CHAPTER 11

Kenneth M. Sabido, RN, MN

ASSESSMENT and

MANAGEMENT OF

PATIENT WITH EYE AND

VISION DISORDERS
LEARNING OBJECTIVES:

On completion of this chapter, the learner will be able to:

1. Identify the major structures and function of the eye.

2. Specify assessment and diagnostic findings used in the evaluation of
ocular disorders.
3. Describe assessment and management strategies for patients with low
vision and blindness.
4. List the pharmacologic actions and nursing management of common
ophthalmic medications.
5. Recognize the clinical features, assessment and diagnostic findings,
and medical or surgical management of glaucoma, cataracts, and
other ocular disorders.
6. Explain the nursing management of patients with glaucoma, cataracts,
and ocular trauma.
7. Discuss general discharge education for patients after ocular surgery.
 ASSESSMENT OF THE EYE:
Anatomic and Physiologic Overview
External Structures of the Eye
Extraocular Muscles
Visual Pathways
THE EYE
The outer layer or tunic
sclera, or white, and cornea
fibrous and protective.
The middle tunic layer
choroid, ciliary body and the iris
vascular.

The innermost layer

the retina
nervous or sensory.
THE EYE
External or fibrous = protective
Sclera
 outer white fibrous coat
 maintain shape
 protect inner structures
Cornea or horny body
 the anterior transparent curved
1/6 portion.
Vascular, middle coat (Oveal tract)
Choroid
thin, vascular, pigmented layer
maintain nutrition of eye
Ciliary body
most anterior vascular tunic with an
opening called pupil.
Innermost tunic – nervous layer
Retina – delicate grayish, transparent;
contains 2 cells:
Rods – dark vision
Cones – color vision in bright light
Refracting Media of the Eye:
Cornea
– clear luminous first refracting
media
Aqueous humor
– clear, serous, alkaline
Lens
Important Visual Reflexes
Accommodation reflex
designed to focus the image
sharply in the retina
ability of the lens to change in
curvature to focus images of
far/near vision
Convergence reflex
to ensure image is focused to
corresponding points.

Light reflex
to regulate the entrance of light
to perceive effectively.
Cross-Section of the Eye
Assessment and Evaluation of
Vision
 Ocular history - Pertinent questions to
ask when taking an ocular history.

 Visual acuity
 Snellen chart
 Record each eye
 20/20 means the patient can
read the “20” line at a
distance of 20 feet
 Finger count or hand motion
Examination of the External
Structures
• Note any evidence of irritation, inflammatory
process, discharge, etc.
• Assess eyelids and sclera
• Assess pupils and pupillary response; use
darkened room
• Note gaze and position of eyes
• Assess extraocular movements
• Ptosis: drooping eyelid
• Nystagmus: oscillating movement of eyeball
Chalazion – granuloma of internal
meibomian gland
Pterygium – abnormal growth of the
conjunctival tissue on the sclera
Strabismus – “Cross eyes”
Esotropia – convergent
Exotropia – divergent
Hypertropia – vertical

Diplopia – “double vision”

Madorosis - loss of eyelashes
Dacrocystitis - inflammation of tear
gland
Epiphora - excessive watering
Hordeolum
“Stye” – acute inflammation of lid
margin; inflammation of sebaceous
gland at the lid margin involving the
lashes.
Test Pupillary Reactions to
Accommodation
 Holdyour finger about 10cm from the
patient's nose.

 Askthem to alternate looking into the

distance and at your finger.

 Observe the pupillary response in each

eye.
Test Pupillary Reactions to
Accommodation
 PERRLA is a common abbreviation that
stands for "Pupils Equal Round Reactive
to Light and Accommodation."

