care of client witheent disorder of

8/6/2019 Care of Client WithEENT Disorder Of

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Special SENSES


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Course Outline: Special Senses

y Review of Anatomy and Physiology of ear and eyes

y Explain the visual pathways

yAssessment of visual acuity: snellen chart

yAssess and examine the External and Internal eye:IPPA

y Identify the common Eye Diagnostic evaluationNursing care of client with External ear problem


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The Ears


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Ears Divided into Three main anatomical Components:

OUTEREAR:

Composed of:y Auricle(Pinna) a cartilagious flap on

the temporal side of the heady External ear cannal or external auditory

meatus Responsible for collecting, conducting,

and amplifying sound waves

The auricle direct sounds through theexternal ear canal to the tympanicmembrane(eardrum)

Lined with Cerumen(earwax) ayellowish brown protective substancethat guards against certain bacteria andsmall insect, and trap dust and debris

that may damage the inner ear Tympanic membrane(TM) serve as

boundary between the outer and middleear, a concave shape on otoscopic exam

As sound waves vibrate against themembrane, the motion is transmitted tothe bone of the inner ear

Middle ear Composed ofThree bones collectively

called as ossicles that includes:1. Malleus (hammer) attached to theupper, inner portion of thetympanic membrane. The head ofthe malleus connects with the incuswhich then joins the stapes

2. Incus ( Anvil)

3. Stapes (stirrups) The vibration created by sound

waves passes through the outer earcanal to the tympanic membraneand then to these three bones

The eustachian tube opens into thepharynx from the middle ear

It is approximately 3- 4 cm long Functions:o is to equalize on both sides of the

eardrum by providing a path(via thenasal passages) to relieve pressure

o Amplification of the sound wavesand stimulation of the oval window

to move the fluid of the inner ear


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Inner EarFunctions:y

Hearingy EquilibriumConsist of:Labyrinth- a complex series of interconnected,

fluid-filled chambers and tubes

- Divided intoThreeMain parts:o Semicircular canalso Vestibuleo cochlea

Semicircular canals function in

providing the sense of balance,open into the vestibuleo Vestibule is the central

chamber of the inner earo Cochlea is a small shaped

structure that contain theauditory organ for the sense ofhearing

Vibration of the stapes createspressure and causes the nervesto respond to different soundsand initiate neural responsesthat are sent along the auditory

nerve(cranial V111 nerve) to thebrain Thus mechanical information is

translated into nerve impulseand sent to the brain, whichtranslate the sound intomeaningful impressions and

language


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Diagnostic Assessmenty External ear is examined by inspection and direct

palpation.y Otoscopic examination used to examine the external

auditory canal and tympanic membrane

yAudiometry it is the single most important dx instrument

in detecting hearing lossTypes:

1. Pure tone audiometry - the louder the tone before theclient perceives it, the greater the hearing loss

2. Speech audiometry spoken word is used to determinethe ability to hear and discriminate sounds and words.The louder the sound before the client perceive it, thegreater the hearing loss


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Tympanogram it measures middle ear musclereflex to sound stimulation and compliance offthe tympanic membrane, by changing the airpressure in a sealed air canal. Complinace is

impaired with the middle ear diseaseOculovestibular test/Caloric Ice water test

irrigate the ear with cold water. Normal: lateral

conjugate nystagmus of the eyes towards areaof stimulation

Abnormal: dysconjugate nystagmus of the eyes.


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y Evaluation of Gross Auditory AcuityTuning ForkTest

1. Whisper test- the untested ear is covered with the palmof the hand and the examiner whispers softly from adistance of 1 -2 feet from the occluded ear. Patient withnormal acuity can correctly repeat what was whispered

2.Weber testy In case of conductive hearing loss, the sound is heard

better in the affected ear

y The sound lateralizes to the better hearing ear

y Useful for detecting unilateral hearing loss

3. Rinne testy Normally, sound heard by air conduction is audibly longer

than sound heard by bone conduction


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Sign and Symptoms of Ear Diseases1. Deafness:

y

hearing loss which may be mild or severey Hearing loss may be conductive, sensorineural or mixed

types

y Common cause of deafness in childhood is: serous otitismedia; In Adults is presbycusis the most common causedue to degeneration of the nervous tissue. More commonamong men age 50 years over

2. Pain:

y Earache or otalgia is a very common complaints

y In children, the most common cause is acute otitis whilein adults is otitis extena

y The most common site for referred pain is the throat ifinfection is responsible, malignant tumor


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3.Discharge

- May be mucoid, purulent or bloody

- Common cause of discharge is otitis externa/otitis media

4. Vertigo

- A form of dizziness where the patient experiences a

spinning sensation- Common symptoms when the balance or vestibular system

of the inner ear is diseased, accompanied by nausea andvomiting

5. Tinnitus- Noise in the ear, is a very common complaint

- Its quality varies from high-pitched whistle to the clangingog bells or recognizable snatches of music


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Disorder of the Ears:

Impaired hearing:- Most common chronic disability, serious

debilitating by limiting the ability to socialize,

work, respond to telephone or alarmTypes ofHearing Loss:

Conductive

SensorineuralMixed hearing loss =both

Congenital


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Conductive hearing lossy Inability of the sound wave to reach the inner ear

y May be due to:

Cerumen buildup/blockage

Perforated tympanic membraneFixation of one or all of the ossicles

SENSORINEURAL Hearing Lossy The inner ear or cochlear portion of cranial nerve V111 may be

abnormal or diseasedy A tumor, infection, trauma, or exposure to loud noises may

cause destruction of the nerve and result in sensorineuralhearing loss

y

Sensorineural loss associated with aging called as Presbycusis


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Assessment in a Client with Hearing Loss

y Irritable, hostile, hypersensitive in IPRy Has difficulty in following directiony Complains about mumblingy Turns up volume on TVy Ask for frequent repetitiony

Answer question inappropriatelyy Leans forward to hear better; face looks serious and strainedy Loses sense of humor, becomes grim and lonelyy Experiences social isolationy Develops suspicious attitudey Has abnormal articulationy Complains of ringing in the earsy Has unusually soft or loud voicey Dominates conversation


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Medical and Surgical MGT:

Medicaly Identify the types of hearing loss and underlying

etiology

y Complete PE and thorough diagnostic test

Surgical

Cochlear implants a receiver/stimulator is implanted inthe skull and a group of electrodes are planted in frontof the round window in the inner ear. The client wears amicrophone near the ear that picks up and translatesound into electrical signal. These signal are thentransmitted to the brain via cochlear implant andcranial nerve V111


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Guidelines for Communicating with Hearing

Impairment

y Talk directly to the person facing him/hery Speak in clearly enunciate words, using normal tone of voice. Do

not shout

y Do not whisper to anybody in front of the hearing-impaired

clienty Use gesture with speech

y Do not avoid conversation with a person who has hearing loss

y Do not show annoyance by careless facial expression

y Move closer to the person or towards the better ear if he/shedoes not hear you

y Do not smile, do not chew gums or cover the mouth whentalking to the person

yEncourage the use of hearing aid


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Hearing Specialist:

Audiologist evaluates hearing and determine the extentand type of hearing loss and provides nonmedicaltreatment such as fitting of hearing aid, advice aboutassistive listening devices and communication/aural

rehabilitative trainingOtolaryngologist (ears, nose and throat physician)

provide medical and surgical interventions

Hearing Aid Specialist is a licensed to dispense hearing

aids but does not have a medical background or training


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Care of Clients with External ear

Problems1. CERUMEN IMPACTION:

y Cerumen (earwax) normally accumulates in the externalcanal in varying amounts and colors

yMay occur, with or without hearing loss

Medical and Surgical Management:

y Irrigation, suction or instrumentation

y Instilling a few drops of warmed glycerin, Olive/ mineral

oil, or half strength hydrogen peroxide into the ear canalfor 30 minutes can soften cerumen before its removal


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2. Foreign Bodiesy Some objects are inserted intentionally into the ear by

adults who have bee trying to clean the external canal orby children who introduce the objects by various reasons

