VISION EXTERNAL STRUCTURES OF THE EYE EYELIDS (PALPEBRAL) (PALPEBRAL) & EYELASHES EY ELASHES • Protect the eye from foreign particles
CONJUNCTIVA PALPEBRAL CONJUNCTIVA • Pink; lines inner surface of eyelids
BULBAR CONJUNTIVA • White with small blood vessels, covers anterior sclera
LACRIMAL APPARA APPARATUS TUS (LACRIMAL GLAND GL AND & ITS DUCTS AND PASSAGES) • Produces tears to lubricate the eye & moisten the cornea nasolacrimal duct which which empties empties into nasal nasal cavity • Tears drain into nasolacrimal
VISION INTERNAL STRUCTURES OF THE EYE
1. EYEBALL 3 LAYERS OF THE EYEBALL
A. OUTER LAYER - fibrous coat that supports the eye eye
A. SCLERAE - Tough, white connective tissue “white of the eye” - located anteriorly & posteriorly
B. CORNEA - Transparent tissue through which light enters the eye. - Located anteriorly
VISION B. MIDDLE LAYER - second layer of the eyeball - vascular & highly pigmented pigmented
A. CHOROID - a dark brown membrane located between the sclera & the retina - it lines most of the sclera & is attached to the retina but can easily detach from the sclera - contains blood vessels that nourishes the retina - located posteriorly
VISION B. MIDDLE LAYER B. CILIARY BODY - connects the choroid with the iris - secretes aqueous humor that helps give the eye its shape
C. IRIS - the colored portion of the eye - located in front of the lens - it has a central opening called the pupil pupil
VISION INTERNAL STRUCTURES OF THE EYE C. INNER LAYER (RETINA) - a thin, delicate delicate structure in which the fibers of the optic nerve are distributed - bordered externally by the choroid & sclera and internally by b y the vitreous - contains blood vessels & photoreceptors (cones & rods)
- light sensitive layer
CONTAINS THE FOLLOWING STRUCTURES
1. CONES - Specialized for fine discrimination, central vision & color vision - Functions at bright levels of illumination
2. RODS - More sensitive to light than cones - Aid in peripheral vision - Functions at reduced levels of illumination
VISION INTERNAL STRUCTURES OF THE EYE 2. FLUIDS OF THE EYE A. AQUEOUS HUMOR - Clear, watery fluid that fills the anterior & posterior chambers of the eye - produced by the ciliary processes, & the fluid drains in the Canal of Sclemm - The anterior chamber lies between the cornea & iris - the posterior chamber lies between the iris & lens - serves as refracting medium & provides nutrients to lens & cornea - contributes to maintenance of IOP
VISION INTERNAL STRUCTURES OF THE EYE 2. FLUIDS OF THE EYE B. VITREOUS HUMOR Clear,, gelatinous/jell-like material that fill the posterior cavity of - Clear the eye - Maintains the form & shape of the eye - Provides additional physical support to the eye - It is produced by the vitreous body
3. VITREOUS BODY - contains a gelatinous substance that occupies the vitreous chamber which is the space between the lens & retina - transmits light & gives shape sh ape to the posterior eye
VISION INTERNAL STRUCTURES OF THE EYE 4. OPTIC DISK - a creamy pink to white depressed area in the retina - the optic nerve enters & exits the eyeball in this area - Referred to as the “BLIND SPOT” - contains only nerve fibers - lack photoreceptors - insensitive to light light
5. MACULA LUTEA - Small, oval, yellowish pink area located lateral & temporal to the optic disk - the central depressed part of the macula is the “FOVEA CENTRALIS” which is an area where acute vision occurs occurs
VISION INTERNAL STRUCTURES OF THE EYE 6. CANAL OF SCHLEMM - a passageway that extends completely around the eye - permits fluid to drain out of the eye into the systemic circulation so that a constant IOP is maintained
7. LENS - A transparent circular structure behind the iris & in front of the vitreous body - Bends rays of light so that the light falls on the retina
8. PUPILS - Control the amount amount of light that enters enters the eye & reaches the retina - Darkness produces dilation while light produces constriction
VISION INTERNAL STRUCTURES OF THE EYE 9. EYE MUSCLES - Muscles do not work independently but work in conjunction with the muscle that produces the opposite movement
A. RECTUS RECTUS MUSCLES - Exert their pull when the eye turns temporarily
B. OBLIQUE MUSCLES - Exert their pull when the eye turns nasally
VISION INTERNAL STRUCTURES OF THE EYE 10. NERVES A. CRANIAL CRANIAL NERVE II
- Optic nerve (nerve of sight)
B. CRANIAL NERVE III - Oculomotor
C. CRANIAL NERVE IV - Trochlear
