Chapter 13: Disorders of the Eye

Chapter 13: Disorders of the Eye

Eye disorders can result from injury, disease processes, or aging

Common eye disorders nurses should recognize:

• Macular degeneration

• Cataracts

• Glaucoma

Macular Degeneration (Age-Related Macular Degeneration, AMD)

Progressive loss of central vision due to damage to the macula

Population: Leading cause of vision loss in older adults

Key Point: No cure

Vision Pattern:

• Central vision loss

• Peripheral vision preserved (important NCLEX distinction

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AMD affects central vision only

Dry = gradual

Wet = fast and severe

Types of Macular Degeneration

Dry Macular Degeneration

• Most common form

• Cause: Gradual blockage of retinal capillary arteries

• Pathophysiology:

  • Reduced blood supply to the macula

  • Ischemia and necrosis from loss of retinal cells

• Progression: Slow, gradual decline in vision

Wet Macular Degeneration

• Less common but more severe

• Cause: Abnormal neovascularization

• Pathophysiology:

  • New blood vessels with thin, fragile walls

  • Leakage of blood and fluid into the retina

• Progression: Rapid vision loss

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AMD affects central vision only

Dry = gradual

Wet = fast and severe

Macular Degeneration Risk Factors

Dry Macular Degeneration

• Smoking (strongest modifiable risk factor)

• Hypertension (vascular damage)

• Female sex

• Short body stature

• Family history

• Diet low in carotene and vitamin E (reduced antioxidant protection)

• Age > 60

• Caucasian race

Wet Macular Degeneration

• Can occur at any age (less age-dependent than dry form)

Macular Degeneration Expected Findings

Loss of depth perception

Objects appear distorted (metamorphopsia)

Blurred vision

Loss of central vision

Blindness (advanced disease)

Macular Degeneration Exams

Diagnostic Procedures

Ophthalmoscopy

• Examines the fundus of the eye, including:

  • Retina

  • Optic disc

  • Macula

  • Blood vessels

Visual Acuity Tests

• Snellen chart (distance vision)

• Rosenbaum chart (near vision)

Macular Degeneration Care

Wet Macular Degeneration Interventions

• Laser therapy to seal leaking blood vessels

• Ocular injections to inhibit abnormal blood vessel growth

  • Anti–endothelial growth factor (anti-VEGF) agents:

    • Bevacizumab

    • Ranibizumab

Client Education

• Encourage intake of foods high in antioxidants, carotene, and vitamins E and B12

• As vision loss progresses, clients may have difficulty:

  • Eating

  • Driving

  • Writing

  • Reading

  • Performing activities of daily living

• Refer clients to community resources for:

  • Transportation assistance

  • Reading devices

  • Large-print books

A nurse is providing teaching for a client who has a new diagnosis of dry macular degeneration. Which of the following instructions should the nurse include in the teaching?

a

Increase intake of deep yellow and orange vegetables.

b

Administer eye drops twice daily.

c

Avoid bending at the waist.

d

Wear an eye patch at night.

Increase intake of deep yellow and orange vegetables.

When taking action, the nurse should instruct the client to increase dietary intake of carotenoids and antioxidants to slow the progression of the macular degeneration.

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A client who has primary open-angle glaucoma should administer eye drops twice daily.

A client who is at risk for increased intraocular pressure, such as following cataract surgery, should avoid bending at the waist.

A client who has had eye surgery, such as cataract surgery, should wear an eye patch at night to protect the eye from injury.

Cataracts

Opacity of the lens that results in impaired vision

Common Causes of Cataracts

Age-Related

• Drying of the lens due to water loss

• Increased lens density from lens fiber compaction

Traumatic

• Blunt or penetrating eye injury

• Foreign body in the eye

• Radiation or ultraviolet light exposure

Toxic

• Long-term use of:

  • Corticosteroids

  • Phenothiazine derivatives

  • Beta blockers

  • Miotic medications

Associated Conditions

• Diabetes mellitus

• Hypoparathyroidism

• Down syndrome

• Chronic sunlight exposure

Complicated (Secondary to Eye Disease)

• Retinitis pigmentosa

• Glaucoma

• Retinal detachment

Health Promotion and Disease Prevention of Cataracts

Teach clients to wear sunglasses outdoors (UV protection)

Educate clients to use protective eyewear during:

• Sports

• Hazardous activities (welding, yard work)

Encourage annual eye examinations

• Especially important for adults over age 40

Cataracts Risk Factors

Advanced age

Diabetes

Heredity

Smoking

Eye trauma

Excessive sun exposure (UV damage)

Chronic medication use, including:

• Corticosteroids

• Phenothiazine derivatives

• Beta blockers

• Miotic medications

Cataracts Expected Findings

Decreased visual acuity

• Frequent prescription changes

• Reduced night vision

• Decreased color perception

Blurred vision

Diplopia (double vision)

Physical Assessment Findings

• Progressive, painless loss of vision (key NCLEX clue)

• Visible lens opacity

• Absent red reflex

A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect?

