Disorders of the eye

Disorders of the eyeIsaac AmankwaaDefinition of TermsVision: Passage of rays of light from an object through the cornea, aqueous humor, lens, and vitreous humor to the retina, and its appreciation in the cerebral cortex.Emmetropia: Normal vision: rays of light coming from an object at a distance of 20 feet (6 m) or more are brought to focus on the retina by the lens.I. Amankwaa2Definition of termsAmetropia: Abnormal vision.Myopia: NearsightednessHyperopia: Farsightedness

I. Amankwaa3Definition of termsAccommodation: Focusing apparatus of the eye adjusts to objects at different distances by means of increasing the convexity of the lens (brought about by contraction of the ciliary muscles).Presbyopia: The elasticity of the lens decreases with increasing age; an emmetropic person with presbyopia will read the paper at arm's length and will require prescription lenses to correct the problem.I. Amankwaa4Definition of termsAstigmatismrefractive error in which light rays are spread over a diffuse area rather than sharply focused on the retina, a condition caused by differences in the curvature of the cornea and lens .

I. Amankwaa5Definition of termsEnucleation: complete removal of the eye-ball and part of the optic nerve exenteration: surgical removal of the entire contents of the orbit, including the eye- ball and lids evisceration: removal of the intraocular contents through a corneal or scleral incision; the optic nerve, sclera, extraocular muscles, and sometimes, the cornea are left intact

I. Amankwaa6Common AbbreviationsOD (oculus dexter) or RE- right eyeOS (oculus sinister) or LE- left eyeOU (oculus unitas)both eyesIOPintraocular pressureIOLintraocular lensEOLextraocular lens

I. Amankwaa7EYE CARE SPECIALISTSOphthalmologist: Physician specializing in diagnosis, surgery, and treatment of the eye. Ophthalmology specialists may focus their practice on a specific part of the eye or disorder, such as a cornea specialist or glaucoma specialist.Optometrist: Doctor of optometry who can examine, diagnose, and manage visual problems and diseases of the eye, but does not perform surgery.Optician: Fits, adjusts, and gives eyeglasses or other devices on the written prescription of an ophthalmologist or optometrist.Ocularist: Technician who makes ophthalmic prostheses.I. Amankwaa8Nursing Care of patients undergoing eye surgeryI. Amankwaa9Specific pre-op carePhysical OrientationAssist the patient to learn details of his room such as the location of furniture, doors, windows, and so forth.Familiarize patient with the voices of those who will care for him after surgery.Familiarize him with the daily sounds and noises in the environment, since he will be more aware of sound without his vision.

I. Amankwaa10Specific pre-op careObservationThe patient should be observed for tendencies to cough or sneeze (smoker's cough, allergies, and so forth). I. Amankwaa11Specific pre-op careEducation.The patient must understand the objective of resting the eyes & avoiding actions that increase intraocular pressure.The head must be kept very still.No reading.No showers, no shampooing, no tub baths.No bending over at the waist.No lifting of heavy objects.No sleeping on the operative side. If both eyes are affected, the patient must sleep on his back.I. Amankwaa12Specific pre-op carePhysical Preparation.Instruct patient to wear dark glasses if atropine drop have been usedA bowel prep is done the evening prior to surgery to prevent the patient from straining at stool during the immediate post-op period.Prepare the affected eye by cleaning the skin of the side of the faceI. Amankwaa13Specific pre-op carePhysical Preparation.Shaving of eyebrows, cutting of eyelashes, and shaving of face should be done only on the order of the surgeon.After the patient has been taken to surgery, prepare a post-op bed, ensuring that the bed is equipped with side rails.Sand bags should be made available for use in immobilizing the head.I. Amankwaa14Post-operative careReturn from Surgery.The patient must be lifted off the stretcher, he is not to move himself.The patient should be positioned on his back or turned to the un-operated side or as prescribed by the physician.Sandbags should be used to immobilize the patient's head, if ordered.I. Amankwaa15Post-operative careReturn from Surgery.If both eyes are bandaged (they normally are), the side rails MUST be raised at all times to protect the patient in the event he becomes disoriented and attempts to get out of bed.Place the call bell within easy reach of the patient's head and let the patient know exactly where it is located.I. Amankwaa16Post-operative careReturn from Surgery.Remind the patient that he should not cough, sneeze, or blow his nose. him to inform the staff if he feels the urge, since these actions will increase intraocular pressure.Eye pad and eye shield should be kept in placeI. Amankwaa17Post-operative careOrientation.Reinforce the physical orientation given during the preoperative period by verbally reviewing the locations of objects in the room.Orient the patient to other people in the room.The patient should have an awareness of his surroundings and know what to expect to avoid being startled or frightened.