Medical and surgical Mgt:

y Irrigation, suction, and instrumentation ma be done

y Contraindication for irrigation are foreign vegetablebodies and insects that tends to swell


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3. External Otitisy Inflammation of the external auditory canal

y causes: water in the ear canal, trauma to the skin of theear canal, vitamin deficiency and endocrine disorders

y Most common bacterial pathogens: StaphylococcusAureus and Pseudonomas

yMost common fungus: Aspergillus

MedicalMgt:

yAnalgesic, systemic antibiotic and anti-fungal agents

Nursing Intervention:

y Teach not to clean the external auditory canal with cottontipped applicators; to avoid swimming, and not to allow

water to enter the ear when washing with shampoo ortaking a shower


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4.Boils- A boil or furuncle found in the outer hair-bearing skin of

the ear canal. Caused by Staphylococcus

5. Tumors

- Malignant tumor of the ear are most common in the outer

ear where both basal cell carcinoma and Squamouscarcinoma are found


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5.Massess of the External Ear

Exostoses:y Small, hard, bony protrusions located in the lower

posterior bony portion of the ear canal usually bilateral

y Common malignant tumors are basal cell carcinomason the Pinna and squamous cell carcinoma in the earcanal

Medical and Surgical Mgt:

y Carcinomas must be removed surgically


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Care of Client withMiddle Ear Problem

1. Tympanic membrane Perforation Cause by infection or trauma: skull Fx, explosive injury,

severe blow to the ear

Medical/ Surgical Mgt:

y Most tympanic membrane perforations healsspontaneously within weeks after rupture

y Ear must be protected from water

y

In case of skull Fx, watch out for the presence ofC

SFy Tympanoplasty


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2. Otitis Media- An infection of the middle ear leading to impaired equalization of air

pressure

Type: serous , acuteEtiology:

Acute: Streptococcus Pneumoniae, Haemophilus influenzae andMoraxella catarrhalis

Serous: URTI, allergies, edematous Eustachian tube Purulent exudate in

the middle ear which may result in a conductive hearing lossS&S: CARDINALSerous: Snapping or popping sound, hearing loss, vertigo

Acute: severe air pain, pulling of ear by kids, fever, tenderness of mastoid

area,y Otorrheay Otalgiay Fever, URTI, rhinitisy Erythematous and bulging tympanic membrane


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Medical and Surgical Mgt:y Careful suctioning of the ear

yAntibiotic therapyy Myringotomy orTympanotomy to relieve pressure and

drain exudates

Nursing Intervention:y Instruct patient to prevent entering of water in external

auditory canal for 6 weeks

y Cover the ear with cotton balls or lambs with petroleum

jellyy Keep the incision dry for 2 days

y Institute safety measure to prevent falls


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3.Mastoiditis- Inflammation of the mastoid, most often the direct result of

chronic or recurrent bacterial otitis media- The recurrent infection may find ways its way into the bone

and structure surrounding the middle ear and if leftuntreated , can cause severe damage, sensorineural deafness,

facial weakness, brain abscess and meningitisMgt:

Mastoidectomy or meatoplasty


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Mastoid surgerya. Assessmenty Health hx: duration, intensity, and causes of ear problem(e.g.:

infection, otalgia, otorrhea, hearing loss. Vertigo); other healthproblems; familyHx of ear infection and medication taken and/orallergies

y Physical assessment: erythema, edema, otorrhea, lesions anddischarge(odor, color, etc)

Nursing intervention:y Reducing anxietyy Relieving painy Preventing infectiony Improving hearing and communicationy Preventing injury

y Preventing altered sensory perceptiony Promoting pound healingy Teach client about: Disease, surgical procedurey Post-op care


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N

ursing care of Client with

inner Ear problem1. Motion Sicknessy Disturbance of equilibrium caused by constant motion

y S&S: sweating, Pallor, nausea, vomiting

MedicalMgt:

y Antihistamine an anticholinergic

y Instruct to avoid driving the car and operating heavy

machines when taking the medication


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2.MENIERES DISEASE

Pathology: overaccumulation of endolymp(Fluid) inmembranous labyrinth of the inner ear -- resulting todilation of lymphatic channel and labyrinthdysfunction, and malabsorption in the endolymphaticsac

Etiology unknownIt is postulated that is due to excessive

accumulation of endolymph in the cochlear ductPossible leakage of endolymph into perilymph due

to increased capillary permeabilityMixing the two fluid chemically alters the

homeostasis of the perilymph and endolymph andcan be responsible for the symptoms of menieresdisease


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Risk Factors:

yMiddle age

y

Family historyDX test:

y Caloric ice water test- test for vestibular function;normal ear is irrigated with hot water, there is a rotary

nystagmus toward that ear; if irrigated with cold water,there is rotary nystagmus toward the opposite ear

yAuditory dehydration test

y Weber and Rinne test

Triad S&S: endolymphaticHydrops( vertigo, tinnitus,hearing loss)

1. Vertigo ass. With nausea & vomiting

2. Tinnitus occur simultaneously with vertigo

3. Unilateral fluctuating hearing loss


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Medical and surgical MGT ofMenieresMedicalMgt:y Symptomatic txy Diagnosis confirmed with:

Caloric Stimulation(through this test isprimarily conducted on comatose clients

MRI to rule out tumorSurgical Mgt:y Endolymphatic, Subarachnoid shunt

placement to drain excessive endolymphy

Vestibular neurectomyNursing Mgt:y Assess vertigo, including hx, onset, duration,

frequency and ear symptomsy Ensure safety during attacky Sodium restricted diety Instruct to sit down when dizzyy Instruct to keep their eyes open and stare

straight ahead during vertigo attacky Encourage fluid intake as toleratedy Assess signs for dehydrationy Educate client about vertigo and its mgt.

PharmacologicalDOC: Dramaminey Antihistamine

y Antiemeticsy Benzodiazepiney Diureticsy Tranquilizer, vasoactive agentsy Oral niacinDuring attack: atropine, diazepam,

compazine, diuretic

DIET:y Strict salt restrictiony Avoid beer, wine,s oda, salty foods,

chocolates caffeinated coffee andtea

Activity:y Prolonged bed rest during the

attacky Avoid driving, operating heavy

equipment during the attack


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3. Labyrinthitis

y Inflammation of the inner ear

y May be bacterial or viral in origin

y Bacterial labyrinthitis occurs as a complication of otitis

mediayViral Labyrinthitis is caused by mumps, rubella, rubeola

and influenza

MedicalMgt

y Intravenous antibiotic, fluid replacement, and vestibularsuppressants

y Treatment for viral labyrinthitis is according to clientssymptoms


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4. Vestibular Neuronitisy

Dysfunction of the vestibular nervey Clinical manifestation: severe vertigo with normal hearing

Causes: viral infection, vascular and demyelinating disease, andtoxins; with hx of previous ear, nose or throat infection

assessment:y Sudden onset with vertigo, nausea and vomiting

y No hearing loss or tinnitus

y First attack is usually worst with decreasing intensity

y Usually recovers without treatment within a few weeks to amonth

y Less common chronic form can persist for months to years


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5. Benign Paroxysmal Position Vertigo

y Brief period of incapacitating vertigo

y Occurs when the position of the head changes withrespect to gravity(typically head back with the affected earturned down)

Assessment:

y Sudden onset

yVertigo

y Nausea and vomitingMedicalMgt:

yVestibular rehabilitation


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6. Ototoxicity

yVariety of medication have adverse affects on thecochlea, vestibular apparatus, or cranial nerve V111

yAspirin and quinine cause reversible hearing loss

y

Aspirin at high dose can produce tinnitusyMost common cause of ototoxicity: aminoglycosides

Nursing Intervention:y C

ounsel the patient regarding he side effects ofototoxic medications


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Acoustic Neuromay

Is a slow-growing and usually benign tumor arising from theSchwann cells of the vestibular portion of the inner ear(cranialnerve V111)

