THE EYE

DISORDERS
 PYRAMID POINTS

• Nursing interventions for the client who is legally

blind
• Assessment findings in a client with a cataract
• Client education following cataract surgery
• Assessment findings in a client with glaucoma
• Client education regarding compliance with
medical treatments for glaucoma
 PYRAMID POINTS

• Assessment findings in the client with retinal

detachment
• Interventions for the client with retinal
detachment
• Emergency interventions for the client with an
eye injury
• Postoperative interventions following enucleation
and exenteration
• Nursing interventions related to organ donation
 LEGALLY BLIND

• CLIENT EDUCATION
– Remain one step behind the nurse when
ambulating
– Using the cane for the blind client, which is
differentiated from other canes by its straight
shape and white color with red tip
– That the cane is held in the dominant hand
several inches off the floor
– That the cane sweeps the ground where the
client’s foot will be placed next, to determine
the presence of obstacles
 CATARACTS

• DESCRIPTION
– An opacity of the lens that distorts the image
projected onto the retina and which can progress
to blindness
– Causes include the aging process (senile
cataracts), inherited (congenital cataracts), and
injury (traumatic cataracts); can also occur as a
result of another eye disease (secondary cataracts)
– Intervention is indicated when visual acuity has
been reduced to a level that the client finds to be
unacceptable or adversely affecting lifestyle
 CATARACTS

• ASSESSMENT
– Opaque or cloudy white pupil
– Gradual loss of vision
– Blurred vision
– Decreased color perception
– Vision that is better in dim light with pupil
dilation
– Photophobia
– Absence of the red reflex
APPEARANCE OF EYE WITH CATARACT

From Black JM, Hawks JH, Keene AM: Medical-surgical nursing: clinical management
for positive outcomes, 6th ed., Philadelphia, 2001 W.B. Saunders. Courtesy of
Ophthalmic Photography, University of Michigan, WK Kellogg Eye Center, Ann Arbor,
MI.
 CATARACTS

• IMPLEMENTATION
– Surgical removal of the lens, one eye at a time
– Intracapsular extraction: the lens is removed
within its capsule through a small incision
– Extracapsular extraction: the lens is lifted out
without removing the lens capsule; may be
performed by phacoemulsification in which the
lens is broken up by ultrasonic vibrations and
extracted
 CATARACT REMOVAL

From Black JM, Matassarin-Jacobs E: Medical-surgical nursing: clinical

management for continuity of care (1997), 5th ed., Philadelphia, W.B. Saunders.
 CATARACTS

• IMPLEMENTATION
– A partial iridectomy may be performed with the
lens extraction to prevent acute secondary
glaucoma
– A lens implantation may be performed at the
time of the surgical procedure
 CATARACTS

• PREOPERATIVE
– Instruct the client regarding the postoperative
measures to prevent or decrease intraocular
pressure
– Administer preoperative eye medications
including mydriatics and cycloplegics as
prescribed
 CATARACTS

• POSTOPERATIVE
– Elevate the head of the bed 30 to 45 degrees
– Turn the client to the back or unoperative side
– Maintain an eye patch; orient the client to the
environment
– Position the client’s personal belongings to
the unoperative side
– Use side rails for safety
– Assist with ambulation
 CATARACT SURGERY

• CLIENT EDUCATION
– Avoid eye straining
– Avoid rubbing or placing pressure on the eyes
– Avoid rapid movements, straining, sneezing,
coughing, bending, vomiting, or lifting objects
over 5 pounds
– Measures to prevent constipation
– Dressing changes and prescribed eye drops
and medications
 CATARACT SURGERY

• CLIENT EDUCATION
– Wipe excess drainage or tearing with a sterile
wet cotton ball from the inner to the outer
canthus
– Use of an eye shield at bedtime
– If a lens implant is not performed, the eye
cannot accommodate and glasses must be
worn at all times
– Cataract glasses act as magnifying glasses
and replace central vision only
 CATARACT SURGERY

