Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chapter 49 Care of Patients with Eye and Vision Problems

2 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Eyelid Disorders  Blepharitis  Inflamed, itchy, red  Greasy scales on brows and lids  Entropion  Inward turning of lid; lashes rub against eye  Surgical correction required  Ectropion  Outward turning of lid  Surgical correction required

3 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Eyelid Disorders (cont’d)  Hordeolum  Internal or external stye  Chalazion  Inflammation of sebaceous gland in eye What are common approaches to care for eyelid disorders?

4 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Ophthalmic Ointment

5 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Blepharitis

6 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Entropion vs. Ectropion

7 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Hordeolum

8 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chalazion

9 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Keratoconjunctivitis Sicca  “Dry eye syndrome”  Changes in tear composition, lacrimal gland malfunction, or altered tear distribution  Artificial tears, lubricating ointment  Surgery

10 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Conjunctival Hemorrhage  Small, well-defined area of bright red hemorrhage under conjunctiva  No pain  No visual impairment  Resolves in 14 days without treatment

11 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Conjunctivitis

12 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Trachoma  Chronic, bilateral scarring form of conjunctivitis  Caused by Chlamydia trachomatis  Chief cause of preventable blindness  Infection control

13 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Corneal Disorders  Corneal abrasion, ulceration, infection  Keratoconus  Cataract

14 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Corneal Transplantation

15 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Eye Donation  Corneal tissue from donors  Donors must be free of infectious disease or cancer at time of death  Care of potential eye donors at death:  Elevate head of bed 30 degrees  Apply antibiotic eyedrops  Close eyelids; apply small ice pack

16 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Cataract  Clouding and blurring of lens  Opacity makes it difficult to see retina  Visual acuity restricted  No pain or eye redness

17 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Cataract (cont’d)

18 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Cataract Surgery

19 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Cataract Surgery (cont’d)  Preoperative  Intraoperative  Postoperative

20 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Postoperative Care  Antibiotics given subconjunctivally  Eye is unpatched, discharge usually occurs within 1 hour  Dark glasses required  Instill antibiotic-steroid eyedrops  Mild itching normal  Pain indicates complications  Reduce IOP  Prevent infection  Assess for bleeding

21 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Community-Based Care  Home care management  Teaching for self-management  Health care resources

22 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Health Teaching  Signs of complications:  Sharp, sudden pain in eye  Bleeding or increased discharge  Lid swelling  Decreased vision  Flashes of light or floating shapes  Avoid activities that might increase IOP  Review procedure for use of eyedrops

23 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Glaucoma  Increased ocular pressure  Cupping and atrophy of optic disc  Symptoms:  Headache or brow pain  Nausea and vomiting  Colored halos around lights  Sudden blurred vision with decreased light perception  Types:  Primary open-angle glaucoma  Angle-closure glaucoma

24 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Diagnostic Tests  Tonometry  Perimetry  Gonioscopy  Optic nerve imaging

25 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Glaucoma Drug Therapy  Types  Patient teaching plan:  How eyedrops work  How to administer  Monitor for side effects  Compliance, timely dosing

26 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Other Eye Disorders  Macular degeneration  Mild blurring and visual distortion  Refractive errors  Myopia, hyperopia, presbyopia, astigmatism  Trauma  Hyphema, contusion, foreign bodies, laceration, penetrating injuries  Vitreous hemorrhage  Ocular melanoma

27 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Reduced Vision  Interventions:  Communication about use of adaptive items  Safety in familiar settings  Ambulation assisted with care  Promote self-care and independence  Support for difficulty of adapting to lost sight

28 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. A 78-year-old patient tells you that over the past 18 months he has noticed a decrease in visual acuity in his left eye. He states that he initially thought he had smudges on his eyeglasses, but when the cloudiness in his vision continued to develop, he saw his doctor who referred him to an ophthalmologist. Upon assessment, it was determined that he has a large cataract that requires surgical removal. The patient asks you why the cataract only affected his left eye. What is your best response?

29 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. After seeing the ophthalmologist, the patient is scheduled for cataract surgery. What preoperative teaching should you provide? A. Instruct him that after surgery, different types of eyedrops will be prescribed for 2 to 4 weeks. B. Remind him that immediately after surgery he will have his best vision. C. Tell him that after surgery he will no longer need to wear eyeglasses for reading. D. Caution him to avoid wearing dark glasses because the retina needs a direct source of light for best vision. (cont’d)

30 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. After the patient’s cataract surgery has been completed, he has been brought to the recovery area. You are preparing to administer eyedrops and other medications. Which order for the patient would you question? A. Antibiotic ophthalmic ointment B. Steroid ophthalmic ointment C. Acetaminophen with oxycodone D. Warfarin (Coumadin) (cont’d)

31 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. After recovery, you provide postoperative teaching for the patient. Which statement by the patient indicates a need for further teaching? A. “I will wear dark sunglasses.” B. “Aspirin will help decrease discomfort.” C. “My daughter will help me if I need to lift something.” D. “My surgeon needs to know if I am experiencing reduced vision.” (cont’d)

Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Chapter 49 Audience Response System Questions 32

33 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Question 1 What are postoperative expected outcomes for a patient who has undergone surgery for cataract removal? A. Pain early after surgery accompanied by nausea and vomiting B. Change in visual acuity accompanied by tearing and redness C. Yellowish drainage and photophobia D. Mild itching and bloodshot appearance

34 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Question 2 Which is a priority intervention after a patient receives a corneal transplant? A. Keeping the eye covered for the first 24 hours postoperatively B. Avoiding straining to have a bowel movement C. Keeping the eye moist D. Assessing the eye for signs of infection

35 Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Question 3 Which patient is at greatest risk of developing primary angle-closure glaucoma? A. 32-year-old Caucasian female B. 42-year-old Hispanic/Latino male C. 52-year-old Asian female D. 64-year-old African-American male