REFRACTIVE ERRORS

VISUAL IMPAIRMENT
NSC 412
 INTRODUCTION
• Refraction is the eye’s ability to bend light rays so that they fall on the retina.
• In the normal eye, parallel light rays are focused through the lens as a sharp
image on the retina. When the light does not focus properly, it is called a
refractive error.
• This defect prevents light rays from converging into a single focus on the retina.
• Defects are as result of irregularities of the corneal curvature, focusing power of
the lens, or length of the eye.
• Refractive errors are the most common visual problem.
• Blurred vision is the major symptom.
• In some cases, the patient may have eye discomfort, eyestrain, or headaches.
• Most refractive errors can be corrected using eyeglasses or contact lenses,
refractive eye laser surgery, or surgical implantation of an artificial lens
 Myopia
• Myopia (nearsightedness) is an inability to accommodate for objects at a
distance.
• It causes light rays to be focused in front of the retina.
• This means the person can see near objects but objects in the distance are blurry.
• Myopia may occur because of excessive light refraction by the cornea or lens or
because of an abnormally long eye.
• Myopia is the most common refractive error.
• About 30% of Americans have this disorder.
• There is strong evidence that many people inherit myopia, or at least have the
tendency to develop myopia.
 Hyperopia

Hyperopia (farsightedness) is an inability to accommodate for near objects.

It causes the light rays to focus behind the retina and requires the person to
use accommodation to focus the light rays on the retina for near objects.

The person with hyperopia can see distant objects clearly.

This type of error occurs when the cornea or lens does not have adequate
focusing power or when the eyeball is too short.
 Presbyopia

Presbyopia is the loss of accommodation associated with age.

One usually begins to notice this condition in the early to mid-

40s.

As the eye ages, the lens becomes larger, firmer, and less elastic.

These changes, which progress with aging, result in an inability to

focus on near objects
 Astigmatism

Astigmatism is an uneven or irregular curvature of the cornea.

The irregularity causes the incoming light rays to be bent

unequally.

Thus, the light rays do not come to a single point of focus on the
retina, which results in visual distortion.

Astigmatism can occur in conjunction with any of the other

refractive errors.
 Symptoms and Signs of Refractive Error

• The primary symptom of refractive errors is blurred vision for distant objects,
near objects, or both.
• Sometimes the excessive ciliary muscle tone can cause headaches.
• Prolonged squinting and frowning with ocular use can also lead to headaches.
• Occasionally, excessive staring can lead to ocular surface desiccation, causing eye
irritation, itching, visual fatigue, foreign body sensation, and redness.
• Frowning and squinting when reading and excessive blinking or rubbing of the
eyes are symptoms of refractive error in children.
 Diagnosis of Refractive Error

• Visual acuity testing

• Refraction
• Comprehensive eye examination
• Visual acuity testing and refraction (determination of refractive error)
as needed should be done every 1 or 2 years.
• Screening children's visual acuity helps detect refractive errors before
they interfere with learning.
• A comprehensive eye examination, done by an ophthalmologist or an
optometrist, should accompany refraction.
 Treatment of Refractive Error
• Eyeglasses
• Contact lenses
• Refractive surgery
• Treatments for refractive errors include :
a. Eyeglasses
b. Contact Lenses
c. Refractive surgery
• Myopia and hyperopia are corrected with spherical lenses.
• Concave lenses are used to treat myopia; they are minus or divergent.
• Convex lenses are used to treat hyperopia; they are plus or convergent.
• Astigmatism is treated with cylindrical lenses.
 Treatment of Refractive Error Cont’d

• Corrective lens prescriptions have 3 numbers.