D. CRANIAL NERVE VI - Abducens
VISION INTERNAL STRUCTURES OF THE EYE 11. BLOOD VESSELS A. OPTHALMIC OPTHALMIC ARTERY ARTERY - Major artery supplying the structures in the eye
B. OPTHALMIC VEINS
- Venous drainage occurs through vision
ASSESSMENT OF VISION VISUAL ACUITY TEST TEST
- measures the client’s distance & near vision vision
SNELLEN CHART - simple tool to record visual acuity - the client stands 20 ft from the chart & covers 1 eye and uses the other eye to read the line that appears more clearly - this procedure is repeated for the other eye - the findings are recorded as a comparison between what the client can read at 20 ft and the no. of feet normally required by an individual to read the same line
EXAMPLE: 20/50 - eye The can client is able at 20 ft from the chart what a healthy read at 50toftread
ASSESSMENT OF VISION CONFRO CON FRONT NTA ATIO TIONAL NAL - Performed to examine visual fields orTEST peripheral vision - The examiner & the client sit facing each other - The test assumes that the examiner has normal peripheral vision
EXTRAOCULAR MUSCLE FUNCTION - tests muscle function of the eyes - tests 6 cardinal positions of gaze 1. Client’s right (lateral position) position) 2. Upward & right (temporal position) 3. Down & right 4. Client’s left (lateral position) position) 5. Upward & left (temporal position) 6. Down & left - client holds head still & asked to move eyes & follow a small object - the examiner looks for any parallel movements of the eye or for nystagmus - an involuntary rhythmic rapid twitching of the eyeballs
ASSESSMENT OF VISION COLOR VISION TEST - Tests Tests for color vision which involve picking nos. or letters out of a complex & colorful picture
ISHIHARA CHART - consists of nos. that are composed of o f colored dots located within a circle of colored dots -- each clienteye is asked to read the nos. on the chart is tested separately - the test is sensitive for the diagnosis of red/gree red/green n blindness but not effective for the detection of the discrimination of blue
PUPILS - Normal Normal:: round & of equal size constriction - Increasing light causes pupillary Decreasing light causes pupillary dilation - the client is asked to look straight ahead while the examiner quickly brings a beam of light ( penlight) in from the side & directs it onto the side - Constriction of the eye is a direct response to the light shining into the eye; constriction of the opposite eye is known as CONSENSUAL
RESPONSE
DIAGNOSTIC TESTS FOR THE EYE FLUORESCEIN ANGIOGRAPHY - detailed imaging & recording of ocular circulation by a series of photographs after administration of the dye
PRE-OP NURSING CARE • Assess for allergies & previous reactions to dyes • Obtain informed consent • A mydriatic medication is instilled in the eye 1 hr. before the test • The dye is injected into the vein v ein of the client’s arm arm • Inform client that the dye may cause ca use the skin to appear yellow for several hrs. after the test & this is gradually eliminated through the urine • The client may experience N&V, N&V, sneezing, paresthesia of the tongue or pain at the injection site • If hives appear, oral or IM antihistamines such as Diphenhydramine (Benadryl) are given as prescribed.
DIAGNOSTIC TESTS FOR THE EYE FLUORESCEIN ANGIOGRAPHY - detailed imaging & recording of ocular circulation by a series of photographs after administration of the dye
POST-OP NURSING CARE • Encourage rest. • Encourage oral fluids. • Remind the client that the yellow skin appearance will disappear • Instruct the client that the urine will appear a ppear bright green until the dye is excreted • Instruct the client to avoid direct sunlight for a few hrs after the test. • Instruct the client that the photophobia will continue until pupil size returns to normal
DIAGNOSTIC TESTS FOR THE EYE COMPUTED TOMOGRAPHY - a beam of x-ray scans the skull & orbits of the eye - a cross-sectional image is formed by the use of a computer - contrast material is not usually administered
NURSING CARE •• No special or follow-up care required Instruct theclient clientpreparation that he or she will be positioned in a confined space & need to keep the head still during the procedure
DIAGNOSTIC TESTS FOR THE EYE SLIT LAMP - allows examination of the anterior ocular structures under microscopic magnification - the client leans on a chin rest to stabilize the head while a narrow beam of light is aimed so that it illuminates only a narrow segment of the eye.