I. Amankwaa18Post-operative carePrecautions.Avoid dislodgement of the eye dressings by securing them with an eye shield or reinforcing loose tape.Restrain the arms of children and disoriented or uncooperative patients, as appropriate. Avoid jarring or bumping the bed, as this may startle the patientI. Amankwaa19Post-operative carePrecautions.A sleeping patient must be watched constantly to ensure that proper positioning is maintained. If the patient is newly blinded as a result of the surgery, observe for depression and take precautions if patient is potentially suicidalI. Amankwaa20Post-operative carePrecautions.Check the physician's orders before giving anything by mouth. Nausea and vomiting must be avoided.Additionally, the motion of chewing may be contraindicatedI. Amankwaa21Post-operative careApproaching the PatientALWAYS speak to the patient upon entering his area and before touching him.Allay the patient's fears by explaining each procedure or activity fully.Continue to reinforce his orientation to the surroundings.Always let the patient know when you are leaving his area.

I. Amankwaa22Post-operative careDiversional Activity.Provide activities that are not fatiguing to the eyes if the eyes are not bandaged.No readingMinimal televisionEncourage visitors to chat with the patient or read to him.I. Amankwaa23DISORDERS OF THE EYE LID

Hordeolum (stye)Chalazion (Meibomian cyst)BlepharitisEntropionEctroponI. Amankwaa2424Structure of the eyelidThe eyelid is made up of the Skinit is thin and characterized by absence of fat.Muscle layerOrbiclaris oculi consist of horizontal concentric fibres. levator palpebral superioris.The end in an aponeurosis which is insertedTarsus Consists of dense fibers tissue.Embidded in it are enormously developed sebaceous glands-the meibomian glands.Mucous layerformed by the palpebral conjunctivaI. Amankwaa25Structure of the eyelid

I. Amankwaa2626Glands of the eyelidMeibomian glands: They are embedded in the tarsus and are modified sebaceous glands. They secret an oily secretion. They open through vertically arranged ducts into the lid margin.Glands of zeis: They are sebaceous glands developed as outgrowth of the hair follcles of the eye lashes. They are situated at the margin.Glands of moll: These are modified sweat glandsI. Amankwaa27Eyelid marginEye lashes-arranged in 2-3 rows anteriorly.Opening of the ducts of the meibomian gland posteriorly.Glands of zies and moll

I. Amankwaa28Inflammation of the eyelidI. Amankwaa29HordeolumThe term stye refers to an inflammation or infection of the glands and follicles of the eyelid marginThere are two typesExternal Hordeolum (stye)Internal HordeolumI. Amankwaa30Hordeolum External hordeolum (stye) Acute bacterial infection of the lash follicle and its associated gland of Zeis or Moll Internal hordeolum Acute bacterial infection of Meibomian gland Infection usually staphylococcal I. Amankwaa3131Acute hordeola Staph. abscess of Meibomian glands Tender swelling May discharge through skin or conjunctiva Staph. abscess of lash follicle and gland of Zeis or Moll Tender swelling at lid margin May discharge through skinInternal hordeolum ( acute chalazion )External hordeolum (stye)

