View
224
Download
0
Category
Preview:
Citation preview
8/7/2019 Visual Problems
1/151
Visual Problems
Lana Opea-Meneses
8/7/2019 Visual Problems
2/151
The Visual System
Complex group of structures that includes the
eyeballs, muscles, nerves, fat, and bones
Ocular adnexa: accessory structures thatsupport and protect the eye (muscles, fat,
bone)
8/7/2019 Visual Problems
3/151
8/7/2019 Visual Problems
4/151
Orbit (eye socket): surrounds and protects most of
the eye so that only a small portion is visible
Ocular muscles: 6 muscles that are attach to the
globe and move the eye through 6 cardial gazes
Four rectus muscles (medial, lateral,superior, inferior):
move the eye horizontally and vertically
Two oblique muscles (superior and inferior): rotate theeye in circular movements to allow vision at all angles
8/7/2019 Visual Problems
5/151
8/7/2019 Visual Problems
6/151
Eyelids: folds of skin that close to protect the anterioreyeball; prevents evaporation and drying of the surfaceepithelium
Palpebral fissure: elliptic space betw
een th
e tw
o openlids
Canthi: corners of the fissure
Meibomian gland: secretes oil
Lacrimal galnd: produces tears Nasolacrimal duct: directs flow of tears into the nose
8/7/2019 Visual Problems
7/151
8/7/2019 Visual Problems
8/151
8/7/2019 Visual Problems
9/151
Internal Structures
Conjuctiva: thin transparent layer of mucous
membrane that lines the eyelids and covers the
eyeball
Cornea: transparent, avascular structurewith a
brilliant, shiny surface
Sclera: fibrous protective coating of the eye; whitedense and continuous with the cornea
8/7/2019 Visual Problems
10/151
Uveal tract: middle vascular layer of the eyethat furnishes the blood supply to the retina
Iris: thin, pigmented diaphragmwith a central
aperture, the pupil; expansion and contration ofthe iris regulate the amount of light entering theeye
Ciliary body: produces and secretes aqueous
humor (clear, alkaline fluid composed mainly ofwater that occupies the space between the irisand the cornea)
Choroid: posterior segment of the uveal tract
between the retina and sclera
8/7/2019 Visual Problems
11/151
8/7/2019 Visual Problems
12/151
Lens: biconvex, avascular, colorless, and
almost completely transparent structure;
focuses light on the retina
Vitreous body: clear, avascular, jelly-like
structure
Vitreous chamber: space occupied by vitreous
fluid
8/7/2019 Visual Problems
13/151
Retina
Thin, semitransparent layer of nerve tissue thatforms the innermost lining of the eye
Contains all the sensory receptors for thetransmission of light and is actually part of thebrain
Rods and cones: retinal receptors
Rods: function best in dim light; damage results tonight blindness; 125 million
Cones: resolution of small visual angles, resultingin perception of fine details; responsible for color
vision; 6 million
8/7/2019 Visual Problems
14/151
8/7/2019 Visual Problems
15/151
Macula: center of the retina, 5mm in diameter
Fovea: depressed center of the macula; point
of finest vision; damage can severely reducecentral vision
8/7/2019 Visual Problems
16/151
Optic nerve:
Located at the posterior chamber of the eye and
transmit visual impulses from the retina to the
brain
Optic disc: head of the optic nerve
8/7/2019 Visual Problems
17/151
8/7/2019 Visual Problems
18/151
Common Health Problems of Neonates
and Infants
Congenital Cataract
Strabismus
Retinoblastoma
8/7/2019 Visual Problems
19/151
Congenital Cataract
Opacity (clouding) of the crystalline lens of the
eye
8/7/2019 Visual Problems
20/151
Incidence and Etiology:
Can be complete or incomplete
Bilateral or unilateral
Acquired or congenital
Acquired: maternal infections during pregnancy,
trauma, systemic disease
Congenital: inherited, prenatal trauma, anoxia,maternal systemic disease, prenatal infection
Congenital is more common; caused by rubella
virus
8/7/2019 Visual Problems
21/151
Pathophysiology:
Lens of capsule form during the 4th-5th week of
fetal development
Lens are normally clear, allowing light to enter
When factors interferewith lens development, it
becomes milky white and cloudy, obscuring light
and thus vision
8/7/2019 Visual Problems
22/151
8/7/2019 Visual Problems
23/151
cataract
8/7/2019 Visual Problems
24/151
8/7/2019 Visual Problems
25/151
Clinical Manifestations
Cloudiness of the lens
Absent or abnormal pupillary reflex
8/7/2019 Visual Problems
26/151
Treatment:
Definitive treatment: surgical removal
Surgery must take place before 8 weeks of age to
prevent an irreversible lack of vision development
After removal of lens, the infant is considered
aphakic (without lens) and will need corrective
lens or contact lens to focus light on the retina Intraocular implants may also be used
8/7/2019 Visual Problems
27/151
Through a small incision of around 2 to 3 mm and undertopical anesthesia, the anterior capsule of the bag,
containing the cataract, is opened. Through this opening
the cataract is emulsified by ultrasounds. This technique is
called phaco-emulsification or better known as phaco.After having vacuumed the emulsified rests of the lens, a
foldable intraocular lens is introduced through the small
incision into the bag.
