NUR 3105-002 Medical-Surgical Nursing: Sensory Alterations; The Eye and the Ear

Refractive Errors:

Hyperopia: Light is perceived past the focal point

Myopia: Light is not perceived to reach the focal point

Astigmatism: Light scatters and reaches the focal point and elsewhere in the eye

How are Refractive Errors Treated:

Corrective Glasses or Contacts

Anatomy and Where Each Disorder Lives: Cataracts

Affected Anatomy: Lens

Effect: Lens becomes cloudy

Anatomy and Where Each Disorder Lives: Macular Degeneration

Affected Anatomy: Macula

Effect: Macular degenerates

Anatomy and Where Each Disorder Lives: Diabetic Retinopathy

Anatomy Affected: Retinal Vessels

Effect: Vessels leak and occlude

Anatomy and Where Each Disorder Lives: Glaucoma

Drainage is impeded

Anatomy and Where Each Disorder Lives: Retinal Detachment

Anatomy Affected: Retina

Effect: Retina lifts away

Cataract:

The lens clouds, everything dims together

Cataract Presentation:

• Painless, gradual, whole-field blur

• Glare and halos night driving becomes difficult

• Colors fade or yellow

• Frequent prescription changes

• Cloudy lens, dimmed red reflex on exam

Cataract Diagnostic:

• Visual Acuity Test

• Slit-lamp exam,

• Ophthalmoscopy: for red reflex

• Biometry: sizes the implant before surgery

Cataract Risk Factors:

• Aging is most dominant

• Ultraviolet exposure

• Smoking

• Diabetes

• Long-term corticosteroids

• Ocular trauma or prior eye surgery

Management of Cataract:

Remove the lens, Implant a new one

Management of Cataract: Outpatient, Topical Anesthesia

Awake and Sedated, home in hours.

• One eye at a time — never both

Management of Cataract: Phacoemulsification

• Ultrasound breaks the clouded lens apart

  • Fragments are aspirated through a tiny incision

Management of Cataract: Intra-ocular lens implantation

• A synthetic lens sits in the capsule

  • Nothing has to be held in position afterwards (remember this)

Intra-ocular lens implantation: Easiest to teach?

Nothing was left inside that has to be held in place, so there is no positioning order and vision improves within days.

• — retinal detachment repair is the opposite

Management of Cataract: Anticipate orders for?

• Antibiotic and corticosteroid drops on a taper

• Eye shield at night

• Follow-up the next day

• Second eye scheduled separately

Post-Surgery Cataract Teaching: Provider Orders

• Drops exactly on the taper — do not stop early

• Shield at night for about a week

• No heavy lifting (> 5 ibs) or straining

• No swimming, hot tubs, or dusty work

• Confirm the surgeon's own limits — they vary

Post-Surgery Cataract Teaching: Nursing Care and Patient Teaching

• Return demonstration for drops: clean hands, tip touches nothing, one drop, punctal occlusion one minute, five minutes between different drops

• Do not rub or press the eye

• Avoid coughing, sneezing, lifting, bending

• Sunglasses for glare

• Assess dexterity — arthritis or tremor means someone else instills

Post-Surgery Cataract Teaching: Teach Pt’s to Report

• Pain—discomfort is normal

• Vision worsens or suddenly drops

• Purulent drainage or spreading redness

• New flashes, floaters, or a shadow

Post-Surgery Cataract Teaching: Sex Expectations

Vision improves over days, mild scratchiness and light sensitivity are normal, and most patients still need reading glasses.

• Flashes and floaters get taught here too — detachment is a known complication of this surgery.

Macular Degeneration

• Central Vision Loss

The center goes, the edges stay

“ I can still walk the dog, but I can’t read the pill bottle or see my grandson’s face.”

Dry Macular Degeneration

About 85% of Cases

• Drusen accumulate, retinal cells atrophy. Slow, over years.

Wet Macular Degeneration

About 15% of Cases

Vessels leak under the macula. Sudden distortion, rapid loss.