• The first number is the power (magnitude) of spherical correction
required (minus for myopia; plus for hyperopia).
• The second number is the power of cylindrical correction required (plus
or minus).
• The third number is the axis of the cylinder.
• As an example, a prescription for a person with myopic astigmatism
may read -4.50 + 2.50 × 90
• A prescription for a person with hyperopic astigmatism may read +3.00
+ 1.50 × 180.
 Corrective Glasses
• The right corrective lenses can enhance vision in those with myopia, hyperopia,
presbyopia, and astigmatism.
• Glasses for presbyopia are often called “reading glasses” because they are usually
worn only for close work.
• Presbyopic correction may be combined with a correction for another refractive
error, such as myopia or astigmatism.
• In these combined glasses, the presbyopic correction is in the lower part of the
spectacle lens. A traditional bifocal or trifocal has visible lines.
• However, most lenses today that correct vision at various distances do not have
visible lines.
• The prescription varies throughout the lens, allowing distance focusing in the top
two thirds and near focus in the bottom one third of the lens.
 Contact Lenses
• Contact lenses are another way to correct refractive errors.
• Contact lenses are made from various plastic and silicone substances.
• They are highly permeable to oxygen and have a high water content.
• These features allow for increased wearing time with greater comfort.
• If the oxygen supply to the cornea is decreased, it becomes swollen, visual acuity decreases, and
the patient has severe discomfort
• In general, you need to know whether the patient wears contact lenses, the pattern of wear (daily
versus extended), and care practices.
• Shining a light obliquely on the eyeball can help visualize a contact lens.
• Contact lenses are associated with microbial keratitis, a severe sight-threatening complication.
• Risk factors for keratitis include poor hand cleaning, poor lens case hygiene, and inadequate lens
cleaning.
• Teach the patient the importance of following recommended cleaning practices and reporting
redness, sensitivity, vision problems, and pain to the eye care provider.
 Surgical Therapy

Surgery can eliminate or reduce the need for

eyeglasses or contact lenses and correct
refractive errors by changing the focus of the eye.

Surgical management for refractive errors

includes laser surgery and IOL implantation.
 Laser
• Laser-assisted in situ keratomileusis (LASIK) may be considered for patients with
low to moderately high amounts of myopia or hyperopia, with or without
astigmatism.
• Photorefractive keratectomy (PRK) is indicated for low to moderate amounts of
myopia or hyperopia, with or without astigmatism.
• It is a good option for a patient with insufficient corneal thickness for a LASIK
flap.
• In PRK, the epithelium is removed and the laser sculpts the cornea to correct the
refractive error.
• Laser-assisted subepithelial keratomileusis (LASEK) is similar to PRK, except that
the epithelium is replaced after surgery.
 Implant
• Refractive intraocular lens (refractive IOL) implantation is an option for patients
with a high degree of myopia or hyperopia.
• Like cataract surgery, it involves removing the patient’s natural lens and implanting
an IOL.
• The IOL implant used is a special lens designed to correct the patient’s refractive
error.
• Refractive IOLs can correct both myopia and presbyopia.
• Phakic intraocular lenses (phakic IOLs) are sometimes called implantable contact
lenses.
• They are implanted into the eye without removing the eye’s natural lens.
• They are used for patients with high degrees of myopia or hyperopia. Unlike
refractive IOLs, the phakic IOL is placed in front of the eye’s natural lens.
 Visual Impairment
• Visual impairment describes vision that cannot be fully corrected by corrective lenses,
medical treatment, or surgery.
• The term visual impairment includes conditions ranging from low vision to the absence
of all vision (total blindness).
• Many terms are used when people refer to visual impairment, including:
1. Low vision refers to impaired vision that cannot be improved by conventional
eyeglasses, contact lenses, medications, or surgery in which some good usable vision
remains
2. Severe visual impairment describes visual impairment in people who are unable to
read ordinary newsprint even with correction. People with a severe visual
impairment may or may not be legally blind
3. Legal blindness refers to central visual acuity of 20/200 or less in the better eye with
correction or a peripheral visual field of 20 degrees or less.
• Most blindness is as a result of common eye diseases, including cataracts, glaucoma,
 Nursing Management: Visual Impairment
Assessment.
• It is important to assess how long the patient has had a visual impairment.
• Recent loss of vision has different implications for nursing care.
• Determine how the patient’s visual impairment affects normal functioning.
• Ask the patient about the level of difficulty involved in doing certain tasks.
• For example, how hard is it for the patient to read, write a check, move from one room to the
next, or view the television?
• Other questions can help determine the personal meaning that the patient attaches to the visual
impairment.
• Ask how the vision loss has affected specific aspects of the patient’s life, whether the patient has
lost a job, or what activities the patient does not engage in because of the visual impairment.
• Determine the patient’s emotional reactions, coping strategies, and support systems.
• The patient may attach many negative meanings to the impairment because of societal views of
blindness.
• For example, the patient may view the impairment as punishment or view themselves as useless
and burdensome
 Planning
• The overall goals are that the patient with impaired vision will
1. make a successful adjustment to the impairment
2. Discuss feelings related to the loss.
3. Identify personal strengths and support systems.
4. Use appropriate coping strategies.
5. If the patient has been functioning at an appropriate or acceptable level, the
goal is to maintain the current level of function.
 Nursing Implementation

