Assessment and Management of Patients with Eye and Vision Disorders

ANATOMIC AND PHYSIOLOGIC OVERVIEW Eye/Globe it sits in a protective bony structure called Orbit Orbit - lined with muscle and connective and adipose tissues 4cm high, wide and deep - shaped like 4-sided pyramid - surrounded by ethmoid sinus (medially), frontal sinus (superiorly), and maxillary sinus (inferiorly) - optic nerve and ophthalmic artery enters at its apex through the optic foramen - Extraocular muscles (4) Rectus Muscles: superior rectus, inferior rectus, lateral rectus (2) (2) Oblique Muscles: superior oblique, inferior oblique - Cranial Nerves CN III Oculomotor (Motor) muscles that move the eye and lid, pupillary constriction, lens accommodation CN IV Trochlear (Motor) muscles that move the eye CN VI Abducens (Motor) muscles that move the eye CN II Optic (Motor) visual acuity and visual fields Eyelids - Thin elastic skin: striated and smooth muscles - Protects anterior portion of the eye - Contains multiple glands: sebaceous glands, sweat glands, accessory lacrimal glands Upper lid covers the uppermost portion of the iris; oculomotor nerve Lid margins contains meibonian glands, inferior and superior puncta, and eyelashes Inner/medial canthus and outer/lateral canthus triangular spaces formed by the junction of the eyelids Tears - Formed by the lacrimal glands and accessory lacrimal glands - Composed of (3) layers: lipoid, aqueous and mucoid Conjunctiva - Contains fine blood vessels - Mucous membrane - Provides barrier to the external environment - Nourishes the eye Goblet cells secrete lubricating mucus Bulbar conjunctiva covers the sclera Palpebral conjunctiva lines the inner surface of the upper and lower eyelids Fornix junction between bulbar conjunctiva and palpebral conjunctiva Sclera - White of the eye Dense, fibrous structure that makes up the posterior 5/6 of the eye Maintains the shape of the eyeball Protects intraocular contents from trauma

Limbus - Conjunctiva meets the cornea - Outermost edge of the iris Cornea - Transparent, avascular, dome-like structure - Forms most anterior portion of the eyeball - Main refracting surface of the eye 5 Layers of the Cornea: 1. Epithelium 2. Bowmans membrane 3. Stroma 4. Descemets membrane 5. Endothelium Anterior Chamber - Behind the cornea Aqueous humor - nourishes the cornea - produced in the ciliary body - production is related to intraocular pressure Normal Intraocular Pressure (IOP): 10-21 mmHg Uvea 1. Iris colored part of the eye; highly vascularized, pigmented collection of fibers surrounding the pupil 2. Ciliary body produces aqueous humor; controls accommodation through the zonular fibers and ciliary muscles Anterior to the lens aqueous humor Posterior to the lens vitreous humor Posterior chamber small space between the vitrous and the iris; manufactures aqueous fluid (by ciliary body) to the trabecular meshwork into the canal of Schlemm 3. Choroid between the retina and sclera; avascular tissue, supplying blood to portion of the sensory retina Pupil - Space that dilates/constricts in response to light - Dilation dilator papillae muscles sympathetic nervous system - Constriction sphincter muscles parasympathetic nervous system Lens - Colorless, completely transparent, biconvex structure - Held in position by zonular fibers - Avascular: no nerve/pain fibers - Responsible for focusing for near vision and refocusing for distance vision Accommodation ability to focus and refocus

Ocular Fundus - Largest chamber of the eye; contains the vitreous humor Vitreous humor clear, gelatinous substance; composed mostly of water; encapsulated by hyaloids membrane; helps maintain the shape of the eye; 2/3 of the eyes volume Retina - The innermost surface of the fundus - Has 10 microscopic layers - A neural tissue, extension of the optic nerve - Landmarks: optic disk, retinal vessels, macula Optic Disc entrance of the optic nerve into the retina Retinal Tissues lines the inner surface of the vitreous chamber Macula responsible for central vision Fovea center of the macula; most sensitive area - 2 Layers of the Retina: 1. Retinal Pigment Epithelium (RPE) absorption of light 2. Sensory Retina photoceptor cells Rods night vision/vision in low light Cones bright light, color vision, and fine detail Visual Acuity depends on: 1. Healthy, functioning eyeballs 2. Intact Visual Pathway retina, optic nerve, optic chiasm, optic tracks, lateral geniculate bodies, optic radiations, visual cortex area of the brain Optic Nerve CN II; transmits impulses from the retina to the occipital lobe of the brain Optic Nerve Head/Optic Disc physiologic blind spot in each eye ASSESSMENT 1. Ocular History - Visual acuity diminished? - Blurred, double, distorted vision? - Pain? Worse when blinking? - Itching or foreign body sensation? - Both eyes affected? - History of discharge? Consistency, color, odor - Duration? - Recurrence of previous condition? - Self-treatment? Symptoms improve? Worsen? - Affects ADL? - Any systemic disease? Medications? - Any ophthalmic condition? Surgery? - Family members same symptoms/condition? 2. Visual Acuity a. Snellen Chart used to test distance vision - Patient is 6m or 20ft away - Near vision testing for patients with difficulty in reading and over 40years old (handheld snellen) Standard normal vision: 20/20 OD right eye OS left eye b. Count fingers (CF) CF/3 (at 3 feet)

c. Hand Motion (HM) hands up and down, side to side d. Light Perception (LP) e. Ishihara chart used to evaluate color vision 3. External Eye Examination - Position of eyelids (2mm of iris covered by upper lid) - Ptosis - drooping eyelid - Lid retraction (too much of the eye exposed) - Edema, erythma, lesions - Scaling/crustin - Sclera opaque and white - Conjunctiva lesion, discharge, tearing or blinking - Pupils pupillary response, color Normal pupil size: 3-5 mm - Direct and consensual response for each eye, speed of reaction, and accommodation - Primary or direct gaze - Head tilt cranial nerve palsy - Extraocular movements Cover test: both eyes open, focus on the object Exophoria tendency to drift to the temporal side Esophoria tendency to drift to the nasal side Coordinated gaze Diplopia one eye fails to move with the other; one or more of the extraocular muscles are failing to function properly Nystagmus oscillating movement of the eyeball; irregular jerking eye movement Caloric Test: instillation of warm or cold water into the ear Normal reaction: rapid nystagmus toward or away from the water injection; vomiting and extreme pain Absence: indicates brain death - Examination of Visual Field - Examiner and patient is 1-2 feet apart - Patient covers 1 eye and looks directly at the examiners nose - Examiner covers 1 eye as a method of comparison - Eyelids close CN III and open CN VII - Ptosis caused by edema, muscle weakness, congenital defect or neurologic problem (CN XI) - Ectropian eye lid turns outward - Entropian eye lid turns inward - Eyelashes position and distribution - Poliosis white eyelashes (albino) - Cornea transparent, smooth, shiny, bright DIAGNOSTIC EVALUATION 1. DIRECT OPHTHALMOSCOPY - Handheld instrument with various plus and minus lenses - Dark room - Patients eye same level as examiners eye - Fundus: silvery or coppery appearance arteriosclerosis - Retina: Intraretinal hemorrhage red smudges Hypertension flame-shaped

DM/Hypercholesterolemia yellowish Microaneurysms red dots Drusen (small, hyaline, globular growths) yellowish spots with indistinct edges 2. INDIRECT OPHTHALMOSCOPY - Larger areas of the retina - Produces bright and intense light 3. SLIT LAMP EXAMINATION - Examines eye with magnification of 10-40 times the real image 4. COLOR VISION TESTING - Ishihara Polychromatic Plates - Diminished color vision: unable to identify hidden shapes - Central vision: unable to identify colors 5. AMSLER GRID - Macular problems - Geometric grid of identical squares with central fixation point 6. ULTRASONOGRAPHY - Lesions in the globe or orbit - Orbital tumors, retinal detachment, and changes in tissue composition - Calculates length of the eye 7. OPTICAL COHERENCE TOMOGRAPHY - Involves low coherence interferometry - Light evaluate retinal and macular diseases, anterior segment condition - noninvasive 8. COLOR FUNDUS PHOTOGRAPHY - Retinal lesions - Pupils are widely dilated, visual acuity is diminished for 30 minutes 9. FLUORESCEIN ANGIOGRAPHY - Macular edema, macular capillary nonperfusion, retinal and choroidal neovascularization (growth of abnormal new blood vessels) in age-related macular degeneration - Flourescent dye is injected into antecubital vein 10-15seconds Gold toned skin, deep yellow/orange urine disappears in 24 hours 10. INDOCYANINE GREEN ANGIOGRAPHY - Abnormalities in choroidal vasculature - Indocyanine green dye is injected IV digital videoangiograohy 30sec to 20min - Patient may experience nausea and vomiting - Contraindicated in patients with history of iodine reactions 11. TONOMETRY - Measures IOP determines amount of force/pressure necessary to indent or flatten a small anterior area of the globe of the eye - Noninvasive and painless - Topical anesthetic eye drop a. Applanation Tonometer drop of fluoroscein dye and anesthetic drop b. Tono-pen 12. PERIMETRY TESTING - Evaluates field of vision: visual field area of extent of physical space visible to an eye in a given position

