Medical-Surgical Nursing 2 Prepared by Dr. Jhason John J. Cabigon

Special Senses: Nursing Management of Patients with Disorders of the Eyes and Ears

The Eye and Vision

A. Review of Anatomy and Physiology1. External/accessory structures

a. Eyelidsb. Conjunctiva – palpebral and bulbar conjunctivac. Lacrimal apparatus – produces and drains tears, a salty solutiond. Meibomian gland or tarsal glands – sebaceous glandse. Extrinsic eye muscles/Extraocular muscles

Lateral rectus Medial rectus Superior rectus Inferior rectus Inferior oblique – elevate, lateral Superior oblique – depress, lateral* Innervations: all EOMs are supplied by the Oculomotor nerve except for LAST (Lateral rectus by Abducens nerve and Superior Oblique by Trochlear nerve)

2. Tunics of the eyea. Sclera – tough, outer fibrous tunic; anterior modification is cornea (transparent membrane through which light

enters the eye)b. Choroid – middle vascular layer; anterior modifications are ciliary body (secretes aqueous humor) and iris

(pigmented membrane behind cornea)c. Retina – innermost neural sensory layer; which contains photoreceptors: rods (dim light) & cones (color vision &

high visual acuity)3. Visual pathway

a. Corneab. Aqueous humor – fluid of anterior segmentc. Pupil – opening of pigmented irisd. Lens – focus light unto photoreceptorse. Vitreous humor – soft, jelly-like fluid of the posterior segmentf. Retinag. Optic nerve – convergence of nerve fibers from the retinah. Optic chiasmai. Optic tractj. Thalamusk. Optic radiationl. Visual cortex (occipital lobe)

4. Other Internal Structures:a. Ciliary zonule – suspends the lens; attached to the ciliary bodyb. Optic Disk or Blind Spot – site on the retina where the optic nerve leaves the eyeball; does not contain

photoreceptorsc. Macula lutea – lateral to the blind spot; high cone densityd. Fovea centralis – center of macula which contains only cones

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5. Eye reflexesa. Convergence – eyes medial when viewing close objectsb. Light reflex – pupils constrict when exposed to bright lightc. Accommodation – pupils constrict when viewing close objects

6. Error of Refractionsa. Emmetropia – normalb. Myopia – nearsighted; light fails to reach retina; concave lens is usedc. Hyperopia – farsighted; light surpasses retina; convex lens is usedd. Astigmatism – unequal curvature of the cornea or lense. Presbyopia – decreasing lens elasticity that accompanies aging

7. Intraocular pressure – normal: 8-21 mmHg; increase in eye pressure may be due to drainage blockage or overproduction of aqueous humor Flow of Aqueous humor

1. Ciliary body secretes aqueous humor2. Aqueous humor slowly flows through the posterior chamber, around the lens, and through the pupil into the

anterior chamber3. Aqueous humor is drained into the trabecular meshwork into the canal of Schlemm found at the angle of the

cornea; and then enters the venous bloodstream

B. Alterations1. Eye Disorders requiring Surgery

A. CataractB. GlaucomaC. Retinal Detachment

2. Inflammatory Diseases of the EyeA. Superficial Eyelid Infections

Blepharitis Hordeolum (Sty) Chalazion

B. ConjuctivitisC. TrachomaD. Corneal Ulcer

3. Age-related Macular Degeneration4. Strabismus5. Corneal Transplantation (Keratoplasty)6. Refractive Surgeries

A. Photorefractive Keratectomy (PRK)B. Laser-Assisted In Situ Keratomileusis (LASIK)

7. Evisceration/Enucleation/Exenteration

Eye Disorders Requiring Surgery

A. Cataract – clouding, or opacity of the lens that leads to blurring of vision and eventual loss of sight; the opacity of the lens is caused by chemical changes in the protein of the lens because of slow degenerative changes of age, injury, poison or intraocular infection; if untreated, cataracts progress to blindness1. Incidence: occur so often in the aged; at 80 years of age, about 85% of all people have some clouding of the lens2. Risk Factors

a. Diabetesb. Exposure to ultraviolet light or high dose radiationc. Drugs such as corticosteroids, phenothiazines, and some chemotherapy agents

3. Classification of Cataractsa. Senile cataracts commonly develop in elderly patient because of degenerative changes in lens proteins b. Congenital cataracts occur in neonates as genetic defects or possibly from measles in the motherc. Traumatic cataracts may occur after injury sufficient to force vitreous humor into the lens capsuled. Secondary cataracts may occur following other eye or systemic diseases (i.e. infections, DM, radiation,

chemicals)4. Assessment

a. Gradual painless vision loss, blurred or distorted vision b. Pupil may appear milky or whitec. Absence of Red Reflex

5. Diagnosticsa. Snellen’s chart or “ E” chart – reveals blurring of vision; perfect vision is 20/20

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b. Slit-lamp examination provides magnification and confirms diagnosis of an opacity c. Other testing to rule out coexisting condition of the eye; tonometry (to determine if there is increased intraocular

pressure [IOP], direct and indirect opthalmoscopy ( to rule out disease of retina), perimetry (to detect any loss of visual field)

6. Surgical Interventionsa. Surgery is the only cure and is recommended when vision causes problems in daily activities.

Intracapsular extraction – removal of the entire lens (nucleus, cortex and capsule); prior to extraction, enzyme alpha-chymotrypsin is injected in the anterior chamber to weaken the zonular ligaments; uses cryosurgery (lens is frozen with a probe)

Extracapsular extraction is usually done by cryosurgery – capsule is preserved; prior to extraction, a viscoelastic substance (clear gel) is injected into the anterior chamber to prevent collapse of the space

Phacoemulsification under local anesthesia – a type of extracapsular extraction (capsule preserved); uses ultrasonic device that liquefies the nucleus and cortex, which are then suctioned out through a tube

