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Ch. 63 eye and vision disorders

Terms in this set (102)

Natural barriers of absorption that diminished the efficacy of ocular medications include:
o Limited size of the conjunctival sac
o Corneal membrane barriers
o Blood-ocular barriers
o Tearing, blinking, and drainage
• Increased tear production, excessive drainage, or excessive blinking may dilute or wash out an instilled eye drop
Aqueous solutions are most commonly used for the eye:
o Topical routes (instilled eye drops and applied ointments) are the most commonly used for ocular disorders
o Least expensive and interfere w/ vision the least
o However, corneal contact time is brief
o Ointments have extended retention time in the conjunctival sac and provide a higher concentrate than eye drops
Major disadvantage of ointments?
blurred vision - can last for a while after application which would be a safety issue
Topical Anesthetic Agents:
o Used before diagnostic procedures or for pts having severe eye pain
o Anesthesia occurs between 20 seconds - 1 minute and can last from 10 - 20 minutes
o Nurses must educate pts to not rub eyes - this can cause corneal damage
o Pts are not usually allowed to take meds home due to risk of overuse - can cause softening of the cornea
o Prolonged use can result in delayed healing & can lead to permanent corneal opacification and scarring, resulting in visual loss
Mydriatic and Cycloplegic Agents
o Usually used in combo for max. pupil dilation
o Educate on the temporary effects: glare, inability to focus properly, difficulty reading
o Effects can last from 3 hours to several days
o Advise to wear sunglasses
o Ability to drive depends on the individual's age, vision, and comfort level
o These agents affect the CNS and are most prominent in younger and older adults - these pts must be assessed closely for symptoms
Mydriatic and Cycloplegic Agents affect the CNS, symptoms include:
• Increased BP
• Tachycardia
• Dizziness
• Ataxia
• Confusion
• Disorientation
• Incoherent speech
• Hallucinations
Mydriatic and Cycloplegic Agents contraindications:
narrow angles or shallow anterior chambers and in pts taking MAOI's or tricyclic antidepressants
Antifungal Meds - Main one is amphotericin B
• Can have serious side effects
Severe pain
Conjunctival necrosis
Inflammation or irritation of the iris (Iritis)
Retinal toxicity
Corticosteroids and NSAIDS
o Used for inflame conditions of eye
o When a suspension is prescribed, instruct pt to shake the bottle prior to use
Most common ocular side effect of long term topical corticosteroid administration include:
• Glaucoma
• Cataracts
• Susceptibility to infection
• Impaired wound healing
• Mydriasis
• Ptosis
• Increase in IOP - reversible after steroid use is discontinued
o To avoid the side effects of corticosteroids, NSAIDS are used as an alternative in controlling inflammation
Anti-allergy Medications
o Common for a pt with allergies
o Not going to get into specific names or brands - just know there are allergy meds for the eye
Ocular Irrigants and Lubricants
May be used to irrigate the eye or for pts with dry eyes such as artificial tears
Nursing Management for Pts Receiving Ocular Medications
• Need to ensure proper administration to maximize the therapeutic effects
• To diminish systemic absorption and minimize side effects, it is important to:
o Put gentle pressure on the inner canthus/puncta of the eye for 1 to 2 mins immediately after instilling eye drops
o Wait at least 5 mins before instilling another eye drop, and 10 mins before instilling another ointment into the eye
• Review medications and side effects and nursing implications for each
GLAUCOMA
• Second leading cause of blindness in adults in the US
• A group of ocular conditions characterized by ocular nerve damage related to increased intraocular pressure from congestion of aqueous humor in the eye
• Aqueous humor flows between the iris and the lens and nourishes cornea and lens, most of the fluid then flows out through the anterior chamber, drains through trabecular meshwork, when it's inhibited from flowing out - pressure builds up within the eye
Glaucoma cont.
