VII

Altered Function of the Eye

Altered Function of the Eye

Altered functions of the Eye - Eyelids - Conjunctiva - Cornea - Retina - Glaucoma - Cataract -Assist in Diagnostic procedures -Preparation and care of client going for surgery

Learning Outcome
Identify the altered functions of the eyes Define each altered functions of the eyes List out the nursing diagnosis in each altered function of the eyes

Eyes Disorders

Eyes

Parts of the Eye

y Cornea -- the transparent front window of the eye. The cornea transmits and focuses light into the eye. y Iris -- the colored part of the eye. The iris helps regulate the amount of light that enters the eye. y Pupil -- the dark center in the middle of the iris. The pupil changes size in response to various degrees of illumination to control the amount of light that is let into the eye.
8

Parts of the Eye

y Lens -- the transparent structure behind the iris that focuses light rays onto the retina. y Retina -- the nerve layer that lines the back of the eye. The retina senses light and creates impulses that are sent through the optic nerve to the brain. y Macula -- a small specialized area in the retina that contains special light sensitive cells. The macula allows us to see fine details clearly.
9

Parts of the Eye

y Optic Nerve -- the nerve that connects the eye to the brain. It carries the impulses formed by the retina to the brain, where it is interpreted as images. y Vitreous -- the clear, jelly-like substance that fills the middle of the eye.

10

Definition of Terms
Vision - Passage of rays of light from an object through the cornea, aqueous humor, lens and vitreous humor to the retina and its appreciation in the cerebral cortex Emmetropia - Normal vision : Rays of light coming from an object at a distance at 20 feet ( 6m) or more are brought to focus on the retina by the lens.
11

 Ametropia : Abnormal vision Myopia - Nearsightedness : rays of light coming from an object at a distance of 20 feet or more are brought to a focus in front of the retina Hyperopia - Farsightedness : rays of light coming from an object at a distance at 20 feet or more are brought to a focus in back of the retina Accommodation - Focusing apparatus of the eye adjust to object at different distances by means of increasing the
12

 Presbyopia - The elasticity of the lens decreases with increasing age: an emmetropic person with presbyopia will read the papers at arm s length and will require prescription lenses to correct the problem Astigmatism - Uneven curvature of the cornea causing the patient to be unable to focus horizontal and vertical rays of light on the retina at the same time.

13

Common Abbreviations
RE - Right eye LE - Left eye OU - Both eyes IOP - Intraocular pressure IOL - Intraocular lens EOL - Extraocular lens

14

Eye Care Specialist

Optalmologist - Medical doctor specializing in diagnosis and treatment of the eye. Ophthalmology specialist may focus their practice on a specific part of the eye or disorder, such as cornea specialist. Optometrist - Doctor of optometry who can examine, diagnose and mange visual problems and disease of the eye but does not perform surgery.
15

Eye Care Specialist

Optician - Fits and adjust and give eyeglasses or other devices on the written prescription of an ophthalmologist or optometrist. Ocularist - Technician opthalmist prostheses. who make

16

Eye Disorder

Myopia

17

Myopia
Myopia -Near :sightedness, caused by elongated eyeball or misshapen cornea; image is in front of the retina Hyperopia :Far-sightedness, caused by eyeball being too shallow, lens being too flat, or misshapen cornea; Image is behind the retina
18

19

Definition
Myopia or nearsightedness is a condition in which object in the distance are blurred either because of the eye is too long or too strong Is the result of both environment and genetic factors

20

Types of Myopia
Simple Myopia - most common - the eyes that are either too long or too powerful Congenital Myopia - develops in infants Noctural Myopia - referred to as Night - Blindness - blurred vision only in darkness

21

Pathophysiology
Nearsightedness or myopia occurs when light entering the eye focuses in front of the retina instead of directly on it. This is caused by a cornea that is steeper. Nearsightedness people se well up close but have difficulty seeing far away

22

Causes
Myopia most often occurs because the eyeball is too long, rather than the normal, more rounded shape. Another less frequent cause of myopia is that the cornea, the eye s clear outer window, is too curved. There is some evidence that nearsightedness may also be caused by too much close vision work.

23

Clinical Manifestations
Blurry distance vision Visions seems clearer when squinting In children, frequent rubbing of the eyes

24

Diagnostic Evaluation
Myopia is often suspected when a teacher notices a child squinting to see a blackboard or a child performs poorly during a routine eye screening. Further examination will reveal the degree of the problem. Vision test IOP
25

Diagnostic Evaluation
Snellen chart Refraction Stilt lamp examination

26

Treatment

Glasses, contact lenses, or refractive surgery can correct myopia. Corrective concave lenses are prescribed to focus light precisely on the retina.

27

 Refractive surgery can reduce or even eliminate your dependence on glasses or contact lenses. The most common procedure, procedure performed with a laser, including: a. Photorefractive Keratectomy - Also called PRK, laser is used to remove a layer of corneal tissue, which flattens the rays to focus closer to or even on the retina

28

Treatment
b. Laser - assisted in situ Keratomileusis commonly called as LASIK, a laser used to cut a flap through the top of the some corneal tissue, then the flap is dropped back into place.

29

Prevention
Avoid prolong close work

30

Presbyopia

31

Introduction
During middle age, usually beginning in the 40s, people experience blurred vision at near point. Presbyopia is the gradual loss of the eyes ability to focus actively on nearly objects. For most people, presbyopia becomes apparent when they need to hold print at arm s length in order to read it.
32

 Many people who a already nearsighted temporarily manage the problem by reading without glasses.

33

Definition
Presbyopia is aging of the lens in the eye and the muscles that control the shape of the lens. It is commonly occurs after age 40, when the lens of the eye becomes more rigid and does not flex as easily. The result is more difficult to read at close range. Presbyopia is a refractive error, means that the shape of your eye does not bend light correctly, resulting in a blurred image.
34

35

Pathophysiology
Difficulty in reading at the usual distance and performing other close work. Due to the decline with age in the ability of the eye to focus on close objects. Different from astigmatism, nearsightedness and farsightedness which are related to shape of the eyeball and caused by genetic factors, disease or trauma.
36

 Stem from a gradual loss of flexibility in the natural lens inside the eye. These age- related changes occur within the proteins in the lens, making the lens harder and less elastic. Age-related changes also take place in the muscle fibers surrounding the lens with less elasticity, the eye is hard to focusing up close.
37

SIGNS & SYMPTOMS

Some signs of presbyopia include the tendecy to hold reading materials of arms length, as the vision gets blurred. This is also known as the short arm syndrome . Most people first notice difficulty reading very fine print like newspaper, prescription on medicines bottles. Their eyes becomes easily fatigued when reading a book or computer screen.
38

 Some people complain of headache when doing close work fatigued when reading a book or computer screen. Presbyopia is sometimes confused with longsightedness (occurs when the cornea is too flat or eyeball too short than the normal eye), where as presbyopia is due to loss of flexibility of the eye.

39

COMPLICATIONS
If uncorrected, progressive vision difficulty can cause problems with driving, lifestyle, or work. Client with presbyopia will read the paper at arm s length and will require prescription lenses to correct the problem.

