Eye Student Outline PDF

**Student Outline** **Chapter 47\--Nursing Assessment: Sensorineural Function (EYE)** **Anatomy of the External Eye** **Anatomy-EOM and Eye Movement** The extraocular muscles are responsible for eye movement.  **Anatomy of the Internal Eye-Figure 47-3** **Accommodation -*...

**Student Outline** **Chapter 47\--Nursing Assessment: Sensorineural Function (EYE)** **Anatomy of the External Eye** **Anatomy-EOM and Eye Movement** The extraocular muscles are responsible for eye movement.  **Anatomy of the Internal Eye-Figure 47-3** **Accommodation -** The ability to focus and refocus **Gerontologic Considerations-Age related changes** - Dry eye - Dysfunction of meibomian glands. Inflammatory changes to tear proteins. - Discomfort and pain with possible vision changes. - Patients complains of vision changes, itching, burning, scratching sensation proportional to increase computer screen time. - Eyelids and lacrimal structures - Loss of skin elasticity and orbital fat, decreased muscle tone; wrinkles develop - Lid margins turn in, causing lashes to irritate cornea and conjunctiva (entropion); or lid margins may turn out, resulting in increased corneal exposure (ectropion) - Patient reports burning, foreign-body sensation, increased tearing (epiphora); injection, inflammation, and ulceration may occur - Refractive changes; presbyopia - Loss of accommodative power in the lens with age - Reading materials must be held at increasing distance in order to focus - Patient reports difficulty in reading at the usual reading distance; need for increased light; reading glasses or bifocals needed - Cataracts - Opacities in the normally crystalline lens - Interference with the focus of a sharp image on the retina - Patient reports increased glare, decreased vision, changes in color values (blue and yellow especially affected) - Posterior vitreous detachment - Liquefaction and shrinkage of vitreous body - May lead to retinal tears and detachment - Patient reports light flashes, cobwebs, floaters - Age-related macular degeneration (AMD) - Drusen (yellowish aging spots in the retina) appear and coalesce in the macula. Abnormal choroidal blood vessels may lead to formation of fibrotic disciform scars in the macula. - Central vision is affected; onset is more gradual in dry AMD, more rapid in wet AMD; distortion and loss of central vision may occur - Patient reports reading vision is affected; words may be missing letters, faded areas appear on the page, straight lines may appear wavy; drusen, pigmentary changes in retina; abnormal submacular choroidal vessels - Low vision - Vision difficulties even with corrective lenses - Vision less than 20/40 with corrective lenses with the best correction possible - Patient reports progressive vision loss in near and far vision with light sensitivity and difficulty seeing at night **Eye Assessment: History and Physical** - History - Common Complaints - Change in vision - Pain or discomfort - Discharge - Past History - Family History - Social History - Physical Assessment - Visual Acuity - External Eye Examination - Diagnostic Examination - Direct Ophthalmoscopy - Amsler Grid - Tonometry - Perimetry Testing - Split-Lamp Exam - Color vision testing - Ultrasonography - Fluorescein Angiography **Chapter 48\--Nursing Management: Patients with Eye and Vision Disorders** **Impaired Vision** - Refractive errors- vision is impaired because a shortened or elongated eyeball prevents light rays from focusing sharply on the retina. Blurred vision from refractive error can be corrected with eyeglasses or contact lenses. - Low Vision- is a general term describing visual impairment that requires patients to use devices and strategies in addition to corrective lenses to perform visual tasks. is defined as a best corrected visual acuity (BCVA) of 20/70 to 20/200. **Blindness** - Absolute blindness- is the absence of light perception. - Legal Blindness - is a condition of impaired vision in which a person has a BCVA that does not exceed 20/200 in the better eye or whose widest visual field diameter is 20 degrees or less. **Clinical Manifestations and Assessment** - The assessment of low vision includes a thorough history and the examination of distance and near visual acuity, visual field, contrast sensitivity, glare, color perception, and refraction (see Chapter 47). Specially designed, low-vision visual acuity charts are used to evaluate patients. **Activities Affected by Visual Impairment with Suggestions for Low-Vision Aids** +-----------------------+-----------------------+-----------------------+ | **Activity** | **Optical Aids** | **Non-optical Aids** | +=======================+=======================+=======================+ | Shopping | Hand magnifier | Lighting, color cues | +-----------------------+-----------------------+-----------------------+ | Fixing a snack | Spectacle magnifier | Color cues, | | | | consistent storage | | | | plan | +-----------------------+-----------------------+-----------------------+ | Eating out | Hand magnifier | Flashlight, portable | | | | lamp | +-----------------------+-----------------------+-----------------------+ | Identifying money | Spectacle, | Arrange paper money | | | spectacle-mounted or | in wallet | | | hand magnifier | compartments or fold | | | | banknotes of | | | | different | | | | denominations | | | | differently. | +-----------------------+-----------------------+-----------------------+ | Reading print | Spectacle, | Lighting, | | | spectacle-mounted, | high-contrast print, | | | dome, hand, or stand | large print, reading | | | magnifier | slit stand magnifier, | | | | electronic books | | | Closed-circuit | | | | television | | +-----------------------+-----------------------+-----------------------+ | Writing | Hand magnifier | Lighting, bold-tip | | | | pen, black ink | +-----------------------+-----------------------+-----------------------+ | Using a telephone | Telescope hand | Large print dial or | | | magnifier | touch tone buttons, | | | | hand-printed | | | | directory | +-----------------------+-----------------------+-----------------------+ | Crossing streets | Telescope | Cane, ask directions | +-----------------------+-----------------------+-----------------------+ | Finding taxis and bus | Telescope | Ask for assistance | | signs | | | +-----------------------+-----------------------+-----------------------+ | Reading medication | Hand magnifier | Color codes, large | | labels | | print | +-----------------------+-----------------------+-----------------------+ | Reading stove dials | Hand magnifier | Color codes, raised | | | | dots | +-----------------------+-----------------------+-----------------------+ | Using a computer | Spectacle or | High-contrast color, | | | spectacle-mounted | large-print program | | | magnifier | | +-----------------------+-----------------------+-----------------------+ | Reading signs | Telescope | Move closer | | | | | | | Portable electronic | | | | magnifier | | +-----------------------+-----------------------+-----------------------+ | Adjusting the | Hand magnifier | Enlarged print model | | thermostat | | | +-----------------------+-----------------------+-----------------------+ | Watching sporting | Telescope | Sit in front rows | | event | | | +-----------------------+-----------------------+-----------------------+ **Web Access for the Visually Impaired** - People with impaired vision need not be left behind in the computer age. Various technologies are available. A list of general equipment needs follows: - Computer: Software specifically developed for people with visual impairment - Internet service provider (e.g., AOL, Netscape, EarthLink, Xfinity) - Screen-reader program: Converts text on the computer screen to synthesized speech (e.g., JAWS for Windows, Windows Eyes, Slimware Window Bridge, ProTalk 32, Hal Screen Reader, WinVision, outSPOKEN for Windows) - Browser program to navigate the World Wide Web (e.g., Microsoft Internet Explorer, IBM Home Page Reader) **Nursing Management** **Types of Adaptation** - Coping with blindness involves three primary adaptations: emotional, physical, and social. - Emotional adjustment is crucial; it determines the success of physical and social adaptations. - Successful emotional adjustment leads to acceptance of blindness or severe visual impairment, which is essential for rehabilitation. - Physical adaptation includes learning to navigate the environment and perform daily activities without sight. - Social adaptation involves maintaining relationships and engaging in social activities despite visual limitations. **Emotional Adjustment Process** - Effective coping often requires the patient to acknowledge the permanence of their blindness. - Clinging to false hopes of regaining vision can hinder adaptation efforts. - Patients and their families typically experience stages of grief: denial, anger, bargaining, depression, and acceptance (Kübler-Ross, 1969). - Acceptance of visual loss and willingness to adapt are key to successful rehabilitation. - Emotional support from healthcare providers and family is vital during this adjustment period. **Promoting Coping Efforts** **Strategies for Effective Coping** - Encourage patients to express their feelings and fears regarding their visual impairment. - Provide education about the nature of their condition and realistic expectations for the future. - Facilitate support groups