Transcript for:
Comprehensive Overview of Eye Disorders

angle-closure glaucoma (ACG) A form of glaucoma that can have a sudden onset and is an emergency; characterized by a forward displacement of the iris, which presses against the cornea and closes the chamber angle, suddenly preventing outflow of aqueous humor. Also known as primary angle-closure glaucoma (PACG), closed-angle glaucoma, narrow-angle glaucoma, or acute glaucoma. arcus senilis An opaque, bluish-white ring within the outer edge of the cornea. cataract A lens opacity that distorts the image projected onto the retina. enucleation Surgical removal of the entire eyeball. glaucoma A condition in the eye that occurs with increased pressure and resulting hypoxia of photoreceptors and their synapsing nerve fibers. hyperopia Farsightedness. keratoconus Degeneration of the cornea. keratoplasty Corneal transplant. The surgical removal of diseased corneal tissue and replacement with tissue from a human donor cornea. macular degeneration Degeneration of the macula causing reduced central vision. myopia Nearsightedness. open-angle glaucoma (OAG) The most common form of glaucoma in the United States; characterized by increase in intraocular pressure due to reduced outflow of aqueous humor through the chamber angle. Also known as primary open-angle glaucoma (POAG). photophobia Sensitivity to light. presbyopia Age-related farsightedness. retinal detachment The separation of the retina from the epithelium. retinal hole A break in the retina, often caused by trauma or aging. retinal tear A jagged and irregularly shaped break in the retina, which can result from traction on the retina. secondary glaucoma Type of glaucoma that develops as a result of another health condition or trauma. http://evolve.elsevier.com/Iggy/ PRIORITY CONCEPTS The priority concept for this chapter is: • Sensory Perception The Sensory Perception concept exemplars for this chapter are Cataract and Glaucoma. Vision is often thought of as most important sense. It helps people to assess surroundings; recognize danger; appreciate beauty; function as independently as possible; and work, play and interact with others. Sensory perception is the ability to perceive and interpret sensory input into one or more meaningful responses (see Chapter 3). Changes in the eye and vision can provide information about the patient’s general health status and problems that might occur in self-care. ANATOMY AND PHYSIOLOGY REVIEW Visual sensory perception takes place when the eye and brain work together. Vision begins when light is changed into nerve impulses in the eye and the impulses are sent on to the brain to fully perceive images (Rogers, 2023). Systemic conditions and eye problems can change vision temporarily or permanently. Structure The eyeball, a round, ball-shaped organ, is located in the front part of the eye orbit. The orbit is the bony socket of the skull that surrounds and protects the eye along with the attached muscles, nerves, vessels, and tear-producing glands. Layers of the Eyeball The eye has three layers (Fig. 39.1). The external layer is the sclera (sometimes called the “white” of the eye) and the transparent cornea on the front of the eye. The middle layer, or uvea, is heavily pigmented and consists of the choroid, the ciliary body, and the iris. The choroid, a dark brown membrane between the sclera and the retina, lines most of the sclera. It has many blood vessels that supply nutrients to the retina. The ciliary body connects the choroid with the iris and secretes aqueous humor. The iris is the colored portion of the external eye; its center opening is the pupil. The muscles of the iris contract and relax to control pupil size and the amount of light entering the eye. The innermost layer is the retina, a thin, delicate structure made up of sensory photoreceptors that begin the transmission of impulses to the optic nerve (Rogers, 2023). The retina contains blood vessels and two types of photoreceptors called rods and cones. The rods work at low light levels and provide peripheral vision. The cones are active at bright light levels and provide color and central vision. The optic fundus is the area at the inside back of the eye that can be seen with an ophthalmoscope. This area contains the optic disc, a pinkish-orange or white depressed area where the nerve fibers that synapse with the photoreceptors join together to form the optic nerve and exit the eyeball. The optic disc contains only nerve fibers and no photoreceptor cells. To one side of the optic disc is a small, yellowish pink area called the macula lutea. The center of the macula is the fovea centralis, where vision is most acute. FIG. 39.1 Anatomic features of the eye. Lateral view of cross-section of human eye is divided into two parts as anterior segment and posterior segment (optic fundus) with labels marked as cornea, anterior chamber, canal of Schlemm, iris, ciliary body, conjunctiva, lens, posterior chamber, ciliary body, vitreous body, lateral rectus muscle, retina, choroid, sclera, macula lutea, fovea centralis, optic nerve, optic disc (blind spot), and medial rectus muscle. FIG. 39.2 Flow of aqueous humor. Cross-section of human eye divided into two segments as anterior segment and posterior segment, shows anterior segment further depicted as anterior chamber of the anterior segment and posterior chamber of the anterior segment. Formation of aqueous humor takes places in posterior chamber of the anterior segment flowing toward anterior chamber of anterior segment. Diffusion of fluid and other constituents takes place in vitreous humor. Filtration and diffusion takes place at retinal vessels. Refractive Structures and Media Light waves pass through the cornea, aqueous humor, lens, and vitreous humor on the way to the retina. Each structure bends (refracts) the light waves to focus images on the retina. Together these structures are the eye’s refracting media. The cornea is the clear layer that forms the external bump on the front of the eye (see Fig. 39.1). The aqueous humor is a clear, watery fluid that fills the anterior and posterior chambers of the eye. This fluid is continually produced by the ciliary processes and passes from the posterior chamber, through the pupil, and into the anterior chamber. This fluid drains through the canal of Schlemm into the blood to maintain a balanced intraocular pressure (IOP), the pressure within the eye (Fig. 39.2). The lens is a circular, convex structure that lies behind the iris and in front of the vitreous body. It is transparent and bends the light rays entering through the pupil to focus properly on the retina. The curve of the lens changes to focus on near or distant objects. A cataract is a lens opacity that distorts the image projected onto the retina. The vitreous body is a clear, thick gel that fills the large vitreous chamber (the space between the lens and the retina). This gel transmits light and maintains eye shape. The eye is a hollow organ and must be kept in the shape of a ball for vision to occur. To maintain this shape, the vitreous humor gel in the posterior segment and the aqueous humor in the anterior segment must be present in set amounts that apply pressure inside the eye to keep it inflated. This pressure is the intraocular pressure (IOP). IOP has to be precisely accurate. If the pressure is too low, the eyeball is soft and collapses, preventing light from getting to the photoreceptors on the retina in the back of the eye. If the pressure becomes too high, the extra pressure compresses capillaries in the eye and nerve fibers. Pressure on retinal blood vessels prevents blood from flowing through them; therefore the photoreceptors and nerve fibers become hypoxic. Compression of the fine nerve fibers prevents intracellular fluid flow, which also reduces nourishment to the distal portions of these thin nerve fibers. Glaucoma occurs with increased pressure and resulting hypoxia of photoreceptors and their synapsing nerve fibers. Continued retinal hypoxia results in necrosis and death of photoreceptors, as well as permanent nerve fiber damage. Blindness occurs when photoreceptor and nerve fiber loss occur. External Structures The eyelids are thin, movable skinfolds that protect the eyes and keep the cornea moist. The canthus is the place where the two eyelids meet at the corner of the eye. The conjunctivae are the mucous membranes of the eye. The palpebral conjunctiva is a thick membrane with many blood vessels that lines the undersurface of each eyelid. The thin, transparent bulbar conjunctiva covers the entire front of the eye. A small lacrimal gland, which is located in the upper outer part of each orbit (Fig. 39.3), produces tears. Tears flow across the front of the eye, toward the nose, and into the inner canthus. They drain through the punctum (an opening at the nasal side of the lid edges) into the lacrimal duct and sac and then into the nose through the nasolacrimal duct. Muscles, Nerves, and Blood Vessels Six voluntary muscles rotate the eye and coordinate eye movements (Fig. 39.4 and Box 39.1). Coordinated eye movements ensure that both eyes receive an image at the same time so that only a single image is seen. The muscles around the eye are innervated by cranial nerves (CNs) III (oculomotor), IV (trochlear), and VI (abducens). The optic nerve (CN II) is the nerve of sight, connecting the optic disc to the brain. The trigeminal nerve (CN V) stimulates the blink reflex when the cornea is touched. The facial nerve (CN VII) innervates the lacrimal glands and muscles for lid closure. The ophthalmic artery brings oxygenated blood to the eye and the orbit. It branches to supply blood to the retina. The ciliary arteries supply the sclera, choroid, ciliary body, and iris. Outflow moves through several venous pathways that empty into the superior ophthalmic vein. FIG. 39.3 Front view of the eye and adjacent structures. From Elsevier Animation Gallery Front view of human eye shows labels for pupil, sclera, iris, lacrimal gland, superior punctum, superior canaliculus, inferior canaliculus, inferior punctum, lacrimal sac, nasolacrimal duct, and opening into inferior meatus of nose. FIG. 39.4 Extraocular muscles. (From Elsevier Animation Gallery.) Lateral view of muscles connected to eye shows labels for superior oblique muscle, inferior oblique muscle, superior rectus muscle, inferior rectus muscle, medial rectus muscle, and lateral rectus muscle. Function The four eye functions that provide clear images and vision are refraction, pupillary constriction, accommodation, and convergence. Refraction bends light rays from the outside into the eye through curved surfaces and refractive media and finally to the retina. Each surface and medium bends (refracts) light differently to focus an image on the retina. Emmetropia is the perfect refraction of the eye in which light rays from a distant source are focused into a sharp image on the retina. Fig. 39.5 shows the normal refraction of light within the eye. Images fall on the retina inverted and reversed left to right. For example, an object in the lower nasal visual field strikes the upper outer area of the retina. Errors of refraction are common. Hyperopia (farsightedness) occurs when the eye does not refract light enough. As a result, images converge behind the retina (see Fig. 39.5). In hyperopia, distant vision is normal, but near vision is poor. It is corrected with a convex lens in eyeglasses or contact lenses. Myopia (nearsightedness) occurs when the eye overbends the light and images converge in front of the retina (see Fig. 39.5). Near vision is normal, but distance vision is poor. Myopia is corrected with a concave lens in eyeglasses or contact lenses. Astigmatism is a refractive error caused by unevenly curved surfaces on or in the eye, especially the cornea. These uneven surfaces distort vision. Pupillary constriction (miosis) and pupillary dilation (mydriasis) (Fig. 39.6) control the amount of light that enters the eye. If the level of light to one or both eyes is increased, both pupils constrict (become smaller). The amount of constriction depends on how much light is available and how well the retina can adapt to light changes. Certain drugs can alter pupillary constriction. Box 39.1 Functions of Ocular Muscles Superior Rectus Muscle • Together with the lateral rectus, this muscle moves the eye diagonally upward toward the side of the head. • Together with the medial rectus, this muscle moves the eye diagonally upward toward the middle of the head. Lateral Rectus Muscle • Together with the medial rectus, this muscle holds the eye straight. • Contracting alone, this muscle turns the eye toward the side of the head. Medial Rectus Muscle • Contracting alone, this muscle turns the eye toward the nose. Inferior Rectus Muscle • Together with the lateral rectus, this muscle moves the eye diagonally downward toward the side of the head. • Together with the medial rectus, this muscle moves the eye diagonally downward toward the middle of the head. Superior Oblique Muscle • Contracting alone, this muscle pulls the eye downward. Inferior Oblique Muscle • Contracting alone, this muscle pulls the eye upward. FIG. 39.5 Refraction and correction in emmetropia (A), myopia (B), and hyperopia (C). From Banasik, J. [2022]. Pathophysiology [7th ed.]