Visual Problems

Lana Opeña-Meneses
 The Visual System
• Complex group of structures that includes the
eyeballs, muscles, nerves, fat, and bones
• Ocular adnexa: accessory structures that
support and protect the eye (muscles, fat,
bone)
• Orbit (eye socket): surrounds and protects most of
the eye so that only a small portion is visible
• Ocular muscles: 6 muscles that are attach to the
globe and move the eye through 6 cardial gazes
– Four rectus muscles (medial, lateral,superior, inferior):
move the eye horizontally and vertically
– Two oblique muscles (superior and inferior): rotate the
eye in circular movements to allow vision at all angles
• Eyelids: folds of skin that close to protect the anterior
eyeball; prevents evaporation and drying of the surface
epithelium
• Palpebral fissure: elliptic space between the two open
lids
• Canthi: corners of the fissure
• Meibomian gland: secretes oil
• Lacrimal galnd: produces tears
• Nasolacrimal duct: directs flow of tears into the nose
• Internal Structures
– Conjuctiva: thin transparent layer of mucous
membrane that lines the eyelids and covers the
eyeball
– Cornea: transparent, avascular structure with a
brilliant, shiny surface
– Sclera: fibrous protective coating of the eye; white
dense and continuous with the cornea
• Uveal tract: middle vascular layer of the eye that
furnishes the blood supply to the retina
– Iris: thin, pigmented diaphragm with a central
aperture, the pupil; expansion and contration of the
iris regulate the amount of light entering the eye
– Ciliary body: produces and secretes aqueous humor
(clear, alkaline fluid composed mainly of water that
occupies the space between the iris and the cornea)
– Choroid: posterior segment of the uveal tract
between the retina and sclera
• Lens: biconvex, avascular, colorless, and
almost completely transparent structure;
focuses light on the retina
• Vitreous body: clear, avascular, jelly-like
structure
• Vitreous chamber: space occupied by vitreous
fluid
• Retina
– Thin, semitransparent layer of nerve tissue that forms
the innermost lining of the eye
– Contains all the sensory receptors for the transmission
of light and is actually part of the brain
– Rods and cones: retinal receptors
– Rods: function best in dim light; damage results to
night blindness; 125 million
– Cones: resolution of small visual angles, resulting in
perception of fine details; responsible for color vision;
6 million
• Macula: center of the retina, 5mm in diameter
• Fovea: depressed center of the macula; point
of finest vision; damage can severely reduce
central vision
• Optic nerve:
– Located at the posterior chamber of the eye and
transmit visual impulses from the retina to the
brain
– Optic disc: head of the optic nerve
 Common Health Problems of Neonates
and Infants
• Congenital Cataract
• Strabismus
• Retinoblastoma
 Congenital Cataract
• Opacity (clouding) of the crystalline lens of the
eye
• Incidence and Etiology:
– Can be complete or incomplete
– Bilateral or unilateral
– Acquired or congenital
• Acquired: maternal infections during pregnancy, trauma,
systemic disease
• Congenital: inherited, prenatal trauma, anoxia, maternal
systemic disease, prenatal infection
– Congenital is more common; caused by rubella virus
• Pathophysiology:
– Lens of capsule form during the 4th-5th week of
fetal development
– Lens are normally clear, allowing light to enter
– When factors interfere with lens development, it
becomes milky white and cloudy, obscuring light
and thus vision
cataract
• Clinical Manifestations
– Cloudiness of the lens
– Absent or abnormal pupillary reflex
• Treatment:
– Definitive treatment: surgical removal
– Surgery must take place before 8 weeks of age to
prevent an irreversible lack of vision development
– After removal of lens, the infant is considered
aphakic (without lens) and will need corrective
lens or contact lens to focus light on the retina
– Intraocular implants may also be used
• Through a small incision of around 2 to 3 mm and under
topical anesthesia, the anterior capsule of the bag,
containing the cataract, is opened. Through this opening
the cataract is emulsified by ultrasounds. This technique is
called phaco-emulsification or better known as “phaco”.
