Visual Problems

8/7/2019 Visual Problems

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Visual Problems

Lana Opea-Meneses


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The Visual System

Complex group of structures that includes the

eyeballs, muscles, nerves, fat, and bones

Ocular adnexa: accessory structures thatsupport and protect the eye (muscles, fat,

bone)


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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 theeye in circular movements to allow vision at all angles


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Eyelids: folds of skin that close to protect the anterioreyeball; prevents evaporation and drying of the surfaceepithelium

Palpebral fissure: elliptic space betw

een th

e tw

o openlids

Canthi: corners of the fissure

Meibomian gland: secretes oil

Lacrimal galnd: produces tears Nasolacrimal duct: directs flow of tears into the nose


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Internal Structures

Conjuctiva: thin transparent layer of mucous

membrane that lines the eyelids and covers the

eyeball

Cornea: transparent, avascular structurewith a

brilliant, shiny surface

Sclera: fibrous protective coating of the eye; whitedense and continuous with the cornea


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Uveal tract: middle vascular layer of the eyethat furnishes the blood supply to the retina

Iris: thin, pigmented diaphragmwith a central

aperture, the pupil; expansion and contration ofthe iris regulate the amount of light entering theeye

Ciliary body: produces and secretes aqueous

humor (clear, alkaline fluid composed mainly ofwater that occupies the space between the irisand the cornea)

Choroid: posterior segment of the uveal tract

between the retina and sclera


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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


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Retina

Thin, semitransparent layer of nerve tissue thatforms the innermost lining of the eye

Contains all the sensory receptors for thetransmission of light and is actually part of thebrain

Rods and cones: retinal receptors

Rods: function best in dim light; damage results tonight blindness; 125 million

Cones: resolution of small visual angles, resultingin perception of fine details; responsible for color

vision; 6 million


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Macula: center of the retina, 5mm in diameter

Fovea: depressed center of the macula; point

of finest vision; damage can severely reducecentral vision


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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


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Common Health Problems of Neonates

and Infants

Congenital Cataract

Strabismus

Retinoblastoma


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Congenital Cataract

Opacity (clouding) of the crystalline lens of the

eye


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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


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Pathophysiology:

Lens of capsule form during the 4th-5th week of

fetal development

Lens are normally clear, allowing light to enter

When factors interferewith lens development, it

becomes milky white and cloudy, obscuring light

and thus vision


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cataract


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Clinical Manifestations

Cloudiness of the lens

Absent or abnormal pupillary reflex


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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


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Through a small incision of around 2 to 3 mm and undertopical 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

h

uman temperature andnicely takes place into the lens bag to position itself

correctly.


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Nursing Management:

Prevent coughing, straining and vomiting to avoid

increase in IOP

Utilize aseptic technique when handling dressings andclosely 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


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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 eyepatching


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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


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Pseudostrabismus: child appears crossed-eyed

because of prominent epicanthic folds and a

flat nasal bridge; disappears as the child grows

old


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Pseudostrabismus vs. Strabismus


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Pseudostrabismus


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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


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Child is clumsy, stumbles often, and has difficulty

picking up objects

Squinting

Persistent crossing of the eyes


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Diagnosis:

Screening at 3-6 months to prevent loss of vision

Hirschberg Corneal Light Reflex Test: light is held

in front of the childs face as the child stares

ahead; light should reflect off the cornea

symmetrically

Cover test: ch

ild looks at a toy, th

e examinercovers one of the childs eye; if uncovered eye

moves, then it can be assumed that it was not

fixed on the toy


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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


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Esotropia


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Exotropia


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Hypertropia


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Medical Treatment

Occlusion therapy: eye patching; stronger eye iscovered to allowweaker eye to work alone for all

or part of each day; most successful when done inpreschool 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)


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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


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Nursing Management:

Stress importance of compliance in promoting

normal visual development

Explain that surgery corrects alignment but not

vision


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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


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Severe Retinoblastoma


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Whitish glow in the pupil

Leukocoria or cats 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


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Leukocoria


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Leukocoria vs. Red Eye Reflex


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Treatment:

Surgery

Radiation therapy

Laser therapy

Cryotherapy (using very cold probes to freeze and

kill the tumor)

Chemotherapy Enucleation: surgical removal of the eye


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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


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Common Health Problems of Adults

Glaucoma

Surgery of the Eye


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Classification

Primary and secondary glaucoma: refer towhether 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


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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 stoppedbecause of obstruction by the trabecular

meshwork


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Angle-Closure Glaucoma

Can develop only in one eyewhen the anterior

chamber angle is anatomically narrow

Occurs due to a sudden blockage of the anterior

angle by the base of the iris


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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


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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


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Clinical Manifestations:

Atrophy and cupping (indentation) of the opticnerve 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; rainbowhalos aroundlight


