University of La Salette Santiago City College of Nursing EENT 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 body VITREOUS 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 occurs 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 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 PUPILS - 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 nasally NERVES 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 clients distance & near vision 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 EXTRAOCULAR MUSCLE FUNCTION - tests muscle function of the eyes - tests 6 cardinal positions of gaze 1. Clients right (lateral position) 2. Upward & right (temporal position) 3. Down & right 4. Clients 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 COLOR VISION TEST - Tests for color vision which involve picking nos. or letters out of a complex& colorful picture ISHIHARA 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 RESPONSE FLUORESCEIN ANGIOGRAPHY - detailed imaging & recording of ocular circulation by a series of photographs after administration of the dye 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 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 y PARASYMPATHOLYTIC DRUGS - used pre-op or for eye examinations to produce mydriasis - C/I in clients with glaucoma because of the risk of increased IOP Classification MYDRIATICS - dilate the pupils (mydriasis) CYCLOPLEGIA - relax the ciliary muscles ANTICHOLINERGICS - block responses of the sphincter muscle in the ciliary body, producingmydriasis Example: Atropine sulfate (Isopto-Atropine, Ocu-Tropine, Atropair, Atropisol) Scopolamine hydrobromide (Isopto-Hyoscine) Cyclopentolate hydrochloride (Cyclogyl, AK-Pentolate, Pentolair) Homotropinehydrobromide (IsoptoHomatrine, 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

y y y y y y

PARASYMPATHOMIMETIC 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 humor - used for chronic open-angle glaucoma or acute & chronic closed-angle Glaucoma Example of miotic drugs AcethylcholineCl (Miochol) Carbachol (Miostat) PilocarpineHCl (IsoptoCarpine, Pilocar) Pilocarpine nitrate (Pilofrin, Liquifilm, Pilagan) Echothiophate iodide (Phospholine iodide) Demecarium bromide (Humorsol) Isoflurophate (Floropryl) Nursing Care: y y y y y y

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 BetaxololHCl (Betoptic) CarteololHCl (Ocupress) LevobunololHCl (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 y Instruct to change positions slowly to avoid orthostatic hypotension ADRENERGIC EYE MEDICATIONS y y Decrease the production of aqueous humor & lead to a decrease in IOP -Used to treat glaucoma

ADRENERGIC MEDICATIONS ApraclonidineHCl (Iopidine) Brimonidine tartrate (Alphagen) DipivefrinHCl (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 y Lower IOP y Used in emergency treatment of acute closed-angle glaucoma y 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 blinking EXAMPLES 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 y -Produce corneal anesthesia y Used for anesthesia for eye examinations, surgery, or to remove foreign bodies from the eye EXAMPLES ProparacaineHCl (Ophthaine, Opthenic) TetracaineHCl (Pontocaine) NURSING CARE Note that the medications should not be given to the client for home use & are not to be selfadministered 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 MEDICATIONS EXAMPLES 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 (NatacynOpthalmic) ANTIVIRAL Idoxuridine (Herplex-Liquifilm) Trifluridine (Viroptic) Vidarabine (Vira-A Opthalmic)

DISORDERS OF THE EYE A.

y

LEGALLY BLIND

Anyone with vision worse than 20/200 that cannot be improved with corrective lenses is considered legally blind. y 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. y Legal blindness is very common in older people because eyesight tends to worsen with time and age. y 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 nurses 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 y 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 y The child should practice having the eyes covered to decrease postoperative fear and restlessness y If both eyes are covered or if vision is greatly restricted, the call light should be placed within the reach of the patient y 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 prevent o Increased IOP o Stress on the suture line o Hemmorage into the anterior chmabe (hyphema) o Infection y Immediately after operative, the patiet must keep still the head still and try to avoid coughing, vomiting, sneezing or moving suddently y 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 y A burning sensation about one hour after surgery usually means that the anesthethic is wearing off y 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 open o Cough medicines and antiemetics can be givenb for cough and vomiting, stool softener and laxatives for constipation y To prevent stress on the suturebline, bending forward is avoided o Sudden jerky movement may result in hemorrhage into the hyphema y 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 y 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 y Care is taken that the dressing is not looased or removed o Bleeding and serous fluid should be minimal o Edema of the eyelids subside within 3 to 4 days o The feeling of something in the eye 4 to 5 days post op usually is because of sutures and is normal o 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

y y

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 lens c. 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 injury 3. Congenital; Those associated at birth 4. 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 clients 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 weeks CLIENT 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 y Lens implanted at the time of cataract extraction y Held position either suture to the iris or by implanting it into the capsular sac y Better binocular vision (ability of both eyes to focus on one subject and fuse the two images into one) y 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 AphakicEyeglasses y Safest least expensive method y Very thick lenses magnify object 25%,m making them appear closer than they are actually are y Cataract glasses act as magnifying glasses & replace central vision only y Cataract glasses magnify, & objects appear closer therefore teach client to judge distance & climb stairs carefully

