Medical-Surgical Nursing 2

Prepared by Dr. Jhason John J. Cabigon

Special Senses: Nursing Management of Patients with Disorders of the Eyes and Ears The Eye and Vision A. Review of Anatomy and Physiology 1. External/accessory structures a. Eyelids b. Conjunctiva palpebral and bulbar conjunctiva c. Lacrimal apparatus produces and drains tears, a salty solution d. Meibomian gland or tarsal glands sebaceous glands e. Extrinsic eye muscles/Extraocular muscles Lateral rectus Medial rectus Superior rectus Inferior rectus Inferior oblique elevate, lateral Superior oblique depress, lateral * Innervations: all EOMs are supplied by the Oculomotor nerve except for LAST (Lateral rectus by Abducens nerve and Superior Oblique by Trochlear nerve) 2. Tunics of the eye a. Sclera tough, outer fibrous tunic; anterior modification is cornea (transparent membrane through which light enters the eye) b. Choroid middle vascular layer; anterior modifications are ciliary body (secretes aqueous humor) and iris (pigmented membrane behind cornea) c. Retina innermost neural sensory layer; which contains photoreceptors: rods (dim light) & cones (color vision & high visual acuity) 3. Visual pathway a. Cornea b. Aqueous humor fluid of anterior segment c. Pupil opening of pigmented iris d. Lens focus light unto photoreceptors e. Vitreous humor soft, jelly-like fluid of the posterior segment f. Retina g. Optic nerve convergence of nerve fibers from the retina h. Optic chiasma i. Optic tract j. Thalamus k. Optic radiation l. Visual cortex (occipital lobe) 4. Other Internal Structures: a. Ciliary zonule suspends the lens; attached to the ciliary body b. Optic Disk or Blind Spot site on the retina where the optic nerve leaves the eyeball; does not contain photoreceptors c. Macula lutea lateral to the blind spot; high cone density d. Fovea centralis center of macula which contains only cones

Prepared by Dr. Jhason John J. Cabigon

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Eye reflexes Convergence eyes medial when viewing close objects Light reflex pupils constrict when exposed to bright light Accommodation pupils constrict when viewing close objects 6. Error of Refractions a. Emmetropia normal b. Myopia nearsighted; light fails to reach retina; concave lens is used c. Hyperopia farsighted; light surpasses retina; convex lens is used d. Astigmatism unequal curvature of the cornea or lens e. Presbyopia decreasing lens elasticity that accompanies aging 7. Intraocular pressure normal: 8-21 mmHg; increase in eye pressure may be due to drainage blockage or overproduction of aqueous humor Flow of Aqueous humor 1. Ciliary body secretes aqueous humor 2. Aqueous humor slowly flows through the posterior chamber, around the lens, and through the pupil into the anterior chamber 3. Aqueous humor is drained into the trabecular meshwork into the canal of Schlemm found at the angle of the cornea; and then enters the venous bloodstream a. b. c. B. Alterations 1. Eye Disorders requiring Surgery A. Cataract B. Glaucoma C. Retinal Detachment 2. Inflammatory Diseases of the Eye A. Superficial Eyelid Infections Blepharitis Hordeolum (Sty) Chalazion B. Conjuctivitis C. Trachoma D. Corneal Ulcer 3. Age-related Macular Degeneration 4. Strabismus 5. Corneal Transplantation (Keratoplasty) 6. Refractive Surgeries A. Photorefractive Keratectomy (PRK) B. Laser-Assisted In Situ Keratomileusis (LASIK) 7. Evisceration/Enucleation/Exenteration Eye Disorders Requiring Surgery

A. Cataract clouding, or opacity of the lens that leads to blurring of vision and eventual loss of sight; the opacity of the lens is
caused by chemical changes in the protein of the lens because of slow degenerative changes of age, injury, poison or intraocular infection; if untreated, cataracts progress to blindness
Prepared by Dr. Jhason John J. Cabigon 2

