Module 6: Alterations In Sensory Perception PDF

Module 6: Alterations In Sensory Perception Sensorineural Anatomy & Physiology External Eye Eyelids Upper eyelid is controlled by cranial nerve 3 Inner/Medial Canthus Triangular Space Outer/Lateral Canthus Triangular Space Tears Produced by the lacrimal gland...

Module 6: Alterations In Sensory Perception Sensorineural Anatomy & Physiology External Eye Eyelids Upper eyelid is controlled by cranial nerve 3 Inner/Medial Canthus Triangular Space Outer/Lateral Canthus Triangular Space Tears Produced by the lacrimal gland Washes eyes Protects against infection Dry eyes increases risk of infection Lacrimal Gland/Apparatus Produces tears Eyelashes Protects against infection by keeping things out Aqueous Humor & Is a gel, clear liquid Located in the front part of eye Keeps the eye nourished and inflated Internal Eye Conjunctiva Put eyedrops in conjunctival sac Conjuntival Barrier Mucous Protects against infection Meibomian Glands Used for dryness Lined in the conjunctival material Sclera White: Normal Jaundice: Liver Issue Red/Pink: Irritation, Infection, Pink Eye Color differences are based on ethnicity Cornea Transparent,clear dome-like structure Covers the iris and the pupil Iris Eye color Lens Helps focus on near or distant vision Accommodates No nerves or pain fibers here Pupil Is where you see out of Choroid Ocular Fundus Retina Optic Nerve (CN II) Aqueous Humor Clear, gel liquid in the front part of the eye Keeps the eye nourished and inflated Eye Anatomy & Physiology Orbit Protective bony structure that the eye sits in Optic (CN II) & Ophthalmic nerves ○ Enter the orbit at its apex, through the optic foramen ○ Optic nerve transmits impulses from the retina to occipital lobe of the brain ○ Optic nerves of right and left eye meet at the optic chiasm Nerves transmit impulses to allow what you see to transfer to brain and be interpreted Movements Coordinated movements of the eyeball through all fields of gaze Are controlled by the extraocular muscles → Move the eyeball left and right Innervated by cranial nerves III, IV, and VI Four Rectus Muscles Two Oblique Muscles Epithelial Cells Replaced every 7 days Intraocular pressure Between 10-21 mm/Hg. Glaucoma → Increased intraocular pressure Beta blockers → Decrease intraocular pressure Fractures Closed Fracture: No open wounds + eye orbit is broken Open Fracture: Open wound (eyeball pops out + huge or bit) + eye orbit is broken Ear Functions Hearing Balance External Ear Auricle (Pinna) External Auditory Canal Hair Allows for adequate hearing Sebaceous Glands Ceruminous Glands Middle Ear Tympanic Membrane AKA Ear Drum Is a translucent or pearly gray color Protects middle ear + helps with sound vibration conduction from external ear to ossicles Ossicles Connects middle ear to the nasopharynx Normally closed but can open to normalize pressure in the middle ear Inner Ear Infections in the inner ear will result in issues with vertigo and balance The inner tube is in the temporal tube Cochlea There is an electrochemical impulse that travels through the cochlear area, the acoustic nerve to the temporal lobe and is interpreted into meaningful sound Semicircular Canals CN VIII + VIIII Organ of Corti End organ for hearing Is what actually allows for transfer of mechanical energy into neural frequency & Vision Abnormalities Risk Factors Age As adults age, they are at an increased risk for decreased visual and hearing acuity Older adults typically have presbyopia (far-sightedness) and presbycusis (can’t focus on objects near) caused by the aging process. At risk for glaucoma, cataracts, and macular degeneration, which can cause vision loss Diabetes Mellitus Chronic Hypertension Mechanical Damage Chemical Damage Genetic Risk Cranial Nerve II (optic) Damage Drug Therapy Physical Trauma Cranial Nerve VIII (acoustic or auditory) damage Occupational Factors Hearing consistent loud noises Genetic Risk Drug Risks Antihistamines Antihypertensives Ototoxic Drugs Salicylates: Aspirin Loop Diuretics: Furosemide (Lasix) Antiepileptic Drugs Antibiotics: Aminoglycosides NSAIDs Assessment Of The Sensorineural System Assessment Of The Eye Health History Common Complaints Vision changes Diminished acuity Blurred vision Distorted or double vision → Cover One Eye Myopia ○ Near Sided Hyperopia ○ Far Sided Presbyopia ○ Can’t focus on objects near ○ Usually occurs with aging Cataracts ○ Lens opacity over the eyes ○ Seen in humans and