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NEUROSENSORYNEUROSENSORYSYSTEMSYSTEM

NEUROSENSORYNEUROSENSORYSYSTEMSYSTEM

Kenneth P. Veluya, RN, MSNKenneth P. Veluya, RN, MSN

Clinical InstructorClinical Instructor

OBJECTIVES: Describe functions and structures of the eyes and adnexa.

MEDICAL SPECIALTIES:

OPHTHALMOLOGIST: Specializes in diagnosing and treating diseases and disorders of the eye.

OPTOMETRIST: Holds a doctor of Optometry (OD) degree and specializes in measuring the accuracy of vision to determine if corrective lenses or eyeglasses are needed.

ANATOMY & PHYSIOLOGYANATOMY & PHYSIOLOGYEYESEYES

EXTERNAL STRUCTURESEXTERNAL STRUCTURES

EYELIDSEYELIDS CONJUNCTIVACONJUNCTIVA

PALBEBRALPALBEBRAL BULBARBULBAR

LACRIMAL APPARATUSLACRIMAL APPARATUS LACRIMAL GLAND, DUCTS & PASSAGESLACRIMAL GLAND, DUCTS & PASSAGES

6 EXTRAOCULAR MUSCLES6 EXTRAOCULAR MUSCLES Levator palpebrae muscleLevator palpebrae muscle

ADNEXA OF THE EYES:

Adnexa oculi Includes:

Orbit Eye muscles Eyelids Eyelashes Conjunctiva Lacrimal apparatus

Adnexa: appendages; or accessory structures of an organ

EYELIDS Upper and lower

eyelids protect eyes from foreign matter, excessive light, and impact.

Canthus: angle where upper and lower eyelids meet.

Inner: nearest the nose

Epicanthus: vertical fold of skin on either side of the nose.

EYEBROWS and EYELASHES

Prevent foreign matter from reaching the eyes.

Edges of eyelids contain cilia (eyelashes) and oil-producing sebaceous glands.

CONJUNCTIVA

Mucous membrane that lines the underside of each eyelid

Continues to form a protective covering over the exposed surface of the eyeball.

Plural: conjunctivae

LACRIMAL APPARATUS

Lacrimal glands: located above the outer corner of each eye; secrete lacrimal fluid (tears) that maintains moisture on the anterior surface of the eyeball.

LACRIMATION:Normal continuoussecretion of tears by the lacrimalglands.

ANATOMY & ANATOMY & PHYSIOLOGYPHYSIOLOGY

EYESEYES ORBITORBIT

EYEBALL : 3 LAYERS: EYEBALL : 3 LAYERS: OUTEROUTER

ScleraSclera CorneaCornea

MIDDLE (Uveal Tract)MIDDLE (Uveal Tract) ChoroidChoroid Ciliary Body Ciliary Body IrisIris

•INNER (Retina)INNER (Retina)–RodsRods

–Sensitive to lightSensitive to light–Peripheral visionPeripheral vision

–CONESCONES–Fine descriminationFine descrimination–Color visionColor vision

Eyeball Layers:Eyeball Layers:

SCLERA Also known as white

of the eye. Fibrous tissue outer

layer of the eye. Maintains eye shape. Protects the delicate

inner layers of tissue. Cornea: transparent

anterior portion of the sclera; provides most of the optical power of the eye.

UVEAL TRACT

Also known as UVEA Vascular layer of the

eye. Includes:

choroidirisciliary body

CHOROID

Also known as choroid layer or choroid coat

opaque middle layer of the eyeball

contains many blood vessels and provides the blood supply for the entire eye

OPAQUE: light cannot pass through the substance

IRIS, PUPIL

IRIS: pigmented (colored) muscular layer that surrounds the pupil

PUPIL: black circular opening in the center of the iris that permits light to enter the eye.

Muscles within the iris control the amount of light allowed to enter the eye

Located within the choroid

Set of muscles and suspensory ligaments that adjust the lens to refine the focus of light rays on the retina.

To focus on nearby objects, these muscles adjust the lens to make it thicker.

To focus on distant objects, these muscles stretch the lens so it is thinner.

CILIARY BODY


EYESEYES LENS – FOCUS IMAGELENS – FOCUS IMAGE

FLUIDS OF THE EYE:FLUIDS OF THE EYE: AQUEOUS HUMORAQUEOUS HUMOR

ANTERIOR & POSTERIOR CHAMBERSANTERIOR & POSTERIOR CHAMBERS ANTERIOR EYE CAVITYANTERIOR EYE CAVITY NUTRIENTS TO LENS & CORNEANUTRIENTS TO LENS & CORNEA INTRAOCULAR PRESSURE MAINTENANCEINTRAOCULAR PRESSURE MAINTENANCE

20-25 mmHg20-25 mmHg VITREOUS HUMORVITREOUS HUMOR

POSTERIOR EYE CAVITYPOSTERIOR EYE CAVITY TRANSPARENCY & FORM OF THE EYETRANSPARENCY & FORM OF THE EYE

Lens is also known as thecrystalline lens.

Clear, flexible, and curvedstructure that focuses imageson the retina.

It is held in place by the suspensory ligaments of theciliary body.

Contained within a clear capsule

Located behind the iris andpupil.

LENS

Sensitive inner nerve layer of the eye located between the posterior chamber and the choroid layer at the back of the eye.

RETINA

Contains specialized light sensitive cells: • rods: black & white receptors• cones: colored receptors• both rods and cones receive images and convert them into nerve impulses

RETINA

MACULA LUTEA and FOVEA CENTRALIS

MACULA LUTEA • Clearly defined yellow area in the center of the retina• Area of sharpest central vision.

FOVEA CENTRALIS • Pit in the middle of the macula lutea.• Color vision is best in this area because of the high concentration of cones.

