Chapter 58: Assessment and Management of Patients with Eye and Vision Disorders
A nurse is performing an eye examination. Which question would not be included in the examination? "Are you able to raise both eyebrows?" "Do any family members have any eye conditions?" Have you experienced blurred, double, or distorted vision?" "What medications are you taking?"
"Are you able to raise both eyebrows?" Explanation: Asking to raise both eyebrows is a test for cranial nerve VII, the facial nerve, and would not be included in an eye assessment.
A client is diagnosed with a corneal abrasion and the nurse has administered proparacaine hydrochloride per orders to assess visual acuity. The client requests a prescription for this medication because it completely took away the pain. What is the best response by the nurse? "It is standard for the doctor to write a prescription for this medication." "Prescriptions of this medication are generally not given because it can cause corneal problems." "I will let the doctor know." "Usually we will send you home with this bottle and written instructions for administering the medication."
"Prescriptions of this medication are generally not given because it can cause corneal problems." Proparacaine hydrochloride can cause corneal softening and other complications if overused. Clients with corneal abrasions or other painful eye disorders have a tendency to overuse the medication, thus leading to the complications. It would not be appropriate to give the bottle with written instructions, and it is not a standard prescription for eye disorders because of the complications from overuse. Telling the client that you will let the doctor know does not provide the education needed about this medication.
A 52-year-old comes to the clinic for a follow-up examination after being diagnosed with glaucoma. The client states, "I'm hoping that I don't have to use these drops for very long." Which response by the nurse would be most appropriate? "You'll need to use the drops for the rest of your life to control the glaucoma." "If the drops don't work, surgery may be needed to cure your condition." "These drops are just the first step to make sure that your vision doesn't get worse." "Most clients need to use the drops for only about a few months."
"You'll need to use the drops for the rest of your life to control the glaucoma." Explanation: The client is demonstrating a lack of understanding about the condition and its treatment. The nurse needs to provide additional information to the client that the condition can be controlled but not cured. The statement about lifelong therapy would be most appropriate. Eye medications would most likely be needed for the long term, not just a few months. Surgery may be used in conjunction with medication therapy; however, neither method cures the condition. The goal of therapy is to reduce the intraocular pressure to prevent optic nerve damage. In some clients, medication may be all that is needed. In other cases, additional or combination treatment with surgery or laser procedures may be necessary.
When undergoing testing of visual acuity with a Snellen chart, the client can read the line labeled 20/50 but misses three letters on the line. The nurse documents this finding as which of the following? 20/20/50 20/50 20/50-3 20/20 + 30
20/50-3 The nurse would document the finding as 20/50-3, indicating that the client missed three of the letters on the line 20/50.
The nurse is establishing a visual test using the Snellen chart for a client experiencing visual changes. At which distance should the nurse instruct the client to stand? A 30-foot distance A 10-foot distance A 20-foot distance A 40-foot distance
A 20-foot distance The nurse is correct in instructing the client to stand at a 20-foot distance from the Snellen chart. Often, the nurse places tape on the floor to denote the correct distance for the client to stand.
On ocular examination, the health care provider notes severely elevated IOP, corneal edema, and a pupil that is fixed in a semi-dilated position. The nurse knows that these clinical signs are diagnostic of the type of glaucoma known as: Chronic open-angle. Normal tension. Chronic angle-closure. Acute angle-closure.
Acute angle-closure. Acute angle-closure glaucoma is characterized by the symptoms listed, as well as by being rapidly progressive and accompanied by pain.
A client has been referred to an ophthalmologist for suspected macular degeneration. The nurse knows to prepare what test for the physician to give the client? Amsler grid Visual field Ishihara polychromatic plates Slit lamp
Amsler grid Explanation: Clients with macular problems are tested with an Amsler grid. It is made up of a geometric grid of identical squares with a central fixation point. The examiner instructs the client to stare at the central fixation spot on the grid and report if they see any distortion of the squares. Clients with macular problems may say some of the squares are faded or wavy. An Ishihara polychromatic plate, visual field, or slit lamp test will not diagnose macular degeneration.
