vision

• Assessment


  • Patient History
  • Physical
• Patient History


  Gender, Occupation, systemic health conditions, medication, Nutrition, Family history
• Occupation

  • blue light on computer, machine operators w/risk for injury and wearing appropriate protection, chronic exposure to UV light
• Systemic health conditions


  • diabetes, HTN, stroke, RA, lupus, aids, MS
• Medications


  • antihistamines, decongestant (dry out eye), corticosteroids, eg, prednisone for RA (increase intraocular pressure, can cause cataracts)
• Nutrition


  • vitamin A (dryness and blindness), lutein (antioxidant), beta keratin (help with retinal function), fruits and vegetables dark green leafy vegetables, eye caps, 10 of these foods daily in adult
• Physical Inspection


  symmetrical, equal distance from nose
• Visual Testing


  snellen chart, thyroid conditions, exophthalmos (protruding of eye), enophthalmos (sunken eye); ptosis drooping of eyelid
• Visual Testing


  1. distance and near vision

  2. Snellen Chart (20 ft back from reading chart and cover one eye and read the smallest letter)

  3. Visual Field (intraocular motion, when can u see my finger to check peripheral vision)

  4. Ishihara Chart (assesses for color blindness, number with tiny dots of colors and pt tells you what number they see)
• Assessment


  1. Tonometry (looks at pressure in eye, preferred to detect glaucoma)

  2. Ophthalmoscope (internal parts of eye)

  3. Structures Assessed (retina assessed, red reflex)
• Refractive Errors


  focusing light on the retina based on the shape
• Refraction


  bending of the light rays
• Myopia (Nearsightedness)


  Eye over refracts the light and bent images fall in front of the retina - not on the retina; near vision normal and distant vision poor
• Hyperopia (Farsightedness)


  Refraction is too weak - images get focused behind the retina; near vision is poor, distance is good
• Presbyopia


  Loss of lens elasticity causing images to fall behind retina; Commonly starts in 30s and 40s; Why we need corrective reading glasses, cannot see close
• Astigmatism


  Uneven curve of cornea causing an image to not focus on the retina
• Terminology


  • Hyperopia
  • Myopia
  • Astigmatism
  • Miosis (pupil constricted when exposed to increased light or close work, such as reading)
  • Mydriasis (pupil dilated when exposed to reduced light or when looking as a distance)
  • Presbyopia (changes in eye with older adults with narrow visual field cannot read small print)
  • Photophobia (sensitivity to light)
• Cataracts


  Lens opacity that distorts the image projected onto the retina, see blurry as a result, experience decreased color perception
• Cataracts

  • Age related - lens loses water and increases in density, lens fibers compressed, lens proteins dry out and form crystals, increased density causes the lens to become opaque and results in painless loss of transparency of the lens; no pain just not as good of vision
• Risk factors for cataracts


  • Heavy sun exposure
  • Trauma
  • Diabetes
  • Medications (steroids)
• Clinical manifestations of cataracts


  • Slight blurred vision
  • Decrease color perception
  • Blurry vision, diplopia(double vision)
• Without surgical treatment, visual impairment from cataracts can progress to blindness
• Cataract treatment


  1. When patient can no longer complete ADLs safely = surgery necessary

  2. Cataract surgery = usually done in ambulatory setting or eye clinical

  3. Surgery = Phacoemulsification (sound waves break up the lens, pieces are sucked out, and the capsule remains largely intact; sometimes replacement lens)
• Pre-operative care for cataract surgery


  1. Administer eye drops several times a day for 2-4 weeks before procedure

  2. Stop anticoagulant meds

  3. Meds given to help dilate pupil and also causes vasoconstriction & paralysis

  4. Local anesthetic injected into muscle in eye so they can remover cataract
• Postoperative care after cataract surgery


  1. Wear dark glasses in bright environment until pupil responds to light

  2. Instruct on eye drop installation (decrease lid, don't touch applicator to eye)

  3. Report significant swelling/bruising (normal but if there's a lot make sure report it)

  4. Tylenol for mild pain (aspirin should be avoided bc of risk for bleeding)

  5. Report headaches accompanied by n/v

  6. Instructions for bathing/washing hair

  7. Activity restrictions (that increase intraocular pressure, lifting heavy and bending at the waist, try to control sneezing, coughing, blowing nose, straining (stool softener)< vomiting, sexual intercourse should be avoided)