After having vacuumed the emulsified rests of the lens, a
foldable intraocular lens is introduced through the small
incision into the bag.
This artificial lens unfolds with human temperature and
nicely takes place into the lens bag to position itself
correctly.
Nursing Management:
• Prevent coughing, straining and vomiting to avoid
increase in IOP
• Utilize aseptic technique when handling dressings and
closely monitor for any signs of infection
• Instill appropriate eyedrops as ordered to prevent
complications of increased IOP, infection and glaucoma
• Prevent edema and pressure in the eye
• Avoid placing affected eye in dependent position
• Family Teaching
– Instillation of eye drops
– Check for signs and symptoms of infection
(drainage, redness, edema, itching)
– Check for signs and symptoms of increasing IOP
(pain, bulging of eye)
– Care, purpose, and methods of maintaining eye
patching
 Strabismus
• Visual lines of each eye do not simultaneously
focus on the same object in space due to lack
of muscle coordination, resulting in crossed-
eye appearance
• Pseudostrabismus: child appears crossed-eyed
because of prominent epicanthic folds and a
flat nasal bridge; disappears as the child grows
old
Pseudostrabismus vs. Strabismus
Pseudostrabismus
• When the EOM move in unison, visual images
falls on the fovea of each eye and the images
form a single image
• When one eye deviates, the brain is unable to
fuse the dissimilar images and double vision
results
• The brain will learn to suppress the image from
the deviated eye (amblyopia) to allow clear
sight in the straight eye
• Clinical Manifestations
– Child is clumsy, stumbles often, and has difficulty
picking up objects
– Squinting
– Persistent crossing of the eyes
• Diagnosis:
– Screening at 3-6 months to prevent loss of vision
– Hirschberg Corneal Light Reflex Test: light is held in
front of the child’s face as the child stares ahead;
light should reflect off the cornea symmetrically
– Cover test: child looks at a toy, the examiner covers
one of the child’s eye; if uncovered eye moves,
then it can be assumed that it was not fixed on the
toy
• Types of Strabismus
– Esotropia: eye turns towards the midline
– Exotropia: eye turns outward
– Hypertropia: eye is out of vertical alignment; one
pupil is higher than the other
Esotropia
Exotropia
Hypertropia
• Medical Treatment
– Occlusion therapy: eye patching; stronger eye is
covered to allow weaker eye to work alone for all
or part of each day; most successful when done in
preschool years
– Eyeglasses: covered lenses
– Miotic drugs: drugs that act on ciliary muscle to
make accomodation easier
– Botulinum toxin: produce temporary muscular
paralysis (wears off in 2 months)
• Surgical correction
– Done for infants less than 12-18 months when
medical management does not work
– Eye patching done before surgery to stimulate
non-involved eye to function
• Nursing Management:
– Stress importance of compliance in promoting
normal visual development
– Explain that surgery corrects alignment but not
vision
• Family Teaching
– Proper care of eyeglasses
– Provide information on dressing changes,
eyedrops, corrective lenses, eye patches, and
restraints
 Retinoblastoma
• Tumor of the eye that develops when immature retinal
cells (retinoblasts) become malignant and grow out of
control
• Rare form of cancer seen only in children
• Usually found in infants and very young children
• Can spread along the optic nerve to reach the brain
• Cancer may spread to lymph nodes, bone, bone marrow,
and other organs
Severe Retinoblastoma
• Clinical Manifestations
– Whitish glow in the pupil
– Leukocoria or cat’s eye reflex instead of the usual
red reflex that appears in photographs (most
common sign of retinoblastoma)
– Strabismus
– Red painful eyes
– Blindness in late stages
Leukocoria
Leukocoria vs. Red Eye Reflex
• Treatment:
– Surgery
– Radiation therapy
– Laser therapy
– Cryotherapy (using very cold probes to freeze and
kill the tumor)
– Chemotherapy
– Enucleation: surgical removal of the eye
• Nursing Management:
