Post on 22-Dec-2015
Disorders of the Eye
Objectives
• Describe common disorders of the eye
• Describe inflammatory conditions of the lid, conjunctiva, and cornea
• Describe the clinical manifestations of common disorders and inflammatory conditions of the eye
Objectives
• Discuss nursing assessment and nursing interventions for eye conditions
• Discuss Diagnostic Tests, medical management, and prognosis for eye conditions
• Discuss patient teaching needs
Blindness and Near-Blindness
• Etiology/pathophysiology• Loss of visual acuity that ranges from partial to
total loss of sight (includes no light perception)–Functional blindness = some light
perception but no usable vision
Blindness or Near-Blindness
• Can be: Congenital or Acquired
• Legal blindness refers to a maximum visual acuity of:
–20/200 with corrective eyewear (normal 20/20)
–Visual field range less than 20 degrees (normal 180)
Blindness or Near-Blindness
– Congenital blindness results from various birth defects
– Acquired blindness in adults:• Diabetic retinopathy• Glaucoma• Cataracts• Retinal degeneration• Acute trauma
Blindness or Near-Blindness
• Acquired Blindness – Clinical manifestations/assessment
• Diplopia• Pain• Floaters and light flashes• Pruritus; burning of the eyes• Loss of peripheral vision• Halos (rainbow colors seen around lights)• A sense of orbital pressure• Bulging of the eyes• Difference in appearance of an eye structure• Emotional symptoms
Blindness or Near-Blindness
• Medical Management– Corrective eyeware– Assistive devices such as canes, guide dogs,
magnifying systems, and telescopic lenses– Surgical correction
Nursing Implications, Considerations, and Responsibilities
Blindness or Near-Blindness
• Assessment– Note patient complaint of blurred vision– Determine onset, severity and duration of
symptoms– Note any factors that relieve symptoms– Observe for squinting and rubbing the eyes– Note compensation measures (eg. Use of
magnifying glass)– Impaired self-care
Effect of Visual Impairment
• Mild losses may require only some adaptations
• Serious losses affect independence, mobility,
employment, and interpersonal relationships
People grieve for the lost function just as they might grieve after the death of a loved one
• Factors that affect a person’s response to this loss include personality, usual coping style, effect of vision loss on the person’s life, and the circumstances of the loss
Care of the Visually Impaired Patient
Be aware of visually impaired person’s thoughts and feelings about handicaps/disabilities
Assume that people with visual impairments can be independent and productive
The person needs help with some tasks but should be treated as an adult
The extent of vision loss determines the types of assistance needed
Care of the Visually Impaired Patient
• Interventions– Comprehensive approach– Educate, Assist, Counsel– Prevention of complications
• Nursing Diagnosis (AEB, R/T)• Risk for Injury r/t environmental hazards• Disturbed Sensory Perception • Ineffective Coping Self-Care Deficit • Ineffective Therapeutic Regimen Management
Figure 51-11
Refraction
• Light rays bend (refract) as they pass through the lens
• Enables light from the environment to focus on the retina
• Refractory errors indicate that the light is not hitting the correct spot on the retina
Refractory Errors
• Etiology/pathophysiology of common refractory errors
• Astigmatism – defect in the curvature of the eyeball surface
• Strabismus—inability of the eyes to focus in one direction; cross-eyed
• Myopia - nearsightedness; eyeball is elongated• Hyperopia - farsightedness; eyeball is too short
Astigmatism
•Clinical Manifestations: – Blurring of vision = primary manifestation
– Assessment: not c/o eye discomfort; mainly blurring, difficulty focusing
– Diagnostic Tests: opthalmoscopy, retinoscopy, visual acuity test, and refraction tests.