. St. Louis: Elsevier. A) A normal eye where light rays enter from lens and meet on the fovea of the retina. B) Myopia (nearsightedness): Left: light rays enter from lens and fall on the sides of the fovea of the retina. Right: Corrected: light rays enter lens through a concave lens and meet on the fovea of the retina. C) Hyperopia (farsightedness): light rays enter from lens and meet behind the fovea of the retina. Right: Corrected: light rays enter lens through a convex lens and meet on the fovea of the retina. FIG. 39.6 (A) Miosis. (B) Normal pupils. (C) Mydriasis. (From Elsevier Gmbh, Mensch Körper Krankheit für den Rettungsdienst, 4. Auflage, 2022, Elsevier.) A closeup of right eye shows slightly squinted eye containing a small pupil. A closeup of right eye shows slightly squinted eye containing a small pupil. a normal sized pupil. A closeup of right eye containing a larger sized pupil. The process of maintaining a clear visual image when the gaze is shifted from a distant to a near object is known as accommodation. The healthy eye can adjust its focus by changing the curve of the lens. Convergence is the ability to turn both eyes inward toward the nose at the same time. This action helps ensure that only a single image of close objects is seen. Eye Changes Associated With Aging Visual acuity decreases with age due to changes inside the eye (Touhy & Jett, 2023). Age-related changes of the nervous system and in the eye support structures also reduce visual function PATIENT-CENTERED CARE: OLDER ADULT HEALTH Changes in the Eye and Vision Related to Aging Structure/Function Change Nursing Implications Appearance Eyes appear “sunken.” Do not use eye appearance as an indicator of hydration status. Arcus senilis forms. Reassure that this change does not affect vision. Sclera yellows or appears blue. Do not use sclera to assess for jaundice. Cornea Cornea flattens, which blurs vision and can cause or worsen astigmatism. Encourage having annual eye examinations and wearing prescribed corrective lenses for best vision. Ocular muscles Muscle strength is reduced, making it more difficult to maintain an upward gaze or a focus on a single image. Reassure that this is a normal finding and to refocus gaze frequently to maintain a single image. Lens Elasticity is lost, increasing the near point of vision (making the near point of best vision farther away). Encourage use of corrective lenses for reading. Lens hardens, compacts, and forms a cataract. Emphasize the importance of annual eye examinations. Iris and pupil Decrease in ability to dilate results in small pupil size and poor adaptation to darkness. Teach that good lighting is needed to avoid bumping into objects, tripping, and falling. Color vision Discrimination among greens, blues, and violets decreases. Assess for any color-coded tools that are used for health purposes (e.g., does the patient use a color-coded medication dispenser? If so, it may be difficult to correctly distinguish colors that correspond with doses.) Tears Tear production is reduced, resulting in dry eyes, discomfort, and increased risk for corneal damage or eye infections. Teach the proper use of lubricant eyedrops to reduce dryness. Teach to increase humidity in the home. (see the Patient-Centered Care: Older Adult Health—Changes in the Eye and Vision Related to Aging box). Structural changes occur with aging, including decreased eye muscle tone that reduces the ability to keep the gaze focused on a single object. The lower eyelid may relax and fall away from the eye (ectropion), leading to dry eye signs and symptoms. Arcus senilis, an opaque, bluish-white ring within the outer edge of the cornea, is caused by fat deposits (Fig. 39.7). This change does not affect vision. Fatty deposits cause the sclera to develop a yellowish tinge. A bluish color may be seen as the sclera thins. With age, the iris has less ability to dilate, which leads to difficulty in adapting to dark environments. Older adults may benefit from additional light for reading and other “close-up” work and to avoid tripping over objects. Functional changes also occur with aging. The lens yellows, hardens, shrinks, and loses elasticity, which reduces accommodation. The near point of vision (i.e., the closest distance at which the eye can see an object clearly) increases. Near objects, especially reading material, must be placed farther from the eye to be seen clearly (presbyopia). The far point (i.e., the farthest point at which an object can be distinguished) decreases. Together these changes narrow the visual field of an older adult. General color perception decreases, especially for green, blue, and violet. More light is needed to stimulate the visual receptors. Intraocular pressure (IOP) is slightly higher in older adults. FIG. 39.7 Arcus senilis. From Swartz, M. H. [2021]. Textbook of physical diagnosis: History and examination [8th ed]. St. Louis: Elsevier. Health Promotion/Disease Prevention Impairment of vision impacts physical and psychological well-being and is identified as one of the top 10 disabilities in the United States (Centers for Disease Control and Prevention [CDC], 2022a). Many vision and eye problems can be avoided, and others can be corrected or managed if found early. Teach all adults about eye-protection methods, adequate nutrition that supports eye health, and the importance of regular eye examinations (See the Patient-Centered Care: Health Equity box.). The risks for cataract formation and for cancer of the eye (ocular melanoma) increase with exposure to ultraviolet (UV) light. Teach adults to protect the eyes by using sunglasses that filter UV light whenever they are outdoors, at tanning salons, and when work involves UV exposure. Patient-Centered Care: Health Equity Promoting Eye Health Evidence shows that people with lower levels of education, food insecurity, financial concerns, and health care coverage through Medicaid are more likely to experience vision loss (CDC, 2022b). Advocate for all patients to gain timely access to eye examinations and eye health resources. Vision can be affected by eye injury, which increases the risk for cataract formation and glaucoma. Teach adults to wear eye and head protection when working with particulate matter, fluid or blood spatter, high temperatures, or sparks. Protection should also be worn during participation in sports or any activity that increases the risk for the eye being hit by objects in motion. Teach adults to avoid rubbing the eyes to avoid trauma to outer eye surfaces. Eye infections can lead to vision loss. Although the eye surface is not sterile, the sclera and cornea have no separate blood supply and therefore are at risk for infection. Teach adults to wash their hands before touching the eye or eyelid. Teach patients who use eyedrops about the proper technique to use these drugs and to not share eyedrops with others. If an eye has a discharge, teach the patient to use a separate eyedrop bottle for this eye and to wash the unaffected eye before washing the affected eye. Other health problems, especially diabetes and hypertension, can seriously affect visual sensory perception. Teach patients with these conditions about the importance of controlling blood glucose levels and managing blood pressure to reduce the risk for vision loss. Annual evaluation by an eye care provider is needed to prevent eye complications and detect problems early. See Box 39.2 for specific recommendations about how often patients should be seen by an eye care provider for a general eye examination. Eye care providers may recommend that adults older than 40 years have an eye examination annually that includes assessment of intraocular pressure and visual fields because the risk for both glaucoma and cataract formation increases with age. NURSING SAFETY PRIORITY Action Alert Teach adults to see a health care provider immediately when an eye injury occurs or an eye infection is suspected. NCLEX Examination Challenge 39.1 Health Promotion and Maintenance The nurse is caring for a healthy 54-year-old client presenting for an annual physical. The nurse would recommend that the client have an eye examination how frequently? A. Once every year B. Every 2 to 4 years C. Every 3 to 5 years D. Only when vision problems occur BOX 39.2 Best Practice for Patient Safety and Quality Care Basic Eye Examination Frequency Age Recommended Frequency 20–39 years, in good health with normal vision Once in the 20s and once in the 30s unless there is an instance of visual impairment, infection, injury, eye pain, or diabetes NOTE: For people in this age category who wear contacts, annual examination is recommended. 20–39 years, Black Every 2–4 years 20–39 years, White Every 3–5 years 40–64 years, people of any race Every 2–4 years 65 years and older, people of any race Every 1–2 years People with special risks (e.g., diabetes, eye surgery or trauma, glaucoma) As recommended by the eye care provider (may be more frequent) Adapted from American Academy of Ophthalmology. (2022). Eye exam and vision testing basics. <https://www.aao.org/eye-health/tips-prevention/eye-exams-101>; and PreventBlindness.org. (2022). How often should I have an eye examination? https://www.preventblindness.org/how-often-should-i-have-eye-exam. RECOGNIZE CUES: ASSESSMENT Patient History General History Collect information to determine whether problems with the eye or vision have an impact on ADLs or other daily functions. Age is an important factor to consider when assessing visual sensory perception and eye structure. The incidence of glaucoma and cataract formation increases with aging. Presbyopia commonly begins in the 40s. Sex assigned at birth may be important. Retinal detachments occur more often in men, and dry eye syndromes occur more often in women. Occupation and leisure activities can affect eye health. Ask if the patient uses computers frequently because they may experience eyestrain. Machine operators are at risk for injury because of high speeds at which particles can be thrown at the eye. Chronic exposure to infrared or UV light may cause photophobia and cataract formation. Trauma to the face or head near the eye when playing sports such as baseball can damage external structures, the eye, the connections with the brain, or the area of the brain where vision is perceived. Teach all people to wear eye protection that is in keeping with their chosen occupation or sport. Social habits such as smoking or vaping can be a significant risk factor for developing eye problems. Specifically, airborne formaldehyde can cause burning and watering of the eyes. Inquire about whether a patient smokes or vapes, and collect pertinent history regarding this practice. Box 39.3 Systemic Conditions and Common Drugs Affecting the Eye and Vision Systemic Conditions and Disorders • Cardiac disease • COVID-19 • Diabetes mellitus • HIV-III (AIDS) • Hypertension • Lupus erythematosus • Multiple sclerosis • Pregnancy • Sarcoidosis • Thyroid problems Drugs • Adrenergic agonists • Adrenergic antagonists (beta blockers) • Antibiotics • Anticholinergics • Antihistamines a • Chemotherapy agents • Cholinergic agonists • Corticosteroids a • Decongestants a • Opioids • Oral contraceptives a Prescription and over the counter. Systemic health problems can affect vision. Check whether the patient has any condition listed in Box 39.3. Determine if the patient has, or recently had, conjunctivitis (“pink eye”), as this is one of the initial signs associated with COVID-19 (Gaur & Sarkar, 2022). Also ask if the patient is active duty military or is a veteran of the Armed Forces. These individuals may have experienced eye injury in the line of duty that needs to be further assessed. Ask about past accidents, injuries, surgeries (including laser surgeries), or head trauma that may have led to the present problem. Drugs can also affect vision and the eye (see Box 39.3). Ask about the use of any prescription or over-the-counter drugs, especially decongestants and antihistamines, which cause eye dryness and may increase intraocular pressure. Document the name, strength, dose, and scheduling for all drugs the patient uses. Ocular effects from drugs include itching, foreign body sensation, redness, tearing, photophobia (sensitivity to light), and development of cataracts or glaucoma. Nutrition History Some eye problems are caused or worsened by vitamin deficiencies, so ask the patient about food choices. Vitamin A deficiency can cause eye dryness, keratomalacia, and blindness. Some nutrients and antioxidants, such as lutein, zeaxanthin, and beta carotene, help maintain retinal function (American Optometric Association, 2023a; Mitra et al., 2021). A diet rich in fruits and red, orange, and dark green vegetables is important to eye health. NCLEX Examination Challenge 39.2 Health Promotion and Maintenance The nurse is caring for a client who wishes to take supplements to benefit their eye health. Which of the following supplements would the nurse discuss? Select all that apply. A. Lutein B. Zeaxanthin C. Vitamin C D. Magnesium E. Saw palmetto Family History and Genetic Risk Ask about a family history of eye problems because some conditions have a familial tendency and some genetic problems lead to visual impairment. Current Health Problems Ask the patient about the onset of visual changes. Question whether the change occurred rapidly or slowly. Determine whether the signs and symptoms are present to the same degree in both eyes. If eye injury or trauma is involved, also ask: • How long ago did the injury occur? • What was the patient doing when it happened? • If a foreign body was involved, what was its source? • Was any first aid administered at the scene? If so, what kind, and what other actions were taken? NURSING SAFETY PRIORITY Critical Rescue Recognize that a sudden or persistent loss of visual sensory perception within the past 48 hours, eye trauma, a foreign body in the eye, or sudden ocular pain is an emergency. Respond by notifying the eye care provider immediately. Physical Assessment Inspection Look for head tilting, squinting, or other actions that indicate that the patient is trying to attain clear vision. For example, patients with double vision may cock the head to the side to focus the two images into one, or they may close one eye to see clearly. Assess for symmetry in the appearance of the eyes. Determine whether they are equally distant from the nose, are the same size, and have the same degree of prominence. Assess for their placement in the orbits and for symmetry of movement. Exophthalmos (proptosis) is protrusion of the eye. Enophthalmos is the sunken appearance of the eye. Examine the eyebrows and eyelashes for hair distribution and determine the direction of the eyelashes. Eyelashes normally point outward and away from the eyelid. Assess the eyelids for ptosis (drooping), redness/hyperpigmentation, lesions, or swelling. The lids normally close completely, with the lid edges touching. When the eyes are open, the upper lid covers a small portion of the iris. The edge of the lower lid lies at the iris. No sclera should be visible between the eyelid and the iris. Scleral and corneal assessment requires a penlight. Examine the sclera for color; it is usually white. In patients with light skin, a yellow color may indicate jaundice or systemic problems. In adults with dark skin, the normal sclera may appear yellow; and small, pigmented dots may be visible (Jarvis & Eckhart, 2024). The cornea is best seen by directing a light at it from the side. It should be transparent, smooth, shiny, and bright. Any cloudy areas or specks may indicate injury. Assess the blink reflex by bringing a hand quickly toward the patient’s face. Tell the patient before you do this so they will be aware that you will be making a sudden movement with your hand. Use extreme caution when performing this maneuver, especially with confused patients. Patients with vision will blink. Pupillary assessment involves examining each pupil separately and comparing the results. The pupils are usually round and of equal size, between 3 and 5 mm in diameter. About 20% of adults normally have a noticeable difference in the size of their pupils, which is known as anisocoria (Merck Manual, 2021). Pupil size varies in adults exposed to the same amount of light. Pupils are smaller in older adults, which reduces vision in low light conditions. Patients with myopia have larger pupils, whereas those with hyperopia have smaller pupils. Observe pupils for response to light. Increasing light causes constriction, whereas decreasing light causes dilation. Constriction of both pupils is the normal response to direct light and to accommodation. Assess pupillary reaction to light by asking the patient to look straight ahead while you quickly bring the beam of a penlight in from the side and direct it at the right pupil. Constriction of the right pupil is a direct response to shining the penlight into that eye. Constriction of the left pupil when light is shined at the right pupil is known as a consensual response. Assess the responses for each eye. (You may see the abbreviation “PERRLA” in the electronic health record, which stands for pupils equal, round, reactive to light, and accommodation.) Evaluate each pupil for speed of reaction. The pupil should immediately constrict when a light is directed at it (i.e., a brisk response). If the pupil takes more than 1 second to constrict, the response is sluggish. Pupils that fail to react are nonreactive or fixed. Compare the reactivity speed of right and left pupils and document any difference. Assess for accommodation by asking the patient to focus on a distant object (which dilates the pupils), then place your finger about 3 inches (7–8 cm) from their nose and ask them to focus there (Jarvis & Eckhart, 2024). Pupils should constrict and there should be convergence of the axes of the eyes (Jarvis & Eckhart, 2024). Vision Testing Visual sensory perception is measured by first testing each eye separately and then testing both eyes together. Patients who wear corrective lenses are tested without and with their lenses. The eye care provider usually conducts this type of testing, which includes: • Testing visual acuity to measure distance and near vision • Using the Snellen eye chart to assess distance vision FIG. 39.8 Checking extraocular movements in the six cardinal positions indicates the functioning of cranial nerves III, IV, and VI. From Silvestri, L. A., & Silvestri, A. E. [2023]. Saunders comprehensive review for the NCLEX-RN® Examination [9th ed.]. St. Louis: Elsevier. An illustration of eye shows six cardinal positions as follows: Upwards, towards nasal bridge, caused by inferior oblique, 3; Upwards, away from nasal bridge, caused by superior rectus, 3; Horizontal, towards the nose, caused by medial rectus, 3; Horizontal, away from the nose, caused by lateral rectus, 6; Downwards, towards nostrils, caused by superior oblique, 4; and Downwards, away from nostrils, caused by inferior rectus, 3. FIG. 39.9 An Ishihara color plate for testing color vision. • Using the Rosenbaum Pocket Vision Screener or Jaeger card to assess near vision • Testing for light perception • Testing the visual field for degree of peripheral vision • Assessing extraocular muscle function (Fig. 39.8) and eye alignment • Assessing color vision via Ishihara color plates (Fig. 39.9) Visual acuity in the United States is described in terms of what an average person can see on an eye chart from 20 feet away. For example, 20/20 vision means that the person can see at 20 feet what an average person can see from 20 feet away. Vision that is 20/40 means that the person can see at 20 feet what an average person can see at 40 feet. Only 35% of adults have 20/20 vision without correction, and about 75% of adults achieve 20/20 vision with correction (e.g., glasses, contacts, or surgery) (American Academy of Ophthalmology, 2022). In places outside of the United States, visual acuity is described in terms of what an average person can see on an eye chart that is 6 meters away; the goal is 6/6 vision (American Academy of Ophthalmology, 2022). A person is declared legally blind when the vision is 20/200 or less in the better eye, even with correction (American Academy of Ophthalmology, 2022). Psychosocial Assessment A patient with changes in visual sensory perception may be anxious about possible vision loss. Patients with severe visual defects may be unable to perform ADLs. Dependency from reduced vision can affect self-esteem. Ask patients how they feel about vision changes. Assess available family support, and the patient’s coping techniques. Provide information about local resources and services as needed. Diagnostic Assessment Laboratory Assessment Results of corneal cultures or conjunctival swabs and scrapings can help diagnose infections. If a culture is ordered, obtain a sample of the exudate from the conjunctiva or an ulcerated or inflamed area before antibiotics or topical anesthetics are instilled. Imaging Assessment CT is useful for assessing the eyes, the bony structures around the eyes, and the extraocular muscles. It can also detect tumors in the orbital space. A contrast agent is used unless trauma is suspected. MRI is often used to examine the orbits and optic nerves and to evaluate ocular tumors. It cannot be used to evaluate injuries involving metal in the eyes. Metal in the eye is an absolute contraindication for MRI. Radioisotope scanning is used to locate tumors and lesions. This test requires that the patient sign an informed consent form, and sedation may be used for those who are very anxious. A tracer dose of the radioactive isotope is given orally or by injection, and then the patient must lie still. The scanner measures the radioactivity emitted by the radioactive atoms concentrated in the area being studied. No special follow-up care is required. Ultrasonography is used to examine the orbit and eye with high-frequency sound waves. This noninvasive test helps diagnose trauma, intraorbital tumors, proptosis, and choroidal or retinal detachments. It is also used to determine the length of the eye and any gross outline changes in the eye and the orbit in patients with cloudy corneas or lenses that reduce direct examination of the fundus. Inform the patient that this test is painless. It is performed with the eyes closed or, when the eyes must remain open, with anesthetic eyedrops instilled first. The patient is usually positioned upright with the chin in the chin rest, although the test can be done with the patient lying back. The probe is touched against the patient’s anesthetized cornea, and sound waves are bounced through the eye. The sound waves create a reflective pattern on a computer screen that can be examined for abnormalities. No special follow-up care is needed. Remind the patient not to rub or touch the eye until the anesthetic agent has worn off. Other Diagnostic Assessment Many tests are used to examine specific eye structures when patients have risks, signs and symptoms, or exposures. These tests are performed only by health care providers. Slit-lamp examination magnifies the anterior eye structures (Fig. 39.10). The patient leans on a chin rest to stabilize the head. A narrow beam (slit) of light is aimed so that only a segment of the eye is brightly lit. The eye care provider can then locate the position of any abnormality in the cornea, lens, or anterior vitreous humor. FIG. 39.10 Slit-lamp ocular examination. From deWit, S. C., Stromberg, H. K., & Dallred, C. V. [2017]. Medical-surgical nursing [3rd ed.]. St. Louis: Elsevier. FIG. 39.11 Use of Goldmann applanation tonometer and a slit lamp to measure intraocular pressure. From Friedman, N. J., Kaiser, P., & Pineda, R. [2021]. The Massachusetts Eye and Ear Infirmary illustrated manual of ophthalmology [5th ed.]. St. Louis: Elsevier. Corneal staining consists of placing fluorescein or other topical dye into the conjunctival sac, and then the eye is viewed through a blue filter. The procedure is noninvasive and is performed under aseptic conditions. The dye outlines corneal surface irregularities in a bright green color. This test is used to assess corneal trauma, problems caused by a contact lens, or the presence of foreign bodies, abrasions, ulcers, or other corneal disorders. Tonometry measures intraocular pressure (IOP) with a tonometer, which applies pressure to the outside of the eye until it equals the pressure inside the eye. The thickness of the cornea affects how much pressure must be applied before indentation occurs. Tonometer readings are indicated for all patients older than 40 years of age. Adults with a family history of glaucoma should have their IOP measured once or twice a year. Normal readings range from 10 to 20 mm Hg (Gudgel, 2022). IOP varies throughout the day and typically peaks at certain times of the day. Always document the type and time of measurement. The most common instrument used by eye care providers to measure IOP is the Goldmann applanation tonometer used with a slit lamp (Fig. 39.11). This method involves direct eye contact. Another instrument, the Tono-Pen XL (Fig. 39.12), is designed for use by eye care providers in extended care or long-term care facilities or for other patients unable to be positioned behind a slit lamp. Evidence shows that the Goldmann tonometer remains the most reliable method of IOP assessment (Brusini et al., 2021). FIG. 39.12 The Tono-Pen XL. Courtesy Medtronic Ophthalmics, Minneapolis, MN. Box 39.4 Structures Assessed by Direct Ophthalmoscopy Red Reflex • Presence or absence Optic Disc • Color • Margins (sharp or blurred) • Cup size • Presence of rings or crescents Optic Blood Vessels • Size • Color • Kinks or tangles • Light reflection • Narrowing • Nicking at arteriovenous crossings Fundus • Color • Tears or holes • Lesions • Bleeding Macula • Presence of blood vessels • Color • Lesions • Bleeding Ophthalmoscopy allows viewing of the eye’s external and interior structures with an ophthalmoscope. The health care provider positions the ophthalmoscope to see the patient’s eye through the sight hole. A red reflex is usually seen in the pupil as a reflection of the light off of the retina. An absent red reflex in an adult may indicate a lens opacity or cloudiness of the vitreous. The provider can also examine the retina, optic disc, optic vessels, fundus, and macula with this tool. Box 39.4 lists the features that can be observed in each structure. The use of an ophthalmoscope may raise anxiety in some patients. When working with a patient with confusion or a patient who does not speak the language used at the agency, use an interpreter service to ensure understanding and cooperation with the examination. NURSING SAFETY PRIORITY Action Alert Encourage caution when the health care provider is using an ophthalmoscope with a confused patient or one who does not understand the language spoken at the agency. This can serve to prevent