Eye and Ear w/ Meds

• Glaucoma

  Group of ocular conditions characterized by optic nerve damage
• Glaucoma


  • Caused by increased intraocular pressure (IOP) or optic neuropathy
  • Second leading cause of blindness in US adults
  • More prevalent in > 40 years; More in African Americans than Caucasians
  • No cure
• Aqueous humor flow

  1. Flows between the iris and the lens then out the anterior chamber into the canal of Schlemm and the episcleral veins

  2. Unimpeded outflow depends on an intact drainage system and an open angle between the iris and the cornea
• Aqueous humor and IOP

  • Amount of aqueous humor decreases with age and with diabetes and ocular inflammation conditions
  • When aqueous humor production = drainage, then IOP is within normal
  • When aqueous humor isn't draining = increased IOP
• IOP


  • Changes with time of day, exertion, diet and medications
  • Increases with blinking, tight lid squeezing and upward gazing
  • Diabetes and intraocular conditions (uveitis and retinal detachment) are associated with increased IOP
• Pathophysiology of glaucoma


  • Direct Mechanical Theory: High IOP damages the retinal layer as it passes through the optic nerve head
  • Indirect Ischemic Theory: High IOP compresses the microcirculation in the optic nerve head = cell injury and death
  • Most are a combination
• Clinical manifestations of glaucoma


  May not seek care until: Blurred vision, See "halos" around lights, Difficulty focusing, Difficulty adjusting eyes in low lighting, Loss of peripheral vision, Aching or discomfort around eyes, Headache
• Stages of glaucoma


  • Initiating Events
  • Structural Alteration in the Aqueous Outflow System
  • Functional Alterations
  • Optic Nerve Damage
  • Visual Loss
• As optic nerve damage increases, visual perception in the area is lost
• Goal of glaucoma treatment


  • Prevent optic nerve damage
  • Glaucoma cannot be cured
  • Maintain IOP within range unlikely to cause further damage
  • Try to lower IOP by 30% and more if needed
• Pharmacologic therapy for glaucoma


  • Beta-Blockers
  • Cholinergics (miotics)
  • Adrenergic agonists
  • Alpha Agonists
  • Prostaglandin analogues
  • Carbonic Anhydrase Inhibitors
• Beta-Blockers


  • Preferred initially due to efficacy, minimal dosing and low cost
  • Blockade of sympathetic nerve endings in ciliary epithelium causing fall in aqueous humor production
  • Side effects: decreased BP, decreased pulse and fatigue
• Cholinergics (miotics)


  • Increase the outflow of the aqueous humor by affecting ciliary muscle contraction and pupil constriction allowing flow through a larger opening between the iris and the trabecular meshwork
  • Increase drainage of intraocular fluid by making pupil size smaller thereby increasing fluid from eye
  • Side effects: dim vision especially at night or in darkened areas due to constriction of pupils
• Adrenergic agonists and Alpha Agonists


  • Increase aqueous outflow, but primarily decrease aqueous production
  • Side Effects: Can burn and sting with eye drop, fatigue, headache, drowsiness, dry mouth and dry nose
• Prostaglandin analogues


  • Reduce IOP by increasing aqueous humor outflow
  • Side effects: Eye redness, corneal deposits, stinging, small bleeds in the white of the eye
• Carbonic Anhydrase Inhibitors

  • Reduce eye pressure by decreasing production of intraocular fluid
  • Side effects of pill – tingling and loss of strength in hands and feet, upset stomach, mental fuzziness, memory problems, depression, kidney stones, frequent urination
  • Side effects of eye drops – stinging, burning, eye discomfort
• If the drugs don't work, surgical management is required
• Nursing management of glaucoma

  • Teaching plan concerning medication regimen
  • Miotics and sympathomemetics = altered focus, need to be cautious when moving around
  • If blindness is worsening or legally blind, help with ADLs and referrals for help
  • Reassurance and emotional support
• Cataracts


  • A lens opacity or cloudiness
  • 3rd leading cause of disability in older adults
  • Leading cause of blindness in the world
  • About one in six of people over 40, more than half of people over 80
• Pathophysiology of cataracts


  • Can develop in one or both eyes at any age
  • Causes: Aging, Associated Ocular Conditions, Toxic Factors, Nutritional Factors, Physical Factors, Systemic Diseases and Syndromes
• Types of senile cataracts


  • Nuclear
  • Cortical
  • Posterior Subcapsular
• Clinical manifestations of cataracts