Diagnostic procedure: MRIS&S:y

Dizziness, unilateral tinnitus, hearing loss with or withoutvertigoy Facial weakness may caused by compression of the tumor on

cranial nerve VIIy Loss of corneal reflexy

Vomiting and headacheMedical/Surgical Mgt:y Surgical removal of the tumorComplications of surgery: cerebral edema; facial nerve paralysis;

cerebrospinal fluid leak and meningitis


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Otosclerosisy

A conductive hearing loss sec. to pathologic change of thebones in the middle ear

y Etiology Unknown

Pathophysiology:

Ossicles become soft, highly vascular and fixed-Thisfixation reduces or prevent transmission of source wavesto inner ear fluid thus stapes affected which must vibrateon the oval window in order to transmit sound waves

S&S:y Subtle changes in hearing

y Low-pitched tinnitus

y Irritable /withdrawm


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Medical and Surgical MGTThreeOption For Treatment:

y The individual may choose to do nothing and obtainperiodic audiometry to evaluate progression of the disease

y 2nd option is to use hearing Aid

y 3rd option surgical mgt

Stapedectomy - to improve hearing loss. Done under localanesthesia/general anesthesia and routinely requires asurgical incision in the posterior ear canal, removal of thestapes and implantation of a plastic prosthesis

Laser Stapedectomy through the ear canal without incision.

The stape tendon is vaporized, chards are removed withdelicate micro instruments, and an opening is madeallowing the surgeon to implant a prosthetic piston. Thisrestore normal vibration against the inner ear.


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Assisting the hearing Impaired Client

y Speak slowly and distinctly after getting the clients attentiony Face the client and sit or stand to be at eye level with the client

y Use short, simple sentences and give the client time torespond. Repeat or rephrase if necessary

y Use written materials when possible to communicateinformation

y Keep a notepad and pen or pencil available to write down newor unfamiliar words and concepts

y

If signs language is the clients preferred methods ofcommunication, locate a persons who understands signlanguage

y If the client wears a hearing aids, make sure that the battery isfunctional, it is turned on and adjusted to a comfortable level


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Aural Rehabilitation

1.H

earing Aidsy Speech and environmental sound are received by a

microphone converted to electrical signals, amplified andreconverted to acoustic signals

y

Makes sounds louder but does not improve the patient'sability to discriminate words or understand speech

y Benefits people with low discrimination scores onaudiogram

Types:y Behind-the ear

y In-the ear

y In the-canal


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Tips for care ofhearing aidsCleaning:

o The ear-mold is the only part of the hearing aid that maybe washed frequently with soap and water. It must be drybefore it is snapped into the receiver

Malfunctioning:

y Inadequate amplification, a whistling noise, or pain fromthe mol can occur when a hearing aid is not functioningproperly

Recognizing Complication:

oWhen occluded by hearing aid, the external auditorycanal can become moist

o Common medical problems: External otitis, pressureulcers in the external auditory canal


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2.Implanted hearing Devicesa. Cochlear Implants

Indication:

Profound bilateral sensorineural hearing loss who do notbenefit from conventional hearing aids

Helps detect medium to loud sounds

Stimulates directly the auditory nerve

A small receiver is implanted in the temporal bone, theelectrodes are in the inner ear

b. Bone Conduction device

y Indication: conductive hearing loss with contraindication for

hearing aids(chronic infection)y Transmits sound through the skull

y Implanted postauricularly under the skin into the skull andan external device is worn above the ear

c. Semi-implantable hearing device not yet approved by FDA


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Assessment of thevisual Function


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Anatomy & Function of the EyeThe BonyOrbit The eye socket Offers protection for the globe Comprised of 7 bones Frontal Zygomatic Maxillary Ethmoid

Sphenoid Lacrimal Palatine Globe takes up 1/5 volumeoforbitAlso present in theorbit: Extraocular muscles

Fascia Orbitalfat Blood vessels Nerves Lacrimal gland


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The Eyeball is Composed of3

Layers:1. Fibrous Tunic

(Connective tissue)

2. Vascular Tunic(Receives blood)

3. Nervous Tunic(Retina: Receives

impulses from thenervous system)

The Eyeball is Composed of 3


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The Eyeball is Composed of3

Layers:1. Fibrous Tunic: The outer

coat of the eyeball.

(1) Cornea

(2) Sclera


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1) Cornea: Anterior portionof the fibrous tunic

a. Nonvascular,transparent coat whichcovers the pigmented iris.

b. Function: Helps focuslight.

(Most importantrefracting surface of the

eye.)


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(2) Sclera: Posteriorportion of the fibroustunic.

a. Also called thewhite ofthe eye.

b. Function: Gives

shape to theeye.


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The Eyeball is Composed of3 Layers

2.Vascular Tunic Themiddle layeroftheeyeball.

(1) Choroid: Posteriorportion of the

vascular tunic.

a. Provides blood supply

and absorbs lightrays


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(2) Ciliary Body:Anterior portion of thevascular tunic.a. Composed of twostructures:

(1) CiliaryProcess (folds of ciliarybody): Secretes

aqueous humor.(2) Ciliary

Muscle: Smoothmuscle that alters

the shape ofthe lens

The Eyeball is Composed


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of3 Layers

(3) Iris: Anteriorportion of the vasculartunic.a. Pigmenteddoughnut-shapedstructure composed

of muscle fibers.b. Function:Regulates theamount of light thatenters the eye.

c. Pupil: Black holein the center oftheiris through whichlight enters theeyeball

Th E b ll i C d


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of3 Layers

3. Nervous Tunic(Retina) The innercoat of the eyeball.a. Found only in theposterior portion of theeyeball.b. Function: Imageformation.

(1) Receives lightand converts lightinto nerve impulses,

it then transmits theinformation to theoptic nerve and thento theoccipitallobe ofthe brain


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The 2 Layers of the

Retina:

1. Outer pigmentedlayer (non-visual portion)

2. Inner nervous tissue layer(visual portion)

a. Contains

Photoreceptors:(1) Rods(2) Cones


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Rods:A. Specializedfor vision and

dim light.

B. Discrimination betweendifferent shades ofdarkandlight.

C. Allows us to see shapesand movement.


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Function of the Cones:A. Color vision andvisual

acuity(sharpnessofvision)


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The LensA.Located behind (posterior)

the pupil and iris.B. The lens is avascular and

normally transparent

Cataract = loss of

transparencyC. Suspensory Ligaments

hold the lens in position

The Interior of the


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The Interior of the

EyeballA. Composed of two

cavities:(1)Anterior Cavity(located anterior tothe lens)

a.AnteriorChamber

b. PosteriorChamber

(2) PosteriorCavity(locatedbetween the lens

and the retina)


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Anterior ChamberA. Located in front

(anterior) ofthe irisand behind the cornea.

(1) Filled withaqueous humor

(2) Pressure is keptwithin normal limits bydrainage of aqueoushumor through theCanal of Schlemn.

-Glaucoma ischaracterized by anincrease inintraocular pressure.


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Posterior CavityLocated between the lens and

the retina.B. It is a much larger cavity.

C. It containsvitreous humor;which helps prevent theeyeballfrom collapsing.


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The LensD. Function: Focus light

rays for clear vision.E. Contact lenseswork by

conforming to thecurvatureofthe cornea.