• CLIENT EDUCATION
– Cataract glasses magnify and objects will
appear closer; therefore, the client needs to
accommodate, judge distance, and climb stairs
carefully
– Contact lenses provide sharp visual acuity but
dexterity is needed to insert them
– Contact the physician for any decrease in
vision, severe eye pain, or increase in eye
discharge
 GLAUCOMA

• DESCRIPTION
– Increased intraocular pressure as a result of
inadequate drainage of aqueous humor from
the canal of Schlemm or overproduction of
aqueous humor
– The condition damages the optic nerve and
can result in blindness
 TYPES OF GLAUCOMA

• ACUTE CLOSED-ANGLE OR NARROW-ANGLE

GLAUCOMA
– Results from obstruction to outflow of aqueous
humor
• CHRONIC CLOSED-ANGLE GLAUCOMA
– Follows an untreated attack of acute closed-
angle glaucoma
• CHRONIC OPEN-ANGLE GLAUCOMA
– Results from overproduction or obstruction to
the outflow of aqueous humor
 OPEN-ANGLE AND CLOSED-ANGLE
GLAUCOMA

From Beare PG, Myers JL (1998): Adult Health Nursing, ed. 3 St. Louis: Mosby.
 TYPES OF GLAUCOMA

• ACUTE
– A rapid onset of intraocular pressure greater
than 50 to 70 mmHg
• CHRONIC
– A slow, progressive, gradual onset of
intraocular pressure greater than 30 to 50
mmHg
 GLAUCOMA

• ASSESSMENT
– Progressive loss of peripheral vision followed
by loss of central vision
– Elevated intraocular pressure (normal
pressure is 10 to 21 mmHg)
– Vision worsening in the evening with difficulty
adjusting to dark rooms
– Blurred vision
– Progressive loss of central vision
 GLAUCOMA

• ASSESSMENT
– Halos around white lights
– Frontal headaches
– Eye pain
– Photophobia
– Lacrimation
 OPHTHALMOSCOPIC IMAGE OF
OPEN-ANGLE GLAUCOMA

From Apple DJ, Rabb MF: Ocular pathology, ed. 5, St. Louis, 1998, Mosby.
 ACUTE GLAUCOMA

• IMPLEMENTATION
– Treat as a medical emergency
– Administer medications as prescribed to lower
intraocular pressure
– Prepare the client for peripheral iridectomy,
which allows aqueous humor to flow from the
posterior to anterior chamber
 CHRONIC GLAUCOMA

• IMPLEMENTATION
– Prepare the client for trabeculoplasty as
prescribed to facilitate aqueous humor
drainage
– Prepare the client for trabeculectomy as
prescribed, which allows drainage of aqueous
humor into the conjunctival spaces by the
creation of an opening
 CHRONIC GLAUCOMA

• CLIENT EDUCATION
– The importance of medications: miotics to
constrict the pupils, carbonic anhydrase
inhibitors to decrease the production of
aqueous humor, and beta blockers to decrease
the production of aqueous humor and
intraocular pressure
– The need for life-long medication use
– Wear a Medic Alert bracelet
– Avoid anticholinergic medications
 CHRONIC GLAUCOMA

• CLIENT EDUCATION
– To report eye pain, halos around the eyes, and
changes in vision to the physician
– That when maximal medical therapy has failed
to halt the progression of visual field loss and
optic nerve damage, surgery will be
recommended
 RETINAL DETACHMENT

• DESCRIPTION
– Occurs when the layers of the retina separate
because of the accumulation of fluid between
them, or when both retinal layers elevate away
from the choroid as a result of a tumor
– Partial separation becomes complete if
untreated
– When detachment becomes complete,
blindness occurs
 RETINAL DETACHMENT
TEAR IN RETINA

From Phipps WJ, Sands, J, Marek JF: Medical-surgical nursing: concepts and
clinical practice, ed. 6, St. Louis, 1999, Mosby.
 RETINAL DETACHMENT
VIEW OF FUNDUS

