Assessment and Management of Patients with Eye and Vision Disorders

Topic Outline
1. Anatomy and physiology of the eye
2. Assessment and Diagnostic test of the eye
3. Refractive errors, vision impairment, and blindness
4. Infectious and inflammatory conditions of the eyes
5. Ocular medication administration
6. Cataract
7. Glaucoma
8. Retinal Detachment

Learning Objectives
After going through this topic, you will be able to:
• Identify significant eye structures and describe their functions.
• Specify assessment and diagnostic findings used in the evaluation of ocular disorders.
• Describe assessment and management strategies for patients with low vision and blindness.
• Discuss clinical features, assessment and diagnostic findings, and medical or surgical management
of glaucoma, cataracts, and other ocular disorders.
• Describe the nursing management of patients with glaucoma, cataracts, and ocular trauma/retinal
detachment.
• Demonstrate instillation of eye drops and ointment, eye irrigation, patch application, and removal
of particles from the eye.
• Discuss general nursing management in eye surgery

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Introduction
The eyes are very complex structures that contain 70% of the sensory receptors of the body. Each eye is
a sphere measuring about 2.5 cm in diameter, surrounded and protected by a bony orbit and cushions of fat. The
primary function of the eye is to collect light from the environment and converts it into nerve impulses. The optic
nerve transmits these signals to the brain, which forms an image so thereby providing sight.
The eye is a sensitive, highly specialized sense organ subject to various disorders, many of which lead to
impaired vision. Impaired vision may affect a person’s independence in self-care, work and lifestyle choices, sense
of self-esteem, safety, ability to interact with society and the environment, and overall quality of life. Many of the
leading causes of visual impairment are associated with aging like cataracts and glaucoma. Younger people are
also at risk for eye disorders, particularly traumatic injuries.
This study guide aims to help you to promote the essential knowledge, skills, and attitude to provide
efficient, quality, and compassionate care among patients with eye disorders

Interesting Facts about the Eyes: Did you know that:

1. The eye is the second most powerful body part after the brain. It can develop about 36,000 bits of
information an hour and is composed of more than 2 million working parts.
2. The eyes focus on 50 different objects every second and can distinguish approximately 10 million
different colors. If the human eye was a digital camera, it would have 576 megapixels.
3. 80 percent of all learning comes through the eyes because memories are determined by what we see.
4. The eyes can detect a candle flame 1.7 miles away.
5. A fingerprint has 40 unique characteristics, but an iris (the colored part of your eye) has 256, a reason
retina scans are increasingly being used for security purposes.
6. The average person blinks 12 times a minute. A blink typically lasts 100-150 milliseconds.
7. The eye is the fastest contracting muscle in the body, contracting in less than 1/100th of a second.
8. The optic nerve contains more than one million nerve cells.
9. The cornea is the only part of the human body that has no blood supply; it gets oxygen directly
through the air.
10. An eye cannot be transplanted. More than 1 million nerve fibers connect each eye to the brain and
currently, we’re not able to reconstruct those connections.
11. Eyes heal quickly. With proper care, it takes only about 48 hours to repair a minor corneal scratch.
12. “Red eye” occurs in photos because light from the flash bounces off the back of the eye. The choroid
is located behind the retina and is rich in blood vessels, which make it appear red on film.

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 EYES
➢ External structures of the eye are the:
o Eyebrows: shade the eyes and keep perspiration away from them.
o Eyelids: thin, loose folds of skin that contain skeletal muscle that enables the eyelid to close; they
protect the eyes from foreign bodies, regulate the entry of light into the eye and distribute tears by
blinking.
o Eyelashes: short hairs that project from the top and bottom borders of the eyelids that help keep dust
out of the eyes; unexpected touch to the eyelashes initiates the blinking reflex to protect the eyes
from foreign objects.
o Conjunctiva: thin, transparent mucous membrane that lines the inner surfaces of the eyelids and folds
over the anterior surface of the eyeball; lubricates the eyes.
o Lacrimal gland: produce tears to lubricate, cleanse and moisten the eye’s surface.

➢ Anatomically, the eye can be divided into three layers, or coats (outer, middle, and inner). The outer,
protective layer consists of the:
o Sclera: white opaque, fibrous connective tissue.
o Cornea: the anterior continuation of the sclera, transparent and avascular.

➢ The middle, vascular layer (also known as the uveal tract) includes the:
o Choroid: a thin, pigmented membrane containing blood vessels that
supply the eye tissues.
o Ciliary body (muscle): the anterior continuation of the choroid
containing muscles that change the shape of the lens to focus vision.
o Iris: the central extension of the ciliary body consisting of two

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muscles and a central opening, the pupil, which constricts and dilates
to regulate the amount of light entering the eye’s interior (constrict
with strong light and near vision, dilates with dim light and far
vision).

➢ The inner, neural layer- the retina – contains layers of nerve cells, including
the rods and cones that translate light waves into neural impulses for
transmission to the brain.
➢ Refractive Media include the:
o Cornea
o Aqueous humor: watery fluid filling the eye’s anterior chamber that
serves as a refracting medium, maintains the hydrostatic intraocular pressure (IOP), and provides
nutrients to the lens and cornea. It is formed by capillaries in the ciliary body, flows anteriorly through
the pupil, and is reabsorbed by the Canal of Schlemm.
o Lens: a biconvex crystalline body located behind the pupil that changes the shape for accommodation
(focusing).
o Vitreous humor: a jellylike substance filling the posterior cavity behind the lens, acting as a refractive
medium, maintaining the shape of the eye and keeping the retina in place.