accidental injury to the eye. Fluorescein angiography, which is performed by a health care provider, provides a detailed image of eye circulation. Digital pictures are taken in rapid succession after the dye is given intravenously. This test helps to assess problems of retinal circulation (e.g., diabetic retinopathy, retinal hemorrhage, and macular degeneration) or to diagnose intraocular tumors. Explain the procedure to the patient, check that the patient has signed the informed consent form, and instill mydriatic eyedrops (cause pupil dilation) 1 hour before the test. Teach that the dye may cause the skin to appear yellow for several hours after the test. The stain is eliminated through the urine, which may be green in appearance. Encourage patients to drink fluids to help eliminate the dye. Remind them that any staining of the skin will disappear in a few hours. Instruct the patient to wear dark glasses and avoid direct sunlight until pupil dilation returns to normal because the bright light will cause eye discomfort. Electroretinography (ERG) graphs the retina’s response to light stimulation. This test is helpful in detecting and evaluating blood vessel changes from disease or drugs. The graph is obtained by placing an electrode on an anesthetized cornea. Lights at varying speeds and intensities are flashed, and the neural response is graphed. The measurement from the cornea is identical to the response that would be obtained if electrodes were placed directly on the retina. Gonioscopy is a test performed when a high IOP is found and determines whether open-angle or closed-angle glaucoma is present. It uses a special lens that eliminates the corneal curve, is painless, and allows visualization of the angle where the iris meets the cornea. Optical coherence tomography, ultrasonic imaging of the retina and optic nerve, creates a three-dimensional view of the back of the eye. It is often used in patients with ocular hypertension or who are at risk for glaucoma because of other health problems. SENSORY PERCEPTION CONCEPT EXEMPLAR: CATARACT Pathophysiology Review The lens is a transparent, elastic structure suspended behind the iris that focuses images onto the retina. A cataract is a lens opacity that distorts the image (Fig. 39.13). Cataracts develop usually in the patient’s 50s as the lens thickens (Touhy & Jett, 2023). With time, as lens density increases and transparency is lost, visual sensory perception is greatly reduced. Both eyes may have cataracts, but the rate of progression is different in each eye. Etiology and Genetic Risk Cataracts may be present at birth or develop at any time although most people develop them later in life. They may be age related or caused by trauma or exposure to toxic agents. They also occur with other diseases and eye disorders (Box 39.5). FIG. 39.14 Appearance of an eye with a mature cataract. From Patton, K. T., & Thibodeau, G. A. [2016]. Anatomy and physiology [9th ed.]. St. Louis: Elsevier. Box 39.5 Common Causes of Cataracts Age • Lens water loss and fiber compaction Trauma • Blunt injury to eye or head • Penetrating eye injury • Intraocular foreign bodies • Radiation exposure, therapy Toxin Exposure • Corticosteroids • Phenothiazine derivatives • Miotic agents Health Conditions • Diabetes mellitus • Hypoparathyroidism • Down syndrome • Chronic sunlight exposure Complications • Retinitis pigmentosa • Glaucoma • Retinal detachment Incidence and Prevalence The age-related cataract is the most common type. By age 75, more than half of all Americans have had a cataract (American Academy of Ophthalmology, 2023). Health Promotion/Disease Prevention Although most cases of cataracts in North America are age related, the onset of cataract formation occurs earlier with heavy sun exposure or exposure to other sources of ultraviolet (UV) light. Teach adults to reduce the risk for cataracts by wearing sunglasses that limit exposure to UV light whenever they are outdoors in the daytime. Cataracts also may result from direct eye injury. Urge adults to wear eye and head protection during sports, such as baseball, or any activity that increases the risk for the eye being hit. Individuals who smoke are at higher risk for development of cataracts versus nonsmokers (Boyd, 2022). Interprofessional Collaborative Care Care for the patient with cataracts occurs in the community, apart from the surgical procedure, which takes place in an ambulatory surgical setting. FIG. 39.13 Visual impairment produced by the presence of a cataract. Recognize Cues: Assessment History Age is important because cataracts are most prevalent in the older adult. Ask about these other predisposing factors: • Recent or past trauma to the eye • Exposure to radioactive materials, x-rays, or UV light • Prolonged use of corticosteroids, chlorpromazine, or beta blockers • Presence of intraocular disease (e.g., recurrent uveitis) • Presence of systemic disease (e.g., diabetes mellitus, hypoparathyroidism, hypertension) • Previous cataract, or family history of cataracts • History of smoking, particularly if patient is a veteran, as studies show that cataract incidence is significantly higher among veterans who smoke compared with those who do not smoke (Brown et al., 2023) Ask patients to describe their vision. For example, you might say, “Tell me what you can see well and what you have difficulty seeing.” Physical Assessment/Signs and Symptoms Early signs and symptoms of cataracts include slightly blurred vision and decreased color perception. At first the patient may think that their glasses are smudged, or contacts are not fitting correctly. As lens cloudiness continues, blurred and/or double vision occurs, and the patient may have difficulty with ADLs. Patients commonly report increasing difficulty seeing at night, especially while driving. Without surgical intervention, visual impairment progresses to blindness. No pain or eye redness is associated with age-related cataract formation. Unless a cataract has matured, it is not always visible to the naked eye on examination. Visual sensory perception is tested using an eye chart and brightness acuity testing. The health care provider will examine the lens with an ophthalmoscope and note any observed densities by size, shape, and location. A slit lamp can also be used to visualize the cornea, iris (and space between the cornea and iris), and lens. A retinal examination will also likely be performed to clearly see the back of the eye. As a cataract matures, the opacity makes it difficult to see the retina, and the red reflex may be absent. When this occurs, the pupil is bluish white (Fig. 39.14). Psychosocial Assessment Loss of vision is gradual, and the patient may not be aware of it until reading or driving is affected. The patient may have anxiety about loss of independence. Encourage the patient and family to express concerns about reduced vision. Analyze Cues and Prioritize Hypotheses: Analysis The priority collaborative problem for patients with cataracts is: 1. Impaired visual sensory perception due to cataracts Generate Solutions and Take Actions: Planning and Implementation The priority problem for the patient with cataracts is impaired visual sensory perception, which is a safety risk. Patients often live with reduced vision for years before the cataract is removed. Improving Vision Planning: Expected Outcomes As long as patients do not have cognitive deficits, they are expected to recognize and report when ADLs cannot be performed safely and independently due to cataracts. At that time, surgery is indicated. For patients on Medicare, coverage is provided for (U.S. Department of Health and Human Services, 2023): • A conventional intraocular lens (IOL) that is implanted during cataract surgery • The cost of the facility, health care provider, and supplies needed to perform the surgery with implantation of the conventional IOL • One pair of eyeglasses or contact lenses after each cataract surgery with IOL implantation Interventions Surgery is the only approach to treat cataracts and should be performed as soon as possible after vision is reduced and ADLs are affected. There are two main types of surgery to address cataracts: phacoemulsification (more common) and extracapsular cataract extraction (ECCE). Preoperative Care The eye care provider provides information about the procedure so that the patient can make informed decisions about treatment, and then obtains informed consent. Preoperatively, assess how reduced vision affects ADLs. Teach that care before and after the procedure requires regular self-examination of the eye and possible instillation of different types of eyedrops several times daily for a prescribed period before surgery. In some cases, an ophthalmologist will not prescribe eyedrops before surgery, particularly in the case of dropless cataract surgery (Assil et al., 2020). Advise the patient to clarify with the ophthalmologist whether there is a need, or lack of need, to use them before the procedure. If patients are unable to instill the drops, help them make arrangements for this care. For planning purposes, remind the patient that an adult will need to drive them home from the procedure following cataract surgery. Ask whether the patient takes any drugs that affect blood clotting, such as aspirin, warfarin, clopidogrel, and dabigatran. Communicate this information to the ophthalmologist because these drugs may need to be discontinued in select patients before cataract surgery. Operative Procedures The lens is often extracted by phacoemulsification (Fig. 39.15) (also called phaco). This procedure is usually done with local or topical anesthesia. A probe is inserted through the capsule, and high-frequency sound waves break the lens into small pieces, which are then removed by suction. The replacement intraocular lens (IOL), a small, clear, plastic lens, is placed inside the capsule to be positioned so that light rays are focused in the retina. Some patients have distant vision restored to 20/20 and may need glasses only for reading or close work. Some replacement lenses have multiple focal planes and may correct vision to the extent that glasses or contact lenses may not be needed. FIG. 39.15 Cataract removal by phacoemulsification. In extracapsular cataract extraction (ECCE), which is often used for more advanced cataracts, the cataract is removed in one piece prior to the insertion of the replacement intraocular lens (IOL). Anesthesia around the eye is required to perform this procedure. Sutures are required to close the wound, resulting in a slower recovery compared with phacoemulsification. Postoperative Care Immediately after surgery, antibiotic and steroid ointments are instilled. The patient is usually discharged very soon following surgery, after stabilization and monitoring. Teach to wear dark glasses outdoors or in brightly lit environments until the pupil responds to light. Teach the patient and family members how to instill the prescribed eyedrops. Help them create a written schedule for the timing and the order of eyedrops administration. Remind the patient that vision in that eye will be blurred and to not drive or operate heavy machinery until the ointment is removed. Stress the importance of keeping all follow-up appointments. Remind the patient that mild eye itching is normal, as is a “bloodshot” appearance. The eyelid may be slightly swollen; however, significant swelling or bruising is abnormal. Cool compresses may be beneficial. Discomfort at the site is controlled with acetaminophen or acetaminophen with oxycodone as prescribed. Aspirin is avoided because of its effects on blood clotting. Pain early after surgery may indicate increased intraocular pressure (IOP) or hemorrhage. Instruct patients to contact the ophthalmologist if pain occurs with nausea or vomiting. To prevent increases in IOP, teach the patient and family about activity restrictions. Activities that can cause a sudden rise in IOP are listed in Box 39.6. Infection is a potential and serious complication. Teach the patient and family to observe for increasing eye redness, a decrease in vision, or an increase in tears and photophobia. Creamy white, dry, crusty drainage on the eyelids and lashes is normal. However, yellow or green drainage indicates infection and must be reported. Stress the importance of proper handwashing to reduce the potential for infection. Box 39.6 Activities That Increase Intraocular Pressure • Bending from the waist • Lifting objects weighing more than 10 lb (4.5 kg) • Sneezing, coughing • Blowing the nose • Straining to have a bowel movement • Vomiting • Having sexual intercourse • Keeping the head in a dependent position • Wearing tight shirt collars or ties Patients usually experience a dramatic improvement in vision within a day of surgery. Remind them that final best vision will not occur until 4 to 6 weeks after surgery. NURSING SAFETY PRIORITY Action Alert Instruct the patient who has had cataract surgery to immediately report any reduction of vision in the eye that just had the cataract removed. Care Coordination and Transition Management Patients are usually discharged within an hour or two following cataract surgery. Nursing interventions in that time frame focus on monitoring recovery and teaching. Some patients are prescribed to wear a light eye patch at night to prevent accidental rubbing. Instruct the patient to avoid getting water in the eye for 3 to 7 