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Eye and Ear Disorders
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Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 58
Assessment and Management of Patients With Eye and
Vision Disorders
Chapter 58
Assessment and Management of Patients With Eye and
Vision Disorders
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
ObjectivesObjectives
• During this session we will:
1.Review the anatomy and physiology of the eye;
2.Discuss assessment of the eye;
3.Discuss common conditions of the eye; and
4.Discuss the management of patients presenting with these conditions.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Cross-Section of the EyeCross-Section of the Eye
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Assessment and Evaluation of VisionAssessment and Evaluation of Vision
• Ocular history
• Visual acuity
– Snellen chart
• Record each eye
• 20/20 means the patient can read the “20” line at a distance of 20 feet
• Finger count or hand motion
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Diagnostic EvaluationDiagnostic Evaluation
• Ophthalmoscopy
– Direct and indirect
– Examines the cornea, lens and retina
• Slit-lamp examination
• Color vision testing
• Amsler grid
• Ultrasonography
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Examination of the External StructuresExamination of the External Structures
• Note any evidence of irritation, inflammatory process, discharge, etc.
• Assess eyelids and sclera
• Assess pupils and pupillary response; use darkened room
• Note gaze and position of eyes
• Assess extraocular movements
• Ptosis: drooping eyelid
• Nystagmus: oscillating movement of eyeball
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Diagnostic EvaluationDiagnostic Evaluation
• Tonometry
– Measures intraocular pressure
• Gonioscopy
– Visualizes the angle of the anterior chamber
• Perimetry testing
– Evaluates field of vision
– Scotomas: blind areas in the visual field
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Impaired VisionImpaired Vision
• Refractive errors
– Can be corrected by lenses which focus light rays on the retina
• Emmetropia: normal vision
• Myopia: nearsighted
• Hyperopia: farsighted
• Astigmatism: distortion due to irregularity of the cornea
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GlaucomaGlaucoma
• A group of ocular conditions in which damage to the optic nerve is related to increased intraocular pressure (IOP) caused by congestion of the aqueous humor
• The leading cause of blindness in adults in the U.S.
• Incidence increases with age
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EatiologyEatiology
• Primary glaucoma
– No evidence of preexisting ocular or systemic disease
• Secondary glaucoma
– Occur from inflammatory processes that affect the eye
– Tumours
– Trauma resulting in haemmorhage (cells obstruct out flow of aquous humor)
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
GlaucomaGlaucoma
• Risk factors
– Family history
– Diabetes
– Hypertension
– African American
• Others
– Older age
– Cardiovascular disease
– Myopia
– Eye trauma
– Prolonged use of systemic corticosteroids
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Normal Outflow of Aqueous HumorNormal Outflow of Aqueous Humor
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Flow of Aquos HumorFlow of Aquos Humor
• Aquos humour produced by ciliary epithelium in posterior chamber
• Flow
– Passes between the anterior surface of the lens and the posterior surface of the iris
– Through the pupil, into anterior chamber
– Filters through the trabecular mesh work
– Enters the canal of schelm
– Then returns to venous circulation
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pathophysiology of GlaucomaPathophysiology of Glaucoma
• Normal IOP is 10-21mm Hg
• In glaucoma, aqueous production and drainage are not in balance.
• When aqueous outflow is blocked, pressure builds up in the eye.
• Increased IOP causes irreversible mechanical and/or ischemic damage.
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Classification/Types of GlaucomaClassification/Types of Glaucoma
• Open-angle
– Chronic open angle glaucoma
– Normal tension glaucoma
– Ocular hypertension
• Close angle (Angle-closure- pupillary block) glaucoma
– Acute angle-closure
– Subacute angle-closure
– Chronic angle-closure
• Congenital glaucomas and glaucoma secondary to other conditions
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Classification/Types Contd.Classification/Types Contd.
