Visual Impairment and Low Vision

Glaucoma

• Symptoms:
  • Severe eye pain
  • Redness in the eye
  • Clouded or blurred vision
  • Nausea and vomiting (n/v)
  • Bradycardia
  • Rainbow halos surrounding lights
  • Pupil dilation
  • Steamy appearance of the cornea
• Secondary glaucoma:
  • Caused by complications from other medical conditions or certain drug therapies
  • Examples: uncontrolled diabetes, hypertension, cataracts, eye tumors, uveitis, or other irritation or inflammation
  • Steroid drugs can also contribute to secondary glaucoma
• Nursing Management:
  • Assessment:
    • Visual field testing reveals loss of peripheral vision and increased IOP
    • Difficulty seeing in low light or darker rooms and increased sensitivity to glare
  • Diagnosis:
    • Patient teaching is necessary due to lack of exposure and inexperience regarding glaucoma causes and treatments
    • Pain resulting from increased IOP
    • Potential for infection resulting from eye drop instillation
    • Decreased ability to dress self resulting from visual impairment
  • Planning and expected outcomes:
    • Patient will have no further loss of vision
    • Patient will follow prescribed glaucoma care guidelines daily
    • Patient will state eye pain is decreased
    • Patient will be free from eye infection
    • Patient will be able to perform ADLs safely and independently
  • Intervention:
    • Teach patient that glaucoma is a chronic condition requiring lifelong medical treatment
    • Follow care guidelines
    • Surgical intervention if medication fails to control rising IOP (trabeculoplasty or trabeculectomy)
  • Evaluation:
    • Documentation of achievement of expected outcomes, no further vision loss, and independent performance of ADLs

Cataracts

• Definition:
  • Most common disorder found in the aging adult
  • Risk factors: smoking, prolonged exposure to UV light, and diabetes
• Pathophysiology:
  • Changes in the lens lead to cataracts
  • Protein meant to keep the lens clear starts to clump together behind the lens
  • Creates a cloud in a small area of the lens
• Symptoms:
  • Dimmed, blurred, or musty vision
  • Need for brighter light to read
  • Glare and light sensitivity
  • Halo that appears around lights
  • Double vision or multiple images in one eye
  • Loss of color perception
  • Recurrent eyeglass prescription changes
• Nursing Management:
  • Assessment:
    • Trouble reading and necessity for constantly changing glasses
    • Lens opacity may be visible on external or internal eye exam
  • Diagnosis:
    • Anxiety resulting from uncertain surgical outcome
    • Need for patient teaching about cataracts resulting from lack of exposure
    • Potential for injury resulting from changes in visual acuity
    • Decreased ability to dress self resulting from inability to see body and face clearly enough to maintain appearance
  • Planning and expected outcomes:
    • Patient will have cataract surgery when recommended
    • Patient will ask questions about preoperative and postoperative care and report satisfaction with information
    • Patient's affected eye will be free from increased IOP, stress on the suture line, hemorrhaging, and infection
    • Patient will verbalize appropriate home care activities to avoid and activities to do after surgery
    • Patient will demonstrate correct administration of eye drops
    • Patient will remain injury-free by maintaining a safe environment to avoid falls or bumping into items
  • Intervention:
    • Preoperative and postoperative surgical care
    • Teaching patient and family home care procedures
    • If lens implant has not been inserted, patients need to wear contact lenses or cataract glasses
  • Evaluation:
    • Documentation of achievement of expected outcomes
    • Patient and family will arrange for assistance with ADLs for the first 24-48 hours after surgery