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Crescent-shaped Scotoma (blind spot)


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Outcome Management:

Facilitate outflow of aqueous humor through

remaining channels and to maintain IOP within a

range that prevents further damage to the opticnerve


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Medical Management:

Reduce IOP (promote aqueous flow): topicalmiotics or epinephrine to constrict pupils in

narrow-angle glaucoma

Topical beta-blockers/ alpha adrenergicagents/ oral carbonic anhydrase inhibitors:

reduces production of aqueous humor


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Nursing Diagnoses:

Disturbed Sensory Perception (Visual) Grieving

Risk for Ineffective Therapeutic Regimen

Management


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Nursing Management:

Obtain accurate list of current medications (suchas 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


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Surgical Management

Laser trabeculoplasty: use of laser to create anopening on the trabecular meshwork


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Trabeculectomy: creation of an opening through

which the aqueous fluid escapes


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Filtering Procedures: trephination, thermal

sclerotomy, and sclerotomy to create an outflow

channel from the anterior chamber into the

subconjunctival space


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Iridotomy:

creation of a new route

for the flow of aqueous

humor to the trabecular

meshwork


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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


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Nursing Management:

Pre-operative care:

Prepare the patient for outpatient or inpatient surgery

E

xplain th

at client may experience popping sounds andflashing 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


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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 avoidpressure on the surgical site

Client may ambulate and eat as soon as effects of

perioperative sedation has worn off

Frequent monitoring ofIOP: continued or

increasing pain, nausea, decreased vision


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Treatment of surgical site

Carefully clean area around eye withwarm 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


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Common Health Problems Across the

Lifespan

Errors in Refraction

Infections and Inflammation of the Eye

Traumatic Injury of the Eye

Retinal Detachment


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Refractive Disorders


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Errors in Refraction

Exists when light rays are not focused

appropriately on the retina of the eye


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Basic Abnormalities

Myopia: nearsightedness, a condition in whichlight rays come into focus in front of the

retina; usually caused by an eyeball that islonger than usual

Hyperopia: farsightedness, a condition inwhich eye focuses light rays behind the eye,

and consequently the image that falls on theretina is blurred


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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


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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 thinlayer 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


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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


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Corneal Ring Implants (In-tacts)

Clear pieces of acrylic that can be surgically

implanted into the cornea

Flatter the cornea and thereby reducenearsightedness


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Nursing Management of the Surgical Patient Assess preoperatively for degree of myopia or

astigmatism (clients with severe refractionproblems may not achieve full correction)

Ensure eye protection by using goggles to preventdry eyes

Tell patient to avoid vigorous activity, activitiesthat could get water inside the eyes, and eyemake-up

Inform patient that steroid eyedrops causewatering of the eye and minimal pain

T ti I j t th E


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Traumatic Injury to the Eye

Corneal Injury

Caused by direct trauma, over-worn contact lens,

chips of flying metal or glass fragments, or dirt


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Manifestations

Painful, profusely lacrimating eye

Bulbar conjunctiva blood vessels will be

prominent


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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



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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


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Dacryocystitis


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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


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Hordeoleum

Hordeoleum


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Hordeoleum


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Blepharitis

Definition: chronic, bilateral inflammation ofthe eyelids

Appearance: itching and burning of the eyes;eyes appear red; scales noted on lashes

Management: wash eyelids with babyshampoo, water, and cotton-tippedapplicators; antibiotic ointments may beprescribed

Blepharitis


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Blepharitis

Blepharitis


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Blepharitis


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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)


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Conjunctivitis (Sore eyes)


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Retinal Detachment


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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 itsblood supply and source of nourishment and

loses its ability to function


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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


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Predisposing factor:

Aging

Cataract extraction

Degeneration of the retina

Trauma

Severe myopia

Previous retinal detachment

Family history of retinal detachment


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Vision in Retinal Detachment


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Surgical Management

General anesthesia is commonly used since

surgery may take hours

Pupils must be dilated No known medical treatment for retinal

detachment


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Laser Photocoagulation

Laser is used to burn the edges of the tear and

halt progression

If the detachment is small, laser can seal theretina against the choroid

OPD using local anesthesia


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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


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Pneumatic Retinopexy

Most effective for detachments that occur in the

upper portion of the eye

Eye is number with local anethesia and a small gasbubble 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


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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


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Scleral buckling


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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 beeninjected

Position patient so that bubble can apply maximalpressure on the retina by the force of gravity

Position, usually head down and to one side,should be maintained for several days


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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 severaltimes a day


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Post-op medications: antibiotic-steroid

combination; cycloplegic agents (dilates pupil

and relax the ciliary muscles, which decreases

discomfort and helps prevent the formation ofiris adhesions to the corneal endothelium)


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