NCM 216 LEC: EENT

PRELIMS – LECTURE 2

2nd SEMESTER | A.Y. 2022 – 2023

EYES: REFRACTIVE ERROR  Asses how visual impairment can affect

OUTLINE normal functioning
 Provide emotional support for recent visual
I. Errors of refraction impairment
II. Cataracts
 Orient to the environment
III. Glaucoma
IV. Retinal Management
V. Macular degeneration
CATARACTS
VI. Strabismus or Double vision  Opacity or cloudiness of the normally
VII. Ocular melanoma transparent crystalline lens
VIII. Ocular emergencies  Lens protein dries out and forms crystal
 AKA “pearl eye”
ERRORS OF REFRACTION
 In refractive errors, vision is impaired which SIGNS AND SYMPTOMS
prevents light rays from focusing sharply in the
retina a. EARLY
 Emmetropia  Painless blurred vision
 Ametropia  Decreased color perception
b. LATE
TYPES OF REFRACTIVE ERROR  Opaque or cloudy white pupil
 MYOPIA  Vision that is better in dim light with
 Nearsightedness; has excessive refractive pupil dilation
strength; focuses light in front of the retina  Gradual loss of vision progressing to
 Near objects can be seen clearly but distant blindness
objects require diverging lens in front of the  Absence of red reflex
eye
DIAGNOSTIC EXAMS
 Treatment: concave lens
 HYPEROPIA  Standard Ophthalmic Exam
 Farsightedness  Visual acuity test
 focuses light at the back of the retina  Eye movement, and Peripheral vision
 Treatment: convex lens  Color blindness
 PRESBYOPIA  Pupil dilation Tonometry
 Old sight  Slit-lamp exam
 Inability to accommodate for near vision SURGICAL MANAGEMENT
due to loss of elasticity of crystalline lens  EXTRACAPSULAR CATARACT
 Treat with bifocal lens reading glasses EXTRACTION (ECCE)
o Removal of the lens while the
SURGICAL MANAGEMENT posterior chamber is left intact for the
a. LASIK (LASER IN SITU implantation of IOL
KERATOMILEUSIS) – uses an excimer o may be performed with:
laser to cut or reshape the cornea  Manual expression
b. ICR (INTRASTROMAL CORNEAL RING)  Phacoemulsification – the lens
– are small devices implanted to correct is broken up vibrations &
vision extracted through aspiration
c. PHAKIC INTRAOCULAR LENS – lens  INTRACAPSULAR CATARACT EXTRACTION
that are made of plastic or silicon; (ICCE)
implanted permanently o the lens is removed within its capsule
BLINDNESS AND LEGALLY BLIND through a small incision
NURSING MANAGEMENT
 Total blindness
PRE-OP
o No light perception and no usable
vision  Instruct measure to prevent increased IOP:
 Functional blindness avoid lifting heavy objects, bending lower than
o Has light perception but no usable waist, reading
vision  Administer pre-op eye medications: mydriatics
 Legally blind or cycloplegics (Atropine) – for pupil dilation to
o Central visual acuity for distance of better visualize the retina
20/200 POST-OP
NURSING MANAGEMENT  Elevate head of the bed 30-45 degrees
 Turn client to the back or un-operative side

BSN 3D
  Pharmacologic: antibiotics, steroids  Progressive loss of peripheral vision “tunnel
(TobraDex), Acetaminophen vision”
 No aspirin due to clotting effects  Followed by a loss of central vision
 Instruct measures to prevent or decrease IOP  Vision worsening in the evening with difficulty
 Wear glasses during the day until the pupils adjusting to dark rooms
respond to light  Blurred vision
 Eye shield at night or while sleeping  Halos around white lights
 For minor pain: ice or heat as prescribed  Frontal headaches
 Shower or bathing is allowed  Photophobia
 Care of the dressing  Increased lacrimation
 Stool softeners DIAGNOSTIC EXAMS
 Istruct to report pain with nausea and vomiting  Tonometry
C– lean post-operative eye  Ocular examination
 Visual field testing
A– analgesics
 Gonioscopy
T– obradex MANAGEMENTS
 For acute glaucoma: treat as medical
A– void lying on operative side emergency
R– report complications  Administer medications as prescribed to lower
IOP
T– he use of eye shield o MIOTICS (Pilocarpine)
o CARBONIC ANHYDRASE INHIBITOR
A– advice hygiene
( Acetazolamide )
GLAUCOMA o BETA-BLOCKERS (
• A group of disorder that all have increased Timolol/Betaxolol )
intraocular pressure, leading to damage to the optic  Use cautiously to patient with
nerve structure with resulting visual field loss asthma and CHF
 Sympathomimetics
• Normal IOP: 12-20 mmHg o Drug of choice to patient with asthma
TYPES OF GLAUCOMA and CHF ( Epinephrine )
SURGICAL MANAGEMENT
1. Open Angle Glaucoma
 Aka Chronic, simple/wide-angle glaucoma  Peripheral Iridectomy
 Most common  Trabeculectomy
 Early stage; asymptomatic & bilateral  Iridotomy
 The fluid cannot leave the eye at the same NURSING MANAGEMENT
rate it is produced — IOP gradually  Maintain on CBR
increases  Administer meds as ordered
 First s/sx; cloudy vision, lessened  Assist according to degree of visual
accommodation, loss of peripheral vision, impairment
persistent dull pain in the morning, failure  Provide emotional support
to detect color accurately  Avoid mydriatics
2. Closed Angle Glaucoma  Prepare patient for surgery
 Aka “narrow-angle glaucoma” or acute
glaucoma RETINAL MANAGEMENT
 Less common  Occurs when the layers of the retina separate
 Movement of the iris against the cornea because of accumulation of fluid between
narrows or closes the chamber angle, them
obstructing the outflow of AH  Also occurs when both retinal layers elevate
 Causes sudden onset of unilateral eye away from the choroid as a result of a tumor
pain with BOV and possibly nausea and  A medical EMERGENCY
vomiting  Types:
 IOP of 40-65 mmHg o Partial Retinal Detachment- localized
SIGNS AND SYMPTOMS o Complete Retinal Detachment- entire
EARLY: retina
CAUSES
 Elevated IOP
 Diminished accommodation  Degenerative changes in the retina vitreous
LATE:  Trauma, inflammation, or tumor
 Diabetic retinopathy

