CHAPTER 58 - middle vascular layer (iris, ciliary body, and
choroid)
ASSESSMENT AND MANAGEMENT OF
PATIENTS WITH EYE AND VISION DISORDERS
EXTERNAL EYE
EYEBALL – situated in the bony protective orbit.
EXTRAOCULAR MUSCLES
- responsible for the eyeball movement through
all fields of gaze
- four rectus muscles and two oblique muscles
- innervated by cranial nerves (CNs) III, IV, and
VI
EYELIDS
- composed of thin, elastic skin
- protects the anterior portion of the eye
- contains multiple glands (sebaceous, sweat,
and lacrimal)
Upper Eyelid
- covers the uppermost portion of the iris
- innervated by the oculomotor nerve (CN III)
- lid margins contain: the eyelashes
- triangular spaces formed by the junction of the
eyelids
a) are known as the inner or medial canthus,
and
b) the outer or lateral canthus
TEARS
- vital to eye health; formed by the lacrimal
gland
- tears are secreted in response to reflex or
emotional stimuli
- healthy tear is composed of three layers:
o lipoid, aqueous, and mucoid
CONJUNCTIVA
- a thin transparent mucous membrane
- provides a barrier to the external environment
extending under the eyelids (palpebral
conjunctiva) and over the sclera (bulbar
conjunctiva).
- the junction of the two portions is known as the
fornix.
INTERNAL EYE
EYEBALL (THREE LAYERS)
- outer dense fibrous layer (sclera and
transparent cornea)
- inner neural layer (retina, optic nerve, and
visual pathway)
EYEBALL (TWO SEGMENTS)
ANTERIOR SEGMENT
- located between the anterior cornea and
posterior iris
- including the anterior and posterior chambers
POSTERIOR SEGMENT
- located between the posterior lens and the
retina
- including the vitreous chamber
EYEBALL (THREE FLUID-CONTAINING
CHAMBERS)
AQUEOUS-FILLED ANTERIOR CHAMBER
- lies between the posterior cornea and the
anterior iris and pupil.
POSTERIOR CHAMBER
- a small aqueous-containing space between the
posterior iris and pupil and anterior lens.
VITREOUS CHAMBER
- contains a clear gelatinous vitreous fluid
- the largest chamber in the ocular fundus
between the lens and retina
AQUEOUS HUMOR
- transparent nutrient-containing fluid that fills the
anterior & posterior chambers of the eye
- produced in the posterior chamber by the
ciliary body.
- Normal IOP is less than 21 mmHg.
VITREOUS HUMOR
- composed mostly of water and encapsulated
by a hyaloid membrane
- helps maintain the shape of the eye.
- the vitreous shrinks and shifts with age.
FLOW OF THE AQUEOUS HUMOR
SCLERA
- white avascular dense fibrous structure
- helps maintain the shape of the eyeball
- protects the intraocular contents
EPISCLERA
- a vascularized loose elastic tissue that overlies
the sclera
- supplying nutritional support and reacting to
inflammation
CORNEA
- a vulnerable transparent avascular domelike
structure
- forms the most anterior portion of the eyeball
- the main refracting surface of the eye
UVEAL TRACT
- the vascular middle layer of the eye
- consisting of the iris, ciliary body, and the
choroid.
IRIS
- surrounds the pupil
- a highly vascularized pigmented collection of
fibers – that gives the eye color.
CILIARY BODY
- works together to form aqueous fluid.
- the choroid lies between the retina and the
sclera, supplying blood and oxygen to the outer
retina.
LENS
- enables focusing for near and distance vision
through accommodation.
RETINA
- the innermost surface of the fundus composed
of neural tissue
- is an extension of the optic nerve
- viewed through the pupil
LANDMARKS of the retina are the:
o Optic disc (point of entrance of the optic
nerve into the retina)
o Retinal vessels
o Macula
TWO LAYERS:
RETINAL PIGMENT EPITHELIUM
- single layer of cells constitutes the retinal
pigment epithelium.
- these cells have numerous functions –
absorption of light.
SENSORY RETINA
- contains the photoreceptor cells: rods and
cones.
- Rods: night or low light vision; absent in fovea
- Cones: visual acuity, color discrimination, and
fine detail; distributed throughout the retina,
with their greatest concentration in the fovea
OPTIC NERVE (CN II)
- transmits impulses from the retina to the
occipital lobe of the brain.