Visual field: 65 upward, 75 downward, 60 in and 95out - Detects scotomas (blind areas in the VF) in macular degeneration and peripheral field defects in glaucoma and retinitis pigmentosa a. Manual use of stationary (static) or moving stimuli or targets tangent screen b. Automated use of stationary targets Other Diagnostic Evaluation 1. CT scan 2. MRI ocular tumors 3. Radioisotopic scanning 4. Corneal staining fluoroscein or other topical dye into the conjunctiva IMPAIRED VISION 1. REFRACTIVE ERRORS - Vision is impaired shortened or elongated eyeball prevents light rays from focusing sharply on the retina - Eyeglasses/contact lenses refraction - Determines depth of the eye ball a. Emmetropia (normal vision) visual image focused on the macula b. Myopia (near sighted) deeper eyeballs; distal visual image focuses in front, or short of the retina; blurred distance vision c. Hyperopia (far sighted) eyes are shallower; visual image focused beyond the retina d. Astigmatism irregularity in the curve of the cornea, decreased acuity of distance and near vision Wavefront Technology sphere, cylinder and higher-order aberrations Wavefront-Guided Refractive Surgery 2. LOW VISION AND BLINDNESS LOW VISION - visual impairment; best corrected visual acuity (BCVA) of 20/70 to 20/200 BLINDNESS - 20/400 to no light perception ABSOLUTE BLINDNESS absence of light perception LEGAL BLINDNESS BCVA less than 20/200 in the better eye or whose visual field diameter is 20 or less; inability to perceive light (having some vision) ** VA of 20/80 to 20/100, VF 60-20 - read at normal level with optical aids ** VA of 20/200 to 20/400, VF 20-10 - read slowly with optical aids TRAVEL VISION ability to negotiate environment without auxillary aids Causes: a. Diabetic Retinopathy b. Macular degeneration Caucasians c. Glaucoma African-Americans d. Cataracts

The External Eye Eyelids and lacrimal structures

Age-Related Changes in the Eye Structural Change Functional Change Loss of skin elasticity and orbital fat, decreased muscle tone; wrinkles develop Lid margins turn in, causing lashes to irritate cornea and conjunctiva (entropian); lid margins may turn out increased corneal exposure (ectropian) Reading materials must be held at increasing distance in order to focus Interference with the focus of a sharp image on the retina Retinal tears and detachment Central vision is affected; onset more gradual in dry AMD, more rapid in wet AMD; distortion and loss of central vision

History and Physical Findings Burning, foreign body sensation, increased tearing (epiphoria); injection, inflammation, and ulceration arms too short; need for increased light; needs reading glasses or bifocals Increased glare, decreased vision, change in color values (blue and yellow) Light flashes, cobwebs, floaters 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

Refractive changes; presbyopia Cataract Posterior vitreous detachment Age-related macular degeneration (AMD)

Loss of accommodative power in the lens with age Opacities in the normally crystalline lens Liquefaction and shrinkage of vitreous body 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.

Assessment and Diagnostic Testing - Thorough history - Distance and near visual acuity - Visual field - Contrast sensitivity - Glare - Color perception - Refraction Patient Interview - Cause and duration of visual impairment Retinitis pigmentosa genetic abnormality Diabetic macular edema fluctuating visual acuity Macular degeneration central acuity problems - ADL - Medication regimen - Habits (smoking) - Acceptance of physical limitations - Expectations of low vision aids Contrast-Sensitivity Testing and Glare Testing - Contrast-Sensitivity Testing measures visual acuity in different degrees of contrast - Glare Testing more realistic evaluation of the patients ability to function in his or her environment Brightness Acuity Tester 3 degrees of bright light Medical Management Goal: Optimize patients remaining vision 1. Low-vision aids and strategies: optical (convex lens aids: magnifiers and spectacles, telescopic devices, antireflective lenses,

2. 3. 4. 5.

electronic reading systems: closed-circuit television and computers with large print) and non-optical devises Referral to social services and community agencies to patients who live alone and cannot self-administer their medications Retinal Implants functional optic nerves Cortical Implants diseased optic nerves Experimental artificial silicon retina microchip retinitis pigmentosa

Nursing Management 1. Promoting coping efforts a. Help patient and family members to recognize permanence of blindness no false assurances! b. Consider value changes, independence-dependence conflicts, coping with stigma, and learning to function in social settings without visual cues and landmarks 2. Promoting spatial orientation and mobility a. Spatial concepts in activities of daily living b. Intensive emotional support to patients who become blind suddenly c. Assess degree of physical assistance d. (Hospital) Bedside table and call button within reach e. All articles and furniture must remain in the same positions f. Introduce self upon entering patients room and alert patient to your departure g. Provide physical assistance, encourage independence and ensure safety

3. Promoting home and community-based care a. Consult low vision specialist or occupational therapist b. Use of Braille or guide dogs (SeeingEye dogs) GLAUCOMA - Group of ocular conditions characterized by optic nerve damage IOP caused by congestion of aqueous humor in the eye - One of the leading causes of irreversible blindness, leading cause of blindness among adults in US - Prevalent among people >40years old, men, African-American and Asians Risk Factors - Family history of glaucoma, African American race, older age, CVD, migraine syndromes, nearsightedness (myopia), eye trauma, prolonged use of topical or systemic corticosteroids Physiology - Aqueous humor flows between the iris and the lens nourishes the cornea and lens - Unimpeded outflow: intact drainage system and open angle (45) between the iris and the cornea - Narrower angle iris is placed closer to trabecular meshwork diminishes angle - Production of aqueous humor decreases with age, systemic diseases (diabetes), or in ocular inflammatory conditions - IOP rate of aqueous production, resistance encountered by aqueous humor as it flows out of the passages, and the venous pressure

of the episcleral veins that drain into the anterior ciliary vein IOP 10-21mmHg balanced aqueous fluid production and drainage Fluctuations of IOP time of day, exertion, diet, medications Increase IOP blinking, tight lid squeezing, upward gazing, hypertension and intraocular conditions (uveitis, retinal detachment)

Pathophysiology Direct Mechanical Theory - High IOP damages retinal layer Indirect Ischemic Theory - High IOP compresses microcirculation in the optic nerve head cell injury and death Stages of Glaucoma 1. Initiating Precipitating factors: Events illness, emotional stress, congenital narrow angles, long term use of corticosteroids, use of mydriatics (meds causing pupillary dilation) 2. Structural Tissue and cellular changes alterations in caused by factors that affect the aqueous aqueous humor dynamics outflow system lead to structural alterations 3. Functional Conditions such as increased alterations IOP or impaired blood flow create functional changes 4. Optic nerve Atrophy of the optic nerve is damage characterized by loss of nerve fibers and blood supply. 5. Vision loss Progressive loss of visual characterized by visual field defects.

Classifications of Glaucoma Types of Glaucoma Clinical Manifestations Treatment Open Angle Glaucoma Usually bilateral, but one eye may be more severely affected than the other. In all three types of open-angle glaucoma, the anterior chamber angle is open and appears normal. Chronic open-angle Optic nerve damage, visual field defects, Decreases IOP 20% - 50%. Topical and glaucoma (COAG) IOP>21mmHg. May have fluctuating IOPs. oral agents. Laser trabeculoplasty (LT) to Usually no symptoms but possible ocular decrease IOP by 20%. Glaucoma filtering pain, headache, and halos surgery. Normal tension IOP<21mmHg. Optic nerve damage, visual Similar to COAG. Goal: lower IOP at least glaucoma field defects 30% Ocular hypertension Elevated IOP. Possible ocular pain or Decrease IOP by at least 20% headache. Angle-Closure (Pupillary Block) Glaucoma Obstruction in aqueous humor outflow due to the complete or partial closure of the angle from the forward shift of the peripheral iris to the trabecula. The obstruction results in an increased IOP Acute angle-closure Rapidly progressive visual impairment, Ocular emergency hyperosmotics, glaucoma (AACG) periocular pain, conjuctival hyperemia, azetazolamide, topical ocular hypotensive and congestion. Pain assoc.with nausea, agents: pilocarpine and beta-blockers. vomiting, bradycardia, and profuse Laser incision in the iris (iridotomy). sweating. Reduced central visual acuity, severely elevated IOP, corneal edema. Pupil is vertically oval, fixed in a semidilated position, and unreactive to light and accommodation

