Eye Disorders

Prepared by:
Emman M. Parangue, R.N.
01
Eyes
• The eyeball is moved through all fields of gaze by the
extraocular muscles.
• The four rectus muscles and two oblique muscles are
innervated by cranial nerves (CNs) III, IV, and VI.
• Normally, the movements of the two eyes are
coordinated and the brain perceives a single image.
Eyes
• Tears are vital to eye health.
• Formed by the lacrimal gland and the accessory
lacrimal glands, tears are secreted in response to
reflex or emotional stimuli.
• A healthy tear is composed of three layers: lipoid,
aqueous, and mucoid.
Eyes
• The conjunctiva, a thin transparent mucous
membrane, provides a barrier to the external
environment extending under the eyelids (palpebral
conjunctiva) and over the sclera (bulbar conjunctiva).
• The junction of the two portions is known as the
fornix.
• The conjunctiva meets the cornea at the limbus on
the outermost edge of the iris.
Eyes
• The aqueous humor (transparent nutrient-containing
fluid that fills the anterior and posterior chambers of
the eye) is produced in the posterior chamber by the
ciliary body.
• Normal IOP is less than 21 mmHg.
Eyes

• Vitreous humor, which is composed mostly of water

and encapsulated by a hyaloid membrane, helps
maintain the shape of the eye.
• The vitreous shrinks and shifts with age.
Eyes
• The sclera is the white avascular dense fibrous
structure that helps maintain the shape of the eyeball
and protects the intraocular contents.
• The cornea, a vulnerable transparent avascular
domelike structure, forms the most anterior portion
of the eyeball and is the main refracting surface of
the eye.
• The uveal tract is the vascular middle layer of the eye
consisting of the iris, ciliary body, and the choroid.
 Eyes
• The iris surrounding the pupil is a highly vascularized
pigmented collection of fibers that give the eye color.
• The ciliary body work together to form aqueous fluid.
• The choroid lies between the retina and the sclera,
supplying blood and oxygen to the outer retina.
 1. Flow of the Aqueous Humor

2. Produced by the ciliary bodies

3. ↓
4. Flows through the pupil

5. ↓
6. Fills the anterior chamber

7. ↓
8. Drains away through the angle
9. (between the iris and cornea)
10. ↓
11. Trabecular meshwork

12. ↓
13. Canal of Schlemm

14. ↓

15. Vein → Bloodstream

 Eyes
• The lens enables focusing for near and distance vision
through accommodation.
• The retina—the innermost surface of the fundus composed
of neural tissue—is an extension of the optic nerve.
02
Cataract

• ▪ the clouding or opacity of the natural lens

• ▪ occurs gradually over time
• ▪ changes color: clear is normal
• hazy, yellow, sea green
• ▪ affects nearly 25 million Americans who are
• 40 years or older
• ▪ by 80 years more than half of the Americans
• have cataract
Risk Factors
1. aging
2. associated ocular conditions
▪ myopia, retinal detachment and surgery,
Infection
3. nutritional factors: poor nutrition, obesity
4. toxic factors: ionizing radiation, aspirin,
corticosteroids, cigarette smoking
5. physical factors: blunt trauma, perforation of the
lens with sharps, UV radiation, x-ray
6. systemic diseases: DM, Down syndrome
Pathophysiology
▪ can develop in one or both eyes at any age from
a variety of risk factors
▪ three common types defined by their location:
nuclear, cortical, posterior subcapsular

▪ Nuclear cataract
▫ has substantial genetic components
▫ causes central opacity in the lens
▫ it is associated with myopia that worsens when
cataract progresses
Pathophysiology
Cortical cataracts
▪ involves the anterior, posterior or equatorial
cortex of the lens
▪ progress at a highly variable rate
▪ vision is worse in very bright light
▪ sunlight exposure is a risk factor
Pathophysiology
Posterior subcapsular cataracts
▪ occur in front of the posterior capsule
▪ develops in younger people
▪ associated with corticoid use, DM and ocular trauma
▪ near vision diminished, sensitive to bright light
Clinical Manifestations
Clinical manifestations
▪ painless, blurry vision is characteristic of cataracts
▪ perceived surrounding as dimmer
▪ light scattering, sensitivity to glare, reduced visual
acuity
▪ others: myopia, astigmatism, diplopia, color changes
Management
Medical management
▪ no medications, eye drops, glasses that can
prevent cataracts

