Abbygail B.

Roderos THE VISUAL PATHWAY

Medical Surgical Nursing - Stimulation of the photoreceptors to bipolar cells to ganglion cells
- Axons in optic tracts travel to thalamus, synapse with neurons (optic
TOPIC: Perceptual Disturbances (EENT Conditions) (Part 1) radiation)
- Visual fields overlap considerably (slightly different view in each eye)
ANATOMY, PHYSIOLOGY AND FUNCTIONS OF THE EYES
REFRACTION
- Contain 70% of body’s sensory receptors
- Primary functions - Bending of light rays as they pass from one medium to another medium
o Encode patterns of lights - Accommodation- Focusing of image on a single point
o Carry coded information to brain - Convergence- Medial rotation of eyeballs that allows focusing of the image
on retinal fovea of each eye
ACCESSORY STRUCTURES OF THE EYE
SUBJECTIVE DATA COLLECTION FOR THE EYE
- Eyebrows, Eyelids, Eyelashes
- Conjunctiva Category Questions to ask Rationale/Significance
- Lacrimal Apparatus during the health
- Extrinsic eye muscles history
Family History Do you have family Many eye disorders are
Eyebrow- Perhaps the most significant role of the eyebrows is to enhance facial members with a history genetically transmitted
expression, aiding in non-verbal communication. They also help keep of diabetes?
perspiration out of the eye and shields the eye from glare Hypertension?
Cataracts? Glaucoma?
Eyelids- Formed primarily by the orbicularis oculi muscle covered with skin, the Blindness? Diabetes
eyelids protect the eye from foreign bodies and block light when closed to allow mellitus?
for sleeping. Periodic blinking also helps moisten the eyes with tears and warm
out debris. Do any family
members wear glasses
Palpebral Fissure: This is the opening between the lids or contact lenses? Is
their vision corrected
Tarsal Glands- These glands which lie along the thickened area at the edge of with the lens?
the eye secretes oil to slow the evaporation of tears and help form a barrier seal Patient’s general How could you Some metabolic
when the eyes are closed health describe your general disorders are precursor
health? to eye disorders, such
Conjunctiva: Is a transparent mucous membrane that lines the inner surface of What health problems as diabetes and
the eyelid and covers the anterior surface of the eyeball (except for the cornea). do you currently have? hypertension.
It secretes a thin mucous film to help keep the eyeball moist. It is very vascular How are they treated? Assess for ocular
which becomes apparent when eyes are “bloodshot” a result of dilated vessels in What health problems effects of systems
the conjunctiva have you had in the medication.
past? Assess preventive
Eyelashes- These hairs along the edges of the eyelids help keep debris out of Have you ever had practices.
the eye. Touching the eyelashes stimulates the blink reflex. trauma to your eyes?
What medications do
Lacrimal Gland- This small gland secretes tears that flow onto the surface of the you take?
conjunctiva. Tears clean and moisten the eye’s surface and also deliver oxygen How often do you have
and nutrients to the conjunctiva. Furthermore, tears contain a bacterial enzyme eye examinations?
called lysozyme that helps prevent infection. When was the last time
you had an eye
Lacrimal Punctum: This is a tiny pore through which tears drain into the lacrimal examination?
canal and the nasolacrimal duct
Visual acuity Do you wear glasses or Any of these signs and
Nasolacrimal Duct- This passageway carries tears into the nasal cavity (which contact lenses? symptoms could
explains why crying or watery eyes can cause a runny nose. Have you had any indicate visual
changes in vison such disorders/disturbances
 Vitreous Humor- the vitreous humor is the transparent gel that gives the as difficulty seeing
eye its shape distances, difficulty
 Ciliary Body- The ciliary body makes the fluid inside the eye. It also enables seeing close up,
the lens of the eye to focus on objects at various distances. difficulty seeing at
 Lens- The lens is clear part that receives the light that enters they eye. It night?
then bounces off this light to the back of the eye. Do you see things
 Iris- The iris is the colored part in front of the eye. It helps screen and double?
Do you have clouded
control the amount of light that enters the eye.
vision?
 Cornea- The cornea is the transparent film-like part that enables the eye to
Do you see halos
focus to images so they do not look blurred around lights?
 Sclera- It is the white part of the eye. It is made of tough material that Does it look like you
protects the inside of the eye. are looking through a
 Choroid- It is the middle layer of the wall of the eye. It is filled with blood veil or web?
vessels that bring oxygen and nutrients to the eye. Is there sensitivity to
 Retina- It receives the light from the lens. It is made up of rods and cones. light?
The rods let the eye sense light while this cone helps identify color. Is there pain? Itching?
 Blood Vessels- Carry blood to and from the eye. They transport oxygen and Tearing? Burning?