where patients can share experiences and coping strategies. - Involve family members in the coping process to enhance support systems. - Address stigma and independence-dependence conflicts that may arise due to visual impairment. **Grieving Process in Patients and Families** - The grieving process can significantly impact the adaptation to blindness. - Family members may also experience grief and require support to help the patient effectively. - Understanding the stages of grief can help healthcare providers offer appropriate interventions. - Emotional and behavioral issues may hinder learning for patients who become blind suddenly, necessitating intensive support. **Promoting Spatial Orientation and Mobility** **Importance of Spatial Orientation** - Patients with chronic progressive eye disorders often develop better cognitive mapping skills than those who become blind suddenly. - Gradual loss of vision allows for the development of spatial and topographic concepts, aiding in adjustment. - Patients who lose vision suddenly may struggle with spatial orientation and require more support. - Teaching spatial concepts is essential for performing activities of daily living (ADLs) effectively. **Techniques for Orientation and Mobility Training** - In a hospital setting, ensure that essential items (e.g., call button, bedside table) are within reach of the patient. - Use descriptive techniques, such as likening the food tray to a clock face, to help patients understand their environment. - Maintain consistent placement of furniture and personal items to aid in spatial memory. - Introduce hospital personnel to the patient upon entering and leaving the room to enhance social interaction. **Promoting Home and Community-Based Care** **Collaborative Assessment and Support** - Nurses, social workers, and family members should collaborate to assess the patient\'s home environment and support systems. - Consult with low-vision specialists or occupational therapists for tailored interventions. - Identify community resources and services that can assist patients with visual impairments. **Assistive Technologies and Services** - Braille and guide dogs are valuable resources for individuals with visual impairments. - Guide dogs provide mobility assistance and companionship, enhancing independence. - It is important to educate the public about the role of guide dogs and the need for permission before approaching them. - Organizations like Fidelco Guide Dog Foundation and Guide Dogs for the Blind offer support and information for potential handlers. **Guidelines for Interacting With People Who Are Blind or Have Low Vision** - **Identify Yourself**: Always introduce yourself when approaching a person who is blind or has low vision, stating your name and role. - **Use Normal Tone**: Speak directly to the person in a normal tone of voice without raising it unless requested. - **Provide Specific Directions**: Use specific distances or clock cues to guide the person, avoiding vague terms like \'over there\'. - **Offering Assistance**: Allow the person to hold onto your arm just above the elbow when guiding them. - **Reading Information**: Offer to read written materials, such as menus or instructions, to assist the person. - **Environment Management**: Ensure the environment is free of obstacles and that all necessary objects are within reach. - **Touch for Communication**: Lightly touch the person's hand or arm to indicate you are about to speak. - **Indicate Changes in Environment**: Inform the person when you are leaving the room or when there are changes in the environment, such as stairs. - **Avoid Pity**: Interact with individuals as you would with anyone else, without expressing pity. - **Respect Service Animals**: Do not distract a service animal unless the owner has given permission. - **Ask for Help Needs**: Always ask the person how you can assist them, as their needs may vary. - Always identify yourself when approaching a person who is blind or has low vision. - Use specific distance or clock cues when giving directions. - Allow the person to hold onto your arm just above the elbow when assisting them. - Service animals should not be distracted unless permission is given by the owner. - It is appropriate to touch a person\'s hand or arm lightly to indicate you are about to speak. **Concept Comparisons** **Aspect** **Interacting with Blind Individuals** **Interacting with Sighted Individuals** ---------------------- ---------------------------------------- ------------------------------------------ Communication Style Speak directly and normally Speak directly and normally Use of Language Use words like \"see\" and \"look\" Use words like \"see\" and \"look\" Physical