THE OPTIC DISK and NERVE

OPTIC DISK• Also known as blind spot• Region in the eye where the nerve endings of the retina gather to form the optic nerve.• Also called the blind spot because it does not contain any rods or cones.

THE OPTIC DISK and NERVE

OPTIC NERVE• Also known as II cranial nerve• transmits nerve impulses from retina to the brain.

FUNCTION OF THE EYES: RECEIVE IMAGES AND TRANSMIT

TO THE BRAIN.

VISUAL PATHWAYSVISUAL PATHWAYSRETINARETINA

OPTIC NERVEOPTIC NERVE

OPTIC CHIASMOPTIC CHIASM

OPTIC TRACTOPTIC TRACT

OCCIPITAL LOBEOCCIPITAL LOBE

ACCOMMODATIONCONVERGENCEEMMETROPIA

ACCOMMODATION Process whereby

the eyes make adjustments for seeing objects at various distances.

Include: constriction

(narrowing) dilation

(widening) of the pupil

movement of the eyes

changes in shape of the lens

CONVERGENCE

Simultaneous inward movement of both eyes (toward each other).

Usually in an effort to maintain single binocular vision as an object comes nearer.

EMMETROPIA

EM Normal relationship

between the refractive power of the eye and the shape of the eye that enables light rays to focus correctly on the retina

emmetr: proper measure opia: vision

Refraction: ability of the lens to bend the light rays to help them focus on the retina.

Physical Examination-Physical Examination-EYEEYE

VISUAL ACUITY : VISUAL ACUITY : SNELLEN’S CHARTSNELLEN’S CHART VISUAL FIELDS: VISUAL FIELDS: PERIMETRYPERIMETRY EXTERNAL STRUCTURESEXTERNAL STRUCTURES

POSITION & ALIGNMENT OF EYESPOSITION & ALIGNMENT OF EYES PUPILS (PERRLA)PUPILS (PERRLA)

EXTRAOCULAR MOVEMENTSEXTRAOCULAR MOVEMENTS PARALYSISPARALYSIS NYSTAGMUSNYSTAGMUS

CORNEAL REFLEXCORNEAL REFLEX

VISUAL ACUITY MEASUREMENT Evaluation of the eye’s ability to

distinguish object details and shape. Assessed by the smallest

identifiable object that can be seen at a specified distance (usually 20 ft or 16 in).

REFRACTION

Determine an eye’s refractive error and the best corrective lenses to be prescribed.

Diopter: unit of measurement of lens refractive power.

TONOMETRY

Measures intraocular pressure (IOP).

Abnormally high pressure may be an indication of glaucoma.

MYDRIATIC DROPS

In preparation for an examination of the interior of the eye, it is necessary to dilate the pupils through the use of mydriatic drops.

Produce temporarily paralysis, forcing the pupils to remain wide open even in the presence of bright light.

Undilated pupil

Dilated pupil

Don’t look at me…

PLANNING FOR HEALTH PLANNING FOR HEALTH PROMOTIONPROMOTION

CARE OF THE EYESCARE OF THE EYES

EYEDROPS, DISCOURAGEDEYEDROPS, DISCOURAGED PRINTED MATTER: 14 INCHES AWAYPRINTED MATTER: 14 INCHES AWAY TV: 10-12 FT AWAYTV: 10-12 FT AWAY READ WITH ILLUMINATION: 100-150 WATTSREAD WITH ILLUMINATION: 100-150 WATTS LIGHT FROM BEHINDLIGHT FROM BEHIND TEACH ABOUT DANGER SIGNALS OF VISUAL TEACH ABOUT DANGER SIGNALS OF VISUAL

DISORDERDISORDER

•PERSISTENT REDNESSPERSISTENT REDNESS•CONTINUED DISCOMFORT & PAIN ESP CONTINUED DISCOMFORT & PAIN ESP

FOLLOWING INJURYFOLLOWING INJURY•CHILDREN: CROSSING OF EYESCHILDREN: CROSSING OF EYES•BLURRED VISION/ SPOTS BEFORE THE EYESBLURRED VISION/ SPOTS BEFORE THE EYES•GROWTH ON THE EYE/ OPACITIESGROWTH ON THE EYE/ OPACITIES•CONTINUAL DISCHARGE, CRUSTING ORCONTINUAL DISCHARGE, CRUSTING OR

TEARINGTEARING•PUPIL IRREGULARITIESPUPIL IRREGULARITIES

PLANNING FOR HEALTH PLANNING FOR HEALTH MAINTENANCE & RESTORATIONMAINTENANCE & RESTORATION INSTILLATION OF EYEDROPSINSTILLATION OF EYEDROPS

LOWER CUL-DE-SACLOWER CUL-DE-SAC JUST CLOSE EYES, NOT SQUEEZEJUST CLOSE EYES, NOT SQUEEZE

INSTILLATION OF EYE OINTMENTINSTILLATION OF EYE OINTMENT FROM INNER CANTHUS, OUTWARDFROM INNER CANTHUS, OUTWARD

HOT/ COLD COMPRESSHOT/ COLD COMPRESS EYE IRRIGATIONSEYE IRRIGATIONS

REMOVE CHEMICALS OR SECRETIONSREMOVE CHEMICALS OR SECRETIONS MASSAGE THE EYEBALLMASSAGE THE EYEBALL

IN GLAUCOMA ESP AFTER OPERATIONSIN GLAUCOMA ESP AFTER OPERATIONS CARE OF CONTACT LENSCARE OF CONTACT LENS

NOT TO WEAR WITH SWIMMINGNOT TO WEAR WITH SWIMMING

DISORDERS - EYEDISORDERS - EYE INJURIES & INJURIES &

TRAUMATRAUMA

INFECTIONSINFECTIONS

CATARACTCATARACT

GLAUCOMAGLAUCOMA

DETACHMENT OF DETACHMENT OF THE RETINATHE RETINA

REFRACTIVE REFRACTIVE ERRORSERRORS

INJURIES & TRAUMAINJURIES & TRAUMA

EMERGENCY:EMERGENCY: TREAT THE PATIENT, LEAVE THE EYE TREAT THE PATIENT, LEAVE THE EYE

ALONE, EXCEPT IN CHEMICAL INJURY ALONE, EXCEPT IN CHEMICAL INJURY - FLUSH EYES STAT- FLUSH EYES STAT

FOREIGN BODIES: FLUSH WITH WATER FOR FOREIGN BODIES: FLUSH WITH WATER FOR 15 MIN WHILE GOING TO THE DOCTOR; 15 MIN WHILE GOING TO THE DOCTOR; DON’T TOUCH CORNEADON’T TOUCH CORNEA

