Eye Disorders

STRUCTURE OF THE EYE

• Conjunctiva
o Barrier

• Ciliary Body
o Produces aqueous humor – R/T intraocular pressure 10-21mgHg

• Canal of Schleman
o Drains fluid ant.

• Iris
o Color part of eye; vasculorized, pigmented

• Pupil
o Dilates and constricts response to light – SNS dilator muscle – PSNS sphincter muscle

• Lens
o Colorless, biconvex; avascular no nerves or pain fibers

• Cornea
o From anterior portion and main refracting surface

• Anterior Chamber
o Aqueous Humor – Nourishes cornea

• Posterior Chamber
o Aqueous Humor – Vitreous humor; manuf. Aqueous fluid

• Retina
o Neural tissue

• Choroid
o Between retina and sclera; vascular tissue; supply blood to sensory retina

• Sclera
o Shape eyeball protects intraocular contents

• Optic Nerve
o Enters retina through optic disk

• Central Retina Vein/Artery

• Macula
o Responsible for central vision

• Vitreous Humor
o Post. To lens; help maintain shape

• Ocular Fundus
o Largest chamber; contains vitreous humor

• Miotic Agents:
o Pupillary constriction
REFRACTORY DISORDERS
• Light enters the eye through the lens, what-ever image we see that image being transfetted
via optic system onto the retina (actually see)
• Light needs to focus ON the lens to be normal vision
• Will not likely be hospitalized, will be take care of in Dr’s office
• Can be found in health fairs, or any type of vision screening

MYOPIA – NEARSIGHTED
• Blurred distance vision
• Light focuses in front of the retina, so it never makes it to the retina where it needs to focus
• Corrected with concave lens, to bend the light so that it will focus on the retina itself
• Radial keratotomy lasik surgery
• When you have myopia and you see things at a distance it looks like one big blob (Tree,
cannot see the leaves)
Signs and Symptoms
• Blurred vision Squinting
• H/A Dizziness
• Clumsiness

HYPEROPIA – FARSIGHTED
• Blurred vision with reading
• Light focus behind retina
• Not unusual for child to have hyperopia until about 7y/o – after that the eye will adjust
• Corrected with convex lens – glasses

ASTIGMATISM
• Irregularity in curve of cornea – Unequal curvature of cornea
• Both distance and near vision will be affected
• Distortion of visual image (Light is bent in different directions)
• Corrected with cylinder eye glasses; rigid or soft contacts

PRESBYOPIA
• Occurs in the aging process
• Lens unable to accommodate or slow to accommodate – blurred
• Will hold whatever they are reading at a distance
o Seen persons > 40y/o
o Corrected with bifocals, trifocals, or bifocal contact lens
o Enlarge fine print with glasses OTC

AMBLYOPIA
• Lazy eye
• Reduced visual acuity in one eye which results when one eye does not receive sufficient
stimulation
• Treatment: Preventable if tx primary defect started before 6 y/o – can be dx at 2 y/o
• May patch the good eye so they have to use the bad eye to make it become stronger.
CATARACTS
• An opaque area of lens that interferes with transmission of light to retina
• Bilateral or unilateral
• Leading cause of blindness
• 3 ½ million cases visual impairment

CLASSIFICATION
Classified according to how they developed
o Congenital
 German measles in 1st trimester of pregnancy; remain stationary (does not
continue to grow) could be bilateral.
 Born with cataract.
o Traumatic
 Direct blow to eye or foreign body; unilateral
o Senile
 Develops after aging (50y/o) 95% all cases; due to chemical changes; loss of
H2O, loss of protein.
 Bilateral
o Metabolic
 Could be bilateral

CAUSES
• Genetic defect
o Occurred in utero due the mother being exposed to diseases during pregnancy

• Aging
• Trauma to the eye
• Retinal Detachment or Myopia can cause cataracts
• Metabolic diseases (DM)
• Viruses
• Exposure to Ultra Violet light (Sun, tanning bed) – Possible develop cataract later in life
• Exposure to toxic fumes or cig. Smoke
• Nutritional factors-*****

