NURSING BOARD EXAMIMPORTANT NOTES!! DISORDERS OF THE EYES!

CATARACT--Watching television is permissible because the eye does not need to move rapidly with this activity, and it does not increase the intraocular pressure. CATARACT -The client is instructed to wear a metal or plastic shield to protect the eye from accidental injury and is instructed not to rub the eye. Glasses may be worn during the day, and an eye shield is worn at night. Aspirin or medications containing aspirin are not to be administered or taken by the client; the client is instructed to take acetaminophen (Tylenol) as needed for pain. The client is instructed not to sleep on the side of the body that was operated on because this action will cause edema and increased intraocular pressure. The client is not to lift more than 5 pounds. CATARACT SURGERY-The client should be instructed that no oral intake is permitted for 6 to 12 hours before the surgical procedure. Local or general anesthesia will be administered, and the client may receive medication to produce relaxation. Eyelashes may be cut before surgery and will grow back, but will grow slowly. Eye medications such as mydriatics, cycloplegics, or -blockers may be administered before the surgical procedure. CATARACT EXTRACTION POSTOP-Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the physician immediately. The other options are incorrect nursing actions. Ice is not applied to the surgical site unless prescribed. The client is not positioned on the operative side because of the risk of increasing intraocular edema from swelling. Although pain medication and an antiemetic might be prescribed, the client's symptoms indicate a serious complication requiring physician notification.

When the client has suffered a chemical burn of the eye, the nurse immediately flushes the site with a sterile solution continuously for 15 minutes. If a sterile eye irrigation solution is not available, running water may be used. Performing an assessment may be helpful but is not the priority action. Applying compresses or bandages is incorrect, because they do not rid the eye of the damaging chemical. Cold compresses are used for blows to the eye, whereas light bandages may be placed over cuts of the eye or eyelid.

Chemical burn of the eye-The immediate first-aid treatment is irrigation of the eye with copious amounts of tap water for a minimum of 5 minutes. As soon as the initial irrigation is complete, the victim should be immediately taken to the nearest medical service. On arrival, eye irrigation should be resumed with water or normal saline for 15 to 20 minutes or until all invasive material is removed and the pH test with litmus paper is about 7.4. A quick test with litmus can be done before, during, and after irrigations to determine the pH and whether the substance was acid or alkaline.

In a scleral buckling procedure, the sclera is compressed from the outside by Silastic sponges or silicone bands that are sutured in place permanently. In addition, an intraocular injection of air, a gas bubble, or both may be used to apply pressure on the retina from the inside of the eye to hold the retina in place. If an air or gas bubble has been injected, it may take several weeks to be absorbed. Vigorous activities and heavy lifting are avoided. An eye shield or glasses should be worn during the day, and a shield should be worn during naps and at night. The client is instructed to clean the eye with warm tap water using a clean washcloth. Hyphema is bleeding into the anterior chamber of the eye that occurs postoperatively as a complication of cataract surgery. Treatment includes bedrest and bilateral eye patching or shielding for 2 to 5 days, during which absorption occurs. The client should be instructed to monitor for signs of increased intraocular pressure, which commonly causes sudden ocular pain. Miotics and cycloplegics may be prescribed. Occasionally, irrigation of the anterior chamber may be done to remove the blood. o A hyphema is the presence of blood in the anterior chamber of the eye. It is caused by an event that ruptures blood vessels in the eye, such as penetrating injury from a BB pellet, or indirectly from a blow to the forehead. The client is treated with bedrest in a semi-Fowler position to assist gravity in keeping the hyphema away from the optical center of the cornea.

A hordeolum is commonly known as a sty. Therapeutic management includes application of a warm compress for 15 minutes four times daily and instillation of an ophthalmic antibiotic ointment prescribed by the physician (not over-thecounter antibiotic ointment) to combat the infectious organism and prevent the spread of infection to surrounding lid glands. The warm compress promotes comfort and aids in rupture of the sty and drainage of purulent contents. If a sty does not rupture spontaneously, it can be incised by the physician with a small sterile instrument. The client should be told not to press on or squeeze