The Functions of the Eye

➢ Vision depends on the complex coordination of ocular structures that mediate the passage of light rays
reflected from an external object to the retina and transmit visual images to the brain for interpretation.
➢ In the retina, rods and cones convert the projected image into nerve impulses and transmit them to the optic
nerve.
➢ Impulses travel along the optic nerve to the brain’s optic chiasm and then to the cerebral cortex, where they
are interpreted as sight.

Vision: is the passage of rays of light from an object through the cornea, aqueous humor, lens, and vitreous
humor to the retina, and its appreciation in the cerebral cortex.

Emmetropia - normal visual acuity; no error of refraction.

Ametropia – subnormal visual acuity caused by some error of refraction, which is correctible by pair of lenses or
contact lenses. It has 2 types:
1. Myopia (Nearsightedness)
a. Light rays coming from an object at a distance of 20 feet or more are brought to a focus in front
of the retina.

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 b.
Nearsighted eye focuses images from a distant object in front of the retina because the eyeball is
too long or the lens is too thick.
c. Correction: concave lens to spread out light rays before they strike the eye.
2. Hyperopia (Farsightedness)
a. Light rays coming from an object at a distance of 20 feet or more are brought to focus in the back
of the retina.
b. Farsighted eye focuses light from near objects “behind” the retina because the eyeball is too short
or the lens too thin.
c. Correction: convex lens to converge light rays before they strike the eye.

Accommodation- adjustment of the shape of the lens to change the focus of the eye (brought about by
contraction of ciliary muscles)
Presbyopia (old sight)- the elasticity of the lens decreases with increasing age.
Astigmatism- uneven curvature of the cornea or lens that scatters light rays which prevents clear focus of the
light from any point on the retina.
Strabismus: Deviation of the eye so that the visual axes are not physiologically coordinated.

ASSESSMENT
1. Ocular history
a. Subjective data for eye assessment includes complaints of altered vision or other symptoms,
associated lifestyle and other factors, and recent and past health history.
b. Explore the chief complaint from the patient by asking the following questions:
i. Is there pain, foreign body sensation (scratchy, something in the eye), photophobia,
dryness, redness, itchiness, lacrimation, or drainage?
ii. Is there blurred vision, double vision, loss of vision, or change in vision in a portion of the

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visual field?
iii. Are there other visual symptoms such as glare, halos, or floaters?
iv. Is there difficulty in functioning, such as driving or reading, because of the visual problem?
External Examination
1. Visual Acuity: measurement of a person’s ability to see at a distance or near (reading distance) and is
measured against a standard of a normal person’s visual ability.
a. Visual Acuity at Distance (Snellen Chart)
▪ Composed of a series of progressively smaller rows of letters and objects, that can be seen
by the normal eye at a distance of 20 feet (6 m) from the chart.
▪ Test the right eye (OD) first and then the left eye (OS).
▪ Each eye is tested separately, with and without glasses whereas the non-testing eye is
completely occluded. Normal result: 20/20.
▪ A person who can identify letters of the size 20 at 20 feet is said to have 20/20 vision.
b. Visual Acuity at Near (Jaeger Chart or Rosenbaum pocket screener)
▪ Letters and objects are of different sizes that can be seen by the normal eye at a reading
distance of 14 inches from the chart.
▪ Letters appear in rows and are arranged, so the normal eye can read them at different levels
on the Jaeger chart.
2. Visual Fields: Determines function of optic pathways and identifies loss of visual field and functional
capacity.
a. Perimetry: measurement of the peripheral visual field; useful in detecting a decreased peripheral
vision in one or both eyes.
◼ The patient is seated 18-24 inches in front of the tester.
◼ The left eye is covered while the patient focuses with the right eye on a spot about 1 foot
from the eye.
◼ A tester object is brought in from the side at 15 degrees intervals, through complete 360
degrees.
◼ The patient signals when he sees the test object and again when the object disappears
through the 360 degrees.
3. Color vision Test: done to determine the person’s ability to perceive primary colors and shades of colors.
a. Equipment: Polychromatic plates- dots of primary colors printed on a background of similar dots
in a confusion of colors.
b. Procedure: Various polychromatic plates are presented to the patient. The pattern may be letters
or numbers that the normal eye can perceive instantly, but that is confusing to the person with a
perception defect.
c. Outcome: Color blindness—a person can’t perceive the figures; Red-green blindness—8% of
males, 0.4% of females; Blue-yellow blindness—rare.

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 4. Refraction: is a clinical measurement of the error of focus in the eye. The refractive state of the eye can
be determined by:
a. Objectively- via retinoscopy or by automatic refraction (a special instrument that measures,
computes, and prints out refraction errors of each eye.
b. Subjectively- trial of lenses to arrive at the best visual image.

Internal Examination
1. Ophthalmoscopic Examination
a. Direct ophthalmoscopy—uses a strong light reflected into the interior of the eye through an
instrument called an ophthalmoscope.
b. Indirect ophthalmoscopy—allows the examiner to obtain a stereoscopic view of the retina. The
light source is from a head-mounted light. The examiner views the retina through a convex lens
held in front of the eye and a viewing device on the head mount. The image appears inverted.
This method of examination allows the examiner to use binocular vision with depth perception and
a wider viewing field.
◼ Clinical significance: 1) Detection of the clarity of the media like cataracts, vitreous opacity,
and corneal scars; 2) Close examination for the pathologic changes in retinal blood vessels;
3) Examination of the choroids like tumors or inflammation; 4) Examination of the retina like
retinal detachment, scars, or exudates and hemorrhages.
2. Slit-lamp Examination
a. Special equipment that magnifies the cornea, sclera, and anterior chamber and provides oblique
views into the trabeculum for examination by the ophthalmologist.
b. Helps detect disorders of the anterior portion of the eye.
c. The room is generally darkened and the pupils are dilated.
d. The patient sits with their chin and forehead resting against equipment supports.