 Pupils with a diminished response to light

but a normal response to accommodation
(Argyll-Robertson Pupils) are a sign of
neurosyphilis.
Diagnostic
Evaluation
 Ophthalmoscopy
 Direct and indirect
 Examines the
cornea, lens and
retina
 Slit-lamp examination
 Color vision testing
 Amsler grid
 Ultrasonography
 Fluorescein and
indocyanine green
angiography
Diagnostic Evaluation
• Tonometry (Shiotz)
– Measures intraocular pressure
– Normal pressure: 12-22 mm Hg
• Gonioscopy
– Visualizes the angle of the anterior
chamber
• Perimetry testing
– Evaluates field of vision
– Scotomas: blind areas in the visual field
Impaired Vision
Refractive errors
– Can be corrected by lenses which focus
light rays on the retina
•Emmetropia: normal vision
•Myopia: nearsighted
•Hyperopia: farsighted
•Astigmatism: distortion due to irregularity
of the cornea
Eyeball shape determines visual acuity
in refractive errors
 Instillation Eye Drops
Nursing Action:
Two most important prerequisite to avoid errors:
- Identify ordered eye drop.
- Ascertain bottle that contain correct drug.
Check order for eye requiring medications.
OD (OCULUS DEXTER) – right eye
OS (OCULUS SINISTER) – left eye
OU (OCULUS UTERQUE/UNITAS) – both eyes
1. Cleanse eye first using cotton with sterile water – remove crust,
lacrimation, etc. from inner canthus to outer canthus.
2. Using forefinger, pull lower lid down gently – to expose cul-de-sac
Instruct to look forward.
3. Drop med. Into cento of lower lid.
4. Instruct gentle closure of lid, do not squeeze.
Note: Ointment application is similar to instillation of eye drops. Avoid
tube end to touch eye.
5. Record time, type, strength and amount of medication and eye
applied with.
Glaucoma
•A group of ocular conditions in which damage
to the optic nerve is related to increased
intraocular pressure (IOP) caused by
congestion of the aqueous humor
•The leading cause of blindness in adults in
the U.S.
•Incidence increases with age
 Pathophysiology of Glaucoma

•Normal Outflow of
Aqueous Humor
• In glaucoma, aqueous production
and drainage are not in balance.
• When aqueous outflow is blocked,
pressure builds up in the eye.
• Increased IOP causes irreversible
mechanical and/or ischemic
damage.
Types of Glaucoma
• Open-angle
– Chronic open angle glaucoma
– Normal tension glaucoma
– Ocular hypertension
• Angle-closure (pupillary block) glaucoma
– Acute angle-closure
– Subacute angle-closure
– Chronic angle-closure
• Congenital glaucomas and glaucoma secondary to other
conditions
Clinical Manifestations

“Silent thief”
•unaware of the condition until there is
significant vision loss; peripheral vision
loss, blurring, halos, difficulty focusing,
difficulty adjusting eyes to low lighting
•May also have aching or discomfort
around eyes or headache
 Diagnostic Findings

• Tonometry to assess
IOP
• Gonioscopy to assess
the angle of the
anterior chamber
• Perimetry to assess
vision loss
• Progression of visual field
defects
 Diagnostic Findings

• Tonometry to assess
IOP
• Gonioscopy to assess
the angle of the
anterior chamber
• Perimetry to assess
vision loss
• Progression of visual field
defects
Treatment
• Goal: To prevent further optic nerve damage
• Maintain IOP within a range unlikely to cause damage
• Pharmacologic therapy

• Surgery
– Laser tribeculoplasty
– Laser iridotomy
– Filtering procedures
– Tribeculectomy
– Drainage implants or shunts
Nursing Management
•Patient education.
•Focus on maintaining the therapeutic regimen
for lifelong control of a chronic condition.
•Emphasize the need for adherence to
therapy and continued care to prevent
further vision loss.
•Provide education regarding use and
effects of medications.
Nursing Management
•Medications used for glaucoma may
cause vision alterations and other side
effects.
•The action and effects of medications
need to be explained to promote
compliance.
•Provide support and interventions to
aid the patient in adjusting to vision
loss/potential vision loss.
Cataracts

•An opacity or cloudiness of the lens

•Increased incidence with aging; by age
80 more than half of all Americans
have cataracts
•A leading cause of disability in the U.S.
Cataract
Clinical Manifestations
• Painless, blurry vision
• Sensitivity to glare
• Reduced visual acuity
• Other effects include myopic shift, astigmatism,
diplopia (double vision), 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 Management
•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
patients are discharged soon afterward.
•Complications are rare but may be
significant.
Types of Cataract Surgery
•Intracapsular cataract extraction
(ICCE)
- removes entire lens, rarely done today