  8. Monitor for s/s of infection (eye redness, decrease in vision, increase in any tear formation and photophobia, greenish drainage)

  9. Antibiotics and steroids

  10. Bloodshot appearance and itching normal, cold compress for discomfort

  11. Wash hair 1-2 days after surgery but make sure not getting into eyes so teach patient to put head back and rinse it out

  12. Issues with IOP= report right away. Headache, NV, pain in eyes call HCP
• Glaucoma


  Group of eye disorders resulting in increased intraocular pressure (IOP)
• Normal IOP


  Requires balance between production and outflow of aqueous humor
• High IOP


  Compression on retinal blood vessels and photoreceptors (rods, cones) and their synapsing nerve fibers, leading to poor oxygenation of photoreceptors and nerve fibers, ischemic nerve tissues, and nerve tissue death, resulting in loss of sight and permanent blindness
• Types of Glaucoma


  • Primary open angle glaucoma (POAG)
  • Primary angle closure glaucoma (PACG)
• Primary open angle glaucoma (POAG)

  Most common, usually affects both eyes and no symptoms early in disease, marked by reduced outflow of aqueous humor through the chamber angle
• Primary angle closure glaucoma (PACG)


  Less common, sudden onset, emergency, narrowed angle and forward displacement of iris = iris presses against cornea and closes the chamber angle = outflow of aqueous humor obstructed
• Clinical Manifestations of Primary Open Angle Glaucoma


  • Gradual onset of symptoms
  • Gradual loss of visual fields
  • Occasional foggy vision, reduced accommodation, mild aching in eyes or headaches, may require frequent changes to prescription lenses
  • Late manifestations: halos around light, loss of peripheral vision, decreased vision not improved with prescription lenses
• Clinical Manifestations of Primary Angle Closure Glaucoma


  • Sudden, severe pain around eyes radiating over face
  • Colored halos around lights, sudden blurred vision and decreased light perception
  • Sclera reddened and cornea foggy
  • Moderately dilated non reactive pupil
• Diagnostic


  1. Ophthalmoscopic exam (cupping/atrophy of the optic disc)

  2. IOP measured by tonometry (open angle glaucoma = 22-32 mmhg, angle closure glaucoma = > 30mmhg)
• Nonsurgical Treatment for Glaucoma


  • Medication that constricts the pupil so ciliary muscle is contracted which allows better circulation of the aqueous humor to the site of absorption
  • Medication that reduces production or increases absorption of aqueous humor
• Eye drop medications for Glaucoma


  • Prostaglandin agonists (Latanoprost-Xalatan)
  • Adrenergic agonists (Brimonidine tartrate - Alphagan)
  • Beta-adrenergic blockers (Timolol-Timoptic)
  • Cholinergic Agonists (Pilocarpine-Ocusert)
  • Carbonic Anhydrase Inhibitors (Brinzolamide- Azopt)
• Common side effects of medicated eye drops


  Tearing, mild burning, red sclera and blurred vision for a few minutes after instilling
• Patient education for eye drop use


  1. Teach to instill drops on time daily and not skip dose

  2. With more than one eye drop, instruct patients to wait 5 to 10 minutes between med installations to prevent one drug from washing out the other

  3. Stress good hand hygiene and avoidance of touching the tip of the container to the eye

  4. Teach to apply pressure on the corner of the eye near the nose to prevent systemic absorption
• Surgical Treatment for Glaucoma


  1. Used when drugs for open-angle glaucoma not effective in lowering IOP

  2. Two common surgical procedures
• Eye drop instillation


  • Wait 5 to 10 minutes between med installations to prevent one drug from washing out the other
  • Stress good hand hygiene and avoidance of touching the tip of the container to the eye
  • Apply pressure on the corner of the eye near the nose to prevent systemic absorption