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AUDIO-VISUAL DISTURBANCES

Finals Concept#01

VISION
EXTERNAL STRUCTURES OF THE EYE
EYELIDS (PALPEBRAL) & EYELASHES
Protect the eye from foreign particles

CONJUNCTIVA
PALPEBRAL CONJUNCTIVA Pink; lines inner surface of eyelids

BULBAR CONJUNTIVA
White with small blood vessels, covers anterior sclera

LACRIMAL APPARATUS (LACRIMAL GLAND & ITS DUCTS AND PASSAGES)


Produces tears to lubricate the eye & moisten the cornea Tears drain into nasolacrimal duct which empties into nasal cavity

VISION
INTERNAL STRUCTURES OF THE EYE

1. EYEBALL
3 LAYERS OF THE EYEBALL

A. OUTER LAYER
- fibrous coat that supports the eye

A. SCLERAE
- Tough, white connective tissue white of the eye - located anteriorly & posteriorly

B. CORNEA
- Transparent tissue through which light enters the eye. - Located anteriorly

VISION
B. MIDDLE LAYER
- second layer of the eyeball - vascular & highly pigmented

A. CHOROID
- a dark brown membrane located between the sclera & the retina - it lines most of the sclera & is attached to the retina but can easily detach from the sclera - contains blood vessels that nourishes the retina - located posteriorly

VISION
B. MIDDLE LAYER
B. CILIARY BODY
- connects the choroid with the iris - secretes aqueous humor that helps give the eye its shape

C. IRIS
- the colored portion of the eye

- located in front of the lens


- it has a central opening called the pupil

VISION
INTERNAL STRUCTURES OF THE EYE
C. INNER LAYER (RETINA)
- a thin, delicate structure in which the fibers of the optic nerve are distributed - bordered externally by the choroid & sclera and internally by the vitreous - contains blood vessels & photoreceptors (cones & rods) - light sensitive layer

CONTAINS THE FOLLOWING STRUCTURES

1. CONES
- Specialized for fine discrimination, central vision & color vision - Functions at bright levels of illumination

2. RODS
- More sensitive to light than cones - Aid in peripheral vision - Functions at reduced levels of illumination

VISION
INTERNAL STRUCTURES OF THE EYE
2. FLUIDS OF THE EYE
A. AQUEOUS HUMOR
- Clear, watery fluid that fills the anterior & posterior chambers of the eye - produced by the ciliary processes, & the fluid drains in the Canal of Sclemm - The anterior chamber lies between the cornea & iris - the posterior chamber lies between the iris & lens - serves as refracting medium & provides nutrients to lens & cornea - contributes to maintenance of IOP

VISION
INTERNAL STRUCTURES OF THE EYE
2. FLUIDS OF THE EYE
B. VITREOUS HUMOR
- Clear, gelatinous/jell-like material that fill the posterior cavity of
the eye

- Maintains the form & shape of the eye


- Provides additional physical support to the eye - It is produced by the vitreous body

3. VITREOUS BODY
- contains a gelatinous substance that occupies the vitreous chamber which is the space between the lens & retina - transmits light & gives shape to the posterior eye

VISION
INTERNAL STRUCTURES OF THE EYE
4. OPTIC DISK
- a creamy pink to white depressed area in the retina
- the optic nerve enters & exits the eyeball in this area - Referred to as the BLIND SPOT - contains only nerve fibers - lack photoreceptors - insensitive to light

5. MACULA LUTEA
- Small, oval, yellowish pink area located lateral & temporal to the
optic disk - the central depressed part of the macula is the FOVEA CENTRALIS which is an area where acute vision occurs

VISION
INTERNAL STRUCTURES OF THE EYE
6. CANAL OF SCHLEMM
- a passageway that extends completely around the eye
- permits fluid to drain out of the eye into the systemic circulation so that a constant IOP is maintained

7. LENS
- A transparent circular structure behind the iris & in front of the vitreous body - Bends rays of light so that the light falls on the retina

8. PUPILS
- Control the amount of light that enters the eye & reaches the retina - Darkness produces dilation while light produces constriction

VISION
INTERNAL STRUCTURES OF THE EYE
9. EYE MUSCLES
- Muscles do not work independently but work in conjunction with the muscle that produces the opposite movement

A. RECTUS MUSCLES
- Exert their pull when the eye turns temporarily

B. OBLIQUE MUSCLES
- Exert their pull when the eye turns nasally

VISION
INTERNAL STRUCTURES OF THE EYE
10. NERVES
A. CRANIAL NERVE II
- Optic nerve (nerve of sight)

B. CRANIAL NERVE III


- Oculomotor

C. CRANIAL NERVE IV
- Trochlear

D. CRANIAL NERVE VI
- Abducens

VISION
INTERNAL STRUCTURES OF THE EYE
11. BLOOD VESSELS
A. OPTHALMIC ARTERY
- Major artery supplying the structures in the eye

