Disorders of the eye

Isaac Amankwaa

Definition of Terms

Vision: Passage of rays of light from an

object through the cornea, aqueous
humor, lens, and vitreous humor to the
retina, and its appreciation in the
cerebral cortex.
Emmetropia: Normal vision: rays of
light coming from an object at a distance
of 20 feet (6 m) or more are brought to
focus on the retina by the lens.
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Definition of terms

Ametropia: Abnormal
vision.
Myopia: Nearsightedness
Hyperopia: Farsightedness

I. Amankwaa

Definition of terms

Accommodation: Focusing apparatus of

the eye adjusts to objects at different
distances by means of increasing the
convexity of the lens (brought about by
contraction of the ciliary muscles).
Presbyopia: The elasticity of the lens
decreases with increasing age; an
emmetropic person with presbyopia will read
the paper at arm's length and will require
prescription lenses to correct the problem.
I. Amankwaa

Definition of terms

Astigmatism

refractive error in which

light rays are spread over
a diffuse area rather than
sharply focused on the
retina, a condition caused
by differences in the
curvature of the cornea
and lens

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Definition of terms

Enucleation: complete removal of the eyeball and part of the optic nerve
exenteration: surgical removal of the
entire contents of the orbit, including the
eye- ball and lids
evisceration: removal of the intraocular
contents through a corneal or scleral
incision; the optic nerve, sclera, extraocular
muscles, and sometimes, the cornea are left
intact
I. Amankwaa

Common Abbreviations

OD (oculus dexter) or RE - right eye

OS (oculus sinister) or LE - left eye

OU (oculus unitas)both eyes

IOPintraocular pressure

IOLintraocular lens

EOLextraocular lens
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EYE CARE SPECIALISTS

Ophthalmologist: Physician specializing in diagnosis,

surgery, and treatment of the eye.
Ophthalmology specialists may focus their practice on
a specific part of the eye or disorder, such as a cornea
specialist or glaucoma specialist.
Optometrist: Doctor of optometry who can examine,
diagnose, and manage visual problems and diseases of
the eye, but does not perform surgery.
Optician: Fits, adjusts, and gives eyeglasses or other
devices on the written prescription of an ophthalmologist
or optometrist.
Ocularist: Technician who makes ophthalmic prostheses.
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NURSING CARE OF
PATIENTS UNDERGOING
EYE SURGERY
I. Amankwaa

Specific pre-op care

Physical Orientation

Assist the patient to learn details of his

room such as the location of furniture,
doors, windows, and so forth.
Familiarize patient with the voices of
those who will care for him after
surgery.
Familiarize him with the daily sounds
and noises in the environment, since
he will beI.more
aware of sound
without
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Specific pre-op care

Observation

The patient should be observed for

tendencies to cough or sneeze
(smoker's cough, allergies, and so
forth).

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Specific pre-op care

Education.The patient must understand

the objective of resting the eyes & avoiding
actions that increase intraocular pressure.

The head must be kept very still.

No reading.
No showers, no shampooing, no tub baths.
No bending over at the waist.
No lifting of heavy objects.
No sleeping on the operative side. If both eyes
are affected, the patient must sleep on his back.
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Specific pre-op care

Physical Preparation.

Instruct patient to wear dark glasses if

atropine drop have been used
A bowel prep is done the evening prior
to surgery to prevent the patient from
straining at stool during the immediate
post-op period.
Prepare the affected eye by cleaning
the skin of the side of the face
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Specific pre-op care

Physical Preparation.

Shaving of eyebrows, cutting of

eyelashes, and shaving of face should be
done only on the order of the surgeon.
After the patient has been taken to
surgery, prepare a post-op bed, ensuring
that the bed is equipped with side rails.
Sand bags should be made available for
use in immobilizing the head.
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Post-operative care

Return from Surgery.

The patient must be lifted off the

stretcher, he is not to move himself.
The patient should be positioned on
his back or turned to the un-operated
side or as prescribed by the
physician.
Sandbags should be used to
immobilize the patient's head, if
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Post-operative care

Return from Surgery.

