Alteration in

Sensory
Perception
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Eye and
Vision
Disorders
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Overview of Anatomy & Physiology of
the Eye
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Assessment
▪ Snellen chart or E Chart for
testing visual acuity
▪ 20 ft.

▪ Cardinal fields

▪ Test extraocular
movement
▪ Cover-uncover test

▪ Test for strabismus

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Diagnostic
Evaluation
▪ Direct Ophthalmoscopy
▪ Slit lamp
▪ Color Vision Testing
▪ Ishihara Polychromic Plates

▪ Amsler Grid
▪ To detect Macular
degeneration
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Refractive Errors

▪ Refractive errors – Can be corrected by lenses which focus light rays on

the retina•
▪ Emmetropia: normal vision•
▪ Myopia: nearsighted•
▪ Hyperopia: farsighted•
▪ Astigmatism: distortion due to irregularity of the cornea
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Refractive Errors
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LASIK Procedure
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Aqueous Humor
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Glaucoma
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Manifestation

▪ Glaucoma is often called the “silent thief of sight” because

most patients are unaware that they have the disease until
they have experienced visual changes and vision loss.
▪ The patient may not seek health care until he or she
experiences blurred vision or “halos” around lights, difficulty
focusing, difficulty adjusting eyes in low lighting, loss of
peripheral vision, aching or discomfort around the eyes, and
headache.
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Diagnostics

▪ Tonometry to measure the IOP,

▪ Ophthalmoscopy to inspect the optic nerve,

▪ gonioscopy to examine the filtration angle of the

anterior chamber
▪ Perimetry to assess the visual fields.
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Surgical Management
▪ laser trabeculoplasty for glaucoma, laser burns are applied to the inner
surface of the trabecular meshwork to open Schlemm, thereby promoting
outflow of aqueous humor and decreasing IOP.
▪ In laser iridotomy for pupillary block glaucoma, an opening is made in the iris
to eliminate the pupillary block. Laser iridotomy is contraindicated in patients
with corneal edema, which interferes with laser targeting and strength.
▪ Filtering procedures for chronic glaucoma are used to create an opening or
fistula in the trabecular meshwork to drain aqueous humor from the anterior
chamber to the subconjunctival space into a bleb (fluid collection on the
outside of the eye), thereby bypassing the usual drainage structures. This
allows the aqueous humor to flow and exit by different routes (ie, absorption
by the conjunctival vessels or mixing with tears).
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Cataract
▪ A cataract is a lens opacity or
cloudiness.

▪ Cataracts rank behind only arthritis

and heart disease as a leading
cause of disability in older adults.
Cataracts affect nearly 20.5 million
Americans who are 40 years of age
or older, or about one in six people
in this age range.

▪ By 80 years of age, more than half

of all Americans have cataracts.

▪ According to the World Health

Organization, cataract is the leading
cause of blindness in the world
(Prevent Blindness America, 2008).
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Causes
▪ Cigarette smoking,
▪ long-term use of corticosteroids, especially at high doses,
▪ sunlight and ionizing radiation,
▪ diabetes,
▪ obesity,
▪ eye injuries can increase the risk of cataracts.
▪ Recent studies have linked cataract risk to lower income and educational
level,
▪ smoking for 35 or more pack-years, and high triglyceride levels in men (Klein,
Klein, Lee, et al., 2003).
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Manifestation

▪ Painless, blurry vision is characteristic of cataracts. The person

perceives that surroundings are dimmer, as if his or her glasses
need cleaning.
▪ Light scattering is common, and the person experiences reduced
contrast sensitivity, sensitivity to glare, and reduced visual acuity.
▪ Myopic shift (return of ability to do close work [eg, reading fine
print] without eyeglasses),
▪ Astigmatism,

▪ Diplopia (double vision),

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Management

▪ Results from the Age-Related Eye Disease Study Research Group

(2001b), a randomized, placebo-controlled trial, found no benefit
from antioxidant supplements, vitamins C and E, beta-carotene, and
selenium.
▪ Results of studies that have attempted to determine the possible
benefit of a once-a-day multivitamin supplement to prevent or delay
the onset of cataracts have been mixed.
▪ In the early stages of cataract development, glasses, contact lenses,
strong bifocals, or magnifying lenses may improve vision.
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Surgical Management
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Retinal Detachment

▪ Retinal detachment
refers to the
separation of the
RPE (Retinal
Pigment Epithelium)
from the sensory
layer.
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Causes
▪ Risk factors
▪ The following factors increase your risk of retinal detachment:
▪ Aging — retinal detachment is more common in people over age 50
▪ Previous retinal detachment in one eye
▪ Family history of retinal detachment
▪ Extreme nearsightedness (myopia)
▪ Previous eye surgery, such as cataract removal
▪ Previous severe eye injury
▪ Previous other eye disease or disorder, including retinoschisis, uveitis or
thinning of the peripheral retina (lattice degeneration)
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Clinical Manifestation

▪ A lot of new gray or

black specks floating in
your field of vision
(floaters)

▪ Flashes of light in one

eye or both eyes

▪ A dark shadow or
“curtain” on the sides
or in the middle of your
field of vision
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Surgical Management: Scleral Buckle

▪ The retinal surgeon

compresses the sclera (often
with a scleral buckle or a
silicone band) to indent the
scleral wall from the outside of
the eye and bring the two
retinal layers in contact with
each other.
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Other Surgical Management