SIGNS AND SYMPTOMS OF CATARACTS

• Blurred Vision
• Looking through fog
• If not treated it will result in Blindness
• Decreased Visual Acuity – Gradual loss of vision
• Painless
• The only way a person notices is when they look in a mirror and notice eyes dont look the
same as before
• Poor night vision because when driving the light from the oncoming cars is blinding
• Best driving time is 5:00 to 7:00 because after 7:00 at night their vision is impaired
• Vision sharper with dim lights
• Increased sensitivity to glare
• Read better without glasses; the glasses are not helping their vision
 • Decreased color perception (purple, blue, greens see as shades of gray)

STAGES
• Immature Cataract
o Pupil is not completely opaque
o Will have some visual image it just will not be as clear
o Light able to pass through with image projected with blurred vision
• Mature Cataract
o Complete Opacity
o Light is not able to pass through so they will not have any kind of visual image
• Hypermature Cataract
o The protein in the lens actually begins to breakdown and get into the circulation and that will
obstruct the trabecular meshwork.
o Develop blindness in eye with visual whiteness

DIAGNOSIS
• Visual Acuity
o First test
• Funduscopic exam
o (With Opthalmascope) Distorted reflex; decreased Red Reflex
• Slit lamp exam
o Establishes the baseline. Visualize the Anterior chamber of the eye to determine the exact
location of cataract or if there are other problems that may exist in the eye; also looking for
progression of cataract.

TREATMENT
• No drugs on the market to reduce or make the cataract go away
• The only way to treat is actual surgical removal
• Before surgery they will make glasses stronger (this is not a medical intervention); can use bifocals,
magnifying glass.

PROCEDURES

• Extra Capsulary Extraction (ECCE)

o Remove Cataract – Post chamber intact
o The capsule is left so implant is possible. The lens is placed in posterior portion
o Viscoelastic Gel is injected in the space between the cornea and lens, this prevents the
space from collapsing.
o Then the intracapsule implant is inserted

• Intra Capsulary Extraction (ICCE)

o Cataract as well as the entire lens capsule. (Nucleus, Cortex, and entire capsule) are going
to be removed. Will set them up for some problems later in terms of the interocular lens
implant.
o Will not be a candidate for the interocular lens implant

• Phacoemulsification
o The nucleus and cortex is liquefied by Ultrasonic vibrations crush cataract and suction out
particle.
o Then the implant is placed in because the posterior capsule will be left intact
o More rapid wound healing

• Once the cataract is removed at the same time a lens implant is done
 • Once the lens of the eye has been removed the individual has not accomidating powers of the eye
so the implant is placed in or they receive Aphakic glasses if they are not a candidate for implants,
or they can have contact lens.

LENS REPLACEMENT AFTER CATARACT REMOVAL

• Aphakic Eye Glasses
o Advantage
 Less expensive than implants / contact lens
 Safe due to no R/F rejection
o Disadvantage
 Not attractive, heavy with thick lens
 Loss of peripheral vision*
• Contact lens
o Advantage
 No distortion of vision fields
o Disadvantage
 Good dexterity (manual)
 Corneal abrasion
 Cost of replacement lens / cleaning supplies
 Increase drying of eye*
 Increase R/F Infection
• Intra Ocular Implant
o Advantage
 Good vision with minimal distortion. A 95
 Implant at time of surgery
 95% client satisfaction
Will be fitted with glasses in 4-8 weeks
o Disadvantage
 Increased R/F Rejection
 Is expensive and Correct distance vision only

COMPLICATION OF SURGERY / PRE OPERATIVE

• When they come to the clinic preparing for the cataract extraction you would need to look at home
Meds:
o AntiCoagulant / ASA Need to be off 5-7 days before surgery.
o NSAID’s or Steroid Off of the Medication for 5-9 days prior to surgery.
o Coumadin will have to be stopped several days before surgery and after surgery*******
• When they come in for surgery the Eyes are dilated agent every 10 minutes – 1hr before surgery
X4 doses possible 6 doses.
• Post Op Antibiotic drops / Ointment (Conj. From inner – outer)
o Need to be taught Pre-Op to client and family
o Apply pressure
 Keep duct from tearing
 Blink meds absorbed
• Other Pre Op Teaching
o Eye patch for 24 hours
o DO NOT Bend Over******for about a month or until the suture line had healed or
sutures are dissolved or removed
o Prepare meals before surgery (NO Meals on Wheels)
 Only need for a short time
o Do not get eye wet – Lean back into shower to wash hair – Or No Rinse Shampoo
 o Try not to sleep on affected side – Metal eye shield at night****Wear for about a
month
o Can take any medications that does not have aspirin: Advil, Tylenol
o Position on back or semi-fowlers position not on operative side

