Saint Michael’s College
College of Nursing (sebaceous, sweat, & accessory
The Eye
Presented by 4E
Definition of terms
• Vision: passage ray of light from an
object through the cornea, aqueous
humor, lens, & vitreous humor to the
retina its appreciation in the
cerebral cortex.
• Emmetropia: normal vision (20/20)
• Ametropia: abnormal vision
» Myopia:
nearsightedness
Hyperopia: farsightedness
• Accomodation: focusing apparatus of
the eye adjusts to object at different
distances by means of increasing the
convexity of the lens.
• Prebyopia: elasticty of the lens
decreases with increase age
• Astigmatism: uneven curvature of
the cornea causing the patient to be
unable to focus horizontal and vertical
rays of light on the retina at the same
time.
Common Abbreviation
• OD (oculous dexter): R eye
• OS (oculus sinister): L eye
• OU (oculus unitas): both eyes
• IOP: intarocular pressure
• IOL: inraocular lens
• EOL: extraocular lens
Eye Specialists
• Ophthalmologists: medical doctor
specialist in diagnosing and treating
the eye.
• Optometrist: examine, diagnose, and
manage visual problems and diseases;
does not perform surgery
• Optician: fits, adjusts, and give
eyeglasses as prescribe.
• Ocularist: technicians who makes
ophthalmic prostheses.
Anatomy and Physiology
(An Overview)
• Eyeball: it is a protective bony
structure known as the orbit.
– Line with muscle
and connective adipose tissue
– 4 sided pyramid surrounded on 3
sides
• Eyelids: composed of thin elastic skin
that covers striated and smooth
muscles
Protect the anterior portion of
the eye
Contain multiple glands
lacrimal glands)
Upper lid, covers the uppermost
portion of iris and is innerviated by
oculomotor nerve (CN III)
triangular spaces (inner/medial
canthus & outer/lateral canthus)
With every blink of the eyes, the
lid wash the cornea and conjunctiva.
• Lacrimal Gland: form TEARS;
secreted in response to reflex or
emotional stimuli.
• Conjunctiva: a mucous membrane,
provides a barrier to the external
environment and nourishes the eye.
Goblet cells (secrete lubricating
mucus)
Bulbar conjunctiva covers sclera
Palpebral conjunctiva lines the
inner surface of the upper and
lower eyelids.
Fornix, junction of the 2 portions
• Sclera: white eye; dense, fibrous
structure that makes up the posterior
five sixthes of the eye.
Helps maintain the shape of the
eyeball and protect intraocular
contents from trauma
Limbus, outermost edge of the iris
(conjunctiva & cornea meets)
• Cornea: transparent, avascular,
dome like structure, forms the most
anterior part portion of the
eyeball.
Main refracting surface of the eye
5 Layers:
Epithelium
Bowman’s membrane
Stroma
Descemet’s membrane
Endothelium
• Anterior chamber: filled with
continually replenished supply of clear
aqueous humor (nourishes the cornea)
Produced by cleary body
Production r/t the IOP
N.V. IOP 10-12 mmHg
• Uvea: iris, ciliary body, & choroid
• Iris: colored part of the eye; highly
vascularized, pigmented collection of
fibers surrounding the pupil.
• Pupil: space that dilatyes and
constricts in response to light.
Normal: round & constrict
symmetrically when a bright light
shines on them
Dilation & Constriction: controlled
by the sphincter & dilator pupillae
muscle
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 • Lens: behind the pupil & iris
Colorless, biconvex structure held
in position by zonular fibers
Avascular & has no nerve or pain
fiber
Responsible for accomodation
• Posterior chamber: small spaces
between the vitreous and the iris
• Choroid: lies between the retina and
the sclera
Avascular tissue, supply blood to
the closest position of retina
• Ocular Fundus: largest chamber of
the eye
Contains vitreous humor (clear,
gelationous substance that mostly of
H2O & encapsulated by a heploid
membrane & helps maintain the shape
of the eye.
• Retina: neural tissue
Landmarks:
Optic Disc: point of entrance of the
optic nerve; pink-oval/circular form
Retinal Vessels: emanating inside
the physiologic depression
Macula: responsible for central
vision
2Layes:
Retinal pigment epithelium
Sensory retina
Performing Physical Assessment of the Eye
It involves assessing the functions,
such as vision (distant, near, color, and
peripheral), eye muscle functioning, and
pupils reflexes, as well as inspecting the
external and internal eye structures.