From Black JM, Hawks JH, Keene AM: Medical-surgical nursing: clinical management
for positive outcomes, 6th ed., Philadelphia, 2001 W.B. Saunders. Courtesy of Opthalmic
Photography, University of Michigan, WK Kellogg Eye Center, Ann Arbor, MI.
 RETINAL DETACHMENT

• ASSESSMENT
– Flashes of light
– Floaters
– Increase in blurred vision
– Sense of a curtain being drawn
– Loss of a portion of the visual field
 RETINAL DETACHMENT

• IMMEDIATE IMPLEMENTATION
– Provide bed rest
– Cover both eyes with patches to prevent further
detachment
– Speak to the client before approaching
– Position the client’s head as prescribed
– Protect the client from injury
– Avoid jerky head movements
– Minimize eye stress
– Prepare the client for the surgical procedure as
prescribed
 RETINAL DETACHMENT
SURGICAL PROCEDURES

• Draining fluid from the subretinal space so that

the retina can return to the normal position
• Sealing retinal breaks by cryosurgery, a cold
probe applied to the sclera, to stimulate an
inflammatory response leading to adhesions
• Diathermy, the use of an electrode needle and
heat through the sclera, to stimulate an
inflammatory response
 RETINAL DETACHMENT
SURGICAL PROCEDURES

• Laser therapy, which stimulates an inflammatory

response to seal small retinal tears before the
detachment occurs
• Scleral buckling, to hold the choroid and retina
together with a splint until scar tissue forms
closing the tear
• Insertion of gas or silicone oil to encourage
attachment because these agents have a specific
gravity less than vitreous or air, and can float
against the retina
 SCLERAL BUCKLING

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for

clinical practice, ed 2, Philadelphia: W.B. Saunders.
 RETINAL DETACHMENT
SURGICAL PROCEDURES

• POSTOPERATIVE
– Maintain eye patches bilaterally as prescribed
– Monitor for hemorrhage
– Prevent nausea and vomiting and monitor for
restlessness, which can cause hemorrhage
– Monitor for sudden, sharp eye pain (notify the
physician)
– Encourage deep breathing but avoid coughing
– Provide bed rest for 1 to 2 days as prescribed
 RETINAL DETACHMENT
SURGICAL PROCEDURES

• POSTOPERATIVE
– Position the client as prescribed
– If gas has been inserted, position as
prescribed on the abdomen and turn the head
so unaffected eye is down
– Administer eye medications as prescribed
– Assist the client with activities of daily living
– Avoid sudden head movements or anything
that increases intraocular pressure
 RETINAL DETACHMENT
SURGICAL PROCEDURES

• POSTOPERATIVE
– Instruct the client to limit reading for 3 to 5
weeks
– Instruct the client to avoid squinting, straining
and constipation, lifting heavy objects, and
bending from the waist
– Instruct the client to wear dark glasses during
the day and an eye patch at night
– Encourage follow-up care because of the
danger of recurrence or occurrence in the
other eye
 HYPHEMA

• DESCRIPTION
– The presence of blood in the anterior chamber
– Occurs as a result of an injury
– The condition usually resolves in 5 to 7 days
 HYPHEMA

From Zitelli BJ, Davis HW: Atlas of Pediatric Physical Diagnosis, ed. 3, St. Louis, 1997, Mosby.
 HYPHEMA

• IMPLEMENTATION
– Encourage rest with the client in semi-Fowler’s
position
– Avoid sudden eye movements for 3 to 5 days
to decrease the likelihood of bleeding
– Administer cycloplegic eye drops as
prescribed to place the eye at rest
– Instruct the client in the use of eye shields or
eye patches as prescribed
– Instruct the client to restrict reading and
watching television
 CONTUSIONS

• DESCRIPTION
– Bleeding into the soft tissue as a result of an
injury
– Causes a black eye and the discoloration
disappears in approximately 10 days
– Pain, photophobia, edema, and diplopia may
occur
• IMPLEMENTATION
– Place ice on the eye immediately
– Instruct the client to receive an eye examination
 FOREIGN BODIES OF THE EYE