B. OPTHALMIC VEINS
- Venous drainage occurs through vision

ASSESSMENT OF VISION
VISUAL ACUITY TEST
- measures the clients distance & near vision

SNELLEN CHART
- simple tool to record visual acuity - the client stands 20 ft from the chart & covers 1 eye and uses the other eye to read the line that appears more clearly - this procedure is repeated for the other eye - the findings are recorded as a comparison between what the client can read at 20 ft and the no. of feet normally required by an individual to read the same line

EXAMPLE: 20/50
- The client is able to read at 20 ft from the chart what a healthy eye can read at 50 ft

ASSESSMENT OF VISION
CONFRONTATIONAL TEST
- Performed to examine visual fields or peripheral vision - The examiner & the client sit facing each other - The test assumes that the examiner has normal peripheral vision

EXTRAOCULAR MUSCLE FUNCTION


- tests muscle function of the eyes
- tests 6 cardinal positions of gaze 1. Clients right (lateral position) 2. Upward & right (temporal position) 3. Down & right 4. Clients left (lateral position) 5. Upward & left (temporal position) 6. Down & left - client holds head still & asked to move eyes & follow a small object - the examiner looks for any parallel movements of the eye or for nystagmus - an involuntary rhythmic rapid twitching of the eyeballs

ASSESSMENT OF VISION
COLOR VISION TEST
- Tests for color vision which involve picking nos. or letters out of a complex & colorful picture

ISHIHARA CHART
- consists of nos. that are composed of colored dots located within a circle of colored dots - client is asked to read the nos. on the chart - each eye is tested separately - the test is sensitive for the diagnosis of red/green blindness but not effective for the detection of the discrimination of blue

PUPILS
- Increasing light causes pupillary constriction Decreasing light causes pupillary dilation - the client is asked to look straight ahead while the examiner quickly brings a beam of light ( penlight) in from the side & directs it onto the side - Constriction of the eye is a direct response to the light shining into the eye; constriction of the opposite eye is known as CONSENSUAL RESPONSE
- Normal: round & of equal size

DIAGNOSTIC TESTS FOR THE EYE


FLUORESCEIN ANGIOGRAPHY
- detailed imaging & recording of ocular circulation by a series of photographs after administration of the dye

PRE-OP NURSING CARE


Assess for allergies & previous reactions to dyes Obtain informed consent A mydriatic medication is instilled in the eye 1 hr. before the test The dye is injected into the vein of the clients arm Inform client that the dye may cause the skin to appear yellow for several hrs. after the test & this is gradually eliminated through the urine The client may experience N&V, sneezing, paresthesia of the tongue or pain at the injection site If hives appear, oral or IM antihistamines such as Diphenhydramine (Benadryl) are given as prescribed.

DIAGNOSTIC TESTS FOR THE EYE


FLUORESCEIN ANGIOGRAPHY
- detailed imaging & recording of ocular circulation by a series of photographs after administration of the dye

POST-OP NURSING CARE


Encourage rest. Encourage oral fluids. Remind the client that the yellow skin appearance will disappear Instruct the client that the urine will appear bright green until the dye is excreted Instruct the client to avoid direct sunlight for a few hrs after the test. Instruct the client that the photophobia will continue until pupil size returns to normal

DIAGNOSTIC TESTS FOR THE EYE COMPUTED TOMOGRAPHY


- a beam of x-ray scans the skull & orbits of the eye - a cross-sectional image is formed by the use of a computer - contrast material is not usually administered

NURSING CARE
No special client preparation or follow-up care required Instruct the client that he or she will be positioned in a confined space & need to keep the head still during the procedure

DIAGNOSTIC TESTS FOR THE EYE


SLIT LAMP
- allows examination of the anterior ocular structures under microscopic magnification - the client leans on a chin rest to stabilize the head while a narrow beam of light is aimed so that it illuminates only a narrow segment of the eye.

NURSING CARE
Explain the procedure to the client. Advise the client about the brightness of the light & the need to look forward at the point over the examiners ear

DIAGNOSTIC TESTS FOR THE EYE

CORNEAL STAINING
- installation of a topical dye into the conjunctival sac to outline the irregularities of the corneal surface that are not easily visible - the eye is viewed through a blue filter, and a bright green color indicates areas of non-intact corneal epithelium

NURSING CARE
If a client wears contact lenses, they must be removed The client is instructed to blink after the dye has been applied to distribute the dye evenly across the cornea

DIAGNOSTIC TESTS FOR THE EYE

TONOMETRY
- the test is primarily used to assess for an increase in IOP and potential glaucoma - NORMAL IOP: 8-21 mm Hg