Astigmatism
•Medical Management: – corrective eyewear – surgical correction
Nursing Intervention and Patient Teaching:Assistance with ADLs prnMake sure eyewear is cleanSafety when eyewear is not worn
Strabismus
• Strabismus: inability of the eye to focus in the same direction [“cross-eyed”]– Clinical Manifestations: eyeball position is not
symmetrical d/t neurological or muscular dysfunction
– Assessment: c/o difficulty in following an object; same is observed
– Diagnostic tests, Medical Management, and Nursing Interventions: same as for Astigmatism
MyopiaThe medical term for nearsightedness The lens is situated too far from the retina Light rays come together to focus in front of the
retina instead of on the retinaThe retina only receives a fuzzy image
People with myopia have difficulty seeing distant images clearly
Snellen test useful New glasses needed approximately every 2 yearsRefractory surgery: ages 20-60
Myopia
• Medical Management– Keratorefractive Surgery
• Surgery to alter the corneal curvature• Surgeon uses a special microsurgical knife or laser
to open and replace a flap of corneal tissue
– Photorefractive Keratectomy (PRK)• Laser is used to reshape the corneal surface• LASIK (Laser-in-situ Keratomileasis)
Myopia
• Nursing Intervention and Patient Teaching– Preop – Instruct pt. to stop wearing hard
contact lens 1-2 dayss before surgical evaluation
• Eye drop routine
Myopia– Post Op
• Eye patch post op• Can be up and around at home though should
be encouraged to rest the first day• Assistance PRN• Medication Instruction: oral analgesics• Instruct s/sx complications: infection, when to
contact MD• Reinforce need to keep MD follow-up
appointments– Usually seen the next day; then at 1 week post-op;
then monthly for 1 year
Hyperopia
• Commonly known as farsightedness• The lens is too close to the retina• Light rays come together behind the retina
producing a fuzzy image
The hyperopic person sees clearly in the distance but has difficulty focusing on close objects
• Convex corrective lenses needed• Diagnostic tests, medical management, Nursing
interventions same as for Myopia. Pt. Teaching: care of corrective lenses or contact lenses
Amblyopia
• Commonly referred to as “lazy eye” - an inaccurate label
• Poor vision due to brain favoring one eye. The weaker eye tends to wander inward or outward even with correction
• Common in children• Diagnosis confirmed when decreased visual
acuity cannot be explained by an organic cause.• Treatment: corrective eyewear; eye patches to
make the weaker eye work
Presbyopia
• Inability to focus on close objects• Poor accommodation due to loss of elasticity of
the ciliary muscles – Accommodation: adjustment of the lens for
near and distant vision– Contraction or relaxation of the ciliary
muscles, which causes the lens to change shape
• It most often develops after age 40 • Corrective lenses are needed
Refractory Errors
• Diagnostic tests• Opthalmoscopy
• Retinoscopy
• Visual acuity tests
• Refraction tests
Inflammatory Disorders of the Eyelid
Blepharitis
• Inflammation of eyelid along eyelid margin
• Ulcerative Blepharitis: Caused by bacteria, most
often by staphylococci
• NonUlcerative Blepharitis: caused by psoriasis, seborrhea, or allergic response
Blepharitis
• Symptoms:– Erythema of eyelid– Eyelid pain– Photophobia– Scales or crusts on the lid margins– Excessive tearing in nonulcerative type
Blepharitis
• Assessment: – Ulcerative type: pt. c/o eye itching, lids adhering
together during sleep
– NonUlcerative: red eyes, patient rubs eyes, sensitivity to light, tear spillage
Blepharitis
• Medical Management:
– Antibiotic ointment (Erythromycin) – NOTE: Be certain that any medication
applied to the eye is an ophthalmic preparation
• Eyelids can be gently cleansed with baby shampoo solution
Nursing Interventions and Patient Teaching
– Primary Objective prevention of spread of infection
– Instruct on use of prescribed eye drops or ointment
– Teach Handwashing, avoidance of irritating perfumes or smoke. The use of make-up should be avoided until all inflammation subsides – then use NEW make-up
Hordeolum
• Commonly called a “stye” • Acute staphylococcal infection (abcess) of the
eyelid margin that originates in a lash follicle or sebaceous gland of the eyelashes
• Affected area of lid is red, swollen, and tender • Treatment - Apply warm, moist compresses several
times a day 10-20 min• Repeated infections may be related to
staphylococcal infections at some other location on the body
• Physician may treat with ophthalmic antibiotics
Chalazion
• Inflammation of the meibomian (sebum) glands in the eyelids (may become a cyst)
• Swelling prevents fluid from leaving the glands, causing tenderness
Treatment:• Warm compresses may bring some relief • Physician may order antibiotics if infection is
present • Surgical removal of the gland necessary if
condition persists
Conjunctivitis
• An inflammation of the conjunctiva caused by:
• Bacterial or viral infection• Allergy• Environmental factors• Commonly called pink eye
Conjunctivitis
• Bacterial Conjunctivitis – Caused by streptococcal, staphlococcal,
gonococcal, pneumococcal, chlamydial organisms
– HIGHLY CONTAGIOUS!– HANDS are the most common transmitters of the
bacteria• Infected people should practice good hand
washing and should avoid sharing washcloths
Conjunctivitis
• Symptoms:– Red conjunctiva, – Mild irritation (gritty feeling) – Edema of eyelid
– Drainage overnight (crusty)
• Diagnostic Test: conjunctiva scraped for bacteria and stained for microscopic exam
Nursing Interventions and Patient Teaching
• Treat with warm compresses and topical antibiotics
• Cleanse lid and lashes with NS• Warm compresses 2-4x/day• When allergies are present: cold compress to
reduce edema• Eye irrigations
– Gentamycin, Erythromycin, Tobramycin, Ciprofloxacin
Nursing Interventions and Patient Teaching
– Instruct client to avoid contact with eyes or soiled material when infection present. Use individual washcloths
– Wash hands before treatment, and when contact is made with eyes **WEAR GLOVES!