Subacute angleclosure glaucoma

Transient blurring of vision, halos around lights; temporal headaches and/or ocular pain; pupil may be semi-dilated Chronic angleProgression of glaucomatous cupping and closure glaucoma significant visual field loss; IOP may be normal or elevated; ocular pain and headache. Clinical Manifestations - Glaucoma silent thief of sight - Blurred vision - Halos around lights - Difficulty focusing - Difficulty adjusting eyes in low lighting - Loss of peripheral vision - Aching or discomfort around the eyes - Headache Assessment and Diagnostic Findings - Ocular and medical history - Tonometry to measure IOP - Ophthalmoscopy to inspect optic nerve Medication Cholinergics (miotics) (pilocarpine, carbachol) Action Increases AH fluid outflow by contracting ciliary muscle and causing miosis (constriction of the pupil) and opening of trabecular meshwork Reduces production of AH and increases outflow

Prophylactic peripheral laser iridotomy. Similar to COAG. Laser irodotomy and medications. Gonioscopy to examine filtration angle of the anterior chamber Perimetry to assess visual fields Pallor (lack of blood supply from cellular destruction) and cupping of the optic nerve disc (exaggerated bending of the blood vessels as they cross the optic disc) Progression of cupping gradual loss of retinal nerve fibers loss of blood supply increased pallor of the optic disc

Medical Management Goal: Prevention of optic nerve damage, maintain IOP within a range unlikely to cause further damage 1. Pharmacologic Therapy Side Effects Periorbital pain, blurry vision, difficulty seeing in the dark Nursing Implication Caution about diminished vision in dimly lit areas

Adrenergic agonist (dipivefrin, epinephrine) BetaDecreases AH production blockers(betaxolol, timolol)

Eye redness and burning, palpitations, elevated BP, tremor, headaches, anxiety Bradycardia, exacerbation of pulmonary disease, hypotension

Punctal occlusion to limit systemic effects CI: asthma, COPD, 2nd-3rddegree heart block, bradycardia, cardiac failure. Punctal occlusion to limit systemic effects. Punctal occlusion to limit systemic effects. Do not administer to patients with sulfa allergies; monitor electrolyte levels Instruct to report any SE

Alpha-adrenergic agonists (apraclonidine, brimonidine) Carbonic anhydrase inhibitors (acetazolamide, methazolamide, dorzolamide) Prostaglanding analogs (latanoprost)

Decreases AH production

Eye redness, dry mouth, nasal passages Anaphylactic reactions, electrolyte loss, depression, lethargy, GI upset, impotence, weight loss, topical allergy Darkening of the iris, conjunctival redness, possible rash

Decreases AH production

Increases uveoscleral outflow

2. Surgical Management a. Laser Trabeculoplasty When IOP is not controlled by meds laser burns are applied to the inner surface of the trabecular meshwork to open the intratrabecular spaces and widen the canal of Schlemm promotes outflow of aqueous humor and decreases IOP Complication: transient increase in IOP (2hours after) b. Laser Iridotomy For pupillary block glaucoma Opening is made in the iris to eliminate pupillary block

CI: corneal edema Complications: burns to the cornea, lens or retina; transient elevated IOP, closure of the iridotomy (prevented by Pilocarpine), uveitis, blurring c. Filtering Procedures For chronic glaucoma Creates an opening or fistula in the trabecular meshwork to drain aqueous humor from the anterior chamber to the subconjunctival space into a bleb bypassing usual drainage structures

Trabeculectomy standard filtering techniwue to remove part of the trabecular meshwork Complications: hemorrhage, extremely low (hypotony) or elevated IOP, uveitis, cataracts, bleb failure, bleb leak, endophthalmitis Goal: incomplete healing of the surgical wound Antifibrosis agents: antimetabolites fluorouracil, mitomycin to prevent scarring d. Drainage implants and shunts Used when failure has occurred with one or more trabeculectomies Tubes implanted in the anterior chamber to shunt AH to an attached plate in the conjuctival space Nursing Management Promoting Home and Community-Based Care 1. Teaching patients self-care a. Patient education: nature of the disease, importance of strict adherence to medication regimen, b. Discuss medication program 2. Continuing care a. Referral to low vision and rehabilitation services b. Reassurance and emotional support CATARACTS - Lens opacity or cloudiness Risk Factors 1. Aging a. Loss of lens transparency b. Clumping or aggregation of lens protein c. Accumulation of yellow-brown pigment due to the breakdown of lens protein d. Decreased oxygen uptake e. Increase in Sodium and Calcium f. Decrease in levels of VitC, protein, and glutathione (antioxidant) 2. Associated ocular conditions a. Retinitis pigmentosa, b. Myopia c. Retinal detachment and retinal surgery d. Infection 3. Toxic factors a. Corticosteroids b. Alkaline chemical eye burns, poisoning c. Cigarette smoking d. Calcium, copper, iron, gold, silver, and mercury 4. Nutritional factors a. Reduced levels of antioxidants b. Poor nutrition c. Obesity 5. Physical factors a. Dehydration assoc.with acute diarrhea, use of purgitives in anorexia nervosa, use of hyperbaric oxygenation b. Blunt trauma, perforation of the lens with a sharp object or foreign body, electric shock c. Ultraviolet radiation in sunlight and xray 6. Systemic disease and syndromes a. DM

b. c. d. e.

Down syndrome Disorders related to lipid metabolism Renal disorders Musculoskeletal disorders

Pathophysiology - Lower income and educational level, smoking history for 35 or more pack-years, high triglyceride levels in men 3 most common types of senile (age-related) cataracts: 1. Nuclear Cataract caused by central opacity in the lens; associated with myopia 2. Cortical Cataract involves anterior, posterior or equatorial cortex (does not interfere with passage of light) of the lens; highest level of sunlight exposure 3. Posterior subcapsular cataracts younger people, associated with prolonged corticosteroid use, diabetes, ocular trauma; diminished near vision, eye is sensitive to glare from bright light; occupational sun exposure in people between 2029years of age Clinical Manifestations - Painless, blurry vision - Light scattering - Reduced contrast sensitivity, sensitivity to glare, and reduced visual acuity - Myopic shift - Astigmatism - Monocular diplopia (double vision) - Color shift (more absorbent at the blue end of the spectrum) - Brunescens (color values shift to yellow-brown) - Reduced light transmission Assessment and Diagnostic Findings - Decreased visual acuity - Snellen visual acuity test - Ophthalmoscopy - Slit-lamp biomicroscopic examination Medical Management - No nonsurgical treatment Surgical Management - Injection-free topical and intraocular anesthesia (1% lidocaine) - When both eyes have cataracts, one eye is treated first, with at least several weeks, preferably months, separating the two procedures 1. Intracapsular Cataract Extraction Entire lens removed and fine sutures are used to close the incision 2. Extracapsular Cataract Extraction Involves smaller incisional wounds Maintains posterior capsule of the lens, reducing complications: aphakic retinal detachment and cystoids macular edema 3. Phacoemulsification Uses ultrasonic device that liquefies the nucleus and the cortex, which are then suctioned out through a tube Posterior capsule is left intact 4. Lens Replacement

After removal of the crystalline lens, the patient is referred to as aphakic a. Aphakic glasses objects are magnified by 25%, making them appear closer than they really are; creates distortion; peripheral vision is limited; binocular vision is impossible b. Contact lenses provides almost natural vision, but need to be removed occasionally; not advised for patients who have difficulty inserting, removing, and cleaning them c. IOL implants low incidence of complications: hyphema, macular edema, secondary glaucoma, damage to the corneal endothelium; CI: recurrent uveitis, proliferative diabetic neuropathy, neovascular glaucoma, rubeosis iridis Toxic Anterior Segment Syndrome/Toxic Endothelial Cells Destruction/Sterile Endophthalmitis - Noninfectious inflammation caused by a toxic agent after uncomplicated and uneventful surgery - A complication of anterior chamber surgery - Characterized by corneal edema less than 24hours after surgery - Reduction in visual acuity and pain Nursing Management 1. Providing Preoperative Care a. Withhold anticoagulant therapy (aspirin, warfarin) to reduce retrobulbar hemorrhage for 5-7days b. Do not withhold anticoagulants in patients at higher risk for transient ischemic attacks or angina c. Dilating drops every 10minutes for 4 doses at least 1 hour before surgery d. Antibiotic, Corticosteroid, Anti-inflammatory 2. Providing Postoperative Care a. Give verbal and written instructions about how to protect the eye, administer medications, recognize signs of complications, and obtain emergency care b. Minimal discomfort take mild analgesic agent: acetaminophen c. Antibiotics, Anti-inflammatory, Corticosteroid 3. Promoting Home and Community-Based Care a. Protective eye patch for 24hours after surgery, eyeglasses worn during the day, and metal shield at night for 14weeks b. Expect slight morning discharge, some redness, and scratchy feeling c. Use clean, damp washcloth to remove slight morning eye discharge d. Notify surgeon: new floaters in vision, flashing lights, decrease in vision, pain, increase in redness e. Eye patch removed after first followup appointment f. Blurring of vision for several days to weeks

