BLINDNESS

INTRODUCTION :-

Low vision is a general term describing visual impairment that requires patients to use
devices and strategies in addition to corrective lenses to perform visual tasks low vision is
defined as a best corrected visual acuity (BCVA) of 20/70 to 20/200.

The clinical definition of absolute blindness is the absence of light

perception. The most common causes of blindness and visual impairement among adults
40years of age or older are diabetic retinopathy macular degeneration glucoma and
cataracts.

INCIDENCE :-

Prevalence Gobally it is estimated that approximately 1.3 billion people live with some
from of disstance or near vision impairment with regards to distance vision 188.5 million
have mild vision impairment 217 million have moderate to severe vision impairment and
36 million people are blind.

DEFINITION :-

According to Emmess

The person cannot read letter of decipher symbols at 3cm (10 feet) large enough to be read
by a normal person at a distance of 60m. (200 feet ).

According to WHO

Blindness is a visual activity of less than 3/60 (snellen) or its equivalen.

According to Javed Ansari

Blindness is the condition of lacking visual perception due to physiological or neurological

factor.

Anatomy and physiology of eye :-

Structure :-

There are three layer of tissue in the walls of tissue in the walls of the eye.

 The outer fibrous layers Sclera and cornea.

 The middle vascular layer or uveal tract consisting of the choroid cilliary body and
iris.
  The inner nervous tissuse layer the ratina.

Sclera and cornea :- The sclera or white of the eye forms the outer most layer of the
posterior and lateral aspects of the eyeboll and is continous anteriorly with the cornea.

Choroid :- The choroid linse the posterior five sixths of the inner surface of the sclera. It is
very rich in blood vessels and is deep chocalate brown in colour.

Ciliary body :- The cilliary body is the anterior continuation of the choroid consisting of
cilliary muscles and secretory epithelial cells.

Iris :- The iris is the visible caloured ring at the front of the eye and extends anteriorly from
the cilliary anteriorly from the cilliary body lying behind the cornea and in front of the
lense.

Lens :- The lens is a highly elastic cirular biconvex boby lying immediately behind the pupil.
It consists of fiber enclosed within a capsule and is suspended form the ciliary body by the
suspensary ligament.

Retina :- The retina is the innermost lyning of the eye. It is an extremely delicate structure
and well adopted for stimulation by light rays.

PHYSIOLOGY OF SIGHT :-

Light waves travel at a speed 300000 kilometers /second. Light is reflected into the eye by
objects within the field of vision.

White light is a combination of all the colours of thevisual spectrum ie. Red, orange, yellow,
green,blue indigo violet.

This is demonstrated by passing white light through a glass prism which bends the rays of
the different colours to a greater or lessure extent depending on their waves length.

Red light has the longest wave length and violet the shortest.

This range of colour is the spectrum of visible lights.

CAUSES OF BLINDNESS :-

Eye disease and condition :-

 Cataract 77.5%
 Refractive error 3.4 %
 Glaucoma 3%
 Posterior segment disorders 2.8%
 Surgical complication 1.2%
 Corneal opacity 3.6%
 Nutritional deficiency (vitamin A) 0.04%
 Aphakia 4.6%
 Other

Congenital disorders :- One eye missing or any other deformity may causes blindness in
child.

Malnutrition :- Mainly vitamin A deficiency and other nutrition may affect the eye hygiene
which can lead to visual impairement.

Injury or accident :-

 Accident cause blindness.

 Chemical burn
 Sports injury

Systemic disease :- Disease like hypertantion tumors diabetes neurogenic disorder may be
responsible loss of vision.

Socioeconomic and environment factor :-

 Sex
 Age
 Dust dirt airborn infections
 Pooverty
 Poor eye hygiene
 Illiteracy unempolyment.
PATHOPHYSIOLOGY :-

Diabetes

Hyperglycemia

Vascular endothelial dysfunction

Retinal ischemia Vascular permeability Diabetic maculo edema

Angiogenesis

Neovascularization

Tractional retinal detachment

Blindness

CLINICAL MANIFESTATION :-

 Blindness is a lack of vision it may also refer to a loss of vision that cannot of correct
with glasses and contact lens.
 Partial blindness means you have very limited vision. Complete blindness means
you cannot see anything and do not see light.
 Vision loss refers to the partial or complete loss of vision, this vision loss may
happen suddenly or over a period of time.
 Increase intra ocular pressure.
 Diplopia, photophobia, glare.
 Pain in eye and headache.
 Floaters and light flashes.
  Pruritus burning of the eyes.
 Bulging of the eye.
 Difference in appearance of an eye structure.
 A sense of orbital pressure.
 Halos (rainbow colors seen around lights).