• Systemic conditions such as DM, inflammation of the eye and retinal detachment have been associated with increased intraocular pressure
• Increase pressure - damages optic nerve which leads to blindness in pts w/ glaucoma
• Increased IOP damages the optic nerve and nerve fiber, but the degree of harm is highly variable
• No cure for glaucoma, but the disease can be controlled
• Peripheral vision loss - first sign
First sign of glaucoma:
• Peripheral vision loss
Risk Factors of glaucoma:
• Family history
• Thin cornea
• African American race
• Older age
• Diabetes mellitus
• Cardiovascular disease
• Migraine syndromes
• Nearsightedness (myopia)
• Eye trauma
• Prolonged use of topical or systemic corticosteroids
Open-angle glaucoma
draining clogged up
o Increase fluid leads to increased IOP, neuronal ischemia and optic nerve degeneration and eventually loss of vision
Open-angle glaucoma signs and symptoms:
usually painless, loss of peripheral vision, and increased IOP
Angle closure (narrowed angle) glaucoma
angle closed and doesn't allow to drain at all
o Obstruction in aqueous humor outflow due to the complete or partial closure of the angle
o The obstruction results in an increased IOP, damages the retina neuron and optic nerve which leads to blindness
o Can be an ocular emergency - should be treated immediately
Angle closure (narrowed angle) glaucoma signs and symptoms:
eye and face pain, malaise, N/V, colored halos around lights, decreased vision, red conjunctiva, corneal cloudiness
Stages of Glaucoma: Initiating event
Must be an initiating event that causes the increased IOP
o Risk factors listed above, can also include illness, emotional stress, congenital abnormalities, long term use of corticosteroids, and use of mydriatics
Stages of Glaucoma: Structural alterations in the aqueous outflow system
not draining properly or no drainage causes pressure to build up
o Tissue and cellular changes caused by factors that affect aqueous humor dynamics lead to structural alterations and may lead to the third stage
Stages of glaucoma: Functional alterations
The built up pressure causes functional changes
o Conditions such as increased intraocular pressure or impaired blood flow create functional changes that may lead to the fourth stage
Stages of glaucoma: Optical nerve damage
o Atrophy of the optic nerve is characterized by loss of nerve fibers and blood supply
o This fourth stage inevitably progresses to the fifth stage
Visual loss
Progressive loss of vision is characterized by visual field defect - usually starts out with peripheral vision
Tonometry
measures intraocular pressure
Funduscopy
inspection of optic fundus w/ ophthalmoscope
Fundugonioscopy
measures the depth of the anterior chamber and determines open angle from closed angle glaucoma
Visual field testing
- determines degree of visual field narrowing
Glaucoma medications: Main treatment
o Must control increased IOP and prevent optic nerve damage
o Cannot be cured or reversed
o Relies on systemic and topical ocular medications that lower IOP
o Takes into account the patients' health and stage of glaucoma
Glaucoma medications:
o Comfort, affordability, convenience, lifestyles, and personality are factors to consider in the patient's adherence to the medical regimen
Glaucoma medications: Beta Blockers
• Topical - 1st line treatment
• Can produce systemic effects including bronchospasms and heart failure
• Assess for allergies
• Vision may be blurred at first but should clear fairly quickly
Glaucoma medications: Cholinergics (miotics) - Prilocarpine, carbachol
• Prilocarpine can be stored at room temperature for up to 8 weeks and then should be discarded
Glaucoma medications: Alpha-adrenergic agonists - apraclonidine, brimonidine
• Assess for hypertension, dysrhythmias and heart disease - contraindicated in these pts
• Be careful when taking it w/ OTC sinus and cold medications such as Sudafed or pseudoephedrine
Glaucoma medications: Carbonic anhydrase inhibitors
acetazolamide, methazolamide, dorzolamide (-zolamide
Glaucoma medications: Prostaglandin analogs
- latanoprost, bimatoprost (-prost)
• Increase uveoscleral (aqueous) outflow
• Can cause blurred vision and stinging
• Long term use can cause darkening of iris and eyebrows - if color change occurs it is usually permanent
• Important to assess eye color and for eye pain
• Usually take this medication at bedtime
Glaucoma treatment: surgery
Trabeculoplasty; trabeculectomy; gonioplasty; laser iridotomy; peripheral iridectomy
o Will not test on specific surgeries - just know that these are for glaucoma & their purpose
o Purpose - increase drainage of aqueous humor and decrease intraocular pressure
Nursing Management for Pts with Glaucoma: Glaucoma
o Disturbed Sensory Perception: Visual
o Risk for Injury
o Anxiety
Nursing management for glaucoma focuses on:
education, administer meds and monitoring for side effects
Medical management and surgical management:
slows the progression but does not cure it.