days after surgery. Patients are prescribed eyedrops to use following surgery; remind them of the importance of adhering strictly to the prescribed administration times. If the patient has difficulty instilling eyedrops, a supportive neighbor, friend, or family member can be taught the procedure. Adaptive equipment that positions the bottle of eyedrops directly over the eye can also be purchased (Fig. 39.16). Many patients are required to come back to the ophthalmologist the day following cataract surgery for a follow-up appointment. Ensure that patients have someone who can drive them to this appointment. Box 39.7 lists items to cover when assessing a patient who returns to the ophthalmologist the day following cataract surgery. Although cataract surgery complications are not anticipated, teach the patient to immediately report any of these symptoms that occur: • Sharp, sudden pain in the eye • Bleeding or increased discharge from the eye • Green or yellow, thick drainage from the eye • Eyelid swelling FIG. 39.16 Autosqueeze, a mechanism for self-administering eyedrops. Courtesy Owen Mumford, Marietta, GA. BOX 39.7 Assessing the Patient After Cataract Surgery • Assess (after the ophthalmologist has removed any dressings): • Visual acuity in both eyes using a handheld eye chart • Visual fields of both eyes • Presence or absence of redness, tearing, and/or draining in the operative eye in comparison with the nonoperative eye • Ask patients if they have: • Pain in or around the operative eye • Any changes in vision (decreased or improved) in the operative eye • Dark spots in their visual field • An increase in the number of floaters • Bright flashes of light in their visual field • Remind the patient of: • Signs and symptoms of complications to report • Drug regimen information • Activity restrictions • Reappearance of a bloodshot sclera after the initial appearance has cleared • Decreased vision in the eye that had surgery • Flashes of light or floating shapes seen in the eye Remind the patient to continue to avoid activities that can increase IOP (see Box 39.6) and to follow any other activity restrictions. Cooking and light housekeeping are permitted, but vacuuming should be avoided for several weeks because of the forward flexion involved and the rapid opposing movements required. Evaluate Outcomes: Evaluation Evaluate the care of the patient with cataracts on the basis of improving visual sensory perception. The expected outcomes include that the patient will have improved visual sensory perception following surgery and recognize signs and symptoms of complications. NCLEX Examination Challenge 39.3 Physiological Integrity Which of the following client statements about instillation of multiple different eyedrops would require the nurse to provide further teaching? Select all that apply. A. “I bought an eyedrop instillation device.” B. “I can instill all of the prescribed eyedrops at one time.” C. “My spouse is going to make a chart showing when drops need to be used.” D. “To avoid contamination and infection, I will not touch the droppers to my eyes.” E. “Labeling eyedrops by numbers can help me easily distinguish which one is which.” SENSORY PERCEPTION CONCEPT EXEMPLAR: GLAUCOMA Pathophysiology Review Glaucoma is a group of eye disorders resulting in increased intraocular pressure (IOP). As described earlier in this chapter, the eye is a hollow organ. For proper eye function, the gel in the posterior segment (vitreous humor) and the fluid in the anterior segment (aqueous humor) must be present in set amounts that apply pressure inside the eye to keep it ball shaped. In adults, the volume of the vitreous humor does not change. However, the aqueous humor is continuously made from blood plasma by the ciliary bodies located behind the iris and just in front of the lens (see Fig. 39.2). The fluid flows through the pupil into the bulging area in front of the iris. At the outer edges of the iris beneath the cornea, blood vessels collect fluid and return it to the blood. Usually about 1 mL of aqueous humor is always present, but it is continuously made and reabsorbed at a rate of about 5 mL daily. A normal IOP requires a balance between production and outflow of aqueous humor (Rogers, 2023). If the IOP becomes too high, the extra pressure compresses retinal blood vessels and photoreceptors and their synapsing nerve fibers. This compression results in poorly oxygenated photoreceptors and nerve fibers. These sensitive nerve tissues become ischemic and die. When too many have died, vision is lost permanently. Tissue damage starts in the periphery and moves inward toward the fovea centralis. Untreated, glaucoma can lead to complete loss of visual sensory perception. Glaucoma is usually painless. The most common type progresses over time, and the patient may be unaware of gradual vision reduction. There are various types of glaucoma (Box 39.8). The most common types are open-angle glaucoma and angle-closure glaucoma. Open-angle glaucoma (OAG), also known as primary open-angle glaucoma (POAG), the most common form of glaucoma, usually affects both eyes and has no signs or symptoms in the early stages. It develops slowly, with gradual loss of visual fields that may go unnoticed because central vision at first is unaffected. Box 39.8 Common Causes of Select Types of Glaucoma Open-Angle Glaucoma • Aging (over 40) • Genetics • Hypertension • Increased intraocular pressure (IOP) Angle-Closure Glaucoma • Increased intraocular pressure (IOP) due to sudden blockage of aqueous humor drainage Secondary Glaucoma • Neovascular glaucoma (formation of new blood vessels on the iris (often occurs with diabetes) • Steroid-induced glaucoma • Trauma (known as traumatic glaucoma) • Uveitis (known as uveitic glaucoma) At times, patients may experience mild eye aching or headaches. Late signs and symptoms occur after irreversible damage to optic nerve function and include seeing halos around lights, losing peripheral vision, and having decreased visual sensory perception that does not improve with eyeglasses. Outflow of aqueous humor through the chamber angle is reduced. Because the fluid cannot leave the eye at the same rate that it is produced, IOP gradually increases. Angle-closure glaucoma (ACG), or primary angle-closure glaucoma (PACG), closed-angle glaucoma, narrow-angle glaucoma, or acute glaucoma, has a sudden onset and is a medical emergency. The problem is a forward displacement of the iris, which presses against the cornea and closes the chamber angle, suddenly preventing outflow of aqueous humor. Secondary glaucoma arises as a result of another health condition or trauma. With secondary glaucoma, a known cause for the change in intraocular pressure is identifiable. Etiology and Genetic Risk Anyone can develop glaucoma. Some adults are at higher risk, such as adults older than 60 (especially Hispanic/Latino individuals), African American people over 40 years of age, and those who have a family history of glaucoma (National Eye Institute, 2022). Incidence and Prevalence Glaucoma is a common cause of blindness in North America. It is usually age related, occurring in about 3 million adults in the United States (CDC, 2020a). Health Promotion/Disease Prevention There are no known ways to prevent glaucoma. The best prevention against damage that glaucoma can cause is for adults to have eye examinations with glaucoma checks done every 2 to 4 years before age 40, every 1 to 3 years between ages 40 and 54, every 1 to 2 years between ages 55 and 64, and every 6 to 12 months over the age of 65 (Glaucoma Research Foundation, 2022c). Interprofessional Collaborative Care Care for the patient with glaucoma generally takes place in the community setting. Members of the interprofessional team who collaborate most closely to care for this patient include the eye care provider and the nurse. For patients who experience psychosocial concerns related to decreased visual sensory perception, collaborate with the mental health provider (see the Interprofessional Collaboration: The Patient With Glaucoma box). INTERPROFESSIONAL COLLABORATION The Patient With Glaucoma The possibility or reality of vision loss can be distressing for patients. Numerous studies have identified a connection between glaucoma and the onset of anxiety and depression. More recent studies have begun to suggest that the anxiety and depression experienced by patients with glaucoma have an impact on the degree and progression of the disorder (Shin et al., 2021). Collaborate with a mental health professional when caring for patients who experience anxiety or depression related to changes in their sight. You can support the patient at regular eye visits, and the mental health professional can provide ongoing counseling and support to the patient during this time of transition. According to the Interprofessional Education Collaborative (IPEC) Expert Panel’s Competency of Roles and Responsibilities, using the unique and complementary abilities of other team members optimizes health and patient care (IPEC, 2016; Slusser et al., 2019). Recognize Cues: Assessment History Ask about visual symptoms that have developed suddenly or over time. Symptoms of acute angle-closure glaucoma include a sudden visual loss, pain, conjunctival erythema, and corneal edema (Jacobs, 2022). In OAG, patients are often asymptomatic in the early stages. The visual fields first show a small loss of peripheral vision that gradually progresses to a larger loss. Physical Assessment/Signs and Symptoms Ophthalmoscopic examination shows cupping and atrophy of the optic disc. It becomes wider and deeper and turns white or gray. The sclera may appear reddened and the cornea foggy. Ophthalmoscopic examination performed by the health care provider reveals a shallow anterior chamber, a cloudy aqueous humor, and a moderately dilated, nonreactive pupil. Diagnostic Assessment An elevated intraocular pressure (IOP) is measured with tonometry. In open-angle glaucoma, the tonometry reading is often between 22 and 32 mm Hg (normal is 8–21 mm Hg [Gudgel, 2022]). In angle-closure glaucoma, the tonometry reading may be 30 mm Hg or higher. Visual field testing by perimetry is performed, as is visualization by gonioscopy to determine whether the angle is open or closed. Usually the optic nerve is imaged to determine to what degree nerve damage is present. Analyze Cues and Prioritize Hypotheses: Analysis The priority collaborative problems for patients with glaucoma include: 1. Impaired visual sensory perception due to glaucoma 2. Need for health teaching due to treatment regimen for glaucoma Generate Solutions and Take Actions: Planning and Implementation Supporting Visual Acuity via Health Teaching Planning: Expected Outcomes With proper intervention, the patient is expected to maintain optimum visual acuity as long as possible by adhering to the treatment regimen. Interventions Nonsurgical Management Teach the patient that loss of visual sensory perception from glaucoma can be prevented by early detection, lifelong treatment, and close monitoring. Use of ophthalmic drugs that reduce ocular pressure can delay or prevent damage. Box 39.9 provides ways to help patients with reduced visual sensory perception to remain as independent as possible. Box 39.10 provides a list of interventions to care for the hospitalized patient or long-term care resident who has impaired vision due to glaucoma. Drug therapy for glaucoma works to reduce IOP in several ways. Eyedrops can reduce the production of or increase the absorption of aqueous humor or constrict the pupil so that the ciliary muscle is contracted, allowing better circulation of the aqueous humor to the site of absorption. These drugs do not improve lost vision but prevent further damage by decreasing IOP. Close adherence to the prescribed dosage schedule is essential to receiving the maximum therapeutic effect of the eyedrops, so teach the patient to be dedicated in the regular timing of administration. Prostaglandins, rho kinase inhibitors, nitric oxides, and miotic or cholinergic agents help drain fluid from the eye, which lowers eye pressure. Alpha-adrenergic agonists, beta blockers, and carbonic anhydrase inhibitors lower the amount of aqueous humor the eye makes. Systemic osmotic drugs such as IV mannitol may be given for angle-closure glaucoma to rapidly reduce IOP. Remind patients that most eyedrops cause tearing, blurred vision, and a reddened sclera for a few minutes after instilling the drug. Some may also cause mild, but temporary, burning. Specific nursing implications related to drug therapy for glaucoma are listed in Table 39.1. Vision rehabilitation is provided by specially trained therapists who teach ways of adaptive living for people with glaucoma and other forms of impaired vision (Glaucoma Research Foundation, 2022b). Certified vision rehabilitation therapists (CVRTs) can help the patient find adaptive ways to maximize their ability to read, use the computer, cook, work, and engage successfully in other ADLs (Duffy, 2021). Certified orientation and mobility specialists (COMSs or O&Ms) work with patients to develop skills to travel safely and independently, use Global Positioning System (GPS) navigation and public transportation, and use long canes (Duffy, 2021). The priority teaching for the patient with glaucoma is about safety. Teach that the benefit of drug therapy occurs only when eye drops are used