Retinal Disorders

• Age-Related Macular Degeneration (AMD):
  • Leading cause of blindness in people over 50
  • Causes damaged to the macula leading to changes in the center of the field of vision
  • Peripheral vision is unchanged
  • Cells within the macula diminish in functional ability with age, and replacement of damaged cells is decreased, causing irreversible damage to the macula
• Diabetic Retinopathy:
  • Loss of visual function is the most common complication of diabetes
  • Altered circulation leads to retinal edema, degeneration, or detachment
  • Affects the retinal capillary circulation
  • Ballooning of tiny vessels leads to hemorrhaging, scarring, and blindness
• Hypertension Retinopathy:
  • Caused by uncontrolled hypertension
  • Chronic hypertension will cause progressive damage to the retina with few or even no symptoms until late advancement of symptoms
• Retinal Detachment:
  • Occurs when the sensory layer of the retina separates from the pigmented layer
  • Tears or holes occur in the retina due to trauma, aging, hemorrhaging, or tumor
• Nursing Management:
  • Assessment:
    • Unable to thread a needle or that words on a page look blurred
    • Retinal detachment: flashes of light followed by floating spots before the eye with progressive loss of vision
  • Diagnosis:
    • Need for patient teaching resulting from lack of exposure to accurate information about the effect of diabetes on the eyes
    • Need for patient teaching resulting from retinal detachment condition, surgery, preoperative and postoperative care, and home care after surgery
    • Anxiety resulting from fear of blindness
  • Planning and expected outcomes:
    • Pt will adjust successfully to vision loss by using low-vision aids
    • Pt will state in their own words the effect of diabetes on the eyes
    • Pt will see an ophthalmologist yearly
    • Pt will ask questions about preoperative and postoperative retinal surgery care and report satisfaction with the information
    • Pt's affected eye will be free from further retinal detachment, infection, or hemorrhaging
  • Intervention:
    • Pt must learn to cope with chronic, gradual vision loss
    • Self-monitor their central vision with an Amsler chart
    • How to obtain and use low-vision aids
    • Teaching about the condition and yearly follow-up visits with ophthalmologist
    • Postoperative care: administration of eye medication, pain medication, antiemetics, and cough medication
    • Avoid jerking movements of the head
    • Home care instructions

Note: ADLs stands for Activities of Daily Living, and IOP stands for Intraocular Pressure.### General Senses

• Touch, pressure, pain, temperature, vibration, and proprioception (position sense) are general senses
• Receptors for these senses are located all over the body, providing sensory information about the body and the environment
• Visceral senses supply information about internal organs

Specialized Senses

• Sight, hearing, taste, smell, and balance are specialized senses
• Produced by localized organs and specialized sensory cells

Sensation and Perception

• Sensation is conscious or unconscious awareness of external and internal stimuli
• Conscious sensation occurs via action potentials generated by receptors that reach the cerebral cortex
• Perception is the interpretation of conscious sensations

Vision

Age-Related Changes

• Eyelids lose tone and become lax, leading to ptosis, redundancy of skin, and malposition of eyelids
• Eyebrows may turn gray and become coarser in men, and outer thinning in both men and women
• Conjunctiva thins and yellows, may become dry due to diminished tear production
• Sclera may develop brown spots
• Cornea yellows and develops a noticeable surrounding ring made up of fat deposits (arcus senilis)
• Pupil decreases in size and loses some of its ability to constrict
• Lens increases in density and rigidity, affecting ability to transmit and focus light
• Peripheral vision decreases, night vision diminishes, and sensitivity to glare increases
• Gradual reduction in ability to see colors
• Color deficits due to multiple disease processes (e.g., diabetes, glaucoma, macular degeneration, Alzheimer's, and Parkinson's)

Common Complaints

Floaters and Flashers

• Floaters appear as dots, wiggly lines, or clouds moving in the field of vision
• More pronounced when looking at a plain background
• Occur more often after age 50, due to degeneration of vitreous gel
• Caused by degeneration of vitreous gel
• More common in older adults who have undergone cataract operations or YAG laser surgery
• Usually normal and harmless, but if increase in number or changes in type, light flashes, or visual hallucinations are noted, may indicate a vitreous or retinal tear/detachment
• Flashers occur when vitreous fluid inside the eye rubs or pulls on the retina, producing the illusion of flashing lights or lightning streaks
• Appear as jagged lines, last 10-20 minutes
• Present in both eyes, may indicate a spasm of blood vessels (migraine)
• Warrant prompt medical attention if large in number, large number of new flashers appear, or partial loss of side vision is noted