MAY USE CARBONATED DRINKS IF WATER IS MAY USE CARBONATED DRINKS IF WATER IS NOT AVAILABLENOT AVAILABLE

INFECTIONSINFECTIONS

HORDEOLUM/ STY -Zeis glandHORDEOLUM/ STY -Zeis gland in the in the folliclefollicle

CHALAZION –meibomian glandsCHALAZION –meibomian glands CONJUNCTIVITIS – pink eyeCONJUNCTIVITIS – pink eye

bacterial infection, allergy, traumabacterial infection, allergy, trauma UVEITIS - irisUVEITIS - iris KERATITIS - corneaKERATITIS - cornea PTERYGIUM – triangular foldPTERYGIUM – triangular fold

From white of the eye to the corneaFrom white of the eye to the cornea

EYELIDS

BLEPHAROPTOSIS

Drooping of the upper eyelid

blepharo: eyelid ptosis: drooping or sagging

ECTROPION Eversion (turning

outward) of the edge of the eyelid

Ec: out trop: turn ion: condition

ENTROPION Inversion (turning inward)

of the edge of the eyelid. En: in

trop: turn ion: condition

HORDEOLUM Stye Infection of one or more

glands at the border of the eyelid.

CHALAZION Internal hordeolum Localized swelling of the

eyelid resulting from obstruction of one of the sebaceous (oil-producing glands of the eyelid).

DACROCYSTITIS

Inflammation of the lacrimal sac.

Associated with faulty tear drainage.

CONJUNCTIVITIS Also known as pink eye Inflammation of the

conjunctiva

Xerophthalmia is the term used to describe the eye signs of vitamin A deficiency. This is a childhood blinding disease which is caused by a lack of vitamin A in the diet. Often, the first symptom is night blindness followed by Bitot's spots on the conjunctiva. Although Bitot's spots differ somewhat in size, location and shape, they have similar appearance. They are accumulations of foamy, cheesy material on the conjunctiva, often in association with other signs of xerophthalmia

XEROPHTHALMIA

Also known as dry eye Drying of eye surfaces Loss of luster of conjunctiva

and cornea

SCLERITIS Also known as pink eye Inflammation of the

conjunctiva Inflammation limited to the

sclera. Note markedly dilated blood vessels which do not extend onto the underside of the lower lid, helping to distinguish scleritis from conjunctivitis. Associated witha number of autoimmune diseases.

CORNEAL ABRASION Inflammation of the cornea kerat: cornea

kerat/o: also means hardA corneal abrasion is simply a scratch in the epithelium (skin), or the thin, outer layer of the cornea. Abrasions usually heal in a short time period, sometimes within hours. Deeper or larger scratches may take up to a week. The cornea has a tremendous number of nerve endings, which makes any damage to the cornea very

painful.

CORNEAL ULCER

Pitting of the cornea caused by an infection or injury.

These ulcers heal with treatment but with a cloudy scar that impairs vision.

Usually due to injuries with a sharp objects, dust, sand or vegetable matter like thorns, leaves etc.,

IRITIS

Inflammation of the iris. In the majority of cases

there is no specific cause. Occasionally, iritis is just

one symptom of diseases such as rheumatoid arthritis, lupus , scleroderma, anklylosing spondylitis, Crohn's disease, ulcerative colitis.

SYNECHIA

Adhesion that binds the iris to any adjacent structure.

Adhesion: holds structures together abnormally.

Plural: synechiae

ANISOCORIA Condition in which

the pupils are unequal in size.

May be congenital or caused by head injury, aneurysm, or pathology of the central nervous system.

aniso: unequal cor: pupil ia: abnormal

CATARACT Loss of transparency

of the lens. May be congenital or

caused by trauma or injury

Formation of most cataracts are associated with aging.

May be due to diabetes, exposure to ultraviolet or infrared radiation, malnutrition

CATARACTCATARACT Opacity of the lens & its capsule which interferes with Opacity of the lens & its capsule which interferes with

transparencytransparency

S/SX:S/SX: Dimness in visual acuityDimness in visual acuity Rapid & marked cxs of refraction errorRapid & marked cxs of refraction error

CLASSIFICATION:CLASSIFICATION: Primary/ senilePrimary/ senile Secondary/ traumaticSecondary/ traumatic CongenitalCongenital

TREATMENT:TREATMENT:•Intracapsular extraction – Intracapsular extraction – lens & capsulelens & capsule•Extracapsular extraction – Extracapsular extraction – lens onlylens only•Cryoextraction – Cryoextraction – probe cooled below 0 probe cooled below 0 ooCC•Phacoemulsification – Phacoemulsification – probe vibratesprobe vibrates•Enzymatic zonulysis – Enzymatic zonulysis – alphachemotrypsin: alphachemotrypsin: fibrinolytic & proteolytic, to anterior chamberfibrinolytic & proteolytic, to anterior chamberIntraocular lens – Intraocular lens – synthetic; distant visionsynthetic; distant vision

for aphasic patientfor aphasic patient

EYE SURGERYEYE SURGERY

NURSING CARE PRE-OPNURSING CARE PRE-OP

Orient to new environmentOrient to new environment Teach deep breathing & how to close Teach deep breathing & how to close

eyes without squeezingeyes without squeezing Eye antibiotics preopEye antibiotics preop Mydiatrics if orderedMydiatrics if ordered