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Orbital Compartment syndrome

Can lead to vision loss

within minutes

Mechanicaltamponade, CRAO,Optic nerve

compressiony Retrobulbar

Hemorrhage

IntraoperativelyfromRBB

Secondary to trauma

Extraocular Muscles


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Extraocular Muscles

6 muscles

Medial rectus: moves eye intoward nose(adduction)

Lateral rectus: moves eye

out awayfrom nose(abduction)

Superior rectus: moves eyeup, in, intorts

Inferior rectus: moves eyedown, in, extorts

Superioroblique: intorts,moves eye down

Inferioroblique: extorts,moves eye up


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Extraocular Muscles

y Responsible for eye

y movements

y

Maintainy binocularity

y Misalignment =

y Strabismus

y Esotropia

y Exotropia

y Hypertropia Esotropia

ye s L t l b i i i lid


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ye s Protect and cover the eyes

Spread tear film across the corneawith blinking

Blinkingoccurs approx. 5times/minute

Upper eyelid: upper lash line toeyebrow

Lower eyelid: lower lash line toupper Cheek

8 layers:

Skin

Orbicularis

Orbital septum Orbitalfat

Tarsus

Levator

Mullers muscle

Conjunctiva

Levator palpebrae superioris raises lid Levator innervated by Oculomotornerve (CN III) Orbicularis oculi closes lids

Orbicularis innervated by Facial nerve(CN VII) Ptosis- CN III palsy Bells palsy- CN VII palsy


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Facial Nerve Palsy

y CN VII palsy

y Lagophthalmos

y

Multiple causesy Bells palsy =

y idiopathic


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Tear Production and Drainage Lacrimal gland: Located superotemporal

aspectoforbit

Produces aqueouscomponent oftears Tearsdrain medially at

the upper andlowerpunta, superior andinferior canaliculi,

common canaliculus,lacrimal sac,nasolacrimal duct intonose


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Tear Film

3 components:

Lipid: from

meibomian glandsAqueous: fromlacrimal gland

Mucin: from goblet

cellsofconjunctiva


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Conjunctivay Mucous membranelining the upper andlower eyelids

Extends over sclera tocorneal margin

Goblet cells producemucous

Accessorylacrimal glands Meibomian glands

Glands ofMoll and Zeiss

C


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CorneaApprox. 12 mm indiameter

Mostofeyes refractive power Clear, avascular

Receives mostofnutritionthrough tear film

Healthy state cornea is

dehydrated, maintained byendothelium

5 layers

Epithelium

Bowmans Layer

Stroma

Descemets Membrane

Endothelium


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Anterior ChamberComprisedofaqueous

humor Produced by ciliary body

Maintains intraocularpressure

Nourishes cornealendothelium andlens

Drains throughtrabecular meshwork,Sclemms canal, toepiscleralveins


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Uveal Tract

Iris

Ciliary Body

Choroid


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Iris

Colored part ofeye

Centeropening = pupil

Sphincter pupillaeconstriction

parasympathetic

Dilator pupillae-

dilation sympathetic


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Ciliary Body

Continuous with iris

Ciliary processes arisefrom here

Zonules connect CB tolens

Zonulardehiscence

post trauma Ciliary muscles

accommodation


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Choroid

Continuous with irisand ciliary body

Vascular structure

Nourishes retina


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Lens

Approx 4mm thick

Enclosed in a capsule

Cortex Nucleus

Nucleus adds layers,hardens with age

Cataract


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Vitreous

Thick gel

99% water, 1% collagen,hyaluronic acid

Shapes eye

Avascular

Retina


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Retina Inner layerofposterior segment Inner aspect nourished by

centralretinal artery

Outer aspect nourished by choroid

Contains photoreceptors

Rods- none in macula

Cones- more in macula lutea,fovea

9 layers ILM

Nerve fiber layer

Ganglion cell

IPL

INL OPL

ONL

ELM

Photoreceptors

Retinal pigment epithelium

Sclera


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Sclera

Opaque

Supportive structure

Thinnest where musclesinsert

Co

mmo

n rupture site

Scleral laceration


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Optic Nerve

Transmits information from retina to brain

One million nerve axons

Corresponds to blind spot CN II


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Visual Pathways


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y The eye allows us to see andinterpret the shapes, colorsand dimensions of objects inthe world by processing thelight they reflect or emit

y The eye is able to see in brightor dim light, but it cannot seeobjects when light is absent

When you look at any object


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When you look at any objecty Light waves from that object enter the eye first through the cornea,which is the

clear dome at the front of the eyey Light waves progress through the pupil, the circular opening in the center of the

colored irisy Immediately behind the iris (and pupil) is the crystalline lens, and light passes

through that alsoy Light waves are bent (converged) first by the cornea, then even more so by the

crystalline lens, to a nodal pointwhich is immediately behind the lensy At the nodal point, the light waves (image) become reversed (turned backwards)

and inverted (turned upside down)y Light waves continue through thevitreous humor, the clear gel that makes up

about 80% of the eyes volume, and then back to a clear focus on the retinabehind the vitreous

y The small, central area of the retina is the macula; it provides the best vision ofany location in the retina

y The light impulses are changed into electrical signals, then sent through the

optic nerve along thevisual pathwayto the occipital cortex, or posterior (back),of the brain

y This is where the electrical signals are seen by the brain as a visual imagey When light entering the eye is bright enough, the pupils will get smaller

(constrict) due to pupillary light response

Extraocular Muscles


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Extraocular Musclesy All of the extraocular

muscles, with the exceptionof the inferior oblique, form acone within the bony orbit

y The apex of the cone is in theposterior aspect (back) of theorbit, while the base of the

cone is the attachment of themuscles around the midlineof the eye. This conicstructure is referred to as theannulus of Zinn, and withinthis cone runs the Opticnerve (cranial nerve H)

y Within the optic nerve arethe ophthalmic arteryandthe ophthalmic vein

The superior oblique muscle is differentfrom the others, because before it attaches

to the eye, it passes through a ring-liketendon, the trochlea, which acts like apulley in the nasal portion of the orbit

The inferior oblique muscle (not a memberof the annulus of Zinn) arises from the

lacrimal fossa in the nasal portion of thebony orbit and attaches to the inferiorportion of the eye


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y The primary muscle thatmoves an eye in a givendirection is known as theagonist

y A muscle in the same eye

that moves the eye in thesame direction as theagonist is known as asynergist

y A muscle in the same eyethat moves the eye in theopposite direction of theagonist is the antagonist

y Cardinal positions ofgaze

y Up/righty Up/left

y Right

y Left

y Down/right

y Down/left

y In each position of gaze,one muscle of each eye is

the primary mover of thateye, and is yoked to theprimary mover of the othereye

A


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y Avergence ordisconjugatemovement involves

simultaneousmovement of botheyes in the oppositedirections

y There are two

principal vergencemovementsy Convergence

both eyes movingnasally or inward

y Divergence botheyes movingtemporally orupward

StrabismusUsually when we see an object, the lines of sight are botheyes intersecting at the object, or both eyes are pointingat the object being viewed. An image of the object isfocused upon the macula of each eye and the brainmerges the two retinal images into one

When there is an extraocular muscle imbalance, one eyeis not aligned with the other eye, which results in astrabismus

With strabismus, while one eye is fixating on aparticular object, the other eye is turned inanother direction, either inward (cross-eyed),outward (wall-eyed), upward, or downward

As a result, the person either experiences

diplopia (double vision) or the brain learns toturn off (suppress) the image of the strabismiceye to maintain single vision

The angle of deviation of the strabismus ismeasured in prism diopters


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L k l l h


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Sclera

y The white part of theeyeball is called thesclera (say: sklair-uh).

The sclera is made of atough material and hasthe important job ofcovering most of the

eyeball. Think of thesclera as your eyeball'souter coat.

y Look very closely at thewhite of the eye, and

you'll see lines that looklike tiny pink threads.These are blood vessels,the tiny tubes thatdeliver blood, to thesclera.


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CORNEAy The part of the sclera in front

of the colored part of the eye iscalled the cornea (say: kor-nee-uh). Unlike the rest of thesclera, which is white, thecornea is transparent, orcompletely clear, which letslight travel through it. Thecornea helps the eye focus aslight makes its way through. Itis a very important part of theeye, but you can hardly see it

because it's made of cleartissue. Like clear glass, thecornea gives your eye a clear

window to view the worldthrough


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IRIS

y Behind the cornea arethe iris and the pupil.The iris (say: eye-riss) is

the colorful part of theeye. When we say aperson has blue eyes, wereally mean the personhas blue irises!