OPTIC NERVE HEAD (OPTIC DISC)
- is the physiologic blind spot in each eye.
ASSESSMENT OF THE EYE
Subjective Data
- Presenting symptoms (pain, foreign body,
photophobia)
- Ocular history (use glasses or contact lenses)
- Obtain medication history
- Determine history of systemic conditions
(diabetes)
- Obtain family history of ocular conditions
(glaucoma, cataracts, macular degeneration,
color blindness)
Visual Acuity
- Visual Acuity at Distance (Snellen Chart)
- Visual Acuity at Near (Rosenbaum pocket
screener)
Common abbreviations r/t vision and eye health
are derived from Latin:
- OD (oculus dexter, right eye)
- OS (oculus sinister, left eye)
- OU (oculus uterque, both eyes)
External Eye Examination
OBSERVE FOR:
- PTOSIS (drooping of the eyelid)
- ECTROPION (turning out of the lower eyelid)
- ENTROPION (turning in of the lower eyelid)
o may involve TRICHIASIS (turning in of
the eyelashes)
- NYSTAGMUS (involuntary oscillating
movement of the eyeball)
Diagnostic Evaluation
DIRECT OPHTHALMOSCOPY
- uses a strong light reflected into the interior of
the eye through an instrument called an
ophthalmoscope.
INDIRECT OPHTHALMOSCOPY
- allows the examiner to obtain a stereoscopic
view of the retina.
- light source is from a head- mounted light.
SLIT-LAMP EXAMINATION
- special equipment that magnifies the:
o cornea, sclera, and anterior chamber
- provides oblique views into the trabeculum
- done by the ophthalmologist
TONOMETRY
- a common procedure to measure IOP
- device used for measuring IOP (tonometer) 1. MYOPIA OR NEARSIGHTEDNESS
Nursing Interventions - light rays are focused in front of the retina
- patient education to the procedure - myopia is caused by eyeball that is longer than
- caution patients to avoid squeezing the eyelids, normal
holding their breath, or performing a Valsalva - treatment: concave or minus lens
maneuver - because these may result in
2. HYPEROPIA OR FARSIGHTEDNESS
abnormally increased IOP.
- light rays are focus behind the eyes
COLOR VISION TESTING
- the image that falls on the retina is blurred
- done to determine the person’s ability to - treatment: convex or plus lens
perceive primary colors and shades of colors.
3. ASTIGMATISM
Polychromatic plates
- light rays are not bent equally by the cornea,
- dots of primary colors printed on a background focus not attained
of similar dots in a confusion of colors. - commonly caused by abnormal curvature of the
cornea
Individual colored disks
- treatment: astigmatic or cylindrical lens
- each disk is matched to its next closest color.
Refractive Surgeries
AMSLER GRID
LASIK SURGERY
- Test often used for patients with macular
- Laser-Assisted In Situ Keratomileusis
problems – MACULAR DEGENERATION
(LASIK)
- Consists of a geometric grid of identical
- involves flattening the anterior curvature of the
squares with a central fixation point.
cornea - by removing a layer.
- Grid should be viewed by the patient wearing
- use of microkeratome (an automatic corneal
normal reading glasses. Each eye is tested
shaper)
separately.
GLAUCOMA
Radiology and Imaging
- a group of ocular conditions characterized by
- Fluorescein Angiography (macular edema,
elevated IOP.
retinal & choroidal neovascularization)
- increased IOP - caused by congestion of
- Eye and Orbit Sonography
aqueous humor in the eye à damages the optic
- Optical Coherence Tomography
nerve and nerve fiber layer
- Electroretinography
- prevalent in people older than 40 years
- Fundus Photography (detect and document
retinal lesions)
- Laser Scanning
- Perimetry Testing (evaluates the field of
vision)
DISORDERS
1) REFRACTIVE ERRORS
2) GLAUCOMA
3) CATARACTS
4) RETINAL DETACHMENT
5) MACULAR DEGENERATION
6) OCULAR TRAUMA
REFRACTIVE ERRORS
EMMETROPIA
- normal vision
- normal refractive condition – clear retinal focus Physiology
with no optical defects
- normal IOP is between 10 and 21 mmHg
- do not need eyeglasses or contact lenses
- IOP is determined by the:
FACTOR THAT DETERMINES REFRACTIVE o rate of aqueous humor production
ERROR: o the resistance encountered by the aqueous
humor as it flows out the passages
 depth of the eyeball
o venous pressure of the episcleral veins that
THREE BASIC ABNORMALITIES drain into the ciliary vein
- when aqueous humor is inhibited from flowing
out, pressure builds up within the eye
 Normally, aqueous humor, which is secreted in
the posterior chamber, gains access to the
anterior chamber by flowing through the pupil.
