This is an essential part of the eye examination and a measure against which all therapeutic outcomes are based.

The Snellen chart, which is composed of a series of progressively smaller rows of letters, is used to test distance vision.

The fraction 20/20 is considered the standard of normal vision.Most people can see the letters on the line designated as 20/20 from a distance of 20 feet.

A person whose vision is 20/200 can see an object from 20 feet away that a person with 20/20 vision can see from 200 feet away.

NOTE: ung first number ayun ung sayo, pero ung second number un ung sa ibang tao. Meaning kapag 20/200 ikaw kailangan mong lumapit ng up to 20 feet para mabasa pero ung ibang tao nababasa nila un kahit 200 feet distanceClients who wear corrective lenses other than for reading should have their vision tested with the lens in place.

Visual Acuity

The confrontational test is performed to examine visual fields or peripheral vision.

The examiner and the client sit facing each other. The client is asked to look directly into the eyes of the examiner throughout the test.

The examiner covers his or her right eye while the client covers his or her left eye (the client covers the eye directly opposite to the examiner's covered eye).

The examiner moves a finger from a nonvisible area into the client's line of vision. The examiner and client should see the object at approximately the same time. When the client sees the object coming into the line of vision, the client informs the examiner.

The procedure is repeated on the opposite eye. The test assumes that the examiner has normal peripheral vision.

Confrontational test

The Ishihara chart consists of numbers composed of colored dots located within a circle of colored dots.

The client is asked to read the numbers on the chart. Each eye is tested separately. Reading the numbers correctly indicates normal color vision The test is sensitive for the diagnosis of red-green blindness but cannot detect discrimination of blue.

Ishihara chart

The pupils are roundand of equal size.Increasing light causes pupillary constriction. Decreasing light causes pupillary dilation. Constriction of both pupils is a normal response to direct light.The client is asked to look straight ahead while the examiner quickly brings a beam of light (flashlight) in from the side and directs it onto the eye.

The constriction of the eye is a direct response to shining a light into that eye; constriction of the opposite eye is known as a consensual response.

Pupils

Normal sclera color is white.In a dark-skinned person, the sclera may normally appear yellow; pigmented dots may be present.

A yellowcolor to the sclera may indicate jaundice or systemic problems.The cornea is transparent, smooth, shiny, and bright.Cloudyareas or specks on the cornea may be the result of an accident or eye injury.

Sclera and cornea

The ophthalmoscope is an instrument used to examine the external structures and the interior of the eye.

The room is darkened so that the pupil will dilate. The instrument is held with the right hand when examining the right eye and with the left hand when examining the left eye.

The client is asked to look straight ahead at an object on the wall.The examiner should approach the client's eye from about 12 to 15 inches away and 15 degrees lateral to the client's line of vision.

As the instrument is directed at the pupil, a red glare (red reflex) is seen in the pupil.

The red reflex is the reflection of light on the vascular retina. Absence of the red reflex may indicate opacity of the lens. The retina, optic disk, optic vessels, fundus, and macula can be examined.

Ophthalmoscopy

The test is used primarily to assess for an increase of intraocular pressure and potential glaucoma.

Normal intraocular pressure is 10 to 21 mm Hg; intraocular pressure varies throughout the day and is normally higher in the morning (always document the time of intraocular pressure measurement).

Tonometry

DISORDERS

The best visual acuity with corrective lenses in the better eye of 20/200 or less or visual acuity of less than 20 degrees of the visual field in the better eye

Legally blind

When speaking to the client who has limited sight or is blind, the nurse uses a normal tone of voice.

Alert the client when approaching.Orient the client to the environment. Use a focal point and provide further orientation to the environment from that focal point.

Allow the client to touch objects in the room.Use the clock placement of foods on the meal tray to orient the client. Promote independence as much as is possible. Provide radios, televisions, and clocks that give the time orally, or provide a braille watch.

When ambulating, allow the client to grasp the nurse's arm at the elbow; the nurse keeps his or her arm close to the body so that the client can detect the direction of movement.

Instruct the client to remain one step behind the nurse when ambulating. Instruct the client in the use of the cane for the blind, which is differentiated from other canes by its straight shape and white color with red tip.

