Patients With Vision and Eye Disorders

Assessment and Management of
Patients with Eye and Vision

Disorders
Copyright © 2008 Lippincott Williams & Wilkins.

External Structures of the Eye

Extraocular Muscles

Visual Pathways

Cross-Section of the Eye

Internal Structures of the Eye

Assessment and Evaluation of Vision
• Ocular history: see Chart 58-1

• 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

Examination of the External Structures
• Note any evidence of irritation, inflammatory process,

discharge, etc.
• Assess eyelids and sclera
• Assess pupils and pupillary response in a darkened room
• Note gaze and position of eyes
• Assess extraocular movements
• Ptosis: drooping eyelid
• Nystagmus: oscillating movement of eyeball

Diagnostic Evaluation
• Ophthalmoscopy
– Direct and indirect
– Examines the cornea, lens, and retina
• Slit-lamp examination
• Color vision testing
• Amsler grid
• Ultrasonography
• Fluorescein and indocyanine green angiography
Diagnostic Evaluation (cont.)
• 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 Vision
• Refractive errors
– Can be corrected by lenses that focus light
rays on the retina
• Emmetropia: normal vision
• Myopia: nearsighted
• Hyperopia: farsighted
• Astigmatism: distortion due to irregularity of the
cornea

Eyeball Shape Determines Visual Acuity in
Refractive Errors

Glaucoma
• 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
• Risk factors: see Chart 58-4

Pathophysiology of Glaucoma
• Normal outflow of • In glaucoma, aqueous
aqueous humor 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
See Chart 58-5

Types of Glaucoma
• Open-angle glaucoma
– Chronic open-angle glaucoma
– Normal-tension glaucoma
– Ocular hypertension
• Angle-closure (pupillary block) glaucoma
– Acute angle-closure
– Subacute angle-closure
– Chronic angle-closure
• Congenital glaucomas and glaucoma secondary to
other conditions
• See Table 58-3
Clinical Manifestations
• Called the “silent thief,” glaucoma renders the

patient unaware of the condition until there is
significant vision loss, including peripheral vision
loss, blurring, halos, difficulty focusing, and
difficulty adjusting eyes to low lighting
• Patient may also experience aching or discomfort

around the eyes or a headache

Diagnostic Findings
• Tonometry to assess • Progression of visual

IOP field defects
• Gonioscopy to assess
the angle of the anterior
chamber
• Perimetry to assess
vision loss

Treatment
• Goal is to prevent further optic nerve damage
• Maintain IOP within a range unlikely to cause damage
• Pharmacologic therapy: see Table 58-4
• Surgery
– Laser trabeculoplasty
– Laser iridotomy
– Filtering procedures
– Trabeculectomy
– Drainage implants or shunts
Nursing Management
• Patient education: see Chart 58-6
• Focus on maintaining the therapeutic regimen for
lifelong control of a chronic condition
• Emphasize the need for 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; the action and effects
of medications need to be explained to promote
compliance
• Provide support and interventions to aid the patient in
adjusting to vision loss/potential vision loss
Cataracts
• An opacity or cloudiness of the lens
• Increased incidence with aging; by age 80,

more than half of all Americans have cataracts
• A leading cause of disability in the U.S.
• Risk factors: see Chart 58-7

Cataracts (cont.)

Clinical Manifestations
• Painless, blurry vision
• Sensitivity to glare
• Reduced visual acuity
• Other effects include myopic shift, astigmatism,
diplopia (double vision), and color shifts including
brunescent c. (color value shift to yellow-brown)
• Diagnostic findings include decreased visual acuity
and opacity of the lens by ophthalmoscope, slit-
lamp, or inspection
Surgical Management
• If reduced vision does not interfere with normal

activities, surgery is not needed
• Surgery is performed on an outpatient basis with
local anesthesia
• Surgery usually takes less than 1 hour and patients
are discharged soon afterward
• Complications are rare but may be significant: see
Table 58-5

Types 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
• Phacoemulsification: an ECCE that 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), which eliminates the need for aphakic lenses;
however, the patient may still require glasses
Nursing Management
• Preoperative care
• Usual preoperative care for ambulatory surgery
• Dilating eye drops or other medications as ordered
• Postoperative care: see Appendix B (Clinical Pathway)
• See Chart 58-8 (Patient Teaching)
• Provide written and verbal instructions
• 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
Corneal Disorders
• Treatment of diseased corneal tissue
– Phototherapeutic keratectomy
– Keratoplasty
– Use of donor tissue for transplant: see Chart 58-9
– Need for follow-up and support
– Potential graft failure; teach signs and symptoms
• Refractive surgery
– Elective procedures to recontour corneal tissue and
correct refractive errors
– Patients need counseling regarding potential
benefits, risks, and complications
LASIK