Equipments
- Snellen’s Chart
- Color vision chart
- Ophthalmoscopes
- Penlight
- Cotton swab/ball
- Gloves if indicated
HISTORY
Remember to look at each history
component as it relates to the eyes.
Ask the patient the following:
 Do you have…
 Vision loss?
 Eye pan?
 Double vision
 Eye tearing?
 Dry eyes?
 Eye drainage?
 Eye appearance changes?
 Blurred vision?
 Have you noticed any changes in
your vision
 Do you wear glasses or lenses?
 Have you ever had surgery? Injury?
 Have you ever seen spots or
floaters, flashes of light, or halos
around the lights?
 Do you a history of recurrent eye
infection?
 When was your last eye exam?
 Do you have a history of HTN or
diabetes?
 What medications are currently
taking?
 Do you take any prescribed or OTC
eye drops?
TESTING VISUAL ACUITY
1. Distance
- Have patient stand 20 ft from
chart.
- Test each eye separately, having
patient cover opposite eye being
tested, then together with and
without corrective lenses.
- Alternate method using pocket
vision screener: Have patient
hold pocket vision screener about
14inches from eye and proceed
testing as above.
- (Myopia) nearsightedness
2. Near Vision
- have patient hold newsprint
about 14 inches away and read.
- Hyperopia ( farsightedness)
3. Color Vision
- have patient identify color bars
on Snellen eye chart
- have patient identify figure
embedded in the Ishihara chart.
- Colorblindness
4. Visual Fields
- stand in front of patient, face to
face about 1-1/2 ft apart.
- Ask patient to fix gaze straight
ahead and cover one eye.
- Bring a pen or wiggle your
finger in from four different
fields (superior, inferior,
temporal, and nasal).
- Have patient say “now” once
fingers or object are seen.
- Measure degree of peripheral
vision using patient’s fixed gaze
as a base.
- Diminished visual fields: Chronic
glaucoma or stroke.
- Peripheral vision intact in both
eyes and all fields.
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ASSESSING THE EXTRAOCULAR
MUSCLES
1. Corneal Light Reflex Test
- Shine light directly in patient’s
eyes; note position of the light
reflection off the cornea in each
eye.
- Light should be seen
symmetrically on each cornea.
- Exotopia (divergent strabismus)
- Congenital exotropia
2. Cover/ Uncover Test
- Cover patient’s eye and have
patient focus on object afar.
- Uncover eye and note any
drifting.
- Gaze should be steady when
eye is covered and uncovered.
No drifting.
- Weakness of extraocular
muscles
3. Cardinal Fields of Gaze Test
- Stand in front of patient and
instruct to fix gaze straight
ahead.
- Allow him to follow your finger
or an object such as a pen
through the six cardinal fields.
- Note for any nystagmus.
INSPECTING THE EXTERNAL STRUCTURES
1. General Appearance
- Note clarity and parallel
alignment.
- Eyes clear and bright, in parallel
alignment.
- Glazed eyes: febrile state
2. Eyelashes
- Note distribution, inversion or
eversion.
- Present and curving outward.
- No crusting or infestation.
- Absence of eyelashes: Alopecia
universalis
- Lice or ticks at base of
eyelashes; infestation
- Inverted eyelashes: Entropion
- Everted eyelashes: Extropion
3. Eyelids
- Note edema, lesions
- Upper eyelid normally covers
one-half of upper iris
- palpebral fissures symmetrical
eyelids in contact
- Asymmetrical of lids: CN III
damage, stroke
- Ptosis of both eyelids:
Myasthenia Gravis
- Lesions f eyelids: Basal cell
carcinoma, squamous cell
carcinoma, xanthelasma,
chalazion, hordeolum.
4. Eyeball
- note for protrusion.
- Exopthalmus
5. Lacrimal gland and Nasolacriminal
Duct
- lacriminal glands located below
eyebrow, nasolacriminal ducts
located on inner canthus or
eyes.
- Note for swelling, redness or
drainage.
- swelling, redness, drainage,
tenderness – inflammation
6. Conjunctiva
- To examine bulbar conjunctiva,
gently pull lower lids down.
- To examine the palpebral
conjunctiva, use a q-tip and
gently roll eyelid up.
- Note color, foreign objects.
- Acute allergic conjunctivitis
- Pterygium
- Pinguecula
- Benign growth: