EYE DISORDERS

PRESENTED BY CARMELITA RAMOS, RN

ANATOMY AND PHYSIOLOGY OF THE EYE

External Anatomy of the Eye

Lacrimal Apparatus of the Eye

Anatomy of the Eyeball Fibrous Tunic:

Cornea Sclera

Vascular Tunic
Choroid coat Ciliary Body (Ciliary muscle, Ciliary process) Iris

Nervous Tunic
Retina

Accessory structures of the Eye from a sagittal view

Internal Anatomy of the Eye

CATARACT

CATARACT
a clouding that develops in the crystalline lens of the eye or in its envelope, varying in degree from slight to complete opacity and obstructing the passage of light. The condition usually affects both the eyes, but almost always one eye is affected earlier than the other. derives from the Latin cataracta meaning "waterfall" and the Greek kataraktes and katarrhaktes, from katarassein meaning "to dash down" (kata-, "down"; arassein, "to strike, dash") In dialect English a cataract is called a pearl, as in "pearl eye" and "pearl-eyed".

Epidemiology
Age-related cataract is responsible for 48% of world blindness, which represents about 18 million people, according to the World Health Organization (WHO). In many countries surgical services are inadequate, and cataracts remain the leading cause of blindness The increase in ultraviolet radiation resulting from depletion of the ozone layer is expected to increase the incidence of cataracts.

History
The earliest records are from the Bible as well as early Hindu records. Early cataract surgery was developed by the Indian surgeon, Sushruta (6th century BCE). The Indian tradition of cataract surgery was performed with a special tool called the Jabamukhi Salaka, a curved needle used to loosen the lens and push the cataract out of the field of vision. The eye would later be soaked with warm butter and then bandaged. The Muslim ophthalmologist Ammar ibn Ali of Mosul performed the first extraction of cataracts through suction. He invented a hollow metallic syringe hypodermic needle, which he applied through the sclerotic and extracted the cataracts using suction.

Classification
Classified by etiology
Age-related cataract
Cortical Senile Cataract

Immature senile cataract (IMSC): partially opaque lens, disc view hazy Mature senile cataract (MSC): Completely opaque lens, no disc view Hypermature senile cataract (HMSC): Liquefied cortical matter

 Congenital cataract

Classification

Secondary cataract Traumatic cataract

Bilateral cataracts in an infant due to Congenital rubella syndrome

Drug-induced cataract (e.g. corticosteroids), DM Blunt trauma (capsule usually intact) Penetrating trauma (capsular rupture & leakage of lens materialcalls for an emergency surgery for extraction of lens and leaked material to minimize further damage)

Causes
Age Long term exposure to UV light Cigarette smoking Heavy alcohol use Eye injury or inflammation Congenital defect DM Medications

What does a mid-stage cataract look like?

What does a late-stage cataract look like?

Pathophysiology
The lens is a clear part of the eye that helps to focus light, or an image, on the retina The lens is made mostly of water and protein. The protein is normally arranged to let light pass through and focus on the retina. Protein clumps together (aging process= degeneration) Small areas of lens begin to cloud Light is blocked from reaching the retina and vision is impaired Over time, the cloudy area in the lens may get larger

Signs and symptoms

Cloudy or blurry vision. Colors seem faded (Decreased color perception) Glare. Headlights, lamps, or sunlight may appear too bright. A halo may appear around lights. Poor night vision. Double vision or multiple images in one eye. (This symptom may clear as the cataract gets larger.) Absence of red reflex Better near vision in those who are farsighted as the lens becomes cloudier the optics of the eye change this may actually allow people who once needed glasses to be able to read without them

Cataract Detection/diagnosis
Eye examination Visual acuity test: This eye chart test measures how well you see at various distances Pupil dilation: the pupil is widened with eye drops to allow your eye doctor to see more of the lens and retina and look for other eye problems Tonometry: This is a standard test to measure fluid pressure inside the eye

TREATMENT
The symptoms of early cataract may be improved with:

new eyeglasses

brighter lighting anti-glare sunglasses magnifying lenses

TREATMENT
CONT.
If these measures do not help:

surgery is the only effective treatment.

Surgery involves removing the cloudy lens and replacing it with an artificial lens.

different types of cataract surgery

Phacoemulsification, or phaco. extra-capsular (extracapsular cataract extraction, or ECCE) intra-capsular (intracapsular cataract extraction, or ICCE).

1. Phacoemulsification,

or phaco.

A small incision is made on the side of the cornea, the clear, dome-shaped surface that covers the front of the eye. Your doctor inserts a tiny probe into the eye. This device emits ultrasound waves that soften and break up the lens so that it can be removed by suction. Most cataract surgery today is done by phacoemulsification, also called "small incision cataract surgery."