Dry Eyes

• Result from diminished quantity and quality of tear production
• Stinging, burning, or scratchy sensation
• Episodes of excess tearing with discomfort, dryness, pain, redness, and possibly discharge in the eyes
• Treatment includes tear replacement or conservation
• Tears may be replaced by instilling an OTC artificial tear preparation
• Solid inserts that gradually release lubricants throughout the day
• Ophthalmologist may temporarily close the lacrimal drainage system
• Conservation involves using a humidifier, wraparound glasses, and avoiding smoke

Common Problems and Conditions

Presbyopia

• Most common complaint of adults older than age 40
• Diminished ability to focus clearly on objects
• Lens loses its ability to focus on close objects
• Accommodation is impaired due to thickening and loss of elasticity of the lens
• Ciliary muscles weaken the lens's ability to contract
• Treatment includes wearing reading glasses or bifocals
• Nursing involves encouraging patients to adjust to glasses and follow up with a visit to the ophthalmologist every 2 years

Health Promotion and Illness Prevention

• Health promotion includes having a yearly eye exam and screening for eye disease and vision problems
• Use a bright light when sewing, reading, and cooking; avoid fluorescent light
• Have an UV-filter coating on spectacle lenses and sunglasses for outdoor activities
• Prevention and treatment of disease involves seeing an HCP/ophthalmologist with the occurrence of any pain, discharge, redness, swelling, or loss of vision
• Take measures for detection and appropriate treatment of vision difficulties and eye disease
• Maintain prescribed corrective lenses, low-vision aids, and medications

Blepharitis

• Chronic inflammation of the eyelid margins
• May be caused by seborrheic dermatitis or infection
• Use of antihistamines, antidepressants, anticholinergics, and diuretics may exacerbate this condition
• Deficiency of tear production due to infection
• Red, swollen eyelids; matting and crusting along the base of the eyelids at the margins; small ulcerations along the lid margins; and complaints of irritation, itching, burning, tearing, and photophobia
• Treatment involves using topical antibiotics or steroids, and teaching scrupulous eye hygiene

Glaucoma

• Second leading cause of blindness in the US; first leading cause among African Americans
• Can occur at any age, most at risk are adults older than 60
• Group of diseases that can result in vision loss and lead to blindness due to damage to the optic nerve
• Results from a blockage in the drainage of fluid in the anterior chamber of the eye
• Chronic open-angle glaucoma develops slowly and is the most common type
• Acute angle-closure glaucoma occurs suddenly and is a medical emergency### Visual Impairment
• Most common sensory problem
• Low vision: 20/50 to 20/200
• Legally blind: visual acuity of 20/200 or worse in the better eye with the aid of the best possible correction with the use of spectacles or contact lens
• Blindness results from diabetic retinopathy, glaucoma, cataracts, and macular degeneration (MD)
• Sudden vision loss is a medical emergency, may be caused by retinal detachment or eye injury
• Nursing Management:
  • Assessment: understanding of the patient's response to vision loss, loss of vision may result in self-esteem disturbance
  • Diagnosis: decreased self-esteem, social isolation, and inadequate coping
  • Planning and expected outcomes: patient will receive himself or herself positively, participate in activities with others, demonstrate increased objectivity, and safely provide self-care
  • Intervention: counseling, problem-solving, and organizing the environment