g. Vision is stabilized when the eye is completely healed, usually within 612 weeks CORNEAL DISORDERS CORNEAL DYSTROPHIES - Inherited as autosomal dominant traits - Manifestations occur 20y.o - Characterized by deposits in the corneal layers - Decreased vision - caused by irregular corneal surface and corneal deposits - Corneal edema and blurring of vision caused by corneal endothelial decompensation - Persistent edema bullous keratopathy (formation of blisters that cause pain and discomfort on rupturing) - Management: bandage contact lens to flatten bullae, protect exposed corneal nerve endings and relieve discomfort - Symptomatic Treatment: hypertonic drops or ointment (5% sodium chloride), lowering IOP KETATOCONUS - Conical protuberance of the cornea with progressive thinning on protrusion and irregular astigmatism - Hereditary - Onset at puberty, may progress for >20years and is bilateral - Corneal scarring in severe cases - Prominent symptom : blurred vision - Management: rigid, gas-permeable contact lenses (correct irregular astigmatism and improves vision) and penetrating keratoplasty CORNEAL SURGERIES Major cause of failure: Tissue rejection 1. PHOTOTHERAPEUTIC KERATECTOMY - Laser procedure that removes or reduces corneal opacities and smoothes anterior corneal surface - Safer and more effective than penetrating/lamellar keratoplasty - C/I: active hepatic keratitis (UV may reactivate latent virus) - SE: induced hyperopia and stromal haze - Complications: delayed reepithelialization (in DM) and bacterial keratitis - Postoperative management: oral analgesics for eye pain, pressure patch or therapeutic soft contact lens, antibiotics, corticosteroid ointments, NSAIDs 2. KERATOPLASTY (CORNEAL TRANSPLANTATION or CORNEAL GRAFTING) - Replaces abnormal host tissue with healthy donor (cadaver) corneal tissue - Indications: keratoconus, corneal dystrophy, corneal scarring from herpes simplex keratitis, chemical burns - Factors affecting success: condition of ocular structures, tear film function, adequacy of blinking, viability of donor endothelium

Tissues not used: tissues that may be a source of disease transmission, corneas with functionally compromised endothelium, and corneas from donors who have undergone laser-assisted in situ keratomileusis (LASIK) Management: mydriatics (pupillary dilation) for 2 weeks, topical corticosteroids for 12 months

Contraindications to the Use of Donor Tissue for Corneal Transplantation: Donor Characteristics 1. Systemic Disorders a. Death from unknown cause b. Creutzfeldt-Jacob disease c. AIDS or high risk for HIV infection d. Hepatitis e. Eye function, systemic function 2. Intrinsic Eye Disease a. Retinoblastoma b. Ocular inflammation c. Malignant tumors of anterior segment d. Disorders of the conjunctiva or corneal surface involving the optical zone of the cornea 3. Other a. History of eye trauma b. Corneal scars c. Previous surgical procedure d. Corneal graft e. LASIK eye surgery Nursing Management 1. Teach patient to identify signs and symptoms of graft failure: blurred vision, discomfort, tearing, redness of eye, and contact ophthalmologist 2. Strengthen surgeons recommendations and instructions reg. why visual rehabilitation and visual improvement 3. Assess patients support system and ability to comply with long-term follow-up 4. Refer to community services when indicated REFRACTIVE SURGERIES - Cosmetic, elective procedures performed to recontour corneal tissue and correct refractive errors so that eye glasses or contact lenses are no longer needed - Does not alter the normal aging process of the eye - Patients must be at least 18years - Corneal structure must be normal, and refractive error must be stable - Discontinue using contact lenses before procedure: 2-3weeks for soft lenses, 4weeks for hard lenses - Preoperative: patient education and counseling about potential risks, complications, and postoperative follow-up - Postoperative: topical corticosteroids, NSAID, antibiotic drops 1. LASER VISION CORRECTION PHOTOREFRACTIVE KERATECTOMY (PRK) - Treat myopia or hyperopia with or without astigmatism - Excimer laser directly applied to the cornea - Myopia: relative curvature is decreased

Hyperopia: relative curvature is increased Bandage contact lens is placed over the cornea - Complications: postoperative pain, subepithelial haze, and prolonged recovery 2. LASER-ASSISTED IN SITU KERATOMILEUSIS - Flattens anterior curvature of the cornea by removing a stromal lamella or layer - Surgeon creates a corneal flap with a microkeratome (automatic corneal shaper). Surgeon retracts a flap of corneal tissue less than 1/3 of the thickness of the human hair to access the corneal stroma and then uses the excimer laser on the stromal bed to reshape the cornea - Less postoperative discomfort, fewer side effects, and safer than PRK Perioperative Complications a. Surgically induced abnormalities - Corneal surface irregularities: central islands (central areas of stiffness or elevation), decentered ablations due to misalignment of laser treatment or from involuntary eye movement during laser treatment, irregular astigmatism - Symptoms: monocular diplopia, ghost images, halos, glare, decreased visual acuity, contrast sensitivity in low light b. Diffuse Lamellar Keratitis - Peculiar, noninfectious, inflammatory reaction in the lamellar interface after LASIK - Characterized by white, granular, diffuse, culture-negative lamellar keratitis - Diagnosis: slit-lamp examination - Treatment: corticosteroid drops, surgery 3. PHAKIC INTRAOCULAR LENSES - Used in either anterior of posterior chamber, natural lens is left in place and normal architecture of cornea is preserved - Complications: cataract, iritis or uveitis, endothelial cell loss, and increased IOP 4. CONDUCTIVE KERATOPLASTY - Correction of low to mild hyperopia - Uses principles of thermal keratoplasty by applying radiofrequency current to the peripheral cornea using a thin, hand-held probe RETINAL DISORDERS - Most commonly affected: sensory retina and the retinal pigment epithelium (RPE) Retinal Detachment - Separation of the RPE from the sensory layer (rods and cones, photoreceptor cells) 4 Types a. Rhegmatogenous - most common - a hole or tear develops in the sensory retina, allowing some of the liquid vitreous to seep through the sensory retina and detach it from the RPE - at risk: high myopia or aphakia after cataract surgery, trauma, proliferative retinopathy (retinopathy assoc with diabetic neovascularization)

b. Traction - Caused by tension or pulling force on the delicate retina - Develop fibrous scar tissue from conditions such as diabetic retinopathy, vitreous hemorrhage, or retinopathy of prematurity c. Combination of rhegmatogenous and traction d. Exudative - Result of production of a serous fluid under the retina from the choroid - Serous fluid caused by uveitis and macular degeneration Clinical Manifestations - Sensation of a shade or curtain coming across the vision of one eye - Cobwebs - Bright flashing lights - Sudden onset of a great number of floaters - No pain Assessment and Diagnostic Findings - Determine visual acuity - Dilated fundus examination using indirect ophthalmoscope and slit-lamp biomicroscopy - Stereo fundus photography - Fluoroscein angiography - Optical coherence tomography - Ultrasound Surgical Management ** Rhegmatogenous detachment surgically reattach sensory retina to RPE ** Traction detachment remove source of traction and sensory retina reattached a. Scleral Buckle - Sclera is compressed with a sclera buckle/silicone band to indent the sclera wall from the outside of the eye and bring the two retinal layers in contact with each other - Less damage to the lens, low risk of endophthalmitis - Complications: diplopia, induced myopia, increased postoperative pain b. Pars Plana Vitrectomy - Intraocular procedure in which 1- to 4-mm incisions are made at the pars plana - One incision allows introduction of a light source, another serves as a portal of entry for the vitrectomy instrument - Indications: removal of foreign bodies, various opacities such as blood, and dislocated lenses, - Tx of macular holes: vitrectomy, laser photocoagulation, air-fluid-gas exchanges, use of growth factor c. Pneumatic Retinopathy - Repair of rhegmatogenous retinal detachment - Least invasive - Gas bubble, silicone oil, or perfluorocarbon and liquids may be injected into the vitreous cavity to help push the sensory retina up against the RPE

Argon laser photocoagulation or cryotherapy is also used to spot-weld small holes