The nurse is demonstrating how to perform punctal occlusion. Which activities does the nurse perform? Applies firm pressure to the upper and lower eyelids at the outer edges to keep eyelids in approximation Applies gentle pressure bilaterally on the bridge of the nose to the inner canthus of each eye Holds down the lower lid of the eye by applying pressure on the eyeball and the cheekbone Applies gentle pressure to the upper eyelid to keep the lid open while telling the client to gaze upward
Applies gentle pressure bilaterally on the bridge of the nose to the inner canthus of each eye Explanation: Punctal occlusion is done by applying gentle pressure to the inner canthus of each eye for 1 to 2 minutes immediately after eye drops are instilled. The nurse does not apply pressure to the eyeball when administering medications. The lower eyelid is held down to expose the conjunctival sac. The other action described will not aid in the retention or absorption of medication.
A client who is blind is awaiting elective surgery. What should the nurse do to promote this client's control over their hospital environment? Arrange the meal tray in a way that is easiest for the nurse to assist the client. Ask the client where to store his or her self-care items. Open all containers without prompting to be helpful. Keep personal care items where the nurse knows their location.
Ask the client where to store his or her self-care items. Ask the client's preference for where to store hygiene articles and other objects needed for self-care. Involving the client promotes his or her control over the environment. Personal care items should be kept in the same location at all times to provide the client with the ability to locate toiletries easily. At mealtime, describe where food is on the plate using the positions on the face of a clock. This measure assists the client to identify the location of food. Allow the client to open containers and offer help if needed. Having a choice facilitates independence.
The nurse is administering an ophthalmic ointment to a patient with conjunctivitis. What disadvantage of the application of an ointment does the nurse explain to the patient? It has a lower concentration than eye drops. It has more side effects than eye drops. Blurred vision results after application. It does not work as rapidly as eye drops do. (An ophthalmic ointment is a semi-solid, greasy or creamy topical treatment for certain eye conditions, whether mild or severe. Ophthalmic ointments are often recommended for eye infections, dry eyes and blepharitis (eyelid inflammation), among many other issues of the eye) conjunctivitis/kờn chơn tờ vái dis/ viem kết matc
Blurred vision results after application. Ophthalmic ointments have extended retention time in the conjunctival sac and provide a higher concentration than eye drops. The major disadvantage of ointments is the blurred vision that results after application. In general, eyelids and eyelid margins are best treated with ointments.
A patient has been diagnosed with bacterial conjunctivitis that was sexually transmitted. The nurse informs the patient that the isolated organism is which of the following? Chlamydia trachomatis Staphylococcus aureus Hemophilus influenzae Streptococcus pneumonia
Chlamydia trachomatis Explanation: Common organisms isolated are Streptococcus pneumoniae, Hemophilus influenzae, and Staphylococcus aureus. Two sexually transmitted agents associated with conjunctivitis are Chlamydia trachomatis and Neisseria gonorrhoeae.
A client is diagnosed with uveitis. Which assessment finding is most important in determining likelihood of recurrence? Glaucoma Ankylosing spondylitis Extended contact use Chemical exposure
D. Halos and glare After LASIK surgery, symptoms of central islands and decentered ablations can occur that include monocular diplopia or ghost images, halos, glare, and decreased visual acuity. These procedures do not cause excessive tearing or result in cataract or stye formation.
Which of the following is the role of the nurse toward a patient who is to undergo eye examinations and tests? Conducting various tests to determine the function and the structure of the eyes Advising the patient on the diet and exercise regimen to be followed Ensuring that the patient receives eye care to preserve his or her eye function and prevent further visual loss Determining if further action is warranted
Ensuring that the patient receives eye care to preserve his or her eye function and prevent further visual loss Explanation: Although nurses may not be directly involved in caring for patients who are undergoing eye examinations and tests, it is essential that they ensure that patients receive eye care to preserve their eye function and/or prevent further visual loss. The nurse is not involved in conducting the various tests to determine the status of the eyes and in determining if further action is warranted. Patients who are to undergo eye examinations and tests are not required to modify their diet and exercise regimen.