An intraocular lens implant is usually inserted at the time of surgery, designed for distance vision b. Congenital cataract is corrected within first 3 months followed by cataract lens to correct vision c. Nonsteroidal anti-inflammatory agents, antibiotic ointments, and possible corticosteroids may be necessary after

lens implantation to reduce inflammation on other eye structures and prevent infection d. If patient is not candidate for lens implant, the lens and capsule are removed (intracapsular extraction), and eye

glasses and contact lenses are used to correct vision; the patient becomes aphakic (w/o lens)7. Nursing Care

a. Before surgery, monitor for worsening of visual acuity, glare, and ability to perform usual activitiesb. Administer pre-op meds:

Mydriatics (pupillary dilators) – ex. Phenylephrine HCl (Neo-synephrine); SE – headache, BOV, HPN, tachycardia

Cycloplegics (paralyzes muscles of accommodation or ciliary muscles) – ex. Atropine SO4; SE – anticholinergic effects

c. Monitor pain level postoperatively. Sudden onset may be caused by a ruptured vessel or suture and may lead to hemorrhage. Severe pain accompanied by nausea and vomiting may be caused by increased IOP

d. Maintain patient position on his back or on the unaffected sidee. Instruct patient not to cough, sneeze or move rapidly to prevent increase in IOPf. Maintain dressing and eye shield to prevent injuryg. Elevate head of bed 30-45 degrees to prevent increase in IOP h. Assess gradual adaptation to lens implant, contact lens, or glasses i. Keep the patient comfortable and advise him not to touch his eyes j. If eye patch or shield is in place, advise using it for several days as prescribed, to rest and protect eye, especially

at night k. Caution the patient against coughing or sneezing, any rapid moment, bending from the waist to prevent increased

IOP for first 24 hour. Instruct the patient to avoid heavy lifting or straining for up to 6 weeks, as directed by surgeon

l. Advise patient to increase activity gradually; can usually resume normal activity the day after the procedure m. Teach proper installation of the eye n. Encourage to follow up ophthalmologic examinations for corrective lenses and checking of IOP. Adjustment to

eye glasses to correct vision may take weeks o. Advise the patient not to get soap in the eyes p. Advise the patient to avoid tilting the head forward when washing hair, and to avoid vigorous head shaking, to

prevent disruption of the lens until cleared by the surgeonq. Use cataract glasses properly; permanent cataract glasses is prescribed 6-8 weeks after surgery

B. Glaucoma – is a condition marked by high intraocular pressure (IOP) that damages the optic nerve1. Two major forms

a. Acute Glaucoma (or Narrow-Angle or Close-angle Glaucoma) Results when the angle between the iris and the cornea becomes narrowed, restricting or blocking the

drainage of aqueous humor through the trabecular network and the canal of Schlemn. This causes IOP to increase suddenly.

It may result from trauma, stress, or any process that pushes the iris forward against the inside of the cornea when there is already an anatomically shallow anterior chamber.

It is an acute, painful condition that can cause permanent eye damage within several hours.b. Chronic (or Wide-Angle or Open-Angle Glaucoma)

Results from the gradual deterioration of the trabecular network that, as in the acute form, blocks drainage of aqueous humor and causes IOP to increase (imbalance in production and drainage)

If untreated, may result in degeneration of the optic nerve and visual field loss. It is the most common form of glaucoma, and its incidence increases with age. Genetics and conditions, such as diabetes and hypertension, also play a role.

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Precipitated by dark environment, emotional stress, excessive of mydriatics and anti-cholinergics2. Assessment

a. Acute Glaucoma: Sudden onset of severe pain, occurring in and around the eyes due to increased IOP; may transitory attacks. Cloudy, blurred vision; halos or rainbow color around lights. Hazy cornea due to edema; may be profuse lacrimation and ciliary injection. Headache, nausea and vomiting may occur. Pupil is mild-dilated and fixed.

b. Chronic Glaucoma Mild, bilateral discomfort (tired feeling in the eyes). Slow loss of peripheral vision – central vision remains unimpaired; in later stages, progressive loss of visual

field (tunnel vision) Increased IOP causes halos to appear around lights.

3. Diagnosticsa. Tonometry shows elevated IOP in acute and chronic disease.b. Gonioscopy studies the angle of the anterior chamber of the eye in acute disease.c. Ophthalmoscopy may show pale optic disk (acute disease) or signs of clipping and atrophy of the disk (chronic

disease). Dilation of the pupil is avoided if the anterior of chamber is shallow.d. Snellen’s chart

4. Medical Interventiona. In acute glaucoma, emergency drug management is initiated to decrease eye pressure

Parasympathomimetics (carbachol, pilocarpine) may be used as miotics to cause the pupil to contract and draw the iris away from the cornea, thus enlarging the angle and allowing aqueous humor to drain.

Carbonic anhydrase inhibitors (acetazolamide, methazolamide), given orally to depress aqueous humor production.

Beta-adrenergic blockers (betaxolol, timolol), given topically, may reduce aqueous humor or facilitate its drainage.