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3. Tonometry: measure the intraocular tension or pressure.
a. Tonometry is indicated as one of the measurements to screen for glaucoma.
b. Normal tension is considered less than or equal to 21 mm Hg
c. Tonometry techniques.
i. Goldmann Applanation tonometry. After the instillation of topical anesthesia, the cornea
is flattened by a known amount of pressure. The pressure necessary to produce this
flattening is equal to the IOP, counterbalancing the tonometer
ii. Schiotz tonometry (rarely used at present).
iii. Electronic tonometer that provides a digital reading of IOP, such as the Tono-Pen.
iv. Pneumatonometer or air applanation tonometry—requires no topical anesthesia and
measures tension by sensing deformation of the cornea in reaction to a puff of pressurized
air.

General Nursing Interventions in Eye Care

1. Ophthalmic medication administration.
a. Ensure that all eye medications are sterile.
b. Do not use unlabeled, cloudy, or discolored solutions.
c. Avoid contact with the eye to prevent contaminating the medication bottle or tube tip.
d. Treat each eye separately; treat the uninfected eye first to avoid cross-contamination.
2. Instillation of eye drops
a. Tilt the client’s head back slightly and using the forefinger, pull the lower lid down gently on the
cheekbone.
b. Have the client lookup
c. Resting your hand on the client’s forehead for support, to prevent eye injury during administration,
instill the prescribed amount of medication into the center of the lower lid.
d. Instruct patient to close eyes slowly but not to squeeze or rub them. Open eye.
e. Wipe off the excess solution with gauze or cotton balls from the inner cantus to the outer cantus.
3. Instillation of eye ointment
a. Follow the same basic procedure as for instilling eye drops
b. Squeeze out a 1/8-inch ribbon of ointment into the center of the conjunctival sac.
c. Instruct the patient to close their eye slowly but do not squeeze their lids tightly or rub them.
4. Self-instillation of eyedrops
a. Tilt head back
b. Using the forefinger, pull the lower lid down
c. With the other hand, hold the dropper horizontally and facing the top of the head.
d. Look up and instill 1 drop onto the lower lid.

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 5. Self-instillation of ointment: Follow the same procedure as for instilling eye drops. Ointment from the
ointment is gently squeezed as a ribbon of medication along the inner lower lid with care taken not to
touch the eye with the end of the tube. Have the client close the lid and roll the eye after instillation.
6. Eye/ocular irrigation.
Sterile equipment: an eyedropper, asepto bulb syringe, and prescribed solution or 1,000 mL of normal
saline solution.
a. Instruct the patient to tilt their head toward the side of the affected eye.
b. Evert the lower conjunctival sac.
c. Instruct the patient to look up; avoid touching the eye with equipment.
d. Allow irrigating fluid to flow from the inner cantus to the outer cantus along the conjunctival sac.
e. Use only enough force to flush secretion from the conjunctiva
f. Occasionally have the patient close his eyes.
g. Pat the eyes dry and dry the patient face with soft cotton.
7. Patch or dressing or application.
1. Have the client close both eyes during the patch application
2. Apply the patch and secure it with two strips of tape extending from the midforehead to the lateral
cheekbone
3. Never apply pressure unless prescribed; if pressure is indicated, use two or three pads and more
tape.
4. Never change an eye patch without the physician’s order.
8. Removing a Particle from the Eye
Typically, removing a foreign body from the eye is an uncomplicated first-aid measure.
a. As the patient looks upward, place your finger below the lower lid and pull downward to expose
the conjunctival sac.
b. Inspect for particles using light and magnifying lenses.

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c. Remove particles with a cotton-tipped applicator moistened in saline by gently wiping across the
conjunctival sac.
If no offending particle is found, proceed to the upper lid.
a. As the patient looks downward, place the cotton applicator horizontally on the upper lid and gently
pull the lid outward and upward over the applicator.
b. Remove particle if found and return eyelid to the neutral position.

GENERAL NURSING INTERVENTIONS IN EYE SURGERY

Preoperative Management
1. Explain expected preoperative procedures to reduce anxiety associated with the unfamiliar and
unexpected.
2. For the same reason, explain what to expect postoperatively (e.g., eye patch application, prescribed
positioning, activity restrictions, ophthalmic medication use, and measure to prevent an increase in IOP.

Postoperative Management
1. Take precautions to prevent IOP, such as:
a. Instructing the patient to lie down on the unoperated side
b. Avoiding constipation
c. Encouraging the patient to avoid sneezing or coughing.
d. Administering an antiemetic to a nauseous client to prevent vomiting
e. Washing the patient’s hair, when allowed with the neck hyperextended rather than flexed
f. Instruct the patient to avoid excessive exertion, such as lifting and pushing heavy objects
2. Take precautions to prevent injury, such as:
a. Orienting the client on the hospital environment
b. Keeping a call bell/light and other needed items within the client's reach and in a consistent place.
c. Keeping the bed in a low position with the side rails up
d. Providing adequate room light or dimming lights if the patient experience photophobia
e. Assisting the patient with ambulation if indicated
f. Advising the client not to rub the eyes to touch an eye patch
3. Instruct the patient to report any sharp pain or feelings of pressure in the eye, which may indicate
hemorrhage, increase IOP, or infection.
4. Promote mobility within postoperative restrictions; post any prescribed activity restrictions on the patient’s
bed.