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PUPIL

y The iris is a muscle. Thisallows the iris to controlhow much light goesthrough the pupi

l(say:

pyoo-pul). The pupil is theblack circle in the center ofthe iris, and it lets lightenter the eye. The pupilswill get smaller when alight shines near them andthey'll open wider whenthe light is gone.

y Between the iris andcornea is the anterior(say: an-teer-ee-ur)chamber. This chamber isfilled with a specialtransparent fluid that givesthe eye oxygen, protein,and glucose (a type ofsugar in the body) to keepit healthy.


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TEARSy Our tears form a

protective layer at thefront of the eye and also

help to direct the lightcoming into our eye.


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y

After light enters thepupil, it hits the lens.The lens sits behindthe iris and is clear and

colorless.T

he lens' jobis to focus light rays onthe back of the eyeball- a part called the

retina (say: reh-tin-uh).


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Retina

y Your retina is in the veryback of the eye, past the

vitreous body. Though

it's smaller than a dime,it holds millions of cellsthat are sensitive to light.The retina takes the lightthe eye receives and

changes it into nervesignals so the brain canunderstand what the eyeis seeing


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y The lens is suspended inthe eye by a bunch offibers. These fibers are

attached to a muscle calledthe ciliary(say: sih-lee-air-ee) muscle. The ciliarymuscle has the amazingjob of changing the shape

of the lens. That's right -the lens actually changesshape right inside your eye!


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VITREOUS BODYy The biggest part of the eye sits behind the lens and is

called thevitreous (say:vih-tree-us) body. Thevitreous body forms two thirds of the eye's volume andgives the eye its shape. It's filled with a clear, jelly-likematerial called thevitreous humor. Ever touch toyeyeballs in a store? Sometimes they're kind of squishy -that's because they're made to feel like they're filled

with vitreous humor. In a real eye, after light passesthrough the lens, it shines straight through the

vitreous humor to the back of the eye.


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Rods and Conesy The retina uses special

cells called rods andcones to process light.

Just how many rods andcones does your retinahave? How about 120million rods and 7million cones - in eacheye!

y Rods and cones are mostsensitive to yellow-greenlight.


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RODSy Rods see in black, white,

and shades of gray andtell us the form or shape

that something has.Rods can't tell thedifference betweencolors, but they are

super-sensitive, allowingus to see when it's verydark.


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CONESy Cones sense color and

they need more lightthan rods to work well.

Cones are most helpfulin normal or bright light.


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y The retina has threetypes of cones - red,green, and blue - to help

you see different rangesof color. Together, thesecones can sensecombinations of light

waves that enable oureyes to see millions ofcolors.


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I cant see

y Sometimes someone'seyeball changes shapeand the cornea, lens, and

retina no longer workperfectly as a team. Theperson's eye may focuson what it sees in front ofor behindthe retina,

instead ofon the retina.When this happens,some of what the personsees will be out of focus.


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Eye Glasses

y To correct this fuzzy vision,many people, includingmany kids, wear glasses.Glasses help the eyes focus

images correctly on theretina and allow someoneto see clearly. As adults getolder, their eyes changeshape and they often needglasses to see things up

close or far away. Mostolder people you know -like your grandparents -probably wear glasses.


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To the Brainy Think of the optic nerve as the great messenger in the

back of your eye. The rods and cones of the retinachange the colors and shapes you see into millions of

nerve messages. Then, the optic nerve carries thosemessages from the eye to the brain! The optic nerveserves as a high-speed telephone line connecting theeye to the brain.


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Reflected lighty Reaches the retina where

it falls onto the conesand rods.

y The critical part of theimaging process is thelens.

y The lens gives the

detailed informationabout the size, shape,and color of an object.


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y The lens is transparentwith spherical surfaces.

y It is convex which meansthicker in the center.


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The lens

y The human eye canchange the shape of thelens automatically.

y The range of change thatthe lens can accomplish

varies from person toperson.


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FOVEAy The area near the center of the retina is called the

fovea.

y The detectors are packed tightly and details of theimage are distinguished easily.


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Peripheral visiony Light that enters your eye from the side does not fall

on the fovea, but on the part of the retinal where thereare fewer detectors.

y This explains why peripheral vision is limited.


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y The placement and

number of cones inyour retina limit howwell you see colors inyour peripheral vision.


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The placement of rods andcones differ in people whichaccounts for the diversity ofvision

Re ate Terms


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Vitreous Humor a gel-like substance that transmits light to the

retinaOptic Chiasm where the visual information is transmitted to

both sides of the brainThe lens provide fine focus for light transmitted to the retinaThe Retina receives images formed by the lens and is the

instrument of visionThe cornea provide the main refractive changes for light entering

the eyesThe iris regulate entrance of light by contracting or dilating the

pupil

Accommodation is the process by which the lenses change shapeto focus the image of the object on the retinaPupils constrict when in bright lightThe extrinsic mscle of the eyeball are responsible for abduction

and adduction


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Diagnostic assessmenty Snellen Chart test for visual acuity, normal result 20/20y Ishihara plate test for color visiony Retinoscopy determine refractive error of an eyey Cover and uncover test differentiates various types of strabismus

y Tonometry indirect measure of IOP, Normal is 11 21 mmHgy Gonioscopy a biomicroscopic examination that visualizes the anterior

chamber angle; Dx congenitaal and secondary glaucomay Perimetry measurement of the peripheral visual fieldy BjerrumTangent Screen measure central visiony Ophthalmoscopy examine the fundus of the eyesy Slit lamp Biomicroscopy assessess the eyes anterior portion under

high magnification and in optical section. Diagnosed astigmatism

a. Visual Acuityh l f


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yy Sharpness or clearness of vision

y Measurement of the resolving power of the eye, with its

ability to distinguish letters and numbers at a givendistance

y Standard Snellen chart is used to examine visual acuity

b. External and Internal Eye examination

y Observe the following:o Position of the eye color and size

o Eyelids and eye lashes Nystagmus

o Blink response Iris and Pupil

o Cornea and corneal reflex Ptosiso Conjunctiva and sclerae Pain

o Cranial nerve palsy


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Present and past health Hx:

y

Previous hospitalization and illnessy Hx of allergies and childhood disease

y Family heallth Hx, specifically eye disorders

DIAGNOSTIC EVALUATION:

A. Fundus Photography

- The use of special retinal camera to document details ofthe fundus of the eyes

- Used to evaluate optic nerve changes in patients withglaucoma

b. Exophthalmometry


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y Used to measure the progressionor regression of eyeprotrusion in patients with tumor of the orbit and thyroid

disordersc. OphthalmicRadiography

yA photographic illustration of the eyes through the use ofX-rays films performed to evaluate orbital conditions

d. MRIy Used to provide detailed images of the eyes to detect

presence of edema, areas of demyelination and vascularlsions

e. UTZy The use of high frequency sound waves to determine

growth and size of a lesion and presence of foreign bodyinside the eyes

f. Ophthalmodynamometry


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y Procedure that applies pressure on the sclera to measurethe pressure in the central retinal arteries and carotidarterial blood flow

g. Electroretinography

y Used to measure the electrical potential of the retina; aids

in the diagnosis of retinitis pigmentosa, presence ofischemia and infection

h. Fluorescein angiography

y Injection of fluorescein dye into the antecubital vein; used

to detect abnormal vessels, abnormal blood flow, presenceof ischemia and hemorrage

Care of Client withImpaired Vision


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1. Refractive Errors

a. Emmetropiay State of normal vision: the eye can focus near and

distant objects clearly

y Light rays focus directly into the retina

b Myopia


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b.Myopiay Nearsightedness: inability to focus on distant object

sharplyy An accurately focused image falls in front of the retina

as a result of abnormally long eyeball

yAn eye that is too long or a cornea that is too steep causes

myopia (or nearsightedness). In nearsighted eyes, theimage isn't focused precisely inside the eye, causingblurring in the distance. The more nearsighted you are,the more blurred the distant object appears, and thethicker your glasses need to be. Most nearsighted people

feel that their condition is severe, due to theirdependence on glasses and contact lenses. In fact, onlyone in ten nearsighted individuals are actually in the"severe" or "extreme" categories.