Hordeolum s/sRed swelling appears in the lash line of the margin of the lidPaintenderness edema of the lidsI. Amankwaa3333HordeolumDiagnosisVisual examculture if neededTreatmentHot compress to alleviate painTopical or systemic antibioticsI. Amankwaa3434HordeolumTreatment and Nursing Considerationwarm soaks to promote drainage, good hand washing and eyelid hygieneTopical or systemic antibioticsIn some cases, incision and drainage may be necessary. Teach patient how to clean eyelid margins and not to squeeze the stye.I. Amankwaa3535CHALAZION (MEIBOMIAN CYST)DefinitionA chalazion is noninfectious obstruction of a meibomian gland causing extravasation of irritating lipid material in the eyelid soft tissues with focal secondary granulomatous inflammation.I. Amankwaa3636CHALAZION (MEIBOMIAN CYST)Etiology, PathologyThe meibomian duct becomes obstructed through proliferation of its epithelium and consequently the gland enlarges.The fatty secretion escapes into the surrounding tissue

I. Amankwaa3737Chalazion DiagnosisVisual ExaminationTreatmentsmall ones usually disappear spontaneously after a month or twolarge ones usually need surgical removalI. Amankwaa3838

Treatment of chalazionInjection of local anaestheticInsertion of clamp

Incision & curettageDifference between chalazion and hordeolumChalaziatend to develop farther from the edge of the eyelid than styes. Chalazion often larger thanstye,chalaziausually isn't painful. Chalazion is not caused by an infection from bacteria, Sometimes, when a astyedoesn't heal, it can turn into achalazion

I. Amankwaa40pterygiumI. Amankwaa41Definition of pterygiumA pterygium is a fleshy growth that invades the cornea. It is an abnormal process in which the conjunctiva grows into the cornea.

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PterygiumThere are two types:Progressive Pterygium: These types of pterygium are those which progress day by day.

Non Progressive Pterygium: Those which after limited growth has been occur than stop their generationI. Amankwaa43Pterygium- causesThe exact cause is not known.The probable causes are:Commonly occurs in people living in hot & dry climate.Dusty atmosphere.Common in outdoor workers.Common in males.It may occur nasal than temporal side.

I. Amankwaa44symptomsRedness Irritation Dryness Tearing May cause decreased vision ( when it reaches the visual axis of cornea)I. Amankwaa45Treatment Local:Lubricant eye drops.Topical steroids for inflammation.

Surgical:Surgical excision when the pterygium progressive towards the cornea.

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Precautions

cataractI. Amankwaa48Cataract DefinitionA cataract is a lens opacity or cloudiness Clouding or opacity of the crystalline lens that impairs vision.IncidenceCataract is the leading cause of blindness in the worldCommon in individuals above 70 yrs

I. Amankwaa49Pathophysiology Cataract formation is characterized chemically by a reduction in oxygen uptake and initial increase in water content This is followed by dehydrationSodium and calcium contents are increased

I. Amankwaa50Pathophysiology Potasium, ascorbic acid and protein are decreased.The protein in the lens undergoes numerous age related changes including yellowing.I. Amankwaa51Pathophysiology Cataract progresses through the following clinical stages of developmentImmature cataracts are not completely opaque, and some light is transmitted through them, allowing useful visionMature cataracts are completely opaque. The former term for this stage was ripe. Vision is significantly reduced

I. Amankwaa52Pathophysiology Hyper-mature senile cataractCortex is disintegrated and transformed Morphological classificationSubcapsular cataractAnterior subcapsular cataractPosterior subcapsular cataractNuclear cataract involves the nucleus of the lensYellow to brown colorationCortical cataractWedge-shaped or radial spoke-like opacitiesPolar cataractI. Amankwaa54I. Amankwaa55

Nuclear cataract Central opacity in lensAssociated with myopiaWorsen on progression

I. Amankwaa56CorticalInvolve the interior and posterior equatorial cortex of the lensWorst in very bright light

I. Amankwaa57Posterior sub-capsular occurs in front of posterior capsuleMostly occurs in younger individualsAssociated with prolonged use of corticosteroids, diabetes, ocular traumaNear vision is diminished

I. Amankwaa58Classification according to maturityAn immature cataractA mature cataractHypermature cataractA morgagnian cataract

