Eye surgery and problems

What are the four functions of the eye?

Refraction

pupillary

constriction/dilation

convergence

What happens to visual acuity with age?

Visual acuity decreases.

How does the appearance of the eye change with age?

The eye may appear sunken, have arcus senilis, and the sclera may yellow or appear blue.

What effect does aging have on the cornea?

The cornea flattens, which can blur vision and worsen astigmatism.

What happens to ocular muscles as we age?

Ocular muscles weaken.

How does the lens change with age?

The lens loses elasticity, hardens, compacts, and may form a cataract.

What happens to the iris and pupil's ability to adapt to darkness with age?

The iris and pupil decrease in their ability to adapt to darkness.

How does color discrimination change with age?

Color discrimination decreases, particularly for blues, violets, and greens.

What happens to tear production as we age?

Tear production reduces.

assessments include

Physical Hx and demographics, nutrition, family Hx, current vision, psychosocial, physical assessment, diagnostics

Exophthalmos

bulging eyes

ptosis

Drooping lids

Enophthalmos

sunken eyes

anisocoria

unequal pupil size

PERRLA

Pupils, Equal, Round, Reactive to Light and Accomodation

Opthalmoscopy

visualization of the eye's internal structures

Tonometry

the measurement of intraocular pressure

emmetropia

20/20 vision; perfect refraction of the eye

myopia

normal near vision; poor distance vision

hyperopia

poor near vision; normal distance vision

Astigmatism

light rays are not equally refracted d/t uneven curves of the cornea

presbyopia

natural condition that occurs later in life making focusing itself more difficult

refraction

measurement of the focusing characteristics of the eye(s)

cataracts

opaque lenses that distort images

etiology of cataracts

•Can be present at birth, or develop at any time

•Often age-related or caused by trauma or toxic exposure

•Can occur with other diseases and eye disorders

clinical symptoms of cataracts (Subjective)

blurred/double vision

decreased color perception

difficulty seeing at night

progressive/painless loss of vision

Clinical symptoms of cataracts (objective)

progressive loss of vision

visible opacity of the lens

Absent red reflex

Medical management of cataracts

surgery; once visual impairment affects independence/safety

Nursing Management for Cataracts

assess vision changes

assess function

increase light, adaptive devices

emotional support

Preop cataract surgery

consent and clearance

preop eye gtts (several times qday, 2-4 weeks)

ensure anticoagulant medications are stopped before surgery

intraop (cataract surgery)

series of ophthalmic drugs are used to dilate the pupils, cause vasoconstriction and paralysis

local anesthetic is injected into muscle cone behind eye

small incision is made and the affected lens is removed and replaced with an intraocular lens (IOL)

Post op (cataract surgery)

antibx and steroid ointments immediately post op

discharge usually an hour after

Post op expectations (cataracts)

bloodshot, mild itching

post op pt education (cataract surgery)

pain management, protect the eye until healed (light and infection)

eye gtt administration and schedule

activity restrictions

when to notify MD

F/u appointments

what to avoid after cataract surgery

any activy that increases IOP

Serious complications of cataract surgery

increased IOP

Hemorrhage

infection

encourage patient to report what after cataract surgery)

any increasing unresolved pain (especially with nausea), any signs of infection, any decrease in vision. signs of infection

Activities that increase IOP

lie on nonoperative side

rapid or jerky head motions (jogging, dancing, vacuuming)

bending from the waist

lifting heavy objects

sneezing, coughing, blowing nose

straining with BM

sexual intercourse

Wearing restricting clothing

Glaucoma

disorders that result in increased fluid pressure within the eye (IOP)

glaucomoa etiology

usually age related, but higher risks include:

African-Americans >40, and anyone >60 (especially Mexican-Americans)

Family Hx

Adults with high eye pressure, corneal thinness, optic nerve abnormality

Primary open-angle glaucoma (POAG)

drainage is reduced (22-32 mm Hg)

primary angle-closure glaucoma (PACG)

Drainage is blocked (>30 mm Hg)