Hyperosmotics (mannitol, glycerol) increase blood osmolarity and diurese the aqueous humor given I.V.b. In chronic glaucoma, a combination of miotic agent and carbonic anhydrase inhibitor is usually given

5. Surgical Interventiona. Surgery is indicated for acute glaucoma if IOP is not maintained within normal limits by pharmacotherapy and if

there is progressive visual field loss with optic nerve damageb. Types of surgery for acute glaucoma include:

Peripheral iridectomy – Small portion of the iris excised so aqueous humor can bypass pupil. Trabeculectomy – part of trabecular meshwork and iris removed. Argon Laser iridectomy – creates multiple incisions in the iris to create openings for aqueous to flow.

c. Types of surgery for chronic glaucoma include: Laser trabeculoplasty – creates multiple surface burns to increase outflow of aqueous humor; treatment of

choice if IOP unresponsive to medical regimen. Iridencleisis – opening between anterior chamber and conjunctiva to bypass blocked meshwork and allow

aqueous humor to be absorbed into conjunctival tissues. Cyclodiathermy or cyclocryotherapy – super-cooled probe or electrical current used to interfere with ability

to secrete aqueous humor by ciliary body. Corneoscleral trephening (rarely done) – a permanent drainage opening is made at the junction of the

cornea and sclera through the anterior chamber.6. Nursing Care

a. Maintain patient position on his back or on the unaffected side b. Monitor for any pain or visual changesc. Take extra precautions at night (i.e. use of siderails and extra lighting)d. Monitor the patient’s compliance with medications and follow-up care.e. Administer antiemetics as directed to prevent vomiting, which will increase IOP.f. Administer medications I.V., orally or topically, as directed, and explain the importance of medications, the proper

procedure for administration of drops, and possible adverse reactions.g. After surgery, elevate head of the bed 30 degrees to promote drainage of aqueous humor after a trabeculectomy.h. Administer medications (steroids and cycloplegics) as directed after peripheral iridectomy to decrease

inflammation and to dilate the pupil.i. Use an eye patch or shield in children for several days to protect the eye; in adults, patch is usually removed

within several hours.j. Alert the patient to avoid prolonged coughing or vomiting, emotional upsets such as worry, fear, anger; exertion

such as pushing and heavy lifting.C. Retinal Detachment – results from separation of the inner sensory layer of the retina containing the rod and cones from

the outer pigmented epithelial layer beneath or both layers separate from the choroid; it may occur spontaneously Prepared by Dr. Jhason John J. Cabigon 4

because of degenerative changes in the retina (as in diabetic retinopathy) or vitreous humor, trauma, inflammation, tumor, or loss of a lens to a cataract; untreated retinal detachment results in loss of a portion of the visual field1. Incidence: rare in children, the disorder most commonly occurs after age 402. Assessment:

a. Initially, the patient complains of flashes of light, floating spots or filaments in the vitreous, or blurred, “sooty” vision. Most of these phenomena result from traction between the retina and vitreous.

b. If detachment progresses rapidly, the patient may report a veil-like curtain or shadow obscuring portions of the visual field. The curtain appears to come from above, below, or from one side; the patient may initially mistake the obstruction for a drooping eyelid or elevated cheek.

c. Straight-ahead vision may be unaffected in early stages but, as detachment progresses, there will be loss of central as well as peripheral vision.

3. Diagnostics – ophthalmoscopy or slit-lamp examination with full pupil dilation shows retina as gray or opaque in detached areas. The retina is normally transparent

4. Surgical Interventions – aims to reattach the retinal layer to the epithelial layer and has a 90% to 95% success rate:a. Photocoagulation, in which a laser or xenon are “spot welds” the retina to the pigment epithelium.b. Electrodiathermy, in which a tiny hole is made in the sclera to drain subretinal fluid, allowing the pigment

epithelium to adhere to the retina.c. Cryosurgery or retinal cryopexy, another “spot weld” technique that uses a super cooled probe to adhere the

pigment epithelium to the retina.d. Scleral buckling, most common procedure done; in which a buckle (a piece of silicone sponge, rubber or semi-

hard plastic) is placed unto the sclera; forces the pigment epithelium closer to the retina thereby allowing retinal tear to settle against the wall; commonly accompanied by vitrectomy.

5. Nursing Carea. Prepare the patient for surgery.

Instruct the patient to remain quiet in prescribed (dependent) position, to keep the detached area of the retina in dependent position.

Patch both eyes. Wash the patient’s face with antibacterial solution. Instruct the patient not to touch the eyes to avoid contamination. Administer preoperative medications as ordered – 10% phenylephrine + 1% cyclogyl (cycloplegic) + ¼

scopolamine (anticholinergic)b. Take measures to prevent postoperative complications.

Caution the patient to avoid bumping head. Encourage the patient no to cough or sneeze or to perform other strain-inducing activities that will increase

intraocular pressure.c. Position patient on operated sided. Encourage ambulation and independence as tolerated; normal activity in 6 weekse. Administer medication for pain, nausea, and vomiting as directed.f. Apply alternate cold and warm compress over the swollen eyelidg. Provide quiet diversional activities, such as listening to a radio or audio books.h. Teach proper technique in giving eye medications.i. Advise patient to avoid rapid eye movements for several weeks as well as straining or bending the head below

the waist.j. Advise patient that driving is restricted until cleared by ophthalmologist.k. Teach the patient to recognize and immediately report symptoms that indicate recurring detachment, such as

floating spots, flashing lights, and progressive shadows.l. Advise patient to follow up.

Inflammatory Diseases of the Eye

A. Superficial Eyelid Infections1. Types:

a. Blepharitis – infection of the eyelid; crusting eyelid, redness, irritation and mucopurulent secretion b. Hordeolum (Sty) – infection of the eyelid folliclesc. Chalazion – infection of the meibomian gland

2. Nursing Carea. Cleanse eyelid margin by applying warm, moist compress for 5 mins 3-4x daily and ask patient to keep hands

away from eyesb. Carefully wipe loose crust away form eyelids and wash hands after eye carec. Apply antibacterial ointments or drops and continue for several days until infection clears

Ex. Erythromycin, Tobramycin and Gentamycin (Garamycin) ophthalmic ointmentsd. Hordeolum and Chalazion may require oral antibiotics (ex. Cloxacillin)

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e. Chronic chalazion requires incision and curettageB. Conjuctivitis – inflammation of the conjunctiva; most common ocular disease worldwide