Nursing Management 1. Promoting Comfort If gas tamponade is used to flatten the retina, position patient to make gas bubble float into the best position: lie face down or on side 2. Teaching about Complications Increased IOP Endophthalmitis Development of other retinal detachments Development of cataracts Loss of turgor of the eye RETINAL VASCULAR DISORDERS - Loss of vision - occlusion of retinal artery or vein: atherosclerosis, cardiac valvular disease, venous stasis, HPN, increased blood viscosity - Risk factors: DM, glaucoma, agiing Central Retinal Vein Occlusion - Common 50 years and older - Decreased visual acuity: mild blurring to severely limited vision - Direct ophthalmoscopy of the retina: optic disk swelling, venous dilation and tortuousness (indirectness), retinal hemorrhages, cotton-wool spots, blood and thunder (extremely bloody) appearance of the retina - Fluorescein angiography: extensive areas of capillary closure - Management: monitor fir signs of neovascularization and neovascular glaucoma - Treatment: laser panretinal photocoagulation for abnormal neovascularization - Complications: neovascular glaucoma, macular edema, macular nonperfusion, vitreous hemorrhage from neovascularization Branch Retinal Vein Occlusion - Sometimes symptom-free; sudden loss of vision if macular area is involved - More gradual loss of vision if macular edema associated with BRVO develops - Grid-like pattern of laser burns reduce macular edema and improves visual acuity - Ocular fundus similar to CRVO, only the affected (by the obstructed veins) portions of the retina has blood and thunder appearance - Diagnostic evaluation: direct ophthalmoscopy, fluorescein angiography - Complications: neovascular glaucoma, macular edema, macular nonperfusion, vitreous hemorrhage from neuvascularization - Associated conditions: glaucoma, systemic HPN, DM, hyperlipidemia, hyperviscosity syndrome

Central Retinal Artery Occlusion - Sudden loss of vision (severe and permanent) - Visual acuity reduced to being able to count examiners fingers, or field of vision tremendously restricted - Relative afferent pupillary defect - Ocular fundus reveals pale retina with cherryred spot at the fovea - Thin retinal arteries, emboli in central retinal artery - Treatment: ocular massage, anterior chamber paracentesis, IV administration of hyperosmotic agents such as acetazolamide and high concentrations of O2 MACULAR DEGENERATION - Age-related Macular Degeneration (AMD) - Most common cause of vision loss in people older than 60 - Characterized by tiny, yellowish spots called drusen beneath the retina - Wide range of visual loss, but do not experience total blindness - Central vision is most affected, peripheral vision retained Risk factors: - Increasing age - Smoking history - Hypertension - Overweight - Hypermyopia - Familial incidence - Wet AMD (Caucasians than African Americans) - Use of thyroid hormones and hydrochlorothiazides - Arthritis Types a. Dry or Nonexudative or Nonneovascular 85% - 90% Outer layers of the retina slowly breakdown appearance of drusen outside macular area no symptoms Appearance of drusen within macular area - gradual blurring of vision Macular drusen may coalesce (unite), causing gradual decrease in central vision. Missing letters in words, blank spots, geographic atrophy, and retinal pigment epithelial abnormalities may appear. No treatment Use of antioxidants (vitamin C, E, and beta-carotene) and minerals (zinc oxide) in megadoses can slow progression of AMD and vision loss for people at high risk for developing advanced AMD b. Wet type or exudative or neovascular Abrupt onset Characterized by the development of an abnormal choroidal neovascular network beneath the macula. These

vessels leak fluid and bleed, causing edema and the development of fibrosis. Visual changes can occur rapidly. Straight lines appear crooked and distorted. The resulting macular disciform scar causes a loss of central vision. Treatment: argon laser to stop leakage, not ideal because it affects vision

Medical Management Photodynamic Therapy - Developed in an attempt to ameliorate the choroidal neovascularization while causing minimal damage to the retina - Reduces risk of visual loss of patients with subfoveal choroidal neovascularization due to macular degeneration - Verteporfin, a photosensitive dye, is infused IV over 10minutes. 15 minutes after start of infusion, a diode laser is used to treat abnormal network of vessels. The dye takes up the energy of the diode laser but the surrounding retina does not, avoiding damage to adjacent areas - Instruct patient to bring dark sunglasses, gloves, wide-brimmed hat, long-sleeved shirt and slacks: because Verteporfin is lightactivated dye - Instruct patient to avoid exposure to direct sunlight or bright light for 5 days after treatment - Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn Nursing Management - Use of bright lighting and magnification devices - Referral to a low vision center - Amsler grids to monitor for suddent onset or distortion of vision Ongoing Research Angiogenesis - Abnormal blood vessel formation - Studies to indentify agents that inhibit angiogenesis - This has implications for ocular neovascularization and the treatment of other disorders, such as solid tumors - Vasoproliferation in exudative AMD caused by underlying angiogenic stimulus known as vascular endothelial growth factor (VEGF) - Macugen (pegaptanib sodium)- inhibit ability of VEGF to bind to cellular receptors - Lucentis (ranibizumab) bind and inactivate all isoforms of VEGF Macular Translocation - Wet macular degeneration development of an abnormal choroidal neovascularization membrane - 360-degree retinal detachment is surgically created and the retina is gently lifted resettled, placing the macular area a slight

distance away from area of choroidal neovascularization. ORBITAL AND OCULAR TRAUMA Orbital Trauma - Associated with head injury - Stabilize general medical condition first - Assess face of underlying fractures (blunt trauma) - Assess visual acuity - Soft tissue orbital injury result in damage to the optic nerve Soft Tissue Injury and Hemorrhage - Blunt or penetrating trauma: tenderness, ecchymosis, lid swelling, proptosis (downward displacement of the eyeball), and hemorrhage; it can result in severe optic nerve damage - sudden or delayed and progressive vision loss - Closed injuries: contusions with subconjuctival hemorrhage (black eye) soft tissue injury to the eyelid or by underlying fracture - Management: thorough inspection, cleansing, and repair of wounds, cold compress followed by warm compress, hematomas that are swollen and fluctuating are surgically drained or aspirated - Immediate loss of vision after ocular injury is irreversible - Management: corticosteroid therapy to reduce optic nerve swelling, surgery (optic nerve decompression) Orbital Fractures - Detected by facial x-ray - Classifications: Blowout compression of soft tissue and the sudden increase in orbital pressure when force is transmitted to the orbital floor Zygomatic or tripod Maxillary Midfacial Orbital apex Orbital roof fractures - dangerous because of potential complications to the brain - CT scan: identified entrapped muscle and its auxiliary structures blunt small objects: fist, knee, elbow, or tennis or golf ball - Management: surgical management by neurosurgeon (orbital roof fractures) and ophthalmologist - nonemergent, usually a period of 10-14 days - Indications for surgical intervention: displacement of bone fragments disfiguring the normal facial contours, interference with normal binocular vision caused by extraocular muscle entrapment, interference with mastication in zygomatic fracture, and obstruction of the nasolacrimal duct Foreign Bodies - Copper, iron, vegetable materials from plants or trees cause purulent infection

X-ray and CT scan, MRI (identify metallic foreign bodies first) Management: removal of foreign bodies, surgical intervention to prevent further ocular injury and maintain integrity of affected areas, obtain culture, prophylactic IC antibiotics

Ocular Trauma - Leading cause of blindness among children and young adults, esp. male trauma victims - Occupational injuries, sports, weapons, assault, motor vehicle rashes, explosions - Two types Chemical burn irrigate eye with tap water or normal saline Foreign object in the eye do not attempt to remove foreign object, instead, protect it from jarring or movement to prevent further ocular damage; do not apply pressure or patch Assessment and Diagnostic Findings - Obtain thorough history: ocular history, preinjury vision in the affected eye or past ocular surgery, details related to the injury, type of activity that caused the injury, onset of vision loss - For chemical eye burns: identify chemical agent, test for pH - Examine corneal surface for foreign bodies, wounds and abrasions - Compare pupillary size, shape and light reaction of the pupil of the affected eye with other eye - Ocular motility (ability of the eyes to move synchronously up, down, right, and left) Medical Management Splash Injuries - Irrigation with normal saline - Ruptured globe: cycloplegic agents (agents that paralyze the ciliary muscle) or topical antibiotics - Parenteral, broad-spectrum antibiotics - Tetanus antitoxin, analgesics Foreign Bodies and Corneal Abrasions - Removal of foreign body - Antibiotic ointment and eye is patched - Contact lens wear is a common cause of corneal abrasion severe pain and photophobia - Corneal epithelial defects: antibiotic ointment and pressure patch - Topical anesthetic eye drops must not be given: they mask further damage, delay healing, and leads to permanent corneal scarring - Avoid corticosteroids while epithelial defect exists Penetrating Injuries and Contusions of the Eyeball - Blunt trauma injuries have worse prognosis