– Emotional support and education of the client and
family
– Teaching families about prevention and early
recognition of side effects of treatment or
recurrence of disease
 Common Health Problems of Adults
• Glaucoma
• Surgery of the Eye
 Glaucoma
• Group of ocular disorders characterized by
increased IOP, optic nerve atrophy, and visual
field loss
• Classification
– Primary and secondary glaucoma: refer to
whether the cause is the disease alone or another
condition
– Acute or chronic glaucoma: refer to the onset and
duration of the disorder
– Open (wide) and closed (narrow): describe the
width of the angle between the cornea and the
iris
TYPES:
• Primary Open-Angle Glaucoma
– Most common form
– Genetically determined, bilateral, insidious onset,
slow to progress
– “thief in the night” because no early clinical
manifestations are present
– Aqueous humor flow is slowed or stopped
because of obstruction by the trabecular
meshwork
• Angle-Closure Glaucoma
– Can develop only in one eye when the anterior
chamber angle is anatomically narrow
– Occurs due to a sudden blockage of the anterior
angle by the base of the iris
• Etiology and Risk Factors
– Chronic open angle glaucoma: degenerative
change in the trabecular meshwork
– HPN, CV diseases, diabetes, and obesity
– Uveitis: inflammation of filtering structures
– Tumor growth
– Secondary glaucoma: edema, eye injury,
inflammation, tumor, advanced cases of cataracts
and diabetes
Pathophysiology
• Obstruction of outflow of aqueous humor
increases IOP (normal is 10-20 mmHg)
• Increased IOP inhibits blood supply to the
optic nerve and retina
• Delicate tissues of optic nerves and retina
become ischemic and gradually lose function
Clinical Manifestations:
– Atrophy and cupping (indentation) of the optic
nerve on ophthalmoscopic examination
– Loss of peripheral vision
– Chronic Open-Angle Glaucoma: Crescent-shaped
scotoma (blind spot) appear in early stages of the
disease
– Acute angle-closure glaucoma: severe pain,
blurred vision, vision loss; rainbow halos around
light
Crescent-shaped Scotoma (blind spot)
• Outcome Management:
– Facilitate outflow of aqueous humor through
remaining channels and to maintain IOP within a
range that prevents further damage to the optic
nerve
Medical Management:
• Reduce IOP (promote aqueous flow): topical
miotics or epinephrine to constrict pupils in
narrow-angle glaucoma
• Topical beta-blockers/ alpha adrenergic
agents/ oral carbonic anhydrase inhibitors:
reduces production of aqueous humor
• Nursing Diagnoses:
– Disturbed Sensory Perception (Visual)
– Grieving
– Risk for Ineffective Therapeutic Regimen
Management
• Nursing Management:
– Obtain accurate list of current medications (such
as antihistamines) that may cause pupillary
dilation
– Let client describe vision changes
– Reassure client that further loss of vision may be
prevented by adhering to the treatment plan
– Health teachings on proper eyedrop instillation
Surgical Management
– Laser trabeculoplasty: use of laser to create an
opening on the trabecular meshwork
– Trabeculectomy: creation of an opening through
which the aqueous fluid escapes
– Filtering Procedures: trephination, thermal
sclerotomy, and sclerotomy to create an outflow
channel from the anterior chamber into the
subconjunctival space
– Trephination: cutting off of a round piece of the
cornea
– Thermal sclerotomy: use of laser to create a hole
in the cornea
– Sclerotomy: surgical incision of the sclera
• Iridotomy:
creation of a new route
for the flow of aqueous
humor to the trabecular
meshwork
• Cyclodestructive procedures: used to damage
the ciliary body and decrease production of
aqueous humor when all other procedures
have failed
– cyclocryoprocedure: application of freezing tip
– Cyclophotocoagulation: application of laser
Nursing Management:
• Pre-operative care:
– Prepare the patient for outpatient or inpatient surgery
– Explain that client may experience “popping” sounds and
flashing lights during laser therapy
– Inform patient that there will be a 1-2 hours waiting period after