Contact Light touch to indicate speaking Varies based on relationship Directional Guidance Use specific distances and cues General directions are often sufficient **Glaucoma** - **Pathophysiology** - Direct Mechanical Theory - Suggests that high IOP directly damages the retinal layer as it passes through the optic nerve head. - Indirect Ischemic Theory - Proposes that high IOP compresses the microcirculation in the optic nerve head, leading to cell injury and death - **Classifications** - **Open-Angle Glaucoma** - Chronic Open-Angle Glaucoma (COAG) - Typically bilateral, but one eye may show more severe symptoms than the other. - Characterized by optic nerve damage and visual field defects, with IOP often exceeding 21 mm Hg. - Treatment focuses on lowering IOP by 20-50% using topical and oral medications. - Normal Tension Glaucoma - Defined by IOP levels of 21 mm Hg or lower, yet still results in optic nerve damage and visual field loss. - Management strategies are similar to COAG, but the optimal treatment approach remains under investigation. - The goal is to reduce IOP by at least 30% to prevent further damage. - Ocular Hypertension - Characterized by elevated IOP without any observable optic nerve damage or visual field loss. - Patients may experience ocular pain or headaches, although many remain asymptomatic. - Treatment aims to lower IOP by at least 20% to prevent progression to glaucoma. - **Angle-Closure (Pupillary Block) Glaucoma** - Acute Angle-Closure Glaucoma - Acute Angle-Closure Glaucoma (AACG) - Presents with rapid visual impairment, severe periocular pain, and symptoms like nausea and vomiting. - Physical examination reveals a fixed, semi-dilated pupil and significantly elevated IOP, often accompanied by corneal edema. - Immediate treatment is critical, involving hyperosmotic agents, acetazolamide, and topical hypotensive medications. - Subacute Angle-Closure Glaucoma - Symptoms include transient blurring of vision and halos around lights, often with temporal headaches. - The pupil may appear semi-dilated, indicating potential progression to acute glaucoma if untreated. - Prophylactic measures, such as peripheral laser iridotomy, are recommended to prevent acute episodes. - Chronic Angle-Closure Glaucoma - Characterized by progressive optic nerve damage and visual field loss, with IOP that may be normal or elevated. - Patients may experience ocular pain and headaches, similar to COAG management. - Treatment includes laser iridotomy and medications to manage IOP effectively. - **Other Types of Glaucoma** - Uveitic Glaucoma - Defined by IOP levels of 21 mm Hg or higher, leading to optic nerve damage and visual field defects. - Treatment may involve both medical and surgical interventions to control IOP and address underlying uveitis. - **Risk Factors** - Family history of glaucoma - Race (African, Caribbean, Hispanic) - Older age (over 60 years of age) - Diabetes mellitus - Cardiovascular disease - Migraine syndromes - Nearsightedness (myopia) - Eye trauma - Prolonged use of topical or systemic corticosteroids - **Progression of Glaucoma** - Initiating events - Precipitating factors include illness, emotional stress, congenital narrow angles, long-term use of corticosteroids, and use of mydriatics (i.e., medications causing pupillary dilation). - ↓ - Structural alterations in the aqueous outflow system - Tissue and cellular changes caused by factors that affect aqueous humor dynamics lead to structural alterations. - ↓ - Functional alterations - Conditions such as increased IOP or impaired blood flow create functional changes. - ↓ - Optic nerve damage - Atrophy of the optic nerve is characterized by loss of nerve fibers and blood supply. This fourth stage inevitably progresses to the fifth stage. - ↓ - Visual loss - Progressive loss of vision is characterized by visual field defects. - **Glaucoma Medical and Nursing Management** - Topical/Oral agents - **Beta Blocker eye drops**- If medical tx unsuccessful...laser surgery to dec IOP - Goal is to maintain IOP within a range to avoid any further damage; decrease IOP by 30% - Teaching plan: The nature of the disease and the importance of strict adherence to the medication regimen must be included in a teaching plan to help ensure compliance. A thorough patient interview is essential to determine systemic conditions, current systemic and ocular medications, family history, and problems with adherence to glaucoma medications. The effects of glaucoma-control medications on vision must also be explained. - Teaching Patients Self-Care - The medical and surgical management of patients with glaucoma slows the progression of glaucoma but does not cure it. The lifelong therapeutic regimen mandates