NURSING CARE • Explain the procedure to the client. • Advise the client about the brightness of the light & the need to look forward at the point over the examiner’s examiner ’s ear ear
DIAGNOSTIC TESTS FOR THE EYE
CORNEAL COR NEAL STAIN STAINING ING - installation of a topical dye into the conjunctival sac to outline the irregularities of the corneal surface that are not easily eas ily visible - the eye is viewed through a blue filter, filter, and a bright green color indicates areas of non-intact corneal epithelium
NURSING CARE • If a client wears contact lenses, they must be removed • The client is instructed to blink after the dye has been applied to distribute the dye evenly across the cornea
DIAGNOSTIC TESTS FOR THE EYE
TONOMETRY - the test is primarily used to assess for an increase in IOP and potential glaucoma - NORMAL IOP: IOP: 8-21 mm Hg
NURSING CARE • Each eye is anesthetized. • The client is asked to stare forward at a point above the examiner’s ex aminer’s ear • A flattened cone is brought in contact with the cornea • The amount of pressure needed to flatten the cone is measured • The client is instructed to avoid rubbing the eye following the examination if the eye has been anesthetized - the potential for scratching the cornea exists
DISORDERS OF THE EYE
Risk factors of eye disorders AGING
PROCESS CONGENITAL DIABETES MELLITUS HEREDITARY
MEDICATIONS TRAUMA
LEGALLY BLIND - a person is legally blind if the best visual acuity with corrective lenses in the better eye is 20/200 or less or a visual field of 20 degrees or less in the better eye
NURSING CARE • When speaking to a client who has limited sight or blind, the nurse uses a normal tone of voice • Alert the client when approaching •• Orient the client environment Use a focal point to & the provide further orientation to the environment from the focal point • Allow the client to touch objects in the room • Use the clock placement of foods on the meal tray to orient the • client Promote independence as much as possible
LEGALLY BLIND NURSING CARE • Provide radios, TVs, & clocks that give the time orally or provide a Braille watch. • When ambulating, allow the client to grasp the nurse’s arm at the elbow - the nurse keeps his or her arm close to the body so that the client can detect the direction of movement • Instruct the client to remain one step behind the nurse n urse when ambulating • which Instruct the client in the useother of thecanes caneby used for the blind client, is differentiated from its straight shape & white
color with red tip • Instruct the client that the cane is held in the dominant hand several inches off the floor • foot Instruct theplaced client that cane sweeps groundofwhere the client’s will be next the to determine determ ine thethe presence obstacles
CATARACTS - an opacity of the lens that distorts distor ts the image projected onto the retina & that can progress to blindness - Intervention is indicated when visual acuity has been reduced to a level that the client finds to be unacceptable or adversely affecting lifestyle
CAUSES
Aging process (Senile cataracts) Inherited (Congenital cataracts)
Injury (Traumatic cataracts)
Can occur as a result of another eye disease (Secondary cataracts)
CATARACTS ASSESSMENT
Opaque or cloudy white pupil Gradual loss of vision
Blurred vision
Decreased color perception
Vision that is better in dim light with pupil p upil dilation Photophobia
Absence of red reflex
CATARACTS MEDICAL MANAGEMENT - surgical removal of the lens, one eye at a time - a lens implantation may be performed at the time of surgical procedure
• EXTRACAPSULAR EXTRACTION - the lens is lifted out without removing the lens capsule - may be performed with Phacoemulsion PHACOEMULSION - the lens is broken up by ultrasonic vibrations & extracted
• INTRACAPSULAR EXTRACTION - the lens is removed within its capsule through a small s mall incision
• PARTIAL IRIDECTOMY - may be performed with lens extraction to prevent acute secondary glaucoma
CATARACTS PRE-OP NURSING CARE • Instruct measures to prevent or decrease IOP • cycloplegics Administer pre-op eye medications including mydriatics & as prescribed
POST-OP NURSING CARE • Elevate the head of the bed 30-45 degrees • Turn the client to the back or un-operative side • Maintain an eye patch & orient the client to the environment • Position the client’s personal belongings on the un-operative un -operative side • Use side rails for safety • Assist with ambulation