I. Amankwaa59Etiological classificationSenile cataracts develop in elderly peopleDue to chemical changes in lens proteinCongenital cataracts occur in neonates Due to inborn errors of metabolism or maternal rubella infectionI. Amankwaa60Etiological classificationTraumatic cataractDevelops after a foreign body injures the lens with sufficient force to allow aqueous or vitrous humor to enter the lens capsule

I. Amankwaa61Causes and Risk FactorsCigarette smoking Long term use of corticosteroids, especially high dosesSun light and ionizing radiationDiabetesObesityEye injuries

cataracts 62CLINICAL MANIFESTATIONPainless, blurred visionThe person perceived that surroundings are dimmerLight scattering is commonMonocular diplopiaReduce visual acuity

cataracts 63Assessment and Diagnostic FindingsDecreased visual acuity is directly proportionate to cataract density.The Snellen visual acuity test, ophthalmoscopy, and slit lamp biomicroscopic examination are used to establish the degree of cataract formation. The degree of lens opacity does not always correlate with the patients functional status.Some patients can perform normal activities despite clinically significant cataracts. Others with less lens opacification have a disproportionate decrease in visual acuity; hence, visual acuity is an imperfect measure of visual impairment.

64Medical ManagementNo nonsurgical treatment cures cataracts. In the early stages of cataract development, glasses, contact lenses, strong bifocals or magnifying lenses may improve vision. Reducing glare with proper light and appropriate lighting can facilitate reading. 65Medical ManagementMydriatics (atropine) can be used as short-term treatment to dilate the pupil and allow more light to reach the retina.66Surgical managementIntracapsular cataract extraction (ICCE)The entire lens (ie, nucleus, cortex, and capsule) is removed, and fine sutures close the incision. ICCE is infrequently usedI. Amankwaa67Surgical managementExtracapsular cataract extraction (ECCE)ECCE achieves the intactness of smaller incisional wounds (less trauma to the eye) and maintenance of the posterior capsule of the lens, reducing postoperative complications, particularly retinal. In ECCE, a portion of the anterior capsule is removed, allowing extraction of the lens nucleus and cortex.

68Nursing ManagementProviding preoperative careTo reduce the risk for retrobulbar hemorrhage, anticoagulation therapy is withheld, if medically appropriate. Aspirin should be withheld for 5 to 7 days, nonsteroidal anti-inflammatory medications (NSAIDs) for 3 to 5 days, and warfarin (Coumadin) until the prothrombin time of 1.5 is almost reached.69Nursing ManagementProviding preoperative careDilating drops are administered every 10 minutes for four doses at least 1 hour before surgery.Additional dilating drops may be administered in the operating room (immediately before surgery) if the affected eye is not fully dilated. Prophylactic antibiotic, corticosteroid, and NSAID drops may be used.70Providing postoperative careThe nurse provides the patient with verbal and written instruction regarding how to protect the eye, administer medications, recognize signs of complications, and obtain emergency care.The nurse instructs the patient regarding home care The nurse also explains that there is minimal discomfort after surgery and instructs the patient to take a mild analgesic agent PRN. Antibiotic, anti-inflammatory, and corticosteroid eye drops or ointments are prescribed postoperatively. 71ENTROPIONMechanism inversion of eye lid into eyeEtiology Aging (course fibrous tissue)Symptoms and Signsforeign body sensationtearing / itching / rednessContinuous rubbing causes conjunctivitis or corneal ulcersDecreased visual acuity if not correctedI. Amankwaa7272I. Amankwaa73

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EntropionDiagnosisvisual examinationTreatmentclean up on its ownif not, minor surgeryI. Amankwaa7575ECTROPONMechanismouturned eye lidsEtiologyElderly (weakness of eye lid muscles)Symptoms and signsdryness of the exposed part of the eyetears run down the cheeksif not treated can cause ulcers and permanent damage to corneaI. Amankwaa7676I. Amankwaa77