Macular Degeneration: Risk Factors

• Age over 50 - most common

• Smoking - strongest modifiable factor

• Family History

• Hypertension, cardiovascular disease

• Lighter iris pigmentation

Macular Degeneration: Presentation and Workup

• Cannot read or recognize faces

• Straight lines look wavy or bent

• Blank patch wherever they look

• Amsler grid, dilated fundoscopy, OCT

• Fluorescein angiography if leakage is suspected

Macular Degeneration Management: Anticipate Provider Orders

• AREDS2-formula supplementation for intermediate or advanced dry AMD (vitamin supplement)

• Intravitreal anti-VEGF injections on a repeating schedule for wet AMD

• Photodynamic or laser therapy in selected cases

• Low-vision rehabilitation referral

Macular Degeneration Management: Nursing Care and Patient Teaching

• Amsler grid daily, one eye at a time, wearing reading glasses

• Smoking cessation — the highest-yield instruction you have

• Magnifiers, large print, high contrast, strong task lighting

• Label medications by touch or color; verbal identification, not written signage

• Keep every injection appointment — the schedule is the treatment

Macular Degeneration Management: Teach PTs to Report

• New or worsening distortion — same day, not next visit

• A new or enlarging blank patch at center

• Pain, worsening redness, or vision loss after an injection

• Any sudden change in one eye

Safety Profile of Macular Degeneration

- Opposite of Glaucoma

• Peripheral vision is intact, so these patients navigate a room and detect obstacles normally.

• The danger is what they cannot read — medication labels, discharge instructions, warning signs — so build teaching around hearing it, not seeing it.

Diabetic Retinopathy:

Hyperglycemia damages retinal blood vessels

“ My sugars have been high for years but my eyes have never bothered me.”

Diabetic Retinopathy: Mechanism and Stages

1. Chronic hyperglycemia weakens retinal capillaries — they leak, then occlude

2. Nonproliferative: microaneurysms, dot-blot hemorrhages, hard exudates, macular edema

3. Ischemic retina releases VEGF, driving fragile new vessels — proliferative disease

4. Those vessels bleed into the vitreous and pull the retina off

Diabetic Retinopathy: Risk Factors

• Duration of diabetes is the strongest predictor; then glycemic control

• Hypertension, hyperlipidemia, nephropathy, smoking, pregnancy

• Silent until advanced — the leading cause of blindness in working-age adults

Diabetic Retinopathy: Workup

• Dilated exam, optical coherence tomography for edema, fluorescein angiography

Diabetic Retinopathy: Anticipate Provider Orders For:

• Glycemic, blood pressure, and lipid control

• Intravitreal anti-VEGF for macular edema and proliferative disease

• Focal or grid laser; panretinal photocoagulation

• Vitrectomy for vitreous hemorrhage or tractional detachment

Diabetic Retinopathy: Nursing Care and Patient Teaching

• Dilated exam every year, even when vision is normal

• Type 2: at diagnosis. Type 1: within five years, then annually

• Pregnancy needs closer monitoring

•Warn before panretinal laser: it trades peripheral and night vision to save central vision

Diabetic Retinopathy: Teach PTs to Report

• Sudden floaters or a red haze — vitreous hemorrhage

• A curtain or shadow — tractional detachment

• New blurring or distortion of central vision

• Any sudden change in one eye

Glaucoma:

Loss of peripheral Vision

Production never stops, so drainage sets pressure

“My eyes feel fine. They’ve never bothered me at all:

Mechanism of Glaucoma:

1. Ciliary body produces aqueous humor continuously, day and night

2. Drainage is impeded at the trabecular meshwork

3. Intraocular pressure rises; the globe can’t expand

4. Optic nerve axons die; peripheral fibers first

Glaucoma Vision Loss:

• Permanent

  • Dead axons DO NOT REGROW;

• Treatment protects the field that remains; never restores what’s gone

Glaucoma Risk Factors:

• Age over 40

• Family history

• African ancestry

• Diabetes

• Hypertension

• Myopia

• Long-term corticosteroids

• Thin cornea

Glaucoma Diagnostic

• Diagnostics follow the mechanism:

• Tonometry for pressure

• Disc assessment for cupping

• Perimetry for the field

• Gonioscopy for the angle.