Retinal Disorders
• Retinal detachment
• Retinal vascular disorders
– Central retina vein occlusion
– Branch retinal vein occlusion
– Central retinal vein occlusion
– Macular degeneration

Retinal Detachment
• Separation of the sensory retina and the retinal
pigment epithelium (RPE)
• Manifestations: sensation of a shade or curtain
coming across the vision of one eye, bright
flashing lights, and sudden onset of floaters
• Diagnostic findings: assess visual acuity; assess
retina by indirect ophthalmoscope, slit-lamp,
stereo fundus photography, and fluroescein
angiography; tomography and ultrasound may
also be used
Retinal Detachment (cont.)

Surgical Treatment
• Scleral buckle
• Pars plana vitrectomy
– Removal of the vitreous, locating the incisions at the
pars plana
– Frequently used in combination with other procedures
• Pneumatic retinopexy
– Injected gas bubble, liquid, or oil is used to flatten
the sensory retina against the RPE
– Postoperative positioning is critical

Scleral Buckle

Nursing Management
• Patient teaching
– Eye surgery is most often done as an outpatient
procedure, so patient education is vital
• Teach the signs and symptoms of
complications, especially increased IOP and
infection
• Promote comfort
• Patient may need to lie in a special position with
pneumatic retinopexy
Retinal Vein or Artery Occlusion
• Loss of vision can occur from retinal vein or artery

occlusion
• Occlusions may result from atherosclerosis, cardiac
valvular disease, venous stasis, hypertension, and
increased blood viscosity; associated risk factors
are diabetes mellitus, glaucoma, and aging
• Patients may report decreased visual acuity or
sudden loss of vision

Macular Degeneration
• Age-related macular degeneration (AMD)
• The most common cause of vision loss in persons older
than age 60
• Types
– Dry or nonexudative type is most common, 85%-90%
 Slow breakdown of the layers of the retina with the
appearance of drusen
– Wet type
 May have abrupt onset
 Proliferation of abnormal blood vessels growing
under the retinachoroidal revascularization (CNV)
Vision Loss Associated With
Macular Degeneration

Retina Showing Drusen and AMD

Progression of AMD—Pathways to
Vision Loss

Photodynamic Therapy for Slowing
Progression of AMD • Light-sensitive verteporfin
dye is injected into vessels;
a laser then activates the
dye, shutting down the
vessels without damaging
the retina
• The result is to slow or
stabilize vision loss
• Patient must avoid
exposure to sunlight or
bright light for 5 days after
treatment to avoid
activation of dye in vessels
near the surface of the skin
Nursing Management
• Patient teaching
• Supportive care
• Safety promotion
• Recommendations include improving lighting,

getting magnification devices, and referring
patient to vision center to improve/promote
function

Trauma
• Prevention of injury: see Chart 58-10
• Patient and public education
• Emergency treatment
– Flush chemical injuries
– Do not remove foreign objects
– Protect using metal shield or paper cup
• Potential exists for sympathetic ophthalmia,
causing blindness in the uninjured eye with some
injuries
Protective Eye Patches

Infectious and Inflammatory Disorders
• Dry eye syndrome
• Conjunctivitis (“pink eye”)
– Classified by cause: bacterial, viral, fungal,
parasitic, allergic, and toxic
– Viral conjunctivitis is contagious: see Chart 58-11
• Uveitis
• Orbital cellulitis
• See Table 58-6

Hyperemia in Viral Conjunctivitis

Ocular Consequences of Systemic Disease
• Diabetic retinopathy
– Diabetes is a leading cause of blindness in

people age 20 to 74
• Ophthalmic complications associated with AIDS
• Eye changes associated with hypertension

Ophthalmic Medications
• Ability of the eye to absorb medication is limited
• Barriers to absorption include the size of the conjunctival

sac; corneal membrane barriers; blood–ocular barriers;
and tearing, blinking, and drainage
• Intraocular injection or systemic medication may be

needed to treat some eye structures or to provide high
concentrations of medication
• Topical medications (drops and ointments) are most