1. Incidence: occur so often in the aged; at 80 years of age, about 85% of all people have some clouding of the lens
2. Risk Factors a. Diabetes b. Exposure to ultraviolet light or high dose radiation c. Drugs such as corticosteroids, phenothiazines, and some chemotherapy agents 3. Classification of Cataracts a. Senile cataracts commonly develop in elderly patient because of degenerative changes in lens proteins b. Congenital cataracts occur in neonates as genetic defects or possibly from measles in the mother c. Traumatic cataracts may occur after injury sufficient to force vitreous humor into the lens capsule d. Secondary cataracts may occur following other eye or systemic diseases (i.e. infections, DM, radiation, chemicals) 4. Assessment a. Gradual painless vision loss, blurred or distorted vision b. Pupil may appear milky or white c. Absence of Red Reflex 5. Diagnostics a. Snellens chart or E chart reveals blurring of vision; perfect vision is 20/20 b. Slit-lamp examination provides magnification and confirms diagnosis of an opacity c. Other testing to rule out coexisting condition of the eye; tonometry (to determine if there is increased intraocular pressure [IOP], direct and indirect opthalmoscopy ( to rule out disease of retina), perimetry (to detect any loss of visual field) 6. Surgical Interventions a. Surgery is the only cure and is recommended when vision causes problems in daily activities. Intracapsular extraction removal of the entire lens (nucleus, cortex and capsule); prior to extraction, enzyme alpha-chymotrypsin is injected in the anterior chamber to weaken the zonular ligaments; uses cryosurgery (lens is frozen with a probe) Extracapsular extraction is usually done by cryosurgery capsule is preserved; prior to extraction, a viscoelastic substance (clear gel) is injected into the anterior chamber to prevent collapse of the space Phacoemulsification under local anesthesia a type of extracapsular extraction (capsule preserved); uses ultrasonic device that liquefies the nucleus and cortex, which are then suctioned out through a tube An intraocular lens implant is usually inserted at the time of surgery, designed for distance vision b. Congenital cataract is corrected within first 3 months followed by cataract lens to correct vision c. Nonsteroidal anti-inflammatory agents, antibiotic ointments, and possible corticosteroids may be necessary after lens implantation to reduce inflammation on other eye structures and prevent infection d. If patient is not candidate for lens implant, the lens and capsule are removed (intracapsular extraction), and eye glasses and contact lenses are used to correct vision; the patient becomes aphakic (w/o lens) 7. Nursing Care a. Before surgery, monitor for worsening of visual acuity, glare, and ability to perform usual activities b. Administer pre-op meds: Mydriatics (pupillary dilators) ex. Phenylephrine HCl (Neo-synephrine); SE headache, BOV, HPN, tachycardia Cycloplegics (paralyzes muscles of accommodation or ciliary muscles) ex. Atropine SO4; SE anticholinergic effects c. Monitor pain level postoperatively. Sudden onset may be caused by a ruptured vessel or suture and may lead to hemorrhage. Severe pain accompanied by nausea and vomiting may be caused by increased IOP d. Maintain patient position on his back or on the unaffected side e. Instruct patient not to cough, sneeze or move rapidly to prevent increase in IOP f. Maintain dressing and eye shield to prevent injury g. Elevate head of bed 30-45 degrees to prevent increase in IOP h. Assess gradual adaptation to lens implant, contact lens, or glasses i. Keep the patient comfortable and advise him not to touch his eyes j. If eye patch or shield is in place, advise using it for several days as prescribed, to rest and protect eye, especially at night k. Caution the patient against coughing or sneezing, any rapid moment, bending from the waist to prevent increased IOP for first 24 hour. Instruct the patient to avoid heavy lifting or straining for up to 6 weeks, as directed by surgeon
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l. Advise patient to increase activity gradually; can usually resume normal activity the day after the procedure m. Teach proper installation of the eye n. Encourage to follow up ophthalmologic examinations for corrective lenses and checking of IOP. Adjustment to eye glasses to correct vision may take weeks o. Advise the patient not to get soap in the eyes p. Advise the patient to avoid tilting the head forward when washing hair, and to avoid vigorous head shaking, to prevent disruption of the lens until cleared by the surgeon q. Use cataract glasses properly; permanent cataract glasses is prescribed 6-8 weeks after surgery Glaucoma is a condition marked by high intraocular pressure (IOP) that damages the optic nerve 1. Two major forms a. Acute Glaucoma (or Narrow-Angle or Close-angle Glaucoma) Results when the angle between the iris and the cornea becomes narrowed, restricting or blocking the drainage of aqueous humor through the trabecular network and the canal of Schlemn. This causes IOP to increase suddenly. It may result from trauma, stress, or any process that pushes the iris forward against the inside of the cornea when there is already an anatomically shallow anterior chamber. It is an acute, painful condition that can cause permanent eye damage within several hours. b. Chronic (or Wide-Angle or Open-Angle Glaucoma) Results from the gradual deterioration of the trabecular network that, as in the acute form, blocks drainage of aqueous humor and causes IOP to increase (imbalance in production and drainage) If untreated, may result in degeneration of the optic nerve and visual field loss. It is the most common form of glaucoma, and its incidence increases with age. Genetics and conditions, such as diabetes and hypertension, also play a role. Precipitated by dark environment, emotional stress, excessive of mydriatics and anti-cholinergics 2. Assessment a. Acute Glaucoma: Sudden onset of severe pain, occurring in and around the eyes due to increased IOP; may transitory attacks. Cloudy, blurred vision; halos or rainbow color around lights. Hazy cornea due to edema; may be profuse lacrimation and ciliary injection. Headache, nausea and vomiting may occur. Pupil is mild-dilated and fixed. b. Chronic Glaucoma Mild, bilateral discomfort (tired feeling in the eyes). Slow loss of peripheral vision central vision remains unimpaired; in later stages, progressive loss of visual field (tunnel vision) Increased IOP causes halos to appear around lights. 3. Diagnostics a. Tonometry shows elevated IOP in acute and chronic disease. b. Gonioscopy studies the angle of the anterior chamber of the eye in acute disease. c. Ophthalmoscopy may show pale optic disk (acute disease) or signs of clipping and atrophy of the disk (chronic disease). Dilation of the pupil is avoided if the anterior of chamber is shallow. d. Snellens chart 4. Medical Intervention a. In acute glaucoma, emergency drug management is initiated to decrease eye pressure Parasympathomimetics (carbachol, pilocarpine) may be used as miotics to cause the pupil to contract and draw the iris away from the cornea, thus enlarging the angle and allowing aqueous humor to drain. Carbonic anhydrase inhibitors (acetazolamide, methazolamide), given orally to depress aqueous humor production. Beta-adrenergic blockers (betaxolol, timolol), given topically, may reduce aqueous humor or facilitate its drainage. Hyperosmotics (mannitol, glycerol) increase blood osmolarity and diurese the aqueous humor given I.V. b. In chronic glaucoma, a combination of miotic agent and carbonic anhydrase inhibitor is usually given 5. Surgical Intervention a. Surgery is indicated for acute glaucoma if IOP is not maintained within normal limits by pharmacotherapy and if there is progressive visual field loss with optic nerve damage b. Types of surgery for acute glaucoma include:
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Prepared by Dr. Jhason John J. Cabigon

