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

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