Instruct the client that the cane is held in the dominant hand several inches off the floor.

Instruct the client that the cane sweeps the ground where the client's foot will be placed next to determine the presence of obstacles.

NURSING INTERVENTIONS

is an opacity of the lens that distorts the image projected onto the retina and that can progress to blindness.

Cataract

Causes include the aging process (senile cataract), inherited (congenital cataract), and injury (traumatic cataract s); cataract s also can result from another eye disease (secondary cataract).

Intervention is indicated when visual acuity has been reduced to a level that the client finds to be unacceptable or adversely affects his or her lifestyle.

Blurred vision and decreased color perception are EARLY signs Diplopia, reduced visual acuity, absence of the red reflex, and the presence of a white pupil are LATE signs.

Loss of vision is gradual and painless

ASSESSMENTS

No nonsurgical (medications, eyedrops, eyeglasses) treatment cures cataracts or prevents age-related cataracts.

In the early stages of cataract development, glasses, contact lenses, strong bifocals, or magnifying lenses may improve vision.

MEDICAL MANAGEMENT

In general, if reduced vision from cataract does not interfere with normal activities, surgery may not be needed.

In deciding when cataract surgery is to be performed, the patients functional and visual status should be a primary

consideration. Surgery is performed on an outpatient basis and usually takes less than 1 hour, with the patient being discharged in 30 minutes or less afterward.

Although complications from cataract surgery are uncommon, they can have significant effects on vision.

When both eyes have cataracts, one eye is treated first, with at least several weeks, preferably months, separating the two procedures.

RATIONALE:Because cataract surgery is performed to improve visual functioning, the delay for the other eye gives time for the patient and the surgeon to evaluate whether the results from the first surgery are adequate to preclude the need for a second operation. The delay also provides time for the f irst eye to recover; if there are any complications, the surgeon may decide to perform the second procedure differently.

SURGICAL MANAGEMENT

Elevate the head of the bed 30 to 45 degrees. Turn the client to the back or nonoperative side. Maintain an eye patch as prescribed (usually for the first 24 hours adter the surgery)

Orient the client to the environment. Position the client's personal belongings to the nonoperative side. Use side rails for safety.Assist with ambulation.

POSTOPERATIVE INTERVENTION

Advise the client to avoid the following activities, because these activities can increase the IOP which can disrupt the sutures and can lead to Retrobulbar hemorrhage

The nurse also explains that there should be minimal discomfort after surgery and instructs the patient to take a mild analgesic agent, such as acetaminophen, as needed. Antibiotic, anti-inflammatory, and corticosteroid eye drops or ointments are prescribed postoperatively.

Advise the client to contact the physiciqn if the following is observed:

NURSING ALERT! If nausea occurs advised the client to call the physician immediately as this is a sign of increase IOPTo prevent accidental rubbing or poking of the eye, the patient wears a protective eye patch for 24 hours after surgery, followed by eyeglasses worn during the day and a metal shield worn at night for 1 to 4 weeks.

Sunglasses should be worn while outdoors during the day because the eye is sensitive to light.

Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days. A clean, damp washcloth may be used to remove slight morning eye discharge.

Because cataract surgery increases the risk of retinal detachment, the patient must know to notify the surgeon if new floaters (dots) in vision, flashing lights, decrease in vision, pain, or increase in redness occurs.

The eye patch is removed after the first follow-up appointment. The patient may experience blurring of vision for several days to weeks. Vision gradually improves as the eye heals. Vision is stabilized when the eye is completely healed, usually within 6 to 12 weeks.

HOME CARE

The term glaucomais used to refer to a group of ocular conditions characterized by optic nerve damage due to increase IOP.

Glaucoma

The eye normally produce fluid to nourish the cornea andlens. These fluilds are known as the AQUEOUS HUMOR.

The Aqueous humor is produced by the cillary body.These fluids will then drain through the TRABECULAR MESHWORK to th canal of Schlemm and will then be reproduced by the cilliary body (cycle sya kung baga)

NORMAL PHYSIOLOGY

GLAUCOMA PHYSIOLOGY

In this type of glaucoma, the production of aqueous humor is rapid and the the cyle is slow.