– Avoid noxious fumes and smoke– Avoid using contact lenses during the
inflammation period
Conjunctivitis
• Viral conjunctivitis • Caused by: herpes simplex virus type 1, herpes
zoster virus, or Chlamydia trachomatis– Characterized by redness and drainage – Round, raised white or gray areas on the
conjunctiva – Infections caused by herpes simplex virus type 1
are treated with antiviral ointments (Acyclovir) or other topical medications
Keratitis
• Etiology/pathophysiology• Inflammation of the cornea• Due to: Injury, irritants, allergies, viral infection,
or diseases• Ulcers may form in the eye membrane layers scattered scarring of the corneal surface
• Pneumococcus, staphylococcus, streptococcus, and pseudomonas are most common types of bacterial causes
• Herpes simplex is most common viral cause
Keratitis
• Clinical manifestations/assessment• Severe eye pain• Photophobia• Tearing• Edema• Visual disturbances (could result in vision loss)
Keratitis
• Assessment: c/o pain, light sensitivity, any vision loss; observe patient for facial grimacing, lacrimation, and photophobia
• Diagnostic tests• C& S• Staining• Opthlamoscope exam
Keratitis
• Medical management• Topical and possible systemic antibiotics,
antivirals, or antifungals (for severe cases)• Analgesics• Pressure dressings• Warm or cold compresses• Epithelial debridement• Keratoplasty (if permanent damage to cornea)
Keratitis
• Nursing Interventions and Patient Teaching• Control of pain• Safety• Prevention of complications• Provide information on self-care of corneal
abrasion• Instruction on instillation of medication• Instruct when to call MD
Keratitis
• Prognosis: • When treatment begun promptly: rapid
healing with minimal visual impairment
• Chronic keratitis with tissue and vision loss if delayed
Corneal Opacity
• Inflammation and infection– When cornea injured by infection or trauma, scar
tissue may form – If scar tissue prevents light from entering the eye,
varying degrees of vision impairment occur
Corneal Opacity
• Medical Management– Only treatment is keratoplasty (removal of the
scarred cornea and replacement with a healthy cornea)
– During keratoplasty, damaged cornea removed first• An identically sized graft then taken from the
donor eye and secured to the recipient’s eye with very fine suture
Figure 51-14
Nursing Implications
Care of the Patient Having Keratoplasty
• After surgery, the keratoplasty patient has an eye pad and a metal shield over the operative eye
• Position supine or non-operated side • Avoid lifting or straining for 1 month post op• Corticosteroid eye drops may be ordered to
reduce inflammation– Other eye drops; protocol
Care of the Patient Having Keratoplasty
• Assessment– Inspect dressing for drainage and ask if patient has pain or
nausea – After dressing is removed, inspect for corneal opacity– Also evaluate the patient’s visual acuity – Healing is slow
• Nursing diagnoses(r/t, AEB)– Risk for Injury – Pain – Impaired Sensory Perception – Ineffective Therapeutic Regimen Management
Figure 51-15
A. Normal appearance a post-keratoplasty B. Acute corneal rejection
Disorder of the Lens
Cataracts
• Etiology/pathophysiology– Noninfectious opacity or clouding of the lens– As a person ages, there is gradual opacification of
the lens– When a cataract develops, the lens becomes
foggy, and vision decreases– Congenital (exposure to rubella); acquired
(systemic disease, toxins, trauma, medication induced) ; senile (age related)
Cataracts• Clinical manifestations/assessment
• Blurred vision; cloudy vision • Seeing spots or ghost images, and floaters• Diplopia• Photosensitivity• Decreased night vision• Opacity in the center portion of lens• Glare • Abnormal color perception
• Visual change is usually gradual– Client notes difficulty in reading, and c/o haziness or fuzzy vision
Cataracts
• Diagnostic Tests: opthalmascope exam or slit-lamp microscopic exam
• Medical Management– Monitoring changes in vision– Surgical removal
• Lens implant &/or glasses
– Complications : Leakage of vitreous humor, hemorrhage into the eye, and opening of the incision
Figure 51-17
Cataracts
• Nursing Interventions and Patient Teaching– Preoperative care – See NCP p. 619
• Eye Drops used before cataract surgery are mydriatics, cycloplegics, antibiotics, and nonsteroidal anti-inflammatory agents
• Administer preop meds• Explain post op procedures and what to expect
Cataracts
• Nursing Interventions and Patient Teaching• Post op Care
• Usually ready to go home within a few hours after surgery• Instruct re: Medications: antibiotic and corticosteroid
drops• Some may have night eye shield• Instruct: Avoid stooping, bending, coughing and lifting
(to avoid increasing the intraocular pressure)• When to notify MD (pain, erythema, drainage, sudden
visual changes)• Avoid direct sunlight
Disorders of the Retina