nursing management:
• The nature of the disease and the importance of strict adherence to the medication regiment must be included in a teaching plan to help ensure compliance
• The diuretic effect of acetazolamide(Diamox) has an additive effect on the diuretic effects of other antihypertensive medications and can result in hypokalemia
Nursing management:
• Patients need to be cautious in navigating their surrounding
• Severe glaucoma and impaired function - referral to series that assist the patient in performing ADLs may be needed
• Loss of peripheral vision impairs mobility the most - need to be referred for low vision and rehabilitation services
nursing management:
• Legal blindness - offered referrals to agencies that can assist them in obtaining federal assistance
• A lifelong disease involving possible loss of sight has psychological, physical, social, and vocational ramifications
• Because the disease has a familial tendency, family members should be encouraged to undergo examinations at least once every 2 years to detect glaucoma
nursing management stated in lecture:
o Slowly progress unless angle closure glaucoma
o Primary progressive or open angle - treatment education
o Contact physician for over the counter medications
o Nursing interventions - focus on safety
CATARACTS
• Clouding of the lens of the eye that interferes with light transmission
• Light scatters and does not have sharp vision
• Can develop in one eye or both eyes
• Half of all patients over the age of 80 have cataracts
Signs and symptoms of cataracts:
• Painless
• Blurry vision - perceives that surroundings are dimmer, as if glasses need cleaning
• Light scattering
• Experiences reduced contrast sensitivity, sensitivity to glare, and reduced visual acuity
• Myopic shift - return of ability to do close work without eyeglasses
Signs and symptoms of cataracts: cont.
• Astigmatism
• Monocular diplopia - double vision
• Color shift - the aging lens become progressively more absorbent at the blue end of the spectrum
• Brunescens - color values shift to yellow brown
Signs and symptoms of cataracts: cont.
• Reduced light transmission
• Reduce visual acuity - can't see things as clear as before
• Color visualization loss
Assessment and Diagnostic Findings of cataracts:
• Snellen visual acuity test is usually used
• Visual inspection with an ophthalmoscope
• Slit-lamp biomicroscopic exam used to establish the degree of cataract formation
• Amount of cloudiness does not equal the amount vision loss
Surgical Removal Is the Only Treatment for cataracts:
• If have in both eyes, will do one eye at a time - can be weeks to months between surgeries
• Usually performed on an outpatient basis with local anesthesia - usually takes less than 1 hour and discharged in 30 minutes or less
• Lens are broken apart and extracted and they will get some type of lens implant
3 lens replacement options for cataracts:
o Aphakic eyeglasses - lens in them to better vision
o Contact lenses
o Intraocular lens implants - most common
•
Cataract surgery is contraindicated in:
pts with recurrent uveitis, proliferative diabetic retinopathy, neovascular glaucoma, or rubeosis iridis
Potential Early Postop Complication (not on chart) of cataract surgery:
o Toxic Anterior Segment Syndrome - Noninfectious inflammation that is a complication of anterior chamber surgery caused by a toxic agent such as agent used to sterilize surgical instruments
Potential Early Postop Complication (not on chart) of cataract surgery: Cont.
o Effects - Corneal edema less than 24 hours postop
o Symptoms - reduced visual acuity and pain
o Management and Outcome - If there is no growth of microorganism, the treatment is topical steroids alone
Pre-operative care for cataract surgery:
o Routine pre-op labs if going for surgical procedure
o The standard battery of preoperative test that were once required in all cases are prescribed only if they are indicated by the patient's medical history - complete blood count, electrocardiogram, urinalysis
Pre-operative care for cataract surgery: Cont.
o Alpha-antagonist, particularly tamsulosin (Flomax), are known to cause a condition called intraoperative floppy iris syndrome
• Can interfere w/ pupil dilation during surgery, resulting in miosis and iris prolapse and leading to complications
• Can still occur even if the patient has stopped taking the medication
• Nurse needs to ask pts about history of taking alpha-antagonists so surgical team can be alerted
Pre-operative care for cataract surgery: Cont.