nutrients to the eye. Do you have
 Optic nerve- Transmits electrical impulses or nerve messages from the eye headaches? If so, what
to the brain. are the precipitating
events?
 THE PHYSICAL ASSESSMENT OF THE EYES - Abnormal eye movements
- Watering or irritation
- Visual field, acuity testing - Changes in vision
- Vision assessment
o Snellen chart AGE RELATED CHANGES IN THE EYE
o E chart
- Inability to accommodate
o Rosenbaum chart
- Cataract development
o Confrontation chart
- Alteration in color perception
- Eye movement assessment
o Cardinal fields, corneal light reflex ASSESSING THE EYES
o Assess convergence
- Diagnostic tests
OBJECTIVE DATA COLLECTION FOR THE EYE o CT, MRI
o Fluorescein, angiography
CATEGORY PHYSICAL POSSIBLE o Refraction, retinoscopy, refractometry
EXAMINATION ABNORMAL
FINDINGS FINDINGS/CAUSES o Tonometry
Visual Acuity Normal vision is 20/20 Hyperopia, myopia, o Ultrasonography
presbyopia, blurred or
cloudy vision DIAGNOSTIC TEST FOR THE EYES
Possible causes:
refractive error, opacity 1. Eye culture
or disorder of pathway 2. Digital imaging
Visual Fields Full peripheral fields Peripheral field loss 3. Optical coherence tomography (OCT)
Muscle Balance and Movement in all six Nystagmus 4. Fluorescein or indocyanine green angiography
Eye movement cardinal fields of gaze Inability to move to all 5. Electroretinography
Corneal light reflex test six fields can indicate 6. Ultrasonography
(light is at the same cranial nerve 7. Imaging Test:
place on both pupils) impairment a. X-ray
Cover test steady gaze Asymmetry could mean b. CT-Scan
muscle weakness
Drifting eye indicates THERAPEUTIC MEASURES FOR THE EYE AND VISION
muscle weakness
Pupillary reflexes Pupillary light reflex Dilated, fixed or 1. Regular eye examination
accommodation constricted pupils - Eye care providers include the ophthalmologist and optometrist (optician)
Absence of constriction 2. Eye Hygiene
or convergence 3. Nutrition for the Eyes
External structures Inspection and Ptosis (drooping of - Eye disorders related to inadequate vitamin intake include corneal damage
palpation of eyebrows, eyelid) usually and night blindness form lack of Vitamin A and optic neuritis as a result of
orbital area, eyelids, indicates nerve vitamin B deficiency
palpebral fissure, dysfunction 4. Eye safety and prevention of Injury
medial canthus, irises, Opaque whitening of
- Many of these injuries could be prevented with education and
corneal clarity, anterior outer rim of cornea can
implementation of safety measures
chamber indicate arcus senilus
Corneal opaqueness EYE SAFETY AND INJURY PREVENTION
can be from cataract or
trauma
TO PROTECT FORM Use these eye safety measures
Foreign objects Water safety goggles
Avoid mowing over rocks or sticks
MUSCLE BALANCE AND EYE MOVEMENT Always wear safety goggles when
using lawn edging yard devices
- Confrontation Chemical splashes Use splash shields when working
- Corneal light reflex with chemicals such as cleaning
solution or body fluids
- Cover test
Close eyes to avoid getting haor
o Normal spray in them
o Esotropia- eyes pointing inward Corneal lens abrasions/infections Follow manufacturers or eye care
o Exotropia- eyes deviates outward from contact lenses professional directions for length of
o Hypotropia- downward turn of the eye use and cleaning procedure
o Hypertropia- upward turn of the eye Do not overwear lenses
Ultraviolet light Wear ultraviolet protected
Pupillary assessment External Eye Internal eye sunglasses when outdoors
Assessment assessment Instruct patients to wear sunglasses
- Size, shape, - Eyelids, puncta, - Ophthalmoscope, with side shields after administration
equality with light conjunctivas, red reflex, lens of mydriatics
- Accommodation sclera, assess and vitreous body Wear a hat to shield sun
corneal sensitivity Visual deficits in adult with corrective Update prescription of glasses yearly
lenses Glasses should fit properly, be calm,
and be free of scratches
HEALTH ASSESSMENT INTERVIEW Eye strain from computer usage The position of the bottom of the
monitor should be 20 degrees below
Analyze issue the line of sight and should be
positioned 13 to 18 inches from the
Observe for: eyes
The light in the room should prevent
- Squinting glare
 Increase the font size on the screen
if letters appear to small
If dry eyes are a problem while using
a computer, adjust the monitor to a
lower level so the eyes do not have
open as wide, which increases
evaporation
Eye injury from sports Wear protective eyewear with
polycarbonate lenses
Wear facemasks or helmets while
participating in ant high contact or
high impact sports
NURSING CARE OF THE PATIENTS WITH EYE DISORDERS
EYE DISORDERS
Complementary therapies
- Frequent eye irrigations
- Soaking lids with warm saline compress prior to cleansing
Nursing Care
- Education
- Preventing spread
- Diagnoses, outcomes, and interventions
o Risk for infection
o Risk for impaired vision
- Continuity of care
o Teach home care, typically managed in community
o Avoid activities like excessive reading
ALTERATIONS IN REFRACTION