Peripheral iridectomy Small portion of the iris excised so aqueous humor can bypass pupil. Trabeculectomy part of trabecular meshwork and iris removed. Argon Laser iridectomy creates multiple incisions in the iris to create openings for aqueous to flow. c. Types of surgery for chronic glaucoma include: Laser trabeculoplasty creates multiple surface burns to increase outflow of aqueous humor; treatment of choice if IOP unresponsive to medical regimen. Iridencleisis opening between anterior chamber and conjunctiva to bypass blocked meshwork and allow aqueous humor to be absorbed into conjunctival tissues. Cyclodiathermy or cyclocryotherapy super-cooled probe or electrical current used to interfere with ability to secrete aqueous humor by ciliary body. Corneoscleral trephening (rarely done) a permanent drainage opening is made at the junction of the cornea and sclera through the anterior chamber. 6. Nursing Care a. Maintain patient position on his back or on the unaffected side b. Monitor for any pain or visual changes c. Take extra precautions at night (i.e. use of siderails and extra lighting) d. Monitor the patients compliance with medications and follow-up care. e. Administer antiemetics as directed to prevent vomiting, which will increase IOP. f. Administer medications I.V., orally or topically, as directed, and explain the importance of medications, the proper procedure for administration of drops, and possible adverse reactions. g. After surgery, elevate head of the bed 30 degrees to promote drainage of aqueous humor after a trabeculectomy. h. Administer medications (steroids and cycloplegics) as directed after peripheral iridectomy to decrease inflammation and to dilate the pupil. i. Use an eye patch or shield in children for several days to protect the eye; in adults, patch is usually removed within several hours. j. Alert the patient to avoid prolonged coughing or vomiting, emotional upsets such as worry, fear, anger; exertion such as pushing and heavy lifting. Retinal Detachment results from separation of the inner sensory layer of the retina containing the rod and cones from the outer pigmented epithelial layer beneath or both layers separate from the choroid; it may occur spontaneously because of degenerative changes in the retina (as in diabetic retinopathy) or vitreous humor, trauma, inflammation, tumor, or loss of a lens to a cataract; untreated retinal detachment results in loss of a portion of the visual field 1. Incidence: rare in children, the disorder most commonly occurs after age 40 2. Assessment: a. Initially, the patient complains of flashes of light, floating spots or filaments in the vitreous, or blurred, sooty vision. Most of these phenomena result from traction between the retina and vitreous. b. If detachment progresses rapidly, the patient may report a veil-like curtain or shadow obscuring portions of the visual field. The curtain appears to come from above, below, or from one side; the patient may initially mistake the obstruction for a drooping eyelid or elevated cheek. c. Straight-ahead vision may be unaffected in early stages but, as detachment progresses, there will be loss of central as well as peripheral vision. 3. Diagnostics ophthalmoscopy or slit-lamp examination with full pupil dilation shows retina as gray or opaque in detached areas. The retina is normally transparent 4. Surgical Interventions aims to reattach the retinal layer to the epithelial layer and has a 90% to 95% success rate: a. Photocoagulation, in which a laser or xenon are spot welds the retina to the pigment epithelium. b. Electrodiathermy, in which a tiny hole is made in the sclera to drain subretinal fluid, allowing the pigment epithelium to adhere to the retina. c. Cryosurgery or retinal cryopexy, another spot weld technique that uses a super cooled probe to adhere the pigment epithelium to the retina. d. Scleral buckling, most common procedure done; in which a buckle (a piece of silicone sponge, rubber or semi-hard plastic) is placed unto the sclera; forces the pigment epithelium closer to the retina thereby allowing retinal tear to settle against the wall; commonly accompanied by vitrectomy. 5. Nursing Care a. Prepare the patient for surgery. Instruct the patient to remain quiet in prescribed (dependent) position, to keep the detached area of the retina in dependent position. Patch both eyes. Wash the patients face with antibacterial solution.

Instruct the patient not to touch the eyes to avoid contamination. Administer preoperative medications as ordered 10% phenylephrine + 1% cyclogyl (cycloplegic) + scopolamine (anticholinergic) b. Take measures to prevent postoperative complications. Caution the patient to avoid bumping head. Encourage the patient no to cough or sneeze or to perform other strain-inducing activities that will increase intraocular pressure. c. Position patient on operated side d. Encourage ambulation and independence as tolerated; normal activity in 6 weeks e. Administer medication for pain, nausea, and vomiting as directed. f. Apply alternate cold and warm compress over the swollen eyelid g. Provide quiet diversional activities, such as listening to a radio or audio books. h. Teach proper technique in giving eye medications. i. Advise patient to avoid rapid eye movements for several weeks as well as straining or bending the head below the waist. j. Advise patient that driving is restricted until cleared by ophthalmologist. k. Teach the patient to recognize and immediately report symptoms that indicate recurring detachment, such as floating spots, flashing lights, and progressive shadows. l. Advise patient to follow up. Inflammatory Diseases of the Eye A. 1. Superficial Eyelid Infections Types: Blepharitis infection of the eyelid; crusting eyelid, redness, irritation and mucopurulent

a.
secretion

b. c.
2.

B.
1. 2.

3.