animals Glaucoma ○ Increased Intraocular pressure Pain ○ From a foreign body or conjunctival irritation (dry eyes or pink eye) ○ Seen with dry eye or pink eye Discharge Age Related Changes Adjust to light more slowly than before → Less safe to drive at night Autoimmune Disorders → Multiple Sclerosis (MS) + Myasthenia Gravis (MG) Past History Recurrence of previous condition? Systemic diseases Medication side effects Ophthalmic surgery Family History Glaucoma Refraction Disorders: Can’t see clearly Physical Assessment Of The Eye Lesions Sclera color Pupils Nystagmus Rapid Eye Movement Extraocular movements Visual Acuity Snellen chart ○ Distance ○ 20/20 is considered normal ○ Numerator: Distance away from the chart. ○ Denominator: Distance at with the normal eye can read the normal line of letters ○ Example: If you have someone 20/40 what does that mean. From 20 feet away they can read things most people can see at 40 feet. ○ Example: What if a person can’t see E up there? Move the patient closer to the chart. If you can't see Snellen chart, start counting fingers, then ask directions of hand motions, then look at light perception. Handheld card ○ Close up ○ 14 inches away External Eye Exam Patient should be able to follow your finger Position of eyelids Alignment of the eyes Ptosis ○ Eye droop Ectropion ○ Eyelids turn outward ○ Causes dry eye Entropion ○ Eyelid fold inward ○ Causes irritation Scaling and crusting  Edema and erythema Diagnostic Evaluation Of the Eye Direct Ophthalmoscopy Ophthalmoscope ○ Handheld instrument used to magnify the cornea, lens, and retina Best way to see the retina, optic nerve, and blood vessels in the back of the eye Use Mydriatic Eye Drops ○ Dilate eye pupils ○ Pts wear sunglasses because they won’t see clearly for a couple of hours ○ Diabetics should have their pupils dilated and checked once a year ○ Contraindications: Head Injuries + Narrow Angle Glaucoma ○ CNS effects are most prominent in children and elderly patients ○ Patients must be assessed closely for symptoms, such as increased blood pressure, tachycardia, dizziness, ataxia, confusion, disorientation, incoherent speech, and hallucination. Amsler Grid Used for patients with macular problems, such as macular degeneration Geometric grid of identical squares with central fixation point Stare at central point and reports distortion of surrounding squares Tonometry How Intraocular pressure (IOP) is measured Pen-like device measures the amount of pressure necessary to indent a small area of the globe of the eye Nursing Considerations → Topical anesthetic eye drop If it is more than 10-21 mm/Hg you have glaucoma. Perimetry Testing 2 Evaluates Visual Field: Area or extent of physical space visible to eye in given position Helpful in detecting blind areas in the visual field in macular degeneration and peripheral field defects in glaucoma Slit-Lamp Examination Binocular microscope mounted on a table Used for examination of both the internal and external eye structures Allows for magnification of 10 to 40 times the actual image Color Testing Examine the structure of the inner and outer portion of the eye Tests the ability to differentiate colors Seen most commonly in med Defect or deficiency in cones results in abnormal color vision ○ Red-green color blindness → Is the most often ○ Blue color blindness ○ Achromatopsia: Complete color blindness Screening done with polychromatic plates → Have a booklet of these in different colors Ultrasonography Evaluate lesions in globe or orbit, retinal detachment, and changes in tissue composition Useful to evaluate retina when it is obscured by opacity, such as cataract or hemorrhage Retinal detachment and can also note acute changes within tissue composition of eye. Fluorescein Angiography Evaluates clinically significant macular edema, macular capillary non-perfusion, and areas of re-vascularization in age-related macular degeneration Fluorescein dye injected into an antecubital vein, and it is visualized in retinal vessels Black and white photographs are taken of retinal vasculature Nursing Considerations ○ Allergies to dye ○ The contrast can turn the skin gold for 24 hours Assessment Of The Ear Health History Common Complaints Changes in hearing acuity Earache/Pain Drainage Tinnitus→ Ringing / Roaring / Hissing of the ear → Occurs with ototoxic medications Past History Infections affecting ear → Chronic Infections → Hearing Loss → Screen more frequently Ototoxic