If both eyes are bandaged (they

normally are), the side rails MUST be
raised at all times to protect the
patient in the event he becomes
disoriented and attempts to get out of
bed.
Place the call bell within easy reach of
the patient's head and let the patient
know exactly where it is located.
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Post-operative care

Return from Surgery.

Remind the patient that he should not

cough, sneeze, or blow his nose.
him to inform the staff if he feels the
urge, since these actions will increase
intraocular pressure.
Eye pad and eye shield should be
kept in place
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Post-operative care

Orientation.

Reinforce the physical orientation given

during the preoperative period by
verbally reviewing the locations of
objects in the room.
Orient the patient to other people in the
room.
The patient should have an awareness of
his surroundings and know what to
expect to avoid being startled or
frightened.
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Post-operative care

Precautions.

Avoid dislodgement of the eye

dressings by securing them with an
eye shield or reinforcing loose tape.
Restrain the arms of children and
disoriented or uncooperative patients,
as appropriate. Avoid jarring or
bumping the bed, as this may startle
the patient
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Post-operative care

Precautions.

A sleeping patient must be watched

constantly to ensure that proper
positioning is maintained.
If the patient is newly blinded as a
result of the surgery, observe for
depression and take precautions if
patient is potentially suicidal
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Post-operative care

Precautions.

Check the physician's orders before

giving anything by mouth.
Nausea and vomiting must be
avoided.
Additionally, the motion of chewing
may be contraindicated

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Post-operative care

Approaching the Patient

ALWAYS speak to the patient upon entering

his area and before touching him.
Allay the patient's fears by explaining each
procedure or activity fully.
Continue to reinforce his orientation to the
surroundings.
Always let the patient know when you are
leaving his area.
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Post-operative care

Diversional Activity.

Provide activities that are not

fatiguing to the eyes if the eyes are
not bandaged.

No reading
Minimal television
Encourage visitors to chat with the
patient or read to him.

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DISORDERS OF THE EYE LID

Hordeolum (stye)
Chalazion (Meibomian cyst)
Blepharitis
Entropion
Ectropon

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Structure of the eyelid

The eyelid is made up of the

Skin

Muscle layer

it is thin and characterized by absence of fat.

Orbiclaris oculi consist of horizontal concentric fibres.
levator palpebral superioris.The end in an aponeurosis
which is inserted
Tarsus Consists of dense fibers tissue.Embidded in it are
enormously developed sebaceous glands-the meibomian
glands.

Mucous layer

formed by the palpebral conjunctiva

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Structure of the eyelid

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Glands of the eyelid

Meibomian glands: They are embedded in the

tarsus and are modified sebaceous glands. They
secret an oily secretion. They open through
vertically arranged ducts into the lid margin.
Glands of zeis: They are sebaceous glands
developed as outgrowth of the hair follcles of
the eye lashes. They are situated at the margin.
Glands of moll: These are modified sweat
glands

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Eyelid margin

Eye lashes-arranged in 2-3 rows

anteriorly.
Opening of the ducts of the
meibomian gland posteriorly.
Glands of zies and moll

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INFLAMMATION OF THE
EYELID
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Hordeolum

The term stye refers to an

inflammation or infection of the
glands and follicles of the eyelid
margin
There are two types

External Hordeolum (stye)

Internal Hordeolum

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Hordeolum

External hordeolum (stye)

Acute bacterial infection of the lash

follicle and its associated gland of Zeis
or Moll

Internal hordeolum

Acute bacterial infection of Meibomian

gland Infection usually staphylococcal

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Acute
hordeola
Internal hordeolum
( acute chalazion )

Staph. abscess of
Meibomian glands

External hordeolum (stye)

Staph. abscess of lash follicle

and gland of Zeis or Moll
Tender swelling at lid margin
Tender swelling
May discharge through skin May discharge through skin
or conjunctiva

Hordeolum s/s
1.

Red swelling appears in the lash

line of the margin of the lid

2.

Pain

3.

tenderness

4.

edema of the lids

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Hordeolum

Diagnosis

Visual exam
culture if needed

Treatment

Hot compress to alleviate pain

Topical or systemic antibiotics

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Hordeolum

Treatment and Nursing

Consideration

warm soaks to promote drainage,

good hand washing and eyelid
hygiene
Topical or systemic antibiotics
In some cases, incision and drainage
may be necessary.
Teach patient how to clean eyelid
Amankwaa
marginsI. and
not to squeeze35the stye.