EctropionDiagnosisvisual examinationTreatmentminor surgery if doesnt disappearI. Amankwaa7878BLEPHAROPTOSIS (PTOSIS)Mechanismweakness of eye muscle that raises eyelid (superior rectus, superior oblique)EtiologyFamilial traumadiabetes mellitus muscular dystrophymyasthenia gravis brain tumorsI. Amankwaa7979BLEPHAROPTOSIS (PTOSIS)Symptoms and signs drooping eyeblocks visionDiagnosisophthalmic examinationLab investigations to rule out underlying disease Treatmentsurgery (strengthen muscles)eye glasses with raised eyelid supporttreat underlying diseaseI. Amankwaa8080I. Amankwaa81

Ocular TraumaLeading cause of blindness among children and young adults, especially male trauma victims. Initial intervention (non-ophthalmic Nurse) is performed in only two conditions:chemical burns: irrigation of the eye with normal saline solution or even plain tap water immediatelyForeign body: no absolute attempt is made to remove the foreign material, small or big, or apply pressure or patch to the injured eye. The eye must be protected using a metal shield, if available, or a stiff paper cup.I. Amankwaa82Assessment and Diagnostic FindingsObtain history (e.g. preinjury vision in the affected eye or past ocular surgery.Details related to the injurynature of the ocular injury (e.g. blunt trauma)type of activity causing the injuryFor chemical eye burns, the chemical agent must be identied The corneal surface is examined for foreign bodies, wounds, and abrasionsPupillary size, shape, and light reaction of the pupil of the affected eye are compared with the other eye. I. Amankwaa83SPLASH INJURIES- managment Irrigate eye with normal saline solutionIn cases of ruptured globe, cycloplegic agents or topical antibiotics must be deferred because of potential toxicity to exposed intra- ocular tissues. Further manipulation of the eye must be avoided until the patient is under general anesthesia. Parenteral, broad- spectrum antibiotics are initiated.Tetanus antitoxin is administered, if indicated, as well as analgesics. Any topical medication (e.g., anesthetic, dyes must be sterile.

I. Amankwaa84Blunt ContusionDefinitionBruising of periorbital soft tissueS/SSwelling and discoloration of the tissueBleeding into the tissue and structures of the eyePainDiagnosisTests must determine if injury to parts of eye and systemic traumaI. Amankwaa85Blunt ContusionManagementTreatment to reduce swellingPain management dependent on structures involvedNote: If there is any possibility of a ruptured globe, a loose patch and shield should be placed and ocular manipulation discouraged until ophthalmologist assessment completed.

I. Amankwaa86Orbital FractureDefinitionFracture and dislocation of walls of the orbit, orbital margins, or bothS/SMay be accompanied by other signs of head injuryRhinorrheaContusionDiplopia

I. Amankwaa87Orbital FractureDiagnosisX-ray, computed tomography (CT)ManagementMay heal on own if no displacement or impingement on other structuresSurgery (repair the orbital floor with plate freeing entrapped orbital tissue)I. Amankwaa88Foreign BodyIntroduction Foreign bodies can be found on the cornea (25% all ocular injuries), conjunctiva Intraocular particles penetrate sclera, cornea, globe

I. Amankwaa89Foreign BodyS/SSevere painLacrimationForeign body sensationPhotophobiaRednessSwellingNote: Wood and plant foreign body may cause severe infection within hours.

I. Amankwaa90Foreign BodyRemoval of foreign body through irrigation, cottontipped applicator, or magnetAfter removal of a foreign body from the surface of the eye, an antibiotic ointment is applied, and the eye is patchedTreatment of intraocular foreign body depends on size, magnetic properties, tissue reaction, locationSurgical removal may be necessaryThe eye is examined daily for evidence of infection until the wound is completely healedI. Amankwaa91Laceration/PerforationDefinitionCutting or penetration of soft tissue or globe S/SPainBleedingLacrimationPhotophobiaI. Amankwaa92Laceration/PerforationManagementSurgical repairmethod of repair depends on severity of injuryAntibioticstopically and systemically complicationsretinal detachment, intraocular tissue avulsion, and herniation)