- Range from minor to causing permanent impairment  Hyperopia- farsightedness

- Disorders of the cornea - Light rays are focused behind the retina when a person is looking at a near
o Greater risk of visual impairment than other outer eye disorders object
 Myopia- Nearsightedness
1. THE PATIENT WITH CONJUNCTIVITIS - Occurs if the eyeball is too long or the cornea is too curved
- Inflammation of conjunctiva - Light ray is focused in front of the retina when the person is looking at a
- Transmission by direct contact distant object
 Astigmatism
 ACUTE CONJUNCTIVITIS - Unequal curvature of the cornea. Light rays are bent unevenly and do not
- Bacterial, viral or fungal come to a single focus on the retina, may co-exists with myopia, hyperopia,
- Adenovirus infection or presbyopia.
- Gonococcal conjunctivitis can lead to corneal perforation
2. THE PATIENT WITH A CORNEAL DISORDER
PATHOPHYSIOLOGY AND MANIFESTATIONS OF CONJUNCTIVITIS 1. Keratitis
Manifestations 2. Corneal ulcer
3. Corneal dystrophies
- Redness/Itching
- Photophobia Interprofessional Care
- Tearing - Diagnosis
- Discharge o Visual acuity
- Systemic
o Fluorescein stain
o Pharyngitis
o Conjunctival/ulcer scrapings
o Fever
o Blood counts
o Malaise
o Antibody titers
o Swollen pre-auricular lymph nodes
Medications
 TRACHOMA
- Chronic conjunctivitis - Antibiotic or antiviral therapy
- Caused by Chlamydia Trachomatis - Topical anti-infectives
- Significant preventable cause of blindness worldwide o Erythromycin
o Gentamicin
Manifestations o Penicillin
- Redness o Bacitracin
- Eyelid Edema o Sulfacetamide Sodium
- Tearing o Amphotericin B
- Photophobia o Idoxuridine
- Entropion - Corticosteroids
- Ulceration and scarring
- Opacity and blindness Corrective lenses

Interprofessional Care - Eyeglasses

- Contact lenses
- Diagnosis
o Culture and Sensitivity Surgery
o Fluorescein stain - Laser eye surgery
o Conjunctival scrapings o Corrects refractive errors
o Blood counts - Types of laser surgery
o Antibody titers o LASIK
o PRK
Medications
o LASEK
- Antibiotic, antiviral, or anti-inflammatory drugs o LTK
- Anti-infectives - Corneal Transplant
- Administered topically, by subconjunctival injection, or intravenous infusion o Replacement of diseases cornea by healthy corneal tissue from a
- Antihistamines donor
 o Lamellar or penetrating Burns