NURSING CARE POST-OPNURSING CARE POST-OP

Reorient patient to his surroundingsReorient patient to his surroundings Prevent increase in IOP & stress on Prevent increase in IOP & stress on

the suture linethe suture line

ACTIVITIES THAT INCREASE IOP:ACTIVITIES THAT INCREASE IOP:

•CoughingCoughing•Brushing Brushing •Shaving Shaving •Vomiting Vomiting •Bending Bending •Stooping Stooping

•Promote comfort of the patient: Promote comfort of the patient: mild analgesic to control painmild analgesic to control pain


NURSING CARE POST-OPNURSING CARE POST-OP

Observe & treat complicationsObserve & treat complicationsCOMPLICATIONS:COMPLICATIONS:•NAUSEA & VOMITINGNAUSEA & VOMITING

•AntiemeticsAntiemetics•Cold compressCold compress

•HEMORRHAGEHEMORRHAGE•Sudden pain of the eyeSudden pain of the eye

•PROLAPSE OF THE IRISPROLAPSE OF THE IRIS•Most common postop complicationMost common postop complication•Can precipitate glaucomaCan precipitate glaucoma

• Promote the rehab of the patientPromote the rehab of the patient•Encourage the patient to become Encourage the patient to become

independent- walk with him when he first independent- walk with him when he first become ambulatorybecome ambulatory•Health teachingsHealth teachings


HEALTH TEACHINGS:HEALTH TEACHINGS:

1-4 wks : dark glasses; temporary corrective 1-4 wks : dark glasses; temporary corrective lenseslenses

6-8 wks: permanent lenses6-8 wks: permanent lenses It will take time to learn distances & climb It will take time to learn distances & climb

stairsstairs Color slightly changedColor slightly changed Use one eye at a time unless with contact lensUse one eye at a time unless with contact lens Decreased peripheral visionDecreased peripheral vision

CHOKED DISK Also known as

papilledema. Swelling and

inflammation of the optic nerve at the point of entrance through the optic disk.

Swelling is due to increased intracranial pressure due to a tumor pressing on the optic nerve.

Normal optic nerve (central pinkish disk)

FLOATERS Also known as vitreous floaters. Particles that float in the

vitreous fluid and cast shadows on the retina.

Usually occur with aging or in association with vitreous detachments, retinal tears, or intraocular inflammations.

Harmless They generally look like specks

of various shapes and sizes, or like cobwebs. They are frequently visible when you are looking at a plain-lighted background like a blank light colored wall, a blue sky or the white pages of a book.

NYSTAGMUS

Involuntary, constant, rhythmic movement of the eyeball.

Unintentional jittery movement of one or both eyes

Causes: - drug abuse - brain tumor - stroke - multiple sclerosis - Meniere's disease - labyrinthitis - alcoholism

RETINAL DETACHMENT

Also known as detached retina

Retina is pulled away from its normal position of being attached to the choroid in the back of the eye.

RETINAL DETACHMENT

Retinal tear: occurs if the retina tears (develops a hole) as it is pulled away from its normal position.

RETINARETINA CHOROIDCHOROID

SCLERASCLERA

OPTIC NERVEOPTIC NERVE

RETINAL DETACHMENTRETINAL DETACHMENT


Fluid accumulationFluid accumulation TumorTumor

CAUSE:CAUSE: Myopic degenerationMyopic degeneration TraumaTrauma Aphakia Aphakia

S/SX:S/SX: Floating spots or opacities Floating spots or opacities

before the eyebefore the eye Casts shadows on the Casts shadows on the

retinaretina BrightFlashes of lightBrightFlashes of light Progressive constriction of Progressive constriction of

vision in 1 eyevision in 1 eye

MANAGEMENT:MANAGEMENT:

Conservative :Conservative :•Quiet in bed with eyes coveredQuiet in bed with eyes covered•Head: positioned so that retinal holes lowerHead: positioned so that retinal holes lower•Photocoagulation – Photocoagulation – small burn to retinasmall burn to retina•Cryotherapy – Cryotherapy – cold probe to freeze retinacold probe to freeze retina

Surgical: Surgical: •Scleral buckling- Scleral buckling- sealing break & reattachingsealing break & reattaching

retinaretina


POST-OP NURSING CARE:POST-OP NURSING CARE: Cover eyesCover eyes Area of detachment, dependentArea of detachment, dependent MydiatricsMydiatrics Discharge instructions:Discharge instructions:

No strenuous exercises & acivity x No strenuous exercises & acivity x 6mos6mos

Contact sports restrictedContact sports restricted No sudden jarring head motionNo sudden jarring head motion No restriction with use of eyesNo restriction with use of eyes

UVEITIS Inflammation anywhere

in the uveal tract. May affect the choroid,

iris, or ciliary body Many possible causes

including diseases elsewhere in the body.

Can rapidly damage the eye and produce complications including cataracts, detached retina, and glaucoma.

Leading cause of blindness in the U.S.

GLAUCOMA Characterized by increased

intraocular pressure. If untreated, optic nerve is

damaged causing loss of peripheral vision, and eventually blindness.

Leading cause of blindness in US.

Does not produce symptoms until optic nerve is damaged.

