Topic 14: Eyes

cataracts

opacity within the lens that may occur in one or both eyes

• age

• blunt or penetrating trauma

• smoking

• alcohol use

• ocular inflammation

• DM

what are causes of cataracts

• gradual decrease in vision

• abnormal color perception

• glare due to light scatter of lens opacities that may be worse at night

what are the S/S of cataracts

• change in glasses prescription may improve visual acuity

• strong reading glasses or magnifiers to help with near vision

• increased lighting

• lifestyle adjustment like drinking during day light hours or having someone else drive at night

what does nonsurgical care for cataracts include

• Most have local anesthesia, so no extensive physical assessment

• evaluate and control other medical problems

• usually outpatient

• give 3 eye drops

  • mydriatic

  • cycloplegics

  • NSAID eyedrops

• may receive anti-anxiety meds

• provide information, support, and reassurance about the surgical and post op experience

• reduce light in the room due to photophobia from eyedrops

what does pre op care for a cataract removal surgery include

mydriatic eye drops

alpha adrenergic agonist eyedrops that are given pre op for a cataract surgery that produce pupillary dilation (mydriasis) by contracting the iris dilator muscle

cycloplegic eye drops

anticholinergic eye drops given before cataract surgery that block the effects of acetylcholine on. the ciliary body and iris sphincter, producing pupillary dilation (mydriasis) and acommodation (cycloplegia)

NSAID eyedrops

eyedrops given before cataract surgery that reduce inflammation and pain i

• teach the patient to wear dark glasses to decrease photophobia

• monitor for signs of systemic toxicity like tachycardia and CNS effects

what does nursing management for giving mydriatic and cycloplegic eye drops include

• usually DC as soon as sedative agents wear off

• antibiotic drops to prevent infection

• corticosteroid drops to decrease inflammation

• mild analgesia as needed

• activity restrictions (ones that increase IOP): bending, stooping, coughing, lifting

• nighttime shielding

• visual acuity may be reduced right after surgery

• some may still need glasses/contacts

what does post op care for cataract surgery include

• no proven measures

• wear sunglasses

• avoid unnecessary radiation

• maintain appropriate intake of antioxidant vitamins and good nutrition

what are ways to prevent cataracts

• they are responsible for almost all post op care so give written and verbal instructions before DC

• proper hygiene and eye care techniques to not contamination the eye

• s/s of infection: increased/purulent drainage, increased redness, any decrease in visual acuity

• avoid certain head positions, bending, coughing, valsava maneuver to prevent increased IOP

• how to instill eye meds aseptically and why adherence is important

• how to take pain meds

  • notify HCP of intense pain which may indicate hemorrhage, infection, or increased IOP

• do not scratch the eye, may have some itchiness or blurriness in the operative eye

• importance of continued follow-up

• measures to cope with visual loss: large screens, audiobooks, additional lighting

• if a patch is used take measures to avoid falls and other injuries as depth perception is impaired

what does patient and caregiver teaching after cataract surgery include

• loss of independence

• lack of control

• significant change in self-perception

what impact can cataracts have on older adults

retinopathy

a process of microvascular damage to the retina that can lead to blurred vision and progressive vision loss that may develop slowly or rapidly and occurs most often in adults with DM or HTN

diabetic retinopathy

a common complication of diabetes that can be proliferative or nonproliferative

nonproliferative retinopathy

The MC form of diabetic retinopathy is characterized by capillary microaneurysms, retinal swelling, hard exudates, dot or blot hemorrhaging, and severe loss of central vision

proliferative retinopathy

The severe form of diabetic retinopathy that leads to severe vision loss

hypertensive retinopathy

Retinopathy caused by blockages in retinal BVs from HTN that present as retinal hemorrhages, anoxic cotton wool spots, and macular swelling; can cause sudden vision loss, and treatment involves lowering BP

retinal detachment

a separation of the sensory retina and the underlying pigment epithelium, with fluid accumulation between the 2 layers; an emergency, and if untreated, risk of permanent vision loss or blindness