o Common practice to withhold any anticoagulant therapy to reduce the risk of retrobulbar hemorrhage for 5 to 7 days before surgery
• A recent study showed that the risk of adverse events for patients who continued anticoagulant therapy before cataract surgery was very low - up to the physician but MUST notify them about this
• Researchers speculated that regular users of aspirin or warfarin are already at higher risk for transient ischemic attacks or angina and suggest that patients may not need to discontinue these medications prior to surgery
Pre-operative care for cataract surgery: Cont.
o Dilating drops are administered prior to surgery
• Every 10 minutes for four doses at least 1 hour before surgery - Additional drops may be administered in the operating room
o Nurses begin pt education about eye medications - Antibiotic, corticosteroid, and anti-inflammatory drops - that will need to be self-administered to prevent postop infection and inflammation
Post-operative care for cataract surgery:
o Receives verbal and written instruction about how to protect the eye, administer medications, recognize signs of complications, and obtain emergency care
o Should be minimal discomfort after surgery - instruct the pt to take a mild analgesic agent, such as acetaminophen as needed
o Antibiotic, anti-inflammatory, and corticosteroid eye drops or ointments are prescribed postoperatively
Promoting home and community based care for cataract surgery:
o To prevent accidental rubbing or poking of the eye, the patient wears a protective eye patch for the first 24 hours after surgery, followed by eyeglasses worn during the day and an eye shield at night for 1 to 4 weeks
o Educate the patient and family about applying and caring for the eye shield
o Sunglasses should be worn while outdoors during the day because the eye is sensitive to light
Promoting home and community based care for cataract surgery:
o Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days
o A clean, damp washcloth may be used to remove slight morning eye discharge
o Because cataract surgery increases the risk of retinal detachment, the patient must know to notify the surgeon if new floaters (dots) in vision, flashing lights, decrease in vision, pain, or increase in redness occurs
Continuing Care for cataracts:
o If an eye patch is worn, it is removed after the first follow up appointment, usually within 48 hours after surgery
o Educate patients on the importance of keeping their follow up appointments
• Monitoring of visual status and prompt intervention of post op complications enhance good visual outcome
Continuing Care for cataracts: cont.
o Vision is stabilized when the eye is completely healed, usually within 6 to 12 weeks, when final corrective prescription is complete
o Visual correctives may still be needed for any remaining refractive errors
o Patients who choose multifocal IOLs should be aware that there may be increased night glare and contrast sensitivity
Diagnoses for cataract:
Decisional Conflict: Cataract Removal and Readiness for Enhanced Self-Health Management
RETINAL DETACHMENT
• Separation of the retina from the sensory layer of eye
• Can occur spontaneously or from trauma to the eye
• Retina allows perception of light - this path is disrupted if the retina is detached
• Several different types - Do not need to know each type of detachment
RETINAL DETACHMENT cont.
• Vitreous humor can shrink with age and can pull retina from back of eye
• Detached retina can increase in size and increase in vision loss
• Must be restored back in contact w/ eye or ischemia can occur which will result in blindness
• Medical emergency - must get it fixed immediately or will result in blindness
Retinal detachment clinical manifestations:
• Sudden onset of floaters or spots
• Sensation of curtain coming across the vision of one eye - going black
• Cobwebs
• Bright flashing light
• May have blurred vision
• Painless
Assessment and Diagnostic Findings for retinal detachment:
• After visual acuity is determine, the patient must have a dilated fundus examination using an indirect ophthalmoscope as well as slit lamp bio microscopy
• Stereo fundus photography and fluorescein angiography are commonly used during the evaluation
Assessment and Diagnostic Findings for retinal detachment: cont.