POST OPERATIVE
• Check Eye Patch 24-48 hours
• MD checks 24hrs post op
• Complication
o Infection Bleeding Increased IOP Retinal Detachment
• S/S of retinal detachment
• NO reading
• If itches
o Apply cool clothe
• Sit near window with a lot of sun without sunglasses
• Avoid coughing, sneezing
• Prepare food before surgery
• Have emergency numbers next to phone
• Avoid driving and vacuuming
• Tylenol for pain
o Avoid products with ASA

NURSING DIAGNOSIS
• Fear R/T Loss of vision
• Impaired home maintenance
• R/F Injury R/T decreased vision
• Social Isolation R/T decreased vision, fear
• Self care deficit R/T visual impairment
• Knowledge deficit

GLAUCOMA

• Cannot be cured
• Group of difficult disease characterized by damage to optic nerve and loss of vision
• Damage results from an increased ocular pressure
o Normal 10-21 mmHg
o If 25 you would continue to monitor (Glaucoma is not diagnosed not will damage
occur)
 If at 5:00 in the afternoon it is 25 then at 8:00 in the morning it is 15 it is not
Glaucoma
o Concern with 30’s
• Can have a secondary causative agent
• Iris and lens – tracebula meshwork or canal of Schleman (99.9%)
• Episclera veins suparachnoid space

RISK FACTORS FOR GLAUCOMA

• Family history - If family members have glaucoma then you would have pressure checked
every 6 months as a preventative treatment.
 • Age and Race – in African Americans
• Eye trauma
• Myopia are more likely to develop glaucoma
• Past surgery on the eye (Cataract surgery)
• Retinal detachment can cause detachment
• Prolonged use of steroids
o Not a weekly dose every few years, Only if you are on Prednisone for years are you
more succeptable to glaucoma
• Existing health problems: DM, Cardiovascular, Migraine Syndrome

FLUCTUATION OF INTRAOCULAR PRESSURE

• The body is constantly producing aqueous humor so the body has to constantly get rid of it.
o It is excreted by one of two ways 99%
 Trabecular Meshwork
 Canal of Schlem
• Normal pressure is 10-21mm Hg
• Depends on time of day (a.m. in normal range – p.m. may be increased)
o Exertion, Food, and Drugs
• Increases With:
o Blinking
o Tight lid squeezing
o Upward gazing – will increase pressure
o HTN
o Uveitis
o Retinal detachments
• Decreases With:
o Exposure to cold weather
o Alcohol, Heroin, Marijuana
o Fat free diet

TWO TYPES:

1. OPEN ANGLE GLAUCOMA

o Have no idea their pressure has increased GRADUALLY

o Loss of peripheral vision
o Usually bilateral – One eye may be more effected
o Anterior chamber angle open and appear normal
o Fluid move around with movement trabecula meshwork - obstruction
 Protein, RBC, Degeneration of meshwork
o Surgery will open up the trabecular meshwork to create a better flow of AH
o Overproduction aqueous humor
o Obstruction flow of aqueous humor or through trabecular meshwork or canal of S
o IOP increase since aqueous humor cannot leave the eye at the same rate of
production
o Can cause optic nerve damage
o Possible ocular pain, H/A, halos
 o Medical Management: Beta Blockers, Timolol, Betaxolol

2. ANGLE CLOSURE
Clinical Manifestations
o Rapidly progressive Visual impairments / Rapid, sudden onset
o Will experience some symptoms:
 Blurring of vision, Halos around lights, ocular pain, headache
o Displacement of iris against cornea causing narrow angle resulting in obstruction to
outflow of aqueous humor
o Obstruction in aqueous humor outflow due to complete / partial closure of angle from
forward shift of peripheral iris to the trabecula, leading to increased IOP
o Lens is pushed forward to iris cause narrow angle without movement to trabecula
meshwork
o Treated as a medical EMERGENCY