Hordeolum (Sty) infection of the eyelid follicles Chalazion infection of the meibomian gland Nursing Care a. Cleanse eyelid margin by applying warm, moist compress for 5 mins 3-4x daily and ask patient to keep hands away from eyes b. Carefully wipe loose crust away form eyelids and wash hands after eye care c. Apply antibacterial ointments or drops and continue for several days until infection clears Ex. Erythromycin, Tobramycin and Gentamycin (Garamycin) ophthalmic ointments d. Hordeolum and Chalazion may require oral antibiotics (ex. Cloxacillin) e. Chronic chalazion requires incision and curettage Conjuctivitis inflammation of the conjunctiva; most common ocular disease worldwide Also known as pink eye because of subconjunctival blood vessel congestion Causes a. Viral discharge is watery, and follicles are prominent; commonly caused by adenovirus (highly contagious) and herpes simplex virus b. Bacterial discharge is mucopurulent; eyes may be difficult to open because of adhesions caused by the exudates; commonly caused by Streptococcus pneumoniae, Haemophilus influenzae and Staphylococcus aureus; profuse and purulent discharge with lymphadenopathy indicates gonococcal conjunctivits; chlamydial conjunctivitis can lead to blindness (refer to trachoma) c. Allergic a part of allergic rhinitis or an independent allergic reaction d. Toxic chemicals Nursing Care a. Frequently administer saline irrigation to remove discharge b. Apply cold compress for about 10 minutes 4-5x/day to soothe pain c. Prevent spread of infection Avoid sharing toiletries Restrict use of face cloth toward the infected eye Wash hands thoroughly and frequently Discard tissues directly into covered bins; use new tissue every wipe of discharge d. Instill chemotherapeutic ointment; wash hands before and after application
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Trachoma a type of chlamydial keratoconjunctivitis;a bilateral chronic follicular conjunctivitis of childhood that leads to blindness; leading cause of preventable blindness 1. Etiology: Chlamydia trachomatis (an intracellular, gram-negative bacterial parasite w/o a cell wall) 2. Assessment: a. Onset is insidious b. Symptoms Early Stage: Red and inflamed eyes, chemosis (swelling of conjunctiva), tearing, photophobia, ocular pain, purulent exudates, preauricular lymphadenopathy and lid edema; follicular and papillary formation Middle Stage: Papillary hypertrophy and follicular necrosis; development of trichiasis (turning inward of hair follicles) and entropion; the lashes then rub against the cornea and, after prolonged irritation, cause corneal erosion and ulceration Late Stage: Scarred conjunctiva, subepithelial keratitis, abnormal vasculature of the cornea (pannus), and residual scars from the follicles that look like depressions in the conjunctiva (Herberts pits); severe corneal ulceration can lead to perforation and blindness 3. Management: a. Tetracycline 1% ointment b. Topical Gentamycin + Systemic Penicillin (with corneal ulceration) c. Surgical management includes correction of trichiasis to prevent conjunctival scarring D. Corneal Ulcer usually due to keratitis (inflammation of the cornea) 1. Assessment a. Pain b. Marked photophobia c. Increased lacrimation d. Injected eye e. If iris is involves Iritis (pus forms in the anterior chamber or hypopyon) f. If corneal ulcer perforates iris prolapsed to the cornea blindness 2. Nursing Care a. Foreign bodies must be quickly removed b. Corneal abrasion must be treated promptly c. Suggest wearing of dark glasses to relieve photophobia d. Administer mydriatics prior to eye examination; instill anesthetic to relieve pain; Fluorescin to outline ulcer e. Administer antibiotic as ordered f. Apply warm compress for comfort Age-Related Macular Degeneration (ARMD) A. ARMD most common cause of visual loss in people older than 60 y/o B. 2 Classic Forms 1. Dry or Atrophic (Non-exudative) 85-90% of people with ARMD a. Results from atrophy to the retinal pigment epithelial layer below the retina, which causes vision loss through loss of photoreceptors (rods and cones) in the central part of the eye b. The outer layer of the retina slowly breaks down; with this breakdown comes the appearance of drusen (tiny, yellowish spots) c. When the drusen appear outside the macular area, patients are asymptomatic; when the drusen occur within the macula, there is gradual blurring of vision that patients may notice when they try to read d. No medical or surgical treatment is available for this condition, however vitamin supplements with high doses of antioxidants (vitamin C, vitamin E and beta-carotene), minerals (zinc oxide), lutein and zeaxanthin and have been suggested 2. Wet (Exudative) a. May have an abrupt onset b. Patients complain that straight lines appear crooked and distorted or that letters in words appear broken c. Results from proliferation of abnormal blood vessels growing under the retina, within the choroid layer (choroidal neovascularization); this vessels can leak fluid and blood, elevating the retina C. Diagnosis: Opthalmoscopy appearance of drusen (hallmark) during fundus examination D. Management
Prepared by Dr. Jhason John J. Cabigon 7

1. Laser Photocoagulation can destroy abnormal vessels but also causes some retinal destruction (leaving blind spots from the scarred area) 2. Photodynamic Therapy developed to provide less damage to retina a. Light-sensitive verteporfin dye is infused IV over 10 minutes b. A diodide laser is aimed at new vessels, which activates the dye, which releases singlet oxygen c. The singlet oxygen is toxic to endothelial cells, shutting down the vessels without damaging the retina d. Nursing Care: Pre-operatively, advise client to bring dark glasses, gloves, wide-brimmed hat, long-sleeved shirt, slacks, socks and shoes on the time of the procedure (because the light-sensitive dye within the blood vessels near the surface of the skin could be activated with exposure to strong light) Post-operatively, advise client to avoid exposure to sunlight and bright lights for 5 days after treatment; if patient must go outdoors, advise patient to cover the skin (inadvertent sunlight exposure may lead to severe blistering and sunburn that may require plastic surgery) Strabismus squint or cross-eyed; a condition in which the eyes are properly aligned with each other A. Causes 1. Muscle imbalance or paralysis of EOM muscle/s 2. Cranial nerve lesion (CN III, IV and VI) 3. Brain Tumor 4. Myasthenia gravis 5. Infection *Normal in young infant but should not persist after 4 months old B. Types 1. Horizontal Strabismus a. Exotropic outwards (away from the midline) b. Esotropic inwards (towards the nose) 2. Vertical Strabismus a. Hypertropia upward b. Hypotropia downward C. Assessment 1. Amblyopia Lazy eye; characterized by poor or indistinct vision in an eye that is otherwise physically normal 2. Diplopia 3. Uncoordinated eye movements 4. Loss of depth perception (loss of ability to see in 3-D) 5. Frequent headaches 6. Squints or tilts head to look at things 7. Permanent loss of vision if not treated early D. Diagnostics 1. Hirschberg Corneal Reflex Test a. Performed by shining a light in the person's eyes and observing where the light reflects off the corneas b. Normal: light reflects on the center of both corneas c. Positive Test: the reflection is not in the same place in each eye 2. Unilateral Cover Test (Cover-Uncover Test) a. Ask patient to focus on an object b. Cover the right eye while watching for a movement of the left eye c. Upon removing the occluder, allow your eyes to return to equilibrium then will proceed by covering the left eye d. Positive test: if there is movement on the uncovered eye, it represents squint 3. Alternating Cover Test the eyes are rapidly and alternately occluded (from one eye to the other and then back again) E. Non-surgical Management 1. Amblyopia, if minor and detected early, can often be corrected with use of an eyepatch on the dominant eye and/or vision therapy, the use of eyepatches is unlikely to change the angle of strabismus 2. Botulinum toxin (Botox)
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G.