Penetrating injuries result in marked loss of vision with ff. signs: hemorrhagic chemosis (edema of the conjunctiva), conjunctival laceration, shallow anterior chamber with or without an eccentrically placed pupil, hyphema (hemorrhage within the chamber), or vitreous hemorrhage Hyphema caused by contusion forces that tear the vessels of the iris and damage the anterior chamber angle prevent rebleeding and prolonged increased IOP, hospitalization with moderate activity restriction, apply eye shield, topical corticosteroid, aminocaproic acid (antifibrinolytic agent, stabilizes clot formation); aspirin is contraindicated Surgical intervention for ruptured globe and severe injuries with intraocular hemorrhage Vitrectomy for traumatic retinal detachments Primary enucleation complete removal of the eyeball and part of the optic nerve if globe is irreparable and has no light perception; performed within 2 weeks of the initial injury to prevent sympathetic ophthalmia (inflammation created in the uninjured eye by the affected eye that can result in blindness of the uninjured eye)

Long term treatment: restoration of the ocular surface through grafting procedure and surgical restoration of corneal integrity and optical clarity Intense lubrication using nonpreserved artificial tears Thermal injury caused by exposure to a hot object Photochemical injury caused by ultraviolet irradiation or infrared exposure Antibiotics and pressure patch for 24 hours Scarring of eyelids: oculoplastic surgery Corneal scarring: corneal surgery

INFECTIOUS AND INFLAMMATORY CONDITIONS - Eye infection is the leading cause of blindness Dry Eye Syndrome (Keratoconjunctivitis sicca) - Deficiency in the production of any of the aqueous, mucin, or lipid tear film components; lid surface abnormalities, or epithelial abnormalities related to systemic diseases (thyroid d/o, parkinsons disease), infection, injury, or complications of medications (antihistamines, oral contraceptives, pehnothiazines) Clinical Manifestation - Scratchy or foreign body sensation - Itching - Excessive mucus secretion - Inability to produce tears - Burning sensation - Redness - Pain - Difficulty moving the lids Assessment and Diagnostic Findings - Slit-lamp examination absent or interrupted tear meniscus (crescent-shaped edge of the rear film in the lower lid margin) at the lower lid margin, conjunctiva is thickened, edematous, and hyperemic and has lost its luster - Chronic dry eyes chronic conjunctival and corneal irritation corneal erosion, scarring, ulceration, thinning, or perforation secondary bacterial infection Management - Installation of artificial tears at day, and ointment at night to hydrate and lubricate eye and preserve moist ocular surface - Anti-inflammatory medications and moisture chambers (moisture chamber spectacles, swim goggles) - Preservative-free ophthalmic solutions - Concurrent treatment of infections: chronic blepharitis and acne rosacea, treating underlying systemic disease: Sjogrens syndrome (autoimmune) - Surgical treatment: punctal occlusion (use of punctal plugs, a silicone material), grafting procedures, and lateral tarsorrhaphy (uniting edges of lids) - Short term occlusion: inserting punctal or silicone rods in all four puncta

Intraocular Foreign Bodies - Diagnosed and localized by slip-lamp biomicroscopy and indirect ophthalmoscopy, CT or ultrasonography; MRI is contraindicated - Extraction route (surgical incision) of the foreign body depends on its location and composition and associated ocular injuries - Use of specifically design IOFB forceps and magnets Ocular Burns - Causes: alkali, acid, other chemically active organic substances: mace, tear gas - Alkali burns: penetrate the ocular tissues rapidly and continue to cause damage long after initial injury, cause immediate rise in IOP - Chemical burns may appear as superficial punctuate keratopathy, subconjunctival hemorrhage, or complete marbleizing of the cornea - Immediate tap-water irrigation, then normal saline or any neutral solution - Local anesthetic is instilled, and lid speculum is applied to overcome blepharospasm (spasms of the eyelid muscles that result in closure of the lids) - Remove particulate matter using moistened, cotton-tipped applicators and minimal pressure on the globe - Continue irrigation until conjunctival pH normalized (between 7.3-7.6) - Instill antibiotics, and patch eye - GOAL: prevent tissue ulceration and promote reepithelialization (patching or therapeutic soft lenses)

Permanent occlusion for adults who do not develop tearing after partial occlusion or who have results on a repeated Schirmers test of 2 mm or less (filter paper is used to measure tear production)

Conjunctivitis - Inflammation of the conjunctiva - Characterized by a pink appearance (pink eye) Clinical Manifestations - Foreign body sensation - Scratching or burning sensation - Itching - Photophobia - May be unilateral or bilateral Assessment and Diagnostic Findings - Four main critical features: Type of discharge (watery, mucoid, purulent, mucopurulent) Type of conjunctival reaction (follicular or papillary) Presence of pseudomembranes (coagulated exudates that adheres to the surface of the inflamed conjunctiva) or true membranes (exudte adheres to superficial layer of the conjunctiva, and removal results in bleeding) Presence or absence of lymphadenopahty (enlargement of the preauricular and submandibular lymph nodes where the eyelids drain) - Follicles - multiple, slightly elevated lesions encircled by tiny blood vessels - Papillae hyperplastic conjunctival epithelium in numerous projections that are usually seen as fine mosaic pattern under slitlamp examination - Diagnosis: distinctive characteristics of ocular signs, acute or chronic presentation, and identifying precipitating events - Positive result: swab smear preparations and cultures Types of Conjunctivitis Microbial Conjunctivitis a. Bacterial Conjunctivitis - Chronic Bacterial Conjunctivitis: seen in patients with lacrimal duct obstruction, chronic dacryocytitis, and chronic blepharitis. - Common cause: streptococcus pneumonia, haemophilus influenza, staphylococcus aureus - Acute: redness, burning, and purulent discharge (severe acute) or mucopurulent (mild cases), papillary formation, conjunctival irritation, and injection in the fornices, exudates on waking in the morning, eyes difficult to open because of adhesions - Management: antibiotics. Conjunctivitis may last a few days, except for gonococcal and staphylococcal conjunctivitis

Gonococcal conjunctivitis: profuse exudates, lumphadenopathy, pseudomembranes may be present Clamydial conjunctivitis: Trachoma bilateral chronic follicular conjunctivitis of childhood that leads to blindness during adulthood if left untreated leading cause of preventable blindness, prevalent in hot, dry and dusty climates and in areas with poor living conditions spread by direct contact or fomites, vectors: insects s/sx: red inflamed eyes, tearing, photophobia, ocular pain, purulent exudates, preauricular lypmhadenopathy, lid edema initial ocular signs: follicular and papillary formations Middle stage: acute inflammation with papillary hypertrophy and follicular necrosis, and trichiasis and entropion begin to develop lashes causes corneal erosion and ulcerations late stage: scarred conjunctiva, subepithelial keratitis, abnormal vascularization of the cornea, residual scars from follicles severe corneal ulceration perforation and blindness Management: broad spectrum antibiotics (topically or systematically), surgical correction of trichiasis (eyelashes growing inward toward conjunctiva and cornea) inclusion conjunctivitis sexually active people with genital chlamydial infection transmitted through oral-genital sex or hand-eye transmission may be transmitted through inadequately chlorinated swimming pool eye lesions 1wk after exposure, may be assoc. with nonspecific urethritis or cervicitis s/sx: mucopurulent discharge, follicles, lymphadenopathy Management: 1week antibiotics, treatment for STD

b. Viral Conjunctivitis - Watery discharge, prominent follicles, severe cases include pseydomembranes - Causative agents: adenovirus (highly contagious) and herpes simplex virus - Adenoviruses: upper respiratory infection - Corneal involvement: extreme photophobia - S/Sx: extreme tearing, redness, foreign body sensation, lid edema, ptosis, conjunctival hyperemia (dilation of the conjunctival blood vessels) - Lasts longer than bacterial conjunctivitis

Epidemic Keratoconjuctivitis (EKC) highly contagious viral conjunctivitis, transmitted through person-person contact; accompanied by preauricular lymphadenopathy and occasionally periorbital edema; marked follicular and papillary formation; can lead to keratopathy Management: not responsive to any tx; cold compress, hand hygiene, avoid sharing hand towels, face cloths, eye drops, avoid all forms of tonometry unless medically indicated

More insidious onset and can involve any portion of the uveal tract Symptoms: photophobia and minimal pain, marked vision, diffuse conjunctival injection, vitreous clouding Severe posterior uveitis such as chorioretinitis there may be retinal and choroidal hemorrhage