on the prescribed schedule; therefore patients must instill drops on time and not skip doses. Remind those who wear contact lenses to remove them before instilling eyedrops. BOX 39.9 Patient and Family Education Promoting Independent Living in Patients With Impaired Vision Drug Therapy • Assist with arranging for a neighbor, relative, friend, or home health nurse to visit weekly to organize the proper drugs for each day (if the patient is unable to do so). • If the patient is to take drugs more than once each day, use a container of a different shape (with a lid) each time. For example, if the patient is to take drugs at 9 a.m., 3 p.m., and 9 p.m., the 9 a.m. drugs would be placed in a round container, the 3 p.m. drugs in a square container, and the 9 p.m. drugs in a triangular container. • Place each day’s drug containers in a separate box, with raised letters on the side of the box spelling out the day. • Smartphone apps can be programmed with alarms to remind patients when to take medications (if they are unable to see an analog or digital clock). • Some drug containers have alarms that can be set. Communication • Phones with large, raised block numbers are helpful. Those with black numbers on a white phone or white numbers on a black phone are most easily seen by a patient with low vision. • Smartphones or apps that recognize vocal commands or have a programmable automatic dialing feature (“speed dial”) are very helpful. Programmed numbers should include those for family, friends, neighbors, and 911. Safety • Leave furniture positioned the way the patient has it (due to familiarity). • Eliminate rugs, as these increase the risk for falls. • Appliance cords should be short and kept out of walkways. • Unbreakable dishes, cups, and glasses are preferable to breakable ones. • Cleansers and other toxic agents should be labeled with large, raised letters. Food Preparation • Meals on Wheels America is a service that many older adults appreciate. This service is local, bringing cooked, ready-to-eat meals. During meal delivery, a Meals on Wheels volunteer or staff member performs a basic safety check on the older adult and contacts emergency services or family if needed. The cost of the meal varies, depending on the patient’s ability to pay. Some older adults do not have to pay anything to receive this valuable service. • Many grocery stores and third-party apps offer delivery service. Customers can create a cart online or shop by phone. The store gathers the ordered food. They can have it ready for pickup, give it to a third party for delivery, or deliver it personally depending on services available in different areas. Costs vary; some stores charge for each delivery, whereas others are more affordable by offering an annual subscription fee. • A microwave oven is a safer means of cooking than a standard stove. If the patient has and will use a microwave oven, others can prepare and label meals ahead of time and freeze them for later use. Also, many complete frozen dinners that comply with a variety of dietary restrictions are available to warm in the microwave. • Friends or relatives may be able to help with food preparation. Often relatives do not know what to give an older adult for birthdays or other gift-giving occasions. One suggestion is a homemade prepackaged frozen dinner that the patient enjoys. Personal Care • Handgrips should be installed in bathrooms. • The shower or tub floor should have a nonskid surface. • Patients who shave should use an electric shaver rather than a razor. • Have patients choose a hairstyle that they like and that is easy to care for; this promotes self-care. Home hair-care services are available in some areas. Diversional Activity • Some patients can read large-print books, newspapers, and magazines (available through local libraries and vision services). • Most computers, smartphones, and tablets can adjust text size. This can enhance reading and communication. • Many books, magazines, newspapers, and forms of entertainment are available by audiotape or by streaming. • Card games, dominoes, and some board games are available in large, high-contrast print. BOX 39.10 Best Practice for Patient Safety and Quality Care Care of the Hospitalized Patient or Long-Term Care Resident With Reduced Vision • Always knock or announce your entrance into the patient’s room or area and introduce yourself; ensure that all members of the health care team also use this courtesy of announcement and introduction. • Ensure that the patient’s reduced vision is noted in the electronic health record, communicated to all staff, marked on the call board, and identified on the door of the person’s room. • Determine to what degree the patient can see, and provide opportunities for safe independence in as many ways as possible. • Orient newly hospitalized patients to the environment, counting steps with them to the bathroom and reminding them to call for assistance. • Help the patient place objects on the bedside table; do not move them without the person’s permission. • Remove all obstacles and clutter in walkways, especially to the bathroom. • Ask the newly hospitalized patient what type of assistance is preferred for grooming, toileting, eating, and ambulating; communicate these preferences with staff. • Describe food placement on a plate in terms of a clock face. • Open milk cartons; open salt, pepper, and condiment packages; and remove lids from cups and bowls prior to meals. • Unless the patient also has a hearing problem, use a normal tone of voice when speaking. • When walking with the patient, offer your arm and walk a step ahead. TABLE 39.1 Common Examples of Drug Therapy (Eyedrops) Glaucoma Drug Category Selected Nursing Implications Adrenergic Agonists Apraclonidine Brimonidine tartrate Ask whether the patient is taking any antidepressants from the MAOI class. These enzyme inhibitors increase blood pressure, as do the adrenergic agonists. When these agents are taken together, the patient may experience hypertensive crisis. Teach the patient to wear dark glasses outdoors and to avoid too much sunlight exposure. This type of drug can cause the eyes to become sensitive to light. Teach the patient not to use the eyedrops with contact lenses in place and to wait 15 minutes after using the drug to put in contact lenses, if worn. These drugs are absorbed by the contact lens, which can become discolored or cloudy. Beta-Adrenergic Blockers Betaxolol hydrochloride Carteolol Levobunolol Timolol Ask whether the patient has moderate-to-severe asthma or COPD. If these drugs are absorbed systemically, they constrict pulmonary smooth muscle and narrow airways. Teach patients with diabetes to check their blood glucose levels more often when taking these drugs. These drugs induce hypoglycemia and can mask the hypoglycemic symptoms. Teach patients who also take oral beta blockers to check their pulse at least twice per day and to notify the primary health care and eye care providers if the pulse is consistently below 60 beats/min. These drugs potentiate the effects of systemic beta blockers and can cause an unsafe decrease in heart rate and blood pressure. Carbonic Anhydrase Inhibitors Brinzolamide Dorzolamide Ask whether the patient has an allergy to sulfonamide antibacterial drugs. Drugs are similar to the sulfonamides; if a patient is allergic to the sulfonamides, an allergy is possible with these drugs. Teach the patient to shake the drug before applying. Drug separates on standing. Teach the patient to not use the eyedrops with contact lenses in place and to wait 15 minutes after using the drug to put in the lenses. These drugs are absorbed by the contact lens, which can become discolored or cloudy. Cholinergic Agonists Carbachol Echothiophate Pilocarpine Teach to not administer more eyedrops than are prescribed and to report increased salivation or drooling to the primary health care and eye care providers. These drugs are readily absorbed by conjunctival mucous membranes and can cause systemic side effects of headache, flushing, increased saliva, and sweating. Teach to use good light when reading and to turn lights on in rooms. The pupil of the eye will not open more to let in more light, and it may be harder to see objects in dim light. This can increase the risk for falls. Nitric Oxide Latanoprostene bunod Teach to refrain from driving and using machinery while using this medication. This drug can cause blurred vision. Prostaglandin Agonists Bimatoprost Latanoprost Tafluprost Travoprost Teach to check the cornea for abrasions or trauma. Drugs should not be used when the cornea is not intact. Teach that eye color may darken, and eyelashes elongate, over time in the eye receiving one of these drugs. Knowing the side effects in advance reassures the patient that their presence is expected and normal. If only one eye is to be treated, teach not to place drops in the other eye to try to make the eye colors similar. Using the drug in an eye with normal IOP can cause a lower-than-normal IOP, which reduces vision. Caution that using more drops than prescribed can reduce drug effectiveness. Drug action is based on blocking receptors, which can increase in number when the drug is overused. Rho Kinase Inhibitors Netarsudil If the patient is dispensed a multiple-dose container, caution about cross-contamination. Reports of bacterial keratitis have arisen when patients with other disorders (e.g., a concurrent corneal disorder) have accidentally contaminated the medication. Combination Drug Brimonidine tartrate and timolol maleate Same as for each drug alone. COPD, Chronic obstructive pulmonary disease; MAOI, monoamine oxidase inhibitor. When more than one drop is prescribed, teach the patient to wait 5 to 10 minutes between drug instillations to prevent one drug from diluting another drug. Stress the need for good handwashing, keeping the eyedrop container tip clean, and avoiding contact of the tip to any part of the eye. Explain potential interactions that may exist between medications and systemic effects that may occur when using these drugs. Also teach the technique of punctal occlusion (placing pressure on the corner of the eye near the nose) immediately after eyedrop instillation to prevent systemic absorption of the drug (Fig. 39.17). FIG. 39.17 Apply punctal occlusion in the circled area to prevent systemic absorption of eyedrops. Used with permission from istockphoto.com, 2020, VectorMine. An illustration of eye shows labels as follows: Eyelid, upper punctum, plica semilunaris, caruncle, superior lacrimal canal, lacrimal sac, lacrimal duct, lower punctum, inferior lacrimal canal, pupil, iris, sclera, eyelashes, lacrimal gland duct, and lacrimal gland. NURSING SAFETY PRIORITY Drug Alert Many eyedrops used for glaucoma therapy can be absorbed systemically and cause systemic problems. It is critical to teach punctal occlusion to patients using eyedrops for glaucoma therapy in order to minimize systemic absorption (see Fig. 39.17). Surgical Management Surgery can be performed when eyedrops for open-angle glaucoma are not effective at controlling IOP. A laser trabeculoplasty burns the trabecular meshwork, scarring it and causing the meshwork fibers to tighten. Tight fibers increase the size of the spaces between the fibers, improving outflow of aqueous humor and reducing IOP. If glaucoma fails to respond to eyedrops and laser trabeculoplasty, an implanted shunt procedure (called tube shunt surgery) may be used. A small tube or filament is connected to a flat plate that is positioned on the outside of the eye in the eye orbit. The open part of the fine tube is placed into the front chamber of the eye. The fluid then drains through or around the tube into the area around the flat plate, where it collects and is reabsorbed into the bloodstream. Potential complications of glaucoma surgery include choroidal hemorrhage and choroidal detachment. If laser trabeculoplasty and tube shunt surgery do not work, cyclophotocoagulation laser treatment may be done. This procedure causes the ciliary processes to shrink, which results in less production of aqueous humor and therefore lower IOP. Laser peripheral iridotomy (LPI) is the first line of treatment for angle-closure glaucoma. A hole is created in the outer edge of the iris, which opens the angle in most patients; then the trabecular meshwork is exposed, and fluid can drain (Glaucoma Research Foundation, 2022a). Care Coordination and Transition Management Patients with glaucoma will need to instill eyedrops regularly as part of home care. If they are unable to instill or resistant to instilling their own eyedrops, teach the caregiver the proper technique or recommend adaptive equipment (see Fig. 39.16). The patient will be seen as an outpatient every 1 to 3 months at the recommendation of the ophthalmologist, depending on how well controlled the IOP is. Teach the importance of good handwashing and keeping the tip of the eyedrop container clean. Remind the patient to instill eyedrops on time as recommended by the ophthalmologist and to not skip doses. For the patient who had surgical management, teach the signs and symptoms of choroidal detachment and hemorrhage. These can occur during or after coughing, sneezing, straining at stools, or Valsalva maneuver. Serous detachment involves some degree of vision loss yet is usually painless. Hemorrhagic detachment involves an immediate loss of vision with