Surgical management
▪ the patient's functional and visual status is the
primary consideration
Management
Phacoemulsification
▪ anterior capsule is removed, allowing extraction
of the nucleus and the cortex while the posterior
capsule zonular support left intact

Lens Replacement
 Post Operative Complications
• ▪ Immediate • ▪ Late postoperative
• ▫ hemorrhage • ▫ sutured-related problems
• ▪ Intraoperative • ▫ malposition of IOL
• ▫ rupture of the posterior • ▫ chronic endophthalmitis
capsule
• Early postoperative
• ▫ acute bacterial
endophthalmitis by
• S. aureus, S. epidermidis,
Pseudomonas, Proteus
GLAUCOMA
▪ a group of ocular disorders characterized by an
increased in intraocular pressure, optic nerve
damaged and visual field loss in some patients

▪ damage of the optic nerve results from increase

pressure in the eye
▪ estimated to affect 2.2 million Americans
▪ prevalent in people older than 40 years
Physiology
▪ normal IOP is between 10 and 21 mm Hg
▪ IOP is determined by the:
▫ rate of aqueous humor production
▫ the resistance encountered by the aqueous
humor as it flows out the passages
▫ venous pressure of the episcleral veins that
drain into the ciliary vein
▪ when aqueous humor is inhibited from flowing
out, pressure builds up within the eye
Pathophysiology
• ▪ there are two theories how increased IOP
• damages the optic nerve in glaucoma:
•

• 1. direct mechanical theory – suggests that high

• IOP damages the retinal layer as it passes the
• through the optic nerve head
• 2. indirect ischemic theory – suggests that high
• IOP compresses the microcirculation in the
• optic nerve head resulting in cell injury and
• death
Pathophysiology
• ▪ some glaucomas appear exclusively mechanical,
• some are exclusively ischemic, typically, most
• cases are combination of both
Classification of Glaucoma
▪ Primary or Secondary
▪ Open-angle glaucoma or angle-closure glaucoma
( pupillary block)
▪ congenital and glaucoma associated with other
conditions
▪ the two common clinical forms in adults are:
▫ primary open-angle glaucoma (POAG)
▫ angle-closure glaucoma
Clinical Manifestations
▪ often called the “silent thief of the sight” because
most patients are unaware that they have the
disease until they have experienced visual changes
and vision loss
▪ blurred vision
▪ halos around lights
▪ difficulty focusing or adjusting to low lighting
▪ loss of peripheral vision
▪ pain or discomforts around the eyes
▪ headache
Assessment and Diagnostic Findings
▪ optic nerve changes are pallor and cupping of the
optic nerve disc
▫ pallor is due to lack of blood supply
▫ cupping is exaggerated bending of the blood
vessels as they cross the optic disc resulting in
enlarged cup with thinned rim
▪ as optic nerve damage increases, visual perception
decreases
▪ scotomas, a localized area of visual loss, represents
loss of retinal sensitivity and nerve fiber damage
Assessment and Diagnostic Findings
Diagnosis is made on
1. measurement of pressure – Tonometer
2. evaluate the health of optic nerve
3. evaluate cause of increase pressure
Medical Management
▪ the goal of treatment is prevention of optic nerve
damage
▪ treatment includes: pharmacologic, laser procedures,
surgery or combination of these approaches
▪ the IOP is set at 30% lower than the current pressure
▪ optic nerve appearance is monitored, if there is
evidence of optic nerve damage, the IOP is again
lowered until stable
▪ glaucoma damage cannot be reversed but
progression can be prevented
Medical Management
Medications
▪ decrease pressure by reducing fluid going into the
eye, or making easier for the fluid to leave the eye
▪ Decrease inflow
1. beta blockers – Timolol, Betagan
▫ decrease aqueous humor production
2. carbonic anhydrase inhibitor – acetazolamide
(Azopt, Truzopt)
▫ decrease aqueous humor production
Medical Management
▪ Increase outflow
1. cholinergics (miotics) – pilocarpine
▫ increase AH outflow by constricting ciliary muscle
and constricting the pupil
2. prostaglandins analogues – Lumigan, Xalatan
Travatan
▫ increase uveoscleral outflow
Medical Management
Decrease Production and Increase Outflow
▪ Alpha adrenergic agonists
apraclonidine (Alphagan)
Medical Management
Laser trabeculoplasty
▪ focusing the laser in the inner surface of the
trabecular meshwork, to open the intratrabecular
spaces and widen the canal of Schlemm
▪ improve fluid outflow
▪ may cause 75% pressure reduction
Surgery
Trabeculectomy – filtering technique
▪ part of the trabecular meshwork is remove
▪ risk
▫ bleeding, infection as it is an invasive surgery
▫ blurred vision (post op)
▫ late infection
▪ Post-operatively, instruct patient to report to the
doctor the presence of: pain, redness, decrease
vision
Surgery
Glaucoma success of treatment is dependent on
1. pressure control, should be consistent with drops
2. monitoring, consistent follow up
Retinal Detachment
▪ the separation of the retina from the choroid, a
membrane dense with blood vessels, that supply
oxygen and nutrients to the eye
▪ when the retina detaches, it is deprived of blood
supply and nourishment and loses its ability to
function
▪ this can impair vision to the point of blindness
Causes and Risk Factors
▪ age – as we age retina may weaken
▪ highly myopic
▪ trauma like from sports: boxing, basketball
▪ DM
▪ degeneration of the retina
▪ previous retinal detachment on the other eye
▪ family history of retinal detachment
Four types of retinal detachment
1. rhegmatogenous
2. traction
3. combination of rhegmatogenous and traction
4. exudative
Rhegmatogenous Detachment
▪ the most common form
▪ a hole or tear developed in the sensory retina
allowing liquid vitreous to seep through the sensory
retina and detach it from retinal pigment epithelium
(RPE)
▪ people at risk:
▫ highly myopic
▫ aphakia (absence of natural lens following surgery)
Traction
▪ cause by tension or pulling force
▪ fibrous scar tissue provides traction
▪ fibrous scar form diabetic retinopathy, vitreous
hemorrhage

