ETIOLOGY

RETINAL DETACHMENT

The retina is the light-sensitive layer of tissue that lines the inside of
the eye and sends visual messages through the optic nerve to the brain.
When the retina detaches, it is lifted or pulled from its normal position. In
some cases there may be small areas of the retina that are torn. These areas,
called retinal tears or retinal breaks, can lead to retinal detachment Retinal
detachment is described as an emergency situation when a critical layer of
tissue the retina at the back of the eye pulls away from the layer of blood
Retinal detachment leaves the retinal cells deprived of oxygen. The longer
retinal detachment goes untreated, the greater the risk of permanent vision
loss in the affected eye.

Three different types of retinal detachment:

Rhegmatogenous A tear or break in the retina causes it to separate

from the retinal pigment epithelium (RPE), the pigmented cell layer that
nourishes the retina, and fill with fluid. These types of retinal detachments
are the most common.

Tractional In this type of detachment, scar tissue on the retina's

surface contracts and causes it to separate from the RPE. This type of
detachment is less common.

Exudative Frequently caused by retinal diseases, including

inflammatory disorders and injury/trauma to the eye. In this type, fluid leaks
into the area underneath the retina subretina.
 KERATITIS

Keratitis is an inflammation of the cornea caused by infection, trauma,

dry eyes, ultraviolet exposure, contact lens overwear, or degeneration.

Keratitis often begins with erosion of the epithelial surface. You can
usually spot it by seeing that the light reflection in the affected region is
hazy and broken up.

Keratitis, the eye condition in which the cornea becomes inflamed,

has many potential causes. Various types of infections, dry eyes, injury, and
a large variety of underlying medical diseases may all lead to keratitis. Some
cases of keratitis result from unknown factors.

RISK FACTORS
The following factors increase your risk of retinal detachment:

Retinal detachment is more common in people older than age 40,

Previous retinal detachment in one eye, A family history of retinal
detachment, Extreme nearsightedness (myopia), high myopia or aphakia
after cataract removal or surgery, Previous severe eye injury or trauma in
rhegmatogenous retinal detachment are associated with proliferative
retinopathy

The following factors increase your risk of keratitis:

Major risk factors for the development of keratitis include any break
or disruption of the surface layer (epithelium) of the cornea.

The use of contact lenses increases the risk for the development of
keratitis, especially if when poor hygiene, improper solutions, or overwear
are associated with contact-lens use.

A decrease in the quality or quantity of tears predisposes the eye to

the development of keratitis.

Disturbances of immune function through diseases such as AIDS or

the use of medications such as corticosteroids or chemotherapy also increase
the risk of developing keratitis.

SYMPTOMATOLOGY
 Retinal detachment

Patients may report the sensation of a shade or curtain coming across

the vision of one eye, cob webs, bright flashing lights, or the sudden onset of
a great number of floaters. But patients do not complain of pain.

Keratitis

Major risk factors for the development of keratitis include any break
or disruption of the surface layer (epithelium) of the cornea.

The use of contact lenses increases the risk for the development of keratitis,
especially if when poor hygiene, improper solutions, or overwear are
associated with contact-lens use.

A decrease in the quality or quantity of tears predisposes the eye to the

development of keratitis.

Disturbances of immune function through diseases such as AIDS or the use

of medications such as corticosteroids or chemotherapy also increase the risk
of developing keratitis.

TECHNIQUES OF PHYSICAL ASSESSMENT

Retinal detachment
 • Visual acuity test: Caregivers may first want to test your vision and
eye movements.

• Ophthalmoscope: This is also called fundoscopy. This test allows

caregivers to see the back of the eye using an ophthalmoscope. An
ophthalmoscope is a magnifying instrument with a light.

• Slit-lamp test: This test uses a microscope with a strong light. It

allows caregivers to look into your eye using a magnifying instrument.

• Ultrasound: This is a test using sound waves to look at your eye.

Pictures of your eye, including the retina and the area around it, show
up on a TV-like screen.

Examination

Complete and comprehensive ophthalmic examination is important in

the assessment of retinal detachment. Patients will receive vision testing,
drops to dilate pupils, and a complete examination of the front and back of
the eye. Pupillary dilation may create blurring, and therefore, it is often best
if a driver accompanies the patient, although it is not absolutely required.
When examining the retina, the ophthalmologist may depress the eye with a
cotton tip applicator or other blunt instrument in order to view the entire
retina.