Which of the following is the role of the nurse toward a patient who is to undergo eye examinations and tests? Ensuring that the patient receives eye care to preserve his or her eye function and prevent further visual loss Conducting various tests to determine the function and the structure of the eyes Advising the patient on the diet and exercise regimen to be followed Determining if further action is warranted
Ensuring that the patient receives eye care to preserve his or her eye function and prevent further visual loss Explanation: Although nurses may not be directly involved in caring for patients who are undergoing eye examinations and tests, it is essential that they ensure that patients receive eye care to preserve their eye function and/or prevent further visual loss. The nurse is not involved in conducting the various tests to determine the status of the eyes and in determining if further action is warranted. Patients who are to undergo eye examinations and tests are not required to modify their diet and exercise regimen.
A client has been prescribed eye drops for the treatment of glaucoma. At the yearly follow-up appointment, the client tells the nurse that she has stopped using the medication because her vision did not improve. Which action by the nurse is appropriate? Refer the patient to the emergency department. Explain the therapeutic effect and expected outcome of the medication. Administer the medication immediately. Talk with the doctor about switching to a different glaucoma medication.
Explain the therapeutic effect and expected outcome of the medication. Explanation: The nurse needs to explain the therapeutic effect and expected outcome of the medication. The medication is not a cure for glaucoma, but can slow the progression. The client will not see improvements in vision with the use of the medication but should experience little to no deterioration of vision. The doctor may choose to switch the medication, but not because the vision is not improving; it would be based on not obtaining the set intraocular pressure. Administering the medication immediately or referring the client to the emergency department is not appropriate because this is not an emergent situation.
The nurse should monitor for which manifestation in a client who has undergone LASIK? Halos and glare Excessive tearing Stye formation Cataract formation
Halos and glare Explanation: Symptoms of central islands and decentered ablations can occur after LASIK surgery; these include monocular diplopia or ghost images, halos, glare, and decreased visual acuity. These procedures do not cause excessive tearing or result in cataract or stye formation.
Which type of benign tumor of the eyelids is characterized by superficial, vascular capillary lesions that are strawberry red in color? Milia Molluscum contagiosum Xanthelasma Hemangioma
Hemangioma Hemangiomas are vascular capillary tumors that may be bright, superficial, strawberry-red lesions or bluish and purplish deeper lesions. Milia are small, white, slightly elevated cysts of the eyelid that may occur in multiples. Xanthelasma are yellowish, lipoid deposits on both lids near the inner angle of the eye that commonly appear as a result of skin aging or a lipid disorder. Molluscum contagiosum lesions are flat, symmetric growths along the lid margin caused by a virus that can result in conjunctivitis and keratitis if the lesion grows into the conjunctival sac.
A client has undergone enucleation. What complication of enucleation should be addressed by the nurse? Pneumonia Nausea and vomiting Hypotension Hemorrhage
Hemorrhage The nurse should take measures to prevent hemorrhage, a complication of enucleation, by applying a pressure dressing. Nausea and vomiting may be common side effects of surgery. Enucleation does not increase risk of developing hypotension or pneumonia.
An ophthalmologist tells a patient that he has a cataract. The nurse explains to the patient that this means there is: Distortion and loss of central vision. Interference with focusing of a sharp image. Increased corneal exposure. A tendency for the retina to tear.
Interference with focusing of a sharp image. Explanation: Refer to Table 48-1 in the text for the distinguishing functional changes associated with a cataract.
The client with chronic open-angle glaucoma is receiving timolol eye drops. Which evaluation finding would indicate to the nurse the treatment is working? Reduced peripheral vision Halos around lights Decrease in nausea and vomiting Intraocular pressure 15 mm Hg
Intraocular pressure 15 mm Hg Explanation: Timolol is a beta-blocker that is used topically to decrease the flow rate of aqueous humor in the eye. As flow rate decreases, the intraocular pressure decreases. IOP of 12 to 21 mm Hg is within normal range. Reduced peripheral vision, halos around lights, and blurred vision are all symptoms of open-angle glaucoma. Nausea and vomiting are more likely to occur with acute angle-closure glaucoma.
Which surgical procedure involves flattening the anterior curvature of the cornea by removing a stromal lamella? Laser-assisted in situ keratomileusis (LASIK) Keratoplasty Keratoconus Photorefractive keratectomy (PRK)
Laser-assisted in situ keratomileusis (LASIK) Explanation: LASIK involves flattening the anterior curvature of the cornea by removing a stromal lamella or layer. PRK is used to treat myopia and hyperopia with or without astigmatism. Keratoconus is a cone-shaped deformity of the cornea. Keratoplasty involves replacing abnormal host tissue with healthy donor (cadaver) corneal tissue.
