MEDICAL SURGICAL NURSING

ASSESSMENT AND MANAGEMENT OF PATIENTS WITH EYE AND VISION DISORDERS

ANATOMY OF THE EYES

EXTERNAL STRUCTURES OF THE EYE

EXTRAOCULAR MUSCLES

VISUAL PATHWAYS
 ASSESSMENT AND MANAGEMENT OF PATIENTS WITH EYE AND VISION DISORDERS

CROSS-SECTION OF THE EYE

NOTE
VISUAL ACUITY TEST
• Nystagmus is involuntary oscillation of the eyeball.
• Snellen Chart: distance
Strabismus is a condition in which there is deviation from
• Rosenbaum pocket screener: near
perfect ocular alignment.
SNELLEN CHART
ASSESSMENT AND EVALUATION OF VISION
• Composed of a series of progressively smaller rows of letters
OCULAR HISTORY
• 20/20 is considered the standard of normal vision.
• Most people can see the letters on the line designated as
• What does the patient perceive to be the problem?
20/20 from a distance of 20 feet.
• Is visual acuity diminished?
• A person whose vision is 20/200 can see an object from 20
• Does the patient experience blurred, double, or distorted
feet away that a person with 20/20 vision can see from 200
vision?
feet away
• Is the discomfort an itching sensation or more of a foreign
• Pt is at usually 20 feet from the chart and is asked to read the
body sensation?
smallest line that he or she can see.
• Are both eyes affected?
• Pt should wear distance correction (eyeglasses or contact
• Is there a history of discharge? If so, inquire about color,
lenses)
consistency, odor.
• Each eye should be tested separately.
• Describe the onset of the problem (sudden, gradual). Is it
• If the patient cannot read the 20/20 line, he or she is given a
worsening?
pinhole occlude.
• What is the duration of the problem?
• If pt can’t read the largest letter, pt should be moved toward
• Is this a recurrence of a previous condition?
the chart to identify largest letter.
• How was the patient self-treated?
• What makes the symptoms improve or worsen? o If pt can recognize only the letter E on the top line at 10
• Has the condition affected performance of activities of daily ft, his visual acuity would be recorded as 10’/200.
living (ADLs) o If pt can’t see letter E at any distance, examiner should
• Are there any systemic disease? What medications are used determine if pt can count fingers (CF) (3 feet).
in their treatment?
• What concurrent ophthalmic conditions does the patient • If pt can’t count fingers, examiner raises one hand up/down
have? or moves side to side and asks in which direction the hand is
moving. This level of vision is known as hand motion (HM).
• Is there a history of ophthalmic surgery?
• Have other family members had the same symptoms or o light perception (LP).
condition? o no light perception (NLP).
 ASSESSMENT AND MANAGEMENT OF PATIENTS WITH EYE AND VISION DISORDERS

EXTERNAL STRUCTURES EXAMINATION

• Note any evidence of irritation, inflammatory process,

discharge, and so on
• Assess eyelids and sclera
• Assess pupils and pupillary response; use darkened room
• Note gaze and position of eyes
• Assess extraocular movements SLIT-LAMP EXAMINATION

• Binocular microscope mounted on a table.

• Examine the eye with magnification of 10-40 times the real
image
• Cataracts may be evaluated by changing the angle of the light

• Ptosis: drooping eyelid

• This is important when screening patients for ocular trauma
or for neurologic disorders
• Nystagmus: oscillating movement of eyeball

DIAGNOSTIC EVALUATIONS
DIRECT OPHTHALMOSCOPY
• The examiner holds the ophthalmoscope in the right hand
and uses the right eye to examine the patient’s right eye.
• The examiner switches to the left hand and left eye when
examining the patient’s left eye.
o During this examination, the room should be darkened,
and pt’s eye should be on the same level as the
examiner’s eye.
COLOR VISION TESTING
• Ability to differentiate colors has a dramatic effect on the
ADLs.
• Inability to differentiate between red and green can
compromise traffic safety.
• Careers (commercial artist, photographer, airline pilot,
electrician) may be closed to people with significant color
deficiencies.
• The photoreceptor cells responsible for color vision are the
cones, and the greatest area of color sensitivity is in the
macula, the area of densest cone concentration.

POLYCHROMATIC PLATES (ISHIHARA TEST)

• Color vision deficits can be inherited.