1. Also known as “pink eye” because of subconjunctival blood vessel congestion2. Causes

a. Viral – discharge is watery, and follicles are prominent; commonly caused by adenovirus (highly contagious) and herpes simplex virus

b. Bacterial – discharge is mucopurulent; eyes may be difficult to open because of adhesions caused by the exudates; commonly caused by Streptococcus pneumoniae, Haemophilus influenzae and Staphylococcus aureus; profuse and purulent discharge with lymphadenopathy indicates gonococcal conjunctivits; chlamydial conjunctivitis can lead to blindness (refer to trachoma)

c. Allergic – a part of allergic rhinitis or an independent allergic reactiond. Toxic – chemicals

3. Nursing Carea. Frequently administer saline irrigation to remove dischargeb. Apply cold compress for about 10 minutes 4-5x/day to soothe painc. Prevent spread of infection

Avoid sharing toiletries Restrict use of face cloth toward the infected eye Wash hands thoroughly and frequently Discard tissues directly into covered bins; use new tissue every wipe of discharge

d. Instill chemotherapeutic ointment; wash hands before and after application C. Trachoma – a type of chlamydial keratoconjunctivitis;a bilateral chronic follicular conjunctivitis of childhood that leads to

blindness; leading cause of preventable blindness1. Etiology: Chlamydia trachomatis (an intracellular, gram-negative bacterial parasite w/o a cell wall)2. Assessment:

a. Onset is insidiousb. Symptoms

Early Stage: Red and inflamed eyes, chemosis (swelling of conjunctiva), tearing, photophobia, ocular pain, purulent exudates, preauricular lymphadenopathy and lid edema; follicular and papillary formation

Middle Stage: Papillary hypertrophy and follicular necrosis; development of trichiasis (turning inward of hair follicles) and entropion; the lashes then rub against the cornea and, after prolonged irritation, cause corneal erosion and ulceration

Late Stage: Scarred conjunctiva, subepithelial keratitis, abnormal vasculature of the cornea (pannus), and residual scars from the follicles that look like depressions in the conjunctiva (Herbert’s pits); severe corneal ulceration can lead to perforation and blindness

3. Management:a. Tetracycline 1% ointmentb. Topical Gentamycin + Systemic Penicillin (with corneal ulceration)c. Surgical management includes correction of trichiasis to prevent conjunctival scarring

D. Corneal Ulcer – usually due to keratitis (inflammation of the cornea)1. Assessment

a. Painb. Marked photophobiac. Increased lacrimationd. Injected eyee. If iris is involves – Iritis (pus forms in the anterior chamber or hypopyon)f. If corneal ulcer perforates iris prolapsed to the cornea blindness

2. Nursing Carea. Foreign bodies must be quickly removedb. Corneal abrasion must be treated promptlyc. Suggest wearing of dark glasses to relieve photophobiad. Administer mydriatics prior to eye examination; instill anesthetic to relieve pain; Fluorescin to outline ulcere. Administer antibiotic as orderedf. Apply warm compress for comfort

Age-Related Macular Degeneration (ARMD)

A. ARMD – most common cause of visual loss in people older than 60 y/oB. 2 Classic Forms

1. Dry or Atrophic (Non-exudative) – 85-90% of people with ARMDa. Results from atrophy to the retinal pigment epithelial layer below the retina, which causes vision loss through loss

of photoreceptors (rods and cones) in the central part of the eye

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b. The outer layer of the retina slowly breaks down; with this breakdown comes the appearance of drusen (tiny, yellowish spots)

c. When the drusen appear outside the macular area, patients are asymptomatic; when the drusen occur within the macula, there is gradual blurring of vision that patients may notice when they try to read

d. No medical or surgical treatment is available for this condition, however vitamin supplements with high doses of antioxidants (vitamin C, vitamin E and beta-carotene), minerals (zinc oxide), lutein and zeaxanthin and have been suggested

2. Wet (Exudative)a. May have an abrupt onsetb. Patients complain that straight lines appear crooked and distorted or that letters in words appear brokenc. Results from proliferation of abnormal blood vessels growing under the retina, within the choroid layer (choroidal

neovascularization); this vessels can leak fluid and blood, elevating the retinaC. Diagnosis: Opthalmoscopy – appearance of drusen (hallmark) during fundus examinationD. Management

1. Laser Photocoagulation – can destroy abnormal vessels but also causes some retinal destruction (leaving blind spots from the scarred area)

2. Photodynamic Therapy – developed to provide less damage to retinaa. Light-sensitive verteporfin dye is infused IV over 10 minutes b. A diodide laser is aimed at new vessels, which activates the dye, which releases singlet oxygenc. The singlet oxygen is toxic to endothelial cells, shutting down the vessels without damaging the retinad. Nursing Care:

Pre-operatively, advise client to bring dark glasses, gloves, wide-brimmed hat, long-sleeved shirt, slacks, socks and shoes on the time of the procedure (because the light-sensitive dye within the blood vessels near the surface of the skin could be activated with exposure to strong light)

Post-operatively, advise client to avoid exposure to sunlight and bright lights for 5 days after treatment; if patient must go outdoors, advise patient to cover the skin (inadvertent sunlight exposure may lead to severe blistering and sunburn that may require plastic surgery)

Strabismus – “squint” or cross-eyed”; a condition in which the eyes are properly aligned with each other

A. Causes1. Muscle imbalance or paralysis of EOM muscle/s2. Cranial nerve lesion (CN III, IV and VI)3. Brain Tumor4. Myasthenia gravis5. Infection*Normal in young infant but should not persist after 4 months old

B. Types1. Horizontal Strabismus

a. Exotropic – outwards (away from the midline)b. Esotropic – inwards (towards the nose)

2. Vertical Strabismusa. Hypertropia – upwardb. Hypotropia – downward

C. Assessment1. Amblyopia – “Lazy eye”; characterized by poor or indistinct vision in an eye that is otherwise physically normal2. Diplopia3. Uncoordinated eye movements4. Loss of depth perception (loss of ability to see in 3-D)5. Frequent headaches6. Squints or tilts head to look at things7. Permanent loss of vision if not treated early