Glaucoma: Open Angle (Slow and Silent)

• Angle open; meshwork drains sluggishly

• No symptoms for years

• Painless peripheral loss; tunnel vision late

• Pupil normal, cornea clear

• Cupped disc; pressure often elevated

• Found on routine screening

Glaucoma: Acute Angle-Closure (Sudden and Emergent)

• Iris pushed forward; angle physically sealed

• Sudden severe eye pain and headache

• Halos, blurred vision, red eye

• Fixed mid-dilated pupil, hazy cornea, hard globe

• Nausea and vomiting — often misread as GI

• Triggered by dilation: dim light, mydriatics, anticholinergics

“ My eye is killing me, I’m seeing rainbows around the lights, and I can’t stop throwing up ”

Glaucoma Management: Orders for Open Angle

• Lifelong pressure-lowering drops

• These drugs work by decreasing aqueous production or by increasing outflow (or both)

• Laser trabeculoplasty when drops are not enough

• Trabeculectomy or a drainage shunt for uncontrolled pressure

Glaucoma Management: Orders for Acute Closure

• Emergency pressure reduction with combined topical agents plus systemic acetazolamide or an osmotic agent

•A miotic once pressure falls

•Definitive laser peripheral iridotomy — and usually prophylactic iridotomy in the other eye

Glaucoma Management: What procedures are NOT DOING

No procedure restores lost vision, and patients still need their drops afterward. * Iridotomy treats the anatomy, not the episode

— which is why the other eye gets treated too, since the same shallow angle is there.

Glaucoma Teaching: Anticipate orders for

• Drops continue for life!!! Even after laser or surgery

• Shield and activity limits after filtering surgery — no lifting, bending, or straining

• Every follow-up appointment; pressure is measured

• Screening for first-degree relatives

Glaucoma Teaching: DROP TECHNIQUE — TEACH BY RETURN DEMONSTRATION

1. Wash hands, tilt head back, pull down the lower lid to form a pouch

2. One drop in the pouch; the tip touches nothing

3. Close gently; press the inner corner for one full minute (punctal occlusion)

4. Five minutes between different drops

5. Never skip or stop because the eye feels fine

6. Prostaglandins darken the iris and lengthen lashes — say so first

Glaucoma Teaching: Teach PTs to Report

• New wheezing or shortness of breath

• A pulse that feels slow, dizziness, fainting

• Eye pain or vision change after a procedure

• Running out of drops before the refill

Glaucoma: NURSING JUDGMENT ON A PROVIDER-ORDERED DROP

Timolol is a beta-blocker absorbed systemically through the nasolacrimal duct.

• Hold the dose for a bradycardia or new wheezing, notify the provider, document. That is judgment in administration, not prescribing — and punctal occlusion is what reduces the absorption.

Retinal Detachment:

• Photoreceptors separate from their blood supply

“There's a shade coming down over one eye. It doesn't hurt at all.”

Retinal Detachment: Risk Factors

• High myopia

• Prior cataract surgery

• Aging vitreous

• Blunt or penetrating trauma

• Previous detachment, either eye

• Diabetic retinopathy

Retinal Detachment: Presentation

• A shower of new floaters

• Flashes of light in the periphery

• A curtain or shadow across the field

Retinal Detachment: Workup

• Acuity drops sharply if the macula lifts

• Dilated indirect ophthalmoscopy; ultrasound if the view is blocked

Retinal Detachment: Time

The detached retina is cut off from the choroidal supply beneath it.

Photoreceptors stop signaling within hours, and once the macula lifts, central vision may not fully return even after successful surgery.

Retinal Detachment: Management (Laser or Cryopexy)

Scars the edges of a tear so fluid cannot track underneath. For tears found before detachment.

Retinal Detachment Management: Bubble

A gas bubble is injected to press the retina back. Positioning aims the bubble at the break.

Retinal Detachment Management: Silicone Band

A silicone band indents the wall of the eye inward to meet the detached retina.

Retinal Detachment Management: Virectomy

Vitreous is removed and replaced with gas or oil to tamponade the retina from inside.

Retinal Detachment Management: Anticipate Orders for

• Same-day ophthalmology evaluation and surgical repair

• A specific positioning order after gas tamponade

• Antibiotic and corticosteroid drops

Retinal Detachment Management: Bubble Placement

If a gas bubble was placed, the bubble is the treatment. It only presses where it floats, and because it is a gas, it expands when outside pressure drops.

Teaching after Retinal Detachment Repair: Anticipate orders for

• Face-down or a specific head tilt, exactly as the surgeon specifies

• Most of every hour, day and night, for days to weeks

• No lifting or straining

• Drops as ordered

Teaching after Retinal Detachment Repair: Present Gas Bubble

ABSOLUTELY:

• No air travel and no high-altitude driving

• No nitrous oxide — tell every anesthesia provider

• Medical alert identification until it absorbs

• Only the surgeon says when the bubble is gone

• Plan support at home: positioning wrecks sleep, meals, and toileting

Teaching after Retinal Detachment Repair: Teach PTs to Report:

• Increasing pain or a hard, red eye

• Vision worsening rather than slowly improving

• New flashes, floaters, or a returning shadow

• Drainage or signs of infection

Teaching after Retinal Detachment Repair: Vision after Repair

A dark line or bubble edge lowers over weeks as the gas absorbs.