Extra-capsular (ECCE) surgery consists of removing the lens but leaving the majority of the lens capsule intact. Intra-capsular (ICCE) surgery involves removing the entire lens of the eye, including the lens capsule, but it is rarely performed in modern practice.

 After the natural lens has been removed, it often is replaced by an artificial lens, called an intraocular lens (IOL). An IOL is a clear, plastic lens that requires no care and becomes a permanent part of your eye. Light is focused clearly by the IOL onto the retina, improving your vision. You will not feel or see the new lens.

diagnoses
Anxiety

Deficient knowledge (diagnosis and treatment) Disturbed sensory perception: Visual Risk for infection Risk for injury

Interventions

Postoperatively, monitor the patient until he recovers from the effects of the anesthetic. Keep the side rails of the bed up, monitor vital signs, and assist him with early ambulation. Apply an eye shield or eye patch postoperatively as ordered. Communication enhancement: Visual deficit; Activity therapy; Cognitive stimulation; Environmental management; Fall prevention; Surveillance: Safety

Nursing Care Plans For Cataract Home Health:

Caution him to avoid activities that increase intraocular pressure, such as straining with coughing, bowel movements, or lifting Clients fitted with cataract eyeglasses need information about altered spatial perception. The eyeglasses should be first used when the patient is seated, until the patient adjusts to the distortion.

Instruct the client to look through the center of the corrective lenses and to turn the head, rather than only the eyes, when looking to the side. Clear vision is possible only through the center of the lens. Hand-eye coordination movements must be practiced with assistance and relearned because of the altered spatial perceptions.

RETINAL DETACHMENT

- a painless, gradual loss of vision described as a veil, curtain, or cobweb that eliminates a portion of the visual field. - occurs when the layers of the retina separates from the choroid, creating a subretinal space where fluid accumulates. - a medical emergency where time is of the essence. Unless the detached retina is promptly surgically reattached, it may lead to permanent loss of vision. Causes - degenerative changes in the retina or vitreous - a tumor e.g. retinoblastomas - inflammation - systemic disease e.g. diabetes - high myopia - cataract surgery - trauma

RETINAL DETACHMENT

TYPES:

PARTIAL RETINAL DETACHMENT

- becomes complete if left untreated

COMPLETE RETINAL DETACHMENT

- when detachment is complete, blindness may occur

RETINAL DETACHMENT

Diagnostic tests
Opthalmoscopy done by fully dilating the pupil for proper diagnosis retina becomes gray and opaque from transparent reveals folds in the retina and a ballooning out of the area Ultrasonography performed when lens is opaque

 Signs and Symptoms

IMMEDIATE RETINAL DETACHMENTNURSING CARE Complete bed rest

Flashes of light Floaters Increase in blurred vision Sense of curtain being drawn Loss of a portion of the visual field

Restriction of eye movement to prevent further detachment with eye patches

Speak before approaching

Position the clients head as prescribed

Protect from injury

No sudden head movements

Minimize eye stress

Prepare for surgical procedure as prescribed

RETINAL DETACHMENT
MEDICAL INTERVENTION
- removing or draining fluid from the sub-retinal space so that the retina can return to its normal position SCLERAL BUCKLING

holds the choroid and retina together with a splint

SEALING RETINAL BREAKS BY CRYOSURGERY (CRYOPEXY)

using an intense cold to freeze the retina around the tear reattaching it to the choroid a local anesthetic numbs the eye then a freezing probe is applied to the outer surface of the eye directly over the retinal defect

INSERTION OF A GAS OR SILICONE OIL

it promotes attachment because air/oil have a specific gravity less than vitreous & can float against the retina

RETINAL DETACHMENT

RETINAL DETACHMENT DIATHERMY

the use of electrode needle

& heat through the sclera to stimulate an inflammatory response leading to adhesions

LASER THERAPY

during photocoagulation, a laser beam is directed through a special contact lens to make burns around the retinal tear creating a scar to weld the retina to the underlying tissue

 POST-OP NURSING CARE

RETINAL DETACHMENT Monitor hemorrhage

Prevent N&V and monitor for restlessness which can cause hemorrhage Monitor for sudden, sharp eye pain (notify the MD stat) Encourage DBE but avoid coughing Provide bed rest 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 limit reading for 3-5 weeks 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

Maintain eye patches bilaterally

Glaucoma

Glaucomanerve is damaged, leading to is a disease in which the optic

progressive, irreversible loss of vision. It is often, but not always, associated with increased pressure of the fluid in the eye Glaucoma is characterized by high IOP associated with optic disk cupping and visual field loss The nerve damage involves loss of retinal ganglion cells in a characteristic pattern has been nicknamed the "silent thief of sight" because the loss of vision normally occurs gradually over a long period of time and is often only recognized when the disease is quite advanced

Normal outflow through trabecular meshwork (large arrow) and uveoscleral routes (small arrow) and related anatomy.

