PRESENTED BY

CARMELITA RAMOS, RN

Vision- Eyes
Accessory structureseye brows, eyelashes- protection
eye lids- protection & lubrication (blinking)
Conjunctiva
Lacrimal apparatusLacrimal Gland lacrimal duct surface of

upper
eyelid

lacrimal
canal
nasolacrimal duct nasal cavity

extrinsic eye muscles- moving eyeball

Superior Rectus, inferior rectus, lateral rectus,

medial rectus, superior oblique, inferior oblique

&

Layers of Eyeball
Fibrous tunic ( Outermost Coat) Anterior

clear
Cornea - bulges anteriorly from its junction with the
sclera
crystal clear due to the arrangement of its collagen
fibers
part of the light-bending apparatus of the eye
allows light to enter the eye
covered with epithelial sheets that help protect the
cornea from abrasion
capable of regeneration and repair
well-supplied with nerve endings (mostly pain
receptors)
One of the organs to be successfully transplanted

Layers of the Eye

Sclera- white of eye
Helps maintain the shape of the eye
Protects internal structures
Provides attachment sites of the extrinsic eye muscles

Vascular Tunic
Choroid- Lines most of internal surface
carries blood vessels
With melanin containing pigment cells so it appears black

in color
Ciliary body- focuses the lens and secretes aqueous humor
- anterior portion of the choroid
Iris- opens & closes pupil contains pigment of eye color.
Pupil = hole for light passage
Adjusted by iris to control amount of light through the lens

Layers of Eyeball (Cont.)

Nervous Tunic
Retina- two layers
Pigmented Retina- with choroid

-keeps light from reflecting back into the

eye by absorbing stray light
Sensory RetinaPhotoreceptor layer- Rods and Cones
Bipolar cell layer
Ganglion cell layer

Photoreceptors
Rods very sensitive, black & white
more numerous
dim light and peripheral vision
receptors
more sensitive to light
do not provide sharp images or color
vision
in dim light colors are indistinct

Photoreceptors
Cones- color sensitive,
3 types-blue, green & red
operate in bright light
provide high acuity color vision
Color vision results from combined input
Cones mostly in central fovea in center of
macula lutea
Area of highest visual resolution
Information bipolar layer ganglion cells
axons = optic nerve

Interior of Eyeball
Two

cavities- Anterior cavity & Vitreous

Chamber divided by lens
Anterior filled with Aqueous humor
Drains into canal of schlemm.- replaced ~90
min.
Maintains eye shape & nourishes lens & cornea
Responsible for intraocular pressure
Vitreous chamber- filled with vitreous body
Gel-like - holds retina against choroid

Internal Chambers of the

Eye

Refraction of Light
Light rays bend on passing from

medium of one density to another

of different density = refraction
75% occurs at cornea

Lens- focuses light on the retina

Image is inverted but brain

adjusts & interprets distance and

size

Accommodation
Lens adjusts for distance to keep image

focused on retina

With distant objects ciliary muscle is relaxed

Contracts as the object becomes closer

Myopia= cant accommodate distant objects-

Eyeball is too long

Hyperopia = cant accommodate far objectsEyeball is too short
Astigmatism= irregular curvature of cornea
or lens

Other
visual
controls
Constriction of pupilautonomic reflex to center light on lens

Convergence- eyes rotate toward midline

as object nears it is necessary to

maintain focus on single object for

binocular vision
Photoreceptors: light neural signal
light is absorbed by a photopigment
(rhodpsin) which splits into opsin &
retinal

Visual Pathway
Each of the visual field is divided into temporal and

nasal half.
After passing through the lens, light from each half
of a visual field projects to the opposite side of the
retina.
An Optic nerve consist of axons extending from the
retina through optic chiasm
About 1/2 cross over into optic tract
The axons synapse in the thalamus
hypothalamus occipital lobes
Right brain sees left side of object
Left brain sees right side of object

CATARACT
a clouding that develops in the crystalline lens of the

eye or in its envelope, varying in degree from slight to

complete opacity and obstructing the passage of light.
The condition usually affects both the eyes, but almost
always one eye is affected earlier than the other.
derives from the Latin cataracta meaning "waterfall"
and the Greek kataraktes and katarrhaktes, from
katarassein meaning "to dash down" (kata-, "down";
arassein, "to strike, dash")
In dialect English a cataract is called a pearl, as in
"pearl eye" and "pearl-eyed".