medications Previous Therapies → Speech Therapy + Read Lips Family History Age related Changes Physical Assessment Of The Ear Inspection and Palpation of the External Ear Susceptibility to skin cancer Mastoiditis Pain or tenderness at the sinus cavity up and down like a bone pain Look in auditory canal and look for cerumen impaction Inspection of the internal ear External auditory canal Tympanic membrane Evaluation of gross auditory acuity Whisper test ○ Cover untested ear whisper from 1-2 feet away and pt should be able to repeat Weber test 2 ○ Tuning fork ○ Tests for unilateral hearing loss ○ People who shoot guns on one side  Rinne test ○ Difference between conductive and sensorineural loss ○ Take the stem of the tuning fork 2 inches from the open ear canal and put against the mastoid bone and will tell if bone conduction is going on Diagnostic Evaluation of The Ear Audiometry Single most important diagnostic test in detecting hearing loss Evaluation of frequency, pitch, and intensity Tympanogram Evaluates movement and compliance of tympanic membrane, and status of middle ear See if tympanic membrane has ruptured Have them lay down. It’s positive if they move and complain of vertigo If it is a superficial view they don’t have to numb it Same capability like with the GI system. Platform Posturography Used to investigate postural control capabilities such as vertigo, and to evaluate response to treatment Middle Ear Endoscopy Small endoscope used to evaluate the ear Tympanic membrane anesthetized pre-procedure so that the endoscope may be passed through the membrane into the middle ear cavity Impaired Vision Chief Causes Blindness believed to be preventable in 50% of cases Diabetic Retinopathy →Killer of kidneys and eyeballs Age-Related Eye Diseases Cataracts Macular Degeneration Glaucoma Retinal Detachment Other Causes Smoking Vaping Poor Diet Impaired Vision Refractive Errors (Difficult to see clearly) Impaired vision due to a shortened or elongated eyeball Corrected by glasses or contact lens with appropriate refraction Types Myopia Nearsighted Hyperopia Farsighted Astigmatism Elongation of the curve of the cornea Causes a distortion of vision Low Vision Visual impairment requiring patients to use devices and strategies in addition to corrective lenses to perform visual tasks Best corrected visual acuity (BCVA) of 20/70 to 20/200 This is very poor vision and requires more than corrective lenses Special huge font books, magnifying glass with big font Blindness Ranges from BCVA from 20/400 to no light perception (NLP) May not even know if the lights are on or off Assessment Examination of distance and near visual acuity, visual field, contrast sensitivity, glare, color, perception, and refraction Cause and duration of visual impairment Manifestations First visual changes are not noticed at first Fluctuating visual acuity Central Acuity Problems: Issues with Reading → Seen in macular degeneration Peripheral Field Defects: Issues with Mobility → Seen in glaucoma Medical Management Optimize remaining vision Other people notice first vision changes Low-vision aids and strategies Magnifiers and spectacles Telescopic devices Anti-reflective lenses Electronic reading systems Large print Make sure the light is up high enough Nursing Management Promotion of Coping Efforts Patient must recognize permanence of blindness  Understanding steps of grieving Promoting Spatial orientation and mobility Onset of blindness Call bell within reach Familiarize with location of telephone, beverage, and other objects on the bedside table Food tray described as face of clock Furniture must not move Introductions upon entering and leaving room Promoting Home and Community-Based Care Collaboration Braille and guide dogs damage to optic nerve & Glaucoma radual loss of visual from 4 lop , causing blindness 19 fields !! IRREVERSIBLE!! Chronic Vision Problem Group of ocular conditions frequent characterized by optic nerve cause of damage related to high blindness intraocular pressure (IOP) Leading cause of blindness among adults in the US Want an IOP below 21 The high pressure is because of congestion of the aqueous loss of peripheralhumor that causes damage to Vision !! the optic nerve “Silent Thief Of Sight” & painless most doutflow Types Common - lop = 10-21 is normal "tunnel vision" &Open-Angle blurred vision, Gradual shift is easier on them halos , & Close Angle - NO outflow Optic damage-blindness ocular S = Rapid=+ Acute