TYPES OF BLINDNESS :-

1. Cataract :- Protein and water make up most of the lens in a person’s eye protein is
arranged in such a way as to let light pass through and focus the retina.
2. Glaucoma :- Glaucoma generally affects older people this happens when fluid in the
eye build up and cause too much pressure in the eye damaging important nerves in
eye.
3. Retinal detachment :- A retinal detachment occurs when the retina is pulled away
from is normal position this is a very serious condition usually and causes blindness
unless treat.
4. Total blindness :- Total blindness 80 % of legally blind people can see something
through thses born totally blind can’t really express what they seen as they have no
concept of colour or light.
5. Diabetic retinopathy :- One of the leading causes of blindness daibetic retinopathy
occurs due to complications from diabetes.
6. Macular degeneration :- This is another leading causes of blindness especially
older people macular degenration results from the deterioration of the macula a
portion of the retina responsible for clear sharp vision.
7. Retinitis pigmentosa :- This is a disease that usually beings when a person is
young and warse as they get older often teaving the blind as adults.
8. Nystagmus :- Nystagmus is characterised by an involuntary movement of the eyes
which may reduce vision or be associated with other more serious condition that
limit vision like achromatopsia nystagmus may be one of several infontile type or
may be aquired later in life.

DIAGNOSTIC EVALUATION :-

History taking :-During history take the cause a duration of the patient visual impairment
are identified patient with retinitis pigmentosa for example have a genetic abnormalitis
patient with diabetic maculoedema typically have flucture visual acuity.

Physical examination of eye :-

External examination :-
Visual acuity at distance (snellen chart and other methods ) – Letters and objects are of
different size that can be see by the normal eye at a distance of 20 feet (6cm) from the
chart.

Visual acuity at near ( jaeger chart and other metthods ) – Letters and objects are of
different size that can be seen by the normal eye at a reading distance of 14 inches from the
chart.

Visual fields :- Determines functions of optic pathways and identifies loss of visual field and
functional capacity.

Colour vision test :- These tests are done to determine the ability to perceive primary
colour and shades of colours. It is particularly significant for people whose occupation
required discrening colour such as workers surgeons and nurse.

Refraction :- Refraction is a clinical measurment of the error of focus in an eye.

Internal examination :-

Ophthalmoscopic examination :- Direct ophthalmoscopy use a strong light refracted into

the interior of the eye through an instrument called an opthalmoscope.

Indirect opthalmoscopy allows the examiner to obtain a stereoscopic view of the reting
light source is from a head mouted light.

Tonometry :- Mesure intraacular pressure which depends on the amount of aqueous

humer secreted into the eye and ear by which it leak.

Radiology and imaging :-

Fluorescen angiography :- Provides informations conncerning vascular obstruction

microorganism abnormal capillary permeability and defects in retina pigment
permeability.

MEDICAL MANAGEMENT :-
SURGICAL MANAGEMENT :-

Eye surgery, also known as ocular surgery, is surgery performed on the eye or its adnexa,
typically by an ophthalmologist.[1] The eye is a very fragile organ, and requires extreme care
before, during, and after a surgical procedure to minimise or prevent further damage. An
expert eye surgeon is responsible for selecting the appropriate surgical procedure for the
patient, and for taking the necessary safety precautions. Mentions of eye surgery can be
found in several ancient texts dating back as early as 1800 BC, with cataract treatment
starting in the fifth century BC. [2] Today it continues to be a widely practiced type of
surgery, having developed various techniques for treating eye problems.

Preparation and precautions

Main article: Anaesthesia for ocular surgery

Since the eye is heavily supplied by nerves, anesthesia is essential. Local anesthesia is most
commonly used. Topical anesthesia using lidocaine topical gel are often used for quick
procedures. Since topical anesthesia requires cooperation from the patient, general
anesthesia is often used for children, traumatic eye injuries, major orbitotomies and for
apprehensive patients. The physician administering anesthesia, or a nurse anesthetist or
anesthetist assistant with expertise in anesthesia of the eye, monitors the patient's
cardiovascular status. Sterile precautions are taken to prepare the area for surgery and
lower the risk of infection. These precautions include the use of antiseptics, such as
povidone-iodine, and sterile drapes, gowns and gloves.