Which surgical procedure involves flattening the anterior curvature of the cornea by removing a stromal lamella layer? Photorefractive keratectomy (PRK) Keratoconus Keratoplasty Laser-assisted stromal in situ keratomileusis (LASIK)
Laser-assisted stromal in situ keratomileusis (LASIK) Explanation: LASIK involves flattening the anterior curvature of the cornea by removing a stromal lamella or layer. PRK is used to treat myopia and hyperopia with or without astigmatism. Keratoconus is a cone-shaped deformity of the cornea. Keratoplasty involves replacing abnormal host tissue with healthy donor (cadaver) corneal tissue.
A nurse conducted a history and physical for a newly admitted patient who states, "My arms are too short. I have to hold my book at a distance to read." The nurse knows that the patient is most likely experiencing: Opacity in the lens. Decreased eye muscle tone. Shrinkage of the vitreous body. Loss of accommodative power in the lens.
Loss of accommodative power in the lens. Presbyopia is a refractive change that occurs with age. The lens of the eye loses accommodative power. Opacity in the lens indicates a cataract.
During an initial assessment, the nurse notes a symptom of a mild case of bacterial conjunctivitis and documents in the electronic medical record that the client is displaying which of the following ? Blurred vision Severe pain Elevated intraocular pressure Mucopurulent ocular discharge
Mucopurulent ocular discharge Explanation: Bacterial conjunctivitis manifests with an acute onset of redness, burning, and discharge. Purulent discharge occurs in severe acute bacterial infections, whereas mucopurulent discharge appears in mild cases.
During an initial assessment, the nurse notes a symptom of a mild case of bacterial conjunctivitis and documents in the electronic medical record that the client is displaying which of the following ? Elevated intraocular pressure Blurred vision Mucopurulent ocular discharge Severe pain
Mucopurulent ocular discharge Explanation: Bacterial conjunctivitis manifests with an acute onset of redness, burning, and discharge. Purulent discharge occurs in severe acute bacterial infections, whereas mucopurulent discharge appears in mild cases.
Which client statement would lead the nurse to suspect that the client is experiencing bacterial conjunctivitis? "It feels like there is something stuck in my eye." "My eyes hurt when I'm in the bright sunlight." "My eyelids were stuck together this morning." "My eyes feel like they are on fire."
My eyelids were stuck together this morning." Explanation: Burning, a sensation of a foreign body, and pain in bright light (photophobia) are signs and symptoms associated with any type of conjunctivitis. The drainage related to bacterial conjunctivitis is usually present in the morning, and the eyes may be difficult to open because of adhesions caused by the exudate.
Assessment of visual acuity reveals that the client has blurred vision when looking at distant objects but no difficulty seeing near objects. The nurse documents this as which of the following? Myopia Hyperopia Emmetropia Astigmatism
Myopia Explanation: Myopia, or nearsightedness, refers to the condition in which the client can see near objects but has blurred distant vision. Astigmatism is an irregularity in the curve of the cornea, which affects both near and distant vision. Hyperopia, or farsightedness, refers to the client's ability to see distant objects clearly but near objects as blurry. Emmetropia refers to normal eyesight in which the image focuses precisely on the retina.
During a routine eye examination, a patient complains that she is unable to read road signs at a distance when driving her car. What should the patient be assessed for? Myopia Astigmatism Presbyopia Anisometropia
Myopia Explanation: Some people have deeper eyeballs, in which case the distant visual image focuses in front of, or short of, the retina; those with myopia Impaired Vision are said to be nearsighted and have blurred distance vision.
To avoid the side effects of corticosteroids, which medication classification is used as an alternative to treat inflammatory conditions of the eyes? NSAIDs Miotics Mydriatics Cycloplegics
NSAIDs NSAIDs are used as an alternative in controlling inflammatory eye conditions and postoperatively to reduce inflammation. Miotics are used to cause the pupil to constrict. Mydriatics cause the pupil to dilate. Cycloplegics cause paralysis of the iris sphincter.
