Neurosesnsory EYES

7/30/2019 Neurosesnsory EYES

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Neurosesnsory

Mae G. Marcojos, RN


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Anatomy and Physiology EYES

Visual System

Eyes

Accessory structures

Eyebrows

Eyelids

Conjunctiva

Lacrimal apparatus

Extrinsic eye muscles

Sensory neurons


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Function of the Eye

Light refraction

Focusing of Images on the Retina


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Eyeball hollow filled sphere

Wall of eye

Fibrous tunic

Vascular tunic

Nervous tunic


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Layers: SCLERAE/ CORNEA

CHOROID

Ciliary Body Iris

RETINA Rods Cones

Blue GreenRed


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Chambers of the Eye

Anterior

Posterior

Vitreous


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Anatomy and Physiology

LENS

VITREOUS HUMOR

AQUEOUS HUMOR

Anterior Chamber

Posterior Chamber


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CONJUNCTIVAE

LACRIMAL GLAND

EYE MUSCLES

Rectus

Oblique

CRANIAL NERVES

CN II, III, IV, VI


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L Eye OS

R Eye OD

Both Eyes OU


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Muscles of the eyes 7 extrinsic muscles:

4 rectus

2 oblique

superior oblique for medial rotation so that it looksdownward and laterally

inferior oblique which turns eyeball upward andlaterally.

1 elevator palpatrae Conjuctiva highly vascular

Lacrimal apparatustears


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Test Vision:

Snellen Chart 20/20 numerator denoting thedistance in ft. at which the test is conducted

usually 20 ft. and the denominator, the distance at

which the smallest letters read on the Snellen

Chart should be seen by and average normal eye Opthalmoscope usually the pupil has to be

dilated with mydriatic. Changes in the optic nerve

head may indicate IOP


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Test Vision:

Biomicroscope/Slit lamp- an instrument used to

examine the anterior segment of the eye under

great magnification by means of binocular

microscope with a brillian beam of light forillumination.

Tonometer accurate measurement of intraocular

pressure (Normal = 11-21mmHg)

Perimeter for measuring the boundary of the

field of vision. Normal field of vision is 90 degrees.


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*Tunnel vision sign of increased IOP

glaucoma Bjerrums Tangent Screen to test central field of

vision

Ishihara color plate test for color blind peopleto identify 3 primary colors RBG

Gonioscopy- angle of the anterior chamber can be

seen


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Planning: Care of EYES

rise of drops should be diagnosed, tears

containing upozone (beta-lysine) IgA, IgG all odd

which inhibit bacterial growth

printed matter should be held at least 14 inchesfrom the eye. When watching TV, stay 10-12 ft

away from the screen.

read in an environment illuminated by bulbs of

100-150 watts. Light should come from behind

and should not reflect a glare


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client should be informed about danger signals of

visual disorders

Persistent redness of eyes

Continued discomfort or pain around the eyesespecially following an injury

Crossing of eyes esp in children

Visual disturbances such as blurred vision or spots

before eyes Continual discharge, crusting, or tearing of the eye

Pupil irregularities


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conjunctivitis- highly infectious

pinpoint pupil - pontine disorder

Normal pupil size 2-6 mm, PERRLA

anisocoria unequal pupils due to

Planning of health maintenance and

restoration


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Nursing Treatments:

Installation of eye drops head of pt should

be tilted backward and inclined slightly to the

site, ask the pt to look up, pull down his lower

lid and drop the medicine in the center of thelower cul-de-sac or space bet the eyeball and

inner surface of the lower lid


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Nursing Treatments:

Installation of eye ointments same as

above. Expel a small quantity of ointment

from the top of the tube without coming in

contact with the lid, beginning at the innercanthus and then moving outward


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Nursing Treatments:

Hot compress ordered for the effect of heat,

unless specified use NSS and temp should

beat or slightly above body temp 46oC to 49oC

Cold compress to help control bleeding and

edema


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Nursing Treatments:

Eye irrigation done to remove secretions to

cleanse the eye preop and to supply warmth

Massage of the eyeball used in treating

glaucoma esp following certain operations


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Meds

Ocular Meds:

Local anesthesia act to anesthetize the eyes and

then prevent pain during various ocular procedures

Topical Pontocaine 0.5%

Injectable Local Anesthetic Novocaine 1-2%,Xylocaine 1-2%

Parasympathetics produce effects resembling

stimulations of parasympathomimetic nerve. Used as

miotics, which causes the pupils to contract (used to

control IOP in glaucoma by widening the filtration

angle and permitting outflow of aqueous humor)


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Meds

mydriatic dilate

miotiocs for glaucoma

Group 1 Cholinergic drugs which acts

directly on the myoneural junction; producedstrong contraction of iris (miosis) and cilairybody musculature (accommodation); ex.

Pilocartine HCl 0.5-10% Group 2 Cholidesterase Inhibitors

anticholinesterase drugs; ex. Eserine


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Meds

Parasympatholytic drugs (anticholinergic

drugs)-produce effects resembling those of

interruption of parasympathetic nerve supply

to a part. Used to facilitate eye exam andrefraction. They cause smooth muscle of

ciliary body and iris to relax thus producing

mydriasis which causes the pupils to dilate &


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Meds

Cycloplegia-paralysis of muscles, resulting in

paralysis of accomadation

Mydriatics Meo-synjephrine 2.5%+10%;

eupthalmine 2%-5%

Cyclophegics atropine sulfate-0.5% hyosein

.25% homatropine hydrobromite 2-5%

cyclogyll


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Meds

Sympathomimetic drugs used primarily to producemydriasis and vasoconstriction, doent causecycloplegia, vasoconstriction increases outflow ofaqueous humor, thus reducing IOP (Adrenaline)

(1:1000) ex; Neosynephrine 1.125-10% Antibiotics Chloromycetin, Neosporin, polymycin(?) B sulfate, bacitracin

Sulfonamides Gantrisin 4%

Carbonic Anhydrase Inhibitors the enzyme isnecessary for the production of aqueous humor.Used as a tx for glaucoma to reduce formation ofaqueous humor and thus reduce IOP. Diuresis isproduced. Eg. Oratol, diamox


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Care of Contact Lenses:

May be hard of soft

(hydrophilic). They tend to

absorb chemicals, therefore

instructions are usually given

not to wear them while theyswim unless using goggles.


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EYE MEDICATIONS

Eye medications refer to drops,ointment, and disks.

PURPOSES:

Therapeutic Purposes

to lubricate the eye or socket fora prosthetic eye

to prevent or treat eye conditionsand infections


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EYE MEDICATIONS

Diagnostic Purposes

Eyedrops can be used to anesthetize the eye

Dilate the pupil

Stain the cornea to identify abrasions and scars.

Cross contamination is a potential problem with eyedrops.

The pt. should adhere to the following safety measures toprevent cross contamination:

each client should have his or her own bottle of eyedrops

discard any solution remaining in the dropper after installation discard the dropper if the tip is accidentally contaminated, as by

touching the bottle or any part of the clients eye


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EYE MEDICATIONS

ASSESSMENT:

Assess the five rights: right client, medication, route,dose, and time. (prevent errors in medicationadministration)

Assess the condition of the clients eye. Are there anycontraindications to administering the medication?(reassessing the client prior to every medication doseprevents possibly injuring the client)

Assess the medication order. (prevent errors inmedication administration)


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EYE MEDICATIONS

DIAGNOSIS:

Risk for injury

Knowledge deficit, related to medicationregime

Sensory/ perceptual alterations due to the

effects of eye medications


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EYE MEDICATIONS

PLANNING:

Expected Outcomes

The right client will receive the right dose of the rightmedication

via the right route at the right time.

The client will encounter the minimum of discomfortduring the

medication administration procedure.

The client will receive the maximum benefit from themedication.


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EYE MEDICATIONS

Equipment Needed:

Medication Administration Record (MAR)

Eye medication

Tissue or cotton ball

Nonsterile gloves (if needed)


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EYE MEDICATIONS

CLIENT EDUCATION NEEDED

Educate the client regarding the reason for thismedication, including the importance of taking theright dose at the right time.