clops 30 nerve erythema · can be Worse + Dangerous Requires emergency treatment can un-noticed because caused by go · medications Risk Factors central vision is unaffected ~ Family history African American race SYMPTOMS : ~ Older age (>60) severe headache · ~ Diabetes mellitus eye pain · Cardiovascular disease N/V · eyes drainage Migraine syndromes halos ~ system= canal · Nearsightedness (myopia) eye redness · Eye trauma of and schlemm Prolonged use of corticosteroids trabecular · infections meshwork · tumors · HTN · retinal detachment mitotics can cause blurry accommodation early sign =I · Vision use good lighting and a lOp ↳ used to constrict the pupil Manifestations acute closure-medical emergency Blurred vision angle Halos around lights MEDICATIONS : Difficulty focusing Difficulty adjusting eyes in low lighting · mitotic/cholinergics (carbachol pilocarpine) constrict pupils = , outflow Loss of peripheral vision to↓ circulation and. Aching or discomfort around the eyes Headache + Aching & dilate adrenergic pupils a agonist"-nidine" , production of lop by I a qu e0S humor Types · beta blockers (timolo FIRST ↓ lop by 2 aqueos humor production Early Glaucoma watch Moving head just 5 degrees. for sulfa carbonic Advanced + Extreme Glaucoma allorgy !! Inhibitors ("-mide") · anhydrase humor production Hard to treat and you won’t get it back. ↓ lop by ↓ aqueous Diagnostic Testing · prostaglandin analogs Ibimatoprost and lantoprost) blood vessels ↑ outflow by dilating EMERGENCY Tonometry Is the best test of pressure systemic · Osmotic s treatment for (IV mannitol po glycerin) angle-closure , Know treatment is working if tonometry shows improvement Ophthalmoscopy Gonioscopy -used to determine the drainage angle of the anterior chamber of the eyes - Perimetry peripheral iridectomy for closed : - Tests peripheral vision to flow allows aqueous humor or if angle · anterior from posterior to meds do not Medical Management CURE trabeculectomy Chamber work for Treatment : laser No cure NO open angle LIFE allows drainage by > - · Goal → Prevent optic nerve damage creating a n opening LONG Systemic and ocular medications lower IOP MED USE !! ○ *Beta-blocker: Timolol* > mods for GLAUCOMA - ○ Miotics and sympathomimetics the pupils Surgical management > miotics = constrict - S Follow-up inspections of optic nerve Will try to clear out the clog bota blockers = & production of lop DO NOT aqueos humor and I on sleep Nursing Management NO ANTICHOLINERGICS !! surgery Side Teaching Self-Care !! IOP measurement and desired range best vision Review medications and side effects Medication schedule = 4- U WKS after Instillation of eye drops surgery Teach them a good intraocular pressure and help them understand b eta blockers can cause : adrenergic toagonists tell dilato pupils ↓ BP - hypotension use in · asthma caution: patient wear sunglasses in ↓ HR e bradycardia · COPD diabetes bright light · ↓ BS ehypoglycemia ↓ RR bronch constriction - N/V = indication of 4 lop AVOIDS ACTIVITIES TO & lop : at waist bending · sneezing Coughing straining · , , head Continuing Care hyperflexion · Referral for assistance with ADLs restrictive clothing · Federal assistance with legal blindness sexual intercourse · Reassurance and emotional support Encourage family members to undergo testing cataract glasses = magnifying Cataracts vision loss is gradual PAINLESS !! S due to or aging Chronic Vision Problem injury & Opacity or cloudiness of the lens → Develops in one or both eyes can Decreased visual acuity is directly proportional to cataract density, progress to blindness but not necessarily proportionate to functional status Most causes are preventable African Americans have brown eyes and now have blue ones. early signs : Risk Factors · age dry = lens Cigarette smoking blurred vision · a color perception · Long-term corticosteroid use & wear sunglasses Sunlight -> excessive exposure outside !! Ionizing radiation -UV light late Diabetes - secondary cataracts sign : diplopia · Obesity Eye injuries ↓ visual · acuity abscence of red reflex & Manifestations WHITE pupils maternal rubella & · myopia · "fundus reflex" light no longer Symptoms are slow to Painless, blurry vision ~ glarefrom nights > - reflects off back of inner and visible i n pupils Dimness - trouble seeing lights eye , develop at Glare sensitivity night Diplopia → Double Vision interventions : of lens Color shifts ed color perception Surgical removal lens lifted broken up by