Immunologic/Allergic Conjunctivitis - Hypersensitivity reaction that occurs as part of allergic rhinitis (hay fever), or can be an independent allergic reaction - History of allergy to pollens and other environmental allergens - Extreme pruritus, epiphora (excessive secretion of tears), injection, and usually severe photophobia, stringlike mucoid discharge - Vernal/seasonal conjunctivitis mostly during warm weather long formations of papillae with cobblestone appearance; hx of asthma or eczema - Management: corticosteroids in ophthalmic or oral preparation, use of vasoconstrictors to decrease swelling: topical epinephrine solution, cold compress, ice packs, cool ventilation Toxic Conjunctivitis - Result of medications, chlorine from swimming pool, exposure to toxic fumes, exposure to irritants: smoke, hair sprays, acids, alkalis - Management: irrigation with saline or sterile water General Management (Conjunctivitis) - Topical antibiotics, eye drops, ointments - Gonococcal : urgent antibiotic therapy Uveitis - Inflammation of the uveal tract (uveitis); affects the iris, ciliary body, or the choroid a. Nongranulomatous - Manifests as an acute condition with pain, photophobia, pattern of conjuctival injection, esp. around the cornea - Pupil is small or irregular, blurred vision - Small, fine precipitates on the posterior corneal surface and cells in the aqueous humor (cell and flare) - Severe: hypopyon (accumulation of pus in the anterior chamber) - May be unilateral or bilateral - Repeated attacks may cause anterior synechiae (peripheral iris adheres to the cornea and impedes outflow of aqueous humor) - Posterior synechiae (adherence of the iris and lens) b. Granulomatous

Management - Photophobia: wear dark glasses outdoors - Ciliary spasm and synechiae: mydriasis: cyclopentolate (Cyclogyl) and atropine - Inflammation: local corticosteroid drops: Pred Forte 1% and Flarex 0.1% 4-6 times a day - Severe cases: systemic corticosteroids or intravenial corticosteroids - Daclizumab (Zenapax) to prevent specific chemical interaction needed by immune cells to produce inflammation (still under study) - Thorough evaluation: complete history, physical examination, diagnostic tests: CBC, erythrocyte sedimentation rate, antinuclear antibodies, venereal disease research laboratory, lyme disease titers - Underlying conditions: autoimmune disorders: ankylosing spondylitis and sacroidosis, toxoplasmosis, herpes zoster virus, ocular candidiasis, histoplasmosis, herpes simpex virus, tuberculosis, syphilis Orbital Cellulitis - Inflammation of the tissues surrounding the eye - May result from bacterial, fungal, or viral inflammatory conditions of contiguous structures: face, oropharynx, dental structures, or intracranial structures - Can result from foreign bodies, or from preexisting ocular infection: dacryocystitis and panophthalmitis, or generalized septicemia - Most frequently cause by sinus infection - Causative agents: staphylococci and streptococci in adults, H.influenzae in children - S/Sx: pain, lid swelling, conjunctival edema (optic nerve compression and increase ICP), proptosis, decreased ocular motility - Severe intraorbital tension by abscess formation and impairment of optic nerve function in orbital cellulitis results in permanent vision loss - Complications: intracranial abscess and cavernous sinus thrombosis Management: - Immediate administration of high-dose, broad-spectrum, systemic antibiotics - Cultures and gram stained smears - Monitor visual acuity, degree of proptosis, CNS function (nausea, vomiting, fever, cognitive changes), displacement of the glove, extraocular movements, pupillary signs, and fundus

Abscess formation or progressive vision loss; surgical drainage of abscess or sinus, sinusotomy or antibiotic irrigation

Orbital and Ocular Tumors Benign Tumors of the Orbit - Masses characterized by lack of infiltration in surrounding tissues: cystic dermoid cysts and mucocele, hemangiomas, lymphangiomas, lacrimal tumors, and neurofibromas - Significant proptosis, jeopardized visual function - Management: excision of benign mass, subtotal resection for deep benign tumors - Complete removal of tumor may endanger visual function Benign tumors of the Eyelids - Nevi may be unpigmented at birth and may enlarge and darken in adolescence or may never acquire any pigment at all - Hemangiomas vascular capillary tumors: bright, superficial, strawberry red lesion or bluish and purplish deeper lesions - Milia small, wile, slightly elevated cysts of the eyelid - Xanthelasma yellowish, lipoid deposits on both lids near the inner angle of the eye - Molluscum contagiosum lesions flat, symmetric growths in conjunctivitis and keratitis if debris gets into conjunctival sac - Treatment: corticosteroid injection to hemangiomal lesion, surgical excision or electrocautery Benign Tumors of the Conjunctiva - Conjunctival nevus congenital, benign neoplasm; flat, slightly elevated, brown spot that becomes pigmented during late childhood or adolescence - Keratin- and sebum-containing dermoid cysts congenital - Dermolipoma congenital tumor: smooth, rounded growth in the conjunctiva near the lateral cathnus - Papillomas soft with irregular surfaces and appear on lid margins - Treatment: Surgical excision Malignant Tumors of the Orbit - Rhabdomyosarcoma most common malignant primary orbital tumor in childhood; sudden painless proptosis of one eye, lid swelling, conjunctival chemosis, impairment of ocular motility; most common site of metastasis is the lung - Management: surgery (resection of the eyeball), radiation therapy, adjuvant chemotherapy Malignant Tumors of the Eyelid - Basal cell carcinoma most common malignant tumor in the eyelid; painless nodule that may ulcerate, lesion is invasive, spread to surrounding tissues, and grows slowly but does not metastasize; usually on the lower lid margin near inner canthus

Squamous cell carninoma grows slowly and painlessly, tends to ulcerate and invade surrounding tissues, can metastasize to regional lymph nodes Malignant melanoma may not be pigmented, can arise from nevi, spread to surrounding tissues and metastasize to other organs Occur more frequently among people with fair complexion with chronic exposure to the sun Management: complete excision of carcinoma followed by reconstruction with skin grafting Monitor postop site and graft donor for bleeding Donor sites: buccal mucosa, thigh, abdomen

Malignant Tumors of the Conjunctiva - Most often grows in the exposed area of conjunctiva - Lesions are gelatinous and whitish due to keratin formation - Grow gradually, deep invasion and metastasis are rare - May arise from preexisting nevus or acquired menalosis - Squamous cell carcinoma - Management: surgical incision, radiation therapy, cryotherapy after excision Malignant Tumors of the Globe - Retinoblastoma malignant tumor of the retina, occurs in childhood, hereditary, requires complete enucleation - Ocular melanoma malignant choroidal tumor that primary occurs in adults - S/Sx: blurred vision, change in eye color - Diagnostic evaluation: complete physical examination, retinal fundus photography, fluorescein angiography, ultrasonography, diagnosis confirmed at biopsy after enucleation - Tumors classified according to boundary lines: small (generally monitored), medium, or large (require treatment) - Management: Radiation therapy through external beam Surgical Procedures and Enucleation Orbital Surgeries - To repair fractures, remove foreign body, remove benign or malignant growths - Those that involve the orbit and lids affect facial appearance (cosmesis) - Goal: recover and preserve visual function and maintain anatomic relationship of ocular structures to achieve cosmesis - Orbital bones are realigned to follow anatomic positions of facial structures - Involve working around the delicate structures of the eye: optic nerve, retinal blood vessels, ocular muscles - Complications: blindness (damage to optic nerve and its blood supply), sudden pain and loss of vision may indicate intraorbital hemorrhage or compression of optic nerve,

ptosis and diplopia (trauma to extraocular muscles) Postoperative: IV antibiotics, IV corticosteroids (optic nerve swelling), topical ocular antibiotics, antibiotic ointments, ice compress for the first 24-48 hours to decrease optic nerve swelling, facial swelling, and hematoma, HOB at 30-45 Discharge teaching: medication instruction for oral antibiotics, installation of ophthalmic medications, application of ocular compresses

Provide information about the surgical procedure and availability of ocular prosthesis

Enucleation - Removal of the entire eye and part of the optic nerve - Indications: Severe injury resulting in prolapsed of uveal tissue or loss of light projection (the ability to identify the direction of light source) or perception An irritated, blind, painful, deformed, or disfigured eye, usually caused by glaucoma, retinal detachment, or chronic inflammation An eye without useful vision that is producing or has produced sympathetic ophthalmia in the other eye Intraocular tumors that are untreatable by other means - Involves separation and cutting of each of the ocular muscles, dissection of the Tenons capsule (fibrous membrane covering the sclera), and cutting of the optic nerve from the eyeball, orbital implant is inserted, conjunctiva is closed, then large pressure dressing is applied over the area - Evisceration surgical removal of the intraocular contents through an incision or opening in the cornea or sclera; done to treat ocular trauma with ruptured globe, severe ocular inflammation, severe ocular infection; final cosmetic result and motility after fitting the ocular prosthesis is enhanced; high risk of sympathetic ophthalmia - Exenteration removal of the eyelids, the eye, and various amounts of orbital contents; indicated in orbital malignancies or when more conservative modalities of tx have failed or are inappropriate Ocular Prosthesis - Orbital implants and conformers (ocular prostheses usually made of silicone rubber) maintains shape of eye after enucleation or evisceration to prevent contracted, sunken appearance; protects suture line, maintains fornices, prevents contracture of the socket in preparation for the ocular prosthesis, promotes integrity of eyelids - Anophthalmic ocular prosthesis: used in absence of the globe - Eye prosthesis: lasts about 6 years - Healing period: 6-8 weeks Medical Management