• Red–green color deficiencies are inherited in an X-linked
manner, affecting approximately 8% of men and 0.4% of
women.
• Acquired color vision losses by medications (eg, digitalis)
• Pathology (eg, cataracts)
INDIRECT OPHTHALMOSCOPY

AMSLER GRID

• Healthy fundus should be free of any lesions. • Used for patients with macular problems, such as macular
• Intraretinal hemorrhages (red smudges – hypertension) degeneration.
• Hypercholesterolemia or DM - lipid has yellowish
appearance.
• Microaneurysms - little red dots, and nevi.
• Macular degeneration - Drusen (yellowish areas)
 ASSESSMENT AND MANAGEMENT OF PATIENTS WITH EYE AND VISION DISORDERS
• Each eye is tested separately. The patient is instructed to
stare at the central fixation spot on the grid and report any
distortion in the squares of the grid itself.
• The Amsler Grid may appear like this for someone without
AMD
• The Amsler Grid may appear like this for someone with AMD
ULTRASONOGRAPHY
• Valuable diagnostic technique when the view of the retina is
obscured by opaque media such as cataract or hemorrhage.
• Used to identify orbital tumors, retinal detachment, vitreous
hemorrhage, and changes in tissue composition
• Minimal discomfort for the patient.
OPTICAL COHERENCE TOMOGRAPHY
• Technology that involves low-coherence interferometry.
• This method is noninvasive and involves no physical contact
with the eye.
FUNDUS PHOTOGRAPHY
• used to detect and document retinal lesions.
• Pt’s pupils are widely dilated before the procedure.
• Visual acuity is diminished for about 30 minutes as a result of
retinal “bleaching” by the intense flashing lights
.
FLUORESCEIN ANGIOGRAPHY
• It is an invasive procedure in which fluorescein dye is
injected, usually into an antecubital vein.
• Within 10 to 15 seconds, this dye can be seen coursing
through the retinal vessels.
• Over a 10-minute period, serial black-and-white photographs
are taken of the retinal vasculature.
• Dye may impart a gold tone to the skin and urine may turn
deep yellow or orange. This discoloration usually disappears
in 24 hours
TONOMETRY
• Measures IOP by determining the pressure necessary to
indent or flatten (applanate) a small anterior area of the
globe of the eye.
• The procedure is noninvasive and usually painless. A topical
anesthetic eye drop is instilled in the lower conjunctival sac,
and the tonometer is then used to measure the IOP.
• Normal eye pressure ranges from 10-21 mm Hg
• Perimetry Testing
• Evaluates the field of vision
• Visual field testing (ie, perimetry) helps identify which parts
of the patient’s central and peripheral visual fields have
useful vision.
• Helpful in detecting blind areas in the visual field in macular
degeneration and the peripheral field defects in glaucoma
and retinitis pigmentosa.
 ASSESSMENT AND MANAGEMENT OF PATIENTS WITH EYE AND VISION DISORDERS

IMPAIRED VISION

• Refractive errors • Hyperopia: farsighted

• Astigmatism: distortion caused by irregularity of the cornea
o Can be corrected by lenses that focus light rays on the
• Eyeball Shape Determines Visual Acuity in Refractive Errors
retina

• Emmetropia: normal vision

• Myopia: nearsighted

LOW VISION AND BLINDNESS

1. Low vision

• Requires devices and strategies in addition to corrective lenses

• Best corrected visual acuity (BCVA) of 20/70 to 20/200

2. Blindness

• BCVA 20/400 to no light perception

• Legal blindness is BCVA that does not exceed 20/200
• Financial Assistance

3. Impaired vision often is accompanied by functional impairment

• (cane, guide dog) and should be encouraged to learn Braille and to use computer aids

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

o Placement of items in room

o Call Buttons
o Clock method” for trays

• Communication strategies
• Collaboration with low-vision specialist, occupational therapist, or other resources
• Braille or other methods for reading and communication
• Service animals
MEDICAL SURGICAL NURSING
ASSESSMENT AND MANAGEMENT OF PATIENTS WITH EYE AND VISION DISORDERS

NOTE • Loss of peripheral vision.