In the angle of the anterior chamber, it passes
through the canal of Schlemm into the venous
system.
 In wide-angle glaucoma, the outflow of
aqueous humor is obstructed at the trabecular
meshwork.
 In narrow-angle glaucoma, the aqueous
humor encounters resistance to flow through
the pupil. Increased pressure in the posterior
chamber produces a forward bowing of the
peripheral iris so that the iris blocks the
trabecular meshwork.
Pathophysiology
TWO THEORIES
- how increased IOP damages the optic nerve in
glaucoma:
1. DIRECT MECHANICAL THEORY
- suggests that high IOP damages the retinal layer
as it passes the through the optic nerve head
2. INDIRECT ISCHEMIC THEORY
- suggests that high IOP compresses the
microcirculation in the optic nerve head resulting in
cell injury and death
 some glaucoma appears exclusively
mechanical, some are exclusively ischemic,
typically, most cases are combination of both
Classification of Glaucoma
Two Most Common Forms in Adults:
1) Wide-angle glaucoma
2) Narrow-angle glaucoma
Other Forms:
- Congenital glaucoma
- Glaucoma associated with other conditions
(developmental anomalies or corticosteroid
use)
 Glaucoma can be primary or secondary –
depending on whether associated factors
contribute to the rise in IOP.
Clinical Manifestations
 often called the “silent thief of the sight”
because most patients are unaware that they
have the disease until they have experienced
visual changes and vision loss
 blurred vision
 halos around lights
 difficulty focusing or adjusting to low lighting
 loss of peripheral vision
 pain or discomforts around the eyes
 headache
Assessment and Diagnostic Findings
- Optic nerve changes are pallor and cupping of
the optic nerve disc
o pallor is due to lack of blood supply
o cupping is exaggerated bending of the
blood vessels as they cross the optic disc
resulting in enlarged cup with thinned rim
- As optic nerve damage increases, visual
perception decreases
- Scotomas, a localized area of visual loss,
represents loss of retinal sensitivity and nerve
fiber damage
Diagnosis is made on:
- measurement of pressure – Tonometer
- evaluate the health of optic nerve
- evaluate cause of increase pressure
Medical Management
- the goal of treatment is prevention of optic
nerve damage
- treatment includes: pharmacologic, laser
procedures, surgery or combination of these
approaches
- the IOP is set at 30% lower than the current
pressure
- optic nerve appearance is monitored, if there is
evidence of optic nerve damage, the IOP is
again lowered until stable
- glaucoma damage cannot be reversed but
progression can be prevented
Pharmacologic Therapy
- decrease pressure by reducing fluid going into
the eye, or making easier for the fluid to leave
the eye
DECREASE INFLOW
1. Beta Blockers – Timolol, Betagan
- decrease aqueous humor production
2. Carbonic Anhydrase Inhibitor –
acetazolamide (Azopt, Truzopt)
- decreases aqueous humor production
INCREASE OUTFLOW
1. Cholinergics (miotics) – pilocarpine
- increase AH outflow by constricting ciliary
muscle and constricting the pupil
2. Prostaglandins Analogues – Lumigan,
Xalatan, Travatan
- increase uveoscleral outflow
 DECREASE PRODUCTION & INCREASE 1) Traumatic cataract (occurs after injury)
OUTFLOW 2) Congenital cataract (occurs at birth)
3) Senile cataract (commonly occurs with aging)
- Alpha adrenergic agonists apraclonidine
(Alphagan) Clinical Manifestations
 Painless, blurry vision – characteristic of
cataracts.
Surgical Management
 Dimmer perception to surroundings
TRABECULECTOMY SURGERY  Light scattering
 Reduced contrast sensitivity
- stabilizes the optic nerve - minimizes further  Sensitivity to glare
visual field damage  Reduced visual acuity
- surgery is performed through a small incision
and does not require creation of a permanent OTHER EFFECTS
hole in the eye wall or an external filtering bleb
 Myopic shift – return of ability to do close work
or an implant.