Nursing care - Chemical

- Heat
- Prevention - Radiation
- Education - Explosion
- Diagnoses, Outcomes, and interventions
o Risk for impaired vision Manifestations
o Acute pain
- Eye pain
o Risk for injury
- Decreased vision
- Continuity of care
- Swollen eyelids
o Eye cleaning, eye patch, excessive reading
- Reddened edematous conjunctiva
o Signs of graft rejection - Possible sloughing
o Avoid increasing intraocular pressure - Cloudy, hazy or ulcerated corneas
o Resources
 National eye institute Penetrating Trauma
 Lighthouse
- Layers of the eye spontaneously reapproximate
- Damage might not be apparent
4. THE PATIENT WITH A DISORDER AFFECTING THE EYELIDS
- Underling eye tissue should be inspected.
Pathophysiology and manifestations
Perforating injury
- Marginal blepharitis is the most common.
- Layers do not spontaneously reapproximate
o Inflammation of the glands and lash follicles on margins of eyelids
- Rupture of glare, potential loss of ocular contents
o Staphylococcal infection or seborrheic in origin
- Seborrheic blepharitis Blunt trauma (punch)
o Red-rimmed, mucous discharge, crusting
o Loss of lashes - Lid ecchymosis
- Subconjunctival hemorrhage
- Hordeolum
o Erythema under conjunctiva
o Staphylococcal abscess
o No pain or discomfort
o External or internal margin of lid
- Orbital flow fracture
- Chalazion
o Usually at ethmoid bone on orbital floor
o Granulomatous cyst or nodule of the lid
o Herniate into underlying maxillary sinus
o Painless
- Hyphemia
o Result of chronic inflammation of meibomian gland
o Seeing reddish tint
- Entropion
o Inversion of the lid margin Interprofessional Care
o Normal aging process
- Ectropion - Diagnosis
o Eversion of lid margin o Fluorescein stain
o Primarily the result of aging o Ophthalmoscopic examination
o Facial X-rays
Interprofessional Care o CT scans
o Ultrasonography
- Typically managed in community
- Excision and drainage - Medications
- Surgery to correct entropion or ectropion o Narcotic analgesics
- Topical antibiotics o Topical anesthetic
o Hordeolum o Antibiotic ointment
o Infection from lid deformity o Sedations, antiemetic medications
- Education  Surgical intervention is usually required to treat penetrating
o Risk of using old make-up wounds
o New cotton for each eye - Interventions for blunt trauma
- Comfort o Bed rest in semi fowler position
o Carbonic anhydrase inhibitor
5. THE PATIENT WITH EYE TRAUMA - Health promotion
- Foreign bodies o Prevention
- Abrasions o First aid
- Lacerations - Diagnoses, outcomes and interventions
- Burns o Impaired tissue integrity: Ocular
- Penetrating objects
- Blunt force CLASSIFICATION OF UVEITIS
- Corneal Abrasion
- Anterior, intermediate, posterior and panuveitis
o Disruption of superficial epithelium of the cornea
o Superficial abrasions 6. THE PATIENT WITH UVEITIS
 Extremely painful, but heal rapidly
- Inflammation of middle vascular layer of the eye
o Deeper abrasions
 Higher risk of infection Iritis
 Slowed healing
 Scar formation - Inflammation of the iris only

Pathophysiology and Manifestations Panuveitis

- Refers to inflammation of all parts of the uvea of the eye, which includes the - Painless, gradual loss of visual fields
iris, ciliary body, and choroid. These makes up the middle layer of the eye. - Elevated IOP

Manifestations - Angle-Closure glaucoma

o Corneal flattening or bulging of the iris leading to narrowing of anterior
- Pupillary constriction
- Erythema around the limbus chamber angle
- Photophobia o Closure of angle leading to blocked outflow of aqueous humor
- Blurred vision o Rapid, permanent loss of vision
- Severe eye pain

7. THE PATIENT WITH CATARACTS Manifestations

- opacification of the lens
- Interference with light transmission to retina - Severe eye and face pain
- General malaise, nausea, vomiting
Incidence and risk factors - Colored halos around lights
- Abrupt decrease in visual acuity
- Half of the population over age 80 is affected - Reddened conjunctiva
o Age - Corneal edema
o Genetics - Pupil fixed at midpoint
o Sun exposure
o Smoking A COMPARISON OF OPEN ANGLE AN ANGLE-CLOSURE GLAUCOMA
o Alcohol
Medications
o Eye trauma
o Diabetes mellitus - Open angle
o Beta-blockers, adrenergic, prostaglandins analogs
Pathophysiology
o Carbonic anhydrase inhibitors
- Lens fibers and proteins degenerate with age - Angle—closure glaucoma
- Clouding caused by clumps of proteins o Topical miotics or beta blockers
o Systemic osmotic agents, carbonic anhydrase inhibitors
Manifestations
Surgery
- Cloudy pupil
- Loss of visual acuity - Open angle
- Bilateral o Laser trabeculoplasty, trabeculectomy
- Glare, color discrimination (blue, purple) - Angle-closure
o Genioplasty
Interprofessional Care
o Laser iridotomy
Surgery o Peripheral iridectomy

- Surgical removal of cataract and lens Nursing care

o When vision and activities of daily living are affected
- Continuity of care
o When cataract causes a secondary condition
o Drug interaction with prescribed and over the counter medications
- Extracapsular extraction
o Regular eye exams
o Removes anterior capsule, nucleus and cortex of the lens
o Acute angle closure glaucoma warning signs
o Leaves posterior capsule intact
o Community resources
- Intraocular lens implant
o Following extracapsular extraction ACUTE ANGLE-CLOSURE GLAUCOMA
o Polymethylmethacrylate or silicone
- Opacification of remaining posterior capsule - Mydriatic medications are contraindicated in AACG
- Continuity of care - Miotic medications constrict the pupil and so may be given to patients with
o Aftercare for surgery AACG
o Manifestations of postoperative complications - D = Dilate = mydriatic = do not give
- Anticipated vision changes - No D = Constricts = miotic = okay to give