NURSING CARE
Each eye is anesthetized. The client is asked to stare forward at a point above the examiners ear A flattened cone is brought in contact with the cornea The amount of pressure needed to flatten the cone is measured The client is instructed to avoid rubbing the eye following the examination if the eye has been anesthetized - the potential for scratching the cornea exists

DISORDERS OF THE EYE

Risk factors of eye disorders


AGING PROCESS CONGENITAL DIABETES MELLITUS HEREDITARY MEDICATIONS TRAUMA

LEGALLY BLIND
- a person is legally blind if the best visual acuity with corrective lenses in the better eye is 20/200 or less or a visual field of 20 degrees or less in the better eye

NURSING CARE
When speaking to a client who has limited sight or blind, the nurse uses a normal tone of voice Alert the client when approaching Orient the client to the environment Use a focal point & provide further orientation to the environment from the focal point Allow the client to touch objects in the room Use the clock placement of foods on the meal tray to orient the client Promote independence as much as possible

LEGALLY BLIND
NURSING CARE
Provide radios, TVs, & clocks that give the time orally or provide a Braille watch. When ambulating, allow the client to grasp the nurses arm at the elbow - the nurse keeps his or her arm close to the body so that the client can detect the direction of movement Instruct the client to remain one step behind the nurse when ambulating Instruct the client in the use of the cane used for the blind client, which is differentiated from other canes by its straight shape & white color with red tip Instruct the client that the cane is held in the dominant hand several inches off the floor Instruct the client that the cane sweeps the ground where the clients foot will be placed next to determine the presence of obstacles

CATARACTS
- an opacity of the lens that distorts the image projected onto the retina & that can progress to blindness - Intervention is indicated when visual acuity has been reduced to a level that the client finds to be unacceptable or adversely affecting lifestyle

CAUSES
Aging process (Senile cataracts) Inherited (Congenital cataracts) Injury (Traumatic cataracts) Can occur as a result of another eye disease (Secondary cataracts)

CATARACTS
ASSESSMENT
Opaque or cloudy white pupil Gradual loss of vision Blurred vision Decreased color perception Vision that is better in dim light with pupil dilation Photophobia Absence of red reflex

CATARACTS
MEDICAL MANAGEMENT
- surgical removal of the lens, one eye at a time - a lens implantation may be performed at the time of surgical procedure

EXTRACAPSULAR EXTRACTION
- the lens is lifted out without removing the lens capsule - may be performed with Phacoemulsion PHACOEMULSION - the lens is broken up by ultrasonic vibrations & extracted

INTRACAPSULAR EXTRACTION PARTIAL IRIDECTOMY


- the lens is removed within its capsule through a small incision - may be performed with lens extraction to prevent acute secondary glaucoma

CATARACTS
PRE-OP NURSING CARE
Instruct measures to prevent or decrease IOP Administer pre-op eye medications including mydriatics & cycloplegics as prescribed

POST-OP NURSING CARE


Elevate the head of the bed 30-45 degrees Turn the client to the back or un-operative side Maintain an eye patch & orient the client to the environment Position the clients personal belongings on the un-operative side Use side rails for safety Assist with ambulation

CATARACTS
CLIENT EDUCATION AFTER CATARACT SURGERY
Avoid eye straining Avoid rubbing or placing pressure on the eyes Avoid rapid movements, straining, sneezing, coughing, bending, vomiting, or lifting objects over 5 lbs Teach measures to prevent constipation Wipe excess drainage or tearing with a sterile wet cotton ball from the inner to the outward canthus Use an eye shield at bedtime If an eye implant is not performed, the eye cannot accommodate & glasses must be worn at all times Cataract glasses act as magnifying glasses & replace central vision only Cataract glasses magnify, & objects appear closer therefore teach client to judge distance & climb stairs carefully Contact lenses provide sharp visual acuity but dexterity is needed to insert them Contact the MD for any decrease in vision, severe eye pain or increase in eye discharge

GLAUCOMA
- increased IOP as a result of inadequate drainage of aqueous humor from the canal of Schlemm or over production of aqueous humor

- the condition damages the optic nerve & can result in blindness

TYPES
ACUTE CLOSED-ANGLE/NARROW ANGLE GLAUCOMA - results from obstruction to outflow to aqueous humor CHRONIC CLOSED-ANGLE GLAUCOMA - follows an untreated attack of acute close-angled glaucoma CHRONIC OPEN-ANGLE GLAUCOMA - results from an overproduction or obstruction to the outflow of aqueous humor ACUTE GLAUCOMA - a rapid onset of IOP > 50-70 mm Hg CHRONIC GLAUCOMA - a slow, progressive, gradual onset of IOP > 30-50 mm Hg