40

COLLABORATIVE CARE
Diagnostic and laboratory test

Laser thermal keratoplasty (LTK). Contact lens, prescription glasses, reading glasses. Refraction test. Retinal examination. Slit-lamp examination.
41

 Surgery:

New surgical options to treat presbyopia such as conductive keratoplasty which uses radio waves to create more culvature in the cornea for a higher plus prescription to improve near vision.

42

NURSING ASSESSMENT
History. External eye. Eye function. Peripheral vision. Visual. Pupil.

43

NURSING DIAGNOSIS 1
Fear related to loss of vision. GOAL  Patient will be able to overcome their fear.

44

NURSING INTERVENTION
Encourage emotional support by family members to reduce fear. Provide information for patient about the disease. Encourage patient to ask question. Introduce the patient to other patient who have the same disease.
45

 Discuss perception of the eye condition and its effects on lifestyle and roles to correct misperceptions and assistive devices for visually impaired.

46

NURSING DIAGNOSIS 2
Headache related to presbyopia. GOAL  Patient will be able to reduce the headache after interventions and feel comfort.

47

 Ask the pt to rate the discomfort of the headache on a scale of 0 to 10. Encourage patient to take enough rest. Advice patient not to do any activities that strain their eyes. Make sure the patient is taking a medication on the right time.
48

NURSING INTERVENTIONS

Provide a quiet and good ventilated room to the

NURSING DIAGNOSIS 3
Knowledge process. deficit related to disease

GOAL Patient will be able to understand more on the disease.

49

NURSING INTERVENTIONS
Give a pamphlet to the patient about the disease. Encourage patient to ask question. Encourage the patient to attend any activities regarding the disease. Make sure the nurses understand the patient s level understanding about the disease.

50

CONCLUSION
Presbyopia is the gradual loss of the eye s ability to focus actively on nearby objects. Caused by a loss of elasticity in the crystalline lens of the eye. This condition usually begins around the age of 40. Signs include the tendency to hold reading material at arm s length as the vision gets blurred known as short arm syndrome . Presbyopia can most often be comfortably corrected through the use of eye glasses.
51

 If uncorrected, progressive vision difficulty can cause problem with driving, lifestyle, and work. Presbyopia can most often be comfortably corrected through the use of eye glasses. New surgical options such as conductive keratoplasty for the temporary reduction of presbyopia.

52

Strabismus

53

DEFINITION
Is a visions problems in which both eyes do not look at the same point at the same time. It most often begins in early childhood Sometimes called `cross eyes`, `walleye`, or `squint`.
54

55

PATHOPHYSIOLOGY
The muscle surrounding each eye work together to move both eyes in the same direction at the same time. Occurs when the eye muscles do not work properly to control eye movements When the eye muscles do not work correctly, the eyes may become misaligned and the brain may not be able to merge the two images.
56

TYPES OF STRABISMUS
ESOTROPIA- eye turning inward EXOTROPIA- eye turning outward
ACCOMMODATIVE ESOTROPIA- occurs

in farsighted children.
57

58

CLINICAL MANIFESTATIONS
Positioned abnormally-Eyes do not look at the same point in space at the same time. Difficulty focusing eyes. Blurred vision. Sensitivity to light. Double vision often occurs at the first develops.
59

Causes
Heredity Weak eye muscles Eye muscle paralysis Eye muscle disease Eye vision disorder (diplopia-double vision)
60

Causes
Vision impairment Eye tumor Orbital tumor cancer at the bony cavity of the eyeball

61

COMPLICATIONS
Amblyopia -commonly called `lazy eye` -affects only one eye -if one eye is weak, the brain ignores the images from its and use only the images from the stronger eye.

62

COMPLICATIONS
Loss of vision Embarrassment over facial appearance with eye patch

63

DIAGNOSTIC TEST
Eye examination Infant-a doctor shines a light into the eyes to see if the light reflects back from the same locations on each pupil Older children-asked to stare objects, sometimes with one eye covered
64

NURSING ASSESSMENT
Take history of eye problems and family history of eye disease. Assess patient visual acuity for sharpness of vision.
Near vision- with Snellen card. Distance vision- read down the chart to place where make mistakes.
65

TREATMENT
Eyeglasses Surgery- eye muscle surgery. During surgery, the doctor changes the length or position of the muscles around the eye to help it align better. Pharmacology - atropine sulfate (atropisol, isopto atropine)to relax eye muscles by inhibiting nerve responses.
66

NURSING DIAGNOSIS 1
Risk for injury related to altered vision

GOAL -Patient injury will be minimize

67

Nursing Interventions
Orient patient to any new environment to prevent injury. Maintain bed in low position to decrease the potential for injury. Raise side rails while patient is in bed. Remove extra pillow and unnecessary furniture to prevent injury.

68

Nursing Interventions
Place the urinal near the patient. Put the call bell near the patient. Ask patient to use glasses to protect the eye. Encourage patient to wear eye shield at night to protect operated eye from injury.

69

HEALTH EDUCATION
Strabismus requires prompt medical evaluation. Call for an appointment with health care provider or eye doctor if child exhibits any of the following: Complains of double vision Has difficulty seeing Appears to be cross-eyed The eyes do not appear to fix on the same point Also if there are academic problems which could possibly be related to the child being unable to see the blackboard or reading material.
70

Eye Disorders
Ectropion & Entropion

71

Ectropion

72

Definition
Is a condition in which the eyelid is turned outward and does not come in contact with the eyeball, and the inner surface is exposed. Because the edge of one eyelid is turned outwards, the two eyelids cannot meet properly and tears are not spread over the eyeball which then cause dryness to the eyes. Ectropion is most common among people over the age of 60 years.

73

 Ectropion. Sagging down of the eye lid. Most common on the lower eye lid.

Etiology
Usually caused by the aging process and the weakening of the connective tissue (orbicularis muscle) of the eyelid which also means a lack of tone of the delicate muscle that hold the lid against the eye which cause the lid to turn out. Also caused by contraction of scar tissue from burns or from facial palsy(Bell s palsy) and may occur as a congenital defect(e.g.: in child with down syndrome)
76

Etiology
Inherited. Where ectropion is influenced by several genes(polygenic inheritance) that effects the skin and other structures that make up the eye lid and that affect the way the skin covers the face and head.

77

Clinical Manifestation
Epiphora(excessive tearing of the eye). Visible outward turning of the eyelid. Chronic eye irritation. Burning sensation at the eye. Gritty, sandy feeling in eyes. Mucopurulent discharge in the eye. Reddening of the exposed conjunctiva.
78

Investigation
Physical examination of the eyes and eyelids, where discharge of any kind or the sagging of the eyelid is being observed. Special tests are not necessary.