CHALAZION (MEIBOMIAN CYST)

Definition

A chalazion is noninfectious
obstruction of a meibomian gland
causing extravasation of irritating
lipid material in the eyelid soft tissues
with focal secondary granulomatous
inflammation.

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CHALAZION (MEIBOMIAN CYST)

Etiology, Pathology

The meibomian duct becomes obstructed

through proliferation of its epithelium
and consequently the gland enlarges.

The fatty secretion escapes into the

surrounding tissue
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Chalazion

Diagnosis

Visual Examination

Treatment

small ones usually disappear spontaneously

after a month or two
large ones usually need surgical removal

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Treatment of chalazion

Injection of local anaesthetic Insertion of clamp

Incision & curettage

Difference between
chalazion and hordeolum

Chalaziatend to develop farther from

the edge of the eyelid than styes.
Chalazion often larger thanstye,
chalaziausually isn't painful.
Chalazion is not caused by an
infection from bacteria,
Sometimes, when a astyedoesn't
heal, it can turn into achalazion
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PTERYGIUM

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Definition of pterygium

A pterygium is a fleshy growth

that invades the cornea. It is an
abnormal process in which the
conjunctiva grows into the cornea.

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Pterygium

There are two types:

1.

Progressive Pterygium:
These types of pterygium are those
which progress day by day.

2.

Non Progressive Pterygium:

Those which after limited growth has
been occur than stop their generation
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Pterygium- causes

The exact cause is not known.

The probable causes are:
i.
Commonly occurs in people living in
hot & dry climate.
ii.
Dusty atmosphere.
iii.
Common in outdoor workers.
iv.
Common in males.
v.
It may occur nasal than temporal
side.
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symptoms

Redness

Irritation

Dryness

Tearing

May cause decreased vision ( when it

reaches the visual axis of cornea)
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Treatment
1.

Local:
i.
ii.

2.

Lubricant eye drops.

Topical steroids for inflammation.

Surgical:
i.

Surgical excision when the

pterygium progressive towards
the cornea.
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Precautions

CATARACT

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Cataract

Definition
1.

2.

A cataract is a lens opacity or

cloudiness
Clouding or opacity of the crystalline
lens that impairs vision.

Incidence
Cataract is the leading cause of blindness
in the world
. Common in individuals above 70 yrs
.

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Pathophysiology

Cataract formation is characterized

chemically by a reduction in
oxygen uptake and initial increase
in water content
This is followed by dehydration
Sodium and calcium contents are
increased
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Pathophysiology

Potasium, ascorbic acid and

protein are decreased.
The protein in the lens undergoes
numerous age related changes
including yellowing.

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Pathophysiology

Cataract progresses through the following

clinical stages of development

Immature cataracts are not completely

opaque, and some light is transmitted
through them, allowing useful vision

Mature cataracts are completely opaque.

The former term for this stage was ripe.
Vision is significantly reduced
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Pathophysiology

Hyper-mature senile
cataract

Cortex is disintegrated and

transformed

Morphological
classification

Subcapsular cataract

Nuclear cataract involves the nucleus of

the lens

Yellow to brown coloration

Cortical cataract

Anterior subcapsular cataract

Posterior subcapsular cataract

Wedge-shaped or radial spoke-like opacities

Polar cataract
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Nuclear cataract
Central opacity in lens
Associated with myopia
Worsen on progression

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Cortical
Involve the interior and
posterior equatorial cortex
of the lens
Worst in very bright light

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Posterior sub-capsular

occurs in front of posterior capsule

Mostly occurs in younger
individuals
Associated with prolonged use of
corticosteroids, diabetes, ocular
trauma
Near vision is diminished
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Classification according to
maturity

An immature cataract
A mature cataract
Hypermature cataract
A morgagnian cataract

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Etiological classification
1.

