Medical Surgical Nursing

Peter Glen L. Reyes, PTRP,

RN,MAN
 Anatomy and Physiology
• Eyes provide a pathway
for visual stimuli.
– External structures of the
eye
2. eyebrows, eyelids and
eyelashes
c. Provides a physical barrier
and protection to dust and
foreign particles.\
d. Distribute tears via
lacrimal glands and ducts
e. Control the amount of
light entering
Copyright JMDairo08
• Layers of the eye
• 1. External layer- the fibrous coat that supports the
eye.
• - Sclera which is the opaque white tissue.”white of
the eye” , forms a tough and protects the intra
ocular structures
• - Cornea- which is a dense transparent portion of
the globe which allows light to enter the eyeball.
is a forward continuation of the sclera and is
transparent and avascular.
• Lacrimal apparatus- located in the upper eyelid,
which provides secretion to moisten the eye and
provides O2 to the cornea. Tears are drained in the
nose
• Extraocular muscles – coordination of the
simultaneous movement of the eyes in the same
direction.

Copyright JMDairo08
• Internal Structures
 Iris – Provides color of the eye
 Pupil – round opening at the
center of the eye allowing light
to enter.
 Symphathetic stimulation
causes dilation of the pupil
 Parasymphathetic causes
constriction of the pupil.
3. Lens – transparent structure
behind the iris; function is to
bend light rays onto retina
4. Retina – lines the inside of the eye,
and is responsible for
converting images into form
that the brain can understand,
includes various layers of nerve
cells, including photo receptors
( Rods and Cones).
 Rods – are stimulated in the
dark environment
 Cones- stimulated to colors in
bright environment.
These rods and cones in the
retina of the eye
Glauco
ma
 Glaucoma
• Is a group ocular Increased intra-ocular pressure
conditions that
characterized by
optic nerve
damage.
• Condition in which
the Intraocular
pressure within the
eyeball is higher
than normal caused
by congestion of
Copyright JMDairo08
 Glaucoma
• Pathophysiology
• - Direct mechanical theory- that high IOP
damages the retinal layer as it passes
through the optic nerve head.
• Indirect Ischemic theory- suggest that IOP
compresses the microcirculation in the optic
head, resulting in cell injury and death.

Copyright JMDairo08
 Risk factor glaucoma
• Family history of glaucoma
• African American race
• Older age
• Diabetes mellitus
• Cardiovascular disease
• Nearsightedness
• Eye trauma
• Prolonged use of topical or systemic
corticosteriods.
Copyright JMDairo08
 Glaucoma
• Classification of Glaucoma
• 1. Open-angle glaucoma the anterior
chamber angle is open and appears normal
• 2. Angle-closure glaucoma the AH
outflow is obstructed due to partial or
complete closure of the angle

Copyright JMDairo08
• Primary open-angle
glaucoma
• a. Occurs when
aqueous fluid does
not drain properly
from the eye related
to pathologic changes
in the trabecular
meshwork of
Copyright JMDairo08
• b. The intraocular pressure increases and
destroys retinal nerve fibers, causing
progressive vision loss in affected areas

• c. Most common type of glaucoma

Copyright JMDairo08
 Canal of
schlemm
Copyright JMDairo08
• Angle -closure
( pupillary block)
glaucoma
- Obstruction in the
aqueous humor
outflow due to the
complete or partial
closure of the angle
from the forward
shift of the peripheral
iris to the trabecula .
Copyright JMDairo08
 GLAUCOMA
• PATHOPHYSIOLOGY
• 1. Direct mechanism direct pressure
damages retina
• 2. indirect mechanism high IOP
compresses the microcirculation in the optic
head resulting to nerve injury and death

Copyright JMDairo08
 Glaucoma

Copyright JMDairo08
 Glaucoma
• Increased intra-ocular pressure

Copyright JMDairo08
 Glaucoma
• ASSESSMENT
• 1. Blurred vision
• 2. halos around the lights
• 3. Loss of peripheral vision
• 4. headache
• 5. discomfort around the eyes

Copyright JMDairo08
Glaucoma stages
• Stages of glaucoma
• 1. Initiating events- Precipitating factors
include illness, emotional stress, congenital
narrow angles, long term use of
corticosteriods and mydratics ( causing
pupillary dilation) that lead to the next
stage.
• 2. Structural alterations in aqueous outflow
system. – Tissue and cellular changes cause
by factors that affect aqueous humor
Copyright JMDairo08
 Glaucoma stages
• 3. Functional alteration- Condition such as
increase intraocular pressure or impaired
blood flow creates functional changes that
lead to the fourth stage.
• 4. Optic nerve damage- Atrophy of the optic
nerve is characterized by loss of nerve fibers
and blood supply
• 5. Visual loss- progressive vision loss is
characterized by visual field defect.
Copyright JMDairo08
 Glaucoma