Instruct the client in ways to prevent contaminationand cross contamination especially when using theeyedrops.

Teach the client to gently press the tear duct closed

while administering the eyedrops to prevent loss ofthe medication and possible systemic complications.


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EYE MEDICATIONS

IMPLEMENTATION

1. Check with the client and the chart for any known

allergies or medical conditions that would

contraindicate use of the drug.2. Gather the necessary equipments.

3. Follow the five rights of drug administration.

4. Take the medication to the clients room and placeon a clean surface.


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EYE MEDICATIONS

IMPLEMENTATION

5. Check clients identification.

6. Explain the procedure to the client; inquire if the

client wants to instill medication. If so, assess theclients ability to do so.

7. Wash hands, use nonsterile gloves if needed.

8. Place client in a supine position with the headslightly hyperextended.


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INSTILLING EYEDROPS1.Remove cap from eye

bottle and place cap on

its side.

2.Squeeze the prescribed

amount of medication

into the eyedropper.

3.Place a tissue below the

lower lid.

4. With dominant hand, hold

eyedropper - inchabove the eyeball, rest

hand on clients forehead

to stabilize.


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INSTILLING EYEDROPS5. Place hand on cheekbone

and expose lowerconjunctival sac by pullingdown on cheek.

6.Instruct the client to lookup and drop prescribed

number of drops intocenter of conjunctival sac.

7.Instruct client to gentlyclose eyes and moveeyes. Briefly place fingers

on either side of theclients nose to close thetear ducts and preventthe medication fromdraining out of the eye.


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EYE OINTMTENT APPLICATION

Lower Lid:1.With non dominant hand,

gently separate clientseyelids with thumb andfinger and grasp lower lid

near margin immediatelybelow the lashes;exert pressure downwardover the bony prominenceof the cheek.

2.Instruct the client to look up.3.Apply ointment along inside

edge of the entire lowereyelid, from inner to outercanthus.


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EYE OINTMTENT APPLICATION

Upper Lid:

1.Instruct the client to look down.

2.With nondominant hand,gently grasp clients lashes near

center of upper lid with thumband index finger, and draw lid upand away from eyeball.

3.Squeeze ointment along upper lidstarting at inner canthus.


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EYE IRRIGATION

Sterile Equipment:

Eyedropper

Asepto bulb syringe or plastic bottle with

prescribed solution

For copious use: sterile normal saline or

prescribed solution

IV set up with tubing


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EYE IRRIGATION

IMPLEMENTATION

PREPARATORY PHASE

1.Verify the eye to be irrigated and the solution

and amount of irrigant.2.The patient may sit with head tilted back or lie

in a supine position.

3.Instruct the patient to tilt head toward theside of the affected eye.


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EYE IRRIGATION

PERFORMANCE PHASE1.Wash eyelashes and lids

with prescribed solution

at room temperature; a

curve basin should beplaced on the affected

side of the face to catch

the outflow.

2.Evert the lowerconjunctival sac.

3.Instruct the patient to look

up; avoid touching eye

with equipment.


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EYE IRRIGATION

PERFORMANCE PHASE4.Allow irrigating fluid to

flow from the innercanthus to the outer

canthus along theconjunctival sac.

5.Use only enough forceto flush secretions

from conjunctiva.6.Ocassionally, have

patient close eyes.


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THE PUPILS

PERRLA

P upils

E qually

R ound

R eactive to

L ight and

A ccommodation


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Assessing Accommodation

Hold an object (pen or pencil) about 10 cms

from the bridge of the clients nose.

Instruct client to look at the top of the object

and then shift to distant object.

Pupils should constrict when looking at near

object and dilate when looking at far object.


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Assessing direct reaction to light

Partially darken the room.

Let patient look straight ahead.

Using a penlight, shine a light from the side of

one eye to the inner. Pupil should constrict in

response to light.

Repeat the process on the other eye.