GLAUCOMA
ASSESSMENT
Progressive loss of peripheral vision followed by a loss of central vision Elevated IOP (Normal pressure is 10-21 mm Hg) Vision worsening in the evening with difficulty adjusting to dark rooms Blurred vision Halos around white lights Frontal headaches Photophobia Increased lacrimation Progressive loss of central vision

GLAUCOMA
NURSING CARE FOR ACUTE GLAUCOMA
Treat as medical emergency Administer medications as prescribed to lower IOP Prepare the client for peripheral iridectomy - allows aqueous humor to flow from the posterior to anterior chamber

NURSING CARE FOR CHRONIC GLAUCOMA


Instruct the client the importance of medications
a. MIOTICS: to constrict the pupils b. CARBONIC ANHYDRASE INHIBITORS: to decrease the production of aqueous humor c. BETA-BLOCKERS: to decrease the production of aqueous humor & IOP Instruct the client the need for life-long medication use Instruct the client to wear a Medic-Alert bracelet

GLAUCOMA
NURSING CARE FOR CHRONIC GLAUCOMA
Instruct the client to avoid anti-cholinergic medications Instruct the client to report eye pain, halos around eyes & changes of vision to the physician Instruct the client that when maximal medical therapy has failed to halt the progression of visual field loss & optic nerve damage, surgery will be recommended Prepare the client for TRABECULOPLASTY as prescribed - to facilitate aqueous humor drainage Prepare client for TRABECULECTOMY as prescribed - allows drainage of aqueous humor into the conjuctival spaces by the creation of an opening

RETINAL DETACHMENT
- occurs when the layers of the retina separate because of accumulation of fluid between them - also occurs when both retinal layers elevate away from the choroid as a result of a tumor

TYPES
PARTIAL RETINAL DETACHMENT
- becomes complete if left untreated

COMPLETE RETINAL DETACHMENT


- when detachment is complete, blindness may occur

RETINAL DETACHMENT
ASSESSMENT
Flashes of light Floaters Increase in blurred vision Sense of curtain being drawn Loss of a portion of the visual field

RETINAL DETACHMENT
IMMEDIATE NURSING CARE
Provide bedrest
Cover both eyes with patches to prevent further detachment Speak to the client before approaching Position the clients head as prescribed Protect the client from injury Avoid jerky head movements Minimize eye stress Prepare the client for surgical procedure as prescribed

RETINAL DETACHMENT
MEDICAL MANAGEMENT
- draining fluid from the subretinal space so that the retina can return to the normal position

SEALING RETINAL BREAKS BY CRYOSURGERY DIATHERMY


- a cold probe applied to the sclera to stimulate an inflammatory response leading to adhesions - the use of electrode needle & heat through the sclera to stimulate an inflammatory response leading to adhesions

LASER THERAPY

SCLERAL BUCKLING
closing the tear

- to stimulate an inflammatory response to seal small retinal tears before the detachment occurs

- to hold the choroid & retina together with a splint until scar tissue forms

INSERTION OF A GAS OR SILICONE OIL

- to encourage attachment because these agents have a specific gravity less


than vitreous or air & can float against the retina

RETINAL DETACHMENT
POST-OP NURSING CARE
Maintain eye patches bilaterally as prescribed Monitor hemorrhage as prescribed Prevent N&V and monitor for restlessness which can cause hemorrhage Monitor for sudden, sharp eye pain (notify the MD stat) Encourage DBE but avoid coughing Provide bedrest for 1-2 days as prescribed If gas has been inserted, position as prescribed on the abdomen & turn the head so unaffected eye is down Administer eye medications as prescribed Assist client with ADL Avoid sudden head movements or anything that increases IOP Instruct the client to limit reading for 3-5 weeks Instruct client to avoid squinting, straining & constipation, lifting heavy objects & bending from the waist Instruct the client to wear dark glasses during the day & an eye patch at night Encourage follow-up care because of the danger of recurrence or occurrence in the other eye

STRABISMUS
- called SQUINT EYE or LAZY EYE
- a condition in which the eyes are not aligned because of lack of muscle coordination of the extraocular muscles

- most often results from muscle imbalance or paralysis of extraocular muscles, but may also result from conditions such as brain tumor, myasthenia gravis or infection - normal in young infant but should not be present after about age 4 months

ASSESSMENT
Amblyopia if not treated early
Permanent loss of vision if not treated early

Loss of binocular vision


Impairment of depth perception Frequent headaches Squints or tilts head to see

STRABISMUS
NURSING CARE
Corrective lenses as indicated Instruct the parents regarding patching (occlusion therapy) of the good eye - to strengthen the weak eye Prepare for botulinum toxin (Botox) injection into the eye muscle - produces temporary paralysis - allows muscles opposite the paralyzed muscle to strengthen the eye Inform the parents that the injection of botulinum toxin wears off in about 2 months & if successful, correction will occur Prepare for surgery to realign the weak muscles as Rx if nonsurgical interventions are unsuccessful Instruct the need for follow-up visits