Health Promotion
• Encourage the patient with preventable causes of
further visual impairment to seek appropriate
health care.
• For example, the patient with vision loss from
glaucoma may be able to prevent further visual
loss by with prescribed therapies and eye
examinations.
 Nursing Implementation : Acute Care
• Provide emotional support and direct care to the patient with recent visual impairment.
• Allow the patient to express fear, anger, and grief.
• Help the patient identify positive coping strategies.
• Caregivers are intimately involved in the experiences that occur with vision loss.
• With the patient’s knowledge and permission, include caregivers in discussions and
encourage them to express their concerns.
• Many people are uncomfortable around a person with visual impairment because they
are not sure what behaviors are appropriate.
• Being sensitive to the patient’s feelings without being overly worried or smothering the
patient’s independence is vital in creating a therapeutic nursing presence.
• Always communicate in a normal conversational tone and manner with the patient and
address the patient, not the caregiver.
•
Nursing Implementation : Acute Care Cont’d
• . Common courtesy dictates introducing yourself and any other people who approach the patient.
• It is important to say good-bye when leaving the patient’s presence
• Making eye contact with the patient achieves several goals.
• It ensures that you are speaking while facing the patient so that the patient has no difficulty
hearing.
• Your head position confirms that you are attentive to the patient.
• In addition, establishing eye contact ensures that you can observe the patient’s facial expressions
and reactions.
• Help the patient using a sighted-guide technique.
• Stand slightly in front and to one side of the patient and offer an elbow for the patient to hold.
• Serve as the sighted guide, walking slightly ahead of the patient with the patient holding the back
of your arm.
• As you walk, describe the environment to help orient the patient. For example, “We’re going
through an open doorway and approaching 2 steps down.”
• Help the patient sit by placing one of his or her hands on the seat of the chair
 Ambulatory Care
• In working with the patient who is visually impaired, remember that a person classified
as legally blind may have some useful vision.
• Rehabilitation after partial or total loss of vision can foster independence, self-esteem,
and productivity.
• Know what services and devices are available and make appropriate referrals. For the
legally blind patient the primary resource for services is the state agency for
rehabilitation of the blind.
• A list of agencies that serve the partially sighted or blind patient is available from the
American Foundation for the Blind (www.afb.org).
• Braille or audio books for reading and a cane or guide dog for ambulation are examples
of vision substitution techniques.
• These are usually best for the patient with no functional vision.
• For most patients who have some remaining vision, vision enhancement techniques can
help in learning to ambulate, read printed material, and perform ADLs.
 Optical Devices for Vision Enhancement

A wide range of newer technologies are available to help people with low vision.

These devices include desktop video magnification/closed circuit units, electronic hand-held
magnifiers, text-to-speech scanners (material read aloud to you), E-readers, and computer tablets
(material read aloud, magnification, image zooming, brighter screen, voice recognition).

Many of these devices require some training by an assistive technology professional.

Encourage patients to practice with the technologic device to ensure they can use it successfully.
 Nonoptical Methods for Vision
Enhancement
• Approach magnification is a simple way to enhance the patient’s residual vision.
• Recommend that the patient sit closer to the television or hold books closer to
the eyes.
• Contrast enhancement techniques include watching television in black and
white, using a black felt-tip marker, and using contrasting colors (e.g., a red stripe
at the edge of steps or curbs).
• Increased lighting can be provided by halogen lamps, direct sunlight, or
gooseneck lamps that are aimed directly at the reading material or other near
objects.
• Large font is often helpful, especially when used with other vision enhancement
 Non–24-Hour Sleep/Wake Disorder
• A common problem that can occur in blind people, especially those who are totally
blind, is non–24-hour sleep/wake disorder (Non-24).
• It is a circadian rhythm sleep disorder in which a person’s biologic clock does not
synchronize to a 24-hour day.
• It is caused by lack of light input to the circadian clock.
• People with Non-24 have problems falling asleep or staying asleep at night.
• During the day, they may have an uncontrollable urge to sleep.
• This can result in severe sleep issues, including insomnia, excessive sleepiness,
changing patterns of when a person sleeps, and social and work consequences.
• Taking melatonin can shift the circadian clock earlier (an advance) or later (a delay).
• Tasimelteon (Hetlioz), a melatonin receptor agonist, also can be used for treatment.
• It works by targeting receptors in the brain that control the timing of the sleep/wake
 Evaluation
• The overall expected outcomes are that the patient with visual impairment will:
• Follow treatment plan to prevent further loss of vision
• Be able to use adaptive coping strategies
• Maintain self-esteem and take part in social interactions
• • Function safely within her or his own environment
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