CATARACTS CLIENT EDUCATION AFTER CATARACT SURGERY • Avoid eye straining • Avoid rubbing or placing pressure on the eyes • Avoid rapid movements, straining, sneezing, coughing, bending, b ending, vomiting, or lifting objects over 5 lbs • Teach measures to prevent constipation • Wipe excess drainage or tearing with a sterile wet cotton ball from the inner to the outward canthus • Use an eye shield at bedtime • If an eye implant is not performed, the eye cannot accommodate & glasses must be worn at all times • Cataract glasses act as magnifying glasses & replace central vision only • Cataract glasses magnify, magnify, & objects o bjects appear closer therefore teach client to judge distance & climb stairs carefully • Contact lenses provide sharp visual acuity but dexterity is needed to insert them • Contact the MD for any decrease in vision, severe eye pain or increase in eye discharge
GLAUCOMA - increased IOP as a result of inadequate drainage of aqueous humor from the canal of Schlemm or over production of aqueous humor
- the condition damages the optic nerve & can result in blindness
TYPES ACUTE CLOSED-ANGLE/NARROW ANGLE GLAUCOMA
- results from obstruction to outflow to aqueous humor CHRONIC CLOSED-ANGLE GLAUCOMA - follows an untreated attack of acute close-angled glaucoma CHRONIC OPEN-ANGLE GLAUCOMA
- results from an overproduction or obstruction to the outflow o utflow of aqueous humor
ACUTE GLAUCOMA
- a rapid onset of IOP > 50-70 mm Hg CHRONIC GLAUCOMA
- a slow, progressive, gradual onset of IOP > 30-50 mm mm Hg
GLAUCOMA ASSESSMENT
Progressive loss of peripheral vision followed by a loss of central vision
Elevated IOP (Normal pressure is 10-21 mm Hg)
Vision worsening in the evening with difficulty adjusting to dark rooms
Blurred vision
Halos around white lights
Frontal headaches
Photophobia Increased lacrimation
Progressive loss of central vision
GLAUCOMA NURSING CARE FOR ACUTE ACUTE GLAUCOMA • Treat as medical emergency • Administer medications as prescribed to lower IOP • Prepare the client for peripheral iridectomy - allows aqueous humor to flow from the posterior to anterior chamber
NURSING CARE FOR CHRONIC GLAUCOMA • Instruct the client the importance of medications a. MIOTICS: to constrict the pupils b. CARBONIC ANHYDRASE INHIBITORS: to decrease the production of aqueous humor c. BETA-BLOCKERS: to decrease the production of aqueous humor & IOP • Instruct the client the need for life-long medication use • Instruct the client to wear a Medic-Alert bracelet bracelet
GLAUCOMA NURSING CARE FOR CHRONIC GLAUCOMA • Instruct the client to avoid anti-cholinergic medications • Instruct the client to report eye pain, halos around eyes & changes chang es of vision to the physician • Instruct the client that when maximal medical therapy has failed to halt the progression of visual field loss & optic nerve damage, surgery will be recommended • Prepare the client for TRABECULOPLASTY TRABECULOPLASTY as as prescribed - to facilitate aqueous humor drainage
• Prepare client for TRABECULECTOMY TRABECULECTOMY as as prescribe prescribed d - allows drainage of aqueous humor into the conjuctival spaces by the creation of an opening
RETINAL DETACHMENT - occurs when the layers of the retina separate because of accumulation of fluid between them - also occurs when both retinal layers elevate away from the choroid as a result of a tumor
TYPES PARTIAL RETINAL DETACHMENT - becomes complete if left untreated
COMPLETE RETINAL DETACHMENT DETACHMENT - when detachment is complete, blindness may occur
RETINAL
DETACHMENT
ASSESSMENT
Flashes of light
Floaters
Increase in blurred vision
Sense of curtain being drawn
Loss of a portion of the visual field
RETINAL DETACHMENT IMMEDIATE NURSING CARE • Provide bedrest • Cover both eyes with patches to prevent further detachment • Speak to the client before approaching • Position the client’s head as prescribed prescribed • Protect the client from injury • Avoid jerky head movements • Minimize eye stress • Prepare the client for surgical procedure as prescribed
RETINAL DETACHMENT MEDICAL MANAGEMENT - draining fluid from the subretinal space so that the retina can return to the normal position
• SEALING RETINAL BREAKS BY CRYOSURGERY - a cold probe applied to the sclera to stimulate an inflammatory response leading to adhesions
• DIATHERMY
- the use of electrode needle & heat through the sclera to stimulate an inflammatory response leading to adhesions