is or · frequent prescription extracapular extraction phasomulsification (ultrasonicvibratina · changes Diagnostic Testing intracapsular extraction - the lens and capsule are · removed completely Snellen Chart lens implantation · Ophthalmoscopy MEDICATIONS : Slit-lamp Examination anticholinergics surgery · = · ↓ red reflex Catropine 1% ophthalmic solution) removal ↳ prevents pupil constriction of the Medical Management y relaxes eye muscles (cycloplegial Ions !! y dilates the eye Non-Surgical Management - > magnifying lens and Y last 7-12 Not as curative increase light in room days & can cause photo sensitivity & Doesn’t prevent age-related cataracts wear sunglasses !! , Surgical Management !!! ↳ Considered when reduced vision interferes with normal activities Typically outpatient and takes less than 1 hour shield at bedtime eye mydriasis pupil dilation · = · prevent & lop and discomfort is normal · itching best vision 4-0 weeks after surgery · =  ↑ tear production and photophobia of infection post-op !! sign = · ophthalmoscopy = examine back of eye (fundus) Y retina ↳ optic disc ↳ macula One eye at a time ↳ blood vessels Teach self care- super high risk for retinal detachment S Wear sunglasses, or a patch over the eye Usually the vision is blurry for a few days after surgery but will return 6-12 weeks after. That’s when you can have the next surgery If a patient reports a new floater they should let their provider know right away because it could be a sign of retinal detachment Nursing Management Providing preoperative and postoperative care Teaching self-care Continuing care deterioration of the FEMALES more at risk & Macular Degeneration & a macula , the area of Short , a vit E ↓ carotene, white , Chronic Vision Problem NO CURE !! central vision drusen dry Development of tiny, yellowish spots and thin the (Drusen) beneath retina affecting central macula !! vision Most common in individuals >50 years old Wide range of visual loss, but most patients do not experience total blindness ophthalmoscopy to examine fundus · & Medical Management seal the Laser treatment blood leaking Used to close abnormal vessels Vessels near the macula !! Controversial & Photodynamic therapy (PDT) Exposure to the sun : Symptoms central vision loss blurry · , Avoid the sun for 5 days blurred or a central vision · Bright Light need brighter lights when · Helpful readin Medication lack of perception · agepth Helpful Amsler Grid Can be located on the fridge : types See if it’s getting worse atrophic e age related or dry exudative e Wet · · - MEDICATIONS : : VEGF Anti Vascular Endothelial Growth Factor (VEGF) Therapy · bevacizumab ranibizumab most common ↳ treats WET macular degeneration ! Y Ocular INJECTIONS !! these are ALL intraocular injections! type Medications used to stop the abnormal blood vessels from leaking, growing and then ↑ bleeding under the retina - exudative atrophic of AGE/DRY : > - vision common cause (AMD) e loss in older adults WET : the retinal detachment of pigment epithelium in · caused by gradual blocking of and necrotic serous macula occurs , fluid and blood · collect under the to an ischemic and visual capillaries leading in scar formation macula , rod and cone photoreceptors die macula, resulting distortion blood vessels that leak of thin · new growth  patient education : · consume foods ↑ in : antioxidants , carotene , Vitamin E and BIZ Adverse Effects Subconjunctival hemorrhage and vitreous hemorrhage are the most common ocular adverse events reported with intravitreal anti-VEGF treatment. The most serious (though rare) ocular adverse events include endophthalmitis and rhegmatogenous retinal detachment. Contraindications For BOTH Steroids and Anti-VEGF Active or suspected ocular or periocular infection Active severe intraocular inflammation Hypersensitivity to the active substance or to any of the excipients. These drugs should be avoided with other cancer drugs. Nursing Management Arterial blood pressure should be measured before each administration, and patients Should be instructed to undertake blood pressure monitoring at home. Administration should be delayed and antihypertensive therapy started if blood pressure is >150/100 mmHg. - Retinal Detachment detachment separation of the or due to roting from the epithelium 4 of fluid or tumor & cumulation Separation of the layers of the retina It can be surgically reattached COMPLETE detachment = blindness Manifestations Sensation of a shade or curtain coming across vision of one eye Bright flashing lights ASSESSMENT : Sudden onset of many floaters · flashes of light No pain occurs · floaters or black spots Diagnostic Testing ↳a sign of bleeding !! 