Contact lenses y 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
y 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 y Flows in the anterior and posterior chamber of the eyes, nourishing the cornea and lens y 90% of fluid flows out the anterior chamber, draining through the spongy trabecular meshwork into the canal of schlemn and the episcleral veins y 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 y Outflow of aquenous humor depends on an intact drainage system and an open angle ( 45 degrees) between the iris and the cornea. IOP y Normal- 10-21 mmhg

y When A.H is inhibited from flowing out, the pressure builds up within the eye ( Increase IOP) y Increase IOP----damages the optic nerve---blindness Two theories regarding how IOP damages the optic nerve y Direct mechanicasl theory  High IOP damages the retinal layer as it passess through the optic nerve head y Indirect ischemic theory  High IOP compresses the microcirculation in the optic nerve head, resulting in cell injury and death

STAGES in the development of Glaucoma 1. Initiating events y PF= illness, emotional stress, congenital narrow angles, long term corticosteroid, mydriatics 2. Structural altrertaion in the aquenous outflow system `
y Tissue and cellular changes 3.Functional alterations: :conditions such as increased IOP or impaired blood flow create functional changes 4. Optic nerve damage: atrophy of the optic nerve is characterized by loss of nerve fibers and blood supply 5. 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 condition Acute and chronic refer to the onset and duration of the disorder Open( 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 glaucoma d. Prior loss of vision in one eye from glaucoma e. 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 (trabecularmeshwork). II.Close angle glaucoma y An acute attack can develop only in an eye in which the anterior chamber angle is anatomically narrow. y Attack occurs due to sudden blockage of the anterior angle by the base of the iris. y When Aqueous flow is obstructed >>> IOP becomes markedly elevated >>> severe pain & blurred vision >>> Blindness y 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. y The eye becomes red, the cornea swells and clouds, and the patient may see haloes around lights and experience blurred vision. y IOP= 50-70 mmhg Risk Factors: a. Race. People from East Asia or with East Asian ancestry, as well as Canadian, Alaskan b. 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 y Resembles Primary Open-Angle Glaucoma y The angle is normal, optic nerves are cupped, & show peripheral vision deficits. y IOP is within normal range. y Treatment is indicated to lower the pressure even further, to avoid progressive optic nerve damage and visual field loss. V.Secondary Glaucoma y 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 drainageangle of the eye. y Certain medicines : corticosteroids

y y

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 accurately Angle- 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 GLAUCOMA GOAL:to reduce IOP and keep it at a safe level o o o o o Diet: no caffeine, low sodium Patient is advised to avoid fatigue or stress and to avoid drinking large quantities of fluids Instruct the client the need for life-long medication use Instruct the client to avoid anti-cholinergic medications Instruct the client to report eye pain, halos around eyes & changes of vision to the physician

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 therapy Topical Miotics Pilocarpine hydrochloride o causes pupillary constriction to open canal of schlemm o constricts pupil & increase outflow Topical epinephrine also increase outflow Topical beta-blockers or alpha-adrenergics Timolol Maleate o Decreases production of aqueous humor Oral 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 meshwrokto allow drainage of aqueous humor into the conjuctival spaces Sclerotomy- 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 formation Ways 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-metabolites Cyclodestructive Procedure- destroying part of ciliaryby 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 mioticseyedroips 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 pigment Ep the patient Diagnostic Tests: Ophthalmoscopy o used to evaluate the extent and source of detachment. o Areas of detachment appearsbluish gray. Immediate nursing care: to prevent further detachment y Provide bedrest y Cover both eyes with patches to prevent further detachment y Speak to the client before approaching y The head is positioned so that the retinal hole is in the lowest part of the eye ( dependent position) y Protect the client from injury y Avoid jerky head movements y Minimize eye stress y 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 adhesions Laser therapy  To stimulate an inflammatriy response to seal small retinal tears before detachment occurs Sceral 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).

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y y y y y

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.
y y

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. y All diabetics are prone to develop retinopathy. y 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. Chemical Clinical manifestation: o Hyperemia redness o Tearing & exudation o Psuedoptosis drooping of the upper lid o 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 compress Antibiotics Incision & drainage as indicated. Chalazion  Is a sterile chronic granulomatous inflammation of a meibomiangland.  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 days NURSING CARE Encourage rest in semi-Fowlers 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 occur NURSING 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 y Wash hands thoroughly before touching the eye Have the client look upward, expose the lower lid, wet a cottontipped 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 y If foreign body is lodged into the cornea, do not attempt to remove it, see a physician y Avoid pressure on the eye, do not touch , do not rub the eye y Use sterile technique, when treating the eyes CHEMICAL BURNS - an eye injury in which a caustic substance enters the eye NURSING 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 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 Dont allow the client to bend Dont 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)

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 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 y Pain y Phaotophobia y Lacrimation y Blepharospasm y Decreased vision Treatment y Trifuridine ( Viroptic), Idoxuridine (IDU) y Mechanical/chemical debridement Corneal Ulceration-medical emergency y May result to corneal perforation, scarring or intraocular infection, permanent impairment of vision Causes y Trauma y Exposure y Allergy y Vit deficiency y Lowered resistance y Bacterial, viral, fungal infection Corneal Opacity- lack of corneal transparency dur to inflammation, ulceration or injury Corneal Transplantation ( keratoplasty) y To repair corneal opacity, perforation of corneal ulcer y Donor eyes for corneal transplantations come from cadavers y 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 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 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 Dont remove or change the dressing without the MDs 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