D. Diagnostics1. Hirschberg Corneal Reflex Test

a. Performed by shining a light in the person's eyes and observing where the light reflects off the corneasb. Normal: light reflects on the center of both corneasc. Positive Test: the reflection is not in the same place in each eye

2. Unilateral Cover Test (Cover-Uncover Test)a. Ask patient to focus on an objectb. Cover the right eye while watching for a movement of the left eyec. Upon removing the occluder, allow your eyes to return to equilibrium then will proceed by covering the left eyed. Positive test: if there is movement on the uncovered eye, it represents squint

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3. Alternating Cover Test – the eyes are rapidly and alternately occluded (from one eye to the other and then back again)

E. Non-surgical Management1. Amblyopia, if minor and detected early, can often be corrected with use of an eyepatch on the dominant eye and/or

vision therapy, the use of eyepatches is unlikely to change the angle of strabismus2. Botulinum toxin (Botox)

a. Classification: Purified Neurotoxinb. Indication: Treatment of disorders of ocular muscle including strabismusc. Action: Temporarily weakens or paralyzes the stronger EOM (need to be repeated 3-4 months later once the

paralysis wears off)d. Adverse Reactions: localized pain, tenderness w/ or w/o bruising, local weaknesse. Nursing Implications: Inform patient that it may cause excessive weakness or atrophy in target muscle

F. Surgical Management – does not change the vision; it attempts to align the eyes by shortening, lengthening, or changing the position of one or more of the extraocular eye muscles and is frequently the only way to achieve cosmetic improvement1. Surgeon loosens or tightens the muscles attached to the eye by changing their length or position; changing the pull of

the muscles can bring the eyes back into line with each other2. A child may need more than one surgery to realign the eyes and improve vision and may have to start or continue

wearing glasses after the surgeryG. Nursing Care – related to negative self-image

1. Emphasize use of corrective lenses of indicated2. Involve patient in classes such as assertiveness, language and social skills3. Provide psychological support (convey confidence and give positive reinforcements)4. Emphasize the need for follow-up

Corneal Transplantation/Keratoplasty

A. Keratoplasty – involves replacing abnormal host tissue with healthy donor (cadaver) corneal tissue B. Indications:

1. Keratoconus (cone-shaped deformity of the cornea)2. Corneal dystrophy (i.e. Fuch’s dystrophy – cells lining the inner surface of the cornea slowly start to die off leading to

blurring of vision)3. Corneal scarring (i.e. herpes simplex keratitis)4. Chemical burns

C. Types:1. Full Thickness Corneal Transplant – Penetrating keratoplasty; the surgeon cuts a circular graft (a "button") from the

donor cornea, which will be fastened to host cornea (after removal of diseased tissue)2. Partial Thickness Corneal Transplant – Lamellar keratoplasty; consists in leaving just the patient's own Descemet

membrane and endothelium, while transplanting approximately 95% of the cornea; advantage – no rejection post-op, faster recovery; disadvantage – vision not as clear as full thickness*5 layers of the Cornea (from anterior to posterior): Anterior Epithelial Layer, Bowman’s membrane, Corneal Stroma, Descemet’s membrane and Endothelium

D. Contraindications to the use of Donor Tissue for Corneal Transplantation1. Death of Donor from unknown cause2. Disease transmission from donor cornea:

a. Infections – Eye infection, Rabies, Viral Hepatitis, HIV, Creutzfeldt-Jakob disease, other viral diseases and terminal septicemia

b. Neoplasms – Leukemia, lymphoma, lymphosarcoma, retinoblastoma, melanomac. Corneal disorder – dystrophies, keratoconus

3. History of eye trauma, corneal scars, previous surgical procedure (i.e. corneal graft and laser-assisted in situ keratomileusis/LASIK)

4. Conditions such as glaucoma, retinal detachment and strabismus can negatively influence the outcome E. Nursing Care

1. Pre-opa. Explain to patient about the procedureb. Explain the local anesthetic regimenc. Administer pre-op meds (myotics, osmotic agents)

2. Post-opa. Eye patch is applied for protectionb. Explain to patient that healing is slow because of vascularity of the cornea (only after several months do patients

start seeing the natural and true colors of their environment)c. Prevent sudden turning of head

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d. Avoid sources of irritants (sneezing, dusting, sweeping, flowers)e. Prevent emotional stress (to prevent increase in IOP)f. Administer post-op meds

Mydriatics for 2 weeks Topical corticosteroids for 12 months – to prevent graft rejection Analgesics (report unrelieved pain because it may indicate that dressing are too tight, graft has slipped or

hemorrhage is occurring)g. Prevent post-op complications

Increase fluids to avoid urinary retention and constipation Prevent infection of eye (avoid touching dressing, use aseptic technique while changing dressings)

h. Introduce activities but avoid those that requires strainingi. Emphasize importance of follow-upj. Watch out for signs of graft rejection (occurs several days to 2 weeks after transplant)

Blurred vision Discomfort Tearing Redness of eye Photophobia

Refractive Surgeries

A. Photorefractive Keratectomy (PRK)1. To treat myopia and hyperopia with or without astigmatism2. The excimer laser is applied directly to the cornea3. The laser reshapes the cornea according to carefully calculated measurements:

a. For myopia, the relative curvature is decreasedb. For hyperopia, the relative curvature is increased

B. Laser-Assisted In Situ Keratomileusis (LASIK)1. An improvement over PRK2. The surgeon creates a corneal flap to expose the corneal stroma, then uses the excimer laser on the stromal bed to

reshape cornea according to calculated measurements3. Less post-operative discomfort, has fewer side effects and faster recovery than PRK

Evisceration/Enucleation/Exenteration

A. Evisceration – removal of the contents of the globe while leaving the sclera and extraocular muscles intact; usually indicated in cases of endophthalmitis unresponsive to antibiotics and for improvement of cosmesis in a blind eye