May be detected through regular eye check-ups (tonometry/visual field testing)

Open-angle glaucoma Closed-angle glaucoma:

Normal vision

Vision of a person with glaucoma

GLAUCOMAGLAUCOMA INCREASED IOPINCREASED IOP PROGRESSIVE LOSS OF PERIPHERAL VISIONPROGRESSIVE LOSS OF PERIPHERAL VISION

CAUSE: CAUSE: OBSTRUCTION TO CIRCULATION OF OBSTRUCTION TO CIRCULATION OF AQUEOUS HUMORAQUEOUS HUMOR

TYPES:TYPES:1.1. CHRONIC/ SIMPLE/ OPEN-ANGLECHRONIC/ SIMPLE/ OPEN-ANGLE2.2. ACUTE ANGLE CLOSUREACUTE ANGLE CLOSURE3.3. CongenitalCongenital4.4. Secondary – trauma, uveitis, postopSecondary – trauma, uveitis, postop5.5. Absolute – uncontrolled- enucleationAbsolute – uncontrolled- enucleation

EYESEYES

CORNEACORNEA

IRISIRIS

CILIARY BODYCILIARY BODYANTERIORANTERIORCHAMBERCHAMBER

LENSLENS

CANAL OF SCHLEMMCANAL OF SCHLEMM

ZONULESZONULES

OPEN-ANGLE GLAUCOMAOPEN-ANGLE GLAUCOMA

EYESEYES

CORNEACORNEA

IRISIRIS

CILIARY BODYCILIARY BODYANTERIORANTERIORCHAMBERCHAMBER

LENSLENS

CANAL OF SCHLEMMCANAL OF SCHLEMM

ZONULESZONULES

ACUTE-ANGLE CLOSURE GLAUCOMAACUTE-ANGLE CLOSURE GLAUCOMA

OPEN ANGLE GLAUCOMAOPEN ANGLE GLAUCOMA

S/SX:S/SX:

Loss of peripheral vision (tunnel)Loss of peripheral vision (tunnel) Difficulty in adjusting to darknessDifficulty in adjusting to darkness Failure to detect changes in colorFailure to detect changes in color Headache, pain behind the eyeballHeadache, pain behind the eyeball HalosHalos Nausea & vomitingNausea & vomiting

OPEN ANGLE GLAUCOMAOPEN ANGLE GLAUCOMA


Conservative :Conservative : Miotics : pupillary constrictionMiotics : pupillary constriction

draw iris smooth muscle away draw iris smooth muscle away from the canalfrom the canal

Given early amGiven early am Acetazolamide : decrease aqueous Acetazolamide : decrease aqueous

productionproduction Fluid restrictionFluid restriction

Aggressive: Aggressive:

Principle: improve drainage of aqueousPrinciple: improve drainage of aqueous

•Iridocleisis-Iridocleisis-anterior chamber & subconjunctival spaceanterior chamber & subconjunctival space

•Corneoscleral trephening – Corneoscleral trephening – junction of cornea & sclerajunction of cornea & sclera

•Trabeculotomy Trabeculotomy •Laser therapy to meshworkLaser therapy to meshwork

Acute Angle GlaucomaAcute Angle Glaucoma

CAUSE:CAUSE: Pupillary dilation by mydiatricsPupillary dilation by mydiatrics Abnormal anterior displacement of irisAbnormal anterior displacement of iris

S/SX:S/SX: Severe eye painSevere eye pain Nausea & vomitingNausea & vomiting Blurred visionBlurred vision Colored halos around lightsColored halos around lights Dilated pupilsDilated pupils Increased IOPIncreased IOP


•MioticsMiotics•DiamoxDiamox•Osmotic agents – glycerolOsmotic agents – glycerol•Surgery - iridectomySurgery - iridectomy

GLAUCOMAGLAUCOMA

NURSING CARE – SURGERYNURSING CARE – SURGERY

PRE-OPPRE-OP Explain that vision lost cannot be restored, Explain that vision lost cannot be restored,

but further loss can be preventedbut further loss can be preventedPOST-OPPOST-OP Flat 24H- prevent iris prolapseFlat 24H- prevent iris prolapse Narcotics or sedativesNarcotics or sedatives Liquid diet until 1Liquid diet until 1stst dressing dressing Turn to unoperative siteTurn to unoperative site

LONG TERM CARE:LONG TERM CARE:

•No restriction on the use of the eyesNo restriction on the use of the eyes•No fluid restriction; exercise permittedNo fluid restriction; exercise permitted•Medical follow up needed for lifeMedical follow up needed for life

MACULAR DEGENERATION Gradually progressive

condition that results in the loss of central vision but not in total blindness.

Age-related macular degeneration: affects older people.

Dry-type: 90% of cases; caused by atrophy of the macula

Wet-type: associated with formation of new blood vessels that produce small hemorrhage.

DIPLOPIA Also known as double vision Perception of 2 images of a single

object. The two images may be vertically

separated (one on top of the other) or

horizontally separated (side by side) or both

(oblique). It generally occurs when the eyes,

which have previously worked together as a

pair, are no longer able to do so because a

squint has developed and the eyes are now

out of alignment with each other.This may

happen suddenly or over a period of time. Double vision is normally the resulting

symptom when one or more of the eye muscles or nerves have been weakened or damaged. This weakness or damage can be caused by a number of conditions.

HEMIANOPIA

Blindness to one side of the visual field.

Whoever may be at risk for stroke is also at risk for hemianopia.

People with high blood pressure or those with an abnormal heart rhythm, which is associated with blood clots in the heart, may be at risk for stroke.

This is how a street scene looks with normal vision.

This is how the same scene looks with right hemianopia.

MONOCHROMATOSIS Also known as color blindness Lack of the ability to distinguish

colors. True color blindness is

extremely rare. World appears in black, gray, or

white only. Inherit the disorder from the

genes of both parents. Less severe forms are those

whose colors visions are not normal.

They may have difficulty differentiating reds and greens (most common) or blues and yellows.

All humans are born color blind and begin to see colors at 4 months.

NYCTALOPIA Also known as night blindness Difficulty seeing at night. The outer area of the retina is

made up of more rods than cones. The rod cells are the cells that enable us to see in poor lighting. This is the reason why loss of side vision often results in night blindness.

