see a physician Avoid pressure on the eye, do not touch , do not rub the eye Use sterile technique, when treating the eyes

CHEMICAL BURNS- an eye injury in which a caustic substance enters the eyeNURSING CARE

• Treatment should begin stat• Flush the eyes at the site of injury with water for at least 15-20 mins• 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• The solution is directed across the cornea & toward the lateral canthus• Prepare for visual acuity assessment• Apply an antibiotic ointment as prescribed• Cover the eye with a patch as prescribed

PENETRATING OBJECTS- an injury that occurs to the eye in which an object penetrates the eyeNURSING 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’t allow the client to bend• Don’t place pressure on the eye• Client is to be seen by MD stat

Refraction errors: Emmetropia: normal refractive state Ammetropia: “sight not in proper measure”

o Hyperopia Farsightedness Parallel rays of light focus behind the retina Corrected with convex lens

o Myopia Nearsightedness Paraleel rays of light focus in front of retina Corrected with concave lens Radial keratomy ( rk surgery)

o Presbyopia

“old sight” Lessening of the effective powers of accommodation, occurs because of

hardening of the lens due to aging process Blurring of near object or visual fatigue when doing “close eye work” Convex reading glasses are recommended

o Astigmatism “distorted vison” Caused by variation in refractive power along different meridians of the eye Optical distortion is most often caused by irregular caorneal curvature

which prevents clear focus of light from any point

Corneal Inflammation ( keratitis)Assessment

Pain Phaotophobia Lacrimation Blepharospasm Decreased vision

Treatment Trifuridine ( Viroptic), Idoxuridine (IDU) Mechanical/chemical debridement

Corneal Ulceration-medical emergency May result to corneal perforation, scarring or intraocular infection, permanent

impairment of visionCauses

Trauma Exposure Allergy Vit deficiency Lowered resistance Bacterial, viral, fungal infection

Corneal Opacity- lack of corneal transparency dur to inflammation, ulceration or injury

Corneal Transplantation ( keratoplasty) To repair corneal opacity, perforation of corneal ulcer Donor eyes for corneal transplantations come from cadavers Ideally, a donated eye is transplanted immediately or is removed form the bidy within 2 – 4

hours of death. Cornea may still be viable within 12 hours after death if the body has been refrigerated; may be trabsplanted up to 48 hours after death if it kept in a sterile container, on a piece of gauzed soaked in NSS at 4 degrees celcius

Eye Surgery

ENUCLEATION - removal of the entire eyeballEXENTERATION - 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

EVISCERATION-removal of the entire eyeball contents and cornea, except the sclera

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

ORGAN DONATION

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°• Instill antibiotic eye drops as RX

• Close the eyes & apply a small ice pack to the closed eyes•

PRE-OP CARE OF THE RECIPIENT• 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

POST-OP CARE TO THE RECIPIENT• Eye is covered with a pressure patch and protective shield that

are left in place until the next day• Don’t remove or change the dressing without the 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

GRAFT REJECTION• Can occur at anytime• Inform the client of signs of rejection• Signs include redness, swelling, decreased vision, & pain• Treated with topical steroids