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• Optometria: Normal vision.
• Myopia is nearsightedness.
• Hyperopia is farsightedness.
• Astigmatism involves irregularities of the cornea.

Diagnosis and Evaluation

• Direct & Indirect Ophthalmoscopy: handheld device with a bright light source
• Slit-Lamp: Used as a binocular microscope
• Tonometry: Measures intraocular pressure (IOP)
• Elevated IOP is commonly tested for in glaucoma screenings
• Valsalva maneuvers (avoid straining, holding breath, etc.) raise IOP
• Color Vision Testing: Ishihara polychromatic plates test color vision
• Amsler Grid: Used to monitor for macular degeneration
• Abnormalities in the grid pattern may indicate macular issues
• Ultrasonography (B-scan): Identifies orbital tumors, retinal detachment, and vitreous hemorrhage
• Measures axial length prior to cataract surgery
• Optical Coherence Tomography (OCT): Light evaluates retinal and macular diseases & anterior segment conditions
• Non-invasive and without physical contact
• Fundus Photography: Detects & documents retinal lesions and macular edema
• requires dilated eye exam
• Used to view photographs in a stereoscopic manner
• Laser Scanning: Images the optic nerve to gather data on glaucoma or papilledema
• Can collect data to track the condition's progression
• Angiography: Employs contrast agents.
• Fluorescein Angiography: Evaluates macular edema, macular capillary non-perfusion, identifies neovascularization
• Fluorescein is injected and seen coursing through retinal vessels
• Indocyanine Green Angiography: Evaluates choroidal vasculature abnormalities
• Indocyanine Green is injected intravenously
• Check kidney function, ensure adequate hydration, and expect warmth prior to injection
• Observe injection site and encourage intake of fluids

Visual Field Testing

• Evaluates central and peripheral vision to identify scotomas (blind spots)
• Scotomas are found in macular degeneration, glaucoma, retinitis pigmentosa.

Blindness

• Ranges from 20/400 to no light perception
• Legal blindness is visual acuity of 20/200 or worse
• Absolute blindness is the absence of light perception

Assessing Low Vision

• Includes exams for distance & near vision, visual field, contrast sensitivity, glare, color, perception, and refraction
• Nursing assessments focus on functional abilities, coping, adaptation in emotional, physical, and social aspects

Managing Vision Loss

• Promoting coping involves grief processing, acceptance, value changes, and learning new functions
• Adaptation includes:
  • Speaking in a normal tone
  • Announcing yourself upon entry and departure in their presence
  • Giving specific directions (use clock method)
  • Keeping consistent environment to avoid obstacles
• Occupational and low vision therapists, as well as service animals can assist someone with blindness or low vision

Ocular Medications

• Maximize the amount of medication reaching the ocular site to produce a beneficial effect
• Absorption, distribution, metabolism, and excretion all play a role in drug effectiveness
• Natural barriers diminish the effect of ocular medications.
  • Size of conjunctival sac
  • Corneal membrane barriers
  • Blood-ocular barriers
  • Tearing, blinking, drainage
• Some medications contain preservatives and may cause allergic reactions

Common Ocular Medications

• Topical medications, such as drops and ointments, can reduce vision loss
  • Least invasive and have lower side effects
  • Permits self administration
• Topical anesthetics numb the eye for treatment/procedures
• Anti-allergy medications alter the allergic reaction / depends on allergen exposed to
• Corticosteroids commonly used as anti-inflammatory/ immunosuppressant agents to control ocular hypersensitivity
• Irrigants & Lubricants cleanse external lids & maintain hygiene / alleviate corneal irritation (dry eye syndrome )
• Mydriatic & Cycloplegic Agents- used in combination to achieve maximal pupil dilation
  • Contraindicated in patients with narrow or shallow angle chambers
• Anti-infective medications include: antibiotics, antifungals, and antivirals
• Nursing Management focuses on ensuring proper administration and ensuring patient safety
• Occlude the puncta to minimize absorption of eye drops

Glaucoma

• Characterized by elevated IOP (greater than 21 mm Hg) and a group of ocular conditions
• Increased aqueous fluid alteration and decreased aqueous production
• Diagnosis involves:
  • Tonometry to measure IOP
  • Ophthalmoscopy inspections of the optic nerve.
• Medications may produce systemic effects -Beta Blockers & change in BP+HR
• Anti-inflammatory, topical, and oral NSAIDs can treat Glaucoma

Instilling Eye Drops

• Wash hands before and after procedure
• Avoid touching the eye or face with dropper
• Instill eye drops before ointment
• After instilling, keep lid closed and apply gentle pressure to inner canthus for 1-2 minutes
• The pressure minimizes drainage!
• Pat dry with tissue after
• Wait 5 minutes before instilling another eye drop and 10 minutes before another ointment