Classification
Classified by etiology

Age-related cataract

Cortical Senile Cataract

Immature

senile cataract (IMSC):

partially opaque lens, disc view hazy
Mature senile cataract (MSC):
Completely opaque lens, no disc view
Hypermature senile cataract (HMSC):
Liquefied cortical matter

Classification
Congenital cataract

Bilateral cataracts in an infant due to

Congenital rubella syndrome

Secondary cataract

Drug-induced cataract (e.g. corticosteroids), DM

Traumatic cataract

Blunt trauma (capsule usually intact)

Penetrating trauma (capsular rupture & leakage of
lens materialcalls for an emergency surgery for
extraction of lens and leaked material to minimize
further damage)

Causes
Age
Long term exposure to UV light
Cigarette smoking
Heavy alcohol use
Eye injury or inflammation
Congenital defect
DM
Medications

What does a mid-stage

cataract
look like?

What does a late-stage cataract

look like?

Pathophysiology
The lens is a clear part of the eye that helps to focus light, or an

image, on the retina

The lens is made mostly of water and protein.
The protein is normally arranged to let light pass through and focus
on the retina.
Protein clumps together (aging process= degeneration)
Small areas of lens begin to cloud
Light is blocked from reaching the retina and vision is impaired
Over time, the cloudy area in the lens may get larger

Signs and symptoms

Cloudy or blurry vision.
Colors seem faded (Decreased color perception)
Glare. Headlights, lamps, or sunlight may appear too

bright. A halo may appear around lights.

Poor night vision.
Double vision or multiple images in one eye. (This
symptom may clear as the cataract gets larger.)
Absence of red reflex
Better near vision in those who are farsighted as the lens
becomes cloudier the optics of the eye change this may
actually allow people who once needed glasses to be able
to read without them

Cataract
Detection/diagnosis
Eye examination
Visual acuity test: This eye chart test

measures how well you see at various distances

Pupil dilation: the pupil is widened with eye
drops to allow your eye doctor to see
more of the lens and retina and look for
other eye problems
Tonometry: This is a standard test to measure
fluid pressure inside the eye

The symptoms of early

cataract may be improved
with:

new eyeglasses
brighter lighting
anti-glare
sunglasses
magnifying lenses

If these measures do not help:

surgery is the only

effective treatment.
Surgery involves
removing the cloudy lens
and replacing it with an
artificial lens.

Phacoemulsification, orphaco.
extra-capsular (extracapsular

cataract extraction, or ECCE)

intra-capsular (intracapsular

cataract extraction, or ICCE).

1. Phacoemulsification,

orphaco.
A small incision is made on
the side of the cornea, the
clear, dome-shaped surface
that covers the front of the
eye. Your doctor inserts a tiny
probe into the eye. This
device emits ultrasound
waves that soften and break
up the lens so that it can be
removed by suction. Most
cataract surgery today is done
by phacoemulsification, also

Extra-capsular (ECCE)
surgery consists of
removing the lens but
leaving the majority of
the lens capsule intact.
Intra-capsular (ICCE)
surgery involves
removing the entire lens
of the eye, including the
lens capsule, but it is
rarely performed in

 After the natural lens has

been removed, it often is

replaced by an artificial
lens, called an intraocular
lens (IOL).
An IOL is a clear, plastic
lens that requires no care
and becomes a permanent
part of your eye. Light is
focused clearly by the IOL
onto the retina, improving
your vision. You will not feel
or see the new lens.