79

Treatment
Daily eye cleaning with boiled water that s been allowed to cool down or with an eye wash solution prescribe by doctor(e.g: normal saline) Artificial tears(e.g:cyclosporine emulsionrestasis, eyemoe)act as lubricant, which may provide relief from dryness and keep the cornea lubricated.
80

Treatment
Antibiotic drops or ointment is ordered to treat infection in the infected eye.(e.g:natamycin-Natacyn,levofloxacinquixin etc depending what infection) Surgery to tighten the muscles that hold the eyelid in place (orbicularis muscle) is usually effective and may be performed as outpatient surgery with local anesthetic.
81

Complications Palpebral (eyelid) conjunctiva thickens and keratinizes result from chronic exposure of conjunctival surface. Preventions Not preventable but the use of artificial tear or lubricant ointment may prevent corneal complication.
82

Nursing Care Plan

1.Nursing diagnosis Disturbed body image due to changes in appearance. Goal Client will be able to verbalize and accept his or her appearance. Intervention -Encourage client to express feelings, about the way they feel, think and view themselves.
83

Nursing Care Plan

-Provide opportunity for client to share with people going through similar experiences. -Prepare family members for physical and emotional changes as they adapt. -Encourage visit from peers. Advise them to share with client how important he or she is to them.
84

2.Nursing diagnosis Knowledge deficit on ectropion. Goal Client will understand the disorder. Intervention -Encourage client to ask questions on the disorder so that nurses could help him understand better. -Give client and family members pamphlets so that they can read and understand more bout the disorder the client is suffering from.
85

Nursing Care Plan

-explain to client what he or she must do and don t do during treatment for the disorder. (e.g: cleanliness of the eye, medication on time)

86

Entropion

87

Definition
Is a condition in which the eye lid is turned in against the eyeball(usually the lower eyelid) and may occur unilaterally or bilaterally. The edge of one eyelid turns in , cause the eyelashes rub against the eye which can lead to ulcer formation and scarring of the cornea. Most often occurs in patient over 50 years old.

88

 Entropion where the eye lid is turned inwards.

Etiology
4. classification of entropion which are senile(involutional),congenital,cicatricial and spastic. Senile(involutional) entropion is most common, caused by disinserted or atrophied lid retractors or tendons and involutional enophthalmos (backwards displacement of the eyeball into the orbit occurring in advanced age).
91

 Congenital entropion effects the upper eyelid. Epiblepharon ( a fold of skin that overlaps the eyelids, pushing the eyelid inwards).

Etiology

92

 Spastic entropion is secondary to neurologic inflammatory or irritative process of the eye lid(e.g:Blepharospasm is when the muscles around the eye spasm, cause severe squinting).

93

Etiology
Cicatricial entropion is a vertical shortening of the tarsus(the connective tissue plate forming the framework of an eyelid) secondary to scarring of the ocular tissue brought by disorders such as StevenJohnsons syndrome (lesion in the eyes-fatal form of erythema multiforme where skin reaction due to unknown cause) and trachoma (chronic infection disease of the conjunctiva and cornea.
94

Clinical Manifestation
Excessive tearing Burning Eye irritation( sandy, gritting eye) Lid turns inward towards eyeball. Decreased vision if cornea is damaged. Eye discomfort or pain.

95

Investigation
Physical examination of the eye and eye lid(e.g: inwards turning of the eyelid) Slit lamp microscope, examine the effects of the in turned eyelashes on the surface of the eyes.

96

Treatment
Treatment should be guided by the underlying cause. Generally, artificial tear drops, bacitracin, erythromycin ointment and surgery is used in all cases of entropion. For senile entropion ,eyelid retraction via taping or thermal cautery (destruction of tissue using hot instruments or electrical current) is done.
97

 In cicatricial cases, excision of the scar with a tarsal plate graft from preserved sclera is done. To resolve spastic entropion, is to remove the offending irritant which is the seventh cranial nerve(essential blepharospasm). Congenital cases, rarely improve on their own, always require surgical correction of the eyelid.

Treatment

98

Complication Trichiasis (inversion of the eyelashes, sensation of a foreign body in the eye) Corneal ulcer(open sore on the cornea). Prevention Not preventable, but for people who have recently traveled to an area with trachoma present (north Africa, South Asia) should seek treatment if they have red eyes.
99

Nursing Care Plan

1.Nursing diagnosis Disturbed body image due to changes in appearance. Goal Client will be able to verbalize and accept his or her appearance. Intervention -Encourage client to express feelings, about the way they feel, think and view themselves.
100

Nursing Care Plan

-Provide opportunity for client to share with people going through similar experiences. -Prepare family members for physical and emotional changes as they adapt. -Encourage visit from peers. Advise them to share with client how important he or she is to them.
101

2.Nursing diagnosis Risk for injury due to blurred vision. Goal Client will relate to fewer injuries. Intervention -keep call bell at client s reach and sight. -encourage client to ask for assistance when doing things. -place client in a room near to nurse s counter.

102

Nursing Care Plan

-use low bed and put side rails up at all times. -instruct client to use sunglasses if couldn't stand the glare of the sun.

103

Eye Trauma

Introduction
The eye is the organ of the sense of sight situated in the orbital cavity and it is supplied by the optic nerve (2nd cranial nerve) It is possible to see with only one eye but three-dimensional vision is impaired when only one side is used, especially in relation to the judgment of distance.
105

Definition What is Eye Trauma actually?

The eyelids, protective layers, surrounding soft tissue, or the globe itself may be injured Vision may be impaired by direct injury or latent scarring
106

PATHOPHYSIOLOGY
Any part of the eye, especially the exposed parts, may be affected by trauma. Foreign bodies, abrasions and lacerations are the most common types of eye injury.

107

CAUSES

What can cause Eye Trauma ?

Blunt or sharp injury Chemical or thermal burns

108

CLINICAL MANIFESTATIONS
CONDITIONS OF EYE TRAUMA : Blunt confusion Hyphema Orbital fracture Foreign body Laceration / perforation Ruptured globe Burns
109

CONDITIONS BLUNT CONTUSION

CLINICAL MANIFESTATIONS

Swelling & discoloration of the tissue Bruising of periorbital soft Bleeding into the tissue & structures of the eye tissue Pain HYPHEMA Presence of blood in the anterior chamber Pain Blood in anterior chamber Increased intraocular pressure 110

Eyelid contusion

111

Hyphema

112

CONDITIONS

CLINICAL MANIFESTATIONS

ORBITAL FRACTURE Fracture and discoloration Rhinorrhea of walls of the orbit, orbital Contusion margins or both Diplopia FOREIGN BODY On cornea, conjunctiva, intraocular particles penetrate sclera, cornea, globe Severe pain Foreign body sensation Photophobia Redness swelling
113

CONDITIONS LACERATION / PERFORATION Cutting or penetration of soft tissue or globe RUPTURED GLOBE Concussive injury to globe with tears in the ocular coats, usually the sclera

CLINICAL MANIFESTATIONS Pain Bleeding Laceration photophobia Pain Altered intraocular pressure Hyphema Hemorrhage
114

CONDITIONS BURNS

CLINICAL MANIFESTATIONS

Chemical Pain Burning Lacrimation Chemical-caused by Photophobia alkali or acid agent Thermal Thermal-usually burn to Pain eyelids- may be 1st, 2nd or 3rd Burned skin degree Blisters Ultraviolet Ultraviolet-excessive Pain-delayed several hours exposure to sunlight, after exposure sunlamp, welding Foreign body sensation Lacrimation Photophobia 115

Eye trauma

116

Eye trauma

117

COLLABORATIVE CARE
DIAGNOSTIC TESTS:  Facial X-rays detect orbital fractures  CT scan - identify the foreign body in the eyes and injury caused by blunt objects  For chemical eye burns, the chemical agent must be identified and tested for pH if a sample is available.
118

PHARMACOLOGY: Antibiotic ointment is applied such as erythromycin or sulfacetamide sodium Topical corticosteroids are prescribed to reduce inflammation Tetanus antitoxin is administered, if indicated as well as analgesics An antifibrinolytic agent, stabilizes clot formation at the site of hemorrhage.
119

SURGERY:
Surgery such as optic nerve decompression may be performed

Cosmetic surgery for deformities of the globe and enophthalmos can be done.

