Chapter 42:Caring for Clients with Eye disorders

Cataracts

-A condition in which the lens of the eye becomes opaque -One or both eyes may be affected -If both are affected each eye may progress differently

Surgical Management of Cataracts

-Cant be treated medically and are surgically removed -If a client has cataracts in both eyes, the surgery is done on one eye and the second one is done weeks later -After surgery, vision is restored with one of 3 methods: IOL implant, corrective eyeglasses, or a contact lens

Age-related Macular Degeneration

-The breakdown of or damage to the macula, the point on the retina where light rays converge for the most acute visual perception -The disorder usually occurs in both eyes, but the vision in one eye tends to deteriorate more rapidly

Glaucoma

-A group of eye disorders caused by an imbalance between the production and drainage of aqueous fluid -When the drainage system is obstructed, the anterior chamber becomes congested with fluid and IOP rises. -Optic nerve damage can occur as a result of the increased IOP

Pneumatic retinopathy

-A less invasive method used to repair larger retinal tears -Methods described previously are used to seal the tear -A gas bubble is then injected within the vitreous to push the detached retina against the sclera

Surgical Management for people with refractive errors

-A number of procedures are used to correct refractive errors. -Any procedure potentially provides complete correction of refractive error but can result in overcorrection or undercorrection

Assessment Findings of a Hordeolum

-A sty appears as a tender, swollen, red pustule in the internal or external tissue of the eyelid -A culture of the exudate, although seldom performed, identifies bacterial pathogens

Nursing Management of Glaucoma

-Acute angle-closure glaucoma is an emergency. The nurse refers the client for medical treatment immediately because vision can be permanently lost in 1 or 2 days. -Mydriatics (drugs that dilate the pupil) must never be administered to clients with glaucoma. -Because glaucoma tends to run in families, the nurse advises adults to be examined regularly. The nurse explains drug installation techniques. -For the client who does not understand the chronic and progressive nature of the disease, it is important to stress that glaucoma has no cure but can be controlled and that blindness caused by glaucoma is usually preventable. Self-care is important in managing the lifelong implications of glaucoma.

Medical and Surgical Management of EYE Trauma

-After emergency first aid is performed, the eye is anesthetized to ease examination. -Clients with blunt blunt trauma are hospitalized to reduce the danger of intraocular complications. -A cut on the eyeball, especially the cornea, is serious and requires immediate treatment.

Medical Management of Glaucoma

-Aimed at achieving the greatest benefit at the least risk, cost, and inconvenience to the client. -Although treatment can't reverse optic nerve damage, further damage can be controlled. -Treatment is most often begun with a topical medication at the lowest dose and then advanced to increase the dosage until the desired IOP level is reached.

Corneal Ulcer

-An erosion in the corneal tissue

Hordeolum (Sty)

-An inflammation and infection of the Zeis or Moll glands, types of oil glands at the edge of the eyelid

Medical Management of Wet AMD

-Angiogenesis inhibitors -Photodynamic therapy -Laser photocoagulation -Macular translocation -Implantable miniature telescope -Vitamin and mineral formulation -Diet -Clients may be provided with suggestions for coping with visual impairment, such as magnifying glasses or high intensity reading lamps

Nursing Management of Retinal Detachment

-Anyone with a sudden loss of vision is referred immediately for examination by a primary provider -Mydriatic eye drops are instilled as ordered to dilate the pupil and facilitate further examination of the retina

Orbital fractures

-Are classified according to their location -Vision can be impaired and there can also be potential injury to the brain if the orbital roof is fractured.

Presbyopia

-Associated with aging and results in difficulty with near vision. -People with presbyopia hold reading material or handwork at a distance to see it more clearly

Assessment Findings for Keratitis

-Associated with localized pain or the sensation that a foreign body is present. -Blinking increases the discomfort

Pathology and Etiology of Cataracts

-Cataracts form on the lens, which is behind the iris and pupil -The normal lens focuses light that passes into the eye, producing distinct and sharp images on the retina -A clear sharp image is impeded, and vision becomes more blurred. -Occur as a result of the aging process or are congenitally acquired, caused by injury to the lens, or secondary to other eye diseases. -In all cases, vision decreases because light no longer has a transparent pathway to the retina

Two types of ocular trauma that require quick responses

-Chemical burns and foreign objects in the eye

Pathology and Etiology of Eye trauma

-Children and adults are subject to eye injuries from wind, sun, chemical sprays, direct blows to the eye, lacerations, and penetrating objects -Cell and tissue injury causes an inflammatory response -When trauma involves the cornea, scar tissue may affect the refraction of light

