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Chapter 51

Eye and VisionDisorders

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Learning Objectives

Identify the data to be collected in the nursing assessment

of the eye and vision. Identify the nursing responsibilities for patients having diagnostic

tests or procedures to diagnose eye disorders. List measures to reduce the risk of eye injuries.

Describe the nursing care of patients who require commontherapeutic measures for eye disorders: irrigation,

application of ophthalmic drugs, and surgery. Describe the pathophysiology, signs and symptoms, diagnosis,

and treatment of selected eye conditions. Assist in developing a nursing care plan for the patient

with an eye disorder.

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Anatomy and Physiology

of the Eye

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External Structures

Eyelids

Eyelashes

Conjunctiva

Cornea

Sclera

Extraocular muscles

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Figure 51-1

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The Eyeball

Sclera

Choroid

Retina

Optic nerve

Fluid chambers

Anterior chamber

Posterior chamber

Lens

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Figure 51-2

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Figure 51-3

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Visual Pathway

Light enters eye, passes through transparent cornea, aqueoushumor, lens, and vitreous humor These structures are called refractive media

Refract (bend) horizontal and vertical light rays so that the light raysfocus on the retina

On retina, light rays are reversed and upside down Images carried as impulses through the optic nerve

At optic chiasm, fibers from the left field from each eye join to formthe left optic tract

Fibers from right field of eye join to form right optic tract

Images transmitted to the brain by way of the optic tracts

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Figure 51-4

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Age-Related Changes in the Eye

Skin around the eye becomes wrinkled and loose

Eyelids usually have some excess tissue; not important unless itinterferes with vision

The amount of fat around the eye decreases, permitting theeyeball to sink deeper into the orbit

Tear secretion diminishes; cornea less sensitive

Grayish ring may be around the outer margin of the iris

Pupil smaller and responds more slowly to light

Presbyopia: ability to focus is impaired

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Health History

History of present illness Record changes in vision

If pain, inquire about location and nature

Sensitivity to light (photophobia) Discharge from the eyes

Complaints that the eyes feel dry and irritated

Past medical history

Diabetes, neurologic disorders, thyroid disease,hypertension

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Health History

Family history

Any eye diseases as well as a history of

arteriosclerosis, diabetes, and thyroid disease

Functional assessment Patients occupation, roles, usual activities

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Physical Examination

Inspect the external eye, assess response of

the pupil to light, and evaluate gross visual

acuity

If abnormalities suspected, inform physician oradvise patient to seek medical evaluation

Acuity commonly tested with Snellen chart

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Figure 51-5

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Diagnostic Tests and Procedures

Ophthalmoscopic examination

Refractometry

Visual fields

Tonometry

Measure of electrical potential

Fluorescein angiography

Corneal staining

Imaging procedures CT, ultrasonography, radioisotope scanning, or MRI

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Figure 51-6

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Figure 51-7

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Figure 51-8

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Figure 51-9

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Therapeutic Measures

Eye irrigation

Topical medications Miotics

Mydriatics

Anesthetics Cycloplegics

Antibiotics

Anti-inflammatory drugs

Eye surgery Surgical incisions, lasers, and cryotherapy

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Preoperative Nursing Care

Assessment

Patients emotional state, ability to perform self-care,

and knowledge of surgical routines and outcomes

Be sure the patient understands the preoperativeroutine

Interventions

Anxiety

Self-Care Deficit

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Postoperative Nursing Care

Assessment Vital signs and level of consciousness

Inspect dressing for bleeding or drainage

Patient comfort, including pain and nausea

If vision impaired, inspect environment for safetyhazards

Before discharge, determine patients understandingof and ability to administer prescribed medications by

having the patient demonstrate self-medication

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Postoperative Nursing Care

Interventions

Risk for Injury

Disturbed Sensory Perception

Acute Pain Anxiety

Ineffective Therapeutic Regimen Management

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Protection of the Eyes

and Vision

Patient teaching

Adults younger than 40 years of age should have

their eyes examined every 3 to 5 years

After the age of 40, examinations every 2 years andshould include testing for glaucoma

When there are symptoms of eye problems, patients

should seek medical advice

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Protection of the Eyes

and Vision

Prevention of injuries Teach young children the danger of throwing or

poking objects at the faces of playmates

Assess toys for safety

Adult activities that produce sparks or causefragments to be dispersed also cause injuries

Advise protective eyewear for such potentiallydangerous activities

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Protection of the Eyes

and Vision

Basic eye care

Gently cleanse the eyelids each time the face is

washed; use a clean cloth without soap

Wash eye from the inner canthus (near the nose)toward the outer canthus

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Effect of Visual Impairment

Mild losses may require only some adaptations

Serious losses affect independence, mobility,

employment, and interpersonal relationships

People grieve for the lost function just as they mightgrieve after the death of a loved one

Factors that affect a persons response to this loss

include personality, usual coping style, effect of vision

loss on the persons life, and the circumstances of the

loss

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Care of the Visually Impaired Patient