A patient can have both rhegmatogenous and traction

retinal detachment
Exudative retinal detachment
▪ results from production of serous fluid under the
retina from the choroid
▪ conditions such as uveitis and macular degeneration
Clinical Manifestations
▪ a sensation of shade or curtain falling across
the vision of one eye
▪ cobwebs
▪ bright flashing lights
▪ sudden onset of great number of floaters
Diagnostic Findings
▪ evaluate visual acuity
▪ dilated fundus examination
▪ ophthalmoscope
Surgical Management
▪ Scleral buckling
-the surgeon compresses the sclera with a
scleral buckle or silicone band
Pars Plana Vitrectomy
▪ an intraocular procedure that allows introduction
of light source through an incision
▪ the second incision is for the vitrectomy instrument
▪ can be used in various procedures like removal of
foreign body, dislocated lenses, vitreous opacity
such as blood
Pars Plana Vitrectomy
Pneumatic Retinopexy
▪ injection of gas bubble, silicone oil or liquids
into the vitreous cavity to help push the sensory
retina to the up against the RPE.
Nursing Management
▪ consist of educating the patient and providing
supportive care
▪ for pneumatic retinopexy, postoperative positioning
is critical as injected bubble must float into a position
overlying the detachment
Refractive Disorders
Three basic abnormalities
1. Myopia or nearsightedness
▪ light rays are focused in front of the retina
▪ in most cases myopia is caused by eyeball that
is longer than normal
▪ treatment: concave or minus lens
Refractive Disorders
2. Hyperopia or farsightedness
▪ light rays are focus behind the eyes
▪ the image that falls on the retina is blurred
▪ treatment: convex or plus lens
3. Astigmatism
▪ light rays are not bent equally by the cornea,
focus not attained
▪ commonly caused by abnormal curvature of the
cornea
▪ treatment: astigmatic or cylindrical lens
Lasik Surgery
▪ laser-assisted in situ keratomileusis
▪ reshapes the cornea to enable light entering the
eye to be properly focused in the retina to produce
a clearer vision
Ocular Trauma
▪ the leading cause of blindness among children
and young adults, especially male trauma victims
▪ Causes:
▫ occupational injuries e.g. construction industry
▫ contact sports, weapons e.g. air guns
▫ assaults
▫ motor vehicle crashes e.g. broken windshields
▫ explosions e.g. blast fragments
 Two types of ocular trauma:
1. chemical burn
2. foreign object in the eye
▪ first response is critical

▪ with chemical burn, the eye should be immediately

irrigated with tap water or normal saline
▪ with a foreign body, no attempt should be made to
remove the foreign object
 Two types of ocular trauma:
▪ the object should be protected from jarring
or movement to prevent further ocular damage
▪ no pressure or patch applied to affected eye
▪ all other traumatic eye injuries should be protected
with patch or shield (or stiff paper cup)
Thank you!
God Bless!