120

COMPLICATIONS
Subconjunctival hemorrhage (commonly known as black eyes )

Severe optic nerve damage

121

NURSING ASSESSMENT
Obtain history of mechanism of injury as well as extent of other injuries Assess level of pain and visual symptoms Assess visual acuity

122

NURSING DIAGNOSIS 1
ACUTE PAIN RELATED TO TISSUE TRAUMA

123

GOAL: Patient will verbalize less pain within 2 - 4 hours

NURSING INTERVENTIONS: Apply cold compress to relieve swelling and pain Provide additional comfort measures, such as dimmed lights and quiet environment. Monitor vital signs and neurologic status (GCS). Monitor signs of infection, such as fever, drainage, increase pain, warmth and redness Medication for pain as directed.

124

PREVENTIONS

IN AND AROUND THE HOUSE

Make sure that all spray nozzles are directed away from you before you press down on the handle

125

PREVENTIONS

Protect your eyes from flying fragments, IN THE WORKSHOP fumes, dust particles, sparks and splashed chemicals by wearing safety glasses
126

PREVENTIONS

Teach children the correct way to handle AROUND CHILDREN potentially dangerous items, such as scissors and pencils.

127

PREVENTIONS
Pick up stones before going over grass with the lawn-mower. These stones can be hurled out of the rotary blades and rebound off curbs or walls, causing severe injury to the eye Avoid to play around, near the low-hanging tree branches.

IN THE GARDEN

128

PREVENTIONS
Before opening the hood of the car, put all smoking materials and matches away. Use a torchlight, not a match or lighter, to look at the battery at night

AROUND THE CAR

129

HEALTH EDUCATIONS
Instruct on use of patch or shield Advise patient to report increase in pain, decrease in vision, redness and fever Advise use of corrective lenses as prescribed Stress the importance of follow-up to prevent further complications Attempt to prevent future trauma with protective 130 eye wear.

131

DEFINITION
Inflammation of the cornea, the transparent membrane that covers the colored part of the eye ( iris ) and pupil of the eye.

132

PATHOPHYSIOLOGY
When the normal ocular defense mechanisms such as the corneal epithelium are compromised, infection may occur. Keratitis occurs in both children and adults.

133

CLINICAL MANIFESTATIONS
Pain Photophobia (inability to tolerate light) Redness Loss of vision/blurred vision Difficulty opening eye Increased tearing

134

CAUSES
Poor contact lens care, overuse of contact lenses Viral infections Spark or other projectile Poor hygiene Poor nutrition (especially a deficiency of vitamin A, which is essential for normal vision)
135

COMPLICATIONS
Glaucoma Ulceration of the cornea Blindness

136

INVESTIGATIONS
DIAGNOSTIC TEST 1) Physical examination 2) Fluorescent staining with Slit lamp microscope to identify the abrasion or ulceration

137

SLIT LAMP MICROSCOPE

138

TREATMENT
PHARMACOLOGY 1) Topical anti-infectives / antibiotic applied as either eye drops or ointment. eg. Erythromycin, penicillin. 2) Corticosteroids 3) Analgesics. eg. Acetaminophen
139

SURGERY Corneal transplant ( keratoplasty ) - Replacement of diseased cornea by healthy corneal tissue from a donor. - The superficial layer of cornea is removed and replaced with a graft. - The graft is then sutured in place using suture finer than human hair.
140

Corneal Transplant

PREVENTIONS
Use sterile lens-cleaning and disinfecting solutions. Tap water is no sterile and should not be used to clean contact lenses Do not over wear contact lenses and remove it if the eyes become red or irritated wearing protective glasses when working or playing.

142

NURSING ASSESSMENT
Evaluate patient for severe pain. Observe for signs of infection such as redness. Assess patient s level of independence. Assess visual acuity.
143

2) Risk for injury related to vision impairment. GOAL: Injury will be minimized. NURSING INTERVENTIONS: 1) Position or raise side rails to prevent fall down and injury. 2) Instruct the patient to call for help before getting up. Assistance helps prevent falls that may not injury the patient. 3) Orient the patient to environment to decrease the potential for injury. 4) Provide for continual supervision/observation to prevent injury. 5) Maintain safe environment such as remove unnecessary furniture and equipment to decrease potential injury.
144

3)Pain Related To Inflammation Of The Eye GOAL: Pain will be reduced within 2-4 hours. NURSING INTERVENTION - Assess pain utilizing a scale of 0 (no pain) to 10 (extreme pain) to determine the deep of the pain. -Teach the patient to apply warm compress to reduce inflammation and pain. - Patch the affected eye if necessary to reduce eye movement and pain. - Administer medication as prescribe by the doctor to reduce pain.

145

HEALTH EDUCATION
Teach the patient the appropriate way to use topical antibiotic. Teach the patient about the signs and symptoms of increasing infection. Instruct the patient about the importance of follow up clinic appointment to prevent further complication. Teach the patient to review safety practices, such as wearing protective eye shields, using contact lenses 146 properly.

HYPHEMA
147

DEFINITION

A hyphema is an accumulation of blood in the front (anterior) chamber of the eye. It is usually caused by blunt eye trauma.

148

HPYPEMA
149

HPYPEMA
150

PATHOPHYSIOLOGY It occurs when blood vessel in the iris bleed and leak into the clear aqueous fluid. Hyphema are usually characterized by pooling of blood in the anterior chamber that may be visible to the naked eye The red blood cells of every small hyphema are visible only with magnification (only seen by microscope). Even the slightest amount of blood in the anterior chamber will cause decrease vision when mixed in the clear aqueous fluid.
151

CLINICAL MANIFESTATION Increase intraocular pressure ( IOP ) Blood in the anterior chamber Pain

152

 Redness of the eye Vision abnormalities Light sensitivity

153

CAUSES
Trauma- a blunt or perforating injury. Severe inflammation of the iris, a blood vessel abnormality or cancer of the eye. Certain ocular tumor Eye injury Sport injury

154

COMPLICATION
Recurring bleeding Blindness Impaired vision through blood staining of the cornea Glaucoma due to increased intraocular pressure Damage to different structure in the eye.

155

DIAGNOSTIC TEST
Eye examination with a slit lamp microscope and opthalmoscope. Intraocular pressure measurement (tonometry) Ultrasound testing to evaluate the remainder of the eye behind front chamber.

156

NURSING ASSESSMENT
Assess level of pain -use pain scale with 0-no pain and 10-severe pain. Visual field testing for deficit -a nurse to face the person and gradually move a finger from the left and the right at face level in toward the center of vision. The person must fix his vision on the nurse face (and not look for the finger) in order the result of the test to be valid. -each eye is tested separately.
157

TREATMENT
In some mild cases, no treatment is required and the blood absorb within a few days. Bed rest Eye patching Sedation to minimize activity and reduce the recurrent bleeding. Use the eye drop to moist the eyes and prevent dryness.
158

 Removal of the blood by an ophthalmologist may be necessary especially if the intraocular is severely increase or the blood is slow to reabsorb. Head should elevated about 40 degrees to help the body reabsorb blood in the eye. Daily check of pressure inside the eye.
159

PREVENTION Many eye injuries can be prevented by wearing safety goggles or other protective eye wear. Always wear eye protection while playing sports such as racquetball or contact sports such as basketball. Avoid wearing contact lens because it may cause injury to the eye.