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 5. Prevent sensory deprivation by providing sensory stimulation (e.g., talk to the client often, provide radio
or TV, encourage frequent visitation by family and friends).
6. Teach appropriate self-care measures, which may include:
a. Not removing the eye patch unless specifically ordered
b. Wearing eye shield at night or when lying down
c. Taking a sponge bath or shower without getting water o the face
d. Wearing dark glasses and dimming room lights if experiencing photophobia or using dilating drops
e. Using the prescribed medications.

INFLAMMATION OF THE EYE

Superficial Lid Infections
1. Blepharitis: inflammation of the margins of the eyelids. It can be caused by a staphylococcal infection, or
it may be seborrheic in origin.
Clinical manifestations are:
a. Irritation, burning, and itching of eyelid margins
b. Eye appears red-rimmed with mucus discharge and there is crusting of lid margins.
c. Lid margins may ulcerate, resulting in a loss of eyelashes.
2. Hordeolum (external sty): infection of eyelash follicle or sebaceous gland of the eyelid. Manifested by
painful, red swelling on the eyelid margin.
3. Chalazion (internal sty): inflammation of the meibomian (tarsal) gland. Manifested by painless, slow-
growing, hard, non-tender nodule or cyst on the eyelid.

Nursing Management
1. Cleanse lid margins by applying warm, moist compress for 5 minutes 3 to 4 times daily.

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2. Carefully wipe loose crusts away from lashes; apply ophthalmic antibacterial ointment and/ or drops as
directed.
3. Continue until the infection clears.
4. Advise the patient to keep his hands away from the eyes and wash his hands after eye care.
5. Chronic chalazion may require incision and curettage.

CONJUNCTIVITIS (PINKEYE)
Inflammation of the conjunctiva

Etiology
1. Allergy
2. Microbial infection [bacteria (streptococcus pneumoniae, haemophilus influenza, chlamydia &
staphylococcus aureus), virus (adenovirus & herpes simplex virus), fungus]
3. Trauma (physical or chemical)

Clinical Manifestation
1. General symptoms
a. Foreign body, scratchy or burning sensation
b. Itching and photophobia
2. Redness and eye pain
3. Lid edema
4. Discharge or exudate (purulent, mucopurulent, watery); lids are frequently stuck together with crusting
upon awakening.

Medical Management
1. Administer antibiotic or viral eye drops or ointment as prescribed if an infection is present. The infection
will clear quickly if treatment is instituted for a specific organism: 1-3 days versus 7-10 days.
2. Antihistamine as prescribed if an allergy is present
3. Irrigate the eye with saline to remove discharge. May use artificial tears for sandy sensation in the eye &
mild pain medication such as acetaminophen.

Nursing Management
1. Infection control measures such as good hand-washing & not sharing towels & washcloths
2. Infected employees & others must not be allowed to work/attend school until symptoms have resolved
3. Cold compresses to lessen irritation and soothe the pain

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 4. Wearing dark glasses for photophobia; eye patches are contraindicated
5. Instruct the child to avoid rubbing the eye to prevent injury
6. Discontinue the use of contact lenses & obtain new lenses to eliminate the chance of re-infection
7. Discard and replace all makeup articles

CATARACT
Opacity or cloudiness of the crystalline lens that impairs vision.
Predisposing Factors
1. Most commonly a result of the aging process, after 70 years of
age (senile cataract).
2. Occurrence at birth (congenital cataract).
3. Occasionally a result of disease or following trauma in young
individuals (traumatic cataract).

Pathophysiology
Altered nutrient metabolism within the lens
↓
Protein in the lens breaks down & loses transparency
↓
Lens becomes cloudy.
↓
Light rays cannot pass through the retina
↓
Visual loss

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Clinical Manifestations
1. Progressively worsening blurred or distorted vision; visual loss is gradual
2. Cloudy appearance lens. Previously dark pupils, progress to a milky white color.
3. Gradual and painless loss of vision.

Diagnostic Evaluation
1. Slit-lamp examination to provide magnification and visualize opacity of the lens.
2. Tonometry to determine IOP and rule out other conditions.
3. Direct and indirect ophthalmoscopy to rule out retinal disease.
4. Perimetry to determine the scope of the visual field (normal with cataract).

General Management
1. Surgical removal of the lens is indicated when a cataract interferes with activities and if it occurs in both
eyes. Surgery is done on only one eye at a time.
2. Done under local anesthesia (regional block or topical anesthesia). Preoperative medications produce
decreased response to pain and lessened motor activity.
3. Oral medications are given to reduce intraocular pressure
4. Intraocular lens implants are implanted at the time of cataract extraction.

Surgical Procedures
1. Two types of extractions
a. Intracapsular Extraction- the lens, as well as the capsule, are removed through a small incision.
b. Extracapsular- the lens capsule is incised, and the lens is extracted or lifted without disturbing the
membrane.

Two Types of procedures for extraction

1. Phacoemulsification surgery- the mechanical breaking up (emulsifying) of the lens by a needle vibrating
at ultrasonic speed. The emulsified particles of the lens is then flushed (irrigated) and aspirated out into
tiny pieces
2. Cryosurgery- a special technique in which a pencil-like instrument with a metal tip is supercooled (-35
C), then is touched to the exposed lens, freezing to it so that the lens is easily lifted out.