Nursing Management for Conjunctivitis

-Clean the eye and instill or apply the prescribed meds -Instructs the client to: -Remain at home and apart from other people -Use separate towels and other personal objects -Wash Hands thoroughly -Use new tissue each time when wiping discharge from eye -Discard eye makeup items and don't use new makeup -Stop wearing contact lenses -For allergic conjunctivitis try to avoid the allergens -Return to the provider if discharge becomes thick and yellowish

Nursing Management for cataracts

-Clients need to wear sunglasses when in bright light for at least a week -Clients need to notify the eye surgeon if they experience new floaters in their vision or increased redness, flashing lights or change in vision. These are symptoms of retinal detachment which is a complication of this surgery

Miotics such as carbachol (Miostat) and pilocarpine (Pilocar)

-Constrict the pupil -These meds pull the iris away from the drainage channels so that the aqueous fluid can escape.

Blindness

-Definitions related to low vision refer to the best corrected visual acuity (BCVA) -A legal term for a BCVA of 20/200 or less even with corrective lenses. -The term visually impaired is used to describe a BCVA between of 20/200 or less even with corrective lenses -Many people who are blind perceive light and motion

Discharge instructions for Cataract surgery

-Do not engage in strenuous activity and heavy lifting -Do not bend or stoop or do other exercises that potentially increase IOP -Do not immerse the eyes in water -Do not engage in any activity that potentially could cause dust or other particles to lodge on the eye

Mydriatics

-Drug that dilates the pupil

Hyperopia

-Farsightedness -People who are hyperopic see objects that are far away better than objects that are close

1 in 3 Americans

-Have some form of vision-impairing eye disease by 65 years of age

Nursing management for the visually impaired

-Help the client achieve independence -Introduce yourself each time you enter the room bc many voices sound similar -Speak before touching the client -Tell the client when you are leaving the room -Call the client by name during group con

Assessment Findings of AMD

-In dry macula degeneration, blurred vision is the first symptom of disease, which becomes noticeable when clients try to read or do close work -In wet macular degeneration, clients experience distortion of vision, such as straight lines appearing wavy or letters in words looking broken -A clients perception of color may also be diminished -The Amsler grid is used to determine if the client has changes in central vision -When the macula becomes irreparably damaged, clients compare their vision to a target in which the bull's-eye area of the image is absent.

Refractive Errors

-In refractive errors, vision is impaired because the eyeball is either shortened or elongated and, therefore, light rays cannot sharply focus on the retina -Refractive errors include myopia, hyperopia, presbyopia, and astigmatism.

Surgical Management of Retinal Detachment

-Include laser surgery, cryopexy, diathermy, retinopexy, and scleral buckling -The method chosen depends on the extent of detachment

Scleral buckling

-Indenting of the surface of the eye -A surgical procedure in which a tiny synthetic band is attached outside the eyeball to lightly push the wall of the eye against the detached retina

Conjuctivitis

-Inflammation of the conjunctiva -Commonly called pinkeye because of inflammation of the subconjuctival blood vessels -Some forms are highly contagious

Keratitis

-Inflammation of the cornea

Blepharitis

-Inflammation of the lid margins, where eyelashes grow -It generally affects both eyes

Intraocular implant (IOL)

-Involves insertion of an IOL at the time of cataract surgery and is the most common method for improving vision. -IOLs are inserted behind the iris -A monofocal or multifocal lens is implanted and reduces the need for corrective glasses

Laser surgery

-Involves making small burns around the tear to attach the retina back in place

If the surgery is performed

-The client is kept on bed rest with position restrictions for several days. The head may be immobilized -If an air bubble is instilled to promote contact between the retina and sclera, the client is positioned with the face parallel to the floor so that the bubble floats to the posterior of the eye

Assessment findings of Retinal detachment

-Many clients notice definite gaps in their vision or blind spots. They describe the sensation of a curtain being drawn over their field of vision, and they often see flashes of light. Seeing spots, "cobwebs," or moving particles in one's field of vision, called floaters, is common. Complete loss of vision may occur in the affected eye.

Medical Management of Blepharitis

-Medications in topical form (drops or ointment) that treat the underlying infection are prescribed

Myopia

-Nearsightedness -People who are myopia hold thins close to their eyes to see them well

Emmetropia

-Normal vision -Means that light rays are bent to focus images precisely on the retina

Nursing Management for people with refractive errors

-Nurses, especially those in pediatric offices, industrial sites, community school systems, and public health clinics, perform screening examinations and refer clients to eye specialists -In addition, nurses provide preoperative and postoperative care and teach clients about postoperative care at home.

