Unit IV - Eye

• "Visually Impaired"
• Congenital (birth defects)
• Acquired (diabetic retinopahy, glaucoma, cataracts, retinal degeneration, trauma)
• Legally Blind - 20/200 or visual field < 20 degrees
• Loss of peripheral vision, halos, orbital pressure, bulging
• Emotional support, assistive devices, family teaching, safety, ADLs
• ID self when approaching

• Astigmatism: defect in the curvature of the lens - blurred vision
• Strabismus: cross eyes
• --esotropia - in
• --exotropia - out
• Myopia: nearsightedness (cannot see far)
• Hyperopia: farsightedness (cannot see close)
• --presbyopia - due to aging

• Opthalmoscope
• Retinoscopy
• Visual acuity tests
• Refraction tests

• Glasses, contacts, laser surgery
• Radial Keratotomy: inscisions to flatten cornea
• LASIK: laser correction with corneal flap

• No NSAIDs or aspirin for one week prior
• No contacts 1-2 days prior
• Eye patch til next morning
• Eye drops for comfort/anti-infective
• Follow up appointment 1-2 days

• Sterile, eye dropper should never touch eye
• Drops: Look up - drop into conjuntival sac
• Ointment: small line along lower lid

Kill bacteria

• Gentamicin
• Tobrex
• Mycostatin

• Control inflammation
• Side effects - increased IOP, masking infection

• Decadron
• Maxitrol

• For eye exam and minor surgery
• Side effects: temporary burning, loss of lid reflex

• Ophthaine
• Pontocaine

• Replace tears, lubricate contacts
• Usually given at night - blurred vision

• Hypotears
• Lacrilube

• Decrease IOP by decreasing production of aqueous humor
• Side effects: cardiac - monitor HR and BP

• Timoptic
• Betoptic
• Timolol
• Betagen

• Decrease IOP by decreasing production of aqueous humor
• Side effects: drowsiness, depression, malaise, diuresis, paresthesia

Diamox

• Profound diuresis - decreases intraocular pressure
• given IV in emergency (eye trauma)
• Side effects: HA, N&V, thirst, diarhhea, agitation

• Mannitol
• Oral glycerin

• Pupil dilation, paralyzes accomodation
• Used during eye exam/surgery
• Side effects: increased IOP, photophobia, dry mouth, hypertension

Need sunglasses

Cyclogyl, Mydriacyl, Mydriafair

• Constricts the pupil, opens canal of Schlemm, drains aqueous humor, decreases IOP
• Side effects: blurred vision, decreased light into eye (provide more light to see)

Pilocarpine, Isopto, Carpine

• Pink eye
• Inflammation of conjuntiva (bacterial or sometimes viral)

• Erythema
• Edema
• Crusting discharge
• Tearing

C&S

• Saline eye irrigations
• Cold compresses for itching/edema
• Topical antibiotics/steroids
• Antihistamines/decongestants (if due to allergies)
• Patient teaching - infection control (keep hands out of eye), cross contamination, wash linens separately, no contacts/smoke/fumes

• Opacity of the lens
• Usually due to age but can be congenital

• UV light exposure
• Diabetes
• Age
• Steroids
• Nutritional deficiencies
• Alcohol
• Congenital defects
• Trauma
• Intraocular infections
• Smoking

• Blurred/hazy vision
• Fog/film over objects
• Profound glare (night driving)
• No pain
• Changes in color vision
• Visible white/gray spot behind pupil

Ophthalmoscope and Silt Lamp

• Surgery is only treatment
• Extracapsular extraction
• Phacoemulsification - ultrasound to break up and extract cataract
• Corticosteroids and antibiotics intra/post-op
• Rare complications - Increased IOP, hemorrhage, retinal detachment, macular edema

• Avoid increased eye pressure: coughing, sneezing, constipation, vomiting, bending, stooping, lifting
• Limited activity for one week
• Sleep with eye sheid
• Do not lay on affected side
• Prescribed eye drops

• Diabetes causes vascular changes in retina
• Venous capillaries dilate and develop microscopic aneurysms
• Edema and small hemorrhages into retina

• 10 years post diabetes DX
• Increased in poorly controlled diabetes
• 85% of diabetics develop

• Diabetic history
• Floaters
• Blurred/spotty vision
• Opacities, hemorrhages, lesions visible

• Ophthalmoscope - dilated vessels, narrow arteries
• Angiography - shows microaneurysms

• Evaluate 3-5 years after Dx then annually
• ACE inhibitors: dilate retinal vessels
• Phoocoagulation: destroys new vssels, seals leaking vessels, prevents retinal edema
• Cryotherapy: decrease bleeding by freezing
• Vitrectomy: removal of the vitreous
• Vitrase (ovine hyalurondase): clears bloodied vitreous in 1 month