Glaucoma Facts

• Damage to the optic nerve related to increased IOP
• Glaucoma is cause by congestion of aqueous humor
• Risk Factors:
  • Black/Asian race
  • Cardiovascular disease
  • Diabetes
  • Family history of glaucoma (screened by 40 yrs old)
  • Prolonged use of topical or systemic corticosteroids
• Clinical Manifestations: -Wide angle: -non-emergent, no pain - progressive tunnel vision. - Fluid stopped up around the eye/manageable over time.
• Narrow acute angle closure:
  • Emergency situation, abrupt onset, less common
  • Rapid increase of IOP.
  • Severe pain.
• Diagnostic Findings:
  • Pallor and cupping of the optic disc
  • Progression of visual field defects
• Glaucoma treatments goal is to always prevent Optic Nerve Damage

Pharmacological therapy for glaucoma

• Laser procedures are used
• Also surgeries possible

Cataracts

• Opacity or cloudiness of the lens and potentially leading to blindness
• Increases in old age (by 80)
• Risks: -Age-related breakdown of lens protein, decreased vitamins, increased sodium & calcium
  • Other ocular conditions: myopia, retinal surgery, uveitis
  • Toxic factors: severe burns, aspirin use, cigarette smoking, corticosteroids
  • Nutritional factors: obesity, poor diet, & low levels of antioxidants
  • Physical factors: blunt trauma, dehydration, UV radiation
  • Systemic diseases: diabetes, lipid metabolism disorders, Down syndrome, retinal disorders, musculoskeletal disorders
• Manifestations & Diagnostic Findings:
  • Painless, blurry vision, sensitivity to glare, myopic shift, astigmatism, diplopia (double vision)
  • Decreased visual acuity and opacity of the lens
  • Diagnosed by Snellen chart, slit-lamp, ophthalmoscope, or inspection
• Nursing Management: -Prevent age related cataracts -Optimal medical management is key
• Post Lens Transplant Post Operations:
  • Verbal and written education needs performed
  • Teach to wear wear glasses and eve shield, wash hanes, avoid laying on injected side at night, avoid lifting/pulling/pushing objects, avoid bonding or stooping

Complications regarding Lens Implantation

• call physician: Immediately if vision changes, continuous flashing lights, significant pain isn't relieved by Ibuprofen

Retinal Detachment

• Separation of retinal pigment epithelium and sensory retina/ Ocular Emergency
• Fluid seeps through the RPE if there is tear developing
• Clinical Manifestations:
  • Sensation of shade or curtain across vision, bright flashing lights, onset floaters/cobwebs, painless
• Cataract diagnosis:
  • Visual acuity
  • Sit lamp
  • Indirect ophthalmoscope
  • Stereo fundus photography
  • Fluorescein angiography
  • Ultrasonography

Managing Retinal Detachment

• Scleral Buckle: Compressing sclera
• Vitrectomy: Uses light
• Signs & Symptoms of increased IOP
• Prone Position Gas Bubble

Macular Degeneration

• Age related and leading cause of irreversible blindness
• Ardrusen builds up underneath the retina
• Dry/Non-exudative type
  • Slow/gradual breakdown, decreased central vision due to blank spots called Geographis Atrophy
• Wet type
  • Abrupt onset, a development of abnormal blood vessels growing under retina (bleed causing edema) rapid -Rapid visual changes, straight lines appear crooked, loss of central vision
• Supportive/Safety Support
• Teach about Amsler Grids
• Talk about lighting, magnification, rear to Vision Contra

Orbital & Ocular Trauma

• Ocular trauma frequently associated with head injury
• Assessment:
  • Pre-injury vision, injury details, pupil size, light reaction, ocular motility
• Emergency:
  • Flush out splash injury/chemical burns, remove object, and protect eye
• Conjunctivitis:
  • AKA "Pink eye"
  • Bacterial, viral, allergic, or toxin
  • Viral is contagious – Orbital Cellulitis Inflammation
  • Untreated can lead to blindness -Bacterial: Tearing, redness, feeling of a foreign object, Swollen eye -Allergic: itching, Pnotopnobia, string like the charge -Toxic: Redness, and Burning

Patient Education with Orbital Cellulitis

• Cool compress, l week of symptoms to resolve, Stay home for 7 days, wash hands, make up/Towels/lines changed
• Eye pain sensitivity, use artificial Tears, note vision ove changes

Medical Surgeries

• Enucleation: Removes eyeball leaving muscles and contents intact
• Evisceration: Removes intraocular contents through cornea or sclera
• Severe ocular trauma/Final cosmetic and motility better than enucleation and prosthesis are onnanced
• Exenteration: Removes entire contents orbit, soft tissue, and all or part of ovelid
• Maintenance-shape of ove actor on Nucleation or ovisceration to provent sunken appearance
• Protect suture line, maintain cornices, prevent contracture, promote eyelid integrity

Ocular Systemic Diseases

• Most are associated with high risk for Cataracts/most common cause of blindness in adults ever 40
• Cytomegalovirus Retinitis
  • Most are common with AIDS,
  • Retinal inflammation, Hello's, decreased peripnoval vision
• Hypertension-Related eye changes associated with atherosclerosis & Retinal arteriolar changed