Select all that apply.

a

Eye pain

b

Floating spots

c

Blurred vision

d

White pupils

e

Bilateral red reflexes

c Blurred vision

d White pupils

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Eye pain is associated with primary angle-closure glaucoma and floating spots are a manifestation associated with retinal detachment.

Bilateral red reflexes are absent in a client who has cataracts.

Cataracts Exams

Diagnostic Procedures

• Ophthalmoscopy

  • Direct visualization of lens opacity

  • Confirms presence of cataracts

Cataracts Care

Assess visual acuity using the Snellen chart

Examine external and internal eye structures with an ophthalmoscope

Determine functional ability related to decreased vision (ADLs, safety)

Increase lighting in the client’s environment

Provide adaptive devices for reduced vision:

• Magnifying lenses

• Large-print books and newspapers

• Talking devices (clocks, watches)

Cataracts Meds

Anticholinergic Agents

• Atropine 1% ophthalmic solution

• Action:

  • Causes mydriasis (pupil dilation)

  • Causes cycloplegia (relaxes ciliary muscles)

• Uses:

  • Preoperative pupil dilation

  • Visualization of internal eye structures

• Nursing Action:

  • Fast onset

  • Long duration of action

Client Education

• Inform clients that medication effects may last 7 to 12 days

• Teach that atropine can cause photosensitivity

  • Instruct to wear sunglasses to protect eyes

Cataracts Therapeutic Procedures

Surgical removal of the lens

• Small incision is made

• Lens removed in one piece or fragmented using sound waves (phacoemulsification)

• Posterior capsule preserved

• Intraocular lens (IOL) implanted

Replacement lens may correct refractive errors, improving vision

Postoperative Nursing Actions

• Focus on:

  • Preventing increased intraocular pressure (IOP)

  • Preventing infection

  • Administering ophthalmic medications

  • Providing pain relief

  • Teaching home self-care and fall prevention

Client Education

• Wear sunglasses outdoors or in bright light (photosensitivity)

• Report signs of infection:

  • Yellow or green drainage

• Avoid activities that increase IOP, including:

  • Bending over at the waist

  • Sneezing

  • Blowing the nose

  • Coughing

  • Straining

  • Head hyperflexion

  • Tight or restrictive clothing (tight collars)

  • Sexual intercourse

• Limit activities, such as:

  • Tilting head back to wash hair

  • Cooking and housekeeping

  • Rapid, jerky movements (vacuuming)

  • Driving or operating machinery

  • Playing sports

• Report pain with nausea or vomiting (possible increased IOP or hemorrhage)

• Expect best vision in 4 to 6 weeks, not immediately

• Report immediately:

  • Lid swelling

  • Decreased vision

  • Bleeding or discharge

  • Sudden sharp eye pain

  • Flashes of light or floating shapes (possible retinal detachment)

Cataracts (Image)

Cataracts Complications

Infection

• Can occur after surgery

• Client education

• Report immediately:

  • Yellow or green drainage

  • Increased redness

  • Eye pain

  • Decreased visual acuity

  • Increased tear production

  • Photophobia (light sensitivity)

Bleeding

• Possible several days after surgery

• Client education:

• Report immediately:

  • Sudden change in vision

  • Increase in eye pain

A nurse is providing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching?

a

“You can resume playing golf in 2 days.”

b

“You need to tilt your head back when washing your hair.”

c

 “You can get water in your eyes in 1 day.”

d

“You need to limit your housekeeping activities.”

D. “You need to limit your housekeeping activities.”

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Do not instruct the client to resume playing golf for several weeks. This could cause a rise in intraocular pressure (IOP) or possible injury to the eye.

Do not instruct the client to tilt the head back when washing their hair. This could cause a rise in IOP or possible injury to the eye.

The client should not get water in their eyes for 3 to 7 days following cataract surgery to reduce the risk for infection and promote healing.