Same as other eye surgery

• Deterioration of the macula (center of the retina)
• Leading cause of visual impairment in US

• Family history
• Diabetes
• Smoking
• Caucasian
• UV light exposure

• Dry: age related, gradual onset
• Wet: caused by blockage in capillaries, sudden onset

• No early symptoms
• Loss of color vision
• Blured vision
• Distortion of lines
• Empty spot in central vision
• Appearance of drusen (yellow exudates)

• Amsler Grid Test
• Ophthalmoscope

• Dry: no treatment
• Wet: photocoagulation of new vessels to prevent growth into macula

• No way to restore central vision
• Visual aids - lenses, magnifying glass
• Vitamins C, E, beta-carotene help slow progression
• Early detection critical

• Retina detaches from choroid layer, causing hemorrhage or leakage of vitreous
• Caused by degenerative changes or trauma
• Partial detachment: progressive vision loss
• Total detachment: blindness

• Sudden change in vision
• Floaters or flashing light
• "Veil" or "curtain" over vision
• No pain (no receptors on retina)

• Ophthalmoscope and silt lamp
• Ultrasound

• Laser photocoagulation: burn off tears/breaks
• Cryotherapy: freezes retina
• Diathermy: burns retina via ultrasound
• Scleral Buckling: silicone band around eyeball to seal tears

• Eye bandaged post op
• Antibiotic, cycloplegic, and mydriatic drops
• Antianxiety meds
• Limited activities 3-5 weeks (to prevent another detachment)
• Avoid constipation and vomiting

• Reattachment 90% successful
• Maximum sight within 3 months
• If not reattached, retina dies -> blindness

• Increase in pressure in he eye caused by changes in outflow of aqueous humor
• Affects peripheral vision
• One of the leading causes of blindness
• Over age 35
• No cure

• Chronic
• Elderly
• Risk factors - hypertension, previous eye inury, African-American
• Possibly hereditary

• aka Narrow Angle
• Sudden onset
• Eye injury interferes with drainage of aqueous humor, increases pressure
• Medical emergency
• Eye drops, Mannitol, surgery

• Gradual onset
• Tired eyes
• Headache
• Difficulty focusing
• Peripheral vision loss
• Halos
• Inability to detect colors
• Increased IOP - Optic disk cupping

• Rapid onset
• Severe pain
• Decreased vision
• N&V
• Enlarged, fixed pupil
• Colored halos
• Increased IOP - Optic disk cupping

• Tonometer
• Visual field studies - decreased peripheral vision

• Eye drops - improve flow, decrease production of aqueous humor
• Miotics - constrict pupil, open canal of Schlemm, drain aqueous humor
• Carbonic anhydrase inhibitors, beta blockers - decrease production of aqueous humor
• Osmotics - IV for emergency

• Trabeculoplasty/Trabeculectomy: laser procedure on iris/surrounding tissue to facilitate aqueous humor flow
• Iridotomy: inscion into iris to create opening for aqueous humor

Both increase aqueous humor outflow/decrease IOP

• Use eye drops regulary
• Medic alert bracelet
• Regular eye exams (q 2-4 years, q 1-2 years > 65)
• Post-surgical eye precautions
• Patient and family teaching - treatment, care, and compliance
• Patient safety
• No OTC allergy meds

• Foreign bodies - dust, propellants, eye lashes, contact lenses
• Burns
• Penetrating wounds

• No bleeding (cornea non-vascular)
• Pain with eye/lid movement
• Tearing
• Redness
• Pruritis
• Vision Loss

• Visual/ophthalmoscope exam
• Fluorescein staining
• Peripheral vision tests
• Silt lamp exam
• Ultrasound, X-ray, CAT scan
• MRI

• Ask about first aid given at scene
• Burns: flush eye 15-20 mins with tap water to prevent scarring -> ER
• Penetrating wounds: do not remove object, cover both eyes -> ER
• Foreign objects:
• -Eye flush - saline
• -Moist q-tip/gauze to remove visible object
• Antibiotic ointment/drops

• Assist with procedures
• Patient teaching
• Handwashing
• Eye safety

• Inflammation of the cornea
• Caused by irritation, bacteria, or virus
• Contact lens wears more succeptible

• Severe eye pain, increased with blinking
• Tearing
• Photophobia, photosensitivity
• Visual disturbances
• Untreated - vision loss

• Ophthalmic exam
• C&S

• Topical antibiotics/steroids (systemic if severe)
• Cycloplegic mydriatic drugs - paralyze ocular muscles, dilate pupil
• Analgesics
• Sunglasses
• Pressure dressings

Surgical removal of the eye (eyeball or eyeball + surrounding structures) due to tumor or trauma

• Emotional support
• Pain relief
• Pressure dressings to control bleeding
• Routine post op care
• Prosthetic fitting 4 weeks