Laser eye surgery

Although the terms laser eye surgery and refractive surgery are commonly used as if they
were interchangeable, this is not the case. Lasers may be used to treat nonrefractive
conditions (e.g. to seal a retinal tear). Laser eye surgery or laser corneal surgery is a
medical procedure that uses a laser to reshape the surface of the eye. This is done to
correct myopia (short-sightedness), hypermetropia (long sightedness) and astigmatism
(uneven curvature of the eye's surface). It is important to note that refractive surgery is not
compatible with everyone, and rarely people may find that eyewear is still needed after
surgery.

Recent developments also include procedures that can change eye color from brown to
Cataract surgery:-

Small incision cataract surgery is now the method of choice of cataract surgery all over the
world. Mannual or non- phaco techniques are becoming popularin the developin countries.

1. Phacoemulsification :- Phacoemulsification is now the standard from of

extracapsular cataract extraction. The machine is known as phacoemulsifier which
has three function
 Irrigation
 Aspiration
 Fragmentation
2. Femtosecond laser cataract surgery :-it is the latest development in cataract
surgery. A femtosecond assisted cataract procedure is guided by in build anterior
segmen imaging system which gives maximum precision in cataract surgery.
3. Intracapsular cataract extraction :- very rarly done now a days as in anterior
disclocation of the lens, grossly subluxated lens etc.
4. Intraocular lens implantation:- now a ays IOL implantation has become the standard
surgical procedure in the management of cataract. The main aim is to replace the
function of the natural crystallin lens, and to restore the vision approximating to pre
cataractous stage.

Glaucoma surgery

Glaucoma is a group of diseases affecting the optic nerve that results in vision loss and is
frequently characterized by raised intraocular pressure (IOP). There are many types of
glaucoma surgery, and variations or combinations of those types, that facilitate the escape
of excess aqueous humor from the eye to lower intraocular pressure, and a few that lower
IOP by decreasing the production of aqueous humor.

1.Canaloplasty

Canaloplasty is an advanced, nonpenetrating procedure designed to enhance drainage

through the eye’s natural drainage system to provide sustained reduction of IOP.
Canaloplasty utilizes microcatheter technology in a simple and minimally invasive
procedure. To perform a canaloplasty, an ophthalmologist creates a tiny incision to gain
access to a canal in the eye. A microcatheter circumnavigates the canal around the iris,
enlarging the main drainage channel and its smaller collector channels through the
injection of a sterile, gel-like material called viscoelastic. The catheter is then removed and
a suture is placed within the canal and tightened. By opening up the canal, the pressure
inside the eye can be reduced.

2. Trabeculectomy :- it is a partial thikness filtering operation, where the fistula is guuarded

by a superficial scleral flap.

3. Cyclocryotherapy :- this is most commonly practised by cyclodestructive procedure,

which involves freezing of the cilliary body, to reduce the rate of aqueous production.
Refractive surgery

Paracentasis :- paracentasis means opening of the anterior chamber for the purpose of
aspiration its contents, partially or completely.

Keratoplasty :- It means surgical replacement of a scarred or diseased cornea with a viable

doner cornea.

Penetrating keratoplasty :- PK is a full-thickness transplant procedure, in which a trephine

of an appropriate diameter is used to make a full-thickness resection of the patient's
cornea, followed by placement of a full-thickness donor corneal graft.

Photorefractive keratectomy(PRK) and laser-assisted sub-epithelial keratectomy (or laser

epithelial keratomileusis (LASEK):-are laser eye surgeryprocedures intended to correct a
person's vision, reducing dependency on glasses or contact lenses. LASEK and PRK
permanently change the shape of the anterior central cornea using an excimer laser to
ablate (remove by vaporization) a small amount of tissue from the corneal stroma at the
front of the eye, just under the corneal epithelium. The outer layer of the cornea is removed
prior to the ablation.

Radial keratocoagulation :- also known as Radial Thermokeratoplasty, was invented in

1985 by Svyatoslav Fyodorov and is used to correct hyperopia by putting a ring of 8 or 16
small burns surrounding the pupil, and steepen the cornea with a ring of collagen
constriction. It can also be used to treat selected types of astigmatism. It is now generally
replaced by laser thermal keratoplasty/laser thermokeratoplasty.