• age

• AMD

• diabetic retinopathy

• eye surgery or trauma

• family/personal history

• severe myopia

• thinning of peripheral retina

what are the RF for retinal detachment

• flashes of light

• floaters (small flecks)

• cobweb, hairnet, or ring in the field of vision

• once detached: gradual loss of peripheral or central vision, like a curtain coming across the field of vision

• NO PAIN

• visual loss corresponds inversely to the area of detamchet

what are the S/S of retinal detachment

• laser photocoagulation and cryopexy

• scleral bucking

• introcular procedures

what surgical therapies are available to treat retinal detachment

• depends on the extent, length, and area of detachment

• may need to be on bed rest and need special positioning

• level of activity restriction varies

• topical antibiotics, anti-inflammatories, and dilating agents

• pain meds

• may be DC within a few hours or stay a few days

• teach s/s of retinal detachment due to increased risk for it in the other eye

• promote use of protective eyewear

what are the post op consideration after surgery for a retinal detachment

age-related macular degeneration (AMD)

the leading cause of irreversible central vision loss that can be classified as dry (nonexudative) or wet (exudative)

dry (nonexudative) AMD

the MC form of age-related macular degeneration (AMD) in which macular cells begin to atrophy leading to slowly progressive and painless vision loss and will notice that close vision tasks become harder

wet (exudative) AMD

The more severe form of age-related macular degeneration (AMD) that accounts for most causes of AMD-related blindness has a more rapid onset of vision loss and development of abnormal BVs in or near the macula; it often develops from dry AMD

• retinal aging

• family history

• obesity

• HTN

• whites

• smoking

• dry: drusen

• wet: high VEGF

what are the RF for age-related macular degeneration (AMD)

• blurred and darkened vision

• scotomas: blind spots in the visual field

• metamorphopsia: vision distortion like the straight lines are wavy or some objects appear smaller than they really are

• acute vision loss

what are the clinical manifestations of age-related macular degeneration (AMD)

• supplements of antioxidant vitamins (C and E), lutein, zeaxanthin, and zinc

• eat dark green, leafy vegetables containing lutein (kale, broccoli, spinach), beef, pork, dairy, and whole grains that are high in zinc

• smoking cessation

• low vision assistive devices

what does management of age-related macular degeneration (AMD) include

glaucoma

a group of disorders characterized by increased IOP, optic nerve atrophy, and peripheral visual field loss; the 2nd leading cause of permanent blindness in the US, and most people are unaware of the condition; types: primary open angle and angle closure

primary open-angle glaucoma (POAG)

The MC type of glaucoma in which the outflow of aqueous humor is decreased in the trabecular meshwork, so the drainage channel becomes clogged, and damage to the optic nerve results

angle-closure glaucoma (ACG)

glaucoma due to a reduction in the outflow of aqueous humor that results from angle closure, which may be caused by the lens bulging forward from the aging process or papilledema in the patient with anatomically narrow angles

• develops slowly

• no pain or pressure

• doesn’t notice gradual visual field loss until peripheral vision has been severely compromised

• eventually has “tunnel vision” with only a small center visual field with all peripheral vision absent

• optic disc cupping

what are the s/s of primary open-angle glaucoma (POAG)

• sudden, severe pain in or around the eye

• N/V

• sees halos around lights, blurred vision, eye redness, eye or brow pain

what are the s/s of angle-closure glaucoma (ACG)

10-21 mmHg

what is the normal range of IOP

greater than 50 mmHG

what is the range of IOP in angle-closure glaucoma (ACG)

22-32 mmHg

what is the range of IOP in primary open-angle glaucoma (POAG)

• drug therapy

• argon laser trabeculoplasty (ALT) to lower IOP if meds are not successful

• filtration surgery if the drug and ALT are not successful

what are the nursing interventions for primary open-angle glaucoma (POAG)

• carbonic anhydrase inhibitor and oral/IV hyperosmotic agents

• laser/surgical peripheral iridotomy

what is the nursing management for acute angle-closure glaucoma (AACG)

• every 2-4 years between 40-54 y/o

• every 1-3 years between 55-64 y/o

• every 1-2 years for 65 y/o and up

what are the current recommendations for eye exams