patient education. - Continuing Care **Patient Education for Managing Glaucoma** - Know your IOP measurement and the desired range. - Be informed about the extent of your vision loss and optic nerve damage. - Keep a record of your eye pressure measurements and visual field test results to monitor your own progress. - Review all your medications (including over-the-counter and herbal medications) with your ophthalmologist, and mention any side effects each time you visit. - Ask about potential side effects and drug interactions of your eye medications. - Ask whether generic or less costly forms of your eye medications are available. - Review the dosing schedule with your ophthalmologist and inform them if you have trouble following the schedule. - Participate in the decision-making process. Let your provider know what dosing schedule works for you and other preferences regarding your eye care. - Have the nurse observe you instilling eye medication to determine whether you are administering it properly. - Be aware that glaucoma medications can cause adverse effects if used inappropriately. Eye drops are to be administered as prescribed, not when eyes feel irritated. - Ask your ophthalmologist to send a report to your provider after each appointment. - Keep all follow-up appointments. **Cataract** - **Risk Factors for Cataract Formation Box 48-6** - Aging: - Loss of lens transparency - Clumping or aggregation of lens protein (which leads to light scattering) - Accumulation of a yellow-brown pigment due to the breakdown of lens protein - Decreased oxygen uptake - Increase in sodium and calcium - Decrease in levels of vitamin C, protein, and glutathione (an antioxidant) - Associated ocular conditions: - Retinitis pigmentosa - Myopia - Retinal detachment and retinal surgery - Infection (e.g., herpes zoster, uveitis) - Toxic factors: - Corticosteroids, especially at high doses and in long-term use - Alkaline chemical eye burns, poisoning - Cigarette smoking - Calcium, copper, iron, gold, silver, and mercury, which tend to deposit in the pupillary area of the lens - Nutritional factors: - Reduced levels of antioxidants - Poor nutrition - Obesity - Physical factors: - Dehydration associated with chronic diarrhea, use of purgatives in anorexia nervosa, and use of hyperbaric oxygenation - Blunt trauma, perforation of the lens with a sharp object or foreign body, electric shock - Ultraviolet radiation in sunlight and x-ray - Systemic diseases and syndromes: - Diabetes mellitus - Down syndrome - Disorders related to lipid metabolism - Kidney disorders - Musculoskeletal disorders - **Pathophysiology\--** Cataracts can develop in one or both eyes at any age for a variety of causes. Visual impairment normally progresses at the same rate in both eyes over many years or in a matter of months. - The three most common types of age-related cataracts are defined by their location in the lens: nuclear, cortical, and posterior subcapsular. The extent of visual impairment depends on their size, density, and location in the lens. More than one type can be present in one eye. - **Medical Management** - Non-surgical - medications, eyedrops, eyeglasses - Surgical - Intracapsular Cataract Extraction - the entire lens is removed and fine sutures are used to close the incision - Extracapsular Cataract Extraction - involves smaller incisional wounds (less trauma to the eye) and maintains the posterior capsule of the lens, thus reducing postoperative complications, particularly aphakic (absence of the lens) retinal detachment and cystoid macular edema - Phacoemulsification - uses an ultrasonic device that liquefies the nucleus and cortex, which are then suctioned out through a tube. - Lens Replacement - Aphakic glasses, although effective, are rarely used. Objects are magnified by 25%, making them appear closer than they actually are. - Contact lenses provide patients with almost normal vision, but because contact lenses need to be removed occasionally, the patient also needs a pair of aphakic glasses. - Insertion of a prosthetic IOL during cataract surgery is the usual approach to lens replacement. After cataract extraction, or phacoemulsification, the surgeon implants an IOL. Extracapsular cataract extraction and posterior chamber IOL are associated with a relatively low incidence of complications - Toxic Anterior Segment Syndrome - Also known as toxic endothelial cell destruction or sterile endophthalmitis, is a noninfectious inflammation caused by a toxic agent that acutely presents 12 to 48 hours following surgery. - TASS is characterized by corneal edema less than 24 hours after surgery and an accumulation of white cells in the anterior chamber of the eye. - **Nursing Management** - Preoperative