They not only see poorly at night, but also require some time for their eyes to adjust from brightly lit areas to dim ones. Contrast vision may also be greatly reduced.

Normal vision

Slow adjustment

PRESBYOPIA Changes in the eyes that

occur with aging. With aging, the lens becomes

less flexible and muscles of the ciliary body become weaker.

Result: eyes are no longer able to focus the image properly on the retina.

Neither a disease or defect. Natural condition that

everyone has to face. Those who are far-sighted,

live in tropical climates and at sea level develop the condition earlier.

Normal vision

Slow adjustment

STRABISMUS Squint Disorder in which the eyes cannot be directed in a parallel

manner toward the same object. Esotropia: strabismus characterized by an inward deviation

of one eye in relation to the other. Exotropia: walleye; strabismus characterized by the

outward deviation of one eye relative to the other.

ExotropiaEsotropia

Condition in which the lens and cornea do not bend light so that it can focus properly on the retina.

REFRACTIVE ERRORSREFRACTIVE ERRORS

REFRACTION – bending of light raysREFRACTION – bending of light raysACCOMMODATION – ability to adjust from near to ACCOMMODATION – ability to adjust from near to

far visionfar visionADAPTATION – ability to see light from darknessADAPTATION – ability to see light from darkness

COMMON ERRORS:COMMON ERRORS: MyopiaMyopia HyperopiaHyperopia PresbyopiaPresbyopia

•AstigmatismAstigmatism•Blindness Blindness

NORMAL VISION1. Light enters the eye

through the cornea, the clear, dome-shaped surface that covers the front of the eye.

2. From the cornea, the light passes through the pupil. The amount of light passing through is regulated by the iris, or the colored part of your eye.

3. From there, the light then hits the lens, the transparent structure inside the eye that focuses light rays onto the retina.

NORMAL VISION1. Next, it passes through the

vitreous humor, the clear, jelly-like substance that fills the center of the eye and helps to keep the eye round in shape.

2. Finally, it reaches the retina, the light-sensitive nerve layer that lines the back of the eye, where the image appears inverted.

3. The optic nerve carries signals of light, dark, and colors to the area of the brain (the visual cortex), which assembles the signals into images (our vision).

AMETROPIA

Error of refraction in which only objects located at a finite distance from the eye are focused on the retina.

Occurs when eyes with visual defects such as astigmatism, myopia, and hyperopia are unable to properly focus light rays into a clear image.

Typically require corrective lenses or eye surgery.

ASTIGMATISM Condition in which the eye does not

focus properly because of unequal curvatures of the cornea.

Cornea is oval like a football instead of spherical like a basketball.

Objects up close and at a distance appear blurry.

May cause eyestrain and may be combines with both near and farsightedness.

ASTIGMATISMASTIGMATISM

Asymmetry or irregular curvature Asymmetry or irregular curvature of the corneaof the cornea

Cylindrical lensesCylindrical lenses

BLINDNESSBLINDNESS

Vision: 20/200Vision: 20/200

HYPEROPIA Farsightedness Defect in which light rays

focus beyond the retina. Caused by a flatter retina or

shorter eye. Occurs most commonly

after age 40. Uncommon in children.

hyperopiahyperopia

FAR-SIGHTEDFAR-SIGHTED

Eyeball A-P dimension too shortEyeball A-P dimension too short Light rays focus behind the retinaLight rays focus behind the retina Good vision for far distancesGood vision for far distances Convex lensesConvex lenses

MYOPIA

Nearsightedness Defect in which light rays focus in

front of the retina. Condition occurs most commonly

in school-aged children. May be inherited.

myopiamyopia

NEAR-SIGHTEDNEAR-SIGHTED

Long A-P dimension of the eyeballLong A-P dimension of the eyeball Light rays focus infront of the retinaLight rays focus infront of the retina Good vision for near distancesGood vision for near distances Concave lensesConcave lenses

presbyopiapresbyopia

FARSIGHTEDNESS OF OLD AGEFARSIGHTEDNESS OF OLD AGE

Gradual loss of accommodationGradual loss of accommodation Loss of lens elasticityLoss of lens elasticity Inability to rad without holding the Inability to rad without holding the

material more than 13 ft from the material more than 13 ft from the eyeeye

Bifocal lensesBifocal lenses

AMBLYOPIA Dimness of vision or the

partial loss of sight without detectable disease of the eye.

Condition where central visual acuity of an apparently healthy eye is reduced because of lack of use during early childhood, from birth up to the age of seven.

Sometimes known as "lazy eye", it is usually due to an eye muscle problem or due to an inequality between the two eyes.

Often it occurs because the "good" eye is preferred.

What happens if amblyopia goes untreated?If not treated early enough, an amblyopic eye may never develop good vision and may even become functionally blind.

BLINDNESS Inability to see. “Legal blindness” refers to a

best-corrected vision of 20/200 or less.

Leading causes of blindness: cataract glaucoma corneal scarring diabetes

SCOTOMA Also known as blind spot An abnormal area of absent

or depressed vision surrounded by an area of normal vision.

A ring or donut shaped scotoma is an area of reduced vision that forms a shape similar to a ring or donut - the patient can see fine in the center and off-center a little bit but then there is an area of reduced vision followed by another area or normal vision.

In age-related macular degeneration, the center part of the eye and retina known as the macula dies-off, leaving a black hole or "scotoma" right at the center.