• Optical coherence tomography and ultrasound are used for the complete retinal assessment, especially if the view is obscured by a dense cataract or virtual hemorrhage
• All retinal breaks, all fibrous brands that may be causing traction on the retina, and all degenerative changes must be identified
Surgical Management:
• Reattach the retina surgically
• Cryotherapy or laser photocoagulation - creates inflammation and adhesion to weld layers back together
• Scleral buckling - causes the fold in sclera to bring the detachment back to contact - contact maintained with a buckle
• Pneumatic retinopexy - air bubble is injected and pushes retina into contact with layer of the eye
Nursing Management for retinal detachment:
• Focuses on educating the patient and providing supportive care
Nursing Management for retinal detachment: Postop for Pneumatic Retinopexy
o Positioning of the patient is critical because the injected bubble must float into a position overlying the area of detachment, providing consistent pressure to reattach the sensory retina
o The patient must maintain a prone position that would allow the gas bubble to act as a tamponade for the retinal break
• Patients with respiratory problems, heart failure, obese pts, etc. will have more difficulty laying prone afterwards
• Must be made aware of the special needs beforehand so that the patient can be made as comfortable as possible
Nursing Management for retinal detachment: Education post surgery
o Activity restriction, no straining to reduce pressure
o Wear an eye shield to protect the eye
o Importance of seeking treatment for changes in vision or any complication such as drainage or pain/pressure that may occur
Nursing Management for retinal detachment: complications
o Increase in IOP
o Endophthalmitis
o Other retinal detachments
o Development of cataracts
• Must be taught the signs and symptoms of complications, particularly of increasing IOP and postoperative infection
• Given telephone numbers and instructed to call immediately if discomfort escalates
• Diagnoses - Ineffective Tissue Perfusion: Retinal and Anxiety
MACULAR DEGENERATION
• Most common cause of vision loss in people over 60
• Pts develop drusen - tiny yellowish spots beneath the retina
o Small cluster of debris or waste material that lie deep within the RPE
o When located in macular area, they can affect vision
Macular degeneration continued:
• Central vision is generally the most affected, with most patients retaining peripheral vision
• Have a wide range of visual loss, but most do not experience total blindness
• Macula is the area of the retina that provides sharp vision, if this area becomes degenerative, then macular degeneration of vision loss occurs
Causes and risk factors of macular degeneration:
• Cause unknown
• Increase age
• Females have higher risk
• Patients who smoke
• Genetics can play a role
• Long term inflammation in eye
Non-exudative/Dry/Non-neovascular macular degeneration (usually occurs slowly)
o Most common type - between 85%-90% of people have dry type
o Outer layer of the retina slowly break down - appearance of drusen occurs
o Drusen outside of the macular area - no symptoms
o Drusen within the macula - gradual blurring of vision that patients may notice when they try to read
o Usually occurs slowly
Exudative/Wet/Neovascular macular degeneration (Abrupt onset)
o Formation of new, weak blood vessels between vessel layers and retina
o New blood vessels are weak and prone to leaking, which interferes with vision
o Repeated bleeding will cause scarring
o Straight lines appear crooked and distorted or that letters in words appear broken
o Blurred vision centrally - peripheral vision usually stays intact
Diagnostic tests for macular degeneration:
• Visual and retina exams
• Fluorescein angiogram done to pass dye through vessels in eye to detect any leaks
Treatments for Non-exudative/Dry Type - No known cure
o Use of antioxidants (vitamin C, vitamin E and beta carotene) and minerals (zinc oxide) in megadoses can slow the progression of AMD and vision loss for people at high risk for developing advanced AMD
Treatment for Wet Type:
Usually targets the development and progression of angiogenesis to prevent leaking from vessels which causes damage
o Can include laser surgery to destroy weak vessels to prevent bleeding
o Photodynamic therapy meds injected that will adhere to new blood vessels and stop leaking
Treatment for Wet Type: cont.
o When administered, light activates the drug and destroys new blood vessels
o After treatment - Avoid direct sunlight or bright indoor light for 5 days
o Newer meds to be given once a month
• ranibizumab (Lucentis)
• aflibercept (Eylea)
Education for macular degeneration:
• Amslers grids - grid with straight line—as long as line are straight vision is fine
o If they see wavy vision is becoming problem
o Report to the physician
o Given to patients to use in their homes to monitor for a sudden onset or distortion of vision
o May provide the earliest signs that macular degeneration is getting worse
o Encouraged to look at grid one eye at a time, several time each week with glasses on
Education for macular degeneration: cont.
• Large print books may help them
• Magnify glasses may be helpful
Orbital trauma:
• Usually associated with a head injury, which MUST be assessed first!
o Assess head injury first (priority), then the eye second
• Soft tissue orbital injuries often result in damage to the optic nerve
• s/s from blunt or penetrating trauma include tenderness, ecchymosis, lid swelling, proptosis or exophthalmos, and hemorrhage
• Closed injuries lead to contusions w/ subconjunctival hemorrhage, commonly known as a black eye
Orbital trauma: cont.
