Eye and Ear Disorders 1

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 58

Assessment and Management of Patients With Eye and

Vision Disorders

Chapter 58

Assessment and Management of Patients With Eye and

Vision Disorders


ObjectivesObjectives

• During this session we will:

1.Review the anatomy and physiology of the eye;

2.Discuss assessment of the eye;

3.Discuss common conditions of the eye; and

4.Discuss the management of patients presenting with these conditions.


Cross-Section of the EyeCross-Section of the Eye


Assessment and Evaluation of VisionAssessment and Evaluation of Vision

• Ocular history

• Visual acuity

– Snellen chart

• Record each eye

• 20/20 means the patient can read the “20” line at a distance of 20 feet

• Finger count or hand motion


Diagnostic EvaluationDiagnostic Evaluation

• Ophthalmoscopy

– Direct and indirect

– Examines the cornea, lens and retina

• Slit-lamp examination

• Color vision testing

• Amsler grid

• Ultrasonography


Examination of the External StructuresExamination of the External Structures

• Note any evidence of irritation, inflammatory process, discharge, etc.

• Assess eyelids and sclera

• Assess pupils and pupillary response; use darkened room

• Note gaze and position of eyes

• Assess extraocular movements

• Ptosis: drooping eyelid

• Nystagmus: oscillating movement of eyeball


Diagnostic EvaluationDiagnostic Evaluation

• Tonometry

– Measures intraocular pressure

• Gonioscopy

– Visualizes the angle of the anterior chamber

• Perimetry testing

– Evaluates field of vision

– Scotomas: blind areas in the visual field


Impaired VisionImpaired Vision

• Refractive errors

– Can be corrected by lenses which focus light rays on the retina

• Emmetropia: normal vision

• Myopia: nearsighted

• Hyperopia: farsighted

• Astigmatism: distortion due to irregularity of the cornea


GlaucomaGlaucoma

• A group of ocular conditions in which damage to the optic nerve is related to increased intraocular pressure (IOP) caused by congestion of the aqueous humor

• The leading cause of blindness in adults in the U.S.

• Incidence increases with age


EatiologyEatiology

• Primary glaucoma

– No evidence of preexisting ocular or systemic disease

• Secondary glaucoma

– Occur from inflammatory processes that affect the eye

– Tumours

– Trauma resulting in haemmorhage (cells obstruct out flow of aquous humor)


GlaucomaGlaucoma

• Risk factors

– Family history

– Diabetes

– Hypertension

– African American

• Others

– Older age

– Cardiovascular disease

– Myopia

– Eye trauma

– Prolonged use of systemic corticosteroids


Normal Outflow of Aqueous HumorNormal Outflow of Aqueous Humor


Flow of Aquos HumorFlow of Aquos Humor

• Aquos humour produced by ciliary epithelium in posterior chamber

• Flow

– Passes between the anterior surface of the lens and the posterior surface of the iris

– Through the pupil, into anterior chamber

– Filters through the trabecular mesh work

– Enters the canal of schelm

– Then returns to venous circulation


Pathophysiology of GlaucomaPathophysiology of Glaucoma

• Normal IOP is 10-21mm Hg

• In glaucoma, aqueous production and drainage are not in balance.

• When aqueous outflow is blocked, pressure builds up in the eye.

• Increased IOP causes irreversible mechanical and/or ischemic damage.


Classification/Types of GlaucomaClassification/Types of Glaucoma

• Open-angle

– Chronic open angle glaucoma

– Normal tension glaucoma

– Ocular hypertension

• Close angle (Angle-closure- pupillary block) glaucoma

– Acute angle-closure

– Subacute angle-closure

– Chronic angle-closure

• Congenital glaucomas and glaucoma secondary to other conditions


Classification/Types Contd.Classification/Types Contd.