This artificial lens unfolds
with
h
uman temperature andnicely takes place into the lens bag to position itself
correctly.
8/7/2019 Visual Problems
28/151
8/7/2019 Visual Problems
29/151
8/7/2019 Visual Problems
30/151
8/7/2019 Visual Problems
31/151
8/7/2019 Visual Problems
32/151
Nursing Management:
Prevent coughing, straining and vomiting to avoid
increase in IOP
Utilize aseptic technique when handling dressings andclosely monitor for any signs of infection
Instill appropriate eyedrops as ordered to prevent
complications of increased IOP, infection and glaucoma
Prevent edema and pressure in the eye
Avoid placing affected eye in dependent position
8/7/2019 Visual Problems
33/151
Family Teaching
Instillation of eye drops
Check for signs and symptoms of infection
(drainage, redness, edema, itching)
Check for signs and symptoms of increasing IOP
(pain, bulging of eye)
Care, purpose, and methods of maintaining eyepatching
8/7/2019 Visual Problems
34/151
Strabismus
Visual lines of each eye do not simultaneously
focus on the same object in space due to lack
of muscle coordination, resulting in crossed-
eye appearance
8/7/2019 Visual Problems
35/151
8/7/2019 Visual Problems
36/151
8/7/2019 Visual Problems
37/151
Pseudostrabismus: child appears crossed-eyed
because of prominent epicanthic folds and a
flat nasal bridge; disappears as the child grows
old
8/7/2019 Visual Problems
38/151
Pseudostrabismus vs. Strabismus
8/7/2019 Visual Problems
39/151
Pseudostrabismus
8/7/2019 Visual Problems
40/151
When the EOM move in unison, visual images
falls on the fovea of each eye and the images
form a single image
When one eye deviates, the brain is unable to
fuse the dissimilar images and double vision
results
The brain will learn to suppress the image
from the deviated eye (amblyopia) to allow
clear sight in the straight eye
8/7/2019 Visual Problems
41/151
Clinical Manifestations
Child is clumsy, stumbles often, and has difficulty
picking up objects
Squinting
Persistent crossing of the eyes
8/7/2019 Visual Problems
42/151
Diagnosis:
Screening at 3-6 months to prevent loss of vision
Hirschberg Corneal Light Reflex Test: light is held
in front of the childs face as the child stares
ahead; light should reflect off the cornea
symmetrically
Cover test: ch
ild looks at a toy, th
e examinercovers one of the childs eye; if uncovered eye
moves, then it can be assumed that it was not
fixed on the toy
8/7/2019 Visual Problems
43/151
8/7/2019 Visual Problems
44/151
Types of Strabismus
Esotropia: eye turns towards the midline
Exotropia: eye turns outward
Hypertropia: eye is out of vertical alignment; one
pupil is higher than the other
8/7/2019 Visual Problems
45/151
Esotropia
8/7/2019 Visual Problems
46/151
Exotropia
8/7/2019 Visual Problems
47/151
Hypertropia
8/7/2019 Visual Problems
48/151
Medical Treatment
Occlusion therapy: eye patching; stronger eye iscovered to allowweaker eye to work alone for all
or part of each day; most successful when done inpreschool years
Eyeglasses: covered lenses
Miotic drugs: drugs that act on ciliary muscle to
make accomodation easier Botulinum toxin: produce temporary muscular
paralysis (wears off in 2 months)
8/7/2019 Visual Problems
49/151
8/7/2019 Visual Problems
50/151
8/7/2019 Visual Problems
51/151
Surgical correction
Done for infants less than 12-18 months when
medical management does not work
Eye patching done before surgery to stimulate
non-involved eye to function
8/7/2019 Visual Problems
52/151
8/7/2019 Visual Problems
53/151
8/7/2019 Visual Problems
54/151
Nursing Management:
Stress importance of compliance in promoting
normal visual development
Explain that surgery corrects alignment but not