• Management of soft tissue hemorrhage is usually conservative
o Inspection, cleansing and repair of wounds
o Cold compresses are used in the early phase, followed by warm compresses
• Immediate vision loss after injury is usually permanent
• Orbital trauma includes orbital fractures and foreign bodies
Orbital Fractures
o Usually non emergent and require surgical repair
o Detected by facial x-rays
Foreign bodies
o Would do an xray or CT to detect
o Surgical intervention is directed at preventing further ocular injury and maintain the integrity of the affected areas
o Cultures are usually obtained, and the pt is placed on prophylactic IV antibiotics that are later changed to ones in a n oral form
Ocular trauma:
• Occurs with occupations injuries, contact sports, weapons, assaults, motor vehicle accidents, and explosions
• Two main types of ocular trauma include chemical burns and foreign objects in the eye
• Other traumatic eye injuries should be protected using a patch, shield, or a stiff paper cup until can obtain medical treatment
Ocular trauma: Chemical burns
o Immediately irrigate the eye with tap water or normal saline
o pH of the eye should be assessed
Ocular trauma: Foreign bodies
o No attempt should be made to remove it
o The object should be protected from jarring or movement to prevent further ocular damage
o Wouldn't want to put any type of pressure or patch on the affected eye
Medical Management: Splash Injuries
o Irrigate with normal saline before further evaluation occurs
o Further manipulation should be avoided until the patient is under general anesthesia
o Parental broad spectrum antibiotics
o Tetanus antitoxin is administered, if indicated, as well as analgesic agents
o Any topical ophthalmic medication must be sterile
Medical management: Foreign bodies and corneal abrasions
o Removed by the physician
o Antibiotic ointments are applied and the eye may be patched if it's a corneal abrasion
o Contact lens wear is a common cause of corneal abrasion
o Topical anesthetic eye drops must not be given to the patient to take home for repeated use after corneal injury because their effects mask further damage, delay healing, and can lead to corneal scarring
Medical management: Penetrating Injuries and Contusions of the Eyeball
o Most penetrating injuries result in marked vision loss and usually have the following manifestations:
• Edema of the conjunctiva (hemorrhagic chemosis)
• Conjunctival laceration
• Shallow anterior chamber with or without an eccentrically placed pupil
Medical management: Penetrating Injuries and Contusions of the Eyeball cont.
• Hyphema (blood within the anterior chamber) - Can lead to increased IOP - must be monitored closely
Preventing rebleeding and prolonged increased IOP are the goals of treatment for hyphema
• Vitreous hemorrhage - if they have a hemorrhage, Aspirin would be contraindicated
o Surgery may be indicated for some of these injuries
Medical management: intraocular foreign body
Should avoid an MRI because if it's metal it could further damage the patient
Medical management: Ocular Burns or Chemical Burns
o Must test the pH of the solution
o Alkali burns (lye or ammonia) result in the most severe injury because they penetrate the ocular tissues rapidly and continue to cause long-term damage - can also cause increased IOP
o Acids (bleach, car batteries, refrigerant) generally cause less damage because the precipitated necrotic tissue proteins form a barrier to further penetration and damage
o In treating chemical burns - urgency is of importance
Medical management: Ocular Burns or Chemical Burns cont.
o Irrigate with normal saline or tap water if not at the hospital
• Irrigation continues until the conjunctival pH normalizes
• The pH of the corneal surface is checked by placing a pH paper strip in the fornix - normal pH is 7.3-7.6
• Antibiotic agents are instilled, and the eye usually is patched
Medical management: Ocular Burns or Chemical Burns cont.
o A brief history and examination are performed
• Critical information includes the name of the substance that went into the eye
• Material safety data sheets (MSDS) should be accessed for reference as to how to treat that certain chemical
o Prognosis depends on the type of injury and adequacy of the irrigation immediately after exposure
Medical management: Thermal injury
Burns related to heat or reflections from snow, sun gazing, etc.
o Can cause corneal epithelial defect, corneal opacity, conjunctival chemosis and injection (congestion of blood vessels), and burns of the eyelids and periocular region
o Antibiotic agents and a pressure patch for 24 hours constitute the treatment of mild injuries
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