• Close angle (narrow angle)- accounts for 5-10% of cases
– Occurs as a result of an inherited anatomical defect
– Causes a shallow/narrow anterior chamber
– Outflow becomes impaired when iris thickens as a result of pupillary dilation
– Blocks circulation between anterior and posterior chambers
– Eliminates or reduce angel where aquos reabsorbtion occurs
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Closed AngleClosed Angle
• Symptoms are related to a sudden increase in IOP:
– occular pain
– Blurred vision
– Pupil may be enlarged
• Symptoms relieved by sleep. If prolonged
– Eye becomes reddened with corneal oedema (eye has hazy appearance)
– Headache
– Nausea and vomiting may occur
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Open angleOpen angle
• Most common form of glaucoma
• Manifests after 35 yrs. of age and incidence of .5 to 2% in persons 40yrs. and older.
• Increased IOP occurs in the absence of obstruction at the iridocorneal angle
• Occurs as a result of an abnormality in the trabecular meshwork that controls the flow of aquos humor in the canal of schelmm
• Usually asymptomatic
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clinical ManifestationsClinical Manifestations• Asymptomatic
– unaware of the condition until there is significant vision loss
• peripheral vision loss, blurring, halos, difficulty focusing, difficulty adjusting eyes to low lighting
• May also have aching or discomfort around eyes
• Headache
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Diagnostic FindingsDiagnostic Findings
• Tonometry to assess IOP
• Opthalmoscopy to inspect optic nerve
• Gonioscopy to assess the angle of the anterior chamber
• Perimetry to assess visual fields
• Progression of visual field defects
• Optic nerve damage presents with
– Pallor and cupping of optic nerve
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
ManagmentManagment
• Medical Management
– Prevention of optic nerve damage
– Life long therapy required
• Pharmacotherapy
• Aim to increase outflow of fluid
– Miotics eg pilocarpine
– Adrenagic agonists eg epinephrine
• Increases production of aquos out flow
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Pharmacologic therapyPharmacologic therapy
• Decreases aquos humor production
– Beta blockers eg. timoxin
– Carbonic anhydrase inhibitors eg. Methazolamide
– Alphaadrenagic agonists eg. brimomidine
• Prostaglandin analogs
– Increases uveosceral outflow
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
GlaucomaGlaucoma
• Surgical
• Depends on cause of increase in IOP
– Trabeculoplasty: opens intratrabecular spaces & the canal of schelm
– Iridotomy: opening in iris to correct papillary block
– Filtering procedures drain aqeous humour into subconjuctival space
– Tribeculectomy: removal of part of the trabecular mesh work
– Drainage implant or shunts
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ComplicationsComplications
• Burns to cornea, retina or lens
• Uveitis
• Closure of iridotomy
• Transient increase in IOP
• Hemorhage
• Cataract formation
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing ManagementNursing Management
• Patient education.
• Adherence to therapy and continued care to prevent further vision loss
• Provide education regarding use and effects of medications.
• Medications used for glaucoma may cause vision alterations and other side effects
• Provide support and interventions to aid the patient in adjusting to vision loss/potential vision loss.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Discharge PlanningDischarge Planning
• Lifelong therapuetic regime for chronic condition
• Ensure pt. and family understands the disease and how it progresses
• Use of medication
• Effect of medication
• Follow up treatment
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Infectious/Inflammatory DisordersInfectious/Inflammatory Disorders
•Conjunctivitis (“pink eye”)
– Classified as:
•bacterial, viral, fungal, parasitic, allergic, and toxic
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ConjuctivitisConjuctivitis
•Clinical manifestations:
– Foreign body sensation
– Scratching or burning sensation
– Itching
– Photophobia
– Discharge, papillary formation, follicles
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ConjuctivitisConjuctivitis• Bacterial
– Acute or chronic
– Causative agents is strep pneumoniae, haemophilus, influenza and staph. Aureus.
– Onset is acute
– Purulent discharge
• Viral conjuctivitis
– Adeno virus, herpes symplex
– Acute or chronic
– Watery discharge
– Follicles prominent
– pseudomembranes
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
ConjunctivitisConjunctivitis
• Assessment & Diagnostic findings
– Appearance
– Lymphadenopathy
– Presence of pseudo or true membranes
– Eye swab
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ManagementManagement
• Depends on type
• Antibiotic therapy (bacterial)
• Corticosteroids and antihistamines (allergic)
• Education to prevent spread (58:9)
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Inflammatory ConditionsInflammatory Conditions
• Uveitis- an inflammation of the uveal tract– Can affect iris ciliary body, choroid
• Orbital cellulitis- inflammation of tissues surrounding the eye.– Bacterial, fungal, viral
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CataractsCataracts• An opacity or cloudiness of the lens that interferes with
light transmission to the retina.