Testing

Patients with retinal detachment are largely diagnosed by clinical

examination. Patients may undergo fundus photography to document the
extent of retinal detachment. This procedure is of little risk to the patient.
OCT imaging can help assess the status of retina and determine if there is a
low lying retinal detachment.

Keratitis

Keratitis is usually diagnosed based on a complete medical history

and physical examination of your child. Cultures of the eye drainage are
usually not required, but may be done to confirm the cause of the infection.

• Slit lamp examaintion

• Fluorescein staining

• Corneal scraping and examination of scrapings under microscope

• Schirmer’s test

• Microbiological culture tests of corneal scrapings

• Keratometry

• Visual acuity

• Tear test

• Pupillary reflex response

• Refraction test

Imaging Studies

Slit lamp photography can be useful to document the progression of the

keratitis, and, in cases where the specific etiology is in doubt, it is used to
obtain additional opinions, particularly in indolent and chronic cases not
responding to antimicrobial therapy.
A B-scan ultrasound can be obtained in eyes with severe corneal ulcers with
no view of the posterior segment where endophthalmitis is being considered.

Procedures

Corneal biopsy: A deep lamellar excision can be made using a disposable

skin punch or a small Elliott corneal trephine. The superficial cornea is
incised and deepened with a surgical blade to approximately 200 microns.
Then, a lamellar dissection is performed, and the material is plated directly
onto culture media. A portion also can be sent for histopathologic
evaluation.

RESULTS AND IMPLICATIONS

Retinal Detachment
 What the Doctor See, in rhegmatogenous retinal detachment, the
ophthalmologist will see one or more breaks in the retina with underlying
fluid. This can be accompanied by a vitreous hemorrhage, or bleeding into
the central jelly of the eye.

In Tractional retinal detachment, there are membranous bands

tethered to the retina causing a detachment. The pulling of these bands can
lead to a retinal tear, owing to a combined rhegmatogenous and Tractional
retinal detachment.

In Exudative retinal detachment, there is fluid under the retina in the absence
of a retinal tear or a tethered band.

Keratitis

Histologic Findings, During the initial stages, the epithelium and the
stroma in the area of injury and infection swell and undergo necrosis. Acute
inflammatory cells (mainly neutrophils) surround the beginning ulcer and
cause necrosis of the stromal lamellae. In cases of severe inflammation, a
deep ulcer and a deep stromal abscess may coalesce, resulting in thinning of
the cornea and sloughing of the infected stroma.

PATHOPHYSIOLOGY

Retinal detachment
Diagnostic test:

• Dilated eye exam

• Retinal exam
• Peripheral retinal exam
• Ophthalmoscope
Keratitis

Interruption of an intact corneal epithelium and/or abnormal tear film

permits entrance of microorganisms into the corneal stroma, where they may
proliferate and cause ulceration. Virulence factors may initiate microbial
invasion, or secondary effector molecules may assist the infective process.
Many bacteria display several adhesis on fimbriated and nonfimbriated
structures that may aid in their adherence to host corneal cells. During the
initial stages, the epithelium and stroma in the area of injury and infection
swell and undergo necrosis. Acute inflammatory cells (mainly neutrophils)
surround the beginning ulcer and cause necrosis of the stromal lamellae.

Diffusion of inflammatory products (including cytokines) posteriorly

elicits an outpouring of inflammatory cells into the anterior chamber and
may create a hypopyon. Different bacterial toxins and enzymes (including
elastase and alkaline protease) may be produced during corneal infection,
contributing to the destruction of corneal substance.

The most common groups of bacteria responsible for bacterial

keratitis are as
follows: Streptococcus,Pseudomonas, Enterobacteriaceae (including Klebsie
lla, Enterobacter, Serratia, and Proteus), andStaphylococcus species.

Up to 20% of cases of fungal keratitis (particularly candidiasis) are

complicated by bacterial

MEDICAL AND NURSING MANAGEMENT

Retinal detachment
Medical management
 Is an attempt to surgically reattach the sensory retina to the RP? In the
traction detachment, the source of traction must be removed and the sensory
retina reattached. New surgical techniques as well as advances in the
instrumentation have led to an increase rate of success of surgical
reattachment and better visual outcomes.