• LASER THERAPY - to an inflammatory response to seal small retinal tears before thestimulate detachment occurs
• SCLERAL BUCKLING - to hold the choroid & retina together with a splint until scar tissue forms closing the tear
OF A GAS OR SILICONE OIL • INSERTION - to encourage attachment because these agents have a specific gravity less
than vitreous or air & can float against the retina
RETINAL DETACHMENT POST-OP NURSING CARE • • • •
Maintain eye patches bilaterally as prescribed Monitor hemorrhage as prescribed Prevent N&V N&V and monitor for restlessness restlessness which can cause hemorrhage Monitor for sudden, sharp eye pain (notify the MD stat)
• Encourage DBE but avoid coughing • Provide bedrest for 1-2 days as prescribed • If gas has been inserted, position as prescribed on the abdomen & turn the head so unaffected eye is down • Administer eye medications as prescribed • Assist client with ADL • Avoid sudden head movements or anything that increases IOP • Instruct the client to limit reading for 3-5 weeks • Instruct client to avoid squinting, straining & constipation, lifting heavy objects & bending from the waist • Instruct the client to wear dark glasses during the day & an eye patch at night n ight • Encourage follow-up care because of the danger of recurrence or occurrence in the other eye
STRABISMUS - called “SQUINT EYE” or “LAZY EYE” - a condition in which the eyes are not aligned because of lack of muscle coordination of the extraocular muscles - most often results from muscle imbalance or paralysis of extraocular muscles, but may also result from conditions such as tumor, myasthenia gravis or infection - brain normal in young infant but should not be present after about age 4 months
ASSESSMENT Amblyopia Amblyopia
if not treated early early Permanent loss of vision if not treated early
Loss of binocular vision
Impairment of depth perception
Frequent headaches Squints or tilts head to see
STRABISMUS NURSING CARE • Corrective lenses as indicated • Instruct the parents regarding patching (occlusion therapy) of the “good” eye eye - to strengthen the weak eye • Prepare for botulinum toxin (Botox) injection into the eye muscle - produces temporary paralysis - allows muscles opposite the paralyzed muscle to strengthen the eye • Inform the parents that the injection of botulinum toxin wears off in about 2 months & if successful, correction will occur • Prepare for surgery to realign the weak muscles as Rx if nonsurgical interventions are unsuccessful • Instruct the need for follow-up visits
CONJUNCTIVITIS also known asof -- inflammation “PINK EYE” EYE” the conjunctiva - usually caused by allergy a llergy,, infection, or trauma
TYPES BACTERIAL OR VIRAL CONJUNCTIVITIS - extremely contagious CHLAMYDIAL CONJUNCTIVITIS - is rare in older children & if diagnosed in a child who is not sexually active, the child should be assessed for possible sexual abuse
ASSESSMENT Itching,
burning or scratchy eyelids
Redness
Edema
Discharge
CONJUNCTIVITIS NURSING CARE • Instruct in infection control measures such as good handwashing & not sharing towels & washcloths • Administer antibiotic or antiviral eye drops or ointment as Rx if infection is present • Administer antihistamines as Rx if an allergy is present • Instruct the parents that the child should be kept home from school or day care until antibiotic eye drops have been administered for 24 hrs • Instruct in the use of cool compresses to lessen irritation & in wearing dark glasses for photophobia • Instruct the child to avoid rubbing the eye to prevent injury • D/C use of contact lenses & to obtain new lenses to eliminate the chance of re-infection • Instruct the adolescent that eye make-up should be discarded & replaced
HYPHEMA - the presence of blood in the anterior chamber - occurs as a result of injury - condition usually resolves in 5-7 days
NURSING CARE • Encourage rest in semi-Fowler’s semi-Fowler’s position position • Avoid sudden eye movements for 3-5 days to decrease bleeding • Administer cycloplegic eye drops as prescribed - to place the eye at rest • Instruct in the use of eye shields or eye patches p atches as prescribed • Instruct the client to restrict reading & watching TV
CONTUSIONS
- bleeding into the soft tissue as a result of an injury
- causes a black eye & the discoloration disappears in approximately 10 days
- pain, photophobia, edema & diplopia may occur
NURSING CARE • Place ice on the eye immediately • Instruct the client to receive an eye examination