CONJUNCTIVITIS
- also known as PINK EYE
- inflammation of the conjunctiva - usually caused by allergy, infection, or trauma

TYPES
BACTERIAL OR VIRAL CONJUNCTIVITIS
- extremely contagious

CHLAMYDIAL CONJUNCTIVITIS
- is rare in older children & if diagnosed in a child who is not sexually
active, the child should be assessed for possible sexual abuse

ASSESSMENT
Itching, burning or scratchy eyelids
Redness
Edema Discharge

CONJUNCTIVITIS
NURSING CARE
Instruct in infection control measures such as good handwashing & not sharing towels & washcloths Administer antibiotic or antiviral eye drops or ointment as Rx if infection is present

Administer antihistamines as Rx if an allergy is present


Instruct the parents that the child should be kept home from school or day care until antibiotic eye drops have been administered for 24 hrs Instruct in the use of cool compresses to lessen irritation & in wearing dark glasses for photophobia Instruct the child to avoid rubbing the eye to prevent injury D/C use of contact lenses & to obtain new lenses to eliminate the chance of re-infection Instruct the adolescent that eye make-up should be discarded & replaced

HYPHEMA
- the presence of blood in the anterior chamber - occurs as a result of injury - condition usually resolves in 5-7 days

NURSING CARE
Encourage rest in semi-Fowlers position Avoid sudden eye movements for 3-5 days to decrease bleeding Administer cycloplegic eye drops as prescribed - to place the eye at rest Instruct in the use of eye shields or eye patches as prescribed Instruct the client to restrict reading & watching TV

CONTUSIONS
- bleeding into the soft tissue as a result of an injury - causes a black eye & the discoloration disappears in approximately 10 days - pain, photophobia, edema & diplopia may occur

NURSING CARE
Place ice on the eye immediately Instruct the client to receive an eye examination

FOREIGN BODIES
- an object such as dust that enters the eye

NURSING CARE
Have the client look upward, expose the lower lid, wet a cottontipped applicator with sterile NSS & gently twist the swab over the particle & remove it If the particle cannot be seen, have the client look downward, place a cotton applicator horizontally on the outer surface of the upper eye lid, grasp the lashes, & pull the upper lid outward & over the cotton applicator, if the particle is seen, gently twist over it to remove

PENETRATING OBJECTS
- an injury that occurs to the eye in which an object penetrates the eye

NURSING CARE
Never remove the object because it may be holding ocular structures in place, the object must be removed by MD Cover the object with a cup Dont allow the client to bend Dont place pressure on the eye Client is to be seen by MD stat

CHEMICAL BURNS
- an eye injury in which a caustic substance enters the eye

NURSING CARE
Treatment should begin stat Flush the eyes at the site of injury with water for at least 15-20 mins At the site of injury, obtain a small sample of the chemical involved At the ER, the eyes is irrigated with NSS or an opthalmic irrigation solution The solution is directed across the cornea & toward the lateral canthus Prepare for visual acuity assessment Apply an antibiotic ointment as prescribed Cover the eye with a patch as prescribed

ENUCLEATION
- removal of the entire eyeball

EXENTERATION
- removal of the eyeball & surrounding tissues Performed for the removal of ocular tumors After the eye is removed, a ball implant is inserted to provide a firm base for socket prosthesis & to facilitate the best cosmetic result A prosthesis is fitted approximately 1 month after surgery

PRE-OP NURSING CARE


Provide emotional support to the client Encourage the client to verbalize feelings related to loss

POST-OP NURSING CARE


Monitor V/S Assess pressure patch or dressing Report changes in V/S or the presence of bright red drainage on the pressure patch or dressing

ORGAN DONATION
DONOR EYES
Obtained from cadavers Must be enucleated soon after death due to rapid endothelial cell death Must be stored in a preserving solution Storage, handling & coordination of donor tissue with surgeons is provided by a network of state eye bank associations across the country

ORGAN DONATION
CARE OF THE DECEASED CLIENT AS A POTENTIAL EYE DONOR
Discuss the option of eye donation with MD & family Raise the head of the bed 30 Instill antibiotic eye drops as RX Close the eyes & apply a small ice pack to the closed eyes

ORGAN DONATION
PRE-OP CARE OF THE RECIPIENT
Recipient may be told of the tissue availability only several hrs to 1 day before surgery Assist in alleviating client anxiety Assess for signs of eye infection Report the presence of any redness, watery or purulent drainage or edema around the eyes to MD Instill antibiotic drops into the eyes as Rx to reduce the no. of microorganisms present Administer IV fluids & medications as Rx