Senile cataracts

2.

develop in elderly people

Due to chemical changes in lens
protein

Congenital cataracts

occur in neonates
Due to inborn errors of metabolism or
maternal rubella infection
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Etiological classification
3.

Traumatic cataract

Develops after a foreign body injures

the lens with sufficient force to allow
aqueous or vitrous humor to enter
the lens capsule

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Causes and Risk Factors

1.
2.

3.
4.
5.
6.

Cigarette smoking
Long term use of corticosteroids,
especially high doses
Sun light and ionizing radiation
Diabetes
Obesity
Eye injuries

cataracts

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CLINICAL MANIFESTATION
1.
2.

3.
4.
5.

Painless, blurred vision

The person perceived that
surroundings are dimmer
Light scattering is common
Monocular diplopia
Reduce visual acuity

cataracts

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Assessment and Diagnostic Findings

1.

2.

3.

4.

Decreased visual acuity is directly proportionate to

cataract density.
The Snellen visual acuity test, ophthalmoscopy,
and slit lamp biomicroscopic examination are used
to establish the degree of cataract formation.
The degree of lens opacity does not always
correlate with the patients functional status.
Some patients can perform normal activities
despite clinically significant cataracts. Others with
less lens opacification have a disproportionate
decrease in visual acuity; hence, visual acuity is an
imperfect measure of visual impairment.
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Medical Management
1.
2.

3.

No nonsurgical treatment cures

cataracts.
In the early stages of cataract
development, glasses, contact
lenses, strong bifocals or
magnifying lenses may improve
vision.
Reducing glare with proper light
and appropriate lighting can
facilitate reading.
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Medical Management

Mydriatics (atropine) can be used as

short-term treatment to dilate the pupil
and allow more light to reach the retina.

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Surgical management

Intracapsular cataract
extraction (ICCE)

The entire lens (ie, nucleus, cortex,

and capsule) is removed, and fine
sutures close the incision. I
CCE is infrequently used

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Surgical management

Extracapsular cataract extraction (ECCE)

ECCE achieves the intactness of smaller

incisional wounds (less trauma to the eye)
and maintenance of the posterior capsule
of the lens, reducing postoperative
complications, particularly retinal.
In ECCE, a portion of the anterior capsule
is removed, allowing extraction of the
lens nucleus and cortex.

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Nursing Management

Providing preoperative care

To reduce the risk for retrobulbar
hemorrhage, anticoagulation therapy is
withheld, if medically appropriate.
Aspirin should be withheld for 5 to 7 days,
nonsteroidal anti-inflammatory medications
(NSAIDs) for 3 to 5 days, and warfarin
(Coumadin) until the prothrombin time of
1.5 is almost reached.

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Nursing Management

Providing preoperative care

Dilating drops are administered every 10
minutes for four doses at least 1 hour before
surgery.
Additional dilating drops may be
administered in the operating room
(immediately before surgery) if the affected
eye is not fully dilated.
Prophylactic antibiotic, corticosteroid, and
NSAID drops may be used.

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Providing postoperative care

The nurse provides the patient with verbal
and written instruction regarding how to
protect the eye, administer medications,
recognize signs of complications, and obtain
emergency care.
The nurse instructs the patient regarding
home care
The nurse also explains that there is
minimal discomfort after surgery and
instructs the patient to take a mild analgesic
agent PRN. Antibiotic, anti-inflammatory,
and corticosteroid eye drops or ointments
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ENTROPION

Mechanism

Etiology

inversion of eye lid into eye

Aging (course fibrous tissue)

Symptoms and Signs

foreign body sensation

tearing / itching / redness
Continuous rubbing causes conjunctivitis or corneal ulcers
Decreased visual acuity if not corrected
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Entropion

Diagnosis

visual examination

Treatment

clean up on its own

if not, minor surgery

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ECTROPON

Mechanism

Etiology

outurned eye lids

Elderly (weakness of eye lid muscles)

Symptoms and signs

dryness of the exposed part of the eye

tears run down the cheeks
if not treated can cause ulcers and permanent
damage toI.cornea
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Ectropion

Diagnosis

visual examination

Treatment

minor surgery if doesnt disappear

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BLEPHAROPTOSIS (PTOSIS)