Glaucoma

Disorder of the optic nerve due to increased intraocular pressure (IOP)

Caused by:

• Decreased aqueous humor drainage

• Increased fluid secretion

Leads to optic nerve atrophy and visual field defects

Normal IOP: 10 to 20 mm Hg

Types Glaucoma

Primary Open-Angle Glaucoma (POAG)

• Most common form

• Angle between iris and sclera remains open

• Impaired aqueous humor outflow due to blockage in:

  • Canal of Schlemm

  • Trabecular meshwork

• Results in gradual increase in IOP

• Onset: Slow and painless

Primary Angle-Closure Glaucoma

• Sudden closure of the angle between iris and sclera

• Causes rapid increase in IOP

• Onset: Sudden

• Medical emergency requiring immediate treatment

Secondary Glaucoma

Results from:

• Eye trauma

• Eye surgery

• Eye tumors

• Uveitis or iritis

• Neovascular disorders

• Degenerative disease

• Central retinal vein occlusion

Clinical Importance

• Glaucoma is a leading cause of blindness

• Early diagnosis and treatment are critical to prevent vision loss

Health Promotion and Disease Prevention of Glaucoma

Encourage annual eye examinations

• Especially for adults over age 40

Educate clients on early symptoms, including:

• Gradual vision reduction

• Mild eye pain

Glaucoma Risk Factors

Increasing age

Infection

Eye tumors

Diabetes mellitus

Genetic predisposition

Hypertension

Eye trauma

Severe myopia

Retinal detachment

A nurse is caring for a male older adult client who has a new diagnosis of glaucoma. Which of the following should the nurse recognize as risk factors associated with this disease?

Select all that apply.

a

Sex

b

Genetic predisposition

c

Hypertension

d

Age

e

Diabetes mellitus

b Genetic predisposition

c Hypertension

d Age

e Diabetes mellitus

Glaucoma Expected Findings

Primary Open-Angle Glaucoma

• Headache

• Mild eye pain

• Loss of peripheral vision (tunnel vision)

• Decreased accommodation

• Halos around lights

• Elevated IOP

  • Greater than 20 mm Hg

  • Often 22 to 32 mm Hg

• Onset: Gradual and often asymptomatic early

Primary Angle-Closure Glaucoma

• Rapid onset of markedly elevated IOP

  • ≥ 30 mm Hg

• Decreased or blurred vision

• Colored halos around lights

• Pupils nonreactive to light

• Severe eye pain with nausea

• Photophobia

• Medical emergency

Glaucoma Exams

Visual Assessments

• Measure decreased visual acuity

• Assess peripheral vision loss

Tonometry

• Measures intraocular pressure

• Normal IOP: 10 to 20 mm Hg

• Elevated in glaucoma, especially angle-closure type

Gonioscopy

• Determines drainage angle of the anterior chamber

• Differentiates open-angle vs angle-closure glaucoma

A nurse is caring for a client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases?

a

Cataracts

b

Open-angle glaucoma

c

Macular degeneration

d

Angle-closure glaucoma

Open-angle glaucoma

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A client who has angle-closure glaucoma experiences sudden nausea, severe pain, and halos around lights

A client who has cataracts experiences a decrease in peripheral and central vision due to opacity of the lens.

A client who has macular degeneration experiences a loss of central vision.

Glaucoma Care

Monitor intraocular pressure (IOP)

• Report IOP > 20 mm Hg

Assess for:

• Decreased vision

• Light sensitivity

• Aching or discomfort around the eye

Explain the disease process and allow clients to express concerns

For angle-closure glaucoma, treat severe pain and nausea with:

• Analgesics

• Antiemetics

General Eye Drop Education

• Use medications exactly as prescribed (often every 12 hours)

• Instill 1 drop at a time

• Wait 5 to 10 minutes between different eye drops

• Do not touch the applicator tip to the eye

• Wash hands before and after use

• Use punctal occlusion after instillation

  • Apply gentle pressure to the inner corner of the eye to reduce systemic absorption

Cholinergic Agents

Adrenergic Agonists

Beta Blockers

Carbonic Anhydrase Inhibitors

Prostaglandin Analogs

Systemic Osmotics

Glaucoma Meds

Glaucoma Meds

General Eye Drop Education

• Use medications exactly as prescribed (often every 12 hours)

• Instill 1 drop at a time

• Wait 5 to 10 minutes between different eye drops

• Do not touch the applicator tip to the eye

• Wash hands before and after use

• Use punctal occlusion after instillation

  • Apply gentle pressure to the inner corner of the eye to reduce systemic absorption