Care\--The patient with cataracts should receive the usual preoperative care for ambulatory surgical patients undergoing eye surgery. - Postoperative care - Education - Wear glasses or metal eye shield at all times following surgery, as instructed by the provider. - Always wash hands before touching or cleaning the postoperative eye. - Clean the postoperative eye with a clean tissue; wipe the closed eye with a single gesture from the inner canthus outward. - Bathe or shower; shampoo hair cautiously or seek assistance. - Avoid lying on the side of the affected eye the night after surgery. - Keep activity light (e.g., walking, reading, watching television). Resume the following activities only as directed by the surgeon: driving, sexual activity, unusually strenuous activity. - Remember not to lift, push, or pull objects heavier than 15 lb. - Avoid bending or stooping for an extended period. - Be careful when climbing or descending stairs. - Know when to contact the surgeon. - **Retinal Detachment** - Retinal detachment refers to the separation of the RPE from the sensory layer. The four types of retinal detachment are rhegmatogenous, traction, a combination of rhegmatogenous and traction, and exudative. - **Clinical Manifestations and Assessment** - Patients may report the sensation of a shade or curtain coming across the vision of one eye, cobwebs, bright flashing lights, or the sudden onset of a great number of floaters. Patients do not complain of pain. - After visual acuity is determined, the patient must have a dilated fundus examination using an indirect ophthalmoscope as well as slit-lamp biomicroscopy. Stereo fundus photography and fluorescein angiography are commonly used during the evaluation. - **Medical Management** - New surgical techniques and advances in instrumentation have led to an increased rate of success of surgical reattachment and better visual outcomes. - In rhegmatogenous detachment, an attempt is made to surgically reattach the sensory retina to the RPE. In traction detachment, the source of traction must be removed and the sensory retina reattached. - The most commonly used surgical interventions are - The scleral buckle - The scleral buckle is a procedure in which a piece of silicone plastic or sponge is sewn onto the sclera at the site of the retinal tear. The buckle holds the retina against the sclera until scarring seals the tear - The pars plana vitrectomy - Pneumatic retinopexy. - **Nursing Management** - For the most part, nursing interventions consist of educating the patient and providing supportive care. - Promoting Comfort - Help with walking and meals - Avoid heavy lifting or strenuous activity. - Reading may be restricted - Sunglasses during the day and eye patch at night. - Driving may be restricted - Teaching about Complications - Ice packs to counter any edema associated with the conjunctiva. - Sleep with head elevated if a vitrectomy with scleral buckling was performed. - Avoid air travel until gas bubble is absorbed. - **Macular Degeneration** - The scleral buckle is a procedure in which a piece of silicone plastic or sponge is sewn onto the sclera at the site of the retinal tear. The buckle holds the retina against the sclera until scarring seals the tear. - It is characterized by tiny, yellowish spots called drusen beneath the retina. **Progression of age-related macular degeneration (AMD): pathways to vision loss.**  - **Pathophysiology** - Approximately 90% of people with AMD have the dry or nonexudative type, which has an insidious onset and leads to a mild to moderate loss of vision, although peripheral vision is preserved. - **Medical Management** - Pearls for Practice: Vitamins and Macular Degeneration - The Age-Related Eye Disease Study demonstrated that daily high-dose multivitamin supplements containing vitamins and minerals that include vitamin C (500 mg), vitamin E (400 IU), zinc oxide (80 mg), and copper (2 mg) are beneficial in reducing the risk of vision loss in patients with high-risk AMD, and a follow-up study of the AREDS2 demonstrated the beneficial effect of lutein (10 mg) and zeaxanthin (2 mg) - **Orbital Trauma** - Head Injury - Soft Tissue Injury and Hemorrhage - Orbital Fractures - Foreign Body - **Ocular Trauma** - Medical Management - Splash Injuries - irrigated with normal saline solution before further evaluation occurs - Foreign Bodies and Corneal Abrasions - After removal of a foreign body from the surface of the eye, an antibiotic ointment is applied and the eye is patched. - Penetrating Injuries and Contusions of the Eyeball - A ruptured globe and severe injuries with intraocular hemorrhage require surgical intervention. Vitrectomy, surgical removal of vitreous fluid