C Hyperopia/Far Sighted


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C.Hyperopia/Far-Sighted

y Farsightedness or the ability of the eyes to focus onnearby objects

y Light rays are focused beyond the retina as the eyeball is

abnormally shorty An eye that is too short, or a cornea that is not steep

enough causes hyperopia (or Farsightedness). Peoplewith hyperopia see blurry when looking at close objects.Young people can slightly overcome hyperopia by using

their focusing muscles to make the image clear.T

his getsharder as they get older. Currently, there are restrictedoptions to correct hyperopia. Most operations are stillunder development.

D Astigmatism


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D. Astigmatismy An abnormal condition of the eye characterized by

blurring of vision in which the light rays cannot befocused clearly in a point on the retina and thespheric curve of the cornea or the lens is not equal toall meridians

y Visual defect caused by the unequal curving of oneor more of the refractive surface of the eyes, usuallythe cornea, producing blurred vision

y Parallel light rays are imperfectly focused on a singlepoint on the retina

2. Low Vision and Blindness


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a. Low vision

y Best corrected visual acuity of 20/70 to 20/200

y Involve the use of special devices aside from correctivelenses to enhance vision

Medical and Surgical Management:

y Use of low vision aids and strategies to enhance themagnification and image

b. Blindness

y Best corrected visual acuity of 20/400 to no light

y Absolute blindness: absence of light perception


y Use low vision aids and non-optical devices

y Rehabilitation training(orientation and mobility training,independent living skills, reading and writing skills)



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yAssess the degrees of assistance the client requires

y O

rient the client to the composition of the meal tray byusing the face of the clock during meals

y Keep the bedside table and call button within reach

y Familiarize the client with the layout of the room

3.Glaucomay A group of ocular conditions characterized by optic nerve


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g p y pdamage related to an abnormal elevation of pressure within theeye caused by obstruction of the outflow of aqueous humor

Hallmarks: Increased IOP and loss of visual field, Tunnel vision

Clinical Forms:

1. Acute or Angle-closure/Closed-Angle/Narrow Angle

o

Narrow angle between the iris and cornea dilates markedlycausing the folded iris to block the exit of aqueous humor fromthe anterior chamber

oAlso called pupillary block

2. Chronic Simple or primaryOpen Angle Glaucoma(POAG)

o Determined genetically; common cause of blindness

o Produce no symptoms except gradual loss of peripheral visionover a number of years

Signs and Symptomsy Blurred vision or halos around lights


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y Problem n focusingy Difficulty in adjusting the eyes in low lighting

y Loss of peripheral visiony Aching or discomfort around the eyesy Headache

Medical/SurgicalMgt:yMiotics(e.g. Pilocarpine)

y Adrenergic agonist (e.g.Dipivefrin, Epinephrine)y Alpha-adrenergic agonist (e,g. apraclonidine, brimonidine)y Beta-blockers(e.g. betaxolol, timolol)y Carbonic anhydrase inhibitors (e.g.acetazolamide,

methazolamide,dorzolamide)y Prostaglandin analogs(e.g. latanoprost)y Laser surgeryy Filtering proceduresy Drainage Implant surgery

Nursing Interventiony Educate about the effect of drugs


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gy Instruct to keep a record of their eyes pressure measurement

and visual field test results

4. CATARACTy Lens opacity or cloudinessSenile Cataracts:y M

ay be congenital or associated with the aging processTypes:1. Nuclear Cataractso Associated with myopiao Progress slowly

o Managed temporarily by periodic changes in prescribedeyeglasses2. Cortical cataractso Progress at a highly variable rate vision is worse in very bright

light

Acataract is a clouding of the eye's natural lens, which lies behind the irisand the pupil


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and the pupilThe lens is mostly made of water and protein. The protein is arranged in aprecise way that keeps the lens clear and lets light pass through it. But as weage, some of the protein may clump together and start to cloud a small areaof the lens. This is a cataract, and over time, it may grow larger and cloudmore of the lens, making it harder to see

3. Posterior Subscapular Cataractsy Usually occur in young people


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y Usually occur in young peopley Associated with inflammation, trauma and prolonged use of

corticosteroidy Near vision is diminishedy Increased sensitivity to bright sunlight and headlightsCAUSES:y Trauma to the eyey

Elevated glucose levels in the aqueous humor(DM

)y Irradiation to the lensy Viruses, chemicals, infectionsy Amino acid or vitamin deficienciesSign and Symptoms:y Painless blurring of visiony Light scatteringy Reduction in contrast sensitivityy Sensitivity to glarey Reduced visual acuity

Medical and Surgical MGT:y Intrascapular cataract Extraction


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y Extrascapular surgeryy Phacoemulsificationy Lens ReplacementNursing Interventions:y Preoperative careo Implement anticoagulant therapy to reduce the risk of

retrobulbar hemorrhageoAdminister dilating drops every 10 minutes for four doses atleast I hour before surgery

y Postoperative care:o Instruct client to avoid rubbing or poking the eye

o Instruct to wear eyeglasses while outdoorso Instruct to immediately notify the surgeon if new floaters,

flashing lights, decrease in vision, pain or increased rednessoccurs

o Instruct to avoid lifting heavy objects

Care of Client with Corneal Disorders1. Corneal Dystrophies


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1. Corneal Dystrophies

y Inherited as an autosomal dominant trait which manifest

at around 20 years of ageSigns and Symptoms:

y Presence of deposits in the corneal layer

y Decrease in vision

y Bullous Keratopathy(formation of blister that cause painand discomfort) due to persistent corneal edema


y Use bandage contact lens to flatten the bullae,

y protect the exposed corneal nerve endings and providecomfort

y Apply hypertonic drops or ointment(5% sodium chloride)to reduce epithelial edema and IOP

2. Keratoconusy A hereditary condition characterized by conical


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A hereditary condition characterized by conicalprotuberance of the cornea with progressive thinning on

protrusion and irregular astigmatismy Higher incidence in women

y Bilateral affectation

y Blurred vision: most prominent symptoms


y Rigid gas-permeable contact lenses to correct irregularastigmatism and improve vision

y

Penetrating keratoplasty, if contact lens correction isineffective

ornea urgery1. Phototherapeutic Keratectomy(PTK)


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y Uses laser to treat diseased corneal tissue by removing or

reducing corneal opacities and smoothing the anteriorcorneal surface to improve functional vision

y More effective alternative than penetrating or lamellarkeratoplasty

y Contraindicated in patients with active herpetic keratitisdue to ultraviolet rays that may reactivate latent virus

Side effect:

y Induced hyperopia and stromal haze

PostoperativeMgt:y Oral analgesics, antibiotic, corticosteroids ointment and

NSAIDs

2 KERATOPLASTYy Replacement of the abnormal host tissue with a healthy donor


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Replacement of the abnormal host tissue with a healthy donorcorneal tissue

y Graft may be partial(Lamellar Keratoplasty) or full (penetratingkeratoplasty) thickness

y Common indications are keratoconus, corneal dystrophy,corneal scarring from herpes simplex, keratitis and chemicalburns

NURSING INTERVENTIONS:y Prescribe mydriatics for 2 weeks and topical corticosteroids for

12 months, which is gradually tapered postoperativelyy Evaluation of graft site and visual acuityy Primary goal of nursing care is to educate the patient in

identifying signs and symptoms of graft failurey An early symptoms of graft failure includes: blurred vision,

discomfort, tearing or redness of the eyesy Treatment of graft rejectiony Prompt administration of hourly topical corticosteroidsy

Periocular corticosteroid injection

Care of Clients with Retinal Detachment


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1. RETINAL DETACHMENT- Separation of the retinal pigment epithelium from the

sensory layer- Results from separation of the sensory layer of the retinacontaining the rod and cones from the pigmented epithelial

layer beneath.- It may occur spontaneously because of degenerativechanges in the retina (as in diabetic retinopathy) or vitreoushumor, trauma, inf lammation, tumor, or loss of a lens to acataract.