vision
8/7/2019 Visual Problems
55/151
8/7/2019 Visual Problems
56/151
Retinoblastoma
Tumor of the eye that develops when immature retinal
cells (retinoblasts) become malignant and grow out of
control
Rare form of cancer seen only in children
Usually found in infants and very young children
Can spread along the optic nerve to reach the brain
Cancer may spread to lymph nodes, bone, bone marrow,
and other organs
8/7/2019 Visual Problems
57/151
8/7/2019 Visual Problems
58/151
8/7/2019 Visual Problems
59/151
Severe Retinoblastoma
8/7/2019 Visual Problems
60/151
Clinical Manifestations
Whitish glow in the pupil
Leukocoria or cats eye reflex instead of the usual
red reflex that appears in photographs (most
common sign of retinoblastoma)
Strabismus
Red painful eyes
Blindness in late stages
8/7/2019 Visual Problems
61/151
Leukocoria
8/7/2019 Visual Problems
62/151
Leukocoria vs. Red Eye Reflex
8/7/2019 Visual Problems
63/151
Treatment:
Surgery
Radiation therapy
Laser therapy
Cryotherapy (using very cold probes to freeze and
kill the tumor)
Chemotherapy Enucleation: surgical removal of the eye
8/7/2019 Visual Problems
64/151
Nursing Management:
Emotional support and education of the client and
family
Teaching families about prevention and early
recognition of side effects of treatment or
recurrence of disease
8/7/2019 Visual Problems
65/151
8/7/2019 Visual Problems
66/151
Common Health Problems of Adults
Glaucoma
Surgery of the Eye
8/7/2019 Visual Problems
67/151
8/7/2019 Visual Problems
68/151
Classification
Primary and secondary glaucoma: refer towhether the cause is the disease alone or another
condition
Acute or chronic glaucoma: refer to the onset and
duration of the disorder
Open (wide) and closed (narrow): describe the
width of the angle between the cornea and the
iris
8/7/2019 Visual Problems
69/151
8/7/2019 Visual Problems
70/151
8/7/2019 Visual Problems
71/151
TYPES:
Primary Open-Angle Glaucoma
Most common form
Genetically determined, bilateral, insidious onset,
slow to progress
thief in the night because no early clinical
manifestations are present
Aqueous humor flow is slowed or stoppedbecause of obstruction by the trabecular
meshwork
8/7/2019 Visual Problems
72/151
8/7/2019 Visual Problems
73/151
Angle-Closure Glaucoma
Can develop only in one eyewhen the anterior
chamber angle is anatomically narrow
Occurs due to a sudden blockage of the anterior
angle by the base of the iris
8/7/2019 Visual Problems
74/151
8/7/2019 Visual Problems
75/151
Etiology and Risk Factors
Chronic open angle glaucoma: degenerative
change in the trabecular meshwork
HPN, CV diseases, diabetes, and obesity
Uveitis: inflammation of filtering structures
Tumor growth
Secondary glaucoma: edema, eye injury,
inflammation, tumor, advanced cases of cataracts
and diabetes
8/7/2019 Visual Problems
76/151
Pathophysiology
Obstruction of outflow of aqueous humor
increases IOP (normal is 10-20 mmHg)
Increased IOP inhibits blood supply to the
optic nerve and retina
Delicate tissues of optic nerves and retina
become ischemic and gradually lose function
8/7/2019 Visual Problems
77/151
8/7/2019 Visual Problems
78/151
Clinical Manifestations:
Atrophy and cupping (indentation) of the opticnerve on ophthalmoscopic examination
Loss of peripheral vision
Chronic Open-Angle Glaucoma: Crescent-shaped
scotoma (blind spot) appear in early stages of the
disease
Acute angle-closure glaucoma: severe pain,
blurred vision, vision loss; rainbowhalos aroundlight
8/7/2019 Visual Problems
79/151
8/7/2019 Visual Problems
80/151
Crescent-shaped Scotoma (blind spot)
8/7/2019 Visual Problems
81/151
8/7/2019 Visual Problems
82/151