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Assessing consensual reaction to light

Assessed by passing light on one eye while

observing for constriction of the pupil on the

other eye.


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DIAGNOSTIC ASSESSMENT

1. Snellen s ChartTests visual acuityNormal is 20/2020/200 legal blindness

bottom to up readingtest eyes separately

20 feet distance from the chart

20/20 at 20 feet person can read what anaverage person can read also

20/60 a person can read at 20 feet what anaverage person can read at 60 feet


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2. Ishihara PlateTests color vision

Uses series of plates with printed round colors

and patterns Normal color vision: person who are able to

discern specific numbers or patterns

Color perception deficiency: Inability toidentify a number or pattern


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Normal Color Vision Red-Green Color Blind

Left Right Left Right

Top 25

29

Top

25

Spots

Middle 45 56 Middle Spots 56

Bottom 6 8 Bottom Spots Spots


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3. RetinoscopyDetermines refractiveerror of an eye

Examiner shines a lightinto the pupillaryopening

Note the movementsof reflex which will varythe type of refractiveerror


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4. Cover-Uncover TestDifferentiates various types ofstrabismus

Types of Strabismus

Concomitant (Heterotropia)-eye adopt an abnormalposition in relation to eachother

Paralytic- shows limitedmovement; diplopia is alwayspresent


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5. Tonometry

Indirect measure of IOP

Normal is 11-21 mm Hg

Measuring of IOP by

determining the resistance

of the eyeball to indentation

by an applied force


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Noncontact tonometry (pneumotonometry).

Applanation (Goldmann) tonometry

Indentation (Schiotz) tonometry.

Electronic indentation tonometry

N i C


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Nursing Care

Anesthetic eyedrops are used for the methods that

involve touching a tonometer to your eye. Theeyedrops prevent you from feeling the instrumenttouch your eye. No numbing eyedrops are neededwhen an air-puff (noncontact) tonometer is used.

Results from tonometry are most accurate when you: Avoid drinking more than 2 cups of fluid 4 hours

before the test.

Avoid drinking alcohol for at least 12 hours beforethe test.

Avoid smoking marijuana for at least 24 hours beforethe test.


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6. GonioscopyMicroscopic examinationof the anterior chamberangle

Gonioscope- mirroredoptic instrument itpermits visualization ofthe angle by means of a

reflected image Diagnoses congenital

and secondary glaucoma


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7. Bjerrum Tangent Screen

Measures central vision


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8. OphthalmoscopyExamines the fundus of theeye

For visualization of thestructure of the eye at anydepth

Ophthalmoscope- includes a

light, a mirror with a singleaperture, and a dial holdingseveral lenses of varyingstrength


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9. Slit Lamp Biomicroscopy

Examines the anterior portion of the eye

Can diagnose astigmatism


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10. Red Reflex Test

A red reflex test will beone of the first eye testsyour baby receives,

when an eye doctorexamines reflectionsfrom the inner back ofthe eye (retina) to test

for possible presence ofeye disease.


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The red reflex test is used to screen for abnormalitiesof the back of the eye (posterior segment) andopacities in the visual axis, such as a cataract orcorneal opacity. An ophthalmoscope held close tothe examiners eye and focused on the pupil is usedto view the eyes from 12 to 18 inches away from thesubjects eyes.

To be considered normal, the red reflex of the 2 eyesshould be symmetrical.

Indications for referral to an ophthalmologist.

Dark spots in the red reflex

a blunted red reflex on 1 side

lack of a red reflex

or the presence of a white reflex (retinal reflection)


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Commonly-

RelatedDisorders

Injuries and

trauma Infections

Pterygium

Cataract

Glaucoma

Detachment of

Retina

INJURIES AND TRAUMA


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INJURIES AND TRAUMA

In general, when an eye injury is present, it is

advisable to treat patient but leave the eye alone

unless chemical injury has occurred and the eyeitself must immediately be flushed with water

Remove foreign particles: dont touch cornea

Irrigation: 15 mins before stopping to move the

patient or to get a doctor. If water is not available,use beer or carbonated beverages