the surgery to evaluate a rise in IOP
– Inform client in advance that he/she should arrange for a
companion and transportation after surgery
• Post-operative care:
– Cover eye with patch and metal/plastic shield for
protection to protect from light or trauma
– Instruct not to lie on the operative side to avoid
pressure on the surgical site
– Client may ambulate and eat as soon as effects of
perioperative sedation has worn off
– Frequent monitoring of IOP: continued or
increasing pain, nausea, decreased vision
• Client Teaching
– Signs of infection: redness, swelling, drainage,
blurred vision, pain
– Increased IOP: increasing pain, nausea, decrease
in vision
– Rationale of eye protection: to protect from
trauma and light
– Medications and eyedrop instillation technique
– Return visit
– Treatment of surgical site
• Carefully clean area around eye with warm tap water
and a clean washcloth
• Do not rub or apply pressure over the closed eye,
which may damage healing tissue
 Common Health Problems Across the
Lifespan
• Errors in Refraction
• Infections and Inflammation of the Eye
• Traumatic Injury of the Eye
• Retinal Detachment
Refractive Disorders
 Errors in Refraction
• Exists when light rays are not focused
appropriately on the retina of the eye
Basic Abnormalities
• Myopia: nearsightedness, a condition in which
light rays come into focus in front of the
retina; usually caused by an eyeball that is
longer than usual
• Hyperopia: farsightedness, a condition in
which eye focuses light rays behind the eye,
and consequently the image that falls on the
retina is blurred
• Astigmatism: condition in which rays of light
are not bent equally by the cornea in all
directions so that a point of focus is not
attained
• Surgical Management
– Laser in situ keratomileusis (LASIK): most common
• A thin layer of cornea is peeled back for laser reshaping
in the middle layer of the cornea and then the thin
layer is put back in place
• Causes little postoperative discomfort, rapid recovery
of clear vision, and quick stabilization of refractive
change
• Takes 10-15 minutes per eye
• Laser epithelial keratomileusis (LASEK)
– Also called epithelial LASIK
– Used for patients with very thin and flat corneas
– dilute alcohol is used to separate the epithelium
from the corneal wall
• Corneal Ring Implants (In-tacts)
– Clear pieces of acrylic that can be surgically
implanted into the cornea
– Flatter the cornea and thereby reduce
nearsightedness
• Nursing Management of the Surgical Patient
– Assess preoperatively for degree of myopia or
astigmatism (clients with severe refraction
problems may not achieve full correction)
– Ensure eye protection by using goggles to prevent
dry eyes
– Tell patient to avoid vigorous activity, activities
that could get water inside the eyes, and eye
make-up
– Inform patient that steroid eyedrops cause
watering of the eye and minimal pain
 Traumatic Injury to the Eye
Corneal Injury
– Caused by direct trauma, over-worn contact lens,
chips of flying metal or glass fragments, or dirt
• Manifestations
– Painful, profusely lacrimating eye
– Bulbar conjunctiva blood vessels will be
prominent
• Treatment:
– Removal of any imbedded items
– Resting the eye (keeping it closed and using
antibiotic ointments)

• Clients who are unconscious may develop

corneal dryness due to lack of blinking
 Infections and Inflammation of the Eye

Dacryocystitis
• Definition: Inflammation of the tear drainage
system
• Appearance: pus-like drainage or raised, red
lump near puncta
• Management: antibiotics, daily massage of
lacrimal system
Dacryocystitis
Hordeolum (stye)
• Definition: infection of glands of eyelids
• Appearance: Redness and swelling of localized
area of eyelid
• Management: warm compress and antibiotics,
may need to be incised and drained
Hordeoleum
Hordeoleum
Blepharitis
• Definition: chronic, bilateral inflammation of
the eyelids
• Appearance: itching and burning of the eyes;
eyes appear red; scales noted on lashes
• Management: wash eyelids with baby
shampoo, water, and cotton-tipped
applicators; antibiotic ointments may be