 Anxiety

Deficient knowledge

(diagnosis and treatment)

Disturbed sensory

perception: Visual
Risk for infection
Risk for injury

Postoperatively, monitor the

patient until he recovers from the

effects of the anesthetic.
Keep the side rails of the bed up,
monitor vital signs, and assist him
with early ambulation.
Apply an eye shield or eye patch
postoperatively as ordered.
Communication enhancement:
Visual deficit; Activity therapy;
Cognitivestimulation;
Environmental management; Fall
prevention; Surveillance: Safety

Caution him to avoid activities

that increase intraocular

pressure, such as straining with
coughing, bowel movements, or
lifting
Clients fitted with cataract
eyeglasses need information
about altered spatial perception.
The eyeglasses should be first
used when the patient is seated,
until the patient adjusts to the

Instruct the client to look

through the center of the

corrective lenses and to turn the
head, rather than only the eyes,
when looking to the side.
Clear vision is possible only

through the center of the lens.

Hand-eye coordination
movements must be practiced
with assistance and relearned
because of the altered spatial
perceptions.

RETINAL DETACHMENT
- a painless, gradual loss of vision described as a veil,
curtain, or cobweb that eliminates a portion of the visual
field.

- occurs when the layers of the retina separates from

the choroid, creating a subretinal space where fluid
accumulates.

- a medical emergency where time is of the essence.

Unless the detached retina is promptly surgically
reattached, it may lead to permanent loss of vision.

Causes

- degenerative changes in the retina or vitreous

- a tumor e.g. retinoblastomas

- inflammation

- systemic disease e.g. diabetes

- high myopia

- cataract surgery

- trauma

RETINAL DETACHMENT
TYPES:
PARTIAL RETINAL DETACHMENT
- becomes complete if left untreated

COMPLETE RETINAL DETACHMENT

- when detachment is complete, blindness may occur

RETINAL DETACHMENT
Diagnostic tests

Opthalmoscopy

done by fully dilating the pupil for proper

diagnosis
retina becomes gray and opaque from
transparent
reveals folds in the retina and a ballooning out of
the area

Ultrasonography

performed when lens is opaque

RETINAL DETACHMENT
Signs and Symptoms

IMMEDIATE NURSING CARE

Complete bed rest

Flashes of light
Floaters
Increase in blurred vision
Sense of curtain being

drawn

Restriction of eye movement to

prevent further detachment with eye
patches

Speak before approaching

Position the clients head as prescribed

Protect from injury

No sudden head movements

Minimize eye stress

Loss of a portion of the

visual field

Prepare for surgical procedure as

prescribed

RETINAL DETACHMENT
MEDICAL INTERVENTION

- removing or draining fluid from the sub-retinal space

so that the retina can return to its normal position

SCLERAL BUCKLING
holds the choroid and retina together with a splint

SEALING RETINAL BREAKS BY CRYOSURGERY (CRYOPEXY)

using an intense cold to freeze the retina around the tear
reattaching it to the choroid
a local anesthetic numbs the eye then a freezing probe is
applied to the outer surface of the eye directly over the retinal
defect

INSERTION OF A GAS OR SILICONE OIL

it promotes attachment because air/oil have a specific gravity
less than vitreous & can float against the retina

RETINAL DETACHMENT

RETINAL DETACHMENT
DIATHERMY

the use of electrode needle & heat

through the sclera to stimulate an
inflammatory response leading to
adhesions

LASER THERAPY
during photocoagulation, a laser
beam is directed through a special
contact lens to make burns around the
retinal tear creating a scar to weld the
retina to the underlying tissue

RETINAL DETACHMENT
POST-OP NURSING CARE

Maintain eye patches bilaterally

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

Glaucoma
is a disease in which the optic nerve is damaged, leading to
progressive, irreversible loss of vision. It is often, but not
always, associated with increased pressure of the fluid in the
eye
Glaucoma is characterized by high IOP associated with optic
disk cupping and visual field loss
The nerve damage involves loss of retinal ganglion cells in a
characteristic pattern
has been nicknamed the "silent thief of sight" because the
loss of vision normally occurs gradually over a long period of
time and is often only recognized when the disease is quite
advanced

Normal outflow through

trabecular meshwork (large

Signs and symptoms

Open-angle Glaucoma

It is painless and does not have acute attacks.