• There is no cure for glaucoma, but can be controlled
• When caring for patients with low vision or blindness, it is
important to encourage and support independence as much
as possible. To guide patients, the nurse should allow the
patient to hold the nurse’s arm above the elbow while
walking a step behind when ambulating. The nurse should
use clock terms to describe placement of items so the patient
can access food or personal items. For safety, the nurse
should remove obstacles in room and describe furniture
RISK FACTORS OF GLAUCOMA
placement
• Family history of glaucoma
OPHTHALMIC MEDICATIONS
• Thin cornea
• Ability of the eye to absorb medication is limited • African American race
• Barriers to absorption include the size of the conjunctival sac; • Older age
corneal membrane barriers, blood–ocular barriers; and • Diabetes mellitus
tearing, blinking, and drainage • Cardiovascular disease
• Topical medications (drops and ointments) are most • Migraine syndromes
frequently used because they are least invasive, have fewest • Nearsightedness (myopia)
side effects, and permit self-administration • Eye trauma
• Topical anesthetics • Prolonged use of topical or systemic corticosteroids
• Mydriatics (dilate) and cycloplegics (paralyze)
PATHOPHYSIOLOGY OF GLAUCOMA
o Contraindicated with narrow angles or shallow anterior
chambers • In glaucoma, aqueous production and drainage are not in
o May cause CNS symptoms and increased BP, especially balance
in children or older adults • When aqueous outflow is blocked, pressure builds up in the
eye
• Anti-infective medications • Increased IOP causes irreversible mechanical or ischemic
damage
o Antibiotic, antifungal, or antiviral products

GLAUCOMA

• Ocular conditions in which damage to the optic nerve is

related to IOP caused by congestion of the aqueous humor
• Increased IOP damages the optic nerve and nerve fiber layer,
but the degree of harm is highly variable
• Glaucoma is the second leading cause of blindness in adults
in US.
 ASSESSMENT AND MANAGEMENT OF PATIENTS WITH EYE AND VISION DISORDERS

TYPES OF GLAUCOMA

• Open angle
• Angle closure
• Congenital
• Associated with other condition

CLINICAL MANIFESTATIONS

• “Silent thief of sight” • difficulty focusing

• peripheral vision loss • difficulty adjusting eyes to low lighting
• Blurring • May also have aching or discomfort around eyes or headache
• Halos
DIAGNOSTIC FINDINGS TREATMENT

• Tonometry to assess IOP • Goal is to prevent further optic nerve damage

• Opthalmoscopy to inspect the optic nerve disc • Maintain normal IOP
• Central visual field testing • Pharmacologic therapy: miotics, beta blockers, alpha2-
agonists, carbonic anhydrase inhibitors, prostaglandins
• Laser procedures
• Surgery

OPHTHALMIC MEDICATIONS NURSING MGT

• Medications used for glaucoma
o Increase aqueous outflow or decrease aqueous
production
o May constrict the pupil and may affect vision
o May also may produce systemic effects
• Anti-inflammatory drugs; corticosteroid suspensions
o Side effects of long-term topical steroids include
glaucoma, cataracts, and increased risk of infection.
• Assess for knowledge level and adherence. Education about
self-care
• Focus on maintaining the therapeutic regimen for lifelong
control of a chronic condition
• 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 or potential vision loss

CATARACTS

• An opacity or cloudiness of the lens

• Leading cause of blindness in the world
• Three types

o Traumatic
o Congenital
o Senile cataract
 ASSESSMENT AND MANAGEMENT OF PATIENTS WITH EYE AND VISION DISORDERS
CLINICAL MANIFESTATIONS
• Painless, blurry vision, surroundings dimmer
• Sensitivity to glare
• Reduced visual acuity
• Myopic shift; astigmatism; diplopia; and color shifts, including
brunescens (color value shift to yellow-brown)
• Diagnostic findings include decreased visual acuity and
opacity of the lens by ophthalmoscope, slit lamp, or
inspection
SURGICAL MGT
• If reduced vision does not interfere with normal activities,
surgery is not needed
• Surgery is preformed on an outpatient basis with local
anesthesia Surgery usually takes less than 1 hour, and pts are
discharged soon afterward
• When both eyes have cataracts, one eye is treated first, with
at least several weeks or months
TYPES OF CATARACT SURGERY
1. Phacoemulsification
• In this method of extracapsular cataract surgery, a portion of
the anterior capsule is removed, allowing extraction of the
lens nucleus and cortex while the posterior capsule and
zonular support are left intact.
• An ultrasonic device is used to liquefy the nucleus and cortex,
which are then suctioned out through a tube
• After the pupil has been dilated, a small incision is made on
the upper edge of the cornea, clear gel is injected into the
space between the cornea and the lens to prevents the space
from collapsing and facilitates insertion of the IOL.
• Incision is smaller so wound heals more rapidly
2. Lens Replacement
• After removal of the crystalline lens, the patient is referred to
as aphakic (without lens).
• TYPES:
o Aphakic Eyeglasses
o Contact Lenses
o IOL Implants
PROVIDING PREOPERATIVE CARE
• CBC, ECG, urinalysis are prescribed only if they are indicated
by the patient’s medical history.
• Withhold any anticoagulant therapy (aspirin, warfarin) to
reduce risk of hemorrhage for 5-7 days before surgery.
• Study showed risk of adverse events who continued
anticoagulant therapy before cataract surgery was very low.
The researchers speculated that regular users of aspirin or
warfarin are already at higher risk for transient ischemic
attacks or angina and suggest that patients may not need to
discontinue these medications prior to surgery
• Dilating drops are administered every 10 minutes for four
doses at least 1 hour before surgery.
o Additional dilating drops may be administered in OR
(immediately before surgery).
o Antibiotic, corticosteroid, and anti-inflammatory drops
may be administered prophylactically to prevent
postoperative infection and inflammation
 ASSESSMENT AND MANAGEMENT OF PATIENTS WITH EYE AND VISION DISORDERS