Classification: Purified Neurotoxin Indication: Treatment of disorders of ocular muscle including strabismus c. Action: Temporarily weakens or paralyzes the stronger EOM (need to be repeated 3-4 months later once the paralysis wears off) d. Adverse Reactions: localized pain, tenderness w/ or w/o bruising, local weakness e. Nursing Implications: Inform patient that it may cause excessive weakness or atrophy in target muscle Surgical Management does not change the vision; it attempts to align the eyes by shortening, lengthening, or changing the position of one or more of the extraocular eye muscles and is frequently the only way to achieve cosmetic improvement 1. Surgeon loosens or tightens the muscles attached to the eye by changing their length or position; changing the pull of the muscles can bring the eyes back into line with each other 2. A child may need more than one surgery to realign the eyes and improve vision and may have to start or continue wearing glasses after the surgery Nursing Care related to negative self-image 1. Emphasize use of corrective lenses of indicated 2. Involve patient in classes such as assertiveness, language and social skills 3. Provide psychological support (convey confidence and give positive reinforcements) 4. Emphasize the need for follow-up b.

a.

Corneal Transplantation/Keratoplasty

A. Keratoplasty involves replacing abnormal host tissue with healthy donor (cadaver) corneal tissue
B. Indications: 1. Keratoconus (cone-shaped deformity of the cornea) Corneal dystrophy (i.e. Fuchs dystrophy cells lining the inner surface of the cornea slowly start to die off leading to blurring of vision) 3. Corneal scarring (i.e. herpes simplex keratitis) 4. Chemical burns C. Types: 1. Full Thickness Corneal Transplant Penetrating keratoplasty; the surgeon cuts a circular graft (a "button") from the donor cornea, which will be fastened to host cornea (after removal of diseased tissue) 2. Partial Thickness Corneal Transplant Lamellar keratoplasty; consists in leaving just the patient's own Descemet membrane and endothelium, while transplanting approximately 95% of the cornea; advantage no rejection post-op, faster recovery; disadvantage vision not as clear as full thickness *5 layers of the Cornea (from anterior to posterior): Anterior Epithelial Layer, Bowmans membrane, Corneal Stroma, Descemets membrane and Endothelium D. Contraindications to the use of Donor Tissue for Corneal Transplantation 1. Death of Donor from unknown cause 2. Disease transmission from donor cornea: a. Infections Eye infection, Rabies, Viral Hepatitis, HIV, Creutzfeldt-Jakob disease, other viral diseases and terminal septicemia b. Neoplasms Leukemia, lymphoma, lymphosarcoma, retinoblastoma, melanoma c. Corneal disorder dystrophies, keratoconus 3. History of eye trauma, corneal scars, previous surgical procedure (i.e. corneal graft and laserassisted in situ keratomileusis/LASIK) 4. Conditions such as glaucoma, retinal detachment and strabismus can negatively influence the outcome E. Nursing Care 1. Pre-op a. Explain to patient about the procedure b. Explain the local anesthetic regimen c. Administer pre-op meds (myotics, osmotic agents) 2. Post-op a. Eye patch is applied for protection b. Explain to patient that healing is slow because of vascularity of the cornea (only after several months do patients start seeing the natural and true colors of their environment) c. Prevent sudden turning of head d. Avoid sources of irritants (sneezing, dusting, sweeping, flowers)

2.

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e. f.

Prevent emotional stress (to prevent increase in IOP) Administer post-op meds Mydriatics for 2 weeks Topical corticosteroids for 12 months to prevent graft rejection Analgesics (report unrelieved pain because it may indicate that dressing are too tight, graft has slipped or hemorrhage is occurring) g. Prevent post-op complications Increase fluids to avoid urinary retention and constipation Prevent infection of eye (avoid touching dressing, use aseptic technique while changing dressings) h. Introduce activities but avoid those that requires straining i. Emphasize importance of follow-up j. Watch out for signs of graft rejection (occurs several days to 2 weeks after transplant) Blurred vision Discomfort Tearing Redness of eye Photophobia Refractive Surgeries A. Photorefractive Keratectomy (PRK) 1. To treat myopia and hyperopia with or without astigmatism 2. The excimer laser is applied directly to the cornea 3. The laser reshapes the cornea according to carefully calculated measurements: a. For myopia, the relative curvature is decreased b. For hyperopia, the relative curvature is increased B. Laser-Assisted In Situ Keratomileusis (LASIK) 1. An improvement over PRK 2. The surgeon creates a corneal flap to expose the corneal stroma, then uses the excimer laser on the stromal bed to reshape cornea according to calculated measurements 3. Less post-operative discomfort, has fewer side effects and faster recovery than PRK Evisceration/Enucleation/Exenteration

A. Evisceration removal of the contents of the globe while leaving the sclera and extraocular muscles intact; usually indicated
in cases of endophthalmitis unresponsive to antibiotics and for improvement of cosmesis in a blind eye

B. Enucleation the removal of the eye from the orbit while preserving all other orbital structures; indicated for the above two
conditions as well as for painful eyes with no useful vision, malignant intraocular tumors, in ocular trauma to avoid sympathetic ophthalmia (an autoimmune eye disease in which a penetrating injury to one eye produces inflammation in the uninjured eye), in phthisis (involution of the eye) with degeneration, and in congenital anophthalmia or severe microphthalmia to enhance development of the bony orbit Exenteration the most radical of the three procedures and involves removal of the eye, adnexa, and part of the bony orbit; indicated mainly for large orbital tumors or orbital extension of intraocular tumors

C.