Diabetic Retinopathy
• Etiology/pathophysiology• A disorder of retinal blood vessels
characterized by: capillary microaneurysms, hemorrhage, exudates, and formation of new vessels and connective tissue in the retina
• Occurs more frequently in patients with long-standing, poorly controlled diabetes mellitus
Diabetic Retinopathy
• Clinical manifestations/assessment– Microaneurysms identified with opthalmoscope– Progressive loss of vision; “floaters” (products of
hemorrhage)
• Assessment: pt. will have varying degrees of visual loss
Diabetic Retinopathy
• Diagnostic Tests: • Opthalmoscopy shows dilated and tortuous
vessels• Slit-lamp exam
• Medical Management• Photocoagulation – destroys new blood
vessels, seals leaking vessels, helps prevent retinal edema by use of laser beam
• Cryotherapy – freezing technique
Diabetic Retinopathy
• Nursing Interventions and Patient Teaching• See p. 630-631 post op photocoagulation,
vitrectomy; cryotherapy, p. 620– Referral to Home Care agency for follow up
after surgery
Age-Related Macular Degeneration
• Etiology/pathophysiology• Slow, progressive loss of central and near
vision due to aging retina. Both eyes usually affected.
• Two types – Wet (exudative)
• Has new vessel growth in the macular region that occurs suddenly
• Macula becomes displaced and scarring occurs• Vision loss is irreversible
Macular Degeneration
– Dry (non-exudative)• Degenerative changes are the cause
– Lipid deposits occur followed by slow atrophy of the macular region
• Clinical manifestations• Upon opthalmic exam “Drusden” appearance: a
yellowish exudate beneath the retinal pigment of epithelium
• Gradual and variable bilateral loss of vision• Color perception may also be affected
Macular Degeneration
• Assessment: Pt. c/o:– difficulty distinguishing colors correctly – gradual loss of ability to see objects clearly– distorted vision – gradual loss of clear color vision– blind spots in the visual fields– a dark or empty area appearing in the center of
vision Note the degree to which the patient can centrally view objects
Figure 51-20
Macular Degeneration
• Diagnostic Tests: ophthalmoscope exam• Medical management/nursing interventions
• Usually no treatment• May use photocoagulation• Low vision aids, special lenses, magnifying glasses are useful• Assess pt. coping• Maximize safety• Assess ability to perform ADLs
• Prognosis: early diagnosis is critical to prevent blindness
Retinal Detachment
• Pathophysiology • Retina separates from the underlying layers of the
eye• Begins when a tear or hole in the retina allows fluid to
collect between the sensory and the pigmented layers The fluid causes the two layers to separate deprives sensory layers of nutrients and oxygen damage to the nerve tissue in the sensory layer partial or complete loss of vision
– Retinal tears may occur spontaneously or as a result of trauma
Retinal Detachment
• Signs and symptoms – A sudden or gradual development of flashes of light,
followed by floating spots, a “cobweb”, “hairnet” and loss of specific visual field
• Assessment: – Pt. c/o of flashing lights unilaterally as well as floaters;
progressive vision restriction in one area– If the tear is acute and extensive, pt. will describe a
sensation like a curtain being drawn across the eye.– Observe pt. for ability to do ADLs and anxiety level
Figure 51-18
Retinal Detachment
• Diagnostic Tests: – Visual Acuity measurements– Opthamoscopy– Slit-lamp exam– Poss. Ultrasound
• Medical and surgical treatment (goal – to seal off the tear or break in the lining) – Laser photocoagulation – Cryotherapy – Diathermy– Scleral buckling
Retinal Detachment
• Nursing care– Before corrective measures, the patient usually is
placed on strict bed rest with the head elevated – Postoperative care essentially the same as for
other patients undergoing eye surgery– Cycloplegic, mydriatic, and anti-infective eye drops– Eye patches; dark glasses
Retinal Detachment
• Nursing Care– Positioning orders may be specific for these
patients (will depend on what was done)– Safety measures– Surgeon prescribes activity limitations– Length of hospitalization depends on location and
severity of the tear, the type of repair, and the surgeon’s routines
Disorders related to Intraocular Pressure
Glaucoma
• Etiology/pathophysiology– An abnormal condition of elevated pressure within
an eye; obstruction of outflow of aqueous humor– Intraocular pressure is above normal – Usually progresses slowly– Peripheral vision is lost first – Field of vision gradually narrows until tunnel vision – Complete blindness eventually occurs
Glaucoma
• Etiology/Pathophysiology cont.– Open-Angle Glaucoma: drainage channels for the
fluid in the aqueous humor become occluded
– Closed-angle Glaucoma: occurs if there is an abrupt angle change of the iris rapid vision loss and dramatic sx.