(e.g., reading fine print) without eyeglasses
TRABECULECTOMY – standard filtering technique  Astigmatism
 Color changes – as lens becomes browner in
- used to create an opening or fistula in the color
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)
COMPLICATIONS:
 hemorrhage
 extremely low (hypotony) or extremely
elevated IOP
 uveitis, cataracts
 bleb failure, bleb leak
 endophthalmitis (intraocular infection)
LASER TRABECULOPLASTY
- a laser beam is applied to the inner surface of
the trabecular meshwork to - open the
intratrabecular spaces and widen the canal of
Schlemm - promoting outflow of aqueous
humor and decreasing IOP.
PERIPHERAL IRIDOTOMY
- indicated for pupillary block glaucoma
- an opening is made in the iris to eliminate the
pupillary blockage.
CONTRAINDICATION: corneal edema (interferes
with laser targeting)
Assessment and Diagnostic Findings
POTENTIAL COMPLICATIONS
Decreased visual acuity – directly proportionate to
 burns to the cornea, lens, or retina cataract density.
 transient elevated IOP
 closure of the iridotomy  Snellen visual acuity test
 uveitis; and blurring  Ophthalmoscopy
 Slit-lamp biomicroscopic examination
CATARACTS - are all used to establish the degree of cataract
- a lens opacity or cloudiness formation.
- cataracts are the leading cause of blindness in Medical Management
the world (Prevent Blindness America, 2020)
- No nonsurgical treatment (e.g., medications,
Pathophysiology eye drops, eyeglasses) cures cataracts or
- can develop in one or both eyes at any age. prevents age-related cataracts.

THREE MOST COMMON TYPES Optimal medical management is PREVENTION:

- risk reduction strategies (smoking cessation,
weight reduction, optimal blood glucose control
for patients with diabetes)
- advise to wear sunglasses outdoors – prevents
early cataract
Surgical Management
PHACOEMULSIFICATION
- a method of extracapsular cataract surgery
- a portion of the anterior capsule is removed,
allowing extraction of the lens nucleus and
cortex while the posterior capsule and zonular
support are left intact.
LENS REPLACEMENT
- three lens replacement options:
o Aphakic eyeglasses (rarely used)
o Contact lenses (provide patients with
almost normal vision)
o IOL implants (most common approach to
lens replacement)
Post-operative Complications
IMMEDIATE
- hemorrhage
INTRAOPERATIVE
- rupture of the posterior capsule
EARLY POSTOPERATIVE
- acute bacterial endophthalmitis (S. aureus, S.
epidermidis, Pseudomonas)
LATE POSTOPERATIVE
- sutured-related problems
- malposition of IOL
- chronic endophthalmitis
Nursing Management
Providing Preoperative Care
- Orient & explain procedures and care plan – to
decrease anxiety.
- Instruct the patient not to touch eyes – to
decrease contamination.
- Administer preoperative eye drops — antibiotic,
mydriatic
Providing Postoperative Care
- Provide medications for symptoms (pain, N/V)
- Caution the patient against coughing,
sneezing, rapid movement or bending from the
waist – to prevent increased IOP.
- Elevate HOB to 30 degrees, lie patient on the
unaffected side
- Encourage the patient to wear eye shield at
night – to protect operated eye from injury while
sleeping.
Retinal Detachment
- refers to the separation of the retinal pigment
epithelium from the neurosensory layer
FOUR TYPES OF RD:
1) Rhegmatogenous (most common form)
2) Traction
3) Combination of Rhegmatogenous &
Traction
4) Exudative
Risk Factors / Etiology
 Age – as we age retina may weaken
 Highly myopic
 Aphakia (absence of the natural lens) post-
cataract surgery
 Trauma like from sports: boxing, basketball
 DM (diabetic retinopathy)
 Degeneration of the retina
 Previous retinal detachment on the other eye
 Family history of retinal detachment
Rhegmatogenous Detachment
- In this condition, a hole or tear develops in
the sensory retina, allowing some of the liquid
vitreous to seep through the sensory retina and
detach it from the retinal pigment epithelium
(RPE)
- PEOPLE AT RISK:
o highly myopic
o aphakia (absence of natural lens following
surgery)
Traction Retinal Detachment
- tension, or a pulling force
- predisposing/precipitating factor: diabetic
retinopathy, vitreous hemorrhage, or the
retinopathy of prematurity - the hemorrhages
and fibrous proliferation associated with these
conditions exert a pulling force on the delicate
retina.