•Extracapsular cataract extraction (ECCE)

- maintains the posterior capsule of the lens,
reducing potential postoperative
complications
Types of Cataract Surgery
• Phacoemuslification
- an ECCE which uses an ultrasonic device to suction
the lens out through a tube; incision is smaller than
with standard ECCE

• Lens replacement
- after removal of the lens by ICCE or ECCE, the
surgeon inserts an intraocular lens implant (IOL).
This eliminates the need for aphakic lenses;
however, the patient may still require glasses.
Nursing Management
•Preoperative care
•Usual preoperative care for ambulatory
surgery
•Dilating eye drops or other medications as
ordered
•Postoperative care
•Patient teaching
•Provide written and verbal instructions
Nursing Management
•Instruct patient to call physician immediately
if vision changes; continuous flashing lights
appear; redness, swelling, or pain increase;
type and amount of drainage increases; or
significant pain is not relieved by
acetaminophen
Corneal Disorders
• Treatment of diseased corneal tissue
– Phototherapeutic keratectomy
– Keratoplasty
– Use of donor tissue for transplant
– Need for follow-up and support
– Potential graft failure; teach signs and symptoms
• Refractive surgery
– Elective procedures to recontour corneal tissue and
correct refractive errors
– Patient need counseling regarding potential
benefits, risks, and complications.
LASIK EYE SURGERY

- Laser-assisted in
situ keratomileusis
LASIK EYE SURGERY
Retinal Disorders
•Retinal detachment
•Retinal vascular disorders
– Central retina vein occlusion
– Branch retinal vein collusion
– Central retinal vein occlusion
– Macular degeneration
Retinal Detachment
•Separation of the sensory retina and
the RPE (retinal pigment epithelium)
Manifestations:
• sensation of a shade or curtain
coming across the vision of one eye,
bright flashing lights, sudden onset
of floaters.
Retinal Detachment
Diagnostic findings:
• assess visual acuity.
assessment of retina by:
• Indirect ophthalmoscope,
• Slit-lamp,
• Stereo fundus photography,
• Fluorescein angiography.
• Tomography and ultrasound may also be used.
Retinal Detachment
Surgical Treatment
•Scleral buckle
- is a piece of silicone sponge, rubber, or
semi-hard plastic that your eye doctor
(ophthalmologist) places on the outside of
the eye (the sclera, or the white of the
eye).
- The material is sewn to the eye to keep it
in place. The buckling element is usually
left in place permanently.
Scleral
Buckle
Surgical Treatment
• Pars plana vitrectomy
– Removal of vitreous locating the incisions at
the pars plana
– Frequently used in combination with
other procedures
• Pneumatic retinoplexy
– Injected gas bubble, liquid, or oil is used is
used to flatten the sensory retina against
the RPE
– Postoperative positioning is critical
Nursing Management
•Patient teaching
– Eye surgery is most often done as an
outpatient procedure so patient
education is vital
– Signs and symptoms of complications,
especially increased IOP and infection
•Promote comfort
•Patient may need to lie in a special
position with pneumatic retinoplexy
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;
and associated risk factors are diabetes
mellitus, glaucoma, and aging.
• Patient may report decreased visual acuity or
sudden loss of vision
Macular Degeneration

• Age-related macular degeneration (AMD)

• The most common cause of vision loss in
persons older than age 60
 Macular Degeneration
Types:
– Dry or nonexudative type; most common, 85–
90%
•Slow breakdown of the layers of the retinal with
the appearance of drusen. (small yellow deposits of fatty
proteins that accumulate under retina)
– Wet type
•May have abrupt onset
•Proliferation of abnormal blood vessels growing
under the retina—choroidal revascularization
(CNV)
Retina Showing
Drusen
&
AMD
Progression of
AMD:
Pathways to
Vision Loss
 Photodynamic Therapy for Slowing
Progression of AMD
Light-sensitive verteporfin dye
• is injected into vessels. A laser then activates
the dye, shutting down the vessels without
damaging the retina.
• The result is to slow or stabilize vision loss.
• Patient must avoid exposure to sunlight or bright
light for 5 days after treatment to avoid activation
of dye in vessels near the surface of the skin.
Nursing Management