Mechanism

weakness of eye muscle that raises eyelid

(superior rectus, superior oblique)

Etiology

Familial
trauma
diabetes mellitus
muscular dystrophy
myasthenia gravis
brain tumors
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BLEPHAROPTOSIS (PTOSIS)

Symptoms and signs

Diagnosis

drooping eyeblocks vision

ophthalmic examination
Lab investigations to rule out underlying disease

Treatment

surgery (strengthen muscles)

eye glasses with raised eyelid support
treat underlying disease
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Ocular Trauma

Leading cause of blindness among children and

young adults, especially male trauma victims.
Initial intervention (non-ophthalmic Nurse) is
performed in only two conditions:

chemical burns: irrigation of the eye with normal

saline solution or even plain tap water immediately
Foreign body: no absolute attempt is made to
remove the foreign material, small or big, or apply
pressure or patch to the injured eye. The eye must
be protected using a metal shield, if available, or a
stiff paper cup.
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Assessment and Diagnostic

Findings

Obtain history (e.g. preinjury vision in the affected

eye or past ocular surgery.
Details related to the injury
nature of the ocular injury (e.g. blunt trauma)
type of activity causing the injury
For chemical eye burns, the chemical agent must
be identified
The corneal surface is examined for foreign bodies,
wounds, and abrasions
Pupillary size, shape, and light reaction of the pupil
of the affected eye are compared with the other eye.
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SPLASH INJURIES- managment

Irrigate eye with normal saline solution
In cases of ruptured globe, cycloplegic agents or
topical antibiotics must be deferred because of
potential toxicity to exposed intra- ocular tissues.
Further manipulation of the eye must be avoided
until the patient is under general anesthesia.
Parenteral, broad- spectrum antibiotics are initiated.
Tetanus antitoxin is administered, if indicated, as
well as analgesics.
Any topical medication (e.g., anesthetic, dyes must
be sterile.

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Blunt Contusion

Definition

S/S

Bruising of periorbital soft tissue

Swelling and discoloration of the tissue
Bleeding into the tissue and structures of the
eye
Pain

Diagnosis

Tests must determine if injury to parts of eye

and systemic trauma
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Blunt Contusion

Management

Treatment to reduce swelling

Pain management dependent on
structures involved
Note: If there is any possibility of a
ruptured globe, a loose patch and shield
should be placed and ocular
manipulation discouraged until
ophthalmologist assessment completed.
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Orbital Fracture

Definition

Fracture and dislocation of walls of the orbit,

orbital margins, or both

S/S

May be accompanied by other signs of head

injury
Rhinorrhea
Contusion
Diplopia

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Orbital Fracture

Diagnosis

X-ray, computed tomography (CT)

Management

May heal on own if no displacement

or impingement on other structures
Surgery (repair the orbital floor with
plate freeing entrapped orbital tissue)

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Foreign Body

Introduction

Foreign bodies can be found on the

cornea (25% all ocular injuries),
conjunctiva
Intraocular particles penetrate sclera,
cornea, globe

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Foreign Body

S/S

Severe pain
Lacrimation
Foreign body sensation
Photophobia
Redness
Swelling
Note: Wood and plant foreign body may
cause severe infection within hours.
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Foreign Body

Removal of foreign body through irrigation,

cottontipped applicator, or magnet
After removal of a foreign body from the surface
of the eye, an antibiotic ointment is applied, and
the eye is patched
Treatment of intraocular foreign body depends on
size, magnetic properties, tissue reaction, location
Surgical removal may be necessary
The eye is examined daily for evidence of
infection until the wound is completely healed

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Laceration/Perforation

Definition

Cutting or penetration of soft tissue or

globe

S/S

Pain
Bleeding
Lacrimation
Photophobia
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Laceration/Perforation

Management

Surgical repairmethod of repair

depends on severity of injury
Antibioticstopically and systemically

complications

retinal detachment,
intraocular tissue avulsion, and
herniation)
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Ruptured Globe

Definition

Concussive injury to globe with tears in the

ocular coats, usually the sclera

Clinical manifestations
Pain

Altered intraocular pressure

Limitation of gaze in field of rupture
Hyphema
Hemorrhage (poor prognostic sign)
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Ruptured Globe