160

 Don t strain the eye. Get enough rest and sleep.

161

NURSING DIAGNOSIS 1
Risk for infection related to surgery.

GOAL
 Minimizing risk of infection.

162

NURSING INTERVENTION
Perform good hand washing technique to defense against transmission of microorganism. Use gloves in direct patient care to decrease microbial contamination. Monitor temperature to facilitate early treatment. Elevation of body temperature indicated presence of infection. Maintain aseptic technique for invasive procedure to reduce the risk of contamination. Avoid direct touch and rub the eye to prevent infection.

163

NURSING DIAGNOSIS 2 Knowledge deficit related to the disease process.

GOAL

 Patient can verbalize and understand about the disease.

164

NURSING INTERVENTION Assess the client s knowledge of the disease to encourage patient to ask question.

Give pamphlet to patient so that they know about the disease

Provide simple understanding.

instruction

for

easy
165

Emphasize importance of personal hygiene to prevent infection. Warn patient not to rub eyes until the anesthetic has worn off to avoid trauma to the eye.

166

 Encourage family member visit the patient frequently. Provide safety and quiet environment to promote rest. Provide psychological support. (e.g. think positively)

167

HEALTH EDUCATION Teach patient and family members how to administer medications such as topical antibiotics. Advise patient to report increase in pain, decrease in vision, redness and swelling Warn patient against straining eyes by exposure to the sun, reading or computer work.
168

Advise use of corrective lenses as prescribed Emphasize the importance of follow up visits. Attempt to prevent future trauma protective eyewear. with

169

IRITIS / UVEITIS

170

DEFINITION
Uveitis is an inflammation anyway in the uvea. The pigmented inside lining of the eye, called the uvea or the uveal track, consist of the 3 structures: the iris, the ciliary body and the choroid. The most common form of uveitis is anterior uveitis, which involves inflammation in the front part of the eye. Its usually limited to the iris.
171

PATHOPHYSIOLOGY
Uveitis is classified by involved structures it. 4 main categories of uveitis: 1) Anterior uveitis involves the iris and ciliary body and is the most common type. 2) Intermediate uveitis affects the ciliary body, vitreous and retina. 3) Posterior uveitis involves the retina, choroid and optic nerve. 4) Diffuse uveitis affects structures both in the front and back of the eye.
172

CAUSES
Some cases the cause remains unknown Infection Autoimmune disorder such as sarcoidosis. Trauma
173

CLINICAL MANIFESTATIONS
Redness of the eye Blurred vision Light sensitivity ( photophobia) Eye pain ( if the optic nerve is involved) Small pupil( constricted pupil)
174

COMPLICATION

175

INVESTIGATION
DIAGNOSTIC TESTS 1) Physical examination 2) Ophthalmoscopy - small flahlight with magnifying lenses that shines a light into the eye to examine the cornea,lens and retina. 3) Tonometry - to determine the intraocular pressure in the eye.
176

TREATMENT
PHARMACOLOGY 1) Atropine eye drops-to dilate the pupils and relieves spasm. 2) Corticosteroid (eg: dexamethasone)-to reduce inflammation 3) Analgesics (eg: tramadol) to reduce pain. OTHERS TREATMENT 1) Keep room likes lights dimmed to decrease pain from photophobia.
177

Opthalmoscopy

178

NURSING ASSESSMENT
Assess pain level on scale of 0( no pain)10(extreme pain) Note the signs and symptoms of infection such as redness. Assess for history of trauma and others risk factors.

179

 Assess for verbal and nonverbal indications of level of anxiety. Encourage client to ask question about the progressive of the disease to reduce anxiety.

180

2) Pain related to inflammation of the eye GOAL: pain will be relieve. NURSING INTERVENTIONS: 1) Monitor vital sign. 2) Ask the patient to rate the degree of the pain utilizing on the scale of o ( no pain )to 10 (extreme pain. 3) Provide additional comfort measures such as dimmed lights. 4) patch the affected eye if necessary. Patching affected eye reduce eye movement and pain. 5) Provide medication that prescribed by the doctor.

181

HEALTH EDUCATION
Instruct client the important or follow up to prevent further complications Instruct the client about technique for instilling eye drops Explain to the client about the signs and symptoms of the disease. Teach the client about the measures to relieve photophobia such as wear sunglasses to decrease pain from photophobia.

182

PTERYGIUM

183

Introduction
A pterygium (Greek word for "winged growth") is a fibrovascular proliferation of the nasal (or, more rarely, temporal) bulbar conjunctiva that grows toward the cornea and eventually over its surface. It results from heavy exposure to sunlight and wind.

184

Definition
Pterygium is a raised, wedge-shaped fibrovascular growth of the conjunctiva. It is most common among those who live in tropical climates or spend a lot of time in the sun.

185

Pathophysiology
Pterygiums are nourished by tiny capillaries that supply blood to the tissue. For some, the growth remains dormant; however, in other cases it grows over the central cornea and affects the vision. As the pterygium develops, it may alter the shape of the cornea, causing astigmatism A pterygium is a growth of tissue from the white (conjunctiva) of the eye exterior onto the clear dome (cornea) in the front of the eye. They can occur on either side of either eye. Patients can have up to four growths at any one time. 186

Causes
Pterygiums are most commonly caused by : Sun exposure( protecting the eyes from sun, dust and wind is recommended)

187

Clinical Manifestations
growth of tissue from the white (conjunctiva) of the eye exterior onto the clear dome (cornea) in the front of the eye, decreased vision, pain, irritation, redness and scarring
188

Treatment
Instilling artificial tears liberally is also helpful to decrease irritation. Steroid drops are prescribed to reduce inflammation. Simple excision to remove the tissue
189

Nursing Diagnosis
Pain related to post surgery Risk for injury related to blurring vision

190

RETINAL DETACHMENT

191

Introduction
Retina -innermost layer of the wall of the eye. - is the photosensitive part of the eye.

192

Definition
A retina detachment is a serious & sight threatening event but it is painless. Occurs when retina becomes separated from it s underlying supportive tissue. The retina cannot function when these layers are detached & unless it is reattached soon, or permanent vision loss may result. Some cases, small areas of the retina that are tom. It means retina tears/ retina breaks can lead to retina 193 detachment.

RETINAL DETACHMENT

Causes
Degenerative changes in the retina or vitreous Trauma Inflammation Tumor Diabetic retinopathy Cataract
195

Sign and Symptoms

Flashes of light Blurred vision Progressive deterioration of vision

196

Complication

Glaucoma Infection

197

A retina detachment is more likely to occur in people who: Are extremely near sighted Had a retina detachment in the other eye Have family history of the retina detachment. Had cataract surgery Have eye disease e.g. retinoschisis, uveitis, Had eye injury

Risk factor

198

Diagnostic test
Indirect ophthalmoscopy. - shows opaque( not transparent) eye. Slit-lamp examination. Three- mirror gonioscopy

199

Treatment
Usually focus to bring the retina & choroid back into contact & reestablishing the blood & nutrient supply of the choroid. There are 4 surgical procedures: Cryotheraphy a laser procedure/freeze treatment.