I. Amankwaa93Ruptured GlobeDefinitionConcussive injury to globe with tears in the ocular coats, usually the scleraClinical manifestationsPainAltered intraocular pressureLimitation of gaze in field of ruptureHyphemaHemorrhage (poor prognostic sign)

I. Amankwaa94Ruptured GlobeDiagnosis: CT, ultrasound ManagementSurgical repairVitrectomyScleral buckleAntibioticsSteroidsEnucleationI. Amankwaa95Burns-Chemical burnsCausealkali or acid agentS/SPainBurningLacrimationPhotophobiaI. Amankwaa96Burns-Chemical burnsManagementCopious irrigation until pH is 7Severe scarring may require keratoplastyAntibiotics

I. Amankwaa97Burns- Thermalusually burn to eyelidsmay be first-, second-, or third-degreeS/SPainBurned skinBlisters I. Amankwaa98Burns- ThermalManagementFirst aidapply sterile dressingsPain controlLeave fluid blebs intactSuture eyelids together to protect eyeif perforation a possibilitySkin grafting with severe second- and third-degree burns

I. Amankwaa99Burns- UltravioletCauseexcessive exposure to sunlight, sunlamp, snow blindness, weldings/sPaindelayed several hours after exposureForeign body sensationLacrimationPhotophobiaNote: Symptoms occur some time after exposure.I. Amankwaa100Burns- UltravioletManagementPain reliefCondition self-limitingBilateral patching with antibiotic ointment and cycloplegics

I. Amankwaa101101HYPHEMADefinitionFrank bleeding into the anterior chamber following contusion of the globe.It is usually due to disruption of blood vessels in the iris or ciliary bodyThis blood usually does not clotwithout bed rest, a red fluid meniscus is form

HyphemaI. Amankwaa103

Classification Etiological classification Traumatic hyphaema - most commonly blunt trauma Strenuous conditions - Whooping cough, Asthma etc. Blood dyscrasia - Aplastic anaemia, leukemia, hemophilia, von Willebrand disease etc. Neovascularization (Rubeosis iridis) - Diabetes mellitusI. Amankwaa104Classification Clinical Mild or simple hyphema (2-3mm)Moderate hyphema (3-5mm) Severe hyphema more than half of anterior chamberTotal hyphema anterior chamb full of bloodI. Amankwaa105Causes:Blunt TraumaIntraocular surgeryLacerating traumaPenetrating and perforating injuryIt also occurs spontaneously w/o any trauma, usually neovascularization, tumor of eye (Retinoblastoma), uveitis or vascular anomaliesUse of medicine which impair blood clotting such as aspirin and analagesic PathophysiologyThere are 2 suggested mechanism of hyphema formationDirect contusive force cause mechanical tearing of blood vasculature of iris and or angleConcussive trauma creating rapidly rising intravascular pressure within the vessels resulting in rupture of vesselsSigns and SymptomsBlurring of visionPainPhotophobiaTearingGRADINGGradeSize of Hyphema0No layered bloodcirculating red blood cells onlyILess than 1/3II1/3 to 1/2III1/2 to less than totalIVTotal

Treatment (medical)Sedation or complete bed rest with limited activitesCycloplegics; Atropine 1% E/D 3. Anti inflamatoty - Steroids, mild NSAIDs Ocular hypotensive agents in case of IOPPlace shield or patch over involved eye or both eyes (controversial) Rx of the causeAspirin and related analgesics w/c impair blood clotting should not be used to relieve painAcetaminophen may be substituted.

Treatment (surgical)Surgical Indication:Inc. IOP of >50 mmHgPersistently (5 to 7 days) high pressureEarly blood staining of the corneaSimple removal of small amount of aqueous humour (Anterior Chamber Paracentesis) or Irrigation of AC may be effective

Surgical ManagementClots should never be removed by means of forceps due to difficulty distinguishing clot from iris. Vitrectomy irrigator aspirator maybe used to aspirate the blood. Corneal ContusionDefinitionCorneal contusion is a contusion (blunt trauma) is caused by the blunt force of the mechanical can cause ocular adnexal or eye damage, caused by a variety of structural lesions in the eye.I. Amankwaa115