• DESCRIPTION
– An object such as dust that enters the eye
 FOREIGN BODIES OF THE EYE

• IMPLEMENTATION
– Have the client look upward, expose the lower
lid, wet a cotton-tipped applicator with sterile
normal saline, and gently twist the swab over
the particle and 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, and pull the upper lid
outward and over the cotton applicator; if the
particle is seen, gently twist swab over it to
remove
 PENETRATING OBJECTS

• DESCRIPTION
– An injury that occurs to the eye in which an
object penetrates the eye
 PENETRATING OBJECTS

• IMPLEMENTATION
– Never remove the object because it may be
holding ocular structures in place; the object
must be removed by the physician
– Cover the object with a cup
– Do not allow the client to bend
– Do not place pressure on eye
– Client is to be seen by a physician immediately
 CHEMICAL BURNS

• DESCRIPTION
– An eye injury in which a caustic substance
enters the eye
 CHEMICAL BURNS

• IMPLEMENTATION
– Treatment should begin immediately
– Flush the eyes at the site of injury with water
for at least 15 to 20 minutes
– At the scene of the injury, obtain a sample of
the chemical involved
 CHEMICAL BURNS

• IMPLEMENTATION
– At the emergency room, the eye is irrigated
with normal saline solution or an ophthalmic
irrigation solution
– The solution is directed across the cornea and
toward the lateral canthus
– Prepare for visual acuity assessment
– Apply an antibiotic ointment as prescribed
– Cover the eye with a patch as prescribed
 ENUCLEATION AND EXENTERATION

• DESCRIPTION
– Enucleation: removal of the entire eyeball
– Exenteration: removal of the eyeball and
surrounding tissues and bone
– 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 and to facilitate the best cosmetic
result
– A prosthesis is fitted approximately 1 month
after surgery
 ENUCLEATION AND EXENTERATION

• PREOPERATIVE
– Provide emotional support to the client
– Encourage the client to verbalize feelings
related to loss
• POSTOPERATIVE
– Monitor vital signs
– Assess pressure patch or dressing
– Report changes in vital signs 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 because
of rapid endothelial cell death
– Must be stored in a preserving solution
– Storage, handling, and coordination of donor
tissue with surgeons is provided by a network
of state eye bank associations across the
country
 ORGAN DONATION

• CARE TO THE DECEASED CLIENT AS A

POTENTIAL EYE DONOR
– Discuss the option of eye donation with the
physician and family
– Raise the head of the bed 30 degrees
– Instill antibiotic eye drops as prescribed
– Close the eyes and apply a small ice pack to
the closed eyes
 PREOPERATIVE: THE RECIPIENT

• Recipient may be told of the tissue availability

only several hours to 1 day before the surgery
• Assist in alleviating client anxiety
• Assess eye for signs of infection
• Report the presence of any redness, watery or
purulent drainage, or edema around the eye to
the physician
• Instill antibiotic drops into the eye as prescribed
to reduce the number of microorganisms present
• Administer IV fluids and medications as
prescribed
 CORNEAL TRANSPLANTATION
KERATOPLASTY

From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing, ed 6,
Philadelphia: W.B. Saunders.
 APPEARANCE OF EYE AFTER
KERATOPLASTY

From Black JM, Hawks JH, Keene AM: Medical-surgical nursing: clinical management
for positive outcomes (2001), 6th ed., Philadelphia, W.B. Saunders. Courtesy of
Opthalmic Photography, University of Michigan, WK Kellogg Eye Center, Ann Arbor, MI.
 POSTOPERATIVE: THE RECIPIENT

• Eye is covered with a pressure patch and

protective shield that is left in place until the next
day
• Do not remove or change the dressing without a
physician’s order
• Monitor vital signs
• Monitor level of consciousness
• Assess dressing
 POSTOPERATIVE: THE RECIPIENT