Intraocular Lens Implantation

▪ The implantation of a synthetic lens is designed for distance vision; the patient may wear prescription
glasses for reading and near vision.

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 ▪ Advantages of the IOL include:
1. Provides an alternative for the person who cannot wear contact lenses.
2. Cannot be lost or misplaced like conventional glasses.
3. Provides superior vision correction and better depth perception than glasses.
▪ Complications (specific to implantation)
1. Pain from inflammation of various eye structures – usually controlled by NSAIDs.
2. Rosy vision (glare) because of keeping pupil from full constriction.
3. Mispositioning or dislocation of the lens

Nursing Diagnoses
1. Deficient Knowledge of operative course.
2. Delayed Surgical Recovery related to complications.

Nursing Interventions
1. Preparing the Patient for Surgery
a. Orient the patient and explain procedures and plan of care to decrease anxiety.
b. Instruct the patient not to touch their eyes to decrease contamination.
c. Obtain conjunctival cultures, if requested, using an aseptic technique.
d. Administer preoperative eye drops
• Antibiotic
• Mydriatic-cycloplegic [Phenylephrine hydrochloride (Neo-Synephrine) Atropine sulfate]
• Other medications—mannitol solution IV, sedative, antiemetic [prochlorperazine (Compazine),
hydroxyzine (Vistaril)], and opioid [meperidine (Demerol)], as directed.
2. Preventing Complications Postoperatively
a. Medicate for pain, as prescribed, to promote comfort.

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b. Administer medication to prevent nausea and vomiting, as needed.
c. Notify the health care provider of sudden pain associated with restlessness and increased pulse, which
may indicate increased IOP, or fever, which may indicate infection.
d. Caution the patient against coughing or sneezing to prevent increased IOP.
e. Advise the patient against rapid eye movement or bending from the waist to minimize IOP. The patient
may be more comfortable with the head elevated 30 degrees and lying on the unaffected side.
f. Allow the patient to ambulate as soon as possible and resume independent activities.
g. Assist the patient in maneuvering through the environment with the use of one eye while the eye
patch is on (1 to 2 days).
h. Encourage the patient to wear an eye shield at night to protect the operated eye from injury while
sleeping.

Patient Education
1. Promoting Independence
a. Orient the patient to his room and personal items.
b. Gradually increase the patient activities each day, as tolerated.
c. Caution the patient to avoid any strain on the eye (e.g., lifting heavy objects, straining at defecation,
and strenuous activity) for up to 6 weeks, as directed.
d. Demonstrate to the patient and family members how to administer medication (drop or ointment
instillation).
2. Convalescence Expectation
a. Apply a plastic shield over the eye at night.
b. Use dark glasses after eye dressing is removed to provide comfort from photophobia because of lack
of pupil constriction from mydriatic–cycloplegic drops.
3. Becoming Familiar with Intraocular Lens
a. Both the operated eye and the unoperated eye can work together after cataract surgery with lens
implantation.
b. No eyeglasses are required for distance but may be needed for reading and writing.
c. Caution against straining of any type.
d. Sponge bath is recommended for bathing.
e. Avoid tilting head forward when washing hair; tilt head slightly backward.

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 RETINAL DETACHMENT
Separation of the retina from the choroids in the posterior eye or detachment
of the sensory area of the retina (rods and cones) from the pigmented epithelium of
the retina.

Etiology and Incidence

➢ Trauma, age-related degenerative changes in the retina, tumor, or cataract
removal.
➢ Diabetic retinopathy commonly leads to retinal degeneration and tears disrupting
the integrity of the retina
➢ It mostly affects people older than age 40

Pathophysiology
Tear in the retina
↓
Vitreous humor seeps in between the retina & choroid layer
↓
Separation of the retina from the choroid layer
↓
Disruption of choroidal blood supply to the retina
↓
Visual deficits
(Detachment may be partial, causing varying degrees of visual deficits, or total blindness in the affected eye)

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Clinical Manifestation
1. Recurrent flashes of light
2. Floating spots
3. A sensation of a veil-like or curtain-like coating coming down, coming up, or sideways in front of the eye
when detachment is extensive.
4. Unless the retinal holes are sealed, the retina will progressively detach; ultimately, there will be a loss of
central vision as well as peripheral vision, leading to legal blindness

Diagnostic Evaluation: Indirect ophthalmoscopy shows gray or opaque retina. The retina is normally transparent.
General Management
1. Sedation, bed rest, and an eye patch may be used to restrict eye movements.
2. Surgical intervention is the only treatment.
3. Return of visual acuity with a reattached retina depends on: the amount of retina detached before surgery,
whether the macula (area of central vision) was detached, the length of time the retina was detached’’ &
the amount of external distortion caused by the scleral buckle.

Surgical Procedures
1. Photocoagulation: a light beam (either laser or xenon arc) is passed through the pupil, causing a small
burn and producing an exudate between the pigment epithelium and retina.
2. Electrodiathermy: an electrode needle is passed through the sclera to allow subretinal fluid to escape. An
exudate forms from the pigment epithelium and adheres to the retina.
3. Cryosurgery or retinal cryopexy: a supercooled probe is touched to the sclera, causing minimal damage;
as a result of scarring, the pigment epithelium adheres to the retina.
4. Scleral buckling: a technique whereby the sclera is shortened to allow a buckling to occur, which forces
the pigment epithelium closer to the retina (often accompanied by vitrectomy).
5. Pneumatic Retinopexy: a gas bubble, silicone oil, or perfluorocarbon & liquids may be injected into the
vitreous cavity to help push the sensory retina up against the pigmented epithelium.