ORGAN DONATION
POST-OP CARE TO THE RECIPIENT
Eye is covered with a pressure patch and protective shield that are left in place until the next day Dont remove or change the dressing without the MDs order Monitor V/S, LOC & assess dressing Position the client on unoperative side to reduce IOP Orient the client frequently Monitor for complications of bleeding, wound leakage, infection & graft rejection Instruct the client in how to apply the patch & eye shield Instruct the client to wear the eye shield at night for 1 month & whenever around small children or pets

GRAFT REJECTION
Can occur at anytime Inform the client of signs of rejection Signs include redness, swelling, decreased vision, & pain (RSDP) Treated with topical steroids

OPTHALMIC AND OTIC MEDICATIONS

INSTALLATION OF EYE DROPS

EYE DROPS
Wash hands Put on gloves Check the name, strength, & expiration date of the medication Instruct the client to tilt the head backward, open the eyes & look up Pull the lower lid down against the cheekbone Hold the bottle, gently rest the wrist of the hand on the clients cheek Squeeze the bottle gently to allow the drop to fall into the conjunctival sac Instruct the client to close the eyes gently & not to squeeze the eyes shut Wait 3-5 minutes before instilling another drop, if more than 1 is Rx - to promote maximal absorption of the medication Dont allow the medication bottle, dropper, or applicator to come in contact with the eyeball

Installation of eye medications


EYE OINTMENTS
Hold the ointment tube near, but not touching, the eye or eyelashes Squeeze a thin ribbon of ointment along the lining of the lower conjunctival sac from the inner to the outer canthus Instruct the client to close the eyes gently Instruct the client that vision may be blurred by the ointment

MYDRIATICS, Cycloplegic & anticholinergic medications MYDRIATICS


- dilate the pupils (mydriasis)

CYCLOPLEGIA
- relax the ciliary muscles

ANTICHOLINERGICS
- block responses of the sphincter muscle in the ciliary body, producing mydriasis

MYDRIATICS, Cycloplegic & anticholinergic medications


- used pre-op or for eye examinations to produce mydriasis - C/I in clients with glaucoma because of the risk of increased IOP - Mydriatics are C/I in cardiac dysrhythmias & cerebral atherosclerosis & should be used with caution in the elderly and in clients with prostatic hypertrophy, diabetes mellitus or parkinsonism

MYDRIATICS & Cycloplegic eye medications

EXAMPLES
Atropine sulfate (Isopto-Atropine, Ocu-Tropine, Atropair, Atropisol)

Scopolamine hydrobromide (Isopto-Hyoscine) Cyclopentolate hydrochloride (Cyclogyl, AK-Pentolate, Pentolair) Homotropine hydrobromide (Isopto Homatrine, AK-Homatropine, Spectro-Homatrine) Tropicamide (Mydriacyl, I-Picamide, Tropicacyl) Phenylephrine hydrochloride (AK-Dilate, Dilatair, Mydfrin, Ocu-Phrin)

MYDRIATICS, Cycloplegic & anticholinergic medications


SIDE EFFECTS
Tachycardia Photophobia Conjunctivitis Dermatitis

ATROPINE TOXICITY
Dry mouth

Blurred vision Photophobia Tachycardia Fever Urinary retention Constipation Headache, brow pain Confusion Hallucinations, delirium Coma Worsening of narrow-angled glaucoma

SYSTEMIC REACTIONS OF ANTICHOLINERGICS


Dry mouth & skin Fever Thirst Confusion Hyperactivity

ALPHA-ADRENERGIC BLOCKER
- example Dapiprazole hydrochoride (Rev-Eyes) - used to counteract mydriasis

MYDRIATICS, Cycloplegic & anticholinergic medications


NURSING CARE
Monitor for allergic reactions Assess for risk of injury Assess for constipation & urinary retention Instruct the client that a burning sensation may occur on installation Instruct the client not to drive or operate machine for 24 hrs after installation of the medication unless otherwise directed by the physician Instruct the client to wear sunglasses until the effects of the medication wear off Instruct to notify MD if blurring of vision, loss of sight, difficulty in breathing, sweating or flushing occurs Instruct the client to report eye pain to the physician

ANTI-INFECTIVE EYE MEDICATIONS


- Kill or inhibit the growth of bacteria, fungi, & viruses

SIDE EFFECTS
Superinfection Global irritation

NURSING CARE
Assess for risk of injury

Instruct the client in how to apply the eye medication


Instruct the client to continue treatment as Rx Instruct the client to wash hands thoroughly & frequently Advise the client that if improvement does not occur, notify the MD