• Close angle (narrow angle)- accounts for 5-10% of cases

– Occurs as a result of an inherited anatomical defect

– Causes a shallow/narrow anterior chamber

– Outflow becomes impaired when iris thickens as a result of pupillary dilation

– Blocks circulation between anterior and posterior chambers

– Eliminates or reduce angel where aquos reabsorbtion occurs


Closed AngleClosed Angle

• Symptoms are related to a sudden increase in IOP:

– occular pain

– Blurred vision

– Pupil may be enlarged

• Symptoms relieved by sleep. If prolonged

– Eye becomes reddened with corneal oedema (eye has hazy appearance)

– Headache

– Nausea and vomiting may occur


Open angleOpen angle

• Most common form of glaucoma

• Manifests after 35 yrs. of age and incidence of .5 to 2% in persons 40yrs. and older.

• Increased IOP occurs in the absence of obstruction at the iridocorneal angle

• Occurs as a result of an abnormality in the trabecular meshwork that controls the flow of aquos humor in the canal of schelmm

• Usually asymptomatic


Clinical ManifestationsClinical Manifestations• Asymptomatic

– unaware of the condition until there is significant vision loss

• peripheral vision loss, blurring, halos, difficulty focusing, difficulty adjusting eyes to low lighting

• May also have aching or discomfort around eyes

• Headache


Diagnostic FindingsDiagnostic Findings

• Tonometry to assess IOP

• Opthalmoscopy to inspect optic nerve

• Gonioscopy to assess the angle of the anterior chamber

• Perimetry to assess visual fields

• Progression of visual field defects

• Optic nerve damage presents with

– Pallor and cupping of optic nerve


ManagmentManagment

• Medical Management

– Prevention of optic nerve damage

– Life long therapy required

• Pharmacotherapy

• Aim to increase outflow of fluid

– Miotics eg pilocarpine

– Adrenagic agonists eg epinephrine

• Increases production of aquos out flow


Pharmacologic therapyPharmacologic therapy

• Decreases aquos humor production

– Beta blockers eg. timoxin

– Carbonic anhydrase inhibitors eg. Methazolamide

– Alphaadrenagic agonists eg. brimomidine

• Prostaglandin analogs

– Increases uveosceral outflow


GlaucomaGlaucoma

• Surgical

• Depends on cause of increase in IOP

– Trabeculoplasty: opens intratrabecular spaces & the canal of schelm

– Iridotomy: opening in iris to correct papillary block

– Filtering procedures drain aqeous humour into subconjuctival space

– Tribeculectomy: removal of part of the trabecular mesh work

– Drainage implant or shunts


ComplicationsComplications

• Burns to cornea, retina or lens

• Uveitis

• Closure of iridotomy

• Transient increase in IOP

• Hemorhage

• Cataract formation


Nursing ManagementNursing Management

• Patient education.

• Adherence to therapy and continued care to prevent further vision loss

• Provide education regarding use and effects of medications.

• Medications used for glaucoma may cause vision alterations and other side effects

• Provide support and interventions to aid the patient in adjusting to vision loss/potential vision loss.


Discharge PlanningDischarge Planning

• Lifelong therapuetic regime for chronic condition

• Ensure pt. and family understands the disease and how it progresses

• Use of medication

• Effect of medication

• Follow up treatment


Infectious/Inflammatory DisordersInfectious/Inflammatory Disorders

•Conjunctivitis (“pink eye”)

– Classified as:

•bacterial, viral, fungal, parasitic, allergic, and toxic


ConjuctivitisConjuctivitis

•Clinical manifestations:

– Foreign body sensation

– Scratching or burning sensation

– Itching

– Photophobia

– Discharge, papillary formation, follicles


ConjuctivitisConjuctivitis• Bacterial

– Acute or chronic

– Causative agents is strep pneumoniae, haemophilus, influenza and staph. Aureus.

– Onset is acute

– Purulent discharge

• Viral conjuctivitis

– Adeno virus, herpes symplex

– Acute or chronic

– Watery discharge

– Follicles prominent

– pseudomembranes


ConjunctivitisConjunctivitis

• Assessment & Diagnostic findings

– Appearance

– Lymphadenopathy

– Presence of pseudo or true membranes

– Eye swab


ManagementManagement

• Depends on type

• Antibiotic therapy (bacterial)

• Corticosteroids and antihistamines (allergic)

• Education to prevent spread (58:9)


Inflammatory ConditionsInflammatory Conditions

• Uveitis- an inflammation of the uveal tract– Can affect iris ciliary body, choroid

• Orbital cellulitis- inflammation of tissues surrounding the eye.– Bacterial, fungal, viral


CataractsCataracts• An opacity or cloudiness of the lens that interferes with

light transmission to the retina.