- It is rare in children, the disorder most commonly occursafter age 40.Untreated retinal detachment results in loss of a portion ofthe visual field

Causes/Risk factors


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Causes/Risk factors

ModifiableTrauma

y Hemorrhage

y Exudates that occur in front of or behind the retina

y Sudden, severe physical exertion especially in persons whoare debilitated.

y Non-modifiableMyopic degeneration

y

Aphakia (absence of crystalline lens)y


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Types:

1. Rhegmatogenous

o Liquid vitreous seeps into the sensory retina and

detached it from the retinal pigment epitheliumo Most common form of retinal detachment

o Associated with myopia and aphakia after surgery andproliferative retinopathy

2. TRACTION

y Results from tension or pulling force

y Associated with diabetic retinopathy vitreoushemorrhage and retinopathy of maturity

3. Combination of Rhegmatogenous and Traction

4 Exudative


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4. Exudative

y Results from the production of a serous fluid under the

retina from the choroids

y Uveitis or macular degeneration the productionmay causeof serious fluid

Signs and Symptoms:

y Sensation of a shade or curtain coming across the vision ofone eye

y Cobweb formation

y

Bright light flashingy Sudden onset of a great number of floaters

y painless

Assessment


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Assessmenty

Initially, the patient complains of f lashes of light, f loatingspots or filaments in the vitreous, or blurred, sooty vision.Most of these phenomena result from traction between theretina and vitreous.

y If detachment progresses rapidly, the patient may report aveil-like curtain or shadow obscuring portions of the visualfield. The veil appears to come from above, below, or fromone side; the patient may initially mistake the obstructionfor a drooping eyelid or elevated cheek.

y Straight-ahead vision may be unaffected in early stages but,as detachment progresses, there will be loss of central aswell as peripheral vision.


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y Diagnostic EvaluationO

phthalmoscopy or slit-lamp examination with full pupildilation shows retina as gray or opaque in detached areas.The retina is normally transparent.

y

Primary Nursing DiagnosisSensory-perceptual alterations (visual) related todecreased sensory reception

y

Medical ManagementSurgical intervention aims to reattach the retinal layer tothe epithelial layer and has a 90% to 95% success rate.

Medical and Surgical MgtyVitrectomy, Argon laser Photocoagulation or cryotherapy


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y, g g y py


y If gas tamponade was used, instruct the patient to lie facedown or on sides

y Educate the patient about the signs of increasing IOP,endophthalmitis, retinal detachments and phthisis(loss of

eye turgor)

Techniques include:Photocoagulation, in which a laser or xenon are spot welds the retina to the pigmentepithelium.

lectrodiathermy, in which a tiny hole is made in the sclera to drain subretinal fluid,allowing the pigment epithelium to adhere to the retina.Cryosurgery or retinal cryopexy, another spot weld technique that uses a super cooledprobe to adhere the pigment epithelium to the retina.Scleral buckling, in which the sclera is shortened to force the pigment epithelium closerto the retina; commonly accompanied by vitrectomy.


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Pharmacologic Interventiony

Drops as prescribed ofCyclopentolate hydrochloride(Cyclogyl) a cycloplegic agent that causes dilation of

the pupil and rest of the muscles of accommodationy Drops as prescribed of antibiotics Gentamicin;

prednisolone acetate to prevent eye infections

y Other Drugs: Antiemetics and analgesics are ordered

to manage nausea, vomiting, and pain.

NursingInterventionPrepare the patient for surgery.

y Instruct the patient to remain quiet in prescribed (dependent) position, to keep thed h d f h i i d d i i


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detached area of the retina in dependent position.y Patch both eyes.y

Wash the patients face with antibacterial solution.y Instruct the patient not to touch the eyes to avoid contamination.y Administer preoperative medications as ordered.

y Take measures to prevent postoperative complications.y Caution the patient to avoid bumping head.y Encourage the patient no to cough or sneeze or to perform other strain-inducing

activities that will increase intraocular pressure.

y Encourage ambulation and independence as tolerated.y Administer medication for pain, nausea, and vomiting as directed.y Provide quiet diversional activities, such as listening to a radio or audio books.y Teach proper technique in giving eye medications.y Advise patient to avoid rapid eye movements for several weeks as well as straining or

bending the head below the waist.y

Advise patient that driving is restricted until cleared by ophthalmologist.y Teach the patient to recognize and immediately report symptoms that indicate

recurring detachment, such as floating spots, f lashing lights, and progressiveshadows.

y Advise patient to follow up

2. Retinal Vascular Disordery Occurs from occlusion of a retinal artery or vein


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y

y Results from atherosclerosis, cardiac valvular disease,

venous stasis, hypertension, or increased blood viscosityTypes:

1. Central Retinal Vein Occlusion

o Decreased visual acuity that may range from mildblurring of vision that is limited only to hand-motion

vision

Medical-SurgicalMgt:

y Monitor carefully for signs of neurovascularization andneovascularglaucoma

y Laser panretinal photocoagulation may be done


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3.Macular Degenerationy Tiny yellowish spot(drusen) beneath the retina


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y y p ( )

y Most common cause of visual loss in people older than 60

year of agey Commonly termed as Age-related macular

degeneration(AMD)

y Central vision is generally the most affected

y Most patient retain peripheral vision

Types:

1. Dry

o Most common type of macular degenerationo Outer layers of the retina slowly breakdown

o No known treatment that can slow or cure this type ofAMD

11. WETy May have abrupt onset

S i h li k d d di d h l i


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y Straight lines appear crooked and distorted or the letters in

words appear broken upMedical and Surgical Mgt:

y LaserTreatment

y Use bright light and magnification devices

yAmsler grids to detect sudden onset of distortion of vision

Care of Client with Orbital and Ocular Trauma1. Orbital Trauma


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y Usually associated with a head injury

y

Patients general medical condition must be 1st

stabilizedbefore conducting an ocular examination

y Visual acuity is assessed as soon as possible to establish theextent of ocular injury

Soft tissue Injury and Hemorrhage:

o Assessment: Tenderness, Ecchymosis, Lid swelling, Proptosis,Hemorrhage

o Closed Injuries lead to contusions with subconjunctivalhemorrhage: Black eye

o

Visual loss can be sudden/ delayed and progressiveo Immediate loss of vision after an ocula injury is usually

irreversible

o Corticosteroids therapy to reduce optic nerve swelling

FRACTUREy Clearly established by facial x-raysy Classification of orbital fractures: blow out Zygomatic or tripod


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y Classification of orbital fractures: blow out, Zygomatic or tripod,maxillary, mid-facial, orbital apex and orbital roof fracture

y Orbital roof fractures are dangerous because of potential complicationsof the brain

Foreign BodiesyUsually tolerated except for copper, iron and

vegetative material, such as those from plants andtrees, which may cause purulent infectionMedical and Surgical Mgt:yUse X-rays and CT scan to identify foreign bodies

yAdminister prophylactic antibioticsy Surgery to prevent further ocular injury and to

maintain the integrity of the affected area

2. Ocular Trauma

y Leading cause of blindness among children and young


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y Leading cause of blindness among children and youngadults, especially in males

y Most common circumstances of ocular trauma:occupational injuries, sports, weapons, motor vehiclecrashes and war

M

edical and SurgicalM

gt:y Perform irrigation with normal saline for splash injuries

y Initiate antibiotics, except for topical ones, to preventpotential toxicity to exposed intraocular tissues

yAdminister TT antitoxin, analgesic, antiemetics

3. Ocular BurnsTypes:


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a. Chemical Burns

1. Alkaline: penetrates the ocular tissues rapidly andcontinues to cause damage long after the injury issustained

11. Acids: cause less damage because the precipitated necrotic

tissue proteins form a barrier to further penetration anddamage

b.Photochemical Injury causes corneal epithelial defect,corneal opacity, conjunctival chemosis, and burns of the

eyelids and periocular regionc. Thermal Injury result from exposure to hot objects

Medical and Surgical Mgt:y Copious irrigation of the corneal surfaces and conjunctival