This can lead to increase IOPPressure by the increase IOP impedes the microcirculation in the optic nerveIf the blood supply in the optic nerve is impeded by the pressure, this can lead to gradual loss of vission.

Open angle glaucoma

In this type of glaucoma, the production of the aqueous humor is normal, however, the trabecular meshwork is block/obstructed due to thick iris

This can lead to increase IOPPressure by the increase IOP impedes the microcirculation in the optic nerveIf the blood supply in the optic nerve is impeded by the pressure, this can lead to gradual loss of vission.

TYPES MANIFESTATIONOpen-Angle Glaucoma Optic nerve damage

Visual field defects(loss of peripheral vission) IOP 21 mm Hg.

May have fluctuating IOPs. Usually no symptoms but possible ocular pain, headache, and halos.

NOTE: not that painful as compare to angle-closure glaucoma

Angle-Closure (Pupillary Block) Glaucoma

Rapidly progressive visual impairment, Periocular painConjunctival hyperemia, and congestion. NOTE: Pain may be associated with nausea, vomiting, bradycardia, and profuse sweating.

Close angle glaucoma (pupillary block)

Four major types of examinations are used in glaucoma evaluation, diagnosis, and management:

Tonometry to measure the IOPOphthalmoscopy to inspect the optic nerve, gonioscopy to examine the filtration angle of the anterior chamber, and perimetry to assess the visual fields. The changes in the optic nerve related to glaucoma are pallor and cupping of the optic nerve disc. The pallor of the optic nerve is caused by a lack of blood supply that results from cellular destruction.Cupping is characterized by exaggerated bending of the blood vessels as they cross the optic

DIAGNOSTIC

The aim of all glaucoma treatment is prevention of optic nerve damage. Lifelong therapy is almost always necessary because glaucoma cannot be cured.Treatment focuses on pharmacologic therapy, laser procedures, surgery, or a combination of these approaches, all of which have potential complications and side effects.

Although treatment cannot reverse optic nerve damage, further damage can be controlled. The goal is to maintain an IOP within a range unlikely to cause further damage.

MEDICAL MANAGEMENT

PHARMACOLOGIC MANAGEMENTMEDICATION

ACTION SIDE EFFECT NURSING INTERVENTION

Cholinergics (miotics) (pilocarpine, carbachol)

Increases aqueous fluid outflowby contracting the ciliary muscle and causing miosis (constriction of the pupil) and opening of trabecular meshwork

Periorbital painBlurry visionDifficulty seeing in the dark

Caution patients about diminished vision in dimly lit areas.

Advise the client to qcoid complex activitirs (driving, operating a machine)

Adrenergic agonists (dipivefrin, epinephrine)

Reduces production of aqueous humor and increases outflow

Eye redness and burningCan have systemic effects, including palpitations, elevated blood pressure, tremor, headaches, and anxiety

Teach patients punctal occlusion to limit systemic effects (Check picture below)

Beta-blockers (betaxolol, timolol)

Decreases aqueous humor production

Can have systemic effects, including bradycardia, exacerbation of pulmonary disease, and hypotension

Contraindicated in patients with asthma, chronic obstructive pulmonary disease, second-or third-degree heart block, bradycardia, or cardiac failure

Teach patients punctal occlusion to limit systemic effects.

Carbonic anhydrase inhibitors (acetazolamide, methazolamide, dorzolamide)

Decreases aqueous humor production due its diuretic effect

Oral medications (acetazolamide and methazolamide) associated with serious side effects, including anaphylactic reactions, electrolyte loss, depression, lethargy, gastrointestinal upset, impotence, and weight loss; side effects of topical form (dorzolamide) include topical allergy

Do not administer to patients with sulfa allergies;

Monitor electrolyte levels.

NOTE: PUNCTUAL OCCLUSION to prevent systemic absorprion of optic medication

In laser trabeculoplastyfor glaucoma, laser burns are applied to the inner surface of the trabecular meshwork to open the intratrabecular spaces and widen the canal of Schlemm, thereby promoting outflow of aqueous humor and decreasing IOP. The procedure is indicated when IOP is inadequately controlled by medications, and it is contraindicated when the trabecular meshwork cannot be fully visualized because of narrow angles. (LASER TRABECULOPLASTY is for OPEN ANGLE GLAUCOMA ONLY)

In laser iridotomy for pupillary block glaucoma, an opening is made in the iris to eliminate the pupillary block. Laser iridotomy is contraindicated in patients with corneal edema, which interferes with laser targeting and strength.