Glaucoma: nonsurgical management

Focus is early detection, lifelong treatment, close monitoring

Medication treatment of glaucoma

do not improve lost vision but prevent further damage

-reduce ocular pressure

medication adherence is important

PACG may be treated with systemic medications to rapidly reduce IOP

eye gtts

do not improve vision but prevent further damage

-dilate the pupil to improve flow of fluid, decrease production, increase absorption

-need to follow strict schedule

Administration of eye gtts

5-10 minutes between eye gtts

- punctal occlusion immediately after gtts

-hand hygiene

-do not touch eye with applicator tip

glaucoma meds

decrease IOP by production of aqueous humor

adrenergic agonists

Ex. Brimonidine

- cannot be used with MAOI antidepressants

Beta-adrenergic blockers

ex. Btaxolol hydrochloride, Timolol

-use caution with Hx of asthma, and use of oral beta-blockers for HTN

Carbonic Anhydrase Inhibitors

Ex. Brinzolamide, Dorzolamide, oral-acetazolamide and methazolamide

-ask about sulfa allergy

Pupils Constrict

Prostaglandin Agonists and Cholinergic Agonists

-Lower IOP by the outflow of aqueous humor

Surgical management of glaucoma

Laser trabeculoplasty

Trabeculectomy

Iridotomy

Implanted shunt

Laser Traveculoplasty

uses low level beams to selectively make openings in the trabecular meshwork that open new channels for fluid outflow

Trabeculectomy

Creates a drainage hole (small flap) near the edge of the iris that allows aqueous humor to drain

shunt

AH flow through this shunt to be reabsorbed by blood vessels

Post-op glaucoma surgery

outpatient; covered by patch

-will need to instill eye gtts regularly

-hand hygiene, keep applicator tip clean

-avoid activity that increases IOP

Possible complications of glaucoma surgery

Chorodial hemorrhage

chorodial detatchment

Corneal abrasion

A scrape or scratch injury of the cornea

corneal abrasion symptoms

pain, reduced vision, photophobia, eye secretions

-may have cloudy or purulent fluid on eyelids/lashes

Causes of corneal abrasions

contact lens use

trauma

malnutrition

dry eye syndromes

certain cancer therapies

Corneal trauma can lead to

infection --> corneal ulceration = emergency

Fluorescein stain

fluorescent dye applied to the eyeball to view corneal abrasions or ulcers (green)

Keratoconus

Cornea loses its shape --> causes visual impairment

-may be due to - Trauma, inherited disorder, inadequately treated corneal infection

keratoplasty

Corneal transplant --> removal of diseased tissue, replaced with donor cornea

Post op care (Keratoplasty)

Antibiotics; wear protective patch; avoid any activity that increases IOP; monitor for signs of infection; teach proper eye gtt admin; do not use ice on eye

Complications of keratoplasty

Bleeding, wound leakage, infection, graft rejection

Macular degeneration

Deterioration of the macula (area of central vision)

Dry macular degen

slow & gradual - No cure

blockage of retinal capillaries (ischemic/necrotic)

central vision declines (bluring and distortion)

Wet macular degen

Progresses quickly

growth of new blood essels with thin walls leak blood and fluid

distortion of vision

Dry macular degeneration management

no cure - focused on slowing the progression and maximizing quality of life

increase lutein and zeaxanthin

Risk factors: smoking, HTN, diabetes, high cholesterol, >60, Caucasian, family hx, female, poor nutrition

wet Macular degeneration management

lost vision cannot be recovered! can occur at any age

management is focused on slowing the process with:

laser therapy, ocular injections

Retinal tears

break in the retina - can occur with trauma or age

Retinal tear

more jagged and irregularly shaped - traction on the retina

Retinal detatchment

separation of the retina from the epithelium

Posterior vitreous detachment

with aging, vitreous gel often shrinks or thickens, causing it to pull away from retina

manifestations of retinal detachment

sudden visual loss that corresponds with the area of detachment

sudden bright flashes of light (photopsia)

floating dark spots

Curtain pulled over part of eye

Scleral Buckle

repair folds and wrinkles in the retina

-silicone is placed against the sclera and held in place by encircling band to promote reattatchment

-gas or silicone oil is placed inside the eye to promote retinal attachment - float up agains sclera to hold it in place