The Ear and Hearing A. Review of Anatomy and Physiology 1. Outer Ear a. Pinna b. External Auditory Canal c. Tympanic membrane (ear drum) 2. Middle Ear a. Auditory ossicles malleus (hammer), incus (anvil), stapes (stirrup) b. Auditory tube (Eustachian tube) drains the middle ear of pressure and fluid 3. Inner Ear a. Cochlea contains the organ of Corti (senses sound waves) b. Vestibule contains Macula (senses Static equilibrium) c. Semicircular canals contains Crista ampullaris (senses Dynamic equilibrium)
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Pathway of sound: Pinna External auditory canal Tympanic membrane Ossicles Oval window Cochlea Organ of Corti Auditory nerve Cerebral cortex (Temporal lobe) 5. Deafness: a. Conduction Deafness sounds through external and middle ears are hindered b. Sensorineural Deafness damage to nervous system involved in hearing c. Presbycusis sensorineural deafness associated w/ aging B. Alterations 1. a. b. 2. 3. Infections of the Ear Infections of the Ear Acute Otitis Media Chronic Otitis Media Menieres Disease Otosclerosis

A. Acute Otitis Media infection of the middle ear, usually lasting less than 6 weeks
1.

a.
b. c. 2.

a. b.
3.

a.
b. c. d. 4. a. b. c. d. palate) 5. normal 6.

Common Pathogens Streptococcus pneumoniae (pneumococcus) Haemophilus influenzae Moraxella catarrhalis Mode of Transmission Through external auditory canal (because of perforated TM) Through eusthachian tube (from the nasopharynx) Assessment Otalgia, which is relieved by spontaneous perforation or surgical incision (myringotomy) Fever Headache Conductive hearing loss Risk Factors Age: <12 months Chronic URT Chronic exposure to secondhand smoke Medical conditions that predispose to ear infections (Downs syndrome, cystic fibrosis, cleft Diagnostic: Otoscopic evaluation the TM appears erythematous and bulging; the external canal is

Complications: Mastoiditis (an infection of mastoid process, the portion of the temporal bone of the skull that is behind the ear which contains open, air-containing spaces) b. Serious intracranial complications (meningitis, brain abscess) 7. Management a. Broad-spectrum antibiotic therapy b. If drainage occurs, an antibiotic otic preparation may be prescribed c. Surgical Management: Myringotomy or Tympanotomy under local anesthesia (incision in the tympanic membrane) to allow drainage and relieve pain; the incision heals in 24-72 hours) 8. Nursing Care a. Administer antibiotics regularly b. Relieve pain (analgesics, warm compress) c. Remind patient not to touch the ear or drainage d. Observe drainage and check for possible bleeding e. Instruct patient to keep ears dry (avoid swimming, plug ears while taking a bath) f. Inform patient about signs of complications (tenderness in mastoid region, persistent headache, nuchal rigidity) B. Subacute Otitis Media lasting 3 weeks to 3 months; persistent purulent discharge from the ear C. Chronic Otitis Media result of recurrent AOM causing irreversible tissue pathology and persistent perforation of the TM; chronic infections of the middle ear damage the TM, ossicles and mastoid bone 1. Assessment a. Symptoms may be minimal b. Varying degrees of hearing loss

a.

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Persistent or intermittent, foul-smelling otorrhea Pain is not usually experienced, except in cases of acute mastoiditis 2. Diagnostic: Otoscopic evaluation may show TM perforation and cholesteatoma (a destructive and expanding growth of squamous epithelium in the middle ear and/or mastoid process) 3. Complications: a. Hearing loss b. Untreated cholesteatoma will continue to enlarge causing damage to facial nerve and destruction of other surrounding structures c. Chronic Mastoiditis may lead to intracranial complications 4. Management: a. Medical antibiotics and steroids b. Surgical Tympanoplasty surgical reconstruction of the TM Ossiculoplasty surgical reconstruction of the middle ear bones to restore hearing; prostheses are used to reconnect the ossicles, thereby reestablishing the sound conduction mechanism Mastoidectomy to remove cholesteatoma, gain access to diseased structures, and create a dry (noninfected) and healthy ear; usually performed through a post-auricular incision; types: 1. Simple (or closed) mastoidectomy: The operation is performed through the ear or through a cut (incision) behind the ear. The surgeon opens the mastoid bone and removes the infected air cells. The eardrum is cut (incised) to drain the middle ear. Topical antibiotics are then placed in the ear. 2. Radical mastoidectomy: The eardrum and most middle ear structures are removed, but the innermost small bone (the stapes) is left behind so that a hearing aid can be used later to offset the hearing loss. 3. Modified Radical mastoidectomy: The eardrum and the middle ear structures are saved, which allows for better hearing than is possible after a radical operation. 4. Postero-anterior mastoidectomy: Combination of simple maastoidectomy and tympanoplasty. Menieres Disease A. Menieres Disease an abnormal inner ear fluid balance caused by a malabsorption in the endolymphatic sac or a blockage in the endolymphatic sac B. Incidence: Men are slightly more affected than women, occurs at 40-60 y/o (often associated with aging but may also follow middle ear infections and head trauma) C. Predisposing factors 1. An increased pressure in the endolymph 2. Sodium retention 3. Vasomotor changes 4. Spasm of the internal auditory artery 5. Smoking 6. 30 years old 7. Metabolic disturbances, like DM 8. Hyperlipidemia 9. Obesity 10. Allergic reaction 11. Emotional reaction, like stress 12. Ear Trauma and Infection 13. Impairment of microvascular tube of inner ear related to abnormal metabolites such as glucose, insulin, cholesterol and triglycerides D. Pathophysiology 1. Endolymphatic hydrops (dilation of endolymphatic space) 2. Increased pressure in the system or rupture of inner ear membrane 3. Symptoms of Menieres disease E. Signs and Symptoms 1. Triad of Menieres disease a. Tinnitus a sensation of ringing, buzzing, or roaring noises in the ear b. Vertigo (the most troublesome compliant of patients) a spinning or whirling sensation that affects the patient's sense of balance
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c. d.