 A patient can have both rhegmatogenous and
traction retinal detachment
Exudative Retinal Detachments
- result of the production of a serous fluid
under the retina from the choroid.
- conditions such as uveitis and macular
degeneration à may cause the production of
this serous fluid.
Clinical Manifestations
 a sensation of shade or curtain falling across
the vision of one eye
 cobwebs
 bright flashing lights
 sudden onset of great number of floaters
Diagnostic Studies
- Evaluate visual acuity
- Dilated fundus examination
- Ophthalmoscope
Surgical Management
SCLERAL BUCKLING
- the surgeon compresses the sclera with a
scleral buckle or silicone band
PARS PLANA VITRECTOMY
- an intraocular procedure that allows
introduction of light source through an incision
- the second incision is for the vitrectomy
instrument
- can be used in various procedures like removal
of foreign body, dislocated lenses, vitreous
opacity such as blood
PNEUMATIC RETINOPEXY
- injection of gas bubble, silicone oil or liquids
into the vitreous cavity to help push the sensory
retina to the up against the RPE
Nursing Management
- Instruct the patient to remain quiet in
prescribed position. (Detached area of retina
remains in dependent position.)
- Assist with all activities and offer frequent
reassurance.
- For pneumatic retinopexy, postoperative
positioning is critical as injected bubble must
float into a position overlying the detachment
- Caution the patient to avoid bumping head.
- Encourage the patient not to cough or
sneeze or to perform activities that will increase
IOP.
Age-Related Macular Degeneration
- AMD is the leading cause of irreversible
blindness and visual impairment in the world
(Bright Focus Foundation, 2020a).
- AMD is characterized by drusen beneath the
retina
- Central vision is generally the most affected,
with most patients retaining peripheral vision
- There are two types of AMD: the dry type and
the wet type
1) DRY (nonneovascular, nonexudative)
- outer layers of the retina slowly break down à
appearance of drusen
2) WET (neovascular, exudative)
- results from choroidal neovascularization.
- abrupt onset and is more damaging to the
vision
- straight lines appear crooked and distorted,
letters in words appear broken
Medical Management
Dry AMD (no known effective treatment or cure)
Wet AMD
- Vascular endothelial growth factor (VEGF)
inhibitors
o given by intravitreal injection
o Ranibizumab, Brolucizumab
Nursing Management
AMSLER GRIDS
- given to patients to use in their homes
- to monitor for a sudden onset or distortion of
vision
- may provide the earliest sign of progressing
macular degeneration
Orbital Trauma
- Injury to the orbit is usually associated with a
head injury
Soft Tissue Injury and Hemorrhage
- from blunt or penetrating trauma
- tenderness, ecchymosis, lid swelling,
exophthalmos (abnormal protrusion of the
eyeball), and hemorrhage.
- Closed injuries lead to contusions with
subconjunctival hemorrhage – commonly
known as black eye.
- Management: cold compresses followed by
warm compress, surgical aspiration/draining if
with swelling
Orbital Fractures
- detected by facial x-rays
- classified as blowout, zygomatic or tripod,
maxillary, midfacial, orbital apex, and orbital
roof fractures
- most common indications for surgical
intervention:
o displacement of bone fragments disfiguring
the normal facial contours
o interference with normal binocular vision
caused by extraocular muscle entrapment
o interference with mastication in zygomatic
fracture
o obstruction of the nasolacrimal duct.
Foreign Bodies
- any foreign bodies that enters the orbit are
usually tolerated, except for steel, copper, iron,
and vegetable materials such as those from
plants or trees, which may cause purulent
infection.
- contraindication to MRI: (+) metallic foreign
bodies
Ocular Trauma
- the leading cause of blindness among children
and young adults, especially male trauma
victims
CAUSES:
 occupational injuries (construction industry)
 contact sports, weapons (air guns)
 assaults
 motor vehicle crashes (broken windshields)
 explosions (blast fragments)
TWO TYPES (first response is critical)
1. CHEMICAL BURN
- management: eye should be immediately
irrigated with tap water or normal saline

.
2. FOREIGN OBJECT
- no attempt should be made to remove the
foreign object
- object should be protected from jarring or
movement to prevent further ocular damage
- No pressure or patch should be applied to the
affected eye
- may use a stiff paper cup until medical
treatment can be obtained