Scleral buckle the retinal surgeon compresses often with a scleral

buckle or a silicone band to indent the scleral wall from the outside of the
eye and bring the 2 retinal layers in contact with each other.
However, there is an increase risk of diplopia and other complication such as
induced myopia and increase postoperative pain.

Pars plana virectomy is used with giant retinal tears, vitreous

hemorrhage blood in the vitreous cavity that obscures the surgeon's view of
the retina, extensive Tractional retinal detachments (pulling from scar
tissue), membranes extra tissue on the retina, or severe infections in the eye
endophthalmitis. Small openings are made through the sclera to allow
positioning of a fiber optic light, a cutting source specialized scissors, and a
delicate forceps. The vitreous gel of the eye is removed and replaced with a
gas to refill the eye and reposition the retina. The gas eventually is absorbed
and is replaced by the eye's own natural fluid. A scleral buckle is often also
performed with the virectomy.

Pneumatic retinopexy the surgeon then injects a gas bubble directly

inside the vitreous cavity of the eye to push the detached retina against the
back outer wall of the eye sclera. The gas bubble initially expands and then
disappears over two to six weeks. Proper positioning of the head in the
postoperative time period is crucial for success. Although this treatment is
inappropriate for the repair of many retinal detachments, it is simpler and
much less costly than scleral buckling. Furthermore, if pneumatic retinopexy
is unsuccessful, scleral buckling still can be performed.

Transconjunctival sutureless virectomy the 25-gauge

transconjunctival sutureless virectomy is a significant advancement in
vitreotinal surgery. Replacement of the larger 20-gauge approach with the
less invasive 25-gauge technique allows for self sealing transconjunctival
pars plana sclerotomies. As a result, postoperative rapid wound healing and
patient recovery.

Nursing Management

Educating the patient and providing supportive care. For

pneumomatic retinopexy, postoperative positioning of the patients critical
because the injected bubble must float into position overlying the area of
detachment, providing consistent pressure to reattach the sensory retina. The
patient must retain in prone position that would allow the gas bubble to act
as tamponade for the retinal break. Patients and family members should be
made aware of these special procedures beforehand so that the patient can be
made as comfortable as possible.
Keratitis

Medical Management
 Conjuntiva and corneal swabs, and flourescein staining can confirm
the diagnosis . The flourecein fixes to damaged corneal tissue and turns the
affected area a bright flourescent green, indicating the extent of the damage .
Topical antibiotic , antiviral, or fungal therapy is usually commenced
immediately to avoid rapid development of complications .

Nursing Management

Pt should be taught not to touch or rub the eye as this may extend the
ulceration. Careful hygiene is essential such as hand washing and using a
clean disposable tissue for wiping to prevent cross infection. Advised to
guard against touching he sores (those who have outbreak of herpes
simplex). Re-education of contact lens wear.

PHARMACOLOGIC

GENERIC NAME: Carbachol

BRAND NAME: carbastat

DRUG CLASS AND MECHANISM:

Converted to epinephrine, which decreases the aqueos production and

increase outflow

USES:

glaucoma, ocular hypertension, neutralizes mydriatrics used during

eye exam

ADVERSE REACTIONS:

CNS: headache

CV: hypertension, Tachycardia, dysrtithmias

EENT: burning, stinging

GI: bitter taste

CONTRAINDICATIONS:

Hypersensitivity to drug

PRECATIONS:

Pregnancy, breastfeeding children, aphakia, hypersensitivity to

carbonic anhydrase inhibitors, sulfonamides, thiazide diuretics, ocular
inhibitors, renal/hepatic insufficiency

NURSING CONSIDERATIONS:
 Monitor ophthalmic exams, intraocular pressure readings, monitor
blood counts; renal/hepatic function test and serum electrolytes during long
term treatments

IMPLEMENTATION:

Storage at room tempreture away from light

GENERIC NAME: tobramycin and dexamethasone

BRAND NAME: Tobradex

DRUG CLASS AND MECHANISM:

Tobradex is a combination of the antibiotic,tobramycin, plus the anti-

inflammatory corticosteroid, dexamethasone. The combination is used to
treat conjunctivitis (inflammation of the inner side of the eyelids) when
bacterial infection is thought to be the cause of the inflammation. Tobradex
was approved by the FDA in 1988.