c.
2. 3. 4. 5. 6. 7. Diagnosis:

Sensorineural Hearing Loss Nystagmus N/V Anxiety Tachycardia Palpitations Diaphoresis

F.

Weber test may indicate sensorineural hearing loss (sound may lateralize to unaffected ear) Rinne test may indicate sensorineural hearing loss (air conduction > bone conduction) Audiometry may indicate sensorineural hearing loss Baranys Caloric Test a test for assessing vestibular function in which the ear is irrigated with either hot or cold water, normally stimulating the vestibular apparatus, resulting in nystagmus; a lack of nystagmus indicates impaired vestibular functioning 5. Romberg test instruct the patient to stand with his feet together and his arms at his side. Have the patient do this with his eyes open and then with his eyes closed; Expect the patient to sway slightly but not fall, if the patient really loses his balance, he may have cerebellar ataxia or vestibular dysfunction G. Nursing Care 1. Comfortable and darkened environment 2. Siderails 3. Emetic Basin 4. Meds: a. Diuretics hydrochlorothiazide to remove endolymph (watch out for hypokalemia) b. Antihistamines meclizine (Bonamine) which suppresses the vestibular system (watch out for sedation) c. Antiemetic promethazine (Phenergan) to control N/V and vertigo because of its antihistamine effect d. Sedatives/Tranquilizers diazepam (Valium) a CNS depressant that can also act as an anti-emetic e. Vasodilator 5. Restrict Sodium (2000 mg/day) and Glucose 6. Limit fluid intake 7. Avoid smoking, alcohol and vasoconstrictors (coffee, tea and decongestants) 8. Care of patient with vertigo (p. 2114-2118) 9. Surgery a. Endolymphatic sac decompression, or shunting a shunt or drain is inserted in the endolymphatic sac through a post-auricular incision; first-line surgical treatment b. Middle and Inner Ear Perfusion ototoxic drugs, like streptomycin and gentamycin, are infused into the middle and inner ear to destroy vestibular function and decrease vertigo; very successful in treating vertigo, but risk of hearing loss is high c. Intraotologic Catheters catheters are used to deliver the medicine directly to the middle ear; path of catheter: external ear canal through or around TM round window niche or membrane d. Vestibular Nerve sectioning cutting the vestibular branch of the CN VIII (vestibulocochlear nerve) e. Total Labyrinthectomy Otosclerosis A. Otosclerosis involves the stapes and is thought to result from the formation of new, abnormal spongy bone, especially around the oval window, with resulting fixation of the stapes B. Causes remains unknown 1. Hereditary 2. Hormonal changes with pregnancy 3. Viral infections (i.e. measles) C. Assessment 1. Gradual Hearing Loss 2. Tinnitus 3. Dizziness
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1. 2. 3. 4.