Medical Management
o Carbonic Anhydrase Inhibitors - Diamox – PO
o Beta Blocker – Timolol – top
o Alpha-adrenergic agonists – Apraclondine
o Unresponsive to :Glycerol, Isosorbide, PO or Mannitol, Urea - IV

SIGNS AND SYMPTOMS OF GLAUCOMA

• Halo vision
• Blurred vision with angle closure
• Redness
• Headache and Pain with angle closure - EMERGENCY
• N/V – more with angle closure
• Problems focusing with both eyes
• Loss of peripheral vision when open
• Hard with angle closure

MANAGEMENT OF GLAUCOMA
• Decrease IOP with medication and surgery
• Prevent optic nerve damage

MEDICATION
• The type of glaucoma depends on the medication

• Cholinergics
o Pilocarpine
o Cause papillary constriction  flow aqueous humor
o Will use the remainder of their life or if they build up a tolerance they will switch
meds.
o  vision with dim lights
• Beta Adrengic Antagonist
o Timoptic*, Beta axol
 o  production of aqueous humor; used over a prolonged period of time in order to
reduce pressure. Rest of their life
o Other problem: CHF, Asthma – use with caution
• Carbonic Anhydrase Inhibitors
o Diamox
o PO 250-500mg Q6,8,12hrs
o Angle closure
o Treatment with Epilepsy
• Osmotic Diuretic
o Mannitol
o Given only with angle closure when they come to the Hospital with a medical
EMERGENCY of IOP – this will give a quick response and get their pressure back
down
• DO NOT use OTC eye drops with Increased IOP – Visine, Clear eyes
o Especially Angle closure

SURGERY
• Trabeculotomy
o Makes an opening to accommodate the increase of outflow of AH
• Peripneral Argatomy
o A portion of the iris is removed so the iris is not as large as it was so you don’t have
a blockage of that angle to facilitate an increase of outflow of AH
o A permanent procedure done so blockage does not occur
• Drainiage Implants
o A trench to cause a permanent opening in the persons eye
• Some Laser surgery
o Intense heat used to create opening in anterior chamber angle to Inc. AH outflow
o Used to open up the blocked trabecualr meshwork so there is an avenue for the fluid
to flow through

POST OP TX OPEN – Able to drain (acute)

• Miotic pilocarpine – top CLOSED – Blockage tribecular
meshwork (chronic)
• At least 3 hrs after administration of acetazolamide or timolol

NURSING DIAGNOSIS
• Knowledge Deficit
• Sensory Perception Alteration
• Perceptory Grieving
• Fear R/T Loss of vision
• Anxiety R/T tx plan
• Powerlessness R/T loss of control

NURSING ACTIONS
• Teach  IOP and causes of  IOP – Keep a diary of pressure results
• Inform the client of the degree of vision loss – Done in conjunction with physician
• Medication education
• Observe the person instilling the eye drops to make sure it is done correctly
• Include family
 • Follow up at 6 months
• NO OTC eye drops

5 STAGES DETERIORATION GALUCOMA Did not discuss in class

• Initiating Events
o Illness, emotional stress, congenital narrow angles, long term use of corticosteroids
o Mydriatics – Meds cause papillary dilation
• Structural Alteration Aqueous Outflow System
o Tissue changes and cellular changes
• Functional Alteration
o Increase in Intraocular Pressure or impaired blood flow
• Optic Nerve Damage
o Atrophy characterized by loss of nerve fibers and blood supply
• Visual Loss
o Progressive loss of vision characterized by visual field defects

DIAGNOSIS
• Tonometry (measures IOP)
o Tip pin must rest on eye itself with puff of wind
• Opthalmoscopy – Inspect optic nerve
• Gonioscopy
o Examine Filtration angle of anterior chamber
• Perimetry
o Assess visual field

OCULAR TRAUMA AND TRAUMATIC INJURIES

• Leading cause of blindness among children and young adults – especially males
• Any injury, penetrating or non penetrating that does cause an insult to the eye structure that
can cause visual changes