Laser thermal keratoplasty (LTK) is a non-touch thermal keratoplasty performed with

a Holmium laser, while conductive keratoplasty (CK) is thermal keratoplasty performed
with a high-frequency electric probe. Thermal keratoplasty can also be used to improve
presbyopia or reading vision after age 40.

Intrastromal corneal ring segments (Intacs) are approved by FDA for treatment of low
degrees of myopia.

Phakic intraocular lens (PIOL) implantation inside the eye can also be used to change
refractive errors. The newest type of intervention is a type of PIOL called the implantable
collamer lens (ICL) which uses a biocompatible flexible lens which can be inserted in the
eye via a 3 mm incision. The ICL is used to correct myopia ranging from −0.5 to −18
diopters, and +0.5 cylinder power to +6.0 for the Toric ICL models.

Generally refractive surgery can be broadly divided into: corneal surgery, scleral surgery,
lens related surgery (including phakic IOL implantation, clear lens extraction,
photophacoreduction and photophacomodulation for correction of pesbyopia)
For presbyopia correction, a corneal inlay consisting of a porous black ring surrounding a
small clear aperture was originally developed by D. Miller, H. Grey PhD and a group at
Acufocus. The inlay is placed under a LASIK flap or in a stromal pocket. [8][9]

Corneal surgery :- Corneal surgery includes most refractive surgery as well as the
following:

Vitreo-retinal surgery:- Vitreo-retinal surgery includes the following

 Vitrectomy
o Anterior vitrectomy is the removal of the front portion of vitreous tissue. It is used for
preventing or treating vitreous loss during cataract or corneal surgery, or to remove
misplaced vitreous in conditions such as aphakia pupillary block glaucoma.
o Pars plana vitrectomy (PPV), or trans pars plana vitrectomy (TPPV), is a procedure to
remove vitreous opacities and membranes through a pars plana incision. It is
frequently combined with other intraocular procedures for the treatment of giant
retinal tears, tractional retinal detachments, and posterior vitreous detachments.
 Pan retinal photocoagulation (PRP) is a type of photocoagulation therapy used in the
treatment of diabetic retinopathy.
 Retinal detachment repair
o Ignipuncture is an obsolete procedure that involves cauterization of the retina with a
very hot pointed instrument.
o A scleral buckle is used in the repair of a retinal detachment to indent or "buckle" the
sclera inward, usually by sewing a piece of preserved sclera or silicone rubber to its
surface.
o Laser photocoagulation, or photocoagulation therapy, is the use of a laser to seal a
retinal tear.
o Pneumatic retinopexy
o Retinal cryopexy, or retinal cryotherapy, is a procedure that uses intense cold to
induce a chorioretinal scar and to destroy retinal or choroidal tissue. [23]
 Macular hole repair
 Partial lamellar sclerouvectomy
 Partial lamellar sclerocyclochoroidectomy
 Partial lamellar sclerochoroidectomy
 Posterior sclerotomy is an opening made into the vitreous through the sclera, as for
detached retina or the removal of a foreign body [1].
 Radial optic neurotomy
 macular translocation surgery
o through 360 degree retinotomy
o through scleral imbrication technique

Oculoplastic surgery

Oculoplastic surgery, or oculoplastics, is the subspecialty of ophthalmology that deals with

the reconstruction of the eye and associated structures. Oculoplastic surgeons perform
procedures such as the repair of droopy eyelids (blepharoplasty), repair of tear duct
obstructions, orbital fracture repairs, removal of tumors in and around the eyes, and facial
rejuvenation procedures including laser skin resurfacing, eye lifts, brow lifts, and even
facelifts. Common procedures are:

NURSING MANAGEMENT :-

Assessment :-

 Collect subjective and objective data about patients general status of health.
 Ascertain what symptoms the patient has been having (eye pain visual loss drainage
history of trauma and now that has impacted usual activity.
 Assess the patient mobility and self care ability.
 Assess visual and other sensory impairments.
 Review the patients daily schedule.
 Record pertinent data in patient record.

Diagnosis :- Risk for infection related to incision as manifested by increase lacrimation.

Goal :- Prevent infection in eye

Intervention :-