Be aware of visually impaired personsthoughts and feelings about handicaps

Assume that people with visual impairments

can be independent and productive The person needs help with some tasks butshould be treated as an adult

The extent of vision loss determines the types

of assistance needed

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Care of the Visually Impaired Patient

Interventions

Disturbed Sensory Perception

Ineffective Coping

Self-Care Deficit Ineffective Therapeutic Regimen Management

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Figure 51-11

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Disorders Affecting the Eye or

Vision:

Inflammation and Infection

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Blepharitis

Inflammation of hair follicles along eyelid margin

Caused by bacteria, most often by staphylococci

Symptoms include itching, burning, and photophobia;

scales or crusts on the lid margins

Physician may prescribe an antibiotic ointment

Be certain that any medication applied to the eye is an

ophthalmic preparation

Eyelids can be gently cleansed with baby shampoosolution

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Hordeolum

Commonly called a stye

Common acute staphylococcal infection of the eyelidmargin that originates in a lash follicle

Affected area of lid is red, swollen, and tender

Apply warm, moist compresses several times a day Repeated infections may be related to staphylococcal

infections at some other location on the body

Physician may treat with ophthalmic antibiotics

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Chalazion

Inflammation of the glands in the eyelids

Swelling prevents fluid from leaving the glands,

causing tenderness

Warm compresses may bring some relief Physician may order antibiotics if infection

Surgical removal of the gland necessary if

condition persists

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Conjunctivitis

Inflammation of the conjunctiva caused by

microorganisms, allergy, or chemical irritants

Bacterial conjunctivitis commonly called

pinkeye Red conjunctiva, mild irritation, drainage

Warm/cool compresses, topical vasoconstrictors

Infected people should practice good hand washing

and should avoid sharing washcloths

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Conjunctivitis

Viral conjunctivitis caused by herpes simplex

virus type 1, herpes zoster virus, or

adenoviruses

Characterized by redness and drainage Round, raised white or gray areas on the conjunctiva

Infections caused by herpes simplex virus type 1 are

treated with ointments or other topical medications

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Keratitis

Inflammation or infection, or both, of the cornea

From bacteria, viruses, fungi; chemical or mechanical

injuries cause inflammation that may be followed by

infection

No noticeable drainage, but considerable pain

Topical antibiotics and topical corticosteroids

Systemic antibiotics after culture and sensitivity

Sometimes physician injects antibiotics directly into theconjunctiva

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Entropion

The lower lid turns inward

Eyelashes rub against the eye, causing pain

and possibly scratching the cornea

Surgical correction usually recommended

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Ectropion

The lower lid droops and turns outward

The eye does not close completely, causing it

to become dry and irritated

The dry cornea is easily injured Requires surgical correction

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Foreign Body

Blinking/tearing wash small irritants from eye

If foreign body remains, evert the upper and lower lids

If object is clearly visible and does not appear to beembedded, you may attempt to remove it

Use sterile cotton swab to touch object gently If object not embedded, it usually clings to swab and can

be removed

If object is embedded, it should be removed only by a

physician

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Figure 51-13

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Corneal Opacity

Inflammation and infection

When cornea injured by infection or trauma, scar tissue may

form

If scar tissue prevents light from entering the eye, varying

degrees of vision impairment occur Only treatment is keratoplasty (removal of the scarred cornea

and replacement with a healthy cornea)

During keratoplasty, damaged cornea removed first

An identically sized graft then taken from the donor eye and

secured to the recipients eye with very fine suture

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Figure 51-14

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Figure 51-15

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Care of the Patient Having

Keratoplasty

After surgery, the keratoplasty patient has an

eye pad and a metal shield over the operative

eye

Corticosteroid eye drops may be ordered toreduce inflammation

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Care of the Patient Having

Keratoplasty

Assessment

Inspect dressing for drainage and ask if patient has pain or

nausea

After dressing is removed, inspect for corneal opacity

Also evaluate the patients visual acuity Interventions

Risk for Injury

Pain

Impaired Sensory Perception Ineffective Therapeutic Regimen Management

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Disorders Affecting the Eye or Vision:

Errors of Refraction

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Myopia

The medical term for nearsightedness

The lens is situated too far from the retina

Light rays come together to focus in front of the

retina People with myopia have difficulty seeing

distant images clearly

New glasses needed approximately every 2

years

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Hyperopia

Commonly known as farsightedness

The lens is too close to the retina

Light rays come together behind the retina

The hyperopic person sees clearly in thedistance but has difficulty focusing on close

objects

Convex corrective lenses needed

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Figure 51-16

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Astigmatism

Irregularities in the cornea or lens

If condition is mild, the natural lens can correctfor the abnormality

If severe, vision is distorted, and correctivelenses are needed

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Presbyopia

Poor accommodation due to loss of elasticity of

the ciliary muscles

Accommodation: adjustment of the lens for near and

distant vision

Contraction or relaxation of the ciliary muscles, which

causes the lens to change shape

It most often develops after age 40 years

Corrective lenses are needed

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Medical Treatment

Corrective lenses for errors of refraction Eyeglasses

Contact lenses

Surgical treatment Photorefractive keratectomy (PRK)