sudden, excruciating, throbbing pain. Any vision loss, particularly when accompanied by pain, should be reported immediately to the eye care provider. If needed, refer the patient to care services that can assist in the home. Support groups for individuals with vision impairment may also be helpful. Evaluate Outcomes: Evaluation Evaluate the care of the patient with glaucoma based on the identified priority patient problem. The primary expected outcome is that the patient will have optimum visual acuity as long as possible, as demonstrated by adherence to the treatment regimen. CORNEAL DISORDERS For a sharp retinal image, the cornea must be transparent and intact. Corneal problems may be caused by inflammation of the cornea (keratitis), degeneration of the cornea (keratoconus), or deposits in the cornea. All corneal problems reduce visual sensory perception, and some can lead to blindness. CORNEAL ABRASION, ULCERATION, AND INFECTION Pathophysiology Review A corneal abrasion is a scrape or scratch injury of the cornea. This painful condition can be caused by a small foreign body, trauma, contact lens use, malnutrition, dry eye syndromes, and certain cancer therapies. The abrasion allows organisms to enter, leading to corneal infection. Bacterial, protozoal, and fungal infections can lead to corneal ulceration, a deeper injury. This problem is an emergency because the cornea has no separate blood supply, and infections that can permanently impair vision develop rapidly. Interprofessional Collaborative Care The patient with a corneal disorder has pain, reduced vision, photophobia, and eye secretions. Cloudy or purulent fluid may be present on the eyelids or lashes. Care for patients with a corneal disorder usually takes place in the community setting. Members of the interprofessional team who collaborate most closely to care for this patient include the eye care provider or family health care provider, and the nurse. Recognize Cues: Assessment Wear gloves when examining the eye. Anticipate the cornea to look hazy or cloudy with a patchy area of ulceration. When fluorescein stain is used, the patchy area appears green. Corneal scrapings (done by an eye care provider after anesthetizing the cornea with a topical agent) and microbial cultures are used to determine the causative organism. For culture, obtain swabs from the ulcer and its edges. Take Actions: Interventions Antiinfective therapy is started before the organism is identified because of the high risk for vision loss. A broad-spectrum antibiotic is prescribed first and may be changed when culture results are known. Steroids may be used with antibiotics to reduce the eye inflammation. Drugs can be given topically as eyedrops or injected subconjunctivally or intravenously. The nursing priorities are to begin the drug therapy, to ensure patient understanding of the drug therapy regimen, and to prevent infection spread. Often the antiinfective therapy involves instilling eyedrops every hour for the first 24 hours. Teach the patient or family member how to instill the eyedrops correctly. If the eye infection occurs only in one eye, teach the patient not to use the drug in the unaffected eye. Reinforce the importance of handwashing after touching the affected eye and before touching or doing anything to the healthy eye. If both eyes are infected, separate bottles of drugs are needed for each eye. Teach the patient to clearly label the bottles “right eye” and “left eye” and not to switch the drugs from eye to eye. Remind the patient not to wear contact lenses during the entire time that these drugs are being used because the eye is more vulnerable to infection or injury, and the drugs can cloud or damage the contact lenses. NURSING SAFETY PRIORITY Action Alert Teach the importance of applying eyedrops as often as prescribed, even at night, and to complete the entire course of antibiotic therapy. Treating the infection can save the vision in the infected eye. Remind the patient to make and keep all follow-up appointments. Drug therapy may continue for weeks to ensure eradication of the infection. Teach patients to avoid using makeup around the eye until the infection has cleared. Instruct them to discard all open containers of contact lens solutions and bottles of eyedrops because these may be contaminated. Patients should not wear contact lenses for weeks to months until the infection is gone and the ulcer is healed. NURSING SAFETY PRIORITY Drug Alert Check the route of administration for ophthalmic drugs. Most are administered by the eye instillation route, not orally. Administering these drugs orally can cause systemic side effects and will not therapeutically treat the eye condition. Be sure to reinforce the correct route when teaching the patient. KERATOCONUS Pathophysiology Review The cornea can permanently lose its shape, become scarred or cloudy, or become thinner, reducing useful visual sensory perception. Keratoconus, the degeneration of corneal tissue resulting in abnormal corneal shape, can occur with trauma or may be an inherited disorder (Fig. 39.18). Inadequately treated corneal infection and severe trauma can scar the cornea and lead to severe visual impairment that can be improved only through surgical interventions. Interprofessional Collaborative Care Keratoplasty (corneal transplant) is a surgical procedure to improve clarity for a permanent corneal disorder that obscures vision. The diseased corneal tissue is removed and replaced with tissue from a cornea donated by a human who has died. Postoperative care involves comprehensive patient teaching. Local antibiotics are injected or instilled. Usually the eye is covered with a pressure patch and a protective shield until the patient returns to the ophthalmologist. Teach the patient how to instill eyedrops. Instruct the patient to lie on the nonoperative side to reduce intraocular pressure (IOP). If a patch is to be used for more than a day, teach application processes. Instruct the patient to wear the shield at night for the first month after surgery and whenever around small children or pets in order to avoid injury. Instruct them to avoid using an ice pack on the eye. Complications after surgery include bleeding, wound leakage, infection, and graft rejection. Teach patients to examine the eye (or have a family member or friend examine it) daily for the presence of infection or graft rejection. Graft rejection can occur and starts as inflammation in the cornea near the graft edge that moves toward the center. Vision is reduced, and the cornea becomes cloudy. Topical corticosteroids and other immunosuppressants are used to stop the rejection process. If rejection continues, the graft becomes opaque and blood vessels branch into the opaque tissue. Loss of vision, eye pain, redness in the eye, purulent drainage, an ongoing leak of clear fluid from the graft site (not tears) and light sensitivity need to be reported to the ophthalmologist right away. The eye should be protected from any activity that can increase the pressure on, around, or inside the eye. Teach the patient to avoid jogging, running, dancing, and any other activity that promotes rapid or jerky head motions for several weeks after surgery. Other activities that may raise IOP and should be avoided are listed in Box 39.6. FIG. 39.18 Profile of a normal cornea and one with keratoconus. Eye donation is a common procedure and needed for corneal transplantation. The Eye Bank Association of America (EBAA, 2023) has published medical standards that detail donor eligibility and contraindications. If a deceased patient is a known eye donor, follow these recommended steps prior to donation: • Raise the head of the bed 30 degrees. • Instill prescribed antibiotic eyedrops. • Close the eyes and apply a small ice pack. RETINAL DISORDERS MACULAR DEGENERATION Pathophysiology Review Macular degeneration, also known as age-related macular degeneration (AMD), is the deterioration of the macula (the area of central vision) and can be age related or exudative. It is the leading cause of blindness in individuals in the United States who are 65 years of age or older (CDC, 2020b). There are two types of AMD: dry and wet. Dry AMD is the more common type of this condition. It is caused by a slow and gradual blockage of retinal capillaries by pigmented residue and photoreceptor waste products in the retina, allowing retinal cells in the macula to become ischemic and necrotic. Central vision declines, and patients describe mild blurring and distortion at first. Night vision is affected, and the ability to see clearly when reading is impaired. Eventually the patient loses all central vision. Dry AMD progresses at a faster rate among smokers than among nonsmokers. Individuals with diabetes, hypertension, and high cholesterol are at risk for developing this condition. Other risk factors include being older than 55 years old, being White, smoking, and having a family history of AMD (National Eye Institute, 2021). Wet (exudative) AMD progresses quickly. Patients experience a sudden decrease in vision after a detachment of pigment epithelium in the macula. Newly formed blood vessels, which have very thin walls, invade this injured area and cause fluid and blood to collect under the macula (like a blister), with scar formation and visual distortion. Wet (exudative) AMD can occur at any age, in only one eye or in both eyes. The patient with dry AMD can also develop wet (exudative) macular degeneration. The risk for macular degeneration can be reduced by increasing long-term dietary intake of lutein, zeaxthin, vitamins C and E, and zinc (American Optometric Association, 2023b). Interprofessional Collaborative Care Recognize Cues: Assessment An eye care provider will likely conduct indirect ophthalmoscopy to assess for gross macular changes, opacities, retinal concerns, and hemorrhage (Rebar & Rebar, 2019). IV fluorescein angiography may be performed by the eye care provider to locate leaking vessels, and the Amsler grid test may be conducted to demonstrate central visual field loss (Rebar & Rebar, 2019). Take Actions: Interventions Dry AMD has no cure. Management in the community setting is focused on slowing the progression of the vision loss and helping the patient maximize remaining vision and quality of life. Central vision loss reduces the ability to read, write, recognize safety hazards, and drive. Suggest alternatives (e.g., large-print books, public transportation) and refer to community resources that provide adaptive equipment. Management of patients with wet (exudative) AMD involves slowing the process and identifying further changes in visual perception. Fluid and blood may reabsorb in some patients. Laser therapy to seal the leaking blood vessels can limit the extent of the damage. Ocular injections with vascular endothelial growth factor inhibitors (VEGFIs), such as bevacizumab or ranibizumab, can improve vision in the patient with wet AMD. Aflibercept, a human recombinant fusion protein that functions as a VEGFI, and faricimab-svoa, a VEGFI and angiopoietin-2 (Ang-2) inhibitor, are other injectables used to treat wet AMD. NCLEX Examination Challenge 39.4 Physiological Integrity The nurse is caring for four outpatient clients being seen for an annual physical examination. Which client would the nurse identify as being at highest risk for development of dry age-related macular degeneration (AMD)? A. 60-year-old client who recently began wearing glasses B. 63-year-old client who has controlled hypertension C. 67-year-old client with hypothyroidism D. 69-year-old client with diabetes mellitus RETINAL HOLES, TEARS, AND DETACHMENTS Pathophysiology Review A retinal hole is a break in the retina caused by trauma or that occurs with aging. A retinal tear is a jagged and irregularly shaped break in the retina, which can result from traction on the retina. A retinal detachment is the separation of the retina from the epithelium. Detachments are classified by the type and cause of their development. One common cause of retinal holes, tears, and detachments is a posterior vitreous detachment (PVD). With aging, the vitreous gel often shrinks or thickens, causing it to pull away from the retina. The patient may experience small flashes of light seen as “shooting stars” or thin “lightning streaks” in one eye, most visible in a dark environment. These flashes of light may be accompanied by “floaters.” In addition to aging, risk factors for PVD include extreme myopia, inflammation inside the eye, and cataract or eye laser surgery. When the PVD does not cause a retinal tear or detachment, no treatment is needed. Interprofessional Collaborative Care Recognize Cues: Assessment The onset of a retinal detachment is usually sudden and painless. Patients may report suddenly seeing bright flashes of light (photopsia) or floating dark spots in the affected eye. During the initial phase of the detachment or if the detachment is partial, the patient may describe the sensation of a curtain being pulled over part of the visual field. The visual field loss corresponds to the area of detachment. Patients who report this type of concern to a telehealth triage nurse should be cautioned to have another individual drive them to their eye care provider of choice. The eye care provider will perform an ophthalmoscopic examination. Detachments are seen as gray bulges or folds in the retina. Sometimes a hole or tear may be seen at the edge