•Patient teaching
•Supportive care
•Promote safety
•Recommendations to improve lighting,
magnification devices, and referral to
vision center to improve/promote
function
Trauma
• Prevention of injury
• Patient and public education
• Emergency treatment
– Flush chemical injuries
– Do not remove foreign objects
– Protect using metal shield or paper cup
• Potential causing blindness in for sympathetic
ophthalmia the uninjured eye with some injuries
Protective
Eye
Patches
Infectious and Inflammatory disorders
• Dry eye syndrome
• Conjunctivitis (“pink eye”)
– Classified by cause—bacterial, viral,
fungal, parasitic, allergic, toxic
– Viral conjunctivitis is contagious
• Uveitis - is a form of eye inflammation.
It affects the middle layer of tissue in
the eye wall (uvea). They include eye
redness, pain and blurred vision
• Orbital cellulitis
Orbital cellulitis
➢ It is an infection of the soft tissues and fat that hold the eye in its socket.
➢ This condition causes uncomfortable or painful symptoms. It's not
contagious, and anyone can develop the condition.
➢ most commonly affects young children and it is potentially dangerous
condition.
Hyperemia in Viral Conjunctivitis
 Ocular Consequences
of Systemic Disease
•Diabetic retinopathy
– Diabetes is a leading cause of blindness in
people age 20–74
•Ophthalmic complications associated with AIDS
•Eye changes associated with hypertension
Ophthalmic Medications
• Ability of the eye to absorb medication is limited.
• Barriers to absorption include the size of the conjunctival
sac, corneal membrane barriers, blood-ocular barriers,
and tearing, blinking, and drainage
• Intraocular injection or systemic medication may be
needed to treat some eye structures or to provide high
concentrations of medication.
• Topical medications (drops and ointments) are most
frequently used because they are least invasive, have
fewest side effects, and permit self administration.
Ophthalmic Medications
• Topical anesthetics
• Mydriatics (dilate) and cycloplegics (paralyze)
– Contraindicated with narrow angles or shallow anterior
chambers and inpatients on monoamine oxidase
inhibitors or tricyclic antidepressant
– May cause CNS symptoms and increased BP
especially in children or the elderly
• Anti-infective medications
– Antibiotic, antifungal, or antiviral products
Ophthalmic Medications
• Medications used for glaucoma
– Increase aqueous outflow or decrease aqueous
production
– May constrict the pupil and may affect ability to focus the
lens of the eye; affects vision
– May also may produce systemic effects
• Anti-inflammatory drugs; corticosteroid suspensions
– Side effects of long-term topical steroids include
glaucoma, cataracts, and increased risk of infection. To
avoid these effects, oral NSAID therapy may be used as
an alternate to steroid use
Low Vision and Blindness
• Low vision
– Visional impairment that requires devices and
strategies in addition to corrective lenses
– Best corrected visual acuity (BCVA) of 20/70 to
20/200
• Blindness
– BCVA 20/400 to no light perception
– Legal blindness is BCVA that does not exceed 20/200 in
better eye or widest filed of vision is 20 degrees or less
• Impaired vision often is accompanied by
functional impairment
Assessment of Low Vision
• History of Eye problem
• Examination of distance and near visual acuity,
visual field, contrast sensitivity, glare, color
perception, and refraction
• Special charts may be used for low vision
• Nursing assessment must include assessment of
functional ability, and coping and adaptation in
emotional, physical, and social areas
Management
• Support coping strategies, grief processes and acceptance
of visual loss
• Strategies for adaptation to the environment
– Placement of items in room
– “Clock method” for trays
• Communication strategies
• Collaboration with low-vision specialist, occupational therapy
or other resources
• Braille or other methods for reading/communication
• Service animals
Safety Measures and Teaching
Patient teaching 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 teaching after eye surgery or trauma
 Potential complications
 Loss of binocular vision with patch or vision
impairment of one eye; safety
 Use of eye patch and shield
 References:
 14th edition - 2014, 2010 Wolters Kluwer Health | Lippincott
Williams & Wilkins
 Janice L. Hinkle, Kerry H. Cheever Brunner & Suddarth’s
Medical-Surgical Nursing