Other general instructions for glaucoma include the following:

-Obtain assistance from a family member, relative, or friend if you have trouble instilling eye drops. -Avoid all drugs that contain atrophine -Maintain regular bowel habits -Avoid heavy lifting that strain or tire the eyes -Limit activities that strain or tire the eyes -Keep an extra supply of prescribed drugs on hand. -Tell all primary providers that you have this disorder and the treatment prescribed by the ophthalmologist. -Maintain all follow-up ophthalmology apportionments.

Assessment Findings of Cataracts

-One of the earliest symptoms is seeing a halo around lights -Under ophthalmic and slit-lamp examination, the lens appears in varying stages of opacity -Tonometry determines whether the cataract is increasing the IOP

Signs and Symptoms of Glaucoma

-Open angle glaucoma may be asymptomatic, and the condition may not be discovered until the client has a. routine ophthalmologic examination -In contrast, clients with acute angle-closure glaucoma become symptomatic quite suddenly. They experience severe headache and eye pain.

Assessment Findings for people with Refractive Errors

-People with refractive errors experience blurred vision -The amount of power needed to improve visual acuity indicates the degree of refractive error -The refractive error is not always the same in both eyes

Pathophysiology and Etiology of Refractive Errors

-Presbyopia occurs because of degenerative changes -Presbyopia is caused by the gradual loss of elasticity of the lens, which leads to decreased ability to accommodate, or focus, or near vision. The loss of accommodation progresses gradually. -Astigmatism results from unequal curvatures in the shape of the cornea.

Legal Blindness

-Refers to a vision loss level that is defined in order to qualify individuals for specific benefits, such as social security disability benefits

Medical Management for people with refractive errors

-Refractive errors usually are corrected with eyeglasses or contact. lenses.

Pathology and Etiology of Conjuctivitis

-Results from a bacterial, viral, or rickettsial infection and can affect on or both eyes -The microorganisms most often are introduced by air transmission, direct contact with sources on the fingers, a contaminated face towel. -Allergic conjunctivitis affects both eyes

Pathology and Etiology or Retinal Detachment

-Retina seperation is associated with a hole or tear in the retina caused by stretching or degenerative changes; may follow a sudden blow, penetrating injury, or eye surgery -tumors, hemorrhage in front of or behind the retina and loss of vitreous fluid are particularly likely to lead to retinal detachment -The separation of the two layers of the retina deprives the sensory layer of its blood supply. Vision is lost in the affected area because the sensory layer no longer can receive visual stimuli.

Nutrition notes for the client with Cataracts

-Several studies have shown that vitamins C and E and beta-carotene can prevent or delay cataract formation. Five to 9 daily servings of richly colored fruits and vegetables are recommended for eye health. -Recent research indicates that a low-sodium diet may help in preventing cataract development -Clients who have had cataract surgery should eat soft, easily chewable foods until healing is complete to avoid tearing from excessive facial movements.

Diagnostic Findings of Eye trauma

-Staining the surface with fluorescein dye identifies a minute foreign body or abrasion to the cornea -A slit-lamp examination examination provides magnification and light to visualize structures in the anterior and posterior segments. -Xrays, CT, and possibly a MRI help find a penetrating foreign body. -An Xray or CT confirms an orbital fracture

Pathology and Etiology of Hordeolum

-Staphylococcus aureus is the most common causative pathogen -Sites are common in clients with diabetes mellitus bc their glucose-rich blood readily supports microbial growth

Assessment Findings for Conjuctivitis

-Symptoms include redness, excessive tearing, swelling, pain, burning or itching, and possibly purulent drainage from one or both eyes. -Clients may complain of photophobia

Pathology and Etiology of Macular Deterioration

-Tends to affect older adults -The leading cause of vision loss in clients older than 50 years of age -Dry AMD does not have any treatment or cure.

Visually impaired

-Term used to describe a BCVA between 20/70 and 20/200 in the better eye with the use or glasses. -People with severe loss of visual field are also referred to as blind and are not able to perceive light -The BCVA is defined as 20/400 to no light perception

Two main types of AMD

-The Dry Type (nonneovascular, nonexudative) -The Wet Type (neovascular, exudative)

Signs and Symptoms of Eye Trauma

-The injured eye is painful or described as feeling "gritty" -There is tearing, and the client usually tries to relieve the discomfort by squeezing the eyelids closed. -Vision may be blurred -If the bony orbit is fractured, the eyes may appear asymmetrical, and the client has diplopia. -A rust ring is seen in retained foreign bodies that contain iron

Pathology and Etiology of Glaucoma

-The leading cause of blindness for people over 60 years of age in the US -In normal eyes, the rate of secretion equals the rate of outflow and the IOP is between 10-21 mmHg.