  • Painless, blurry vision
  • Perceives that surroundings are dimmer
  • Light scattering is common
  • Reduced contrast sensitivity, sensitivity to glare, and reduced visual acuity
  • Myopic shift, Astigmatism, monocular diplopia, color shift, brunescens and reduced light transmission
• Decreased visual acuity is directly proportionate to cataract density
• Only surgical treatment, no nonsurgical treatment cures or prevents age-related cataracts
• Cataract surgery


  1. Outpatient surgery, usually takes 1 hour

  2. One eye at a time with several weeks to months in between
• Preoperative nursing management


  • CBC, EKG, UA and other tests specific to patient
  • To give or not to give anticoagulant?
  • Dilating drops every 10 minutes for four doses at least 1 hour before surgery
  • Antibiotic, corticosteroid, and anti-inflammatory drops for postoperative infection and inflammation prevention
• Postoperative nursing management


  • Verbal and written instructions
  • Protection of eye
  • Medication administration
  • Signs of complications
  • Emergency care
  • Should be minimal discomfort, can take Tylenol
  • Antibiotic, anti-inflammatory, and corticosteroid eye drops or ointment are prescribed
• Teaching self-care after cataract surgery

  • Wear a protective eye patch x 24 hours
  • Then, wear eyeglasses during the day and metal shield at night x 1-4 weeks
  • May have some slight morning discharge, some redness and a scratchy feeling x a few days
  • Notify physician if develop new floaters (dots) in vision, flashing lights, decrease in vision, pain, or increase in redness
• Continuing care after cataract surgery


  • May experience blurring of vision for several days to weeks
  • Sutures, if necessary, are left in the eye and may result in some blurring and some astigmatism
  • Vision gradually improves as eye heals
  • Vision stabilizes after 6-12 weeks when eye is healed and final corrective prescription is completed
• Retinal detachment


  • Separation of the retinal pigment epithelium (RPE)
  • Four types: Rhematogenous, Traction, Rhematogenous/Traction Combination, Exudative
• Rhegmatogenous retinal detachment


  • Hole or tear develops in the sensory retina allowing liquid vitreous to seep through the sensory retina and detach it from the retinal pigment epithelium
  • Risk factors: Family History, High myopia (nearsightedness), Aphakia after cataract surgery, Trauma, Proliferative retinopathy, Associated with diabetic neovascularization
• Traction retinal detachment


  • Caused by tension or pulling force
  • Generally, have fibrous scar tissue from diabetic retinopathy, vitreous hemorrhage, retinopathy of prematurity
• Exudative retinal detachment


  • Result of serous fluid under the retina from the choroid
  • Caused by uveitis and macular degeneration
• Clinical manifestations of retinal detachment

  • Sensation of a shade or curtain coming across the vision of one eye
  • Cobwebs
  • Bright flashing lights
  • Sudden onset of a great number of floaters
  • No complaint of pain
• Pneumatic retinopexy


  1. Gas bubble is injected into eye so the bubble presses against the detached retina and pushes it back into place

  2. A laser or cryotherapy is then used to reattach the retina firmly into place
• Nursing management of retinal detachment


  • Education and Supportive Care
  • Increased IOP
  • Signs and symptoms of Endophthalmitis (inflammatory condition of the intraocular cavities: the aqueous and vitreous humor)
  • More Retinal Detachments
  • Cataracts
  • Signs and symptoms of Postoperative Infection
• Symptoms of endophthalmitis

  • Visual loss
  • Eye pain/irritation
  • Headache
  • Photophobia
  • Ocular Discharge
  • Intense Ocular and Periocular Inflammation
• Postoperative positioning for pneumatic retinopexy


  • Prone or as instructed
  • Need the injected bubble to float into a position overlying the area of detachment providing constant pressure to reattach the sensory retina
  • Cannot fly - change in altitude causes bubble to expand and increase pressure inside the eye
• Specific signs and symptoms to monitor for retinal detachment


  • Bright flashes of light
  • Floating dark spots = "Floaters"
  • Partial: "Curtain drawing over visual field" sensation
  • Loss of vision
• Nursing actions for retinal detachment


  1. Restrict activity to prevent additional detachment

  2. Cover affected eye with patch

  3. Monitor for drainage

  4. Administer medications as prescribed (Mydriatics (dialating); Antiemetics; Analgesics)

  5. Avoid activities that increase IOP: Bending over at the waist, Sneezing, coughing, Straining, Vomiting, Head hyperflexion, Wearing restrictive clothing (like a tight collar)