▪ Laser photocoagulation ‰
‰
▪ Cryotherapy
▪ ‰
Pneumatic retinopexy
▪ ‰
Expanding gases
▪ ‰
Air injection ‰
▪ Silicone oil injections ‰
▪ Vitrectomy
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Nursing Management
▪ Initial management of the patient with retinal detachment
includes restriction of physical activity and reduction in eye
movement.
▪ In some cases, bilateral patching can reduce the potential
effect of inertial forces caused by head and eye
movements that could increase the extent of the
detachment.
▪ Following the diagnosis of significant retinal detachment,
immediate referral to a retina specialist should be made
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Macular Degeneration•

▪ Age-related macular degeneration (AMD)

▪ • The most common cause of vision loss in persons older than age 60•
▪ Types – Dry or nonexudative type; most common, 85–90% •
▪ Slow breakdown of the layers of the retinal with the appearance of drusen
– Wet type
▪ • May have abrupt onset
▪ • Proliferation of abnormal blood vessels growing under the retina—
choroidal revascularization (CNV)
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Treatment

▪ No known cure

▪ vitamin C, vitamin E, and betacarotene) and minerals

(zinc oxide) in megadoses- slows progression.
▪ Ranibizumab (Lucentis)- bind and inactivate all
isoforms of VEGF.
▪ Bevacizumab (Avastin)- helpful in the treatment of neovascular AMD
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Nursing Management

▪ Provide Amsler grid

▪ Educate patient and family when to
notify physician.
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Ears & Hearing Disorders
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Overview of ear anatomy
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Assessment
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Otitis Externa Vs.
Otitis Media
▪ • Otitis Externa is an
infection of the external
auditory canal (EAC)
that can be divided
according to the time
course of the infection.
▪ Otitis Media is the
infection of the middle
ear: Common to children
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Causes

▪ • Swimming
▪ • Constriction of the ear canal
from bone growth (Surfer's
ear) • Saturation diver
▪ • the use of objects such as
cotton swabs or other small
objects to clear the ear canal
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Medical
Management

▪ Pain medications

▪ Corticosteroids

▪ Broad spectrum
antibiotics (oral or in
otic solution) Co-
amoxiclav or ofloxacin
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Surgical Management

▪ Tympanoplasty ( OE)- surgical repair

of the tympanic membrane), can be
perform in OPD setting.
▪ Myringotomy (OM)- is a procedure to create
a hole in the ear drum to allow fluid that is
trapped in the middle ear to drain out.
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Otosclerosis

▪ Involves the stapes and is

thought to result from the
formation of new, abnormal
spongy bone, especially
around the oval window,
with resulting fixation of the
stapes
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Manifestation

▪ Otosclerosis may involve one or both ears and manifests as a

progressive conductive or mixed hearing loss. The patient may or may
not complain of tinnitus. Otoscopic examination usually reveals a
normal tympanic membrane.
▪ Bone conduction is better than air conduction on Rinne testing.
▪ The audiogram confirms conductive hearing loss or mixed loss,
especially in the low frequencies.
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Management

▪ Fluoride- helps in bone maturation.

▪ Hearing aid
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Surgical Management

▪ stapedectomy
involves removing
the stapes
superstructure and
part of the footplate
and inserting a tissue
graft and a suitable
prosthesis.
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Meniere’s Disease

▪ Ménière’s disease is an
abnormal inner ear fluid
balance caused by a
malabsorption in the
endolymphatic sac or a
blockage in the
endolymphatic duct.
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Clinical Manifestation

▪ Symptoms of Ménière’s disease include

fluctuating, progressive sensorineural hearing loss;
▪ Tinnitus or a roaring sound;

▪ A feeling of pressure or fullness in the ear;

▪ Incapacitating vertigo,

▪ Often accompanied by nausea and vomiting.

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Management

▪ Pharmacologic therapy for Ménière’s disease consists of antihistamines, such

as meclizine (Antivert), which suppress the vestibular system.
▪ Tranquilizers such as diazepam (Valium) may be used in acute instances to
help control vertigo.
▪ Antiemetic agents such as promethazine (Phenergan) suppositories help
control the nausea and vomiting and the vertigo because of their
antihistamine effect.
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Management

▪ Diuretic therapy (eg, hydrochlorothiazide [Dyazide], triamterene

[Dyrenium]) may relieve symptoms by lowering the pressure in
the endolymphatic system.
▪ Intake of foods containing potassium (eg, bananas, tomatoes,
oranges) is necessary if the patient takes a diuretic that causes
potassium loss.
▪ There is no scientific basis for the use of vasodilators, such as
papaverine hydrochloride (Pavabid) to alleviate the symptoms,
but they are often used in conjunction with other therapies, such
as methantheline bromide (Banthine).
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Surgical Management

▪ Endolymphatic Sac Decompression

▪ Endolymphatic sac decompression, or shunting, theoretically equalizes the
pressure in the endolymphatic space. A shunt or drain is inserted in the
endolymphatic sac through a postauricular incision. This procedure is
favored by many otolaryngologists as a first-line surgical approach to treat
the vertigo of Ménière’s disease because it is relatively simple and safe
and can be performed on an outpatient basis.
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Surgical Management

▪ Vestibular Nerve Sectioning

▪ Vestibular nerve sectioning provides the greatest success rate
(approximately 98%) in eliminating the attacks of vertigo. It can be
performed by a translabyrinthine approach (ie, through the hearing
mechanism) or in a manner that can conserve hearing (ie,
suboccipital or middle cranial fossa), depending on the degree of
hearing loss. Most patients with incapacitating Ménière’s disease
have little or no effective hearing. Cutting the nerve prevents the
brain from receiving input from the semicircular canals. This
procedure may require a brief hospital stay. A plan of nursingcare
for the patient with vertigo is presented in Chart.
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