SURGICAL MANAGEMENT

Instruct the client on the importance of medication. (CHECK THE TABLE ABOVE)Instruct the client of the need for lifelong medication use. Instruct the client to wear a Medic Alert bracelet. Instruct the client to avoid anticholinergic medications (atropine sulfate, this medication can cause increase IOP by dilating the pupil)

Instruct the client to report eye pain, halos around the eyes, and changes in vision to the physician.

Instruct the client that when maximal medical therapy has failed to halt the progression of visual field loss and optic nerve damage, surgery will be recommended.

Prepare the client for trabeculoplasty or laser iridectomy as prescribed to facilitate aqueous humor drainage.

NURSING INTERVENTIONS

Detachment or separation of the retina from the epithelium Retinal detachment occurs when the layers of the retina separate because of the accumulation of fluid between them, or when both retinal layers elevate away from the choroid as a result of a tumor.

Partial detachment becomes complete if untreated. When detachment becomes complete, blindness occurs.

Retinal detachment

Flashes of light Floaters or black spots (signs of bleeding) Increase in blurred vision Sense of a curtain being drawn over the eye Loss of a portion of the visual field

ASSESSMENTS

Provide bed rest. Cover both eyes with patches as prescribed to prevent further detachment. Speak to the client before approaching. Position the client's head as prescribed. If the detachment is on the right side of the eye ball position the client's head on the right side also to prevent further detachment

Protect the client from injury.Avoid jerky head movements. Minimize eye stress.Prepare the client for a surgical procedure as prescribed. (SCLERAL BUCKLING)

IMMEDIATE INTERVENTIONS

Maintain eye patches as prescribed. Monitor for hemorrhage. Prevent nausea and vomiting and monitor for restlessness, which can cause hemorrhage

Monitor for sudden, sharp eye pain (notify the physician). Encourage deep breathing but avoid coughing.Provide bed rest for 1 to 2 days as prescribed. Position the client as prescribed (positioning depends on the location of the detachment).

Administer eye medications as prescribed. Assist the client with activities of daily living. Avoid sudden head movements or anything that increases intraocular pressure.Instruct the client to limit reading for 3 to 5 weeks. Instruct the client to avoid squinting, straining and constipation, lifting heavy objects, and bending from the waist.

Instruct the client to wear dark glasses during the day and an eye patch at night. Encourage follow-up care because of the danger of recurrence or occurrence in the other eye.

POSTOPERATIVE INTERVENTIONS

Bleeding into the soft tissue as a result of an injury. A contusion causes a black eye; the discoloration disappears in about 10 days. Pain, photophobia, edema, and diplopia may occur.

Contusion

Place ice on the eye immediately. Instruct the client to receive a thorough eye examination.

INTERVENTIONS

An eye injury in which an object penetrates the eye Penetrating objects

NEVER remove the object because it may be holding ocular structures in place; the object must be removed by the physician.

Cover the object with a cup. Both eyes shouls be coveredDo not allow the client to bend over. Do not place pressure on the eye. Client is to be seen by a physician immediately. X-rays and CT scans of the orbit are usually obtained. Magnetic resonance imaging (MRI) is contraindicated because of the possibility of metal-containing projectile movement during the procedure.

INTERVENTIONS

An eye injury in which a caustic substance enters the eye Chemical burn

Treatment should begin immediately. Flush the eyes at the scene of the injury with water for at least 15 to 20 minutes.

At the scene of the injury, obtain a sample of the chemical involved. At the emergency room, the eye is irrigated with normal saline solution or an ophthalmic irrigation solution for at least 10 minutes.

The solution is directed across the cornea and toward the lateral canthus. Prepare for visual acuity assessment. Apply an antibiotic ointment as prescribed. Cover the eye with a patch as prescribed.

INTERVENTIONS

ASSESSMENT OF EYESTuesday, December 9, 2014 16:34