Outcome Management:
Facilitate outflow of aqueous humor through
remaining channels and to maintain IOP within a
range that prevents further damage to the opticnerve
8/7/2019 Visual Problems
83/151
Medical Management:
Reduce IOP (promote aqueous flow): topicalmiotics or epinephrine to constrict pupils in
narrow-angle glaucoma
Topical beta-blockers/ alpha adrenergicagents/ oral carbonic anhydrase inhibitors:
reduces production of aqueous humor
8/7/2019 Visual Problems
84/151
Nursing Diagnoses:
Disturbed Sensory Perception (Visual) Grieving
Risk for Ineffective Therapeutic Regimen
Management
8/7/2019 Visual Problems
85/151
Nursing Management:
Obtain accurate list of current medications (suchas antihistamines) that may cause pupillary
dilation
Let client describe vision changes
Reassure client that further loss of vision may be
prevented by adhering to the treatment plan
Health teachings on proper eyedrop instillation
8/7/2019 Visual Problems
86/151
Surgical Management
Laser trabeculoplasty: use of laser to create anopening on the trabecular meshwork
8/7/2019 Visual Problems
87/151
8/7/2019 Visual Problems
88/151
Trabeculectomy: creation of an opening through
which the aqueous fluid escapes
8/7/2019 Visual Problems
89/151
8/7/2019 Visual Problems
90/151
Filtering Procedures: trephination, thermal
sclerotomy, and sclerotomy to create an outflow
channel from the anterior chamber into the
subconjunctival space
8/7/2019 Visual Problems
91/151
8/7/2019 Visual Problems
92/151
Iridotomy:
creation of a new route
for the flow of aqueous
humor to the trabecular
meshwork
8/7/2019 Visual Problems
93/151
Cyclodestructive procedures: used to damage
the ciliary body and decrease production of
aqueous humor when all other procedures
have failed cyclocryoprocedure: application of freezing tip
Cyclophotocoagulation: application of laser
8/7/2019 Visual Problems
94/151
Nursing Management:
Pre-operative care:
Prepare the patient for outpatient or inpatient surgery
E
xplain th
at client may experience popping sounds andflashing lights during laser therapy
Inform patient that there will be a 1-2 hours waiting period after
the surgery to evaluate a rise in IOP
Inform client in advance that he/she should arrange for a
companion and transportation after surgery
8/7/2019 Visual Problems
95/151
Post-operative care:
Cover eye with patch and metal/plastic shield for
protection to protect from light or trauma
Instruct not to lie on the operative side to avoidpressure on the surgical site
Client may ambulate and eat as soon as effects of
perioperative sedation has worn off
Frequent monitoring ofIOP: continued or
increasing pain, nausea, decreased vision
8/7/2019 Visual Problems
96/151
8/7/2019 Visual Problems
97/151
8/7/2019 Visual Problems
98/151
Treatment of surgical site
Carefully clean area around eye withwarm tap water
and a clean washcloth
Do not rub or apply pressure over the closed eye, which
may damage healing tissue
Common Health Problems Across the
8/7/2019 Visual Problems
99/151
Common Health Problems Across the
Lifespan
Errors in Refraction
Infections and Inflammation of the Eye
Traumatic Injury of the Eye
Retinal Detachment
8/7/2019 Visual Problems
100/151
Refractive Disorders
8/7/2019 Visual Problems
101/151
Errors in Refraction
Exists when light rays are not focused
appropriately on the retina of the eye
8/7/2019 Visual Problems
102/151
8/7/2019 Visual Problems
103/151
Basic Abnormalities
Myopia: nearsightedness, a condition in whichlight rays come into focus in front of the
retina; usually caused by an eyeball that islonger than usual
Hyperopia: farsightedness, a condition inwhich eye focuses light rays behind the eye,