Nursing Diagnoses
1. Anxiety related to visual deficit and surgical outcome.
2. Delayed Surgical Recovery related to complications
Nursing Interventions
1. Reducing Anxiety Before Surgery
a. Provide emotional support.
b. Instruct the patient to remain quiet and in the prescribed position to prevent further detachment of
the retina (usually the detached area dependent).
c. Patch both eyes. Make sure that the patient is oriented to their surroundings and can call for assistance

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9
 d. Explain preoperative orders and postoperative expectations.
e. Administer prescribe sedation and tranquilizers for comfort and relief.
f. Instruct the patient not to touch their eyes.

2. Preventing Postoperative Complications

a. Proper positioning: supine or on the unoperated side. Enforcing bed rest for 1 day postoperatively
b. Caution the patient to avoid bumping head.
c. Encourage the patient to breathe deeply but not to cough or sneeze or to perform activities that will
increase IOP.
d. Assist the patient with activities, as needed.
e. Encourage ambulation and independence.
f. Administer medications for pain, nausea, and vomiting, as prescribed.
g. Provide diversional activities such as radio, audiobooks, and moderate TV viewing. No handwork or
reading.
h. If the patient’s anticoagulation therapy has been stopped, provide preventative measures such as
compression stockings, and leg exercises, and carefully monitor for signs and symptoms of thrombosis
and embolism.

Patient Education
1. Self-care is possible at discharge if done in an unhurried manner
2. Instruct the patient in the following:
a. Rapid eye movement from side to side should be avoided for several weeks.
b. Driving is restricted
c. Avoid straining and bending the head below the waist.
d. Symptoms that indicate a recurrence of the detachment: floating spots, flashing light, and

NCM-116
progressive shadow, recommend the patient to contact a physician.
3. The first follow-up visit to the ophthalmologist should take place in 2 weeks.

GLAUCOMA
A condition in which an obstruction of aqueous humor through the canal of Schlemm leading to increased
pressure within the eyeball. It is associated with progressive visual field loss and eventual blindness if allowed to
progress.
Canal of Schlemm: small veins at the junction of the cornea and iris of the eye; the site of reabsorption of
aqueous humor into the blood.

Pathophysiology
➢ In chronic open-angle glaucoma, obstruction to the outflow of aqueous humor through the canal of Schlemm
→ accumulation of aqueous humor (fluid) → increase Intraocular Pressure (IOP). It is usually bilateral.
➢ Increased IOP eventually destroys the optic nerve function, causing blindness.
➢ Acute closed-angle glaucoma typically involves sudden, complete, unilateral closure with pupil dilation
stimulated by a dark environment, emotional stress, or mydriatic drugs. It is considered a medical emergency;
delay in treatment leads to blindness within several days of onset.

Classification
1. Open-angle (wide-angle) glaucoma
2. Closed-angle (narrow-angle) glaucoma
3. Congenital
Principal Contributing Factor
1. Primary- genetically based
2. Secondary- result to ocular disease, injury, neoplasia, or surgery.

Acute (Closed-Angle) Glaucoma

Clinical Manifestations
1. Severe pain in and around the eyes due to increase ocular pressure (often above 75mmHg).
2. Rainbow of color (halos) around lights.
3. Vision becomes cloudy and blurred.
4. Pupil mid-dilated and fixed
5. Nausea and vomiting may occur
6. Hazy-appearing cornea because of corneal edema

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10
Diagnostic Evaluation
1. Tonometry-elevated IOP, usually greater than 50 mm Hg.
2. Gonioscopy (using a special instrument called gonioscope) to study the angle of the anterior chamber of
the eye.

Medical Management
1. Pharmacotherapy is initiated to decrease pressure before surgery
2. Medication classifications prescribed include:
a. Parasympathomimetic (cholinergic) drugs: used as miotic drugs- pupils contract → iris is drawn
away from the cornea → promoting outflow of aqueous humor into the canal of Schlemm.
e.g. pilocarpine HCL (Pilocar), carbachol (Miostat)
b. Carbonic anhydrase inhibitor: restricts the action of the enzyme that is necessary to produce
aqueous Humor → reduce the formation of aqueous humor.
e.g. acetazolamide (Diamox), methazolamide (Neptazane), dorzolamide (truzopt)
c. Beta-adrenergic blockers (nonselective): decrease the formation of the aqueous humor and
prevent the sympathetic response of pupil dilation and thereby may facilitate the outflow of
aqueous humor.
e.g. timolol (Timoptic), betaxolol (Betoptic)
d. Hyperosmotic agents: to reduce IOP by promoting diuresis.
3. Avoid mydriatics like atropine, as these drugs dilate the pupils, and the iris is brought closer to the angle
of outflow of aqueous humor.

Surgical Management
1. Surgery is indicated if:
a. IOP is not maintained within normal limits by medical regimen.

NCM-116
b. There is progressive visual field loss with optic nerve damage.
2. Types of surgery include:
a. Peripheral iridectomy: excision of a small portion of the iris whereby aqueous humor can bypass
the pupil; treatment of choice.
b. Trabeculectomy: partial-thickness scleral resection with a small part of trabecular meshwork
removed and iridectomy.
c. Laser iridotomy: multiple tiny laser incisions to the iris to create openings for aqueous flow; may
be repeated.