of the detachment. Take Actions: Interventions If a retinal hole or tear is discovered before it causes a detachment, the defect may be closed or sealed. Closure prevents fluid from collecting under the retina and reduces the risk for a detachment. Treatment involves creating a scar with laser photocoagulation—a procedure in which focused light beams seal tissue around the hole. Cryopexy, a procedure that involves a freezing probe, can be used to bind the retina and choroid together around the break. Spontaneous reattachment of a totally detached retina is rare. Surgical repair—called scleral buckling—is needed to place the retina in contact with the underlying structures. Preoperative Care Most patients are anxious and fearful about the possible permanent loss of vision. Nursing priorities include providing information and support. Instruct the patient to restrict activity and head movement before surgery to prevent further tearing or detachment. An eye patch is placed over the affected eye to reduce eye movement. Topical drugs are given before surgery to inhibit pupil constriction and accommodation. Operative Procedures Surgery is performed with the patient under general anesthesia. In scleral buckling, the ophthalmologist repairs wrinkles or folds in the retina and indents the eye surface to relieve the tugging pressure on the retina. The indentation or “buckling” is performed by placing a small piece of silicone against the outside of the sclera and holding it in place with an encircling band. This device keeps the retina in contact with the choroid for reattachment. Any fluid under the retina is drained. Silicone oil or gas is placed inside the eye to promote retinal reattachment. These agents float up and against the retina to hold it in place until healing occurs. Postoperative Care After surgery an eye patch and shield are usually applied. Monitor the patient’s vital signs, and check the eye patch and shield for drainage. Activity after surgery varies. If oil or gas has been placed in the eye, teach the patient to keep the head in the position instructed by the ophthalmologist to promote reattachment. Teach the patient to report sudden increase in pain or pain occurring with nausea to the ophthalmologist immediately. Remind the patient to avoid activities that increase intraocular pressure (IOP) (see Box 39.6). Instruct the patient to avoid reading, writing, and work that requires close vision in the first week after surgery because these activities cause rapid eye movements and detachment. Teach the signs and symptoms of infection and detachment (sudden reduced visual acuity, eye pain, pupil that does not constrict in response to light) that must be reported to the ophthalmologist immediately. REFRACTIVE ERRORS Pathophysiology Review The ability of the eye to focus images on the retina depends on the length of the eye from front to back and the refractive power of the lens system. Refraction is the bending of light rays. Problems in either eye length or refraction can result in refractive errors. Myopia is nearsightedness, in which the eye overrefracts the light and the bent images fall in front of, not on, the retina. Hyperopia, also called hypermetropia, is farsightedness, in which refraction is too weak, causing images to be focused behind the retina. Presbyopia is the age-related problem in which the lens loses its elasticity and is less able to change shape to focus the eye for close work. As a result, images fall behind the retina. This problem usually begins in adults in their 40s. Astigmatism occurs when the curve of the cornea is uneven. Because light rays are not refracted equally in all directions, the image does not focus on the retina. Interprofessional Collaborative Care Recognize Cues: Assessment Refractive errors are diagnosed through a refraction test. The patient is asked to view an eye chart while lenses of different strengths are systematically placed in front of the eye. With each lens strength, the patient is asked whether the lenses sharpen or worsen vision. The strength of the lens needed to focus the image on the retina is expressed in measurements called diopters. Take Actions: Interventions Nonsurgical Management Refractive errors are corrected with eyeglasses or contact lenses that focus light rays on the retina (see Fig. 39.5). Hyperopic vision is corrected with a convex lens that moves the image forward. Myopic vision is corrected with a concave lens that moves the image back to the retina. Surgical Management Surgery can correct some refractive errors and enhance vision. The most common vision-enhancing surgery is laser in situ keratomileusis (LASIK). This procedure can correct nearsightedness, farsightedness, and astigmatism. The superficial layers of the cornea are lifted temporarily as a flap, and powerful laser pulses reshape the deeper corneal layers. After reshaping is complete, the corneal flap is placed back into its original position. Usually both eyes are treated at the same time, which is convenient for the patient, although this practice has risks. Many patients have improved vision within an hour after surgery, and complete healing takes up to 4 weeks. The outer corneal layer is not damaged, and pain is minimal. Complications of LASIK are rare, yet include temporary or chronic dry eyes, halos around lights, double vision, light sensitivity, or vision loss. Risks for these complications are higher in patients with weak immune systems. TRAUMA Trauma to the eye or orbital area can result from almost any activity. Care varies, depending on the area of the eye affected, whether the globe of the eye has been penetrated, surrounding injuries, and the mechanism of trauma. If there is any type of object protruding from the area of injury, do not attempt to remove it. The provider of care will assess whether the object is holding other structures in place, and which mechanism of removal is appropriate. Foreign Bodies Eyelashes, dust, dirt, and airborne particles can come in contact with the conjunctiva or cornea and irritate or abrade the surface. The patient usually reports the feeling of something being in the eye and may have blurred vision. Pain occurs if the corneal surface is injured. Tearing and photophobia may be present. Visual sensory perception is assessed before treatment. If nothing is seen on the cornea or conjunctiva, the eyelid is everted to examine the conjunctivae. The eye is examined with fluorescein, followed by irrigation with normal saline (0.9%) to gently remove the particles. Remember, if both eyes are affected, irrigate them simultaneously using separate personnel and equipment. If an eye dressing or patch is applied after the foreign body is removed, tell the patient how long this must be left in place. Follow-up as directed by the eye care provider is needed to confirm that appropriate healing is taking place. Lacerations Lacerations are caused by sharp objects and projectiles. The injury occurs most commonly to the eyelids and cornea, although any part of the eye can be lacerated. The patient with a laceration should receive medical attention right away. Corneal lacerations are an emergency because eye contents may prolapse through the laceration. Symptoms include severe eye pain, photophobia, tearing, decreased vision, and inability to open the eyelid. If the laceration is the result of a penetrating injury, an object may be seen protruding from the eye. Minor lacerations of the eyelid can be sutured in an emergency department, an urgent care center, or an eye care provider’s office. A microscope is needed in the operating room if the patient has a laceration that involves the eyelid margin, affects the lacrimal system, involves a large area, or has jagged edges. Antibiotics are given to reduce the risk for infection. Depending on the depth of the laceration, scarring may develop. If the scar alters vision, a corneal transplant may be needed later. If the eye contents have prolapsed through the laceration or if the injury is severe, enucleation (surgical eyeball removal) may be indicated. Penetrating Injuries A penetrating eye injury often leads to permanent loss of visual sensory perception. Glass, high-speed metal or wood particles, BB pellets, and bullets are common causes of penetrating injuries. The particles can enter the eye and lodge in or behind the eyeball. A wound may be visible. Depending on where the object enters and rests within the eye, vision may be affected. Never remove an object protruding from the eye; the health care provider will assess the immediate condition and determine how to proceed. X-rays and CT scans of the orbit are usually performed. MRI is contraindicated because the procedure may move any metal-containing projectile and cause more injury. Surgery is usually needed to remove the foreign object, and sometimes vitreal removal is needed. IV antibiotics are started before surgery, and a tetanus booster is given if necessary. NURSING SAFETY PRIORITY Action Alert An object protruding from the eye is removed only by an eye care provider because it may be holding the eye structures in place. Improper removal can cause structures to prolapse out of the eye. Get Ready for The Next-Generation NCLEX® Examination! Essential Nursing Care Points Mastery Questions 1. The telehealth nurse receives a call from a client who had surgery this morning to repair a retinal detachment. When the client reports pain in the affected eye with diminished visual acuity, which nursing response is appropriate? A. “Take acetaminophen to address the pain.” B. “Contact your ophthalmologist right away.” C. “This is a normal response to the type of surgery you had.” D. “If the symptoms are still present in 24 hours, seek emergency care.” 2. A client comes to the emergency department reporting the new sensation of something in the eye. Which of the following assessment data would the nurse anticipate that is consistent with a foreign body? Select all that apply. A. Pain B. Fever C. Tearing D. Photophobia E. Blurred vision 3. Which condition would the nurse anticipate when a client explains having slow, progressive visual disturbance over the past 2 years? A. Cataract B. Retinal hole C. Corneal abrasion D. Angle-closure glaucoma NGN Challenge 39.1 The nurse is reviewing the health record of a client who is here for an eye examination. • 64 years old • Weight 130 lb (59 kg) • Height 66 inches (167.6 cm) • Medical history: Hypertension, type 2 diabetes • Social history: Smokes 1 pack of cigarettes daily; denies alcohol or illicit substance use • Family history: Hypertension, type 2 diabetes, glaucoma NURSING FLOW SHEET Date Reason for Visit Vision Acuity Blood Pressure 6-17-2020 Annual eye exam; reports occasional dry eyes after working at the computer all day 20/20 130/86 mm Hg 6-26-2021 Annual eye exam; reports no changes in vision since last appointment 20/20 132/88 mm Hg 7-3-2022 Annual eye exam; reports noticing mild changes in vision stating, “Things are starting to look clouded over to me in my left eye. I must just be getting old.” 20/60 150/98 mm Hg Which of the following actions would the nurse plan to take at this time? Select all that apply. ○ Schedule client for cataract removal. ○ Prepare for scleral buckling procedure. ○ Teach about progressive nature of glaucoma. ○ Recognize these findings as a medical emergency. ○ Reassure that these findings are a normal part of aging. ○ Gather information to teach about eyedrop instillation. ○ Explain that drug therapy will halt the progression of eye changes. ○ Remind that accompanying symptoms such as eye redness will soon start. NGN Challenge 39.2 The nurse reviews the notes for a 33-year-old client who has been brought by a coworker to the ophthalmologist. History and Physical Nurses’ Notes Imaging Studies Laboratory Results 1111: Brought by car to emergency department by coworker. Reports being at work this morning in a meeting when suddenly they saw “shooting stars” in the left eye followed by the sensation of “someone closing a curtain” over the outer periphery of the eye. Denies pain. No other significant medical history is present. VS: T 98.2°F (36.8°C); HR 84 beats/min; RR 16 breaths/min; BP 124/92 mm Hg; SpO2 99% on RA. Alert and oriented × 4; moves all extremities strongly and equally. PERRLA. Cranial nerves intact. Conjunctiva clear and sclera white bilaterally. Ophthalmologist in to see client. Complete the diagram by selecting from the choices to specify what potential condition the client is likely experiencing, 2 nursing actions that are appropriate to take, and 2 parameters the nurse should monitor to assess the client’s progress. A chart shows the condition most likely experiencing at the center connected to 2 boxes labeled actions to take, on left and 2 boxes labeled parameters to monitor, at right. Action to Take Parameter to Monitor Condition Most Likely Experiencing Action to Take Parameter to Monitor Actions to Take Potential Conditions Parameters to Monitor Place in Trendelenburg position Open angle glaucoma Signs of infection in the eye Recommend glasses to correct vision Retinal tear Drainage around the eye shield Prepare for laser photocoagulation Cataract Formation of clouding over the eye Place a patch over the unaffected eye Myopia Ability to see with newly prescribed glasses Apply topical medication to inhibit pupil constriction and accommodation Pupil that should begin to constrict to light