Visual problems

Normal IOP =

10-21 mm Hg

Group of disorders characterized by increased IOP and subsequent optic nerve atrophy. Tissue damage starts in the periphery, causing peripheral vision loss

• Incidence increases with age; unaware

• Early detection and tx important to prevent blindness

Glaucoma

• Most common type of glaucoma

• The outflow of aqueous humor is decreased in the trabecular meshwork

• The drainage channels become clogged

• Damage to the optic nerve results

POAG

Pathophysiology of glaucoma

• Aqueous production (inflow) and aqueous reabsorption (outflow) must be balanced to maintain IOP

• Outflow occurs at angle where iris meets cornea

• Inflow > outflow → increased IOP

• Increased IOP → permanent loss of vision

Outflow of aqueous decreased; drainage channels clogged → optic nerve damage

Primary open-angle glaucoma (POAG)

Reduced outflow from angle closure

Angle-closure glaucoma (ACG)

Clinical manifestations of POAG

• Initially asymptomatic (develops slowly w/o sx of pain or pressure)

• Gradual loss of peripheral vision (visual field loss may not be noticeable until severe peripheral vision loss

• Late or untreated: tunnel vision

Clinical manifestations of AACG

• Severe, sudden pain in or around eye

• NV

• Colored halos around lights

• Blurred vision

• Ocular redness (may be mistaken for eye infection)

• A reduction in the outflow of aqueous humor that results from angle closure

• Caused by the lens bulging forward (can occur because of the aging process)

• May occur because of pupil dilation in the patient with anatomically narrow angles

PACG

Acute attack of PACG may be precipitated by:

Prolonged pupil dilation, causing increase in IOP

• Drug-induced mydriasis (ophthalmic and systemic medications)

• Emotional excitement

• Darkness

What can cause prolonged pupil dilation and increase IOP, resulting in an acute PACG attack?

• Drug-induced mydriasis (ophthalmic and systemic medications)

• Emotional excitement

• Darkness

• Check before administering drugs that may cause pupil dilation

POAG IOP →

22-32 mm Hg

AACG →

IOP > 50 mm Hg

Diagnostic studies for glaucoma

• IOP measurement

  • POAG—IOP 22 to 32 mm Hg

  • AACG —IOP > 50 mm Hg

• Slit lamp microscopy

• Visual acuity measurements

• Ophthalmoscope: optic disc cupping

Diagnostic studies for retinal detachment

• Visual acuity measurements

• ophthalmoscope or slit lamp examination

• US

Health promotion for glaucoma:

• Early detection and treatment

• Eye examination: Age 40 to 64 every 2 to 4 years

• Age 65+ every 1 to 2 years

• Blacks—more frequent → ↑ incidence

Postoperative considerations for retinal detachment

• Bedrest/Activity restrictions

• Medications: analgesia and topical

• Patient education

A clouding or opacity within the lens of the eye that distorts the images projected on the retina causing blurred vision.

Cataract

What is the pathophysiology of cataracts?

Caused by an abnormal metabolic process within the lens Water and protein accumulate in the lens fiber structure. This affects lens transparency and vision

What are risk factors for cataracts?

• Advanced age

• Eye trauma

• Congenital infection (i.e., maternal rubella)

• Radiation or UV light exposure (Sun is bad!)

• Long-term corticosteroid use

• Ocular inflammation

What are clinical manifestations of cataracts?

• Decreased vision

• Abnormal color perception

• Glare, especially at night

• No pain or eye redness is associated with age-related cataract formation

No pain or eye redness is associated with age-related cataract formation. True or false?

True

Interprofessional care for age-related macular degeneration:

• Medications injected every 4 to 6 weeks into vitreous cavity to stop new vessel formation and slow vision loss

• Photodynamic therapy (PDT) uses dye and laser to damage abnormal blood vessels

  • Patients must avoid sunlight and intense light for 5 days

• Nutrition: vitamin C and E; beta-carotene, zinc, lutein

• Smoking cessation

What is nursing education for PDT to treat age-related macular degeneration?

Patients must avoid sunlight and intense light for 5 days

What does dietary management of age-related macular degeneration involve?

• Vitamin C and E; beta-carotene, zinc, lutein

• Smoking cessation

Diagnosis of cataracts =

Ophthalmoscope or slit lamp examinatio

Health promotion for cataracts:

• No specific preventative measures

• Wear sunglasses, avoid unnecessary radiation

• Antioxidant vitamins (C and E); adequate nutrition

Intraoperative care for cataracts

• Decrease lighting for photophobia

• Administer abx and corticosteroids

Post-op care for cataracts

Mild analgesia, monitor for complications, understand and adhere to therapy, physical and emotional comfort.