frequently used because they are least invasive, have
fewest side effects, and permit self-administration
Ophthalmic Medications (cont.)
• Topical anesthetics
• Mydriatics (dilate) and cycloplegics (paralyze): see Table
58-7
– Contraindicated with narrow angles or shallow
anterior chambers and for inpatients on monoamine
oxidase inhibitors or tricyclic antidepressants
– May cause CNS symptoms and increased BP especially
in children and the elderly
• Anti-infective medications
– Antibiotic, antifungal, and antiviral products
Ophthalmic Medications (cont.)
• Medications used for glaucoma
– Increase aqueous outflow or decrease aqueous
production
– May constrict the pupil and affect ability to focus the
lens of the eye; affects vision
– May also may produce systemic effects
• Anti-inflammatory drugs; corticosteroid suspensions
– Side effects of long-term topical steroids include
glaucoma, cataracts, and increased risk of infection;
to avoid these effects, oral NSAID therapy may be
used as an alternate to steroid use
Low Vision and Blindness
• Low vision
– Visional impairment that requires devices and
strategies in addition to corrective lenses
– Best corrected visual acuity (BCVA) of 20/70 to
20/200
• Blindness
– BCVA of 20/400 to no light perception
– Legal blindness is BCVA that does not exceed
20/200 in better eye, or widest field of vision is
20 degrees or less
• Impaired vision often is accompanied by functional
impairment
Assessment of Low Vision
• History
• Examination of distance and near visual acuity,

visual field, contrast sensitivity, glare, color
perception, and refraction
• Special charts may be used for low vision
• Nursing assessment must include assessment of

functional ability and coping and adaptation in
emotional, physical, and social areas

Management
• Support coping strategies, grief processes, and
acceptance of visual loss
• Strategies for adaptation to the environment
– Placement of items in room
– “Clock method” for trays
• Communication strategies: see Chart 58-3
• Collaboration with low vision specialist, occupational
therapy, or other resources
• Braille or other methods for reading/communication
• Use of service animals
Guidelines for Instilling Eye Medications
• Shake suspensions or “milky” solutions to obtain

the desired medication level.
• Wash hands thoroughly before and after the

procedure.
• Ensure adequate lighting.
• Read the label of the eye medication to make sure

it is the correct medication.
• Assume a comfortable position.
• Do not touch the tip of the medication container to

any part of eye or face.
• Hold the lower lid down; do not press on the eye-

ball. Apply gentle pressure to the cheek bone to
anchor the finger holding the lid.

(cont.)
• Instill eye drops before applying ointments.
• Apply a ½-inch ribbon of ointment to the lower

conjunctival sac.

(cont.)
• Keep the eyelids closed, and apply gentle pressure

on the inner canthus (punctal occlusion) near the
bridge of the nose for 1 or 2 minutes immediately
after instilling eyedrops.
• Using a clean tissue, gently pat skin to absorb

excess eyedrops that run onto the cheeks.
• Wait 5 to 10 minutes before instilling another eye

medication.

Safety Measures and Teaching
• Patient teaching is a vital nursing intervention for
patients with eye and vision disorders
• Prevention of eye injuries; education
• Provide safety strategies for patients with low vision
in the hospital and home setting
• Patient teaching after eye surgery or trauma
– Potential complications
– Loss of binocular vision with patch or vision
impairment of one eye; safety
– Use of eye patch and shield

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Patients With Vision and Eye Disorders

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Assessment and Management of

Patients with Eye and Vision

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

• Ocular history: see Chart 58-1

Copyright © 2008 Lippincott Williams & Wilkins.

• Note any evidence of irritation, inflammatory process,

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

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

• Risk factors: see Chart 58-4

Copyright © 2008 Lippincott Williams & Wilkins.

See Chart 58-5

• Called the “silent thief,” glaucoma renders the

• Patient may also experience aching or discomfort

Copyright © 2008 Lippincott Williams & Wilkins.

• Tonometry to assess • Progression of visual

Copyright © 2008 Lippincott Williams & Wilkins.

• An opacity or cloudiness of the lens

• Increased incidence with aging; by age 80,

• A leading cause of disability in the U.S.

• Risk factors: see Chart 58-7

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

• If reduced vision does not interfere with normal

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

• Retinal vascular disorders

– Central retina vein occlusion

– Branch retinal vein occlusion

– Central retinal vein occlusion

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

• Loss of vision can occur from retinal vein or artery

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

• Recommendations include improving lighting,

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

Copyright © 2008 Lippincott Williams & Wilkins.

– Diabetes is a leading cause of blindness in

• Ophthalmic complications associated with AIDS

• Eye changes associated with hypertension

Copyright © 2008 Lippincott Williams & Wilkins.

• Barriers to absorption include the size of the conjunctival

• Intraocular injection or systemic medication may be

• Topical medications (drops and ointments) are most

• Examination of distance and near visual acuity,

• Special charts may be used for low vision

• Nursing assessment must include assessment of

Copyright © 2008 Lippincott Williams & Wilkins.

• Shake suspensions or “milky” solutions to obtain

• Wash hands thoroughly before and after the