Hearing and Balance

• External ear, middle ear, and inner ear
• External and middle ear involved only in hearing
• Inner ear involved in both hearing and balance
• Age-Related Changes:
  • Auricle appears larger due to continued cartilage formation and loss of skin elasticity
  • Lobule of the auricle becomes elongated, with a wrinkled appearance
  • Auditory canal narrows, and hairs lining the canal become coarser and stiffer
  • Cerumen glands atrophy
  • Dull, retracted, and gray appearance of the tympanic membrane
  • Decreased vestibular sensitivity
  • Balance decline due to decreased sensory input, slowing of motor responses, and musculoskeletal limitations
• Common problems and conditions:
  • Pruritus: itching within the external auditory canal
  • Cerumen impaction: reversible, often overlooked, cause of conductive hearing loss
  • Tinnitus: subjective sensation of noise in the ear
  • Hearing loss: not a normal part of the aging process, affects 17% of adults

Dizziness and Disequilibrium

• 5 age-related conditions of disequilibrium:
  • Benign paroxysmal positional vertigo
  • Ampullary disequilibrium
  • Macular disequilibrium
  • Vestibular ataxia of aging
  • Meniere's disease
• Causes: visual disturbances, musculoskeletal disorders, neurologic dysfunctions, metabolic abnormalities, cardiovascular disease, and medications
• Signs and symptoms: whirling dizziness, imbalance, and constant feeling of imbalance
• Nursing Management:
  • Assessment: description of vertigo episodes, a list of accompanying symptoms, and a history of balance problems
  • Diagnosis: potential for injury, need for patient teaching, and anxiety
  • Planning and expected outcomes: patient will accurately follow the prescribed medication regimen and exercise protocol
  • Intervention: antivertiginous drugs, vestibular rehabilitation therapy, and surgery

Taste and Smell

• Senses of smell and taste diminish with aging
• Decreased sensitivity to odors: potential risk for noxious chemicals and poisonings
• Age-Related Changes:
  • Result from alterations in the oral mucosa and tongue, and the pathological state of the nasal cavity
  • In health older adults, olfactory losses result from normal aging, medications, viral infections, long-term exposure to toxic fumes, and head trauma
• Common problems and conditions:
  • Xerostomia: dry mouth, reduced salivary flow, and disease states of the nervous and endocrine systems
  • Nursing Management:
    • Assessment: health history of factors leading to disease in salivary flow and patient's oral complaints
    • Diagnosis: inadequate oral mucous membrane and inadequate nutrition
    • Planning and expected outcomes: patient will verbalize an increase in taste sensation, exhibit unimpaired oral mucosa tissue integrity, and demonstrate a correct oral hygiene regimen
    • Intervention: attaining intact oral mucosa tissue integrity, teaching patients about factors leading to a decrease in salivary flow, and oral hygiene

Touch

• Involves tactile information on pressure, vibration, and temperature
• Age-Related Changes:
  • Decreased density of cutaneous receptors for touch sensation
  • Tactile vibratory thresholds progressively increase with age
  • Warm-cold difference threshold increases
• Common disorders affecting tactile information:
  • CVA, PVD, and diabetic neuropathy
• Intervention:
  • Preventing accidental trauma and injury
  • Patient education on skin, leg, and foot care

Cardiovascular Function

• Heart disease is the leading cause of death and major cause of disability
• Age-Related Changes:
  • Heart rate decreases, and the left ventricular wall thickens
  • Increase in collagen and decreased in elastin in the heart muscle and vessel walls
  • Size of the left atrium increases, and aortic distensibility and vascular tone decrease
• Common Cardiovascular Problems:
  • CVD is the leading cause of death
  • Risk factors: elevated cholesterol, HTN, diabetes, tobacco use, physical inactivity, obesity, and advancing age
  • Atherosclerosis: underlying cause of most clinical cardiovascular problems
• Nursing Management:
  • Assessment: health history, physical examination, and diagnostic tests
  • Diagnosis: risk factors, signs and symptoms, and disease state
  • Planning and expected outcomes: patient will verbalize understanding of risk factors, signs and symptoms, and treatment of CVD
  • Intervention: patient education, diet, exercise, stress management, and smoking cessation