The only signs are gradually progressive visual field

loss, and optic nerve changes (increased cup-todisc ratio on fundoscopic examination).
Closed-angle Glaucoma
characterized by sudden ocular pain
seeing halos around lights
red eye
very high intraocular pressure (>30 mmHg)
nausea and vomiting, sudden decreased vision
fixed, mid-dilated pupil
Acute angle closure is an ocular emergency.

Glaucoma classified according

to etiology
Primary glaucoma

Open-angle glaucoma

Chronic angle-closure

Angle-closure glaucoma
Congenital glaucoma
Secondary glaucoma

Siderosis

Trauma
Neovascular glaucoma
Open-angle, trabecular
abnormality

Congenital Glaucoma
Onset: antenatally to 2 years old

Symptoms
Irritability
Photophobia
Epiphora
Poor vision

Signs
Elevated IOP
Buphthalmos
Haabs striae
Corneal clouding
Glaucomatous cupping
Field loss

Congenital Glaucoma
Buphthalmos and cloudy corneas

Congenital Glaucoma
Buphthalmos,
glaucomatous
cupping, and
cloudy cornea
OD

Normal OS

Haabs striae

pathophysiology

The major risk factor for most Glaucomas and focus of

treatment is increased intraocular pressure
In primary open-angle glaucoma, aqueous outflow by
these pathways is diminished

In angle-closure glaucoma, the iris is abnormally

positioned so as to block aqueous outflow through the
anterior chamber (iridocorneal) angle
.As aqueous fluid accumulates in the eye, increased
pressure inhibits the blood supply to the optic nerve and
the retina.
These delicate tissues become ischemic and gradually lose
function

Normal optic disc. Note the

distinct optic disc margins, the
well-demarcated cup, and the
healthy pink color of the
neuroretinal rim.
The cup-to-disc ratio of this optic
nerve is 0.6. Clinical correlation
with the patient's history and
examination is required to
decide if this optic nerve is
abnormal.
Glaucomatous optic nerve cupping.
The cup in this optic nerve is
enlarged to 0.8, and there is typical
thinning of the inferior neuroretinal
rim, forming a "notch."

Causes - Risk Factors

Ocular hypertension (increased pressure within the

eye)
African descent are three times more likely to develop
primary open angle glaucoma.
Elder people have thinner corneal thickness and often
suffer from hypermetropia
family history of glaucoma
"secondary glaucomas
(steroid-induced glaucoma), DM, hypertension, ocular
trauma (angle recession glaucoma); and uveitis
genetics

GLAUCOMA
Tonometry

Applanation

Schiotz

GLAUCOMA
Goldmann applanation
tonometer

GLAUCOMA
Tonopen

GLAUCOMA
Goldmann
perimeter

Glaucoma visual
fields

THE VISUAL FIELD

Humphrey automated perimetry

GLAUCOMA
Early

Visual fields in
glaucoma
Late

GLAUCOMA
Cup-to-disk ratio

GLAUCOMA

DISK CUPPING

Normal

Glaucoma

Management
The modern goals of glaucoma

management are to avoid glaucomatous

damage, nerve damage, preserve visual
field and total quality of life for patients
with minimal side effects.

Surgery

Canaloplasty- an incision is made into the eye to gain

access to Schlemm's canal in a similar fashion to a
viscocanalostomy
Laser surgery

Laser Trabeculoplasty- The use of laser to create an

opening in the trabecular meshwork is often indicated before
filtering surgery is considered.
The laser produces scars in the trabecular meshwork causing
tightening in the meshwork fibers

Trabeculectomy1- A half thickness scleral flap is

loosely sutured over the created opening through which the
fluid escapes. Resulting in subconjunctival absorption of the
aqueous humor.

Iridotomy- the creation of new route for the flow of

aqueous humor to the trabecular meshwork.

Care after Surgery

Teach the client and family and provide written

information on the following:

Manifestation of infection
Manifestation of increased intraocular pressure
The rationale for eye protection
Medications and Eye drops instillation techniques
Scheduled return visit and time
Treatment for the surgical site

- Carefully clean the area with tap warm water and clean wash
cloth
- Do not rub or apply pressure over the closed eye, which may
damage healing tissue.