• Most common cause of age related vision loss
• Increased incidence with aging
• Occur in 50% of persons 65 to 74 yrs. And in 70% of persons 75yrs. and older
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
CataractsCataracts
• Etiology
– Injury to lens
– Aging process, diabetes
– Prolong exposure to ultra violet light
– Radiation
– Drugs (corticosteroids)
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Risk FactorsRisk Factors
• Aging
• Other occula conditions (infections)
• Toxic factors (corticosteroids, smoking)
• Nutrition (poor)
• Physical (trauma, ultraviolet radiation)
• Diseases (diabetes, renal disorders)
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PathophysiologyPathophysiology
• May be unilateral or bilateral
• Can develop in years or in months
• With normal aging the nucleus and cortex of the lens enlarge when new fibres are formed in cortical zone of lens
• Lens protein become more insoluble
• Concentrations of calcium, sodium, potassium and phosophate increases
• Leads to loss of lens transparency
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CataractsCataracts
• Types
– Congenital
– Traumatic/ secondary to disease
• Further categorized by the part of lens that is affected:
– Nuclear cataract formation
– Cortical cataract formation
– Posterior subcapsular cataract
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Clinical ManifestationsClinical Manifestations
• Painless, blurry vision
• Sensitivity to glare
• Reduced visual acuity
• Other effects include myopic shift
• Astigmatism, diplopia (double vision),
• color shifts including brunescens (color value shift to yellow-brown)
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Cataract/ Diagnostic findingsCataract/ Diagnostic findings
• Diagnostic findings include decreased visual acuity and opacity of the lens by ophthalmoscope, slit-lamp, or inspection
• Assessment and Diagnosis
– Visual acuity test
– Opthalmoscopy
– Slit lamp examination
• Medical management
– Use of glasses, contact lens, bifocals to improve sight
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Types of Cataract SurgeryTypes of Cataract Surgery
• Intracapsular cataract extraction (ICCE): removes entire lens, rarely done today
• Extracapsular cataract extraction (ECCE): maintains the posterior capsule of the lens, reducing potential postoperative complications
• Phacoemuslification: an ECCE which uses an ultrasonic device to suction the lens out through a tube; incision is smaller than with standard ECCE
• Lens replacement: after removal of the lens by ICCE or ECCE, the surgeon inserts an intraocular lens implant (IOL). The patient may still require glasses.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing ManagementNursing Management
• Preoperative care
• Usual preoperative care for ambulatory surgery
• Dilating eye drops or other medications as ordered
– Antibiotic drops
– Mydriatics
• Enema to prevent constipation & straining post surgery
• Facial scrub morning of surgery
• Place personal items on bedside of unoperated eye
• Educate on preventing stress on suture
– Rubbing eye, coughing, sneezing,
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Postoperative Care: Cataract SurgeryPostoperative Care: Cataract Surgery
• Eye care: patch and shield is applied to operative eye
• IV is maintained
• Administer eye drops as prescribed
– Anti inflammatory, antibiotic
• allow pt. to rest
• Provide tea, soft meal
– If tolerated IV could be D/C
• Observe pt for severe pain, restlessness, tachycardia
– Inidcates ruptured suture/hemorrhage
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Postoperative Care: Cataract SurgeryPostoperative Care: Cataract Surgery
• Administer analgesics for pain
• If vomiting (can IOP) administer antiemetic
• Advice pt not to sneeze, cough, bending, rubbing eyes
• Teach pt. how to instil drops
• Reorient pt. to environment
• Assist with hygienic needs
• Psychological support to family and pt.
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Postoperative Care: Cataract SurgeryPostoperative Care: Cataract Surgery
• Instruct patient to call physician immediately if vision changes; continuous flashing lights appear; redness, swelling, or pain increase; type and amount of drainage increases; or significant pain is not relieved by acetaminophen