• Most common cause of age related vision loss

• Increased incidence with aging

• Occur in 50% of persons 65 to 74 yrs. And in 70% of persons 75yrs. and older


CataractsCataracts

• Etiology

– Injury to lens

– Aging process, diabetes

– Prolong exposure to ultra violet light

– Radiation

– Drugs (corticosteroids)


Risk FactorsRisk Factors

• Aging

• Other occula conditions (infections)

• Toxic factors (corticosteroids, smoking)

• Nutrition (poor)

• Physical (trauma, ultraviolet radiation)

• Diseases (diabetes, renal disorders)


PathophysiologyPathophysiology

• May be unilateral or bilateral

• Can develop in years or in months

• With normal aging the nucleus and cortex of the lens enlarge when new fibres are formed in cortical zone of lens

• Lens protein become more insoluble

• Concentrations of calcium, sodium, potassium and phosophate increases

• Leads to loss of lens transparency


CataractsCataracts

• Types

– Congenital

– Traumatic/ secondary to disease

• Further categorized by the part of lens that is affected:

– Nuclear cataract formation

– Cortical cataract formation

– Posterior subcapsular cataract


Clinical ManifestationsClinical Manifestations

• Painless, blurry vision

• Sensitivity to glare

• Reduced visual acuity

• Other effects include myopic shift

• Astigmatism, diplopia (double vision),

• color shifts including brunescens (color value shift to yellow-brown)


Cataract/ Diagnostic findingsCataract/ Diagnostic findings

• Diagnostic findings include decreased visual acuity and opacity of the lens by ophthalmoscope, slit-lamp, or inspection

• Assessment and Diagnosis

– Visual acuity test

– Opthalmoscopy

– Slit lamp examination

• Medical management

– Use of glasses, contact lens, bifocals to improve sight


Types of Cataract SurgeryTypes of Cataract Surgery

• Intracapsular cataract extraction (ICCE): removes entire lens, rarely done today

• Extracapsular cataract extraction (ECCE): maintains the posterior capsule of the lens, reducing potential postoperative complications

• Phacoemuslification: an ECCE which uses an ultrasonic device to suction the lens out through a tube; incision is smaller than with standard ECCE

• Lens replacement: after removal of the lens by ICCE or ECCE, the surgeon inserts an intraocular lens implant (IOL). The patient may still require glasses.


Nursing ManagementNursing Management

• Preoperative care

• Usual preoperative care for ambulatory surgery

• Dilating eye drops or other medications as ordered

– Antibiotic drops

– Mydriatics

• Enema to prevent constipation & straining post surgery

• Facial scrub morning of surgery

• Place personal items on bedside of unoperated eye

• Educate on preventing stress on suture

– Rubbing eye, coughing, sneezing,


Postoperative Care: Cataract SurgeryPostoperative Care: Cataract Surgery

• Eye care: patch and shield is applied to operative eye

• IV is maintained

• Administer eye drops as prescribed

– Anti inflammatory, antibiotic

• allow pt. to rest

• Provide tea, soft meal

– If tolerated IV could be D/C

• Observe pt for severe pain, restlessness, tachycardia

– Inidcates ruptured suture/hemorrhage



• Administer analgesics for pain

• If vomiting (can IOP) administer antiemetic

• Advice pt not to sneeze, cough, bending, rubbing eyes

• Teach pt. how to instil drops

• Reorient pt. to environment

• Assist with hygienic needs

• Psychological support to family and pt.



• Instruct patient to call physician immediately if vision changes; continuous flashing lights appear; redness, swelling, or pain increase; type and amount of drainage increases; or significant pain is not relieved by acetaminophen

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Eye and Ear Disorders 1