ANTI-INFECTIVE EYE MEDICATIONS


ANTIBACTERIAL
Chloramphenicol (Chloromycetin, Chloroptic) Ciprofloxacin hydrochloride (Cipro) Erythromycin (Ilotycin)

Gentamicin sulfate (Garamycin, Genoptic)


Norfloxacin (Chibroxin) Tobramycin (Nebcin, Tobrex) Silver nitrate 1%

ANTIFUNGAL
Natamycin (Natacyn Opthalmic)

ANTIVIRAL
Idoxuridine (Herplex-Liquifilm) Trifluridine (Viroptic) Vidarabine (Vira-A Opthalmic)

ANTI-INFLAMMATORY EYE MEDICATIONS


- Control inflammation, thereby reducing vision loss & scarring - Used for uveitis, allergic conditions, & inflammation of the conjunctiva, cornea, & lids

SIDE EFFECTS
Cataracts Increased IOP Impaired healing Masking S/S of infection

NURSING CARE
Assess for risk of injury Instruct the client in how to apply the eye medication Instruct the client to continue treatment as Rx Instruct the client to wash hands thoroughly & frequently Advise the client that if improvement does not occur, notify the MD Note that dexamethasone (Maxidex) should not be used for eye abrasions & wounds

ANTI-INFLAMMATORY EYE MEDICATIONS EXAMPLES


Dexamethasone (Maxidex) Diclofenac (Voltaren) Flurbiprofen Na (Ocufen) Suprofen (Profenal) Ketorolac tromethamine (Acular)

Prednisone acetate (Predforte, Econopred)


Prednisolone Na phosphate (AK-Pred, Inflamase) Rimaxolone (Vexol)

TOPICAL ANESTHETICS FOR THE EYE


- Produce corneal anesthesia - Used for anesthesia for eye examinations, for surgery, or to remove foreign bodies from the eye

SIDE EFFECTS
Temporary stinging or burning of the eye Temporary loss of corneal reflex

NURSING CARE
Assess for risk of injury Note that the medications should not be given to the client for home use & are not to be self-administered by the client Note that the blink reflex is temporarily lost & that the corneal epithelium needs to be protected Provide an eye patch to protect the eye from injury until the corneal reflex returns

TOPICAL ANESTHETICS FOR THE EYE EXAMPLES


Proparacaine HCl (Ophthaine, Opthenic)
Tetracaine HCl (Pontocaine)

EYE LUBRICANTS
- Replace tears or add moisture to the eyes

- Moisten contact lenses or an artificial eye


- Protect the eyes during surgery or diagnostic procedures - Used for keratitis, during anesthesia or in a disorder that results in unconsciousness or decreased blinking

SIDE EFFECTS
Burning in installation Discomfort or pain in installation

NURSING CARE

Inform the client that burning may occur on installation Be alert to allergic responses to the preservatives in the lubricants

EYE LUBRICANTS
EXAMPLES
Hydroxypropyl methylcellulose (Lacril, Isopto Plain) Petroleum-based ointment (Artificial Tears, Liquifilm Tears)

MIOTICS
- reduce IOP by constricting the pupil & contracting the ciliary muscle,
thereby increasing the blood flow to the retina & decreasing retinal damage & loss of vision - open the anterior chamber angle & increase the outflow of aqueous humor - used for chronic open-angle glaucoma or acute & chronic closed-angle glaucoma - used to achieve miosis during eye surgery - C/I in clients with retinal detachment, adhesions between the iris & lens, or inflammatory diseases - used with caution in clients with asthma, hypertension, corneal abrasion,hyperthyroidism, coronary vascular disease, urinary tract obstruction, GI obstruction, ulcer disease, parkinsonism, or bradycardia

MIOTICS
MIOTIC CHOLINERGIC MEDS
- reduce IOP by mimicking the action of acetylcholine

MIOTIC ACETYLCHOLINE INHIBITORS MEDS


- reduce IOP by inhibiting the action of cholinesterase

MIOTICS
SIDE EFFECTS
Myopia Headache Eye pain

SYSTEMIC EFFECTS
Flushing Diaphoresis GI upset & diarrhea Frequent urination Increased salivation Muscle weakness Respiratory difficulty

Decreased vision in poor light


Local irritation

TOXICITY
Vertigo & syncope Bradycardia Hypotension Cardiac dysrhythmias Tremors Seizures

MIOTICS
EXAMPLES
Acethylcholine Cl (Miochol) Carbachol (Miostat) Pilocarpine HCl (Isopto Carpine, Pilocar) Pilocarpine nitrate (Pilofrin, Liquifilm, Pilagan) Echothiophate iodide (Phospholine iodide) Demecarium bromide (Humorsol) Isoflurophate (Floropryl)