INFECTIONS


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INFECTIONS

Hordeolum or sty infection of the zeis glandin the follicle of a lash

Chalazion involves a meibomian gland,

locate dint he lateral plate of the lid, Rx: I&D;an anti-bacterial ointment

Conjunctivitis caused by a wide variety ofbacteria, often called pink eye. May resultalso from bacterial infection, allergy, traumaas in sunburn and viruses


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INFECTIONS


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INFECTIONS

Uveitis inflammation ofiris

Keratitis Inflammation ofcornea

PTERYGIUM

A triangular fold ofmembrane which forms inconjunctiva which tendfrom white of the eye tothe cornea - outgrowth


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CATARACT

opacity of the crystalline lens or of its capsule

which interferes with transparency Signs and symptoms:

dimness of visual acuity

rapid and marked changes or refraction error


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CATARACT

Classifications: Primary or senile begins first in one eye and then

the other eye from 45 years on, it is rare that thisbecomes unilateral; occur as degenerative changeswith age

Secondary or traumatic due to some disease orinjury of the eye; ex. DM, traumatic cataract due todirect blow or due to exposure to intense light

Congenital not seen at time of birth but when

defective vision comes evident during childhood.Associated with attack of German measles in themother during 1st trimester of pregnancy


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CATARACT TREATMENT

Intracapsular extraction lens is removedwithin its capsule

Extracapsular extraction lens capsule is

excised and the lens is expressed by pressurein the eye from below with a metal spoon

Cryoextraction cataract is lifted from the eyeby a small probe that has been cooled totemperature below zero to the next surface ofthe cataract


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CATARACT TREATMENT

Phacoemulsification - incision just large

enough to insert a needle probe that vibrates

40,000 times per sec to break up the lens and

flush it out in tiny suction


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CATARACT TREATMENT

Enzymatic zonumolysis a technique that

invoves injecting alpha-chymotrypsin, a

fibrinolytic and proteolytic enzyme into the

anterior chamber. The enzyme frees theattachment of the monules to the lens capsule

and thereby facilitate removal of the lends

without tearing the lens in the process ofremoving it


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CATARACT TREATMENT

Intraocular lens implantation of a synthetic

lens designed for distance upon, the patient

wears prescribed glasses for reading and near

vision. It is an alternative to sight correctionwith glasses or contact lenses for the aphakic

patient


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Pre-Op Nursing Care:

orient the pt to his new environment

begin rehab as soon after admission

deep-breathing exercises, instruct how to

close eyes without squeezing the lids

reduce conjunctival edema use of antibiotics

prepare affected eye for surgery, instill

mydriatics if ordered *use sterile technique


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Post-Op Nursing Care:

reorient pt to surroundings prevent inc IOP and stress on the suture line

promote pt comfort: mild analgesic to controlpain

observe and treat for complications: nausea and vomiting use of anti-emetic drugs and

cold compress

hemorrhage notify physician if pt complains of

sudden pain in the eye prolapse of the iris most common post-op

complication and can precipitate acute glaucoma


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promote the rehab of the pt:

encourage pt to become independent

walk with pt when first become ambulatory

health teachings

use dark glasses

temporary corrective glasses may be

prescribed 1-4 weeks after surgery


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permanent lenses will be prescribed 6-8wks

after the surgery the glasses will take the

place of the crystalline lens. In 6mos time the

eyes have made the necessary adjustment pt should know that it will take time to learn

to judge distance, climb stairs, and do other

simple things


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color of objects seen with lens removed is

slightly changed

ambulatory pt should have slip-on slippers to

avoid bending/stooping. Peripheral vision isdecreased, so that the pt needs to be taught

to turn his head and utilize central vision

provided by the lenses.