Nursing Diagnoses
1. Acute Pain related to increased IOP.
2. Fear related to pain and potential loss of vision.
Nursing Interventions
1. Relieving Pain
a. Notify the health care provider immediately of the patient’s condition.
b. Administer opioids and other medications, as directed. The patient may be medicated with an
antiemetic if nausea occurs.
c. Reassure the patient that, with the reduction in IOP, pain and other signs and symptoms should
subside
2. Relieving Fear
a. Provide reassurance and a calm presence to reduce anxiety and fear.
b. Prepare the patient for surgery, if necessary.
c. Describe the procedure to the patient; surgery will likely be done on an outpatient basis.
i. Patch will be worn for several hours and sunglasses may help with photophobia.
ii. Vision will be blurred for the first few days after the procedure.
iii. Frequent initial follow-up will be necessary for tonometry to make sure control of IOP.

Patient Education
1. Instruct the patient in the use of medications and carry prescribe medication at all times.
2. Remind the patient to keep follow-up appointments.
3. Instruct the patient to seek immediate medical attention if signs and symptoms of increased IOP return
such as severe eye pain, photophobia, and excessive lacrimation
4. Taking precautions at night
5. Need to avoid stooping, heavy lifting or pushing, emotional upset, excessive fluid intake, constrictive
clothing around the neck
6. Avoid mydriatics

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11
 Chronic (Open-Angle) Glaucoma
The most common form of glaucoma (about 90% of cases).

Clinical Manifestations
1. Mild, bilateral discomfort (tired feeling in eyes, foggy vision).
2. Progressive loss of visual field.
3. Slowly developing impairment of peripheral vision - central vision unimpaired.
4. Halos are present around lights with increased ocular pressure.

Diagnostic Test
1. Visual Acuity: reduced
2. Tonometry: reading of greater than 24 mmHg suggests glaucoma.
3. Perimetry: reveals a defect in the visual field.

Medical Management:
1. Often treated with a combination of topical miotic agents and oral carbonic anhydrase inhibitors and beta-
adrenergic blockers.
2. Remission may occur; however, there is no cure. The patient should continue to see a health care provider
at 3- to 6-month intervals for control of IOP.

Surgical Management
1. Trabeculectomy: to create artificial openings for the outflow of aqueous humor wherein part of the
trabecular meshwork is removed.
2. Laser trabeculoplasty (LTP): an outpatient procedure, treatment of choice if increased ocular pressure

NCM-116
unresponsive to medical regimen only. The laser burns are applied to the inner surface of the trabecular
meshwork to open the intratrabecular spaces and widen the canal of Schlemm. A maximum decrease in
ocular pressure is achieved in 2-3-months, but intraocular pressure may rise again in 1-2 years.
3. Iridencleisis: an opening is created between the anterior chamber and space beneath the conjunctiva;
this bypasses the blocked meshwork and aqueous humor is absorbed into conjunctival tissues.
4. Cyclodiathermy or cyclocryotherapy: the ciliary body’s function of secreting aqueous humor is decreased
by damaging the body with a high-frequency electrical current or supercooled probe applied to the surface
of the eye over the ciliary body

Nursing Diagnosis: Deficient Knowledge about glaucoma and surgical procedure.

Nursing Interventions
1. Providing Information about Glaucoma
a. Review the normal anatomy and physiology of the eye as well as the changes that occur in the
drainage of aqueous humor with glaucoma.
b. Make sure that the patient understands that, although asymptomatic, IOP could still be elevated
and damage to the eye could be occurring. Therefore, ongoing use of medication and follow-up is
essential.
c. Teach the patient the action, dosage, and adverse effects of medications. Make sure of adequate
administration of eye drops by watching the patient give a return demonstration.
i. Timolol and betaxolol—adverse effects include headache, eye irritation, decreased corneal
sensitivity, blurred vision, bradycardia, palpitations, bronchospasm, hypotension, and
heart failure.
ii. Pilocarpine—adverse effects include eye irritation, blurring, and redness; headache; pupil
constriction; poor vision in dim light; possible hypertension and tachycardia;
iii. Acetazolamide and methazolamide—adverse effects include drowsiness, anorexia,
paresthesia, stomach upset, tinnitus, and fluid and electrolyte imbalance.
d. Inform the patient that surgery is done on an outpatient basis and recovery is quick.
e. After surgery, elevation of the head by 30 degrees will promote aqueous humor drainage after a
trabeculectomy.
f. Additional medications after surgery include topical steroids and cycloplegics to decrease
inflammation and dilate the pupil.

Patient Education
1. Patient must remember that glaucoma cannot be cured, but it can be controlled.
2. Remind the patient that periodic eye checkups are essential because pressure changes may occur.
3. Alert the patient to avoid, if possible, circumstances that may increase IOP:

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12
 Upper respiratory infections.
o
Emotional upsets—worry, fear, anger.
o
Exertion, such as snow shoveling, pushing, and heavy lifting.
o
Recommend the following
4. Recommend the following:
o Continuous daily use of eye medications as prescribed.
o Exercise in moderation to maintain general wellbeing.
o Fluid intake is not restricted.
o Maintenance of regular bowel habits.

