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

TRAUMATIC INJURIES
 • Retinal Detachment

o Tearing away of retina from Choroid Body (vascular bed)

 Decreases blood flow
 Can be caused by penetration or blunt trauma

 Other Causes:
• Trauma – Cataract surgery – not uncommon to develop
• Tumors
• Age
• Degeneration due to diabetes

o Signs and Symptoms

 Floaters (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
 Painless

TREATMENT
• Immediate rest
• Bandage both eyes
• Scleral bulking
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: Apply pressure and maintain correct position – 2
weeks

OCULAR TRAUMA
• Increases in children and males
• Occupation
• Sports
• Weapons
• Assaults
• MVA

Mechanical Injuries
• Foreign bodies
o Assessment
o Irrigate with NS
o Never put pressure on eye
o May require local anesthesia and magnification to remove object
• Lacerations
 o Eye patching
o Sutures – fine
o Never apply pressure
o Administration of tetanus antitoxin
• Penetrating injury
o DO NOT attempt to remove object
o DO NOT apply pressure
o Get help immediately
• Corneal abrasions
o Painful
o Patch eye
o Antibiotic eye drops
o Anesthetic eye drops
o Observe ulceration
• Contusions and Hematomas
o Apply cold compress for first 24 hours
o Warm compress after 48 hours
o Increased IOP injury serious
o Slight discomfort 24-48o after injury
o OTC meds for pain

ASSESSMENT
• History of eye problems
• Unaffected with affected
• Determine nature of injury

REFRACTORY DISORDERS
MYOPIA – NEARSIGHTED
• Blurred distance vision
• Light focuses in front of the retina
• Corrected with concave lens, radial keratotomy lasik surgery
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 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
• Distortion of visual image (Light is bent in different directions)
• Corrected with cylinder eye glasses; rigid or soft contacts
• Soft lens due to discomfort with hard
PRESBYOPIA
• Lens unable to accommodate or slow to accommodate – blurred
o Usually seen in the aging
o Seen persons > 4y/o
o Corrected with bifocals
o Enlarge fine print with glasses OTC
o R/O eye flat
o May have to go to trifocal lens

ANISOMETROPIA
• Different refractory strength in each eye
• Corrected with lens that will correct each eye

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
• May close one eye to see

STRABISMUS
• Malalignment of eyes R/T muscle imbalance, paralysis, poor vision, congenital defects
• Brain receives two images
• Cross eyed
• TX: eye patch – unaffected eye – or surgery

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)
o Viral – Infection with human and virus – not contagious
o Allergic – Because contact with allergen (pollens) assess environmental
o Trauma
o Chemical Injury – cause it to develop
• Signs and Symptoms
o Purulent drainage
 Inner Campus
o Crusting eye lids
 Warm wash cloth
o Itching
 With allergic
o Tearing
 Any cause
o Pain
 Increases with bacteria
o Photophobic
 C/O light / sunglasses
 o Burning sensation
• Treatment
o Saline irrigation – Remove crustation
o Antibiotic ointments or bacterial drops – Topamycin, Garamycin
o Cool compresses
o Good hand washing
o Separate towels, wash cloths

GLAUCOMA
• Cannot be cured
• Group of difficult disease characterized by damage to optic nerve and loss of vision
• Damage R/T increased ocular pressure
o Normal 10-21 mmHg
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

Two Types:
OPEN ANGLE GLAUCOMA
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 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

ANGLE CLOSURE
Clinical Manifestations
o Rapidly progressive Visual impairments / Rapid, sudden onset
 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 – forward to iris cause narrow angle without movement to trabecula meshwork
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
• Headache
 • Blurred vision with angle closure
• Redness
• Pain with angle closure
• N/V – more with angle closure
• Problems focusing with both eyes
• Loss of peripheral vision when open
• Hard with angle closure

RISK FACTORS FOR GLAUCOMA

• Family history – Age Race – in African Americans
• Eye trauma Myopia
• Prolonged use of steroids
• Existing health problems: DM, Cardiovascular, Migraine Syndrome

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

• Diuretics
o Lasix  K, Muscle spasms, Cramping of legs

• Cholinergics (Pilocapine)
o Cause papillary constriction  flow aqueous humor
o  vision with dim lights

• Beta Adrengic Antagonist

o Timoptic
o  production of aqueous humor
o Other problem: CHF, Asthma – use with caution