FOREIGN BODIES - an object such as dust that enters the eye Have the client look upward, expose the lower lid, wet a cottonNURSING CARE tipped applicator with sterile NSS & gently twist the swab over •
the particle & remove it If the particle cannot be seen, have the client look downward, place a cotton applicator horizontally on the outer surface of the upper eye lid, grasp the lashes, & pull the the upper lid outward & over the cotton applicator, if the particle is seen, gently twist over it to remove
•
PENETRATING OBJECTS
- an injury that occurs to the eye in which an object penetrates the eye
NURSING CARE Never remove the object because it may be holding ocular structures in place, the object must be removed by MD Cover the object with a cup Don’t allow the client to bend Don’t place pressure on the eye Client is to be seen by MD stat
•
• • • •
CHEMICAL BURNS - an eye injury in which a caustic substance subs tance enters the eye
NURSING CARE • Treatment should begin stat • Flush the eyes at the site of injury injur y with water for at least 15-20 mins • At the site of injury, injury, obtain a small sample of the chemical involved • At the ER, the eyes is irrigated with NSS or an opthalmic irrigation solution • The solution is directed across the cornea & toward the lateral canthus • Prepare for visual acuity assessment • Apply an antibiotic ointment as prescribed • Cover the eye with a patch as prescribed
ENUCLEATION - removal of the entire eyeball
EXENTERATION
- removal of the eyeball e yeball & surrounding tissues
• Performed for the removal of ocular tumors • After the eye is removed, a ball implant is inserted to provide a firm base for socket prosthesis & to facilitate the best cosmetic result • A prosthesis is fitted approximately 1 month after surgery
PRE-OP NURSING CARE • Provide emotional support to the client • Encourage the client to verbalize feelings related to loss
POST-OP NURSING CARE • Monitor V/S • Assess pressure patch or dressing • Report changes in V/S or the presence of bright red drainage on the pressure patch or dressing
ORGAN DONATION DONOR EYES • •
• •
Obtained from cadavers Must be enucleated soon after death due to rapid endothelial cell death Must be stored in a preserving solution Storage, handling & coordination of donor tissue with surgeons is provided by a network of state eye bank associations across the country
ORGAN DONATION
CARE OF THE DECEASED CLIENT AS A POTENTIAL EYE DONOR Discuss the option of eye donation with MD & family • • • •
Raise the head of the bed 30 ° Instill antibiotic eye drops as RX Close the eyes & apply a small ice pack to the closed eyes
ORGAN DONATION PRE-OP CARE OF THE RECIPIENT •
• • •
•
•
Recipientt may be told of the tissue availability Recipien availability only several hrs to 1 day before surgery Assist in alleviating client anxiety Assess for signs of eye infection i nfection Report the presence of any redness, watery or purulent drainag drainage e or edema around Instill antibiotic antib iotic drops intothe theeyes eyestoasMD Rx to reduce the no. of microorganisms present Administer IV fluids & medications as Rx
ORGAN DONATION POST-OP CARE TO THE RECIPIENT
Eye is covered with a pressure patch and protective shield that are left in place until the next day Don’t remove or change the dressing without the MD’s order Monitor V/S, LOC & assess dressing dressing Position the client on unoperative side to reduce IOP Orient the client frequently Monitor for complications of bleeding, wound leakage, infection & graft rejection Instruct the client in how to apply the patch & eye shield Instruct the client to wear the eye shield at night for 1 month &
•
• • • • •
• •
whenever around small children or pets
GRAFT REJECTION • • •
•
Can occur at anytime Inform the client of signs of rejection Signs include redness, swelling, decreased vision, &Treated pain (RSDP) with topical steroids
OPTHALMIC AND OTIC MEDICATIONS
INSTALLATION OF EYE DROPS EYE DROPS • • • •
Wash hands Put on gloves Check the name, strength, & expiration date of the medication Instruct the client to tilt the head backward, open the eyes & look up • Pull the lower lid down against the cheekbone • Hold the bottle, gently rest the wrist of the hand on the client’s cheek • Squeeze the bottle gently to allow the drop to fall into the conjunctival sac • Instruct the client to close the eyes gently & not to squeeze the eyes shut • Wait 3-5 minutes before instilling another drop, if more than 1 is Rx - to promote maximal absorption of the medication • Don’t allow the medication bottle, dropper, or applicator to come in contact with the eyeball