Activity
Written Assignments: 1. Prepare a chart that identifies significant eye structures and their functions.
2. Prepare a chart that summarizes the clinical features, assessment, and diagnostic findings, including the
medical or surgical management, of glaucoma and cataracts.
Group Assignments: 1. In small groups, describe the assessment and diagnostic findings that are used
in the evaluation of ocular disorders. 2. As a group, prepare drug cards that identify the pharmacologic actions
and nursing management of common ophthalmic medications.
Web Assignment: Review the Internet for information discussing discharge instructions for a patient
undergoing ocular surgery. Summarize your findings

Interactive Link
https://tinyurl.com/ycky6p8k (Cataract)
https://tinyurl.com/4f5hkwpf (Glaucoma)
https://tinyurl.com/yck69kb2 (Eye Drop Administration)
https://tinyurl.com/4c9wsacf (Eye Assessment Nursing)

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https://tinyurl.com/2274dk43 (Visual Acuity Test with Snellen Eye Chart Exam)
https://tinyurl.com/2p94zawz (Goldmann applanation tonometry)

Memory Tips
❖ Cataract
➢ Main Problem: Opacity of the lens usually associated with aging, prolonged intake of steroids, and chromosomal
aberrations
➢ Initial manifestation: painless blurring of vision
➢ Laboratory data: Slit-lamp test reveals a milky white color of the pupils
➢ Nursing diagnosis: potential for injury related to visual loss
➢ Interventions: Prepare patient for surgery
Postoperatively instruct the patient to avoid activities that require bending, and report sudden eye
pain, this indicates hemorrhage and increased IOP.
Avoid lifting and rapid head movements
Position in fowlers position or instruct patient to lie down on the unaffected side

❖ Glaucoma
➢ Main problem: increased intraocular pressure due to accumulation of aqueous humor
➢ Initial manifestation: Tunnel Vision, Gun Barrel Vision
Closed-angle – with pain
➢ Laboratory Data: Tonometer reading of 25 mm Hg and above
➢ Nursing Diagnosis: Potential for Injury related to visual impairment
➢ Interventions: Explain to the patient that glaucoma cannot be cured but can be controlled
Administer Miotics (pilocarpine)
Mydriatics contraindicated (ATSO4)
Instruct patient to avoid activities that can contribute to increased IOP
Teach patient about trabeculoplasty – creation of an opening in the trabecular meshwork to increase
the outflow of aqueous humor.

Summary
The structures of the external eye are vulnerable to trauma and infection. While usually minor, these
problems can cause significant pain, scarring and clouding of the cornea, and loss or impairment of vision.
Cataracts, glaucoma, and age-related macular degeneration are leading causes of visual impairment in.
While these conditions cannot, in most cases, be prevented, they often can be treated or their progress slowed,
preserving vision.
Age, smoking, diabetes, and long-term use of certain drugs are risk factors for cataract development.
Removal of the clouded lens with insertion of an intraocular lens is the treatment of choice for cataracts. Surgery

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13
is elective, performed only when the cataract significantly impairs the ability to maintain ADLs and recreational
activities.
Glaucoma is a progressive loss of visual fields associated with increased intraocular pressure and impaired
aqueous humor drainage. Open-angle glaucoma, the predominant form of the disorder, can be controlled using
medications and, as needed, laser surgery to promote aqueous humor drainage.
Angle-closure glaucoma is a medical emergency requiring immediate treatment to lower intraocular
pressure to preserve vision. Angle-closure glaucoma usually affects only one eye; however, the person is at risk
of future attacks affecting the other eye.

Case Study (Chronic Open-Angle Glaucoma)

Patient Profile: Mrs. Dela Cruz, a 60-year-old woman, was seen in her ophthalmologist’s office for a routine
eye examination. Her last examination was 7 years ago.

Subjective Data
• Has no current ocular complaints
• Has not kept annually scheduled examinations because her eyes have not bothered her
• Takes metoprolol tartrate (Lopressor) for hypertension
• Has a family history of glaucoma
• Uses over-the-counter diphenhydramine (Benadryl) for her seasonal allergies

Objective Data
• BP: 130/80
• HR: 75 bpm

Ophthalmic Examination

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• Visual acuity: OD 20/20, OS 20/20
• Intraocular pressure: OD 25, OS 28; by tonometry
• Direct and indirect ophthalmoscopy: small, scattered retinal hemorrhages; optic discs appear normal with
no cupping
• Visual field perimetry: early glaucomatous changes, OU

Collaborative Care: The health care provider prescribes betaxolol (Betoptic) gtt 1 OU. The nurse instructs the
patient on the reasons for the drug and how to do punctal occlusion.

Critical Thinking & Discussion Questions

Using a separate sheet of paper, answer the following questions:
1. Why should Mrs. Dela Cruz have been seeing an ophthalmologist every year even though she had no
ocular complaints?
2. What should the nurse teach Mrs. Dela Cruz about administering the eye drops?
3. Why is it permissible for Mrs. Dela Cruz to use her antihistamine? What would the nurse have told her if
gonioscopy had revealed angle-closure glaucoma?
4. Will Mrs. Dela Cruz be able to discontinue her eyedrops once her intraocular pressures are within the
normal range? Explain your answer.
5. If topical therapy does not control Mrs. Dela Cruz’s intraocular pressures, what should she be told about
alternative therapies?
6. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are
there any collaborative problems?

Readings and References

➢ Smeltzer, Suzanne C. (2014). Brunner & Suddarth’s. Textbook of Medical-Surgical Nursing-13th Edition,
Wolters Kluwer/Lippincott Williams & Wilkins
➢ Lemone et al. (2017). Medical-Surgical Nursing Critical Thinking for Person-Centered Care, 3rd Edition,
Pearson Australia.
➢ Nettina, Sandra N. (2019). Lippincott Manual of Nursing Practice, 11th Edition, Wolters Kluwer.
➢ Lewis et al. (2014). Medical-Surgical Nursing Assessment and management of Clinical Problems, 9th
Edition. Mosby, an imprint of Elsevier Inc.
➢ Udan (2017). Medical-Surgical Nursing Concepts and Clinical Applications, 3rd edition, APD Educational
Publishing House.

All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
14