B. Enucleation – the removal of the eye from the orbit while preserving all other orbital structures; indicated for the above two conditions as well as for painful eyes with no useful vision, malignant intraocular tumors, in ocular trauma to avoid sympathetic ophthalmia (an autoimmune eye disease in which a penetrating injury to one eye produces inflammation in the uninjured eye), in phthisis (involution of the eye) with degeneration, and in congenital anophthalmia or severe microphthalmia to enhance development of the bony orbit

C. Exenteration – the most radical of the three procedures and involves removal of the eye, adnexa, and part of the bony orbit; indicated mainly for large orbital tumors or orbital extension of intraocular tumors

The Ear and Hearing

A. Review of Anatomy and Physiology1. Outer Ear

a. Pinnab. External Auditory Canalc. Tympanic membrane (ear drum)

2. Middle Eara. Auditory ossicles – malleus (hammer), incus (anvil), stapes (stirrup)b. Auditory tube (Eustachian tube) – drains the middle ear of pressure and fluid

3. Inner Eara. Cochlea – contains the organ of Corti (senses sound waves)b. Vestibule – contains Macula (senses Static equilibrium)c. Semicircular canals – contains Crista ampullaris (senses Dynamic equilibrium)

4. Pathway of sound: Pinna External auditory canal Tympanic membrane Ossicles Oval window Cochlea Organ of Corti Auditory nerve Cerebral cortex (Temporal lobe)

5. Deafness:Prepared by Dr. Jhason John J. Cabigon 9

a. Conduction Deafness – sounds through external and middle ears are hinderedb. Sensorineural Deafness – damage to nervous system involved in hearingc. Presbycusis – sensorineural deafness associated w/ aging

B. Alterations1. Infections of the Ear

a. Acute Otitis Mediab. Chronic Otitis Media

2. Meniere’s Disease3. Otosclerosis

Infections of the Ear

A. Acute Otitis Media – infection of the middle ear, usually lasting less than 6 weeks1. Common Pathogens

a. Streptococcus pneumoniae (pneumococcus)b. Haemophilus influenzaec. Moraxella catarrhalis

2. Mode of Transmissiona. Through external auditory canal (because of perforated TM)b. Through eusthachian tube (from the nasopharynx)

3. Assessmenta. Otalgia, which is relieved by spontaneous perforation or surgical incision (myringotomy)b. Feverc. Headached. Conductive hearing loss

4. Risk Factorsa. Age: <12 monthsb. Chronic URTc. Chronic exposure to secondhand smoked. Medical conditions that predispose to ear infections (Down’s syndrome, cystic fibrosis, cleft palate)

5. Diagnostic: Otoscopic evaluation – the TM appears erythematous and bulging; the external canal is normal6. Complications:

a. Mastoiditis (an infection of mastoid process, the portion of the temporal bone of the skull that is behind the ear which contains open, air-containing spaces)

b. Serious intracranial complications (meningitis, brain abscess)7. Management

a. Broad-spectrum antibiotic therapyb. If drainage occurs, an antibiotic otic preparation may be prescribedc. Surgical Management: Myringotomy or Tympanotomy under local anesthesia (incision in the tympanic

membrane) – to allow drainage and relieve pain; the incision heals in 24-72 hours)8. Nursing Care

a. Administer antibiotics regularlyb. Relieve pain (analgesics, warm compress)c. Remind patient not to touch the ear or drainaged. Observe drainage and check for possible bleedinge. Instruct patient to keep ears dry (avoid swimming, plug ears while taking a bath)f. Inform patient about signs of complications (tenderness in mastoid region, persistent headache, nuchal rigidity)

B. Subacute Otitis Media – lasting 3 weeks to 3 months; persistent purulent discharge from the earC. Chronic Otitis Media – result of recurrent AOM causing irreversible tissue pathology and persistent perforation of the TM;

chronic infections of the middle ear damage the TM, ossicles and mastoid bone1. Assessment

a. Symptoms may be minimalb. Varying degrees of hearing lossc. Persistent or intermittent, foul-smelling otorrhead. Pain is not usually experienced, except in cases of acute mastoiditis

2. Diagnostic: Otoscopic evaluation – may show TM perforation and cholesteatoma (a destructive and expanding growth of squamous epithelium in the middle ear and/or mastoid process)

3. Complications:a. Hearing lossb. Untreated cholesteatoma will continue to enlarge causing damage to facial nerve and destruction of other

surrounding structures

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c. Chronic Mastoiditis – may lead to intracranial complications4. Management:

a. Medical – antibiotics and steroidsb. Surgical

Tympanoplasty – surgical reconstruction of the TM Ossiculoplasty – surgical reconstruction of the middle ear bones to restore hearing; prostheses are used to

reconnect the ossicles, thereby reestablishing the sound conduction mechanism Mastoidectomy – to remove cholesteatoma, gain access to diseased structures, and create a dry (non-

infected) and healthy ear; usually performed through a post-auricular incision; types:1. Simple (or closed) mastoidectomy: The operation is performed through the ear or through a cut (incision)

behind the ear. The surgeon opens the mastoid bone and removes the infected air cells. The eardrum is cut (incised) to drain the middle ear. Topical antibiotics are then placed in the ear.

2. Radical mastoidectomy: The eardrum and most middle ear structures are removed, but the innermost small bone (the stapes) is left behind so that a hearing aid can be used later to offset the hearing loss.

3. Modified Radical mastoidectomy: The eardrum and the middle ear structures are saved, which allows for better hearing than is possible after a radical operation.

