ASSESSMENT Ocular History - The nurse through careful questioning, elicits the necessary information that can lead

d to the diagnosis of an ophthalmic condition. Visual Acuity - Essential part of an eye examination and a measure against all therapeutic outcomes are based Snellen chart- to test distance vision 20/20- standard normal vision Distanced of 20 feet Wear distance correction in reading the chart if required. Each eye tested separately. Pinhole occluder- given when the pt cannot read the 20/20 line. If the pt cannot read the largest letter on the chart(the 20/200) line), the pt should be moved toward thechart or chart moved toward the pt. If can recognize letter E on top line at 10 feet distance= 10/200. Count fingers(CF)- pt cannot see the letter E at any distance; random number of fingers -ex. 3 feet- CF/3 Hand Motion(HM)- if pt cannot count fingers - Examiner raises one hand up/down or moves it side to side and asks the direction of the hand. Light Perception(LP)- perceive light only No Light Perception- no light perceived External Eye Examination -the position of the eyelids is noted -the upper 2 mm of the iris are covered by the upper eye lid

-pt examined for ptosis(drooping eyelid) and lid retraction(too much of the eye exposed) -sclera is inspected -lesions on the conjunctiva, discharge, and tearing or blinking are noted. Normal sclera- nopaque and white -Room should be darkened so that pupils can be examined. -Pupillary response is checked with penlight. Irregular pupil- trauma, previous surgery, or disease process.

-eyes observed in primary or direct gaze, head tilt is noted. Cranial nerve palsy- head tilt Nystagmus- oscillating movement of the eyeball

DIAGNOSTIC EVALUATION 1.) Direct Ophthalmoscopy -the examiner holds the ophthalmoscope in the right hand and uses the right eye to examine the patients right eye. -room is darkened Pts eye on the same level as the examiners eye -pt given a target to gaze and encouraged to keep both eyes open and steady -When fundus is examined, vasculature comes into focus first. -Veins larger in diameter than arteries. Cup- central depression in the disc Normal cup- 1/3 the size of the disc Arteriosclerosis- silvery or coppery appearance Macula- the last area of the fundus to be examined; most sensitive to light

Cellophane reflex- retina with glistening effect Intraretinal haemorrhages- red smudges or if with HPN, flamed-shaped Lipiid may be present in the retina of pt with hypercholesterolemia or diabetes Microaneurysms- red dots and nevi Drusen- small hyaline, globular growths found in macular degeneration 2.) Indirect Ophthalmoscopy - to see larger areas of the retina 3.) Slit-Lamp Examination - to examine the eye with magnification of 10-40 times the real image. -Cataracts may be evaluated by changing the angle of the light. 4.) Color Vision Testing - the ability to differentiate colors Polychromatic plates- screening test to establish whether a persons color vision is within normal range Ishihara polychromatic plates- color vision testing Plates bound on a booklet Pts with central vision conditionshave more difficulty identifying colors than those with peripheral vision conditions because central vision identifies color.

- lesions in the globe or the orbit may not be directly visible and are evaluated. - valuable diagnostic technique esp when the view of the retina is obscured by opaque media such as cataract or hemorrhage. - used to identify orbital tumors, retinal detachment and changes in tissue composition. 7.) Optical Coherence Tomography - involves coherence interferometry -light is used to evaluate retinal and macular diseases -non-ivasive and involves no physical contact with the eye 8.) Color Fundus Photography - to detect and and document retinal lesions -pupils are widely dilated -visual acuity diminished for about 30 minutes due to retinal bleaching by the intense flashing lights. 9.) Fluorescein Angiography - evaluates clinically significant macular edema, documents macular capillary nonperfusion, and identifies retinal and choroidal neovascularisation (growth of abn new blood vessels) -invasive; fluorescein dye injected in antecubital vein - within 10-15 seconds, dye can be seen in the retinal vessels Skin- gold tone Urine- deep yellow or orange Discoloration disappears in 24 hours 10.) Ondocyanine Green Angiography - evaluate abnormalities in the choroidal vasculature -indocyanine green dye injected IV and multiple images captured by digital videoangiography

5.) Amsler Grid - used for patients with macular problems, such as macular degeneration. Neovascular choroidal membraneadvanced stage of macular degeneration cahracterized by groeth of abnormal choroidal vesels . 6.) Ultrasonography

-dye cause nausea and vomiting -allergic reactions are rare -CI in pts with hx of iodide reactions. 11.) Tonometry - measures IOP by determining the amount of force or pressure necessary to indent or flatten the globe of the eye -principle: soft eye is dented more easily than a hard eye -Pressures measured in mmHg -High readings indicate high pressure and vice versa -noninvasive and usually painless -topical anesthetic eye drop is instilled in the lower conjunctival sac; tonometer Applanation tonometer- used by more skilled examiner - Fluorescein dye drop and anesthetic drop instilled in the eye - Applanation tip pressed against the cornea Tono-pen- battery operated; used in many clinical settings - Tension reading is displayed in a liquid crystal display window

Refractive Errors - Vision is impaired because a shortened or elongated eyeball prevents light rays from focusing sharply on the retina. - Blurred vision can be corrected with eyeglases or contact lenses - Depth of eyeball important in determining the refractive error Emmetropia (normal vision)- pt for whom the visual image focuses precisely on the macula and who do not need eyeglasses Myopia- nearsightedness - Deeper eyeballs: distant visual image focuses in front of the retina - Blurred distance vision Hyperopia- farsightedness - Shorter depth in eyes, shallower eyes - Near vision blurriness; distance vision excellent Astigmatism- important cause of retractive error - Irregularity in the curve of the cornea - Acuity of distance and near vision can be decreased - Hard contact lenses or soft toric contact lenses Low Vision and Blindness Low vision- visual impairment Best corrected visual acuity of 20/70 to 20/200 Blindness- BCVA that can range from 20/400 to no light perception Absolute blindness- absence of light perception Legal Blindness- condition of impaired vision in which a person has BCVA that does not exceed 20/200 in the better eye

12.) Perimetry Testing - evaluates the field of vision Visual field- area or extent of physical space visible to an eye in a given position - 65U, 75D, 60I, 95O -helps identify which parts of the pts central and peripheral visual fields have useful vision -most helpful in detecting central scotomas ( blind areas in the visual field) in macular degeneration and the peripheral field defects in glaucoma and retinitis pigmentosa. IMPAIRED VISION

Travel vision- ability to negotiate their environment without auxillary aids. Most common causes of blindness and visual impairment: -diabetic retinopathy -macular degeneration -glsucoma -cataracts

2.) Glaucoma - Optic nerve damage related to IOP caused by congestion of aqueous humor in the eye - Theres range of pressures considered as normal but may be associated with vision loss Stages of Glaucoma a. Initiating events- precipitating factors include illness, emotional stress, congenital narrow angles, low term use of corticosteroids, use of mydriatics (cause pupil dilation) b. Structural Alterations in the aqueous outflow system- Tissue and cellular changes are caused by factors that affect aqueous humor dynamics lead to structural alterations c. Functional alterations- Increased IOP and impaired blood flow d. Optic nerve damage- atrophy of the optic nerve is characterized by loss of nerve fibers and blood supply e. Visual loss- visual field defects Classification of Glaucoma a.) Open angle glaucoma-

Assessment and Diagnostic Testing Patient Interview Contrast Sensitivity Testing and Glare Testing Contrast Sensitivity Testing- measures visual acuity in different degrees of contrast -initial test: turning on the lights while testing the distance acuity Glare testing- enables the examiner to obtain a more realistic evaluation of the pts ability to function in his/her environment. Brightness Acuity tester- device that tests glare - Produce 3 degrees of bright light to create a dazzle effect while pt is viewing a target Medical Mgt: Magnification and image enhancement with the use of low vision aids Retinal Implants Artificial silicon retina microchip- for retinitis pigmentosa

Nursing Mgt: Promote coping efforts Promote spatial orientation and mobility