Diagnosis:

CT,
ultrasound

Management

Surgical repair
Vitrectomy
Scleral buckle
Antibiotics
Steroids
Enucleation
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Burns-Chemical burns

Cause

alkali or acid agent

S/S

Pain
Burning
Lacrimation
Photophobia

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Burns-Chemical burns

Management

Copious irrigation until pH is 7

Severe scarring may require
keratoplasty
Antibiotics

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Burns- Thermal

usually burn to eyelidsmay be

first-, second-, or third-degree
S/S

Pain
Burned skin
Blisters

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Burns- Thermal

Management

First aidapply sterile dressings

Pain control
Leave fluid blebs intact
Suture eyelids together to protect eye
if perforation a possibility
Skin grafting with severe second- and
third-degree burns
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Burns- Ultraviolet

Cause

excessive exposure to sunlight, sunlamp, snow

blindness, welding

s/s

Paindelayed several hours after exposure

Foreign body sensation
Lacrimation
Photophobia
Note: Symptoms occur some time after
exposure.
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Burns- Ultraviolet

Management

Pain relief
Condition self-limiting
Bilateral patching with antibiotic
ointment and cycloplegics

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HYPHEMA

Definition

Frank bleeding into the anterior chamber

following contusion of the globe.
It is usually due to disruption of blood vessels
in the iris or ciliary body
This blood usually does not clot
without bed rest, a red fluid meniscus is form

Hyphema

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Classification

Etiological classification
1.

2.

3.

4.

Traumatic hyphaema - most commonly

blunt trauma
Strenuous conditions - Whooping cough,
Asthma etc.
Blood dyscrasia - Aplastic anaemia,
leukemia, hemophilia, von Willebrand
disease etc.
Neovascularization (Rubeosis iridis) Diabetes mellitus
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Classification

Clinical
1.
2.
3.

4.

Mild or simple hyphema (2-3mm)

Moderate hyphema (3-5mm)
Severe hyphema more than half of
anterior chamber
Total hyphema anterior chamb full
of blood

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Causes:

Blunt Trauma
Intraocular surgery
Lacerating trauma
Penetrating and perforating injury
It also occurs spontaneously w/o any trauma,
usually neovascularization, tumor of eye
(Retinoblastoma), uveitis or vascular anomalies
Use of medicine which impair blood clotting
such as aspirin and analagesic

Pathophysiology

There are 2 suggested mechanism

of hyphema formation

Direct contusive force cause

mechanical tearing of blood
vasculature of iris and or angle
Concussive trauma creating rapidly
rising intravascular pressure within
the vessels resulting in rupture of
vessels

Signs and Symptoms

.
.
.
.

Blurring of vision
Pain
Photophobia
Tearing

GRADING
Grade

Size of Hyphema

No layered blood
circulating red blood cells
only
Less than 1/3

II

1/3 to 1/2

III

1/2 to less than total

IV

Total

Treatment (medical)

Sedation or complete bed rest with limited

activites
Cycloplegics; Atropine 1% E/D 3.
Anti inflamatoty - Steroids,
mild NSAIDs
Ocular hypotensive agents in case of IOP
Place shield or patch over involved eye or
both eyes (controversial)
Rx of the cause

Aspirin and related analgesics w/c

impair blood clotting should not be
used to relieve pain

Acetaminophen may be substituted.

Treatment (surgical)

Surgical Indication:
Inc. IOP of >50 mmHg
Persistently (5 to 7 days) high
pressure
Early blood staining of the cornea

Simple removal of small amount of

aqueous humour (Anterior
Chamber Paracentesis) or Irrigation
of AC may be effective

Surgical Management

Clots should never be removed by

means of forceps due to difficulty
distinguishing clot from iris.
Vitrectomy irrigator aspirator
maybe used to aspirate the blood.

Corneal Contusion

Definition

Corneal contusion is a contusion

(blunt trauma) is caused by the blunt
force of the mechanical can cause
ocular adnexal or eye damage,
caused by a variety of structural
lesions in the eye.

I. Amankwaa

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