MIOTICS
NURSING CARE
Assess V/S & risk of injury Assess the client for the degree of diminished vision Monitor S/E & toxic effects Monitor for postural hypotension & instruct the client to change positions slowly Assess breath sounds for rales & rhonchi - cholinergic meds cause bronchospasms & increased bronchial secretions Maintain oral hygiene - due to increased salivation Have Atropine sulfate available as antidote for Pilocarpine Instruct the client regarding the correct administration of eye meds Instruct the client not to stop the meds suddenly

Instruct to avoid activities such as driving while vision is impaired


Instruct clients with glaucoma to read labels on OTC meds & to avoid Atropine-like meds - Atropine increase IOP

OCUSERT SYSTEM
Its a thin eye wafer (disk) impregnated with time-release Pilocarpine Devised to overcome the frequent application of Pilocarpine Placed in the upper or lower cul-de-sac of the eye Pilocarpine is released over 1 wk & disk is replaced every 7 days Drawbacks of its use include sudden leakage of Pilocarpine, migration of the system over the cornea, & unnoticed loss of the system

NURSING CARE

Assess the clients ability to insert the medication disk


Store the medication in the refrigerator Instruct the client to discard damage or contaminated disks Inform the client that temporary stinging is expected but to notify MD if blurred vision or brow pain occurs Instruct the client to check for the presence of the disk in the conjunctival sac daily qHS & upon arising Since vision may change in the first few hours after the eye system is inserted, instruct the client to replace the disk at bedtime

BETA-ADRENERGIC BLOCKING EYE MEDICATIONS


- Reduce IOP by decreasing sympathetic impulses & decreasing aqueous humor production without affecting accommodation or pupil size - Used to treat chronic open-angle glaucoma - C/I in the client with asthma - systemic absorption can cause increased airway resistance - Used with caution in the client receiving oral beta-blockers

SIDE EFFECTS
Ocular irritation

Visual disturbances
Bradycardia Hypotension Bronchospasm

BETA-ADRENERGIC BLOCKING EYE MEDICATIONS

EXAMPLES
Betaxolol HCl (Betoptic) Carteolol HCl (Ocupress) Levobunolol HCl (Betagan) Metipranolol (Optipranolol) Timolol maleate (Timoptic)

BETA-ADRENERGIC BLOCKING EYE MEDICATIONS


NURSING CARE
Monitor V/S before administering medication esp. BP & PR If the pulse is below 60 or if systolic BP is below 90 mm Hg, withhold the medication & contact MD Monitor for shortness of breath and I&O Assess for risk of injury

Instruct the client to notify MD if shortness of breath occurs


Instruct not to D/C medication abruptly Instruct to change positions slowly to avoid orthostatic hypotension Instruct to avoid hazardous activities

Instruct to avoid OTC meds without the MDs approval

ADRENERGIC EYE MEDICATIONS


- Decrease the production of aqueous humor & lead to a decrease in IOP - Used to treat glaucoma

ADRENERGIC MEDICATIONS
Apraclonidine HCl (Iopidine) Brimonidine tartrate (Alphagen)

Dipivefrin HCl (Propine)


Epinephrine borate (Epinal, Eppy) Epinephrine HCl (Epifrin, Glaucon)

CARBONIC ANHYDRASE MEDICATIONS


- Interfere with the production of carbonic acid which leads to decreased aqueous humor formation & decreased IOP
- Used for long-term treatment of open-angle glaucoma - C/I in the client allergic to sulfonamides

SIDE EFFECTS
Appetite loss GI upset Paresthesias in the fingers, toes & face Polyuria Hypokalemia Renal calculi Photosensitivity Lethargy & drowsiness Depression

CARBONIC ANHYDRASE MEDICATIONS


NURSING CARE
Monitor V/S Assess visual acuity Assess for risk of injury Monitor I&O Monitor weight Maintain oral hygiene Monitor for side effects such as lethargy, anorexia, drowsiness, polyuria, nausea, & vomiting Monitor electrolytes for hypokalemia Increase fluid intake unless C/I Advise the client to avoid prolonged exposure to sunlight Encourage the client to use artificial tears for dry eyes Instruct not to D/C the medication abruptly Instruct to avoid hazardous activities while vision is impaired

OSMOTIC MEDICATIONS
- Lower IOP - Used in emergency treatment of acute closed-angle glaucoma

- Used pre-op & post-op to decrease vitreous humor volume

SIDE EFFECTS
Heache Nausea, vomiting, diarrhea Disorientation Electrolyte imbalance

NURSING CARE
Monitor weight and I&O Monitor electrolytes

Assess V/S, visual acuity & risk for injury

Increase fluid intake unless C/I Monitor for changes in level of orientation

OSMOTIC EYE MEDICATIONS


EXAMPLES
Glycerin (Glyrol, Osmoglyn) Mannitol (Osmitrol) Urea (Ureaphil)