200

Scleral Buckle Procedure involves localizing the position of all retina breaks with cryoprobe. Supporting all the retina breaks with a scleral buckle. A buckle is a piece of silicone sponge/ solid silicone. It is sewn into the sclera. It pushes in on the retina break & effectively closes the break. Post operatively, no positioning requirement & pt can resume most activities within several days.

201

Scleral Buckle

203

Electrodiathermy
- An electrode needle is passed through the sclera to allow subretinal fluid to escape.

Photocoagulation
Photocoagulation therapy is a method of treating detachments (tears) of the retina (the layer of light-sensitive cells at the back of the eye) with an argon laser. The highintensity beam of light from the laser is converted into heat, which forces protein molecules in the affected tissue to condense and seal the tear. Purpose to reattach a torn or detached portion of the retina and/or prevent further growth of abnormal blood vessels in the retina that can cause a detachment.
204

Nursing assessment
Preoperative Assess for history of trauma or other risk factor Assess level of anxiety and knowledge level regarding procedures Determine visual limitation and obtain visual description from patient to determine assistance needed.
205

Post operative
Assess pain level Assess visual acuity if unoperated eye not patched Determine patient s ability to ambulate and resume independent activities as tolerate.
206

Nursing Diagnosis
Risk for injury related to eye surgery. Goal- the client may not have injury caused by complication of postoperative.

207

Nursing Intervention
Caution patient to avoid bumping head Assist patient with activities as needed Encourage ambulation and independent Administer medications for pain, nausea, and vomiting as prescribed. Provide sedate, diversional activities such as radio, audio books. 208

Patient Education and Health Maintenance

Instruct patient about the following:
Rapid eye movements should be avoided for several weeks. Driving is restricted Within 3 weeks, light activities may be pursued. Avoid straining and bending head below the waist.
209

 Apply a clean, warm water, to eyes and eyelids several times a day for 10 minutes to provide soothing and relaxing comfort. Symptoms that indicate a recurrence of the detachment.

210

 Advice patient to follow up. The 1st followup visit to the ophthalmologist should occur in 2weeks,with other visits scheduled thereafter. Encourage self-care at discharge, if done in an unhurried manner. Avoid falls, jerks, bumps, or accidental injury.

211

Diabetic Retinopathy

212

Definition
Retinopathy is the medical term for damage to the tiny blood vessels (capillaries) that nourish the retina, the tissue at the back of your eye that captures light and relays information to your brain. These blood vessels are often affected by the high blood sugar levels associated with diabetes.
213

Pathophysiology
During early stage, the capillaries in the eye weaken and blood vessels develop small bulges that may burst and leak into the retina. As the condition progresses, new fragile blood vessels grow on the surface of the retina and the blood vessels may break easily and cause bleeding into the middle of the eye.
214

 Diabetic retinopathy develop when high blood sugar level damages the capillaries of the retina. These blood vessels weaken and develop small bulges which may burst and leak into the retina. Later, new fragile blood vessel grow on the surface of the retina that may break and bleed in the eyes.
215

Clinical Manifestation
Pain in the eye Partial or total loss of vision Blurred vision results from macular edema Cataracts results from lens opacity A dark or empty spot in the center of your vision

216

 Poor night vision Difficulty adjusting from bright light to dim light Dark streaks or a red film that blocks vision

217

Investigation
Visual acuity testing

Regular screening

Ophthalmoscope And slit lamp exam

Investigation

Fluorescein angiogram

Gonioscopy

Tonometry

218

Complication
Macular edema Severe vision loss Blindness

219

Treatment
Maintain safety. Early prevention by control of blood sugar level and blood pressure with regular checkup. Laser therapy (photocoagulation) to remove hemorrhagic tissue to decrease scarring. Cataract removal with lens implant improves vision.
220

Medication
Aspirinprevent or delay the development of diabetic retinopathy Angiotensin- converting enzyme (ACE) inhibitors - may reduce the risk of progression of diabetic retinopathy
221

Nursing Assessment
Take patient s history of symptoms Assess if there are any interruption in the patient s lifestyle Assess the patient s visual acuity

222

Nursing Diagnosis
Impaired visual perception related to disease process. GOAL The patient will be able to perform ADL independently

223

Nursing Intervention
Introduce self to patient and acknowledge visual impairment to reduce patients anxiety. Orientate patient to environment to reduce fear related to unfamiliar environment. Provide adequate light to improve vision for patient with diminished vision. Dont make unnecessary changes in the environment, to ensure safety and maintaining
224

 Encourage the use of the sense of touch and become familiar with unfamiliar objects. Keep bed in locked position to prevent falls

225

Health Education
1. Control the blood sugar.

2. Keep an eye on vision changes. 3. Keep your blood pressure down. 4. Control your cholesterol. 5. Stop smoking. 6. Control stress.

226

227

GLAUCOMA Acute & Chronic

228

ACUTE (ANGLE-CLOSURE) GLAUCOMA DEFINITION

-An obstruction occurs at the access to the trabecular meshwork and the canal of Schlemm. -Abnormally high pressure of fluid inside the eyeball (intraocular pressure, (IOP).

.
229

PATHOPHYSIOLOGY * Mechanical blockage of anterior chamber angle results in accumulation of aqueous humor (fluid). * The shallow chamber with narrow anterior angles is more prone to physiologic events that result in closure. * When pupillary dilated or iris displace forward, it can cause angle close. * Angle closure can occur in subacute, acute or chronic forms.

230

 If not treated it can cause a dramatic response and permanent eye damage. * Within several days, scar tissue forms between the iris and cornea closing the angle. The iris and ciliary body begin to atrophy, the cornea degenerates because of edema and the optic nerve begins to atrophy.
231

CLINICAL MANIFESTATIONS
Pain in and around eyes. Rainbow of colour around lights. Vision becomes cloudy and blurred. Pupil mid-dilated and fixed. Nausea and vomiting may occur.
232

DIAGNOSTIC EVALUATION
Tonometry- measurement of tension or pressure Ocular examination may reveal a pale optic disk. Gonioscopy (using special instrument called gonioscope) to study the angle of the chamber of the eyes.
233

MANAGEMENT
PHARMACOLOGIC Pharmacotherapy is initiated to decrease eye pressure before surgery. Medications are prescribed at the discretion of the opthalmologist according to the patient condition and needs.

234

 Medication classifications prescribed include : * Parasympathomimetic drugs used as miotic drugs pupil contract, iris is drawn away from cornea. * Carbonic anhydrase inhibitor restricts action of enzyme that is necessary to produce aqueous humor. * Beta- adrenergic blockers nonselective reduce production of aqueous humor. * Hyperosmotic agents promoting diuresis. may

to reduce IOP by

235

SURGERY

 Surgery is indicated if : - IOP is not maintained within normal limits by medical regimen. - There is progressive visual field loss with optic nerve damage.

236

 Types of surgery include :

- Peripheral iridectomy ~ excision of a small portion of the iris whereby aqueous humor can bypass pupil - Laser iridotomy ~ multiple tiny laser incision to iris to creat opeing for aqueous flow. - Trabeculectomy ~ creation of fistula between the area chamber of the eye and the subconjuctival space by surgical removal of a portion of the trabecular meshwork.