the sty to induce rupture because such pressure could force infectious material into the venous system and transmit infection to the brain. Keratoplasty The client is told that sutures are usually left in place for as long as 6 months. After sutures are removed and complete healing has occurred, corrective glasses or contact lenses will be prescribed. enucleation --Postoperative nursing care includes observing the dressing and reporting any staining or bleeding to the surgeon because this finding could indicate hemorrhage. Options 1, 2, and 3 are inaccurate nursing actions if staining or bleeding is present on the dressing following enucleation. Legal blindness implies that the person cannot perform work that requires visual ability. The person who is legally blind usually retains some perception of light and movement. Total blindness means the absence of all light perception. Low vision is a term that is used to refer to legally blind persons with severe vision impairment who still have some visual ability. RETINAL DETACHMENT-Complaint of a sudden burst of black spots or floaters indicates that bleeding has occurred as a result of the detachment. This is not a normal, expected finding and if it occurs, it indicates hemorrhage. There is no need to restrict fluids. The nurse places an eye patch over the client's affected eye to reduce eye movement, but the patch should have already been in place. RETINAL DETACHMENT -The nurse places an eye patch over the client's affected eye to reduce eye movement. Some clients may need bilateral patching. Depending on the location and size of the retinal break, activity restrictions may be needed immediately. These restrictions are necessary to prevent further tearing or detachment and to promote drainage of any subretinal fluid. The nurse positions the client as prescribed by the physician. Visitors do not need to be restricted. If an eye injury is the result of a penetrating object, the object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea. The most appropriate action by the nurse from the options presented is to accompany the victim to the emergency department. EYE INJURY-Surface foreign bodies are often removed simply by irrigating the eye with sterile normal saline. The nurse would not use clamps because this action will risk causing further injury to the eye. Applying an eye patch would not provide relief for the problem. Visual acuity tests are not the priority at this

time and might not be feasible because the client most likely has excessive blinking and tearing as well at this time. EYE INJURY-Placing the client in a lying position may increase intraocular pressure and intracranial pressure (ICP) if an accompanying head injury is sustained. A reclining position can cause a penetrating object to advance farther into the eye. The client is placed in a sitting position with head support. Laser trabeculoplasty is performed in the outpatient setting and requires about 30 minutes. The client will experience little discomfort and may resume all normal activities including returning to work within 1 to 2 days. The treatment prevents further visual loss, but the lost vision cannot be restored. GLAUCOMA-The client should tie shoelaces by bending the knee, raising the thigh, and bringing the foot within reach. Objects weighing 20 pounds or more can be moved by pushing the object on the floor by using the feet or a mechanical dolly. Primary open-angle glaucoma results from obstruction by the trabecular meshwork and is the most common form of glaucoma. It is insidious in onset, bilateral, and slow to progress. Because it occurs gradually, the client may not notice the loss of vision, which is irreversible. Angle-closure glaucoma results from sudden blockage of the anterior angle by the base of the iris. Lowtension glaucoma resembles primary open-angle glaucoma, except that the changes develop despite normal intraocular pressures. Secondary glaucoma is often due to edema or delayed corneal wound healing as a complication of eye surgery. Angle-closure glaucoma can occur only if the client has a congenital narrowing of the anterior chamber angle. At some point, this anterior angle can become blocked by the base of the iris. Because glaucoma is usually symptom free, the client may first note changes in peripheral visual acuity. If pain occurs with glaucoma, it is usually late in the course of structural changes, with an intraocular pressure of 40 to 50 mm Hg or higher. Severe pain is characteristic of absolute glaucoma (total vision loss). Glare from bright lights is a complaint of a client with a cataract. Blurred central vision occurs with macular degeneration.

Aphakia (absence of the lens of the eye) can be corrected by prescriptive glasses, contact lens, or intraocular lens. Only central vision is corrected with these prescriptive glasses, and the peripheral vision is distorted. There is approximately 30% magnification of central vision with prescriptive glasses. This requires adjustment to daily activities and safety precautions. Because of

the magnification, objects viewed centrally appear distorted, and it is difficult to judge distances such as in driving a car or sitting in a chair. MACULAR DEGENERATION-The most common symptom of macular degeneration is blurred central vision that often occurs suddenly. Clients complain of difficulty with reading and seeing fine detail. Formation of a central scotoma (blind spot) occurs in some clients. Clients might complain of visual distortion, usually described as a bending or irregularity of straight lines. Peripheral vision is spared, so although affected persons cannot see to read, drive, watch television clearly, or distinguish faces, they do have the ability to walk. Tonometry is an effective screen for the early detection of glaucoma. The normal intraocular pressure is 12 to 22 mm Hg. An intraocular pressure of 20 mm Hg is a normal finding. The six cardinal fields of gaze track the client's ocular movements horizontally and diagonally to the left and right. These are the responsibility of the coordinated effort of cranial nerves III, IV, and VI. Peripheral and central vision is assessed during testing of visual acuity. The corneal reflex, or blink reflex, occurs with proper function of cranial nerve V (trigeminal nerve). DIPLOPIA-The ability of the eyes to focus on the same point in space and fuse the images into a single mental impression is called binocular vision. Optic nerve function is responsible for transmitting visual images to the brain for interpretation. Ocular muscle control governs eye movements. Depth perception is the ability to see images in three dimensions instead of two. No effective treatment for age-related macular degeneration has been found. Treatment for macular degeneration focuses on supportive measures including large-print books, use of public transportation, and adequate nutritional intake. Laser eye therapy may be used for clients with wet/exudative macular degeneration.