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GLAUCOMA

eye disease characterized by inc IOP assoc

with progressive loss of peripheral vision

Cause: obstruction to the circulation of

aqueous humor through the meshwork at theangle of the anterior chamber of the eye

where the peripheral iris and cornea meet


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GLAUCOMA

Types: Chronic simple or wide open angle glaucoma

Cause: heredity predisposition to the thickening of themeshwork

Signs and Symptoms: Loss of peripheral vision (tunnel vision) before central visions

Difficulty in adjusting to darkness

Failure to detect changes in color

Tearing

Misty visions

Headache

Pain behind the eye

Nausea and vomiting


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GLAUCOMA: Treatment

Miotics eg. Pilocarpine to construct the pupil and to drawthe smooth muscle of the iris away from the canal of schlema

to permit aqueous humor to drain out. Drops are prescribed at

early AM since IOP is usually higher on arising on AM.

Acetazolamide (Diamox) to reduce formation of aqueoushumor

Avoid fatigue/stress

Avoid drinking large quantities of fluid

GLAUCOMA T


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GLAUCOMA: Treatment

Certain limitations are not necessary-may drink normalamounts of coffee and tea

Surgery the principle is to drain the drainage of the

intraocular fluid or aqueous humor thereby lessening the

pressure of the eye Iridecleisis formation of the fistula bet the anterior chamber

and the subjunctival space

Corneoscleral trephening of Elliots operation small opening

is made at the junction of the cornea and sclera leaving apermanent opening through which aqueous humor may drain

GLAUCOMA T


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GLAUCOMA: Treatment

Langranges operation sclerectomy sclera is excised

combined with irridectomy

Dyclodialysis new passage within eye itself is made from

the anterior chamber to the supracholoidal space. The

principle of operation employing low voltage and high

frequency

Trabeculectomy and trabeculotomy excision of a rectangle

of the sclera that includes the trabeculae sclemas and scleral

spur

Non surgical laser therapy approx 50-100 beams areapplied to the pigmented band of the tubular meshwork

resulting to permanent increase in tension on the trabeculum

and open the outflow channel

A t l l l


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Acute angle closure glaucoma

result of abnormal displacement of iris against the angle ofthe anterior chamber; rare May be

Congenital

Secondary - from other existing eye problems like uveitis or trauma or

post op complications Absolute end-result of uncontrolled glaucoma

Signs and Symptoms: severe eye pain

nausea and vomiting

abdominal pains

blurred vision colored halos around the lights

dilated pupils

inc IOP

A t l l l


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Acute angle closure glaucoma

Treatments:

Myotics

Diamox

Glycerol to reduce pressure

Iridectomy portion of iris is removed

*iridotomy-butas para madrain yung abnormal

accumulation of aqueous fluid


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Terms:

Enucleation removal of the eye, rectus

muscle are attached to implant to provide

most of prostheticExenteration- removal of eye plus

surrounding structures

Evisceration-removal of contents of the eye

except sclera

C ft l


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Care after glaucoma surgery:

Miotics

Flat and quiet for 24 hrs prevents prolapse of

iris (like putting trochanter roll for head)

Use of narcotics or sedatives to keep patient

quiet and comfortable

Liquid diet until first dressing

Turn on non-operative side

*drug of choice: Demerol

DETACHMENT OF RETINA


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Occur when layers accumulate excessively andelevation of both retinal layer away fro the

choroids as in the presence of tumor

Causes: myopic degeneration



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Signs and Symptoms:

floating spots of opacities before the eye dt

blood and retinal cells that are freed at the

time of the tear

cast shadows on the retina as they seem to

drift about the eye,

flashes of light

progressive obstruction of vision in one eye

T t t


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Treatment:

Conservative quiet in bed with eyes covered to tryto prevent further detachment

Non-surgical method employed to seal retinalbreaks before retina becomes detached

Photocoagulation small burn made in retina byshining very bright light

Cyrotherapycold probe

Surgical methods aimed at sealing the retinal break,reattaching the retina and preventing the retina from

detaching Scleral buckling - fluid that has an accumulation

under the retina and the wall of the eye is buckled

P t O C


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Post-Op Care

Eyes are covered to prevent ocular movement

Positioned so that the area of detachment is

dependent

Pupils dilated by mydriatics

Discharge instructions:

avoid strenuous exercise and activity for 6 mos

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