Cholinergic Agents

• Examples: Carbachol, Echothiophate, Pilocarpine

• Action: Miotics that constrict the pupil and increase aqueous humor outflow

• Side Effect: Blurred vision

• NCLEX Note: Pilocarpine is a second-line drug for POAG

• Client Education: Use good lighting to prevent falls

Adrenergic Agonists

• Examples: Apraclonidine, Brimonidine tartrate, Dipivefrin

• Action:

  • Decrease aqueous humor production

  • Dilate pupils to improve fluid movement

• Client Education: Wear sunglasses due to pupil dilation

Beta Blockers

• Example: Timolol

• First-line therapy for glaucoma

• Action: Decrease aqueous humor production

• Nursing Considerations:

  • Can be systemically absorbed

  • May cause:

    • Bronchoconstriction (use caution in asthma, COPD)

    • Hypoglycemia masking (use caution in diabetes)

    • Bradycardia and hypotension

Carbonic Anhydrase Inhibitors

• Examples: Acetazolamide, Dorzolamide, Brinzolamide

• Action: Reduce aqueous humor production

• Nursing Action:

  • Assess for sulfa allergy (sulfa-based medications)

Prostaglandin Analogs

• Examples: Bimatoprost, Latanoprost

• Action: Increase aqueous humor outflow via uveoscleral pathway

• Client Education:

  • Do not use if cornea is not intact

  • May cause permanent darkening of iris color with long-term use

Systemic Osmotics

• Examples: IV mannitol, oral glycerin

• Use: Emergency treatment for acute angle-closure glaucoma

• Action: Rapidly decreases IOP by osmotic diuresis

Cholinergic Agents

Examples: Carbachol, Echothiophate, Pilocarpine

Action: Miotics that constrict the pupil and increase aqueous humor outflow

Side Effect: Blurred vision

NCLEX Note: Pilocarpine is a second-line drug for POAG

Client Education: Use good lighting to prevent falls

Adrenergic Agonists

Examples: Apraclonidine, Brimonidine tartrate, Dipivefrin

Action:

• Decrease aqueous humor production

• Dilate pupils to improve fluid movement

Client Education: Wear sunglasses due to pupil dilation

Beta Blockers

Example: Timolol

First-line therapy for glaucoma

Action: Decrease aqueous humor production

Nursing Considerations:

• Can be systemically absorbed

• May cause:

  • Bronchoconstriction (use caution in asthma, COPD)

  • Hypoglycemia masking (use caution in diabetes)

  • Bradycardia and hypotension

Carbonic Anhydrase Inhibitors

Examples: Acetazolamide, Dorzolamide, Brinzolamide

Action: Reduce aqueous humor production

Nursing Action:

• Assess for sulfa allergy (sulfa-based medications)

Prostaglandin Analogs

Examples: Bimatoprost, Latanoprost

Action: Increase aqueous humor outflow via uveoscleral pathway

Client Education:

• Do not use if cornea is not intact

• May cause permanent darkening of iris color with long-term use

Systemic Osmotics

Examples: IV mannitol, oral glycerin

Use: Emergency treatment for acute angle-closure glaucoma

Action: Rapidly decreases IOP by osmotic diuresis

Glaucoma Therapeutic Procedures

Glaucoma Surgery

• Laser trabeculectomy

• Iridotomy

• Shunt placement

Purpose: Improve aqueous humor outflow by opening a drainage channel

Nursing Action

• Emphasize strict medication adherence to prevent optic nerve damage

Client Education

• Wear sunglasses in bright environments

• Report signs of infection:

  • Yellow or green drainage

• Avoid activities that increase IOP:

  • Bending at the waist

  • Sneezing, coughing

  • Straining

  • Head hyperflexion

  • Tight clothing around the neck

  • Sexual intercourse

• Do not lie on the operative side

• Report immediately:

  • Severe eye pain

  • Nausea or vomiting

  • Decreased vision

  • Lid swelling

  • Bleeding or discharge

  • Flashes of light or floating shapes

• Limit activities:

  • Tilting head back to wash hair

  • Housekeeping and cooking

  • Rapid or jerky movements

  • Driving or operating machinery

  • Playing sports

• Best vision expected in 4 to 6 weeks after surgery

Glaucoma Complications

Blindness

• Potential outcome of untreated glaucoma

• Vision loss is irreversible once it occurs

Client Education:

Glaucoma Screening Schedule

• Before age 40: Every 2 to 4 years

• Ages 40 to 54: Every 1 to 3 years

• Ages 55 to 64: Every 1 to 2 years

• Ages 65 and older: Every 6 to 12 month