and consequently the image that falls on theretina is blurred
8/7/2019 Visual Problems
104/151
Astigmatism: condition in which rays of light
are not bent equally by the cornea in all
directions so that a point of focus is not
attained
8/7/2019 Visual Problems
105/151
8/7/2019 Visual Problems
106/151
Surgical Management
Laser in situ keratomileusis (LASIK): most common
A thin layer of cornea is peeled back for laser reshaping
in the middle layer of the cornea and then the thinlayer is put back in place
Causes little postoperative discomfort, rapid recovery
of clear vision, and quick stabilization of refractive
change
Takes 10-15 minutes per eye
8/7/2019 Visual Problems
107/151
8/7/2019 Visual Problems
108/151
Laser epithelial keratomileusis (LASEK)
Also called epithelial LASIK
Used for patients with very thin and flat corneas
dilute alcohol is used to separate the epithelium
from the corneal wall
8/7/2019 Visual Problems
109/151
8/7/2019 Visual Problems
110/151
Corneal Ring Implants (In-tacts)
Clear pieces of acrylic that can be surgically
implanted into the cornea
Flatter the cornea and thereby reducenearsightedness
8/7/2019 Visual Problems
111/151
8/7/2019 Visual Problems
112/151
Nursing Management of the Surgical Patient Assess preoperatively for degree of myopia or
astigmatism (clients with severe refractionproblems may not achieve full correction)
Ensure eye protection by using goggles to preventdry eyes
Tell patient to avoid vigorous activity, activitiesthat could get water inside the eyes, and eyemake-up
Inform patient that steroid eyedrops causewatering of the eye and minimal pain
T ti I j t th E
8/7/2019 Visual Problems
113/151
Traumatic Injury to the Eye
Corneal Injury
Caused by direct trauma, over-worn contact lens,
chips of flying metal or glass fragments, or dirt
8/7/2019 Visual Problems
114/151
8/7/2019 Visual Problems
115/151
8/7/2019 Visual Problems
116/151
Manifestations
Painful, profusely lacrimating eye
Bulbar conjunctiva blood vessels will be
prominent
8/7/2019 Visual Problems
117/151
Treatment:
Removal of any imbedded items
Resting the eye (keeping it closed and using
antibiotic ointments)
Clients who are unconscious may develop
corneal dryness due to lack of blinking
Infections and Inflammation of the Eye
8/7/2019 Visual Problems
118/151
Infections and Inflammation of the Eye
Dacryocystitis
Definition: Inflammation of the tear drainage
system
Appearance: pus-like drainage or raised, red
lump near puncta
Management: antibiotics, daily massage of
lacrimal system
Dacryocystitis
8/7/2019 Visual Problems
119/151
Dacryocystitis
8/7/2019 Visual Problems
120/151
Hordeolum (stye)
Definition: infection of glands of eyelids
Appearance: Redness and swelling of localized
area of eyelid
Management: warm compress and antibiotics,
may need to be incised and drained
Hordeoleum
8/7/2019 Visual Problems
121/151
Hordeoleum
Hordeoleum
8/7/2019 Visual Problems
122/151
Hordeoleum
8/7/2019 Visual Problems
123/151
Blepharitis
Definition: chronic, bilateral inflammation ofthe eyelids
Appearance: itching and burning of the eyes;eyes appear red; scales noted on lashes
Management: wash eyelids with babyshampoo, water, and cotton-tippedapplicators; antibiotic ointments may beprescribed
Blepharitis
8/7/2019 Visual Problems
124/151
Blepharitis
Blepharitis
8/7/2019 Visual Problems
125/151
Blepharitis
8/7/2019 Visual Problems
126/151
Conjunctivitis
Definition: inflammation of conjunctiva from
various microorganisms
Appearance: redness, tearing, and exudation
of eyelid; may progress to eyelid drooping,
abnormal tissue growth
Management: antibiotic eyedrops
Conjunctivitis (Sore eyes)
8/7/2019 Visual Problems