4. Postero-anterior mastoidectomy: Combination of simple maastoidectomy and tympanoplasty.

Meniere’s Disease

A. Meniere’s Disease – an abnormal inner ear fluid balance caused by a malabsorption in the endolymphatic sac or a blockage in the endolymphatic sac

B. Incidence: Men are slightly more affected than women, occurs at 40-60 y/o (often associated with aging but may also follow middle ear infections and head trauma)

C. Predisposing factors1. An increased pressure in the endolymph2. Sodium retention3. Vasomotor changes4. Spasm of the internal auditory artery5. Smoking6. 30 years old7. Metabolic disturbances, like DM8. Hyperlipidemia9. Obesity10. Allergic reaction11. Emotional reaction, like stress12. Ear Trauma and Infection13. Impairment of microvascular tube of inner ear related to abnormal metabolites such as glucose, insulin, cholesterol

and triglyceridesD. Pathophysiology

1. Endolymphatic hydrops (dilation of endolymphatic space)↓

2. Increased pressure in the system or rupture of inner ear membrane↓

3. Symptoms of Meniere’s diseaseE. Signs and Symptoms

1. Triad of Meniere’s diseasea. Tinnitus – a sensation of ringing, buzzing, or roaring noises in the earb. Vertigo (the most troublesome compliant of patients) – a spinning or whirling sensation that affects the patient's

sense of balancec. Sensorineural Hearing Loss

2. Nystagmus3. N/V4. Anxiety5. Tachycardia6. Palpitations7. Diaphoresis

F. Diagnosis: 1. Weber test – may indicate sensorineural hearing loss (sound may lateralize to unaffected ear)2. Rinne test – may indicate sensorineural hearing loss (air conduction > bone conduction)3. Audiometry – may indicate sensorineural hearing loss

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4. Barany’s Caloric Test – a test for assessing vestibular function in which the ear is irrigated with either hot or cold water, normally stimulating the vestibular apparatus, resulting in nystagmus; a lack of nystagmus indicates impaired vestibular functioning

5. Romberg test – instruct the patient to stand with his feet together and his arms at his side. Have the patient do this with his eyes open and then with his eyes closed; Expect the patient to sway slightly but not fall, if the patient really loses his balance, he may have cerebellar ataxia or vestibular dysfunction

G. Nursing Care1. Comfortable and darkened environment2. Siderails3. Emetic Basin4. Meds:

a. Diuretics – hydrochlorothiazide to remove endolymph (watch out for hypokalemia)b. Antihistamines – meclizine (Bonamine) which suppresses the vestibular system (watch out for sedation)c. Antiemetic – promethazine (Phenergan) to control N/V and vertigo because of its antihistamine effectd. Sedatives/Tranquilizers – diazepam (Valium) a CNS depressant that can also act as an anti-emetice. Vasodilator

5. Restrict Sodium (2000 mg/day) and Glucose6. Limit fluid intake7. Avoid smoking, alcohol and vasoconstrictors (coffee, tea and decongestants)8. Care of patient with vertigo (p. 2114-2118)9. Surgery

a. Endolymphatic sac decompression, or shunting – a shunt or drain is inserted in the endolymphatic sac through a post-auricular incision; first-line surgical treatment

b. Middle and Inner Ear Perfusion – ototoxic drugs, like streptomycin and gentamycin, are infused into the middle and inner ear to destroy vestibular function and decrease vertigo; very successful in treating vertigo, but risk of hearing loss is high

c. Intraotologic Catheters – catheters are used to deliver the medicine directly to the middle ear; path of catheter: external ear canal through or around TM round window niche or membrane

d. Vestibular Nerve sectioning – cutting the vestibular branch of the CN VIII (vestibulocochlear nerve) e. Total Labyrinthectomy

Otosclerosis

A. Otosclerosis – involves the stapes and is thought to result from the formation of new, abnormal spongy bone, especially around the oval window, with resulting fixation of the stapes

B. Causes – remains unknown1. Hereditary2. Hormonal changes with pregnancy3. Viral infections (i.e. measles)

C. Assessment1. Gradual Hearing Loss2. Tinnitus3. Dizziness

D. Diagnostics – reveal conductive hearing lossE. Surgical Management

1. Stapedectomy – removal of stapes superstructure and part of footplate and inserting a tissue graft and a suitable prosthesis

2. Stapedotomy – creates a tiny opening in the stapes, in which to secure a prosthetic

QUICK REVIEW OF SPECIAL SENSES

A. Common Eye Disorders and Characteristic Vision Loss1. Cataract – painless blurring of vision2. Acute glaucoma – painful BOV; halos or rainbow around lights3. Chronic glaucoma – tunnel-like vision (loss of visual field)4. Retinal detachment – floaters; curtain-like or veil-like vision5. Macular degeneration – loss of central vision

B. Cataract – opacity of the lens; most common in the elderly (senile cataract); painless blurring of vision*Surgical Management1. Intracapsular extraction – removal of the entire lens (nucleus, cortex and capsule)2. Extracapsular extraction is usually done by cryosurgery – capsule is preserved

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3. Phacoemulsification under local anesthesia – a type of extracapsular extraction (capsule preserved); uses ultrasonic device that liquefies the nucleus and cortex, which are then suctioned out through a tube

4. Intraocular lens implant is usually inserted at the time of surgery, designed for distance vision*Pre-op Nursing Carea. Monitor for worsening of visual acuity, glare, and ability to perform usual activitiesb. Administer pre-op meds:

a. Mydriatics (pupillary dilators) – ex. Phenylephrine HCl (Neo-synephrine); SE – headache, BOV, HPN, tachycardiab. Cycloplegics (paralyzes muscles of accommodation or ciliary muscles) – ex. Atropine SO4; SE – anticholinergic

effects*Post-op Nursing Care 1. Promote safety – most important2. Monitor pain bleeding and hemorrhage3. Elevate head 30-45o4. Maintain position on back or unaffected side5. Avoid coughing, sneezing, moving rapidly, bending forward, straining increase IOP6. Use of glasses7. Advise eye patch or shield, esp. at night8. Normal activity in 6 weeks

C. Glaucoma – increased intraocular pressure due to blockage of aqueous humor drainage (normal IOP: 10-21 mmHg) *Types:1. Acute – narrow or close-angle glaucoma (sudden, painful condition that can cause permanent eye damage within

several hours); painful BOV; halos or rainbow around lights 2. Chronic – wide or open-angle glaucoma (gradual deterioration of the trabecular network); tunnel-like vision (loss of

visual field)*Diagnostics1. Tonometry shows elevated IOP in acute and chronic disease.2. Gonioscopy studies the angle of the anterior chamber of the eye in acute disease.3. Ophthalmoscopy may show pale optic disk (acute disease) or signs of clipping and atrophy of the disk (chronic

disease); dilation of the pupil is avoided if the anterior of chamber is shallow*Medical Intervention 1. Pilocarpine – miotic (pupilary constrictor) improving drainage2. Timolol – beta-blocker reduce aqueous humor production 3. Acetazolamide – carbonic anhydrase inhibitor reduce aqueous humor production *Surgical Intervention1. Iridectomy – small portion of the iris excised so aqueous humor can bypass pupil2. Trabeculectomy – part of trabecular meshwork and iris removed*Post-op Nursing Care

i. Maintain patient position on his back or on the unaffected side ii. Monitor for any pain or visual changesiii. Take extra precautions at night (i.e. use of siderails and extra lighting)iv. Monitor the patient’s compliance with medications and follow-up care.v. Administer antiemetics as directed to prevent vomiting, which will increase IOP.vi. Administer medications I.V., orally or topically, as directed, and explain the importance of medications, the proper

procedure for administration of drops, and possible adverse reactions.vii. After surgery, elevate head of the bed 30 degrees to promote drainage of aqueous humor after a trabeculectomy.viii. Administer medications (steroids and cycloplegics) as directed after peripheral iridectomy to decrease inflammation

and to dilate the pupil.ix. Use an eye patch or shield in children for several days to protect the eye; in adults, patch is usually removed within

several hours.x. Alert the patient to avoid prolonged coughing or vomiting, emotional upsets such as worry, fear, anger; exertion such

as pushing and heavy lifting.D. Retinal Detachment – separation of retina from the choroid; curtain-like or veil-like vision; floaters (blood cells released

into the eye by the detachment)*Surgical Management1. Photocoagulation, in which a laser or xenon are “spot welds” the retina to the pigment epithelium2. Cryosurgery or retinal cryopexy, another “spot weld” technique that uses a super cooled probe to adhere the pigment

epithelium to the retina.3. Scleral buckling, most common procedure done; in which a buckle (a piece of silicone sponge, rubber or semi-hard

plastic) is placed unto the sclera; forces the pigment epithelium closer to the retina thereby allowing retinal tear to settle against the wall; commonly accompanied by vitrectomy

*Pre-op Nursing Care1. Maintain on bedrest (dependent position)

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2. Patch both eyes (to limit eye movement)*Post-op Nursing Care1. Prevent increase in IOP2. Position on operated side3. Encourage ambulation and independence4. Normal activity in 6 weeks

E. Macular Degeneration – breakdown of retina causing tiny; presence of yellowish spots in the retina (drusen); loss of central vision

F. Hearing Loss*Types:1. Conduction Deafness – External and middle ear affected2. Sensorineural Deafness – Inner ear and nervous system affected3. Presbycusis – sensorineural deafness associated w/ aging

G. Otitis Media – infection of the middle ear*Types:1. Acute OM – <6 wks, painful2. Chronic OM – recurrent OM, typically w/ perforation, otorrhea and cholesteatoma*Complications:1. Hearing loss2. Mastoiditis – swelling and pain behind the ear; unrelieved by myringotomy3. Labyrinthitis – infection of labyrinth leading to hearing loss, nystagmus, tinnitus and vertigo 4. Intracranial infection – meningitis, brain abscess*Nursing Care:1. Administer antibiotics regularly2. Relieve pain (analgesics, warm compress)3. Remind patient not to touch the ear or drainage4. Observe drainage and check for possible bleeding5. Instruct patient to keep ears dry (avoid swimming, plug ears while taking a bath)6. Inform patient about signs of complications (tenderness in mastoid region, persistent headache, nuchal rigidity)

H. Meniere’s Disease – an abnormal inner ear fluid balance caused by a malabsorption in the endolymphatic sac or a blockage in the endolymphatic sac*Triad:1. Vertigo – a spinning or whirling sensation that affects the patient's sense of balance2. Sensorineural Hearing Loss 3. Tinnitus – a sensation of ringing, buzzing, or roaring noises in the ear*Nursing Care1. Safe and darkened environment 2. Restrict Sodium (2000 mg/day) and Glucose 3. Limit fluid intake 4. Avoid smoking, alcohol and vasoconstrictors (coffee, tea and decongestants) 5. Administer meds

a. Antihistamines and anti-emetics – control acute attack of N/V and vertigo (ex. phenergan)b. Sedatives – also anti-emetics (ex. diazepam)c. Diuretic – removes endolymph (ex. HCTZ)

I. Acoustic Neuroma – benign Tumor of the vestibular or acoustic nerve*Assessment1. Tinnitus2. Sensorineural hearing loss3. Facial nerve impingement *Management: Tumor removal (craniotomy)

J. Impacted Cerumen – sensation of fullness w/ or w/o hearing loss*Nursing Care:1. Ear Irrigation – contraindicated in perforated TM and OM2. Soften cerumen:

a. Hydrogen peroxide 3 gtts BIDb. Glycerin or mineral oil 3 gtts qHSc. Irrigate after several days

K. Foreign bodies*Nursing Care:1. Irrigate carefully if vegetable matter2. Kill insect before removal; instill mineral oil or diluted alcohol3. Small forceps to remove object; do not push

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