PROVIDING POSTOPERATIVE CARE

• Verbal and written instructions about how to protect the eye, administer medications, recognize signs of complications, and obtain
emergency care.
• Explain that there should be minimal discomfort after surgery and instructs the patient to take a mild analgesic agent, such as
acetaminophen, as needed.
• Antibiotic, anti-inflammatory, and corticosteroid eye drops or ointments are prescribed postoperatively.

PATIENTS SELF-CARE

• Wear a protective eye patch for 24 hours after surgery, followed by eyeglasses worn during the day and a metal shield worn at night for 1
to 4 weeks.
• Sunglasses should be worn while outdoors during the day because the eye is sensitive to light.
• Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days.
• Cataract surgery increases the risk of retinal detachment, pt must know to notify the surgeon if new floaters (dots) in vision, flashing
lights, decrease in vision, pain, or increase in redness occurs.
• Vision is stabilized when the eye is completely healed, usually within 6 to 12 weeks, when final corrective prescription is completed.

CORNEAL DYSTROPHIES
• Inherited, autosomal dominant
• Manifests at 20 years of age
• Deposits in corneal layers
• Decreased vision is caused by the irregular corneal surface
and corneal deposits. Edema leads to formation of blisters
that cause pain and discomfort on rupturing This is
associated with primary open-angle glaucoma
• A bandage contact lens is used to flatten the bullae, protect
the exposed corneal nerve endings, and relieve discomfort.
• Two types
• Onset occurs at puberty; the condition may progress for
more than 20 years and is bilateral.
• Blurred vision is a prominent symptom. Rigid, gas-permeable
contact lenses correct irregular astigmatism and improve
vision. Advances in contact lens design have reduced needs
for surgery
• Penetrating keratoplasty is indicated when contact lens
correction is no longer effective

o Keratoconus
o Fuchs endothelial dystrophy

KERATOCONUS

• Conical protuberance of the cornea with progressive thinning

on protrusion and irregular astigmatism.
• Hereditary condition has a higher incidence among women.
 ASSESSMENT AND MANAGEMENT OF PATIENTS WITH EYE AND VISION DISORDERS

PHOTOTHERAPEUTIC KERATECTOMY NOTE

• PTK is a laser procedure of removing or reducing corneal
opacities and smoothing the anterior corneal surface to
improve functional vision.
• Contraindicated in patients with active herpetic keratitis
because the ultraviolet rays may reactivate latent virus.
• Postop mgt consists of oral analgesics for eye pain.
• Pressure patch or therapeutic soft contact lens. Antibiotic
and corticosteroid ointments and NSAIDs are prescribed
postoperatively.
• Follow-up examinations are required for up to 2 years
• Discharge instructions should include
o Avoid lying on the side of the affected eye the night
after surgery
o Keep activity light (e.g., walking, reading, watching
television). Resume the following activities only as
directed by the ophthalmologist driving, sexual activity,
unusually strenuous activity
o Avoid lifting, pushing, or pulling objects heavier than 15
lb
o Avoid bending or stooping for an extended period
o Be careful when climbing and descending stairs
o Sneezing if necessary should not be held in because it
would increase IOP. Sneezing should be done with an
open mouth to decrease pressure

RETINAL DISORDERS

• Retina is composed of multiple microscopic layers, the two

innermost layers, the sensory retina and the retinal pigment
epithelium (RPE)
• Just as the film in a camera captures an image, so does the
retina, the neural tissue of the eye.
• The rods and cones, the in the sensory layer of the retina.