Laser in situ keratomileusis (LASIK)

Nursing care

Encourage periodic examinations and know if thepatient uses corrective lenses

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Disorders Affecting the Eye or

Vision

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Cataract

Lens opaque (cloudy); no longer transparent

Causes: congenital, traumatic, degenerative

Pathophysiology

Injuries cause opacity rapidly, whereas age-relatedopacity progresses slowly

Signs and symptoms: cloudy vision, seeing

spots or ghost images, and floaters

Medical treatment

Cataract extraction

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Figure 51-17

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Cataract

Complications

Leakage of vitreous humor, hemorrhage into the eye,

and opening of the incision

Lens replacement Cataract eyeglasses

Contact lenses

Intraocular lenses

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Care of the Patient with Cataracts

Preoperative care

Drops used before cataract surgery are mydriatics,

cycloplegics, antibiotics, and nonsteroidal anti-

inflammatory agents

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Care of the Patient with Cataracts

Postoperative care Assessment

Pain and nausea

Patient is likely to wear a patch and shield over operative

eye Note any drainage

Also note level of consciousness and orientation

Interventions Risk for Injury

Impaired Sensory Perception

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Glaucoma

Pathophysiology Intraocular pressure is above normal

Caused by interference with outflow of aqueoushumor

Although glaucoma may follow trauma, exact causeis often unknown

Peripheral vision is lost first

Field of vision gradually narrows until tunnel vision

Complete blindness eventually occurs

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Types of Glaucoma

Open-angle glaucoma Prevents the normal passage of aqueous humor through the

trabecular meshwork

Usually there are no signs and symptoms at first

Tired eyes, blurred vision, and halos around lights

Need for frequent changes in eyeglass prescriptions

Treated first with drug therapy Beta-adrenergic blockers, adrenergics, cholinergics, carbonic

anhydrase inhibitors, and hyperosmotic agents

Surgical procedures: trabeculoplasty, trabeculectomy, and

cyclocryotherapy

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Glaucoma

Angle-closure glaucoma Flow of aqueous humor through the pupil is blocked

Pressure forces iris forward; blocks trabecular meshwork

Rapid rise in intraocular pressure; if not lowered promptly,permanent blindness can result

Signs and symptoms: sudden, acute pain; blurred vision,halos around lights, nausea and vomiting, and headache onthe affected side

Drugs for treatment: miotics and oral or intravenous carbonicanhydrase inhibitors

After pressure lowered, iridotomy or iridectomy usuallyrecommended to prevent recurrence

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Glaucoma

Assessment

Collect data about patient knowledge of the disease

and treatment and patient ability to carry out self-care

Interventions Risk for Injury

Fear and Ineffective Therapeutic Regimen

Management

Pain

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Retinal Detachment

Pathophysiology Separation of sensory layer from pigmented layer

Begins when a tear in the retina allows fluid to collect between

the sensory and the pigmented layers

The fluid causes the two layers to separate Separation deprives sensory layers of nutrients and oxygen that

normally are supplied by the blood vessels in the choroid

Leads to damage to the nerve tissue in the sensory layer and

resultant partial or complete loss of vision

Retinal tears may occur spontaneously or as a result oftrauma

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Retinal Detachment

Signs and symptoms

Depend on location and extent of detachment

Patients report seeing light flashes or floaters

Vision may be cloudy If area of detachment is large, vision may be lost

completely

Some patients say it seems as if a curtain has come

down or across the line of vision

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Figure 51-18

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Retinal Detachment

Medical and surgical treatment Laser photocoagulation

Cryotherapy

Scleral buckling

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Retinal Detachment

Nursing care Before corrective measures, the patient usually is placed on

strict bed rest with the head elevated

Postoperative care essentially the same as for other patients

undergoing eye surgery Positioning orders may be specific for these patients

Surgeon prescribes activity limitations; length of hospitalization

depends on location and severity of the tear, the type of repair,

and the surgeons routines

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Figure 51-19

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Senile Macular Degeneration

Changes in the eye cause the macula to degenerate Both eyes usually affected

Two types

Dry (strophic) Abnormal blood vessels develop in or near the macula resulting

in loss of vision in a specific area Wet (exudative)

Central vision gets gradually worse

Special telescopic lenses may be helpful

Laser treatments may offer hope to some patients

Nurse needs to help the patient and family members learn to copewith declining vision

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Figure 51-20

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Enucleation

Removal of the eye

From injury, infection, sympathetic ophthalmia, and

some glaucomas and malignancies

Postoperative observe for excessive bleeding or

increasing pain Report any temperature elevation

After pressure dressing removed, physician may order wound

care and topical medications

Approximately 1 month after the enucleation, a prosthesis canbe fitted by an optician

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Figure 51-21