Assessment of visual acuity reveals that the client has blurred vision when looking at distant objects but no difficulty seeing near objects. The nurse documents this as which of the following? Hyperopia Astigmatism Emmetropia Myopia
NSAIDs Explanation: NSAIDs are used as an alternative in controlling inflammatory eye conditions and postoperatively to reduce inflammation. Miotics are used to cause the pupil to constrict. Mydriatics cause the pupil to dilate. Cycloplegics cause paralysis of the iris sphincter.
To avoid the side effects of corticosteroids, which medication classification is used as an alternative to treating inflammatory conditions of the eyes? Miotics Nonsteroidal anti-inflammatory drugs (NSAIDs) Mydriatics Cycloplegics
Nonsteroidal anti-inflammatory drugs (NSAIDs) NSAIDs are used as an alternative in controlling inflammatory eye conditions and postoperatively to reduce inflammation. Miotics are used to cause the pupil to constrict. Mydriatics cause the pupil to dilate. Cycloplegics cause paralysis of the iris sphincter.
An aging client is brought to the eye clinic by the son. The son states he has seen his parent holding reading materials at an increasing distance to focus properly. What age-related changes does this indicate? Myopia Cataract Presbyopia Macular degeneration
Presbyopia Explanation: Refractive changes, such as presbyopia, occur in older adults where the lens cannot readily accommodate aging. In such cases, the client is observed holding reading materials at an increasing distance to focus properly. In case of a cataract, the client should report increased glare, decreased vision, and changes in color perception. Macular degeneration affects the central vision. Myopia is the inability to see things at a distance clearly.
The nurse is reviewing the medical record of a client with glaucoma. Which of the following would alert the nurse to suspect that the client was at increased risk for this disorder? Prolonged use of corticosteroids Hyperopia since age 20 years Age younger than 40 years History of respiratory disease
Prolonged use of corticosteroids Risk factors associated with glaucoma include prolonged use of topical or systemic corticosteroids, older age, myopia, and a history of cardiovascular disease.
A 68-year-old client reports a change in vision when driving during the night. Which strategies would the nurse recommend to mitigate this problem? Propose reading eyeglasses for presbyopia, which is changing only their night vision. Utilize an eye shield during the day to promote and protect night vision. Recommend contrast sensitivity testing measures to determine visual function. Wear darkly tinted sunglasses since the eyes are now more sensitive to glare.
Recommend contrast sensitivity testing measures to determine visual function. Explanation: With aging, structural and functional changes occur in the eye. Clients having visual changes while driving should have a contrast sensitivity testing done. Contrast sensitivity testing measures visual acuity in different degrees of light and dark, which determines visual function. Glare testing is also used to determine visual function. Those affected by loss of contrast sensitivity and glare have difficulty functioning in low light, or driving at night or in foggy conditions. With the results from testing, appropriate strategies can be recommended. Presbyopia, the loss of accommodative power in the lens, interferes with the ability to adequately focus (difficulty seeing small print) and is the factor responsible for most older adults requiring some form of corrective lenses. Presbyopia interferes with vision during the day and night. An eye shield is proposed for clients' postoperative management after cataract surgery. Wearing yellow tinted, not darkly tinted, glasses may help cut night glare during driving.
Which statement is accurate regarding refractive surgery? Refractive surgery may be performed on all clients, even if they have underlying health conditions. Refractive surgery is an elective, cosmetic surgery performed to reshape the cornea. Refractive surgery will alter the normal aging of the eye. Refractive surgery may be performed on clients with an abnormal corneal structure as long as they have a stable refractive error.
Refractive surgery is an elective, cosmetic surgery performed to reshape the cornea. Explanation: Refractive surgery is an elective procedure and is considered a cosmetic procedure (to achieve clear vision without the aid of prosthetic devices). It is performed to reshape the cornea for the purpose of correcting all refractive errors. Refractive surgery will not alter the normal aging process of the eye. Clients with conditions that are likely to adversely affect corneal wound healing (corticosteroid use, immunosuppression, elevated intraocular pressure) are not good candidates for the procedure. The corneal structure must be normal and refractive error stable.
Which of the following surgical procedures involves taking a piece of silicone plastic or sponge and sewing it onto the sclera at the site of a retinal tear? Scleral buckle Phacoemulsification Pneumatic retinopexy Pars plana vitrectomy
Scleral buckle Explanation: The scleral buckle is a procedure in which a piece of silicone plastic or sponge is sewn onto the sclera at the site of the retinal tear. The buckle holds the retina against the sclera until scarring seals the tear. The other surgeries do not use this type of procedure.