• Vision returns over weeks to months, not days, and may not return fully if the macula lifted. Positioning is key, even at night when sleeping.

Why is Painless and Painful Vision loss is severe?

The Painful One: Acute angle-closure. Pain, halos, vomiting, fixed mid-dilated pupil. Pressure is strangling the nerve right now.

The Painless One: Retinal detachment. Floaters, flashes, a curtain, no pain at all. Photoreceptors are losing perfusion right now.

Ocular Test NTN: Tenometry

Measures intraocular pressure

• Screens and monitors glaucoma; very high in angle-closure

Ocular Test NTN: Amsler Grid

A grid checked at home, one eye at a time

• Wavy lines or a missing patch; patient-performed monitoring

Nursing Implication: Eye Exam Dilating Drops

Dilating drops blur vision and cause photophobia for hours

• Arramge a driver and sunglasses

• Check angle-closure risk before mydriatics are administered

Disorder of the Canal or Eardrum:

• Conduction hearing loss

Wax, infection, perforation

Disorder of the Ossicles:

• Conduction Hearing Loss

Otosclerosis, fluid

Disorder of the Cochlea:

• Perception hearing loss

Presbycusis, noise, ototoxicity, Ménière's

Disorder of the CN VIII:

• Perception Hearing Loss

Acoustic Neuroma

Conduction

Mechanical

• Vibration carried inward. Blockage or stiffness, and often correctable.

Perception

Neural

• Hair cells and nerve. They do not regenerate — managed, not repaired.

Conductive Hearing Loss

— SOUND CANNOT GET IN

• Lesion: canal, eardrum, or ossicles

• Causes: cerumen impaction, otitis media or effusion, perforation, otosclerosis, foreign body

• All frequencies muffled; volume is the problem

• Own voice sounds loud, so the patient speaks softly

• Often correctable

Sensorineural Hearing Loss:

— SOUND CANNOT BE PROCESSED

• Lesion: cochlear hair cells or CN VIII

• Causes: aging, noise, ototoxic drugs, Ménière's, acoustic neuroma

• High frequencies first; clarity is the problem

• Hears you but cannot understand you in noise

• Not reversible

Sensorineural Hearing Loss: Severity

Sudden one-sided sensorineural hearing loss is an emergency. Patients should seek care immediately.

Ménière's Disease

• Too much Endolymph, attacks that come in waves

“The room spins for two hours, my ear feels full, and then I'm wiped out for a day.”

Ménière's Disease: The attack

• Rotational vertigo, 20 minutes to hours

• Fluctuating low-frequency hearing loss

• Tinnitus

• Fullness or pressure in the ear

• Nausea, vomiting, nystagmus

Usually one ear; often well between attacks

Ménière's Disease: RISK & TRIGGERS

• Age 40 to 60; family history

• Migraine, autoimmune disease

• Triggers: high sodium, caffeine, alcohol, nicotine, stress

Ménière's Disease: Workup

• Audiometry, vestibular testing

• MRI to rule out acoustic neuroma

Ménière's Disease: Anticipate Orders For

• Low-sodium diet as maintenance therapy

• Limit caffeine

• A diuretic to reduce endolymph volume

• Vestibular suppressants and antiemetics for acute attacks

• Intratympanic corticosteroid or gentamicin if refractory

• Surgery — sac decompression, nerve section, labyrinthectomy — last

Ménière's Disease: Teaching — Safety First, Then Control

• At the first fullness or aura, sit or lie down immediately

• Stay still in a quiet, dim room until it passes

• Do not drive, climb, or carry a child when one threatens

• Spread sodium restriction across the whole day

• Limit caffeine, alcohol, nicotine; keep a trigger and attack diary

Ménière's Disease Teaching: Teach PTs to Report

• Attacks becoming more frequent or severe

• Hearing that does not recover between attacks

• New one-sided symptoms

• Falls or injuries during an attack

Ménière's Disease Teaching: Nursing Judgment

Vestibular suppressants sedate.

In an older adult they add fall risk and slow the brain's own compensation, so they are for acute attacks rather than daily use — assess sedation and gait before ambulating a patient who just received one.