Installation of eye medications EYE OINTMENTS • Hold the ointment tube near, near, but not touching, the eye or eyelashes • Squeeze a thin ribbon of ointment along the lining of the lower conjunctival sac from the inner to the outer canthus • Instruct the client to close the eyes gently • Instruct the client that vision may be blurred by the ointment
MYDRIATICS, MYDR IATICS, Cycloplegic & anticholinerg anticholinergic ic medications MYDRIATICS
- dilate the pupils (mydriasis)
CYCLOPLEGIA - relax the ciliary muscles
ANTICHOLINERGICS - block responses of the sphincter muscle in the ciliary body bod y, producing mydriasis
MYDRIATICS, MYDR IATICS, Cycloplegic anticholinergic ic medications& anticholinerg - used pre-op or for eye examinations to produce mydriasis - C/I in clients with glaucoma because of the risk of increased IOP - Mydriatics are C/I in cardiac dysrhythmias & cerebral atherosclerosis & should be used with caution in the elderly and in clients with prostatic hypertrophy, hypertrophy, diabetes mellitus or parkinsonism
Monitor for allergic reactions Assess for risk of injury Assess for constipation & urinary retention Instruct the client that a burning sensation may occur on installation Instruct the client not to drive or operate machine for 24 hrs after installation of the medication unless un less otherwise directed by the physician • Instruct the client to wear sunglasses sunglass es until the effects of the medication wear off • Instruct to notify MD if blurring of vision, loss of sight, difficulty in breathing, flushing occurs • Instruct thesweating client to or report eye pain to the physician
ANTI-INFECTIVE EYE MEDICATIONS - Kill or inhibit the growth g rowth of bacteria, fungi, & viruses
SIDE EFFECTS
Superinfection Global irritation
NURSING • Assess for risk ofCARE injury • Instruct the client in how to apply the eye medication • Instruct the client to continue treatment as Rx • Instruct the client to wash hands thoroughly & frequently • Advise the client that if improvement does not occur, notify the MD
ANTI-INFLAMMATORY EYE MEDICATIONS - Control inflammation, thereby reducing vision loss & scarring - Used for uveitis, allergic conditions, & inflammation of the conjunctiva, cornea, & lids
SIDE EFFECTS
Cataracts Increased IOP Impaired healing Masking S/S of infection
•NURSING Assess for risk ofCARE injury • Instruct the client in how to apply the eye medication • Instruct the client to continue treatment as Rx • Instruct the client to wash hands thoroughly & frequently • Advise the client that if improvement does not occur, notify the MD
• Note that dexamethasone (Maxidex) should not be used for eye abrasions & wounds
• Prednisone acetate (Predforte, Econopred) • Prednisolone Na phosphate (AK-Pred, Inflamase) • Rimaxolone (V (Vexol) exol)
TOPICAL ANESTHETICS FOR THE EYE - Produce corneal anesthesia - Used for anesthesia for eye examinations, for surgery, or to remove foreign bodies from the eye
SIDE EFFECTS
Temporary stinging or burning of the eye Temporary loss of corneal reflex
NURSING CARE • Assess for risk of injury • Note that the medications should not be given to the client for home use & are not to be selfself-administered administered by the client • Note that the blink reflex is temporarily lost & that the corneal epithelium needs to be protected • Provide an eye patch to protect the eye from injury until the corneal reflex
returns
TOPICAL ANESTHETICS FOR THE EYE EXAMPLES • Proparacaine HCl (Ophthaine, Opthenic) • Tetracaine HCl (Pontocaine)
EYE LUBRICANTS - Replace tears or add moisture to the eyes - Moisten contact lenses or an artificial eye - Protect the eyes during surgery s urgery or diagnostic procedures - Used for keratitis, during anesthesia or in a disorder that results in unconsciousness or decreased blinking
SIDE EFFECTS
Burning in installation
Discomfort or pain in installation
NURSING CARE • Inform the client that burning may occur on installation • Be alert to allergic responses to the preservatives in the lubricants