PRESCRIPTION: yes
GENERIC AVAILABLE: no
PREPARATIONS:
Ophthalmic solution or ointment containing 0.3% tobramycin and 0.1%
dexamethasone.
STORAGE: Tobradex should be kept at room temperature, 15-30°C (59-
86°F) and protected for direct light.
PRESCRIBED FOR: Tobradex is used for the treatment of conjunctivitis
believed to be due to bacterial infection.

DOSING: The hands should be washed before each use of Tobradex or any
eye medication. The head is tilted back, and the lower eye lid is pulled down
with the index finger to form a pouch. The tip of the dropper should not
touch the eye or eyelid. The bottle of Tobradex should be squeezed slightly
to allow the prescribed number of drops (generally 1 or 2 drops) into the
pouch. If the ointment is being used, a small strip (about 1cm or 1/2 inch) of
ointment should be squeezed into the pouch. The eye should then be closed
gently for 1 to 2 minutes without blinking.

DRUG INTERACTIONS: No drug interactions have been described with

Tobradex eye drops or ointment.
PREGNANCY: Although no human studies have assessed the effects of
Tobradex on the fetus, animal studies have shown adverse fetal effects.
Physicians should use it only if its benefits are deemed to outweigh the
potential risks.
NURSING MOTHERS: It is not known if Tobradex is excreted into breast
milk.
SIDE EFFECTS: The most frequently reported side effects noted with
Tobradex are itching and swelling of the eye lids and redness of the
conjunctivae. These effects occur in fewer than 1 of every 25 persons who
uses Tobradex.

DISCHARGE PLANNING

Retinal Detachment

1. Take measures to prevent postoperative complications.

2. Caution the patient to avoid bumping head.

3. Encourage the patient no to cough or sneeze or to perform other

strain-inducing activities that will increase intraocular pressure.

4. Encourage ambulation and independence as tolerated.

5. Administer medication for pain, nausea, and vomiting as directed.

6. Provide quiet divers ional activities, such as listening to a radio

or audio books.
7. Teach proper technique in giving eye medications.

8. Advise patient to avoid rapid eye movements for several weeks as

well as straining or bending the head below the waist.

9. Advise patient that driving is restricted until cleared

by ophthalmologist.
10. Teach the patient to recognize and immediately report symptoms that

indicate recurring detachment, such as floating spots, flashing lights,

and progressive shadows.
11. Advise patient to follow up.

Keratitis

1. Educate the pt. about the topical eye medication.

2. Care of the eye is very necessary, inform if advise to go back for
dressing.
3. Advise not to drive because their peripheral vision may reduced.
4. Restrictions of the activities depends on the surgery or procedure per
doctor’s order.

MULTIPLE CHOICE QUIZ AND ANSWERS

1. It is In this type of detachment, scar tissue on the retina's surface

contracts and causes it to separate from the RPE.

a. Tractional

b. Rhegmatogenous

2. useful to document the progression of the keratitis

a. Slit lamp photography

b. Tear tests
3. the light-sensitive layer of tissue that lines the inside of the eye and

sends visual messages through the optic nerve to the brain.

a. lens

b. retina

4. described as an emergency situation when a critical layer of tissue the

retina at the back of the eye pulls away

a. keratitis

b. retinal detachment

5. Is an inflammation of the cornea caused by infection, trauma, dry

eyes,ultraviolet exposure, contact lens overwear, or degeneration

a. Tractional detachment

b. Keratitis

6. Mr. Sasuke has just gone through surgery, scleral buckle of his eyes.

What nursing management should be implemented for consistent

reattachment of his sensory retina?
a. place patient in prone postion
b. give dexamethasone ophthalmic 2 drops

7. MS. Shakira demonstrates understanding of her condition after her

surgery when she

a. drives slowly because she knows her pheripheral vision is working

b. doesn’t touch her eyes

8. which is wrong with regards to the nursing management of retinal

detachment?
a. inform family members of that the patient should place the patient in

prone position to promote pressure on his/her retina

b. inform the family members that he/she can go strolling alone in the

park because the sun is good for his eyes

9. Dr. Bancal knows that one of the common groups causing Keratitis is?

a. corona virus

b. Enterobacteriaceae

10. One of Dr. Naruto’s patient, Ms. Celiz, Is complaining about her eyes

A week after surgery. Possible complications of retinal detachment

might be

a. tuberculosis

b. proliferative retinophaty

KERATITIS AND RETINAL DETACHMENT

Presented by:
 Bancal, gliezl M.

Celiz, Leah Caressa L.

Presented to:

Kristel Ramos RN