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fornices using normal saline or any neutral solution

y Irrigation continues until the conjunctival pH normalizesbetween 7.3 and 7.6

y Long term Tx

y Restoration of the ocular procedure surface through grafting

proceduresy Surgical restoration of corneal integrity and optical clarity

Care of Client withInfectious and Inflammatory Condition1. DRYEYE SYNDROME

f h d f f h


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y Deficiency in the production of any of the aqueous,

mucin, or lipid tear film componentsy May be related to systemic disease infection or injury

Signs and Symptoms:

y Scratchy or foreign body sensation(common complaint)

yItching, redness, pain

y Excessive mucus secretion

y Inability to produce tears

y Burning sensation

y Difficulty in moving the lidsy Slit lamp examination shows an absent or interrupted

tear meniscus at the lower lid margin and thickenededematous, hyperemic, and not lustrous conjunctiva

urs ng n erven onsy Explain to the patient that the dry eye condition is a long-

bl d h l b f


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term problem and that complete abatement of symptom

is unlikelyy Hydration and lubrication through tear stimulation,

artificial tears and lubricants, tear preservation,preservation of a moist ocular surface, and anti-

inflammatory medicationsy Medical mgt include preservative-free ophthalmic

solutions, Punctal occlusion, grafting procedures andlateral tarsorrhapy(suturing together of the eyelids

partially or entirely to shorten the palpebral fissure or toprotect the cornea)

2. CONJUCTIVITIS (Pink EYE)y Inflammation of the conjunctiva as the result of

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subconjunctival blood vessel hemorrhage

Signs and Symptoms:y Scratching or burning sensation

y Itching, photophobia

y Presence of pseudomembranes and lymphadenopathy


yApply topical antibiotic, eye drops or ointment,corticosteroids in ophthalmic preparations

y

Vasoconstrictors and topical epinephrine solutiony Irrigation of the eye immediately and profusely with saline

or sterile water

Nursing Intervention:y Implement and instruct patient to do frequent hand


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washing

y Disinfect equipment used for eye examinationyApply cold compress, ice packs and cool ventilation to

provide comfort

Uveitisy Inflammation of the uveal tract of the eye including the


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iris, ciliary body and choroid

Types:1. Non-granulomatous

o An acute problem with pain, photophobia and pattern ofconjunctival infection, particularly around the cornea

11.Granulomatous

o Onset is insidious and chronic

o Involves any portion of the uveal tract

o Symptoms, such as photophobia and pain, may beminimal and keratic precipitate may be large and grayish

o Vision is markedly and adversely affected

Medical Mgt:y Use cyclogel and atropine for ciliary spasm and


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synechia(abnormal union of parts, especially adhesion of

the iris to the cornea in front, or to the lens capsulebehind

y Use local corticosteroid drops for 4 -6 times a day todecrease inflammation

Nursing MGT:y Instruct the patient to wear dark glasses during outdoor

activities

4. Orbital Cellulitisy Inflammation of the tissue around the eye secondary to bacterial,

fungal or viral inflammatory conditions


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fungal, or viral inflammatory conditions

y Most frequent cause is the infection of the sinus

y Result from foreign bodies and from a preexisting ocular infection

Origin of Infection

o Children: ethmoid and maxillary sinuses

oAdults: frontal-ethmoid

Predisposing Factors:

y Recurrent sinusitis

y Polyps allergy

y Trauma

y Recent dental extraction

Causative organism:

y Children: H. Influenza

y Adults: Staphylococci and Streptococci


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Nursing Intervention:y Monitor changes in visual acuity; degree of ptosis, and CNS

f ti


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function

yAssess for displacement of the globe, pupillary signs andthe fundus

5. MUCORMYCOSIS

yAn acute, usually fulminating, infection by a fungus of the

Mucorales order, usually accompanies a systemic disordersuch as Dm, lymphoma

y Causes: fungal infection by phycomycetes

yAssessment:

o Early symptoms: pain and proptosis; necrosis; sinusitis;pharyngitis; Nasal discharge; late symptoms: brain abscessand meningitis

Medical and Surgical Mgt:y Treat the underlying metabolic condition

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y Surgical interventions to remove the necrotic tissues and

drain the abscessy Irrigate with antifungal antibiotics

yAdminister AmphotericinB


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STYE - HORDEOLUMyA pustular inflammation of an eyelash follicle or sebaceous

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gland on the lid margin

Caused:y Staphylococcal organism

S &S:

y Pain, redness, and swelling of the specific area of the eyelid

Tx:

yWarm compress

y Topical antibiotic ointment

y Severe cases:I&D

CHALAZIONy Is a cyst of the meibomian glands, which are sebaceous

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glands located at the junction of the conjunctiva and inner

eyelid marginsS&S:

y Painless localized swelling that develops over a period ofweeks

Tx:

y Surgical excesion if the cyst is large, become infected

Nursing Process for Client with Altered Ocular

Function due to Systemic Diseases


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1. Diabetic Retinopathy

y Most common Cx of DM affecting the small blood vesselsthat nourish the retina

y Characterized by capillary microaneurysms, hemorrhage,

exudates, and the formation of new vessels andconnective tissue


y Laser tx

y Vitrectomy microsurgical procedure for removing anopacity from vitreous cavity of the eye


y Teach patient about blood glucose monitoring


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p g g

y Educate the patient about proper eye care

yAssist the client in his/her adjustment to impaired vision

yAdvice patient to consult an ophthalmologist

2. Cytomegalovirus Retinitisy Most common form of retinal inflammation in patient


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with AIDS

y Patient complain of floaters, decrease in peripheralvision, paracentral or central scotoma(blindness withinthe visual field) and fluctuation in vision from macularedema


y Pharmacologic agent include ganciclovir, foscarnet, andcidofoviar

3 Hypertension Related to Eye


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3.Hypertension-Related to Eye

Changes

y Chronic HTN and atherosclerosis can cause retinal

tortuousness, narrowing and change in light reflexyAcute HTN can cause retinal hemorrhages, cotton wall spots,

retinal edema, and retinal exudates, often clustered aroundthe macula

y

Ischemic optic neuropathy and papilledema may result

Surgical Procedures and Enucleation1. Orbital Surgeries

y T i F f i b d b i


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y To repair Fx, remove foreign body, or remove benign or

malignant growthsy To recover and preserve visual function and maintain the

anatomic relationship of the ocular structures to cosmesis

y Complication: blindness as a result of damage to the optic

nerve and its blood supplyNursing Intervention:

y Elevate the head of the bed from 30 to 45 degrees

y Apply light ice compresses over the periocular area todecrease periorbital swelling, facial swelling andhematoma

y Provide comfort, reassurance, and emotional support tothe client

2. Enucleation

y Removal of the entire eye and part of the optic nerve


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y Removal of the entire eye and part of the optic nerve

y Performed for the following conditions:o Severe injury resulting in prolapse of uveal tissue

o Irritated, blind, painful, deformed,or disfigured eye

o Eye without useful condition that produces or has created

sympathetic ophthalmia in the other eyeo Intraocular tumors that are untreatable by other means

THYROID EYE DISEASE


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y 1. Soft tissue involvement

y Periorbital and lid swelling

y Conjunctival hyperaemia

y

Chemosisy Superior limbic keratoconjunctivitis

2. Eyelid retraction

3. Proptosis

4. Optic neuropathy

5. Restrictive myopathy

Soft Tissue Involvement

y Periorbital and lid swelling


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y Periorbital and lid swelling y Conjunctival hyperaemia

ChemosisSuperior limbickeratoconjunctivitis

gns o eye retract onBilateral lid retraction

No associated proptosis

Bilateral lid retraction

Bilateral proptosis


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Unilateral lid retraction

Unilateral proptosisLid lag in downgaze

Uninfluenced by treatment of hyperthyroidism


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Axial and permanent in about 70% May be associated withchoroidal folds

Treatment optionsSystemic steroids

Radiotherapy

Surgicaldecompression


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care of client witheent disorder of

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