237

COMPLICATIONS Uncontrolled IOP that can lead to optic atrophy and total blindness.

238

NURSING ASSESSMENT Evaluate patient for severe pain, nausea and vomiting, signs of increased IOP. Assess visual symptoms. Establish history of onset of attack and previous attacks. Assess patient level knowledge base. of anxiety and
239

CHRONIC (OPEN- ANGLE) GLAUCOMA

Is characterized as a disorder of increased IOP, degeneration of the optic nerve and visual field loss.

240

PATHOPHYSIOLOGY
Degenerative changes occur in the trabecular meshwork and canal of Schlemm, causing microscopic obstruction. Aqueous fluid cannot be emptied from the anterior chamber, increasing IOP. IOP varies with activity and some people tolerate elevated IOP without optic damage (ocular hypertension).
241

 Whereas others exhibit visual field defects and optic damage with minimal or transient IOP elevation. The risk of eye damage increases with age, family history of glaucoma, diabetes and hypertension.

242

CLINICAL MANIFESTATION
Mild, bilateral discomfort ( tired feeling in eyes, foggy vision ). Slowly developing impairment of peripheral vision central vision unimpaired. Progressive loss of visual field. Halos may be present around lights with increased ocular pressure.
243

DIAGNOSTIC EVALUATION
Tonometry pressure measurement of tension /

Ocular examination to check for clipping and atrophy of the optic disk. Visual fields testing for deficits.
244

MANAGEMENT
Commonly treated with a combination of topical miotic agents (increase the outflow of aqueous humor by enlarging the area around trabecular meshwork). Continue to see health care provider at 3 to 6 month intervals for control of IOP.

245

 Types of surgery include :

Laser trabeculoplasty Iridenclesis Cyclodiathermy or cyclocryotherapy Corneoscleral trephine

246

NURSING ASSESSMENT
Assess frequency, duration and severity of visual symptoms. Assess patient knowledge of disease process and anxiety about the diagnosis. Assess patient motivation to participate in long- term treatment.
247

NURSING DIAGNOSIS
Acute pain related intraocular pressure to increased to

GOAL -The clients will verbalize his comfort.

248

NURSING INTERVENTIONS Notify health care provider immediately of clients condition. Administer opioids and other medications as directed. Explain procedures to clients. Monitor degree of eye pain every 30 minutes. Monitor blood pressure, pulse and respiration.

249

HEALTH EDUCATION
Tell the patient that glaucoma cannot be cured but it can be controlled. Instruct patient in use of medication to control the disease. Remind patient to keep follow up because pressure changes may occur.

250

 Instruct patient to seek immediate medical attention if sign and symptom of increased IOP return. Advice patient to notify all health care providers of condition and medication and to avoid use of medication that may increased IOP.

251

CATARACT

MATURED CATARACT
252

Definition

Clouding or opacity of the crystalline lens that impairs vision

254

Pathophysiology & Etiology

Senile cataract - commonly occurs with aging Congenital cataract - occurs at birth Traumatic cataract - occurs after injury Aphakia - absence of crystalline lens
255

Risk Factors
Additional risks include: - Diabetes - Ultraviolet light exposure - High dose radiation - Drugs : corticosteroids, phenothiazines, chemotherapy agents

256

Clinical Manifestations
Blurred or distorted vision Glare form bright lights Gradual and painless loss of vision Previously dark pupil may appear milky or white
257

Diagnostic Evaluation
Slit lamp examinationto provide magnification and visualize opacity of lens Tonometry - to determine IOP and rule out other conditions Direct and indirect Opthalmoscopy - to rule out retinal disease Perimetry - to determine the scope of the visual field
258

Treatment
Surgical removal of lens is indicated. A patient with one cataract will usually managed without surgery If cataract occurs at both eyes, surgery is recommended when vision in the better eye cause problems in daily activities. Surgery is done on only one eye at a time
259

 Oral medications is given to reduce IOP. E.g Diamox IOL implantation are usually implanted at the time of cataract extraction, replacing thick glasses. If intraocular lens implant is not used, the patient fitted with appropriate glasses or a contact lens to correct refraction after the healing process.
260

Surgery

types of extraction: Extra-capsular (ECCE) surgery consists of removing the lens but leaving the majority of the lens capsule intact. High frequency sound waves) are sometimes used to break up the lens before extraction. Intra-capsular (ICCE) surgery involves removing the entire lens of the eye, including the lens capsule.
261

 Cataract surgery is usually done under local anesthesia . Preoperative eye drops produce decreased response to pain and lessened motor activity.

262

 In either extra-capsular surgery or intracapsular surgery, the cataractous lens is removed and replaced with a plastic lens (an intraocular lens implant) which stays in the eye permanently.

263

Complication
Blindness

264

Nursing Assessment
Preoperative: Assess knowledge procedure level regarding

Assess level of fear and anxiety Determine visual limitations

265

Cont..
Postoperative Assess level of pain: a. Sudden onset - may be due to ruptured vessel or suture and may lead to hemorrhage b. Severe pain -accompanied by nausea and vomiting maybe caused by increased of IOP and may require immediate treatment. Assess visual acuity in unoperated eye
266

Nursing Diagnosis
Knowledge deficit of operative course Acute pain related to surgical interventions

267

Patient Education
Advise patient perform activities as tolerated, unless given strict restriction by the surgeon Caution against activities that cause patient to strain ( lifting heavy objects, straining at defecation and strenuous activity) up to 6 weeks as directed Instruct patient and family about proper eye drop or ointment instillation
268

 Encourage patient to wear dark sun glasses after eye dressing are removed to provide Comfort from photophobia due to lack of pupil constriction from mydriatriccycloplehic drops Stress the importance of follow - up after surgical intervention Advice patient to avoid getting soap at ayes
269

 Advise avoidance of tilting head forward when washing hair. Vigorous shaking of the head is to be avoided

270

Ocular Examination
External Exam Snellen Chart Visual Field Color Vision Test Refraction Internal Exam Opthalmoscopic Exam

OCULAR EXAMINATION EXTERNAL EXAMINATION SNELLEN CHART VISUAL FIELD COLOR VISION TEST REFRACTION INTERNAL EXAMINATION OPTHALMOSCOPIC EXAMINATION

273

Snellen Chart

Snellen Chart

External Examination Snellen Chart A screening test for distant visions consist of character in different size. Each eye is tested separately with and without glasses. Letter or objects are of a size that can be seen by the normal eyes at a distance at 20 feet (6m) from the chart. The letter is appears in rows and are arranged so the normal eye can see them at distances at 30, 40 and 50 feet (9, 12 and 15m)
276

SCORE COUNT AND RANGE A person who can identify the letters of the size 20 at 20 feet (6 at 6 meters) is said to have 20/20 (6/6) vision. The results is recorded as a fraction of the distance from chart in meters over the normal reading distance of the last complete line read. Plus the number of extra letter read from the line below.
277

 Minus the number of letters incorrectly. If the vision is less than (20/200) test maybe recorded as follows. a)Counting Finger ~ at feet (meters) b) Hand Movement ~ ability to detect hand movement at a certain distance. c)Light Perception And Projection. d)Light Perception Only e)No Light Perception
278