Nursing Management 1. Teaching about postsurgical and prosthetic care a. Purpose of large ocular pressure dressing b. Application of ophthalmic topical antibiotic ointment c. Extra caution in ambulation and movement d. Confirmers may accidentally fall out of the socket: if it falls, wash, wipe dry, and place back in socket e. Emotional support 2. Promoting home and community based care a. Insertion, removal, and care for prosthetic eye b. Proper hand washing c. Suction cup if having problems with manual dexterity d. Drape towel over sink and close sink drain to avoid loss of prosthesis 3. Continuing Care a. Daily irrigation of prosthesis with normal solution, hard contact lens solution, or artificial teats b. Dry eye: ophthalmic lubricants or oil-based drops, such as VitE and mineral oil c. Remove crusting and mucous discharge that accumulate at night d. Repositioning of prosthesis with clean fingers e. Remove prosthesis when it becomes uncomfortable, or when there is increased mucous discharge Ocular Consequences of Systemic Disease Diabetic Retinopathy - Leading cause of new cases of blindness in people between 20 and 74 years if age Cytomegalovirus Retinitis - CMV is the most common cause of retinal inflammation in patients with AIDS - S/Sx: floaters, decrease peripheral vision, paracentral or central scotoma, fluctuations in vision from macular edema, thinning and atrophy of the retina and susceptible to retinal tears and breaks - Hemorrhagic: large areas of white, necrotic retina assoc. with retinal hemorrhage - Brushfire: yellow-white margin begins at edge of burned-out atrophic retina, this expands, and if untreated, involves entire retina - Granular: white granular lesion in the periphery of the retina gradually expand; white, feathery infiltration of the retina destroys sensory retina and leads to necrosis, optic atrophy, and retinal detachment Medical Management Pharmacologic Therapy a. Ganciclovir (Cytovene) - IV, oral or intravitreously - 4-mm intraocular implant or insert: surgically placed in the posterior segment of the eye,

and medication diffuses locally to the site of the infection over a period of 5-8 months before insert must be replaced - Can cause neutropenia, thrombocytopenia, anemia, and elevated serum creatinine levels - Complications of inserts: endophthalmitis, retinal detachment, hypotony b. Foscarnet (Foscavir) - Inhibits viral DNA replications - IV or intravitreal injection - Complication: nephrotoxicity with systemic foscarnet - monitor renal function c. Cidofovir (Vistide) - Impedes CMV replication - IV - Delays progression of CMV retinitis - SE: nephrotoxicity, proteinuria, and increased serum creatinine levels AIDS - Highly active antiretroviral therapy (HAART): nucleoside analog (zidovudine) combined with one or more protease inhibitors (ritonavir) - SE: immune recovery uveitis, characterized by intraocular inflammation, cystoids macular edema, and formation of epiretinal membranes - Immune recovery uveitis: injection of corticosteroids into sub-Tenons area of the eye Hypertension-Related Eye Changes - Atherosclerosis associated retinal arteriolar changes: tortuousness, narrowing, and a change in light reflex - Fundoscopic examination reveals copper or silver coloration of the arterioles and venous compression (arteriovenous nicking) at the arteriolar and venous crossings - Intraretinal hemorrhages: flame-shaped; occur in the nerve fiber layer of the retina - HPN as a consequence of pheochromoctyoma, acute renal failure, pregnancy induced HPN cotton-wool spots, retinal hemorrhages, retinal edema, retinal exudates clustered around macula - Profound and abrupt rise in BP and resulting vasoconstriction affects choroid - Ischemia results in serious retinal detachment and infarction of the RPE - Ischemic optic neuropathy and papilledema (swelling of the optic disc due to increased IOP) Concepts in Ocular Medication Administration - Objective: maximize amount of medication that reaches ocular site of action in sufficient concentration to produce beneficial therapeutic effect - Ocular absorption entry of med into the aqueous humor through diff. routes of ocular medication administration Natural Barriers of Absorption:

Limited size of conjunctival sac (can hold only 50L) Corneal membrane barriers Blood-ocular barriers Tearing, blinking, drainage Aqueous solutions are most commonly used; corneal contact time is brief Ophthalmic meds have extended retention time in conjunctival sac and provide higher concentration than eye drops; results in blurred vision after application Contact lenses and collaged shields soaked in antibiotics as alternative delivery methods for treating corneal infections Benzalkonium chloride: prevents growth of organisms and enhances corneal permeability of most medications

Commonly Used Ocular Medications: Topical Anethetics - Proparacaine hydrochloride (Ophthaine 0.5%) and Tetracaine hydrochloride (Pontocaine 0.5%): before diagnostic procedures (tonometry and gonioscopy) and in minor ocular procedures (removal of sutures or conjuctival or corneal scrapings) - Used for severe eye pain to allow patient to open eyes for examination or treatment - Occurs within 20sec to 1 min and last 10-20 mins - Instruct not to rub eyes - Overuse results in corneal softening - Prolonged use can delay wound healing and can lead to permanent corneal opacification and scarring, then visual loss Mydriatics and Cycloplegics - Mydriasis or pupil dilation during surgery andfundus examinations - Mydriatrics potentiate alpha-adrenergic sympathetic effects that result in the relaxation of the ciliary muscle causes pupil dilation - Strong light used during eye examination also stimulates miosis (pupillary contraction) - Cycloplegic medications used to paralyzed the iris sphincter - Instruct about effects: glare and inability to focus properly, difficulty reading (effects can last 3hours to several days) - Advise to wear sunglasses - Can affect CNS: assess for symptoms: increased BP, tachycardia, dizziness, ataxia, confusion, disorientation, incoherent speech, and hallucination - Contraindications: narrow angles or shallow anterior chambers, patients taking monoamine oxidase inhibitors or tricyclic antidepressants Medications Used to Treat Glaucoma - Used to lower IOP by decreasing aqueous production or increasing aqueous outflow - Instruct about ocular and systemic side effects

Affects accommodation of lens and limits light entry through a constricted pupil Affects visual and the ability to focus

Anti-infective Medications - Drops, ointments, subconjunctival or intravitreal injections - Antibiotics: penicillin, cephalosporin, aminoglycosides, fluoroquinolones - Antifungal: amphotericin B (SE: severe pain, conjunctival necrosis, iritis, retinal toxicity) - Antiviral: acyclovir, ganciclovir treatment of ocular infections associated with herpes virus and CMV Corticosteroids and Nonsteroidal Antiinflammatory Drugs - Used in inflammatory conditions of the eyelids, conjunctiva, cornea, anterior chamber, lens and uvea - Less effective in posterior segment diseases that involve posterior sclera, retina and optic nerve - Topical eye drop preparations are suspension shake bottle several times before administering - SE: glaucoma, cataracts, susceptibility to infection, impaired wound healing, mydriasis, and ptosis, high IOP - Prevention of SE: NSAIDs to control inflammatory eye conditions and postoperatively to reduce inflammation Antiallergy Medications - Ocular hypersensitivity: allergic conjunctivitis - Corticosteroids as inflammatory and immunosuppressive agents to control ocular hypersensitivity reactions Ocular Irrigants and Lubricants - Irrigating solutions to cleanse external lids to maintain lid hygiene, to irrigate external corneal surface to regain normal pH, to irrigate corneal surface to eliminate debris, or to inflate the globe intraoperatively - May have sodium, potassium, magnesium, calcium, bicarbonate, glucose, and glutathione - Dacriose sterile irrigating solution for lid hygiene - Normal saline solutions to irrigate corneal surface when chemical burns occur - Lubricants: artificial tears (methyl or hydroxypropyl cellulose) helps alleviate corneal irritation such as dry eye syndrome Nursing Management 1. Ensure proper administration 2. Ensure safety: monitor systemic and local side effects 3. Maintain 1-minute interval between instillation of different types of ocular drops 4. Warn that blurred vision, stinging, burning sensation are symptoms that ordinarily occur 5. Emphasize risk for interactions of ocular medications and systemic medications 6. Hand hygiene techniques

7. Tip of eye drop bottle or ointment tube must never touch any part of the eye 8. Recap medication after use 9. If unable to feel eye drops, refrigerate it because cold drop is easier to detect 10. Maintain 5-minute interval between successive administrations 11. Demonstrate actual eye drop or ointment instillation and punctal occlusion