TYPES OF INJURY
• Mechanical
o Foregin body – woodworking and wood sliver gets in your eye
o Remove by flushing out with water or flip the lid and get a q-tip and remove it
 Irrigate with NS and NEVER PUT PRESSURE on the eye.
o May use an antibiotic ointment and cover the eye with a patch
 Covering with an eye patch is not a pressure dressing
 If being patched to prevent movement both eyes will need to be patched
 If being patched to protect and decrease light one eye will be patched
o Eye drops may be used
• Chemical
o Must Flush for 20 minutes*****
• Penetrating Injuries
o DO NOT remove the object
• Lacerations and Corneal Abrasions
o May have sutures
o Painful with increased tearing
o Eye patches needed; do not apply pressure
 o Antibiotic eye drops
o Observe for ulceration; may be on the eye or under the lid
• Contusions and Hematomas
o Cold compresses for 24 hours then follow with warm compresses after 48 hours

• Will be an Increase in IOP with a serious injury

o Person will experience discomfort for about 24 to 48 hours
• If a minor injury the IOP will not be elevated

• Retinal Detachment
o Most traumatic of all injuries
o Tearing away of retina from Choroid Body (vascular bed)
 Decreases blood flow
 Causes:
• Trauma Cataract surgery Tumors
• Age Neoplasms
• Degeneration of retina due to diabetes Congenital malformations

TYPES OF RETINAL DETACHMENT

• Regamatoginous
o The most common type of retinal detachment
o Caused by trauma and the aging process
• Traction
o Caused by DM
• Combination of both
• You need to know what type of the retinal has been detached

SIGNS AND SYMPTOMS

• Floaters
o Black spots while reading – Pieces of RBC into circulation
• Shadow or curtain falling across line of vision
• Spots on eyes
• Flashes of light
• Blank areas of vision
o Can be looking directly at a person and only seeing half of the persons body.
• Painless

TREATMENT
• Immediate rest
• Bandage both eyes
• Scleral bulking
o MOST COMMON
o Silicone squeeze back together
• Photo coagulation – Laser
• Vitrectomy
• Growth factor
• Cryotherapy: Cold probe touch retina with freeze contact
• Diathermy
 • Intraocular injection of gas bubble:
o Depending on where the retinal detachment is; that will determine the position the
client will have to be in after surgery.
o You must know what portion of the eye that was affected
o Bedrest 24-48 hours
o Both Eyes will be bandaged – because if one is left open and it moves the bad eye
will move and continue to tear the retina.
o Apply pressure and maintain correct position – 2 weeks

POST OP
• Prevent any falls or jarring movement
• Monitor them for purelent drainage (infection)
• Monitor for Nausea and vomiting; if it increases you have a problem that is going to have to
be dealt with. So don’t give phenergan or zophran. Monitor and make sure it does not
continue.
• Vision will be cloudy until the retinal is reattached
• Teach about things that Increase the IOP
o Discourage watching tv or reading – causes rapid eye movement
• Pain control
• Antibiotic therapy
• Eye drops
INFECTIONS

CONJUNCTIVITIS
• Inflammation of conjunctiva
• Unilateral most of the time

• Caused By:
o Bacteria
 Pink eye caused by staph after influenza
 Gonorrhea at birth
 Contagious and child must be isolated
o Viral
 Infection with human and virus
 Not contagious
o Allergic
 Because contact with allergen (pollens) assess environment
o Trauma
o Chemical Injury
 Cause it to develop

• Signs and Symptoms

o Purulent drainage
 Causes pussing of the eye – The eye is crusted over
 Inner Campus
o Crusting eye lids
 Warm wash cloth
o Itching
 With allergic conjunctivitus
o Tearing
 Any cause
o Pain
 Increases with Bacterial
o Photophobic
 C/O light / sunglasses
o Burning sensation

• Treatment
o Warm moist Saline irrigation – Remove crustation – if home warm tap water
o Antibiotic ointments or bacterial drops – Topamycin, Garamycin
o Warm compresses
o With Bacterial
 Good hand washing
 Cant return to work without clearance from physician
o DO NOT use the same bath towel or wash cloths
o Separate towels, wash cloths