Visual Field

Visual Field Range of what the eyes can see with respect to angle of view. Test to assess the functioning of the macula and peripheral visions. Important aid to diagnosis of retinal detachment and neurological disease. Most to helping in detecting central scotomas (blind areas in the visual fields), macular degeneration and the field defects in glaucoma and retinitis pigmentosa.
280

NORMAL VISUAL FIELD

Average extend  65 upward  75 downward  60 inward  95 outward

281

How To Determine Function Of Optic Pathway Equipment ~ Light source (penlight) and Test Object Patient is sitting 18-24 inch (45.5 to 61cm) in front of the examiner . Covered the Left eye and focus with Right eye on a spot about 30.5cm from eye. On the other hand, the examiner should close the opposite eye. 282

 Move the test object from periphery toward the center from right to left, above and below from the middle of each of these directions. Patient signals when he see the test object and when the object disappears through 360 Both examiner and the patient should see the test object enter the field of vision at the same time.
283

284

285

286

287

288

 The standard test for color vision involve picking numbers or letter out of a complex and colorful picture. This test are done to determine the person ability to perceive primary colors and shades of colors. The patterns maybe letters or numbers that the normal eye can perceive instantly but that are confusing to the person with a perception defect.

Color Vision Test

289

 A recognition of color as the result of changes in the pigments of the cones in the retina that react to varing intensities of red and green It is particularly significant for people whose occupation requires discerning colors such as artists, decorators, transportation workers, surgeon, nurses pilot and etc.

290

OUTCOME Color Blindness ~ Person can t perceive the figures. Red Green Blindness ~ 8% of males, 0.4% of females . Blue Yellow Blindness ~ Rare Color blindness can also acquired. It is characteristic of certain disease such as Optic Neuritis and some Macular disorder and may develop in people with drug dependency.
291

Refraction

REFRACTION
In ophthalmology, the testing of eyes to ascertain the amount and variety of refractive error that may be present in each of them. Problem with visual acuity that result from refractive errors, such as: o Emmetropia ~ Normal Vision o Myopia (nearsightedness) ~ Deeper eyeballs, image focuses in front of retina. Correct with biconcave lens.
293

o Hyperopia/hypermetropia (Farsightedness) ~ Short eyeballs; image focuses behind retina. Correct with biconvex lens. o Astigmatism ~ Blurred vision when abnormal curvature of part of the cornea or lens prevents focus on retina. Correct with cylindrical lenses.

294

 Refraction and internal examination maybe accomplished by instilling medication with Cycloplegic and Mydriatic properties such as Tropicamide (Mydriacyl) or Cylopentolate (Cyclogyl) that cause ciliary muscle relaxation, pupil dilation (Mydriacyl) & lowered accommodative power (Cyclogyl) This drug is used for young children & elder.
295

 Multiple pinhole can help screen for refractive causes of decreased vision versus decreased vision secondary to organic disease Determined refractive state of eye: o Objectively ~ retinoscopy or automatic refraction. o Subjectively ~ Placing various types or lenses in front of the patient eyes to determine which lens arrive at the best visual image.
296

Internal Examination Opthalmoscopic Examination

a) Direct Opthalmoscopy ~Uses a strong light reflected into the interior of the eye through an instrument called an ophthalmoscope. ~ Produce an upright image& a 15 times magnification.

297

Ophthalmoscope

299

b) Indirect Opthalmoscopy ~Allows the examiner to obtain a stereoscopic view of the retina. ~Light source is from a head-mounted light (binocular device is placed on the examiner head) ~The examiner views the retina through a convex lens held in front of the eye & a viewing device on the head mount. ~Image appear is inverted & 2 - 5 times magnification.
300

Indirect Ophthalmoscope

301

c) Clinical Significance: ~Detection of cataracts, vitreous opacities, corneal scar ~Close examination for the pathologic changes in retinal blood vessels that may occur with diabetes or hypertension. ~Examination of the choroid for tumors or inflammation. ~Examination of the retina for retinal detachment, scars or exudates & hemorrhages of diabetes.
302

Slit Lamp Examination

Is a table mounted binocular that shines a light into the eye to let the doctor examines the entire eye under high magnification. It magnifies the cornea, sclera, anterior chamber and provide oblique views into the trabeculum for examination by the ophthalmologist.
303

Slit Lamp Examination

Patient sits with chin and forehead resting against equipment support. The room is generally darkened and the pupils are dilated Clinical Significance: help in detect disorder of the anterior portion of the eye.
304

305

Tonometry
a) Schiotz s Tonometry Quickly detect increased pressure in the eye. Eye drops that contain a topical anesthesia are given then the instrument is gently placed on the cornea (eyeball) and a reading is obtained in millimeters of mercury (mmHg) Normal tension is approximately 11-22 mmHg

306

b) Applanation Tonometry More accurate method for determining Intraocular Pressure (IOP) Usually attached to a slit lamp After numbing the eye with topical anesthesia, a instrument is gently moved until it rests upon the cornea while the doctor observes the cornea through a slit lamp The amount of pressure it takes to indent the cornea is related to the pressure within the eye.
307

Applanation Tonometry

308

Applanation Tonometry

309

c) Air Applanation Tonometry Use to screen for elevated pressure in the eye Not highly accurate A small puff of air is blown against the cornea which causes the person to blink but is not uncomfortable.

i.

ii. The puff of air flatter the cornea and the device measure the time (in thousand of a second) it take to flatten the cornea.

310

d) Clinical significance: ~to measure the pressure of aqueous humor within the eye (Intraocular Pressure) ~To detect certain type of glaucoma & monitor its treatment.

311

Nursing Responsibilities Assemble the ophthalmoscope begin with the light setting in the large white light &the lens wheel at 0 setting. Darken the room and have the patient to remove the glasses. Allows time for the patient s pupils to dilate. Patient should be sitting during the procedure. Sit facing the patient and ask him to look straight ahead during examination.
312

 Keep both eye open while looking through the ophthalmoscope viewer Shine the light on the pupil and observe the round red or orange grow (red reflex) Focusing on the red reflex slowly move the ophthalmoscope. Rotate the lens wheel until internal eyes structure are sharp and clear. Ask patient to look up, down and from side to side assessing the characteristic of retina correctly
313

EYE Disorder

General Procedures and Treatment Modalities

315

Instillation of Medications
Opthalmic medications may be used for diagnostic and therapeutic procedures: To dilate and contract the pupil To relive pain, discomfort, itching, and inflammation To act as an antiseptic in cleansing the eye To combat infection
316

Irrigation of the Eye

Occular irrigation is often necessary for the following: To irrigate chemicals or foreign bodies from the eyes to remove the secretions from the conjuntival sac To treat infections To relieve itching
317

Removing a Particle From the Eye

Typically, removing a foreign body from the eye, is an uncomplicated first aid measure However, if the object appears to be embedded, medical intervention is required, that is, LA, antibiotic therapy, clinical expertise in using other instruments The cornea should be evaluated or abrasion from the foreign body by use of the fluorescent staining, even if a foreign body cannot be found
318

Application of Dressing or Patch One or both eyes may need shielding for the following: To keep an eye at rest, thereby promoting healing To prevent the patient from touching the eyes to absorb secretions To protect the eye To control or lessen edema ( For procedure please refer to the Photostat
319