• Position the client on the nonoperative side to

reduce intraocular pressure
• Orient the client frequently
• Monitor for complications of bleeding, wound
leakage, infection, and graft rejection
• Instruct the client how to apply a patch and eye
shield
• Instruct the client to wear the eye shield at night
for 1 month and whenever around small children
or pets
• Advise the client not to rub the eye
 POSTOPERATIVE: THE RECIPIENT

• GRAFT REJECTION
– Can occur at any time
– Inform the client of the signs of rejection
– Signs include redness, swelling, decreased
vision, and pain (RSVP)
– Treated with topical corticosteroids
Dry Eye

59
 What is Dry Eye Disease?

•Dry eye disease (DED) is a condition caused

by many factors that result in inflammation of
the eye and tear-producing glands.
•Inflammation can decrease the ability of the
eye to produce normal tears that protect the
surface of the eye and keep it moist and
lubricated.

60
 Definition

 Dry eye is not a trivial complaint. It can cause significant

discomfort and affect quality of life significantly.

 In 1995 the National Eye Institute defined dry eye disease

(DED) as “ a disorder of the tear film due to tear deficiency
or excessive tear evaporation which causes damage to the
interpalpebral ocular surface and is associated with
symptoms of ocular discomfort”.

61
 Definition

 In 2007 the International Dry Eye Workshop

defined it as

“ a multifactorial disease of the tears and ocular surface that

results in symptoms of discomfort, visual disturbance, and
tear film instability with potential damage to the ocular
surface. It is accompanied by increased osmolarity of the
tear film and inflammation of the ocular surface.”
62
Dry Eye is more than a red eye.

63
 Dry Eye
Affects Quality of Life

64
 The Healthy Eye

Normal tearing
depends on a
neuronal feedback loop Secretomotor
Nerve Impulses

Lacrimal
Glands Tears Support and Maintain
Ocular Surface

Ocular Surface
Neural Stimulation

65
Dry Eye Disease: An Immune-Mediated Inflammatory
Disorder

Inflammation disrupts
normal neuronal
Lacrimal Glands: control of tearing
• Neurogenic
Interrupted Secretomotor
Inflammation Nerve Impulses
• T-cell Activation
• Cytokine
Secretion into
Tears Tears Inflame Ocular Surface

Cytokines
Disrupt Neural Arc

66
 Multiple Factors in Dry Eye

• Transient discomfort

• May be stimulated by
environmental conditions

• Inflammation and ocular

surface damage

• Altered tear film

composition 1
67
de Paiva and Pflugfelder. In: Dry Eye and Ocular Surface Disorders. 2004;
2
Pflugfelder et al. In: Dry Eye and Ocular Surface Disorders. 2004.
 Role of Inflammation
in Chronic Dry Eye
• Inflammation may be present but not clinically apparent
• Cycle of inflammation and dysfunction
• If untreated, inflammation can damage lacrimal gland
and ocular surface
• Consequences:
– Lower tear production
– Altered corneal barrier function

68
Pflugfelder. Am J Ophthalmol. 2004.
 Healthy Tears

• A complex mixture of proteins,

mucin, and electrolytes
– Antimicrobial proteins:
Lysozyme, lactoferrin
– Growth factors & suppressors of
inflammation: EGF, IL-1RA
– Soluble mucin secreted by goblet
cells for viscosity
– Electrolytes for proper osmolarity

Stern et al. In: Dry Eye and Ocular Surface Disorders. 2004.
69
Image adapted from: Dry Eye and Ocular Surface Disorders. 2004.
 Tears in Chronic Dry Eye
• Decrease in many proteins
• Decreased growth factor
concentrations
• Altered cytokine balance
promotes inflammation
• Soluble mucin 5AC greatly
decreased
– Due to goblet cell loss
– Impacts viscosity of
tear film
• Proteases activated
Solomon et al. Invest Ophthalmol Vis Sci. 2001.
• Increased electrolytes Zhao et al. Cornea. 2001.
70
Ogasawara et al. Graefes Arch Clin Exp Ophthalmol. 1996.
Image adapted from: Dry Eye and Ocular Surface Disorders. 2004.
Who Is Likely to Have Dry
Eye?