Glaucoma
• Assessment:• Note time of day when eye pain occurs• c/o peripheral vision loss• maladaptation to darkness• halos around lights • c/o headaches; presence of n/v• Need for frequent changes in eyeglass
prescriptions• Upon exam elevated intraocular pressure
Glaucoma
• Diagnostic tests:– Shiotz Tonometry– Visual Field studies
• Medical Management:– Primary open-angle glaucoma
• Medication Therapy: beta-blockers, miotics, carbonic anyhydrase inhibitors
• Surgery: trabeculectomy; trabeculoplasty
Glaucoma
• Primary (acute) closed-angle glaucoma:– Medications: Osmotic diuretics (Mannitol)– Iridectomy; Trabeculectomy
• Review P. 625-626 Medication Chart
Glaucoma
• Nursing Interventions– Educate about disease process and treatment– Risk for Injury – protect pt. safety– Assess compliance to therapy– Reinforce discharge instructions– Nursing Diagnosis may include:
• Fear and Ineffective Therapeutic Regimen Management
– Pain– Collect data about patient knowledge of the disease and
treatment and patient ability to carry out self-care – “Patient Teaching” P. 627
Corneal Injuries
Corneal Injuries
• Etiology/pathophysiology– Result from injuries to corneal layers of the eye– Foreign bodies are the most common cause– Penetrating injuries are the most serious– Burns from chemicals are considered a medical
emergency– Abrasions or lacerations from fingernails or
clothing
Corneal Injuries
• Clinical manifestations• Pain with movement of eye• Excessive tearing; pruritus• Acute pain and burning with any topical burn to
the eye• Erythema of conjunctiva
Corneal Injuries
• Assessment:• Note time and type of injury• Degree of severity of eye pain• Any first aid treatment provided• Observations of the foreign body and extent of damage
including fluid leakage• For burns, type of chemical involves• Assess condition of eye and surrounding tissue
• Diagnostic Tests: visual and opthalmoscopic exam; flouresein staining, peripheral vision tests, slit-lamp exam.
Corneal Injuries• Medical management/nursing interventions
• Foreign bodies: – Flush with normal saline or water– Antibiotic drops or ointment
• Burns– Prolonged tap-water flush immediately– Antibiotics topically
• Penetrating wounds– Do not remove object if present– Protect object
– Cover both eyes ( e.g. styrofoam cup)
Corneal Injuries
• Nursing Interventions and Patient Teaching– See above Medical Management for response to the
different injuries– Assess ability of patient and/or family to apply
ointments and dressings; warm or cool compresses– Instruct re: proper handwashing technique– Instruct re: environmental changes to avoid recurrence
of future episodes– Reinforce follow-up visits with MD– Referral to Home Health care prn
Protection of the Eyes and Vision
• Patient teaching– Adults younger than 40 years of age should have
their eyes examined every 3 to 5 years – After the age of 40, examinations every 2 years
and should include testing for glaucoma – When there are symptoms of eye problems,
patients should seek medical advice
Protection of the Eyes and Vision
• Prevention of injuries– Teach young children the danger of throwing or
poking objects at the faces of playmates – Assess toys for safety – Adult activities that produce sparks or cause
fragments to be dispersed also cause injuries – Advise protective eyewear for such potentially
dangerous activities
Protection of the Eyes and Vision
• Basic eye care– Wash hands before administering eye drops – Gently cleanse the eyelids each time the face is
washed; use a clean cloth without soap – Wash eye from medial to lateral
Visual Field Deficits
May be caused by:• Cataracts• Tumors• Vascular lesions (atherosclerosis, CVA)• Demyelination of the neural pathways
– Retina– Optic Nerve– Visual Cortex of the brain (occipital lobe)