A client with glaucoma has presented for a scheduled clinic visit and tells the nurse that she has begun taking an herbal remedy for her condition that was recommended by a work colleague. What instruction should the nurse provide to the client? The client should monitor her IOP closely for the next several weeks. The client should report any adverse effects to her pharmacist. The client should discuss this new remedy with her ophthalmologist promptly. The client should do further research on the herbal remedy.
The client should discuss this new remedy with her ophthalmologist promptly. Explanation: Clients should discuss any new treatments with an ophthalmologist; this should precede the client's own further research or reporting adverse effects to the pharmacist. Self-monitoring of IOP is not possible.
A patient visits a clinic for an eye examination. He describes his visual changes and mentions a specific diagnostic clinical sign of glaucoma. What is that clinical sign? A significant loss of central vision Diminished acuity Pain associated with a purulent discharge The presence of halos around lights
The presence of halos around lights Explanation: Colored halos around lights is a classic symptom of acute-closure glaucoma.
A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first aid treatment? To serve as a stopgap measure until help arrives To eliminate the need for medical care To hasten formation of scar tissue To prevent vision loss
To prevent vision loss Explanation: Prolonged eye irrigation after a chemical burn is the most effective way to prevent formation of permanent scar tissue and thus help prevent vision loss. After a potentially serious eye injury, the victim should always seek medical care. Eye irrigation isn't considered a stopgap measure.
To straighten the ear canal in an adult for examination, the nurse practitioner would grasp the auricle and pull it: Up and backward. Downward. Slightly outward. Upward and outward.
Up and backward. Explanation: The tympanic membrane is inspected with an otoscope, which should be held in the examiner's right hand. Using the opposite hand, the auricle is grasped and gently pulled upward and back to straighten the canal in an adult.
A patient is suspected of having retinal detachment. The nurse would expect to prepare the patient for which of the following? Select all that apply. Slit lamp biomicroscopy Amsler grid testing Visual acuity testing Fluorescein angiography Tonometry Indirect ophthalmoscopy
Visual acuity testing Indirect ophthalmoscopy Slit lamp biomicroscopy Fluorescein angiography Testing for retinal detachment includes - visual acuity testing, - indirect ophthalmoscopy, - slit lamp biomicroscopy, and - fluorescein angiography. The Amsler grid is used to evaluate for macular degeneration. Tonometry is used to evaluate for glaucoma.
A client suffered trauma to the sclera and is being treated for a subsequent infection. During client education, the nurse indicates where the sclera is attached. Which structure would not be included? pupil eyelids iris cornea
eyelids Explanation: The sclera does not attach to the eyelids. The sclera protects structures in the eye, and connects directly to the cornea, anterior chamber, iris, and pupil.
A client suffered trauma to the sclera and is being treated for a subsequent infection. During client education, the nurse indicates where the sclera is attached. Which structure would notbe included? pupil cornea eyelids iris
eyelids Explanation: The sclera does not attach to the eyelids. The sclera protects structures in the eye, and connects directly to the cornea, anterior chamber, iris, and pupil.
When obtaining the health history from a client with retinal detachment, a nurse expects the client to report: light flashes and floaters in front of the eye. headaches, nausea, and redness of the eyes. a recent driving accident while changing lanes. frequent episodes of double vision.
ight flashes and floaters in front of the eye. Explanation: The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment. Difficulty seeing cars in another driving lane suggests gradual loss of peripheral vision, which may indicate glaucoma. Headache, nausea, and redness of the eyes are signs of acute (angle-closure) glaucoma. Double vision is common in clients with cataracts.
After a fall at home, a client hits their head on the corner of a table. Shortly after the accident, the client arrives at the ED, unable to see out of their left eye. The client tells the nurse that symptoms began with seeing spots or moving particles in the field of vision but that there was no pain in the eye. The client is very upset that the vision will not return. What is the most likely cause of this client's symptoms? chalazion retinal detachment eye trauma angle-closure glaucoma
retinal detachment A detached retina is associated with a hole or tear in the retina caused by stretching or degenerative changes. Retinal detachment may follow a sudden blow, penetrating injury, or eye surgery.