PENETRATING KERATOPLASTY

• PKP; corneal transplantation or corneal grafting

• Removes the diseased cornea, places the
donor cornea on the recipient bed, and
sutures it in place. Sutures remain in place
for 12 to 18 months and are then
removed. RETINAL DETACHMENT
• Potential complications - graft failure,
trauma, acute infection, and persistently • Separation of the
increased IOP and rejection. sensory retina and
• Postop, pt receives mydriatics for 2 weeks and topical the RPE (retinal
corticosteroids for 12 months (daily doses for 6 months and pigment
tapered doses thereafter). These drops should be epithelium)
preservative free to prevent a reactive inflammation. • Manifestations:
sensation of a
REFRACTIVE SURGERY shade or curtain coming across the vision of one eye, bright
flashing lights, sudden onset of floaters
• Elective procedures to correct refractive errors and
astigmatism by reshaping cornea SURGICAL TREATMENT
• Patient needs counseling regarding potential benefits, risks,
and complications • Scleral buckle
• Compresses sclera
 ASSESSMENT AND MANAGEMENT OF PATIENTS WITH EYE AND VISION DISORDERS

PARS PLANA VITRECTOMY o Wet type

• A vitrectomy is - May have abrupt onset

an intraocular - Proliferation of abnormal blood vessels growing under
procedure in the retina– choroidal revascularization
which incisions
are made at
the pars plana.
• One incision -
light source
and another
incision serves
as the portal
for the
vitrectomy
instrument. PROGRESSION OF AMD: PATHWAYS TO VISION LOSS
• Used in various procedures, including the removal of foreign
bodies, vitreous opacities such as blood, and dislocated
lenses

PNEUMATIC RETINOPEXY

• Least invasive of the three procedures described.

• A gas bubble, silicone oil, or perfluorocarbon and liquids may
be injected into the vitreous cavity
• Postop positioning of pt is critical because the injected
bubble must float into a position overlying the area of
detachment, providing consistent pressure to reattach the
sensory retina.
• The patient must maintain a PRONE position that would
allow the gas bubble to act as a tamponade for the retinal
break

PHOTODYNAMIC THERAPY FOR SLOWING PROGRESSION

OF AMD

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, or increased blood
viscosity; associated risk factors are diabetes, glaucoma, and
aging
• 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
• Pt 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

AGE-RELATED MACULAR DEGENERATION

• Accounts for 54% of all blindness

• Types

o Dry or nonexudative

- most common, 85% to 90%

- Slow breakdown of the layers of the retina with the
appearance of drusen
 ASSESSMENT AND MANAGEMENT OF PATIENTS WITH EYE AND VISION DISORDERS

• Potential for sympathetic ophthalmia causing blindness in the

uninjured eye with some injuries

NOTE

• When an exposure occurs, the eye should be continuously

flushed with tap water for 20 minutes. It is important to
begin the flushing process within 5 minutes for the best
outcome. Additional education should include saving the
bottle or container, if a chemical exposure, for the
emergency response providers so the chemical involved is
known to provide further emergent care
NURSING MANAGEMENT

• Patient education
• Supportive care
• Promote safety
• Recommendations to improve lighting, magnification devices,
and referral to vision center to improve or promote function

INFECTIOUS AND INFLAMMATORY DISORDERS

• Dry eyes
• Conjunctivitis (“pink eye”)

o Classified by cause: bacterial, viral, fungal, parasitic,

allergic, toxic

• Uveitis
• Hyperemia
• Hyperemia in Viral Conjunctivitis
• Orbital cellulitis

OCULAR CONSEQUENCES OF SYSTEMIC DISEASE

• Diabetic retinopathy
• Diabetes is a leading cause of blindness in people aged 20 to
74 years
• Ophthalmic complications associated with AIDS
• Eye changes associated with hypertension

SAFETY MEASURES AND EDUCATION

• Patient education is a vital nursing intervention for patient

with eye and vision disorders
• Prevention of eye injuries; education
• Safety strategies for patients with low vision in the hospital
and home setting
• Patient education after eye surgery or trauma

o Potential complications
o Loss of binocular vision with patch or vision impairment
of one eye; safety
o Use of eye patch and shield

TRAUMA

• Prevention of injury
• Patient and public education
• Emergency treatment

o Flush chemical injuries

o Do not remove foreign objects
o Protect using metal shield or paper cup