MIOTICS - reduce IOP by constricting the pupil & contracting the ciliary muscle, thereby increasing the blood flow to the retina & decreasing retinal damage & loss of vision - open the anterior chamber angle & increase the outflow of aqueous humor - used for chronic open-angle glaucoma or acute & chronic closed-angle glaucoma - used to achieve miosis during eye surgery - C/I in clients with retinal detachment, adhesions between the iris & lens, or inflammatory diseases - used with caution in clients with asthma, hypertension, corneal abrasion,hyperthyroidism, abrasion,hyperthyr oidism, coronary vascular disease, urinary tract obstruction, GI obstruction, ulcer disease, parkinsonism, or bradycardia
MIOTICS MEDS MIOTIC - reduce IOP byCHOLINERGIC mimicking the action of acetylcholine MIOTIC ACETYLCHOLINE INHIBITORS MEDS
- reduce IOP by inhibiting the action of cholinesterase
Assess V/S & risk of injury Assess the client for the degree of diminished vision Monitor S/E & toxic effects Monitor for postural hypotension & instruct the client to change positions slowly • Assess breath sounds for rales & rhonchi - cholinergic meds cause bronchospasms & increased bronchial secretions • Maintain oral hygiene - due to increased salivation • Have Atropine sulfate available as antidote for Pilocarpine • Instruct the client regarding the correct administration of eye meds • Instruct the client not to stop the meds suddenly • Instruct to avoid activities such as driving while vision is impaired • Instruct clients with glaucoma to read labels on OTC meds & to avoid
OCUSERT SYSTEM - It’s a thin eye wafer (disk) impregnated with time-release time-release Pilocarpine - Devised to overcome the frequent application of Pilocarpine - Placed in the upper or lower cul-de-sac of the eye - Pilocarpine is released over 1 wk & disk is replaced every 7 days - Drawbacks of its use include sudden leakage of Pilocarpine, migration of the system over the cornea, & unnoticed loss of the system
NURSING CARE • Assess Assess the client’s client’s ability to insert the medication medication disk • Store the medication in the refrigerator refrigerator • Instruct the client to discard damage or contaminated disks • Inform the client that temporary stinging is expected but to notify MD if blurred vision or brow pain occurs • Instruct the client to check for the presence of the disk in the conjunctival co njunctival sac daily qHS & upon arising
• Since vision may change in the first few hours after the eye system is inserted, instruct the client to replace the disk at bedtime
BETA-ADRENERGIC BLOCKING EYE MEDICATIONS - Reduce IOP by decreasing sympathetic impulses & decreasing aqueous humor production without affecting accommodation or pupil size - Used to treat chronic open-angle glaucoma - C/I in the client with asthma - systemic absorption can cause increased airway resistance - Used with caution in the client receiving oral beta-blockers
BETA-ADRENERGIC BLOCKING EYE MEDICATIONS NURSING CARE • Monitor V/S before administering medication esp. BP & PR • If the pulse is below 60 or if systolic BP is below 90 mm Hg, withhold the medication & contact MD • Monitor for shortness of breath and I&O • Assess for risk of injury • Instruct the client to notify MD if shortness of breath occurs • Instruct not to D/C medication abruptly • Instruct to change positions slowly to avoid orthostatic hypotension • Instruct to avoid hazardous activities • Instruct to avoid OTC meds without the MD’s M D’s approval approval
ADRENERGIC EYE MEDICATIONS - Decrease the production of aqueous humor & lead to a decrease in IOP - Used to treat glaucoma
CARBONIC ANHYDRASE MEDICATIONS - Interfere with the production of carbonic acid which leads to decreased aqueous humor formation & decreased IOP - Used for long-term treatment of open-angle glaucoma - C/I in the client allergic to sulfonamides
SIDE EFFECTS
Appetite loss GI upset Paresthesias in the fingers, toes & face Polyuria Hypokalemia Renal calculi Photosensitivity Lethargy & drowsiness
Monitor V/S Assess visual acuity Assess for risk of injury Monitor I&O Monitor weight Maintain oral hygiene
• Monitor for side effects such as a s lethargy, lethargy, anorexia, drowsiness, polyuria, nausea, & vomiting • Monitor electrolytes for hypokalemia • Increase fluid intake unless C/I • Advise the client to avoid prolonged exposure to sunlight • Encourage the client to use artificial tears for dry eyes
Instruct not to D/C the medication abruptly • Instruct to avoid hazardous activities while vision is impaired
OSMOTIC MEDICATIONS - Lower IOP - Used in emergency treatment of acute closed-angle glaucoma - Used pre-op & post-op to decrease vitreous humor volume