127/151
Conjunctivitis (Sore eyes)
8/7/2019 Visual Problems
128/151
8/7/2019 Visual Problems
129/151
Retinal Detachment
8/7/2019 Visual Problems
130/151
Retinal Detachment
Separation of the retina from the choroid, a
membrane dense with blood vessels that is
located between the retina and the sclera
When retina detaches, it is deprived from itsblood supply and source of nourishment and
loses its ability to function
8/7/2019 Visual Problems
131/151
8/7/2019 Visual Problems
132/151
Rhegmatogenous retinal detachment
most common type and is due to a retinal hole
Liquid in the vitreous body seeps through the hole
and separates the retina from its blood supply
8/7/2019 Visual Problems
133/151
Predisposing factor:
Aging
Cataract extraction
Degeneration of the retina
Trauma
Severe myopia
Previous retinal detachment
Family history of retinal detachment
8/7/2019 Visual Problems
134/151
8/7/2019 Visual Problems
135/151
Vision in Retinal Detachment
8/7/2019 Visual Problems
136/151
Vision in Retinal Detachment
Vision in Retinal Detachment
8/7/2019 Visual Problems
137/151
Vision in Retinal Detachment
8/7/2019 Visual Problems
138/151
Surgical Management
General anesthesia is commonly used since
surgery may take hours
Pupils must be dilated No known medical treatment for retinal
detachment
8/7/2019 Visual Problems
139/151
Laser Photocoagulation
Laser is used to burn the edges of the tear and
halt progression
If the detachment is small, laser can seal theretina against the choroid
OPD using local anesthesia
8/7/2019 Visual Problems
140/151
8/7/2019 Visual Problems
141/151
Cryopexy
Uses nitrous oxide to freeze the tissue behind the
retinal tear, stimulating scar tissue formation that
will seal the edges of the tear OPD under local anesthesia
8/7/2019 Visual Problems
142/151
8/7/2019 Visual Problems
143/151
Pneumatic Retinopexy
Most effective for detachments that occur in the
upper portion of the eye
Eye is number with local anethesia and a small gasbubble in injected into the vitreous body
Bubbles rises and presses against the retina,
pushing it against the choroid
Gas bubble is slowly absorbed over the next 1 or 2
weeks
8/7/2019 Visual Problems
144/151
8/7/2019 Visual Problems
145/151
Scleral Buckling
Sclera is depressed from the outside by rubber-
like silicon sponges (Silastic) or bands that are
sutured permanently In addition to buckling, an intraocular injection of
air or sulfur hexaflouride gas bubble, or both, may
be used to apply pressure on the retina from the
inside of the eye
8/7/2019 Visual Problems
146/151
Scleral buckling
8/7/2019 Visual Problems
147/151
g
8/7/2019 Visual Problems
148/151
Nursing Management Help client cope with the fears and reality of loss
of vision and to adapt to changes in vision
After surgery, observe eye patch for any drainage
Assess level of pain and presence of nausea
Activity restrictions if gas or bubble has beeninjected
Position patient so that bubble can apply maximalpressure on the retina by the force of gravity
Position, usually head down and to one side,should be maintained for several days
8/7/2019 Visual Problems
149/151
Provide suggestions for comfort in position
like pillows under stomach, elbows, or ankles
Encourage to resume regular diet and fluids as
tolerated
Eye patch and shield removed the day after
surgery
Warm or cold compress for comfort severaltimes a day
8/7/2019 Visual Problems
150/151
Post-op medications: antibiotic-steroid
combination; cycloplegic agents (dilates pupil
and relax the ciliary muscles, which decreases
discomfort and helps prevent the formation ofiris adhesions to the corneal endothelium)
8/7/2019 Visual Problems
151/151
Recommended