How Do We Diagnose It?

71
 Dry Eye: Multifactorial nature
Elderly woman

Taking
Post glaucoma
menopausal medications
Contact lens
user

Working for long Air-conditioned

hours in front of environment
computer

72
Patient Types with High Incidence
of Dry Eye Disease
• Women aged 50 or older
• Women using postmenopausal hormone
replacement therapy
• Those with ocular co-morbidities –
xerophthalmia, cicatrical pemphigoid,
atopic keratoconjunctivitis, ocular rosacea

• Contact lens wearers

• Smokers
73
 Dry Eye Disease: Predisposing Factors

• Ageing
• Menopause - Decreased Androgens
• Allergy Response
• Environmental Stresses
– Low Humidity: Heating/AC
– Contact Lens Wear
– Wind – Lack of Sleep
– Air Pollution – Use of Computer Terminals
• Ocular Surgery (LASIK, Corneal Transplant)
• Medications
74
 Medications That May Contribute
to Dry Eye Disease

• Systemic Topical
– Anti-hypertensives – Preservatives in
– Anti-androgens Tears
– Anti-cholinergics
– Antidepressants
– Cardiac Anti-arrhythmic Drugs
– Parkinson’s Disease Agents
– Antihistamines

75
 Dry Eye Disease:
Autoimmune Triggers

• Systemic Autoimmunity
– Rheumatoid Arthritis
– Lupus
– Sjögren’s Syndrome
– Graft vs. Host Disease
• All can result in immune-mediated inflammation in the eye.
• Inflammatory mediators secreted into tears.
– Promote inflammation of ocular surface.

76
 Current Triggers of Dry Eye Disease

Environment Rheumatoid
Medications Arthritis
Contact Lens Irritation Inflammation
Lupus
Surgery Sjögren’s
Graft vs Host

Tear
Deficiency/ Postmenopause
Meibomian
Instability Gland Disease

Symptoms of Ocular Surface Disease 77

78
 Dry Eye Disease Symptoms

• Discomfort
• Dryness
• Burning, Stinging
• Foreign-Body Sensation
• Gritty Feeling, Stickiness
• Blurry Vision
• Photophobia, Itching,
• Redness

Note: Symptoms seldom correlate with clinical signs

79
Clinical Presentation Can Vary in
Severity
Mild Severe

Slitlamp

Fluorescein
Dye Stain

80
 Slit lamp examination

• Increased debris/mucin strands in tear film

• Inspection of tear meniscus at lid margin.
– Normal thickness – 1mm, convex.
– < 0.5mm – tear deficiency.
– In severe cases – Marginal tear meniscus is
concave, small & absent.

81
Filaments ( comma shaped) over corneal surface
which move on blinking
82
Mucous plaques – semi-transparent, white to grey,
slightly elevated lesions
Stain with rose bengal.
83
• Bulbar conjunctival vessels may be dilated  Red Eye

• Corneal surface – irregularity/ dry areas.

• Blinking – incomplete/infrequent.

• Meibomian gland dysfunction/ blepharitis.

84
 Diagnostic Tests

• Appropriate choice of test helps the clinician to

arrive at an accurate diagnosis as well as for
individualization of therapy.

85
86
 1. Basic Secretion Test

• Purpose – to measure basal secretion by eliminating

reflex tearing.
• < 5mm  hyposecretion.

87
 2. Schirmer’s Test I

• Purpose – measurement of the total (reflex + basal) tear

secretion.
• Eyes should not be manipulated before starting this test.

88
Schirmer Test

89
• Normal wetting 10-15 mm
• Dry Eye
– Mild 9-14 mm
– Moderate 4-8 mm
– Severe < 4 mm

90
 Schirmer Test II

• Purpose – to ascertain reflex secretion.

• Measured after 2 minutes.
• After Strips are placed in eye un-
anaeasthetized nasal mucosa is irritated.
• Less than 15 mm failure of reflex secretion.

91