BSN 3D
 Myopia and loss of a lens from a cataract  Metamorphosia (distortion of vision)
extraction ( aphakia ) DIAGNOSTIC EXAMS
DIAGNOSTIC EXAMS Amsler Grid Test
 Ophthalmoscopy
 Slit-lamp exam  A pattern of intersecting lines with a black dot
 Gonioscopy in the middle. The central black dot is used for
fixation (a place for the eye to stare at).
IMMEDIATE NURSING CARE MANAGEMENT
 Provide bedrest Surgical:
 Cover both eyes with patches to prevent
 Laser macular photocoagulation
further detachment
 Photodynamic therapy (PDT)
 Speak to the client before approaching
Pharmacologic:
 Position the client’s head as prescribed
 Protect the client from injury  Pegaptanib (Macugen)
 Avoid jerky head movements  Ranibizumab (Lucentis)
 Minimize eye stress Nursing Interventions:
 Prepare the client for surgical procedure as
prescribed  Discuss strategies or modifications to carry out
usual activities
SURGICAL MANAGEMENT  Assist with self activities
 SEALING RETINAL BREAKS BY  Engage support people in assistance with
CRYOSURGERY patient activity
o A cold probe applied to the sclera to  Advice patient to memorize environment while
stimulate an inflammatory response some vision is intact
leading to adhesions  Use side rails as needed, and make sure that
 DIATHERMY the patient can call for help if need
o The use of electrode needle and heat  Rest eyes as needed
through the sclera to stimulate an  Green leafy vegetables with lutein
inflammatory response leading to STRABISMUS or DOUBLE VISION
adhesions  “SQUINT EYE” / “CROSSED EYE”
 LASER THERAPY  The eyes are not aligned because of lack of
o To stimulate an inflammatory muscle coordination of the extraocular muscle
response to seal small retinal tears  Normal in the young infant but should not be
before the detachment occurs present about 4 months
 SCLERAL BUCKLING Risk Factors
o To hold the choroid and retina
together with a splint until scar tissue Family history
forms closing the tear Farsightedness
MACULAR DEGENERATION In children:
 Age-related macular degeneration is a medical o Unknown
condition that results in a loss of vision in the o congenital rubella
center of the visual field ( the macula ) o Cerebral palsy
because of damage to the retina o retinopathy of prematurity
 The most common cause of irreversible central o traumatic brain injury
vision loss in persons over 60 o hemangioma near the eye
2 forms:  In adults:
o Diabetes
 Dry (nonexudative) - slow onset; macular
o traumatic brain injury
cells start to atrophy
 Wet (exudative) - rapid onset; development of o injuries to the eye
abnormal blood vessels around the macula o stroke
RISK FACTORS DIAGNOSTIC TESTS
 Retinal exam
 Related retinal aging  Ophthalmic exam
 Genetics  Visual acuity
 long term exposure to UV lights  Neurologic exam
 hyperopia
 cigarette smoking Treatment
Manifestations
 Glasses
 Blurred or darkened vision  Eye patch
 Scotomas (blind spots in visual fields)  Eye muscle exercise

BSN 3D
 OCULAR MELANOMA swab over the particle and remove
 CANCER of the EYE it
 Melanocytes produce the dark-colored  Blink several times to let particles
pigment melanin move out
 found in many places in our body, including  If specks remain, keep eyes
the skin, hair, and lining of the internal organs, closed
including the eye 5. Hyphema
ETIOLOGY:  Management: bed rest in semi fowlers
position
 Unknown  Avoid sudden movements for 3-5 days
 ultraviolet (UV) rays  Eye patch and shields
 dysplastic naevus syndrome  It may resolve in 5-7 days
 ocular melanocytotic  Cycloplegic medications to rest the
Manifestations: eyes injured
 blurred vision
 flashing lights and shadows
 change in Iris color
 red and/painful eye
 loss of peripheral vision
DIAGNOSTIC EXAMS
 Ophthalmoscopy
 Ultrasound
 MRI/CT scan
MANAGEMENT
 Radiotherapy – achieved by external beam
performed in repeated doses for several days
 Transpupillary thermotherapy – a method of
delivering heat through the dilated pupil into
the posterior segment of the eye using a diode
laser
OCULAR EMERGENCIES
 Conditions that necessitate early action to
prevent severe or permanent damage to the
eye
 It occurs from accidents and from debris in the
air

1. Blows to the Eye

 Apply cold compress for about 15
minutes to reduce swelling and pain
and help prevent bleeding
2. Chemical burns
 Immediately flush eye with water,
normal saline or ophthalmic irrigation
solution for minimum of 15-20 minutes
 Using fingers to keep eye open as
wide as possible
3. Penetrating objects
 Do not attempt to wash or remove
object stuck in the eye
 Do not apply pressure to the eye
injured
 Be careful not to rub
4. Foreign bodies
 Never rub a speck or particle in
the eye
 Have the client look upward,
expose the lower lid, wet a cotton-
tipped applicator with sterile
normal saline, and gently twist the

BSN 3D