Nursing care of patient with eye disorders Glaucoma Cataract 1

Glaucoma assessment Refers to ocular conditions that are characterized by optic nerve damage. Is a leading cause of irreversible blindness. Is called the silent thief of sight; Aqueous humor flows between Iris and lens; nourishing cornea and lens. Most of fluid flows out of anterior chamber through trabecular meshwork; 10 % through ciliary body –suprachoroidal space—venous circulation open angle 45 degree between Iris and cornea; a narrow angle places the iris closer to the trabecular meshwork. Many types: open-angle glaucoma; angle closure glaucoma; congenital glaucoma;the most common is open angle (see Table 58-3, P. 2056). Patients may not seek medical attention until experience blurred vision or halos around lights, loss of peripheral vision; aching around the eye 2

Pathophysiology continues Assessment focuses on 4 examination Tonometry: to measure the intraocular pressure Ophthalmoscopy: to inspect the optic nerve Gonioscopy: to examine the filtration angle of the anterior chamber Perimetry: to assess the visual field Changes in damaged optic nerve—pallor an cupping of optic nerve disc

Glaucoma medical management The goal is to Prevent optic nerve damage; lifelong therapy is necessary Maintain IOP within a range unlikely to cause further damage Pharmacologic therapy : Topical beta blockers are preferred initially; One eye is treated The other is used as control to evaluate efficacy of the treatment Ocular medictions: Miotics (Cholinergics): increases aqueous fluid outflow by contracting ciliary muscle Epinephrine, adrenergic agonist: reduces production of aqueous humor & increases outflow Timolol, Beta blockers: decreases production of aqueous humor Read Table 58-4, P 1771. 4

Laser trabeculoplasty: Other approaches Laser trabeculoplasty: Laser burns applied to the inner surface of the trabecular meshwork to Open the intra-trabecular space & widen canal of Schlemm Ongoing assessment of IOP Laser iridotomy for pupillary block glaucoma—an opening is made in the iris to eliminate the block; Potential complications: burns to cornea, lens or retina Filtering procedure: creating opening or fistula in the trabecular meshwork to drain aqueous humor from anterior chamber to sub- conjunctival space; This allows aqueous humor to flow & exit a) mixing with tears or b) absorbed by conjunctival vessels Drainage implant / shunt 5

Glaucoma nursing management Patient education: importance of strict adherence to medication lifelong A thorough assessment including problems to compliance Discuss medications program; because of interaction effect: diuretic effect of Acetazolamide, Diamox, on antihypertensive agents— hypokalemia Miotics & sympathomimetics result in altered focus; cautious about navigating surroundings Assistance in ADLs because of loss of peripheral vision Assurance & emotional support Read chart 58-7,P. 1771. for patient education. 6

Is lens opacity or cloudiness Cataract Is lens opacity or cloudiness A major cause of blindness in the world (WHO, 2002) Research links cataract to Lower income and educational level Smoking 35-packs or more a year High triglycerides in men Visual impairment progresses in both eyes at the same rate over years or months Read 58-8, P. 1772. for cataract risk factors 7

Clinical manifestations: painless blurry vision Cataract Clinical manifestations: painless blurry vision Patients perceive surrounding as dimmer—as glasses requires cleaning Reduced sensitivity to glare, reduced visual acuity Medical management: No non-surgical treatment cures cataract Smoking, long use of corticosteroids, DM increase risk for cataract 8

Cataract surgical management The person’s visual and functional status should be considered Surgery is performed in outpatient basis It take less than 1 hour; and discharge within 30 minutes Injection-free topical & intraocular anesthesia; small incision to the cornea is safe with minimal invasion When both eyes have cataract; one is treated first. Weeks and preferably months separate the 2 procedures Surgery can be done through different approaches 9

Cataract preoperative nursing management Routine blood tests, urine analysis A common practice is to withhold anticoagulant therapy 5-7 days before surgery; unless at risk for ischemic attack Four doses of Dilating drops are administered every 10 minutes; 1 hour before surgery Additional dilating drops may be administered in the operating theater Antibiotics, anti-inflammatory may be administered prophylactically 10

Cataract postoperative care Wear protective pad for 24 hours Teaching how to administer medications; recognize complications Minimal discomfort—analgesics Eyeglasses during day; metal shield during night, for 1-2 weeks A clean, damp washcloth for morning discharge Complication of cataract surgery—retinal detachment: teach to notify physician if new floaters; flashing lights; decreases in vision Read Table 58-5, P. 1774, for complications of cataract surgery. 11

Home-related instructions Wash hands before cleaning the postoperative eye Clean the postoperative eye with a clean tissue; wipe the closed eye from inner canthus outward Avoid lying on the side of the affected eye the night after surgery Keep activity light (walking, reading, watching TV) Not to lift or push objects heaver than 15 lb Avoid bending for an extended period Read chart 58-9; P. 1776