4 blurry vision · Ophthalmoscopy "Curtain" over eyes · Slit-lamp testing · painless peripheral or Optical coherence tomography Central vision loss Ultrasound Medical Management Surgical reattachment of retinal layers Re-evaluation of vision and need for vision correction 6-8 weeks post op Nursing Management Promoting comfort Post OP assistance  · PROVIDE BED REST Things to avoid Eye protection Edema reduction Teach about complications Increased IOP Endophthalmitis - > inflammation of inner coats of eye Future retinal detachment or cataract development Loss of eye turgor Symptoms to report immediately If they are hospitalized, help with meals and walking Avoid heavy lifting, blowing your nose, sneezing, straining to poop, avoid air travel because they inject an air bubble and you can have all sorts of problems after until the air bubble is reabsorbed. Wear eye protection and use colds to reduce swelling. Call office if there is any drainage avoid head movements · jerky a stress eye · surgical procedures : retina to return drain fluid e allows · to normal position cryosurgery,sealing,useacoldprobaa · leading to adhesions · diather heat to stimulate my use an y inflammatory response laser therapy , Sealsmallretinalar · as scleral the choroidand rotnas a · buckling t holdscar tissue forms , the tear closing gasor agentsto float agains a · - these the reting hold it in Oil place until healing occurs !!  Glaucoma Med Surg: Sensory (Visual & Auditory) Pathophysiology Leading cause of blindness, where increased Open angle Over time pressure within the eye results from an Over angle issue in the optic nerve (cranial nerve 2) 2 forms Closed angle 1 HCP Open angle EXAM Closed angle Signs & Symptoms Memory trick Common NCLEX Question Closed angle Close a door Identify which image shows the effects of glaucoma? Open angle: mild pain & gradual loss of 1. Option 1 peripheral vision (tunnel vision) 2. Option 2 PRIORITY 3. Option 3 Closed angle: 4. Option 4 sudden EXTREME pain NCLEX TIPS LIFE & LIMB 3 Key words 1 HCP EXTREME, “severe”, “sudden” eye pain Diagnostics Education Tonometry test (normal IOP: 10 - 21 mmHg) AVOID NCLEX TIPS HIGH PRESSURE >21 mmHg Added pressure AFTER surgery NO Coughing, sneezing Pharmacology Most TESTED Closed angle NO Bending at the waist Beta blockers - Timolol NO Lifting heavy objects Mannitol (osmotic diuretic) MANNITOL NO Nausea & vomiting NO Valsalva maneuver Surgical (bearing down) Constipation Priority * NOT Usually Tested NO Anticholinergics Laser treatments: to kill the aqueous humor producing cells to decrease fluid. (Atropine, Ipratropium) Trabeculoplasty: helps closed angle by punching a small NO Diphenhydramine hole in the iris. (brand: Benadryl) Implants: bypass the collecting systems & shunt fluid out. Retinal Detachment Med Surg: Sensory (Visual & Auditory) Separation of the retina Pathophysiology Detachment or separation of the retina from the back of the eye, resulting in loss of vision. Causes Any type of trauma to the head, like being hit in the head with a baseball bat or even being in a car accident Signs & Symptoms The most tested Kaplan Question Assessing a client with a Hairnet like vision PRIORITY detached retina. Which of the following should “curtain-like half vision loss” the nurse expect the client to report? It's like a curtain Floaters & cobweb looking vision closed over my eye Flashes of light Surgical Repair Key points Education NCLEX TIPS Avoid pressure here! AVOID Straining on the toilet (NO constipation) Rubbing / scratching Eye straining activities (reading, TV, computer etc.) REPORT “Sudden” “New” Vision loss, Pain, flashing light Notes Macular Degeneration Med Surg: Sensory (Visual & Auditory) Pathophysiology Central loss of vision & blindness. One of the top causes of blindness over the age of 60. Currently no cure & NOT a common part of aging. One of TOP causes > 60 years old Signs & Symptoms NCLEX TIP KEY POINT Blurry spot in the middle of vision When you get an exam question about a client stating they have a blurry spot in the middle of vision while reading or while watching Macular degeneration MIDDLE vision loss something, then report this to the HCP immediately. MEMORY TRICK M - MIDDLE of vision M - Macular degeneration Notes