Copyright JMDairo08
 Glaucoma
• DIAGNOSTIC TEST
• 1. Tonometry to measure the IOP
• 2. Ophthalmoscopy to inspect the optic
nerve
• 3. Gonioscopy to examine the angle
• 4. Perimetry to detect visual field changes

Copyright JMDairo08
 The Heidelberg Retina Tomagraph (HRT3) uses a scanning laser to
create a 3D topography of the optic nerve.
It then compares this very exact image to a database of images with
normal eyes and with statistical analysis determines the likelyhood of glaucoma.
It also can determine if there are any changes over time of the optic nerve
which would indicate glaucoma.
Copyright JMDairo08
 Opthalmoscope

Opthalmoscopy is used to examine the inside of the eye,

especially the optic nerve.
In a darkened room, the doctor will magnify your eye by
using an ophthalmoscope (an instrument with a small light on the
end).

Copyright JMDairo08
Perimetry. The Goldman perimetry test is also called a visual
field test.
No computers are used in this test. During this test, you
will be asked to look straight ahead and then indicate when a
moving light passes your peripheral (or side) vision.
Copyright JMDairo08
 Tonometer

Tonometry is a simple, painless procedure that measures

your intraocular pressure.
It is usually the initial screening test for glaucoma.

Copyright JMDairo08
Gonioscopy is a painless eye test that checks if the angle
where the iris meets the cornea is open or closed, showing if
either open angle or closed angle glaucoma is present.

Copyright JMDairo08
 Glaucoma
• MEDICAL MANAGEMENT
• 1. Laser surgery
• 2. Drug therapy to lower Increased IOP
• A. MiOtics to cause cOnstriction
• B. Adrenergics, beta-blockers to cause
reduced production

Copyright JMDairo08
 Medication for glaucoma
Eyedrops. Glaucoma Alpha-adrenergic agents.
treatment often starts These reduce the
with medicated production of aqueous
eyedrops. humor. Examples include
apraclonidine (Iopidine)
Beta blockers. These and brimonidine
reduce the production (Alphagan). Possible side
of aqueous humor. effects include increased
Side effects can blood pressure; dizziness;
include low blood red, itchy or swollen eyes;
pressure, reduced pulse dry mouth; and allergic
rate, and fatigue. reactions.
Copyright JMDairo08
 medication
Carbonic anhydrase inhibitors. These medications, which include
dorzolamide (Trusopt), reduce the amount of aqueous humor.

Possible side effects include frequent urination and a tingling

sensation in the fingers and the toes, but these occur more
frequently when a carbonic anhydrase inhibitor is taken orally.

Prostaglandin analogues. These eyedrops increase the outflow of

aqueous humor. These hormone-like substances, which include
latanoprost (Xalatan), may be used in conjunction with a drug that
reduces production of aqueous humor.

Copyright JMDairo08
Miotics. Miotics, such as pilocarpine (Isopto Carpine,
Pilocar) increase the outflow of aqueous humor.

Copyright JMDairo08
Different laser surgery for glaucoma
Laser Peripheral Iridotomy (LPI)
Laser Peripheral Iridotomy (LPI) is
used for the treatment of narrow-
angle glaucoma. Narrow-angle
glaucoma occurs when the angle
between the iris and the cornea in
the eye is too small. This causes the
iris to block fluid drainage,
increasing inner eye pressure. LPI
makes a small hole in the iris,
allowing it to fall back from the
fluid channel and helping the fluid
Copyright JMDairo08 drain.
Different laser surgery for glaucoma
Argon Laser Trabeculoplasty
(ALT) is used for the treatment of
primary open angle glaucoma
(POAG). The laser beam opens
the fluid channels of the eye,
helping the drainage system work
better.

Copyright JMDairo08
 Selective Laser Trabeculoplasty is
used for the treatment of primary
open angle glaucoma (POAG).

Copyright JMDairo08
 Glaucoma
• NURSING INTERVENTION
• 1. Teach patient about glaucoma care
• 2. Use of medications can slow the
progression but not cure it
– Information about instilling eye drops
– Information as to the corrective SURGERY to
prevent irreversible blindness!!!

Copyright JMDairo08
 GLAUCOMA
NURSING INTERVENTION
• 3. Reduce anxiety and Agitation
– Familiar, noise free, less stimulating
environment
– Remain calm, and unhurried during agitation
attacks
• Iridotomy, trabeculectomy

Copyright JMDairo08
 Planning/Implementation for
glaucoma

• 1. Explain the importance of continued use

of eye medications as ordered to prevent
further visual loss
• 2. Explain the need for continued medical
supervision for observation of intraocular
pressure to ensure control of the disorder

Copyright JMDairo08
 Planning/Implementation for
glaucoma

• 3. Teach the client to avoid exertion,

stooping, straining for a bowel movement,
coughing, heavy lifting, or wearing
constricting clothing, since these increase
intraocular pressure

• 4. Instruct the client to report severe eye or

brow pain and nausea to the physician
Copyright JMDairo08