• Carbonis Anhydrase Inhibitors

o Diamox – PO 250-500mg Q6,8,12
o Angle closure
o Treatment with Epilepsy

• Osmotic Drug Choice with Angle Closure

o Mannitol

• Ephinephrine with caution with CHF Clients

• Alphagan Decreases Aqueous Humor Production

• DO NOT use OTC eye drops with Increased IOP – Visine, Clear eyes
o Especially Angle closure

5 STAGES DETERIORATION GALUCOMA

• 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

SURGERY
• Laser: intense heat used to create opening ant. chamber angle facilitate aqueous humor outflow
• Trabeudoplasty: Focus with burning a hole pathway for fluid to leave chamber
• Peripheral Iridotomy: Shave off portion of Iris cause widening to increase flow

POST OP TX
• Miotic pilocarpine – top
• At least 3 hrs after administration of acetazolamide or timolol

OPEN – Able to drain (acute)

CLOSED – Blockage tribecular meshwork (chronic)

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

NURSING DIAGNOSIS
• 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
• Medication education
• Include family
• Follow up at 6 months

FLUCTUATION OF INTRAOCULAR PRESSURE

• Depends on time of day, Exertion, Food, and Drugs
• Increases With:
o Blinking
o Tight lid squeezing
o Upward gazing
 o HTN
o Uveitis
o Retinal detachments
• Decreases With:
o Exposure to cold weather
o Alcohol
o Fat free diet
o Heroin
o Marijuana

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
o Congenital
 German measles in 1st trimester of pregnancy; remain stationary could be
bilateral
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
o Metabolic
 Could be bilateral

CAUSES
• Genetic defect
• Aging
• Trauma (Retinal Detachment)
• Metabolic diseases (DM)
• Viruses
• Radiation (UV light rays)
• Exposure to toxic fumes or cig. Smoke

SIGNS AND SYMPTOMS OF CATARACTS

• Blurred Vision
• Looking through fog
• Blindness
• Decreased Visual Acuity – Gradual loss of vision
• Painless
• Poor night vision
• Vision sharper with dim lights
• Increased sensitivity to glare
• Read better with out glasses
 • Decreased color perception (blue, greens see as shades of gray)

STAGES
• Immature Cataract
o Not see C/O Visual Changes
o Light able to pass through with image projected with blurred vision
• Mature Cataract
o Complete area without light pass through
o Degree distorted vision depends on opaque
• Hypermature Cataract
o Develop blindness in eye with visual whiteness

TREATMENT
• DO NOT wait for ripening how 20/40 vision
• Extra Capular Extraction (ECCE)
o Remove Cataract – Post chamber intact
o Only with capsule left for implant
• Intracapsular Extraction (ICCE)
o Cataract with lens capsule
• Phacoemulsification
o Ultrasonic wave crush cataract and suction out particle with implant placed
• No medications type treatment
• Glasses, Contacts, strong bifocals, meg. Lens, improve
• Proper light decreases glare

DIAGNOSIS
• Reflective mirror
• Fundus exam – Distorted reflex
• Slit lamp exam – Ant. Segment

COMPLICATIONS
• 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
• Implant
o Advantage
 Good vision
 Minimal Distortion
  Implant at time of surgery
 95% client satisfaction
o Disadvantage
 Increased R/F Rejection
 Cost
 Correct distance vision only

* 4-8 weeks fitted with glasses

COMPLICATION OF SURGERY
• Coagulant / ASA contain products 5-7 days pre op due to bleeding
• Steroid held 5-9 days pre op
• Eye dilated agent every 10 minutes – 1hr before surgery X4 doses possible 6 doses
• Post Op Antibiotic drops / Ointment (Conj. From inner – outer)
o Apply pressure – Keep duct from tearing – Blink meds absorbed

POST OPERATIVE
• Check Eye Patch 24-48 hours
• MD checks 24hrs post op
• Metal eye shield at night
o For protection
• Complication
o Infection
o Bleeding
o Increased IOP
o Retinal Detachment
• Teach about eye drops
• S/S of retinal detachment
• NO reading
• If itches
o Apply cool clothe
• Sit near window with a lot of sun without sunglasses
• DO NOT bend over
• Avoid coughing, sneezing
• Prepare before surgery
• Tylenol for pain
o Avoid products with ASA