Assessment findings for Blepharitis

-The lid margins appear inflamed -Patchy flakes cling to the eyelashes and are readily visible about the lids -Eyelashes may be missing

Medical and surgical Management of Hordeolum

-The nurse assures the client that treatment provides relief from pain and discomfort -Explains how to avoid transferring microorganisms from the sty to areas of the body by cleaning the unaffected eye first and changing the washcloth, towel, and water after contact with the affected eye -Instructs the client to use separate fresh tissues, cotton balls, or gauze for each wiping stroke when cleaning exudate from the eye

Nursing management for AMD

-The nurse helps the client cope with loss of vision

Nursing Management for Enucleation

-The nurse observes the client after surgery for signs and symptoms of bleeding or infection -When healing is complete, in about 2 to 4 weeks, the nurse teaches the client how to insert and remove the prosthetic shell. -The nurse instructs the client to hold the head over a soft surface, such as a bed or padded table, when removing or inserting the prosthesis to avoid damage if the prosthetic eye falls. -The client should clean the shell after removal and keep it in a safe place where it will not become scratched or broken.

Diagnostic Findings of Glaucoma

-Tonometry reveals elevated IOP and reduced aqueous outflow. -The visual field examination demonstrates a loss of peripheral vision -Nasal and superior areas are usually impaired first

Eye trauma

-Trauma or injury to the eye and surrounding structures can result in decreased or total loss of vision

Pathology and Etiology of Keratitis and corneal ulcer

-Trauma to the cornea, infectious agents, or exposure to contaminated water can cause keratitis -Most clients experience severe pain bc of the abundance of nerve endings in the cornea -When and if scar tissue forms, visual impairment is permanent -The degree of visual change depends on the size and density of the corneal scar tissue

Medical Management for Conjuctivitis

-Treatment for bacterial conjunctivitis may include antibiotic ointments or drops, but often it will clear up without any treatment -There is no treatment for viral conjunctivitis

Medical and Surgical Management for Keratitis

-Treatment is begun promptly to avoid permanent loss of vision -Keratitis is treated with topical anesthetics, mydriatics, and local and systemic antibiotics. -Dark glasses are recommended to relieve photophobia -Treatment in the early stages for corneal ulcer is the same for keratitis. Once corneal scar tissue has formed, the only treatment is corneal transplatation (keratoplaty)

Beta-blockers such a timolol (Timoptic)

-Used to decrease the flow rate ofaqueosus humor into the eye

Prostagladins such as latanoprost (Xalatan) and bimatoprost (Lumigan)

-Used to increase the outflow of the fluid in the eye and reduce IOP are also used to treat glaucoma

Astigmatism

-Visual distortion caused by an irregularly shaped cornea. -Defect of the curvature of the cornea and lens producing refractive errors. -Parallel rays are imperfectly focused on the retina

Surgical Management of Glaucoma

-When adherence to treatment is poor or drug therapy is no longer effective or if the client develops severe adverse reactions to the medications, more aggressive treatment becomes necessary to preserve vision -There are a number of potential procedures that may be done to create accessory drainage channels, with the goal of promoting the drainage of aqueous humor and reducing IOP. -Laser surgeries are used extensively in the treatment of glaucoma.

Medical and surgical Management of Enucleation

-When enucleation is performed, a metal or plastic ball is buried in the capsule of connective tissue from which the eyeball is removed. A pressure dressing is applied to control hemorrhage, a complication of enucleation. After the tissues have healed, a shell-shaped prosthesis is placed over the buried ball. The shell is painted to match the client's remaining eye. The shell is the only portion that is removed for cleaning.

Retinal Detachment

-When the sensory layer becomes separated from the pigmented layer of the retina

Enucleation

-he surgical removal of an eye. -It is necessary when the eye is destroyed by injury or disease, when a malignant tumor develops (rare), or to relieve pain if the eye is severely damaged and sightless

How to instill Eye Medications

-wash hands -wipe lids & lashes with wet gauze/cotton ball...inner corner out -pull the tissue near the cheek downward, forming a sac in the lower lid -tilt head slightly backward and toward the eye -instill the prescribed number of drops into the conjunctival pocket -close eye gently -wipe excess meds away -If there is a dressing, secure it -Do not rub the eye -keep follow-up appts to check the condition of the eye