and stabilization of the retina, is performed for traumatic retinal detachments. - Intraocular Foreign Bodies - IOFB is diagnosed and localized by slit-lamp biomicroscopy and indirect ophthalmoscopy, as well as CT or ultrasonography. MRI is contraindicated because most foreign bodies are metallic and magnetic. It is important to determine the composition, size, and location of the IOFB and affected eye structures. - Ocular Burns - Immediate tap-water irrigation - Only a brief history and examination then immediately irrigated with normal saline. - Local anesthetic is installed and a lid speculum is applied. **INFECTIOUS AND INFLAMMATORY CONDITIONS** **Conjunctivitis** - Clinical Manifestations and Assessment - Conjunctivitis may be unilateral or bilateral, but the infection usually starts in one eye and then spreads to the other eye by hand contact. The main symptoms are redness, discharge, and discomfort - Types of Conjunctivitis - Microbial Conjunctivitis - Bacterial Conjunctivitis - can be acute or chronic. The acute type can develop into a chronic condition. Signs and symptoms can vary from mild to severe. - Viral Conjunctivitis - Viral conjunctivitis can be acute and chronic. The discharge is watery, and follicles are prominent. - Allergic Conjunctivitis - is a hypersensitivity reaction that occurs as part of allergic rhinitis (hay fever), or it can be an independent allergic reaction. - Toxic Conjunctivitis - Chemical conjunctivitis can be the result of medications; chlorine from swimming pools; exposure to toxic fumes among industrial workers; or exposure to other irritants, such as smoke, hair sprays, acids, and alkalis. - **Common Infections and Inflammatory Disorders of Eye Structures** - Hordeolum (stye) - Acute suppurative infection of the glands of the eyelids caused by Staphylococcus aureus. The lid is red and edematous, with a small collection of pus in the form of an abscess. There is considerable discomfort. - Chalazion - Sterile inflammatory process involving chronic granulomatous inflammation of the meibomian glands; can appear as a single granuloma or multiple granulomas in the upper or lower eyelids. - Blepharitis - Chronic bilateral inflammation of the eyelid margins. There are two types: staphylococcal and seborrheic. Staphylococcal blepharitis is usually ulcerative and is more serious due to the involvement of the base of hair follicles. Permanent scarring can result. - Bacterial keratitis - Infection of the cornea by S. aureus, Streptococcus pneumoniae, and Pseudomonas aeruginosa. - Herpes simplex keratitis - Leading cause of corneal blindness in the United States. Symptoms are severe pain, tearing, and photophobia. The dendritic ulcer has a branching, linear pattern with feathery edges and terminal bulbs at its ends. Herpes simplex keratitis can lead to recurrent stromal keratitis and persist to 12 months, with residual corneal scarring. - **Management of Conjunctivitis** - Bacterial Conjunctivitis - Antibiotics - Viral Conjunctivitis - Not responsive to any treatment. - Cold compresses may alleviate some symptoms. - Allergic Conjunctivitis - Corticosteroids - Use of vasoconstrictors, such as topical epinephrine solution, cold compresses, ice packs, and cool ventilation, usually provides comfort by decreasing swelling. - Toxic Conjunctivitis - The eye must be irrigated immediately and profusely with saline or sterile water. - **Patient Education\-- Instructions for Patients with Viral Conjunctivitis** - Your eyes will look red and will have watery discharge, and your lids will be swollen for about a week. - You will experience eye pain, a sandy sensation in your eye, and sensitivity to light. - Symptoms will resolve after about 1 week. - You may use light, cold compresses over your eyes for about 10 minutes four to five times a day to soothe the pain. - You may use artificial tears for the sandy sensation in your eye, and mild pain medications, such as acetaminophen. - You need to stay at home. Children must not play outside. You may return to work or school after 7 days, when the redness and discharge have cleared. You may obtain a doctor's note to return to work or school. - Do not share towels, linens, makeup, or toys. - Wash your hands thoroughly and frequently, using soap and water, including before and after you apply artificial tears or cold compresses. - Use a new tissue every time you wipe the discharge from each eye. You may dampen the tissue with clean water to clean the outside of the eye. - You may wash your face and take a shower as you normally do. - Discard all of your makeup articles. You must not apply makeup until the disease is over. - You may wear dark glasses if bright lights bother you. - If the discharge