Severus, 42y.o, is receiving Severus, 42y.o, is receiving cryotherapy for repair of a cryotherapy for repair of a detached retina. When taking detached retina. When taking history from him, which symptom history from him, which symptom would the nurse expect him to would the nurse expect him to have?have?

a.a. DiplopiaDiplopiab.b. Severe eye painSevere eye painc.c. Sudden blindnessSudden blindnessd.d. Bright flashes of lightBright flashes of light


EARSEARSEXTERNAL EAREXTERNAL EAR AURICLEAURICLE PINNAPINNA TYMPANIC MEMBRANETYMPANIC MEMBRANE

MIDDLE EARMIDDLE EAR OSSICLES: MALLEOUS, INCUS, STAPESOSSICLES: MALLEOUS, INCUS, STAPES EUSTACHIAN TUBEEUSTACHIAN TUBE

EAREAR

ANATOMY & PHYSIOLOGYANATOMY & PHYSIOLOGYEARSEARS

INNER EARINNER EAR ORGAN OF CORTI ORGAN OF CORTI

HEARINGHEARING

VESTIBULAR APPARATUSVESTIBULAR APPARATUS BALANCEBALANCE 3 SEMICIRCULAR CANALS3 SEMICIRCULAR CANALS UTRICLEUTRICLE

EAREAR

ANATOMY & PHYSIOLOGYANATOMY & PHYSIOLOGYEARSEARS

SOUND WAVES TO TYMPANIC MEMBRANESOUND WAVES TO TYMPANIC MEMBRANE

OSSICLES IN MOTIONOSSICLES IN MOTION

VIBRATION FROM STAPES TO OVAL WINDOWVIBRATION FROM STAPES TO OVAL WINDOW

COCHLEA : ORGAN OF CORTICOCHLEA : ORGAN OF CORTI

CRANIAL NERVE 8 TO TEMPORAL LOBECRANIAL NERVE 8 TO TEMPORAL LOBE

HEARINGHEARING

AUDITORY ASSESSMENTAUDITORY ASSESSMENT

EXTERNAL EAR EXAMINATIONEXTERNAL EAR EXAMINATION

Inspection & palpation of auricleInspection & palpation of auricle Visualization: straighten the auditory canal: Visualization: straighten the auditory canal:

PULL AURICLE UP, & BACKPULL AURICLE UP, & BACK

NORMAL EARDRUM: NORMAL EARDRUM: slightly conicalslightly conical ShinyShiny pearly gray in colorpearly gray in color


HEARING TEST:HEARING TEST:

Tests for acuteness of hearing or degree of Tests for acuteness of hearing or degree of deafness:deafness:

Whisper or spoken voice testWhisper or spoken voice test Audiometer :Audiometer :

Pure tone – mx loudness in decibelPure tone – mx loudness in decibel Speech – ability to understand & descriminateSpeech – ability to understand & descriminate

Watch tick testWatch tick test Tuning fork testTuning fork test


HEARING TEST:HEARING TEST:

Test to localize cause of deafness:Test to localize cause of deafness:

Schwabach’sSchwabach’s Rinne’sRinne’s Weber’sWeber’s

SCHWABACH’SSCHWABACH’S

•Bone conduction vs normal hearingBone conduction vs normal hearing•Tuning fork @ px’s mastoid until the patientTuning fork @ px’s mastoid until the patient

hears no sound.hears no sound.•TF transferred to examiner’s earTF transferred to examiner’s ear•N = no sound heardN = no sound heard•ABN = ABN = sensorineural hearing losssensorineural hearing loss

RINNE’S TESTRINNE’S TEST

•Sound heard better: air vs boneSound heard better: air vs bone

•N = positive; air conduction is betterN = positive; air conduction is better•ABN: negative: bone conduction betterABN: negative: bone conduction better

conductive hearing lossconductive hearing loss

WEBER’SWEBER’S

•TF top midline of the headTF top midline of the head•Sound heard: normal ear vs affected earSound heard: normal ear vs affected ear•Better in affected ear: Better in affected ear: conductiveconductive•Better in normal ear : Better in normal ear : sensorineuralsensorineural


TEST FOR VESTIBULAR FUNCTONTEST FOR VESTIBULAR FUNCTON

CALORIC TESTCALORIC TEST Check direction of nystagmusCheck direction of nystagmus COWS ( cold-opposite; warm-same side of stimulated ear)COWS ( cold-opposite; warm-same side of stimulated ear)

ROTATION (BARANY) TESTROTATION (BARANY) TEST Rotating chairRotating chair Nystagmus is opposite to the direction of rotationNystagmus is opposite to the direction of rotation

HEALTH PROMOTIONHEALTH PROMOTION

EAR PROTECTIONEAR PROTECTION

Noise over 70 decibels is potentially damaging Noise over 70 decibels is potentially damaging to hearingto hearing

Most common & impt type of occupational Most common & impt type of occupational hearing is caused by LOUD NOISEhearing is caused by LOUD NOISE

GENERAL EAR CAREGENERAL EAR CARE

Ear is self-cleaningEar is self-cleaning Cerumen-lubricant; traps dirtCerumen-lubricant; traps dirt Keep eyes, mouth & both nostrils while Keep eyes, mouth & both nostrils while

blowing the noseblowing the nose Cleanse the external ear reached by vision Cleanse the external ear reached by vision

NURSING INTERVENTIONSNURSING INTERVENTIONS

EAR DROPSEAR DROPS WarmWarm After adm’n, head should remain tiltedAfter adm’n, head should remain tilted

SOFTENING & REMOVING IMPACTED SOFTENING & REMOVING IMPACTED CERUMENCERUMEN

Few drops of hydrogen peroxide/ warm glycerineFew drops of hydrogen peroxide/ warm glycerine Irrigate the earIrrigate the ear

NURSING INTERVENTIONSNURSING INTERVENTIONS

EAR IRRIGATIONEAR IRRIGATION

To clean the external canalTo clean the external canal Remove impated cerumenRemove impated cerumen Caloric testCaloric test Apply antiseptic solutionsApply antiseptic solutions Remove foreign bodiesRemove foreign bodies