D. Diagnostics reveal conductive hearing loss E. Surgical Management 1. Stapedectomy removal of stapes superstructure and part of footplate and inserting a tissue graft and a suitable prosthesis 2. Stapedotomy creates a tiny opening in the stapes, in which to secure a prosthetic QUICK REVIEW OF SPECIAL SENSES A. Common Eye Disorders and Characteristic Vision Loss 1. Cataract painless blurring of vision 2. Acute glaucoma painful BOV; halos or rainbow around lights 3. Chronic glaucoma tunnel-like vision (loss of visual field) 4. Retinal detachment floaters; curtain-like or veil-like vision 5. Macular degeneration loss of central vision B. Cataract opacity of the lens; most common in the elderly (senile cataract); painless blurring of vision *Surgical Management 1. Intracapsular extraction removal of the entire lens (nucleus, cortex and capsule) 2. Extracapsular extraction is usually done by cryosurgery capsule is preserved 3. Phacoemulsification under local anesthesia a type of extracapsular extraction (capsule preserved); uses ultrasonic device that liquefies the nucleus and cortex, which are then suctioned out through a tube 4. Intraocular lens implant is usually inserted at the time of surgery, designed for distance vision *Pre-op Nursing Care a. Monitor for worsening of visual acuity, glare, and ability to perform usual activities b. Administer pre-op meds: a. Mydriatics (pupillary dilators) ex. Phenylephrine HCl (Neo-synephrine); SE headache, BOV, HPN, tachycardia b. Cycloplegics (paralyzes muscles of accommodation or ciliary muscles) ex. Atropine SO4; SE anticholinergic effects *Post-op Nursing Care 1. Promote safety most important 2. Monitor pain bleeding and hemorrhage 3. Elevate head 30-45o 4. Maintain position on back or unaffected side 5. Avoid coughing, sneezing, moving rapidly, bending forward, straining increase IOP 6. Use of glasses 7. Advise eye patch or shield, esp. at night 8. Normal activity in 6 weeks C. Glaucoma increased intraocular pressure due to blockage of aqueous humor drainage (normal IOP: 10-21 mmHg) *Types: 1. Acute narrow or close-angle glaucoma (sudden, painful condition that can cause permanent eye damage within several hours); painful BOV; halos or rainbow around lights 2. Chronic wide or open-angle glaucoma (gradual deterioration of the trabecular network); tunnellike vision (loss of visual field) *Diagnostics 1. Tonometry shows elevated IOP in acute and chronic disease. 2. Gonioscopy studies the angle of the anterior chamber of the eye in acute disease. 3. Ophthalmoscopy may show pale optic disk (acute disease) or signs of clipping and atrophy of the disk (chronic disease); dilation of the pupil is avoided if the anterior of chamber is shallow *Medical Intervention 1. Pilocarpine miotic (pupilary constrictor) improving drainage 2. Timolol beta-blocker reduce aqueous humor production 3. Acetazolamide carbonic anhydrase inhibitor reduce aqueous humor production *Surgical Intervention 1. Iridectomy small portion of the iris excised so aqueous humor can bypass pupil 2. Trabeculectomy part of trabecular meshwork and iris removed *Post-op Nursing Care i. Maintain patient position on his back or on the unaffected side
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Monitor for any pain or visual changes Take extra precautions at night (i.e. use of siderails and extra lighting) Monitor the patients compliance with medications and follow-up care. Administer antiemetics as directed to prevent vomiting, which will increase IOP. Administer medications I.V., orally or topically, as directed, and explain the importance of medications, the proper procedure for administration of drops, and possible adverse reactions. vii. After surgery, elevate head of the bed 30 degrees to promote drainage of aqueous humor after a trabeculectomy. viii. Administer medications (steroids and cycloplegics) as directed after peripheral iridectomy to decrease inflammation and to dilate the pupil. ix. Use an eye patch or shield in children for several days to protect the eye; in adults, patch is usually removed within several hours. x. Alert the patient to avoid prolonged coughing or vomiting, emotional upsets such as worry, fear, anger; exertion such as pushing and heavy lifting. D. Retinal Detachment separation of retina from the choroid; curtain-like or veil-like vision; floaters (blood cells released into the eye by the detachment) *Surgical Management 1. Photocoagulation, in which a laser or xenon are spot welds the retina to the pigment epithelium 2. Cryosurgery or retinal cryopexy, another spot weld technique that uses a super cooled probe to adhere the pigment epithelium to the retina. 3. Scleral buckling, most common procedure done; in which a buckle (a piece of silicone sponge, rubber or semi-hard plastic) is placed unto the sclera; forces the pigment epithelium closer to the retina thereby allowing retinal tear to settle against the wall; commonly accompanied by vitrectomy *Pre-op Nursing Care 1. Maintain on bedrest (dependent position) 2. Patch both eyes (to limit eye movement) *Post-op Nursing Care 1. Prevent increase in IOP 2. Position on operated side 3. Encourage ambulation and independence 4. Normal activity in 6 weeks E. Macular Degeneration breakdown of retina causing tiny; presence of yellowish spots in the retina (drusen); loss of central vision F. Hearing Loss *Types: 1. Conduction Deafness External and middle ear affected 2. Sensorineural Deafness Inner ear and nervous system affected 3. Presbycusis sensorineural deafness associated w/ aging G. Otitis Media infection of the middle ear *Types: 1. Acute OM <6 wks, painful 2. Chronic OM recurrent OM, typically w/ perforation, otorrhea and cholesteatoma *Complications: 1. Hearing loss 2. Mastoiditis swelling and pain behind the ear; unrelieved by myringotomy 3. Labyrinthitis infection of labyrinth leading to hearing loss, nystagmus, tinnitus and vertigo 4. Intracranial infection meningitis, brain abscess *Nursing Care: 1. Administer antibiotics regularly 2. Relieve pain (analgesics, warm compress) 3. Remind patient not to touch the ear or drainage 4. Observe drainage and check for possible bleeding 5. Instruct patient to keep ears dry (avoid swimming, plug ears while taking a bath) 6. Inform patient about signs of complications (tenderness in mastoid region, persistent headache, nuchal rigidity) H. Menieres Disease an abnormal inner ear fluid balance caused by a malabsorption in the endolymphatic sac or a blockage in the endolymphatic sac *Triad: 1. Vertigo a spinning or whirling sensation that affects the patient's sense of balance 2. Sensorineural Hearing Loss 3. Tinnitus a sensation of ringing, buzzing, or roaring noises in the ear *Nursing Care 1. Safe and darkened environment
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ii. iii. iv. v. vi.

Restrict Sodium (2000 mg/day) and Glucose Limit fluid intake Avoid smoking, alcohol and vasoconstrictors (coffee, tea and decongestants) Administer meds a. Antihistamines and anti-emetics control acute attack of N/V and vertigo (ex. phenergan) b. Sedatives also anti-emetics (ex. diazepam) c. Diuretic removes endolymph (ex. HCTZ) I. Acoustic Neuroma benign Tumor of the vestibular or acoustic nerve *Assessment 1. Tinnitus 2. Sensorineural hearing loss 3. Facial nerve impingement *Management: Tumor removal (craniotomy) J. Impacted Cerumen sensation of fullness w/ or w/o hearing loss *Nursing Care: 1. Ear Irrigation contraindicated in perforated TM and OM 2. Soften cerumen: a. Hydrogen peroxide 3 gtts BID b. Glycerin or mineral oil 3 gtts qHS c. Irrigate after several days K. Foreign bodies *Nursing Care: 1. Irrigate carefully if vegetable matter 2. Kill insect before removal; instill mineral oil or diluted alcohol 3. Small forceps to remove object; do not push

2. 3. 4. 5.

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