from your eye turns yellowish and pus-like, or you experience changes in your vision, you need to return to the health care provider for an examination. - **ORBITAL CELLULITIS** - Pathophysiology - Orbital cellulitis may result from bacterial, fungal, or viral inflammatory conditions of contiguous structures, such as the face, oropharynx, dental structures, or intracranial structures - Clinical Manifestation and Assessment - The symptoms include pain, lid swelling, conjunctival edema, proptosis, and decreased ocular motility. - Medical and Nursing Management - Immediate administration of high-dose, broad-spectrum, systemic antibiotics is indicated. **TREATMENT MODALITIES FOR EYE INJURIES AND DISORDERS** - **Surgical Procedures** - Orbital Surgeries - Orbital surgeries may be performed to repair fractures, remove a foreign body, or remove benign or malignant growths. - Enucleation - Enucleation is the removal of the entire eye and part of the optic nerve. - Evisceration - Evisceration involves the surgical removal of the intraocular contents through an incision or opening in the cornea or sclera. - Exenteration - Exenteration is the removal of the eyelids, the eye, and various amounts of orbital contents **PHARMACOLOGIC TREATMENT** - Ocular Medication Administration - Ensure adequate lighting - Perform hand hygiene - Don clean gloves and, if necessary or required, gently clean any crusts or drainage from the eyelid margins, wiping from the inner to the outer canthus and using a fresh gauze pad or cotton ball moistened with warm water for each stroke. - Prepare medication. Read the label of the eye medication to make sure it is the correct medication. Shake suspensions or "milky" solutions to obtain the desired medication level. Verify which eye is to be treated. - Assume proper position for instillation of eye medications. - Do not touch the tip of the medication container to any part of the eye or face. Hold the lower lid down; do not press on the eyeball. Apply gentle pressure to the cheek bone to anchor the finger holding the lid. - Apply medication. Instill eye drops before applying ointments. - For eye drops: - Eye drops should be instilled at a distance of approximately 1 in from the eye. Before instilling the eyedrops, instruct the patient to look up and away. The lower lid is gently pulled down to instill the drops in the conjunctival sac. Immediately after instilling eye drops, apply gentle pressure on the inner canthus (punctal occlusion) near the bridge of the nose for 3--5 minutes. - Using a clean tissue, gently pat the skin to absorb excess eyedrops that run onto the patient's cheeks. - For eye ointment: - Apply a ½-in ribbon of ointment to the lower conjunctival sac. Immediately after ointment instillation, ask the patient to roll their eyes behind closed lids. - Wait 5 minutes before instilling another eye medication. - Perform hand hygiene. - **Commonly Used Ocular Medications** - Topical Anesthetics - Mydriatics and Cycloplegics\--Mydriatics and Miotics - Antiglaucoma Medications - Anti-Infective Medications - Corticosteroids and Nonsteroidal Anti-Inflammatory Drugs - Antiallergy Medications - Ocular Irrigants and Lubricants - **Pediatric Eye Conditions** - Clinical Manifestations of Visual Disorders - Strabismus - Congenital or acquired - Eyes appear misaligned to observer - May occur only when child is tired. - Symptoms include squinting and frowning when reading; closing one eye to see; having trouble picking up objects; dizziness and headache. - Treatment: occlusion therapy (patching the good eye for one to two hr.), compensatory lenses, surgery of the rectus muscles, eye drops to make the good eye blurry, prisms, vision therapy. - Amblyopia (lazy eye) - Reduced vision in one or both eyes. - Symptoms the same as Strabismus - Treatment: Compensatory lenses, Occlusion therapy, Atropine. - Cataracts - Occurs when all or part of the lens of eye becomes opaque, which prevents refraction of light rays onto retina. - Can affect one or both eyes, may be congenital or acquired. - Clouding of lens, distorted red reflex, may be associated with fetal alcohol syndrome, down syndrome, and turner syndrome. - Treatment: Must be diagnosed at young age, surgical removal of lens and corrective lenses, lens implant may be used, eye protectors and restraints are used post operatively to proviant injury. - Glaucoma - Increased intraocular pressure damages eye and impairs vision function. - Congenital glaucoma - Tearing, blinking, corneal clouding, eyelid spasms, and progressive enlargement of eye. - Juvenile glaucoma - Constant bumping into objects in child's periphery, seeing halos around objects. - Treatment - Surgery to reduce IOP is treatment of choice.