COMMON EAR PROBLEMSCOMMON EAR PROBLEMS

1.1. OTOSCLEROSISOTOSCLEROSIS

2.2. MENIERE’S DSEMENIERE’S DSE

3.3. HEARING IMPAIRMENTHEARING IMPAIRMENT

OTOSCLEROSISOTOSCLEROSIS

Normal bone is replaced by spongy boneNormal bone is replaced by spongy bone

Ankylosis of the footplate of the stapesAnkylosis of the footplate of the stapes

Impaired vibration systemImpaired vibration system


ASSESSMENTASSESSMENT

Gradual hearing loss Gradual hearing loss Difficulty hearing a whisperDifficulty hearing a whisper Own voice is loudOwn voice is loud Paracusis : hear better in loud environmentParacusis : hear better in loud environment Rinne’s test: bone conduction betterRinne’s test: bone conduction better


PLANNING & IMPLEMENTATIONPLANNING & IMPLEMENTATION

Hearing aidHearing aid Surgery – primary form of txSurgery – primary form of tx

StapedectomyStapedectomy Stapes mobilization operationStapes mobilization operation Fenestration operation : new window is createdFenestration operation : new window is created

EAR SURGERYEAR SURGERY

PRE-OP CARE;PRE-OP CARE;

Hair shampooHair shampoo Inform client:Inform client:

Head still during surgeryHead still during surgery Post op: get out of bed with assistancePost op: get out of bed with assistance

avoid nose blowing until 1 weekavoid nose blowing until 1 week


POST OP POST OP

Promote comfort & safetyPromote comfort & safety Promote psychological well-beingPromote psychological well-being Prevent complicationsPrevent complications

COMFORT & SAFETYCOMFORT & SAFETY

•24h bed rest24h bed rest•No TVNo TV•Pain relieverPain reliever•Gradual ambulation with assistanceGradual ambulation with assistance

PSYCHOLOGICAL WELL-BEINGPSYCHOLOGICAL WELL-BEING

•Reassurance about decreased hearing from Reassurance about decreased hearing from swelling & dressingswelling & dressing

•Slushing within the ear- report to physicianSlushing within the ear- report to physician

COMPLICATIONS;COMPLICATIONS;

•Facial nerve involvementFacial nerve involvement•Facial paralysis, facial weaknessFacial paralysis, facial weakness•Inability to show teeth, wrinkle forehead,Inability to show teeth, wrinkle forehead,

raise eyebrows or close eyesraise eyebrows or close eyes•Meningitis – bacterialMeningitis – bacterial

•Report signs & symptomsReport signs & symptoms•Bleeding Bleeding


DISCHARGE PLANNINGDISCHARGE PLANNING

Discharged with dressingDischarged with dressing Sudden head movement, avoidedSudden head movement, avoided No elevatorsNo elevators No hair washing at least 2 weeksNo hair washing at least 2 weeks Avoid people with URTIAvoid people with URTI

MENIERE’S DSEMENIERE’S DSE

Chronic Chronic Increase in endolymphatic pressureIncrease in endolymphatic pressure

ASSESSMENT:ASSESSMENT: TinnitusTinnitus Unilateral hearing lossUnilateral hearing loss Vertigo Vertigo



CONSERVATIVE: palliativeCONSERVATIVE: palliative Bed restBed rest MedsMeds

Sedative :PhenobarbitalSedative :Phenobarbital Antihistamine Antihistamine AntiemeticsAntiemetics

Low salt dietLow salt diet



SURGERY- delayed until client’s hearing SURGERY- delayed until client’s hearing below the serviceable levelbelow the serviceable level Destruction of the labyrinthDestruction of the labyrinth Decompression of endolymphatic sacDecompression of endolymphatic sac Sectioning of the vestibular nerveSectioning of the vestibular nerve Cryosurgery of the labyrinthCryosurgery of the labyrinth

HEARING IMPAIRMENTHEARING IMPAIRMENT

TYPES OF HEARING LOSSTYPES OF HEARING LOSS

CONDUCTIVE CONDUCTIVE Damage to the conducting systemDamage to the conducting system Hearing aid is usefulHearing aid is useful

SENSORINEURALSENSORINEURAL Damage to the:Damage to the:1.1. Organ of CortiOrgan of Corti2.2. Cochlear nerveCochlear nerve3.3. Acoustic branch of the auditory nerveAcoustic branch of the auditory nerve

COMMUNICATING WITH COMMUNICATING WITH HEARING-IMPAIRED CLIENTSHEARING-IMPAIRED CLIENTS

Avoid use of gestures without speechAvoid use of gestures without speech Do not shoutDo not shout Speak distinctly & as close to the clientSpeak distinctly & as close to the client Use short phrasesUse short phrases Do not communicate with someone else in front of a Do not communicate with someone else in front of a

hearing-impaired clienthearing-impaired client Hearing impairment goes with visual problems in Hearing impairment goes with visual problems in

elderlyelderly

SOUND AMPLIFICATIONSOUND AMPLIFICATION

TYPES OF HEARING AIDS;TYPES OF HEARING AIDS;

Post-auricularPost-auricular Body-typeBody-type In-the ear modelIn-the ear model

Select hearing aid that has cotrollable volume & is Select hearing aid that has cotrollable volume & is properly fittedproperly fitted

Albus, 62 yo, has a stapedectomy. Which Albus, 62 yo, has a stapedectomy. Which of the following is the most important for of the following is the most important for the nurse to include in the post-op care the nurse to include in the post-op care plan?plan?

a.a. Checking the gag reflexChecking the gag reflex

b.b. Encouraging independenceEncouraging independence

c.c. Instruct not to blow noseInstruct not to blow nose

d.d. Position on the operative sidePosition on the operative side

““that’s that’s allallfolks”folks”

““that’s that’s allallfolks”folks”

n104semi kenafafal;fa

Documents

eye lens

eye shape

entire eye opaque

choroid layer

thecrystalline lens

focus of light rays

pupil pupil

lower eyelids