prescribed
Blepharitis
Blepharitis
Conjunctivitis
• Definition: inflammation of conjunctiva from
various microorganisms
• Appearance: redness, tearing, and exudation
of eyelid; may progress to eyelid drooping,
abnormal tissue growth
• Management: antibiotic eyedrops
Conjunctivitis (Sore eyes)
Conjunctivitis (Sore eyes)
 Retinal Detachment
• Separation of the retina from the choroid, a
membrane dense with blood vessels that is
located between the retina and the sclera
• When retina detaches, it is deprived from its
blood supply and source of nourishment and
loses its ability to function
• Rhegmatogenous retinal detachment
– most common type and is due to a retinal hole
– Liquid in the vitreous body seeps through the hole
and separates the retina from its blood supply
• Predisposing factor:
– Aging
– Cataract extraction
– Degeneration of the retina
– Trauma
– Severe myopia
– Previous retinal detachment
– Family history of retinal detachment
• Clinical Manifestations
– Described by clients as “shadow or curtain falling
across the field of vision”
– No pain
– Sudden onset and may be accompanied by a burst
of black spots or floaters indicating that bleeding
has occurred as a result of the detachment
– Client may report flashes of light
– Visual field loss occurs in the opposite quadrant of
the actual detachment
– Giant tears may result in temporary blindness
while peripheral tears may not interfere with
central vision
Vision in Retinal Detachment
Vision in Retinal Detachment
• Surgical Management
– General anesthesia is commonly used since
surgery may take hours
– Pupils must be dilated
– No known medical treatment for retinal
detachment
• Laser Photocoagulation
– Laser is used to burn the edges of the tear and
halt progression
– If the detachment is small, laser can seal the
retina against the choroid
– OPD using local anesthesia
• Cryopexy
– Uses nitrous oxide to freeze the tissue behind the
retinal tear, stimulating scar tissue formation that
will seal the edges of the tear
– OPD under local anesthesia
• Pneumatic Retinopexy
– Most effective for detachments that occur in the
upper portion of the eye
– Eye is number with local anethesia and a small gas
bubble in injected into the vitreous body
– Bubbles rises and presses against the retina,
pushing it against the choroid
– Gas bubble is slowly absorbed over the next 1 or 2
weeks
• Scleral Buckling
– Sclera is depressed from the outside by rubber-
like silicon sponges (Silastic) or bands that are
sutured permanently
– In addition to buckling, an intraocular injection of
air or sulfur hexaflouride gas bubble, or both, may
be used to apply pressure on the retina from the
inside of the eye
Scleral buckling
• Nursing Management
– Help client cope with the fears and reality of loss
of vision and to adapt to changes in vision
– After surgery, observe eye patch for any drainage
– Assess level of pain and presence of nausea
– Activity restrictions if gas or bubble has been
injected
– Position patient so that bubble can apply maximal
pressure on the retina by the force of gravity
– Position, usually head down and to one side,
should be maintained for several days
• Provide suggestions for comfort in position
like pillows under stomach, elbows, or ankles
• Encourage to resume regular diet and fluids as
tolerated
• Eye patch and shield removed the day after
surgery
• Warm or cold compress for comfort several
times a day
• Post-op medications: antibiotic-steroid
combination; cycloplegic agents (dilates pupil
and relax the ciliary muscles, which decreases
discomfort and helps prevent the formation of
iris adhesions to the corneal endothelium)
• Self-care
– Wash eye with warm tap water using a clean
washcloth
– Warm compresses may be continued at home
– Eye shield or glasses worn during daytime
– Shield should be worn during naps and at night
– Avoid vigorous activities and heavy lifting during the
immediate post-operative period
– Advise client to avoid air travel several weeks after
surgery because gas bubbles in eye expand at high
altitudes