8. THE PATIENT WITH GLAUCOMA 9. THE PATIENT WITH AGE RELATED MACULAARR DEGENERATION
- Optic neuropathy - Cause unknown, but associated with:
- Gradual loss of peripheral vison o Aging
- Increased intraocular pressure o Smoking
- Incidence and risk factors o Race
o Affects 2.7 million people over age 40 in the US o Genetic factors
o Leading cause of blindness worldwide
Pathophysiology
o Age
o Race - Non-exudative macular degeneration
o Gradual detachment of pigment
Pathophysiology
o Epithelium in small areas
- Open-Angle Glaucoma o Caused by accumulation of drusen
o Normal anterior chamber angle between iris and cornea o Sensory function of the macula impaired
o Outflow of aqueous humor relatively obstructed o Can progress to exudative stage

Manifestations: Manifestations
- Blurred/distorted central vision (unilateral) - Risk factors
- Intact peripheral vision o Aging
o Myopia
Interprofessional care
o Aphakia
- Diagnosis
Interprofessional care
o Vision and retinal examination
o Amsler grid - Inflammation treatments
o Fluorescein angiogram o Cryotherapy, cryopexy
- Treatments o Super-cooled probe
o High dose antioxidants o Laser photocoagulation
o Zinc - Pneumatic retinopexy
o Photodynamic therapy - Scleral buckling
- Laser surgery
- Photodynamic therapy Nursing care
- Prompt recognition
- Priorities of care
- Rapid referral for ophthalmologic evaluation
o Early identification and treatment
- Slowly progressive AMD
- Diagnoses, outcome and evaluations
o Heling patient, family adapt
o Ineffective tissue perfusion: retinal
o Anxiety
10. THE PATIENT WITH DIABETIC RETINOPATHY
- Continuity of care
o Limitations before or following repair
- Capillaries of the retina become sclerotic
o Activity restrictions, eye shield
- Insufficient oxygen and nutrients transported to retina
o Early manifestations
Pathophysiology and manifestations
12. THE PATIENT WITH RETINITIS PIGMENTOSA
 Background retinopathy- - Retinal atrophy and loss of function
- Earliest stage, in which microaneurysms form on the retinal capillary walls - Progresses from periphery to central region
o These microaneurysms may leak blood into the central retina or - Inherited
macula - Can be associated with other genetic defects
o If the leakage causes edema, the patient my notice a decrease in color - No effective treatment
discrimination and visual acuity - Manifestations
o Difficulty with night vision
 Non-proliferative retinopathy  Often noted during childhood
- Retinal edema or small hemorrhage o Slow loss of visual fields
- Few symptoms might occur o Photophobia
o Disrupted color vision
 Proliferative retinopathy
o Tunnel vision
- Large areas of retinal ischemia
o Blindness
- Neovascularization- prone to rupture
- Retinal edema, hemorrhage into the vitreous body Nursing care
- Increased risk for retinal detachment
- Providing information
Interprofessional care - Referral for genetic counselling
- Yearly ophthalmologist exams
- Blood glucose levels and blood pressure 13. THE PATIENT WITH AN ENUCLEATION
- Laser photocoagulation - Surgical removal of an eye
o Ranibizumab (lucentis) improves laser treatment for patients with - Necessitated by trauma, infection, glaucoma, intractable pain, or
macular edema malignancy
- Education - Complications
o Regular exams o Hemorrhage
o Report changes quickly o Infection
o Incurable, slowed with aggressive self-management
Enucleation:

11. THE PATIENT WITH A RETINAL DETACHMENT - The entire eye, including the globes, is removed but the orbital contents are
- Separation of the retina from the choroid left in place.
- Causes of detachment - Globe is removed
o Trauma - Conjunctiva and eye muscles are sutured to a round implant
o Shrinkage of vitreous humor - A prosthesis is fittedNursing care
o A break or tear in the retina - Teaching
- Psychologic support
Pathophysiology and manifestations - Observation for complications

- Detached area
o Can rapidly increase in size
o Can cause permanent vision loss unless contact is reestablished
- Manifestations
o Floaters
o Lines of flashes of light
o Curtain sensation
o No pain; eye appears normal