 Open-angle Glaucoma

Signs and symptomsnot have acute It is painless and does

attacks. The only signs are gradually progressive visual field loss, and optic nerve changes (increased cup-to-disc ratio on fundoscopic examination).

Closed-angle Glaucoma characterized by sudden ocular pain seeing halos around lights red eye very high intraocular pressure (>30 mmHg) nausea and vomiting, sudden decreased vision fixed, mid-dilated pupil Acute angle closure is an ocular emergency.

Glaucoma classified according to etiology

Chronic angle-closure
Primary glaucoma
Open-angle glaucoma Angle-closure glaucoma

Siderosis

Congenital glaucoma Secondary glaucoma

Trauma

Neovascular glaucoma
Open-angle, trabecular abnormality

Congenital Glaucoma
Onset: antenatally to 2 years old

Symptoms Irritability Photophobia Epiphora Poor vision

Signs Elevated IOP Buphthalmos Haabs striae Corneal clouding Glaucomatous cupping Field loss

Congenital Glaucoma Buphthalmos and cloudy corneas

Congenital Glaucoma
Buphthalmos, glaucomatous cupping, and cloudy cornea OD

Normal OS

Haabs striae

pathophysiology

The major risk factor for most glaucomas and focus of treatment is increased intraocular pressure In primary open-angle glaucoma, aqueous outflow by these pathways is diminished

In angle-closure glaucoma, the iris is abnormally positioned so as to block aqueous outflow through the anterior chamber (iridocorneal) angle.

Normal optic disc. Note the distinct optic disc margins, the well-demarcated cup, and the healthy pink color of the neuroretinal rim.
The cup-to-disc ratio of this optic nerve is 0.6. Clinical correlation with the patient's history and examination is required to decide if this optic nerve is abnormal. Glaucomatous optic nerve cupping. The cup in this optic nerve is enlarged to 0.8, and there is typical thinning of the inferior neuroretinal rim, forming a "notch."

Causeshypertension (increased pressure Ocular - Risk Factors

within the eye) African descent are three times more likely to develop primary open angle glaucoma. Elder people have thinner corneal thickness and often suffer from hypermetropia family history of glaucoma "secondary glaucomas (steroid-induced glaucoma), DM, hypertension, ocular trauma (angle recession glaucoma); and uveitis genetics

Diagnosis

eye examination Tonometry optical coherence tomography (OCT), scanning laser polarimetry (GDx), scanning laser ophthalmoscopy also known as Heidelberg Retina Tomography (HRT3)

GLAUCOMA
Tonometry

Applanation

Schiotz

GLAUCOMA
Goldmann applanation tonometer

GLAUCOMA
Tonopen

GLAUCOMA
Goldmann perimeter Glaucoma visual fields

THE VISUAL FIELD

Humphrey automated perimetry

GLAUCOMA
Early

Visual fields in glaucoma

Late

GLAUCOMA
Cup-to-disk ratio

GLAUCOMA DISK CUPPING

Normal Glaucoma

Management

The modern goals of glaucoma management are to avoid glaucomatous damage, nerve damage, preserve visual field and total quality of life for patients with minimal side effects.

Medication
The possible neuroprotective effects of various topical and systemic medications are also being investigated. Prostaglandin analogs like latanoprost (Xalatan), bimatoprost (Lumigan) and travoprost (Travatan) increase uveoscleral outflow of aqueous humor. Bimatoprost also increases trabecular outflow Topical beta-adrenergic receptor antagonists such as timolol, levobunolol (Betagan), and betaxolol decrease aqueous humor production by the ciliary body. Alpha2-adrenergic agonists such as brimonidine (Alphagan) work by a dual mechanism, decreasing aqueous production and increasing trabecular outflow. Less-selective sympathomimetics such as epinephrine decrease aqueous humor production through vasoconstriction of ciliary body blood vessels. Miotic agents (parasympathomimetics) like pilocarpine work by contraction of the ciliary muscle, tightening the trabecular meshwork and allowing increased outflow of the aqueous humour. Ecothiopate is used in chronic glaucoma. Carbonic anhydrase inhibitors like dorzolamide (Trusopt), brinzolamide (Azopt), acetazolamide (Diamox) lower secretion of aqueous humor by inhibiting carbonic anhydrase in the ciliary body. Physostigmine is also used to treat glaucoma and delayed gastric emptying.

Surgery
Canaloplasty- an incision is made into the eye to gain access to Schlemm's canal in a similar fashion to a viscocanalostomy Laser surgery
Laser trabeculoplasty Trabeculectomy

Glaucoma drainage implants Laser assisted non-penetrating deep sclerectomy