Postoperative phase for cataract care:

• Discharged after sedation wears off

• Post-op medications: abx and corticosteroids drops

• Activity restrictions: avoid IOP such as bending, stooping, coughing, or lifting

• Nighttime shielding

• Follow-up for visual acuity; may or may not need glasses/lenses

Surgical therapy for cataracts in preoperative phase:

• Give anti-inflammatory and pupillary dilating drops

• Mydriatic = alpha-adrenergic agonist → dilation

• Cycloplegic = Anticholinergic—paralysis of accommodation and dilation

• Drug Alert: Patients wear dark glasses to reduce photophobia; monitor for systemic toxicity (tachycardia and CNS effects)

Surgical therapy for cataracts in intraoperative phase:

• Phacoemulsification—ultrasonic vibrations dissolve lens ; fragments are removed

• Extracapsular cataract extraction procedure—remove lens in one piece; requires sutures

• Intraocular lens (IOL) implantation

• Administration of abx and corticosteroids

Nonsurgical therapy for cataracts

• Is only temporary (need surgery to treat)

• prescription eyewear; visual aids; increased light; change lifestyle

A deterioration of the macula (area of central vision) and is related to retinal aging. It is the most common cause of irreversible central vision loss in people over the age of 60.

• Macular cells start to atrophy, leading to a slow, progressive, and painless vision loss

Age-related Macular Degeneration

Predisposing factors to AMD

• Smoking

• HTN

• Caucasian ethnicity

• Family hx of AMD

• Chronic inflammatory conditions

What are clinical manifestations of AMD?

• Blurred and darkened vision

• *Decline in central vision

• *Blind spots in the visual field (scotomas)

• *Distortion of vision (metamorphopsia)

• Acute vision loss (wet AMD)

• Nonexudative

• Atrophy of macular cells

• More common

• Slow, progressive, painless vision loss

Dry AMD

• Exudative

• More severe; abnormal blood vessels develop in or near macula

• Rapid onset of vision loss; AMD related blindness

Wet AMD

Diagnostic studies for AMD

• Visal acuity measurements;

• Ophthalmoscopy

• Amsler grid test

• *Sudden, excruciating pain in or around the eye

• *NV

• *Halos around lights

• Blurred vision

• Ocular redness that may be mistaken for an eye infection

These are clinical manifestations of what condition?

AACG

• Appears gradually

• Hx of *halos around lights, blurred vision and ocular redness, or eye/brow pain

PACG (gradual)

Surgical therapy for retinal detachment:

Surgical therapy—seal retinal breaks

by inflammation/adhesion or scar

• Laser photocoagulation—inflammation

蚠 Cryopexy—freezing  scar

蚠 Scleral Buckling—band placed around globe (Fig. 22-

14

What are post-op considerations for surgery of retinal detachment

• Bedrest/Activity restrictions

• Medications: analgesia and topical

• Patient education

What are clinical manifestations of retinal detachment?

• Photopsia (light flashes)

• Floaters, and cobweb/hairnet or ring in field of vision

• Curtains closing slowly

• Separation of retina and underlying epithelium; fluid accumulation between layers

• Etiology: Breaks—holes (spontaneous) or tears (aging)

Retinal detachment

• Photopsia (light flashes)

• Floaters, and cobweb/hairnet or ring in field of vision

• Curtains closing slowly

These are clinical manifestations of what condition?

Retinal detachment

Intraocular procedures for retinal detachment?

• Pneumatic retinopexy—intravitreal injection of gas to form bubble to close retinal break

• Vitrectomy—removal of vitreous

• Initially asymptomatic (develops slowly w/o sx of pain or pressure)

• Gradual loss of peripheral vision (visual field loss may not be noticeable until severe peripheral vision loss

• Late or untreated: tunnel vision

These are clinical manifestations of what condition?

POAG

• Blurred and darkened vision

• *Decline in central vision

• *Blind spots in the visual field (scotomas)

• *Distortion of vision (metamorphopsia)

• Acute vision loss (wet)

These are clinical manifestations of what condition?

AMD

• Decreased vision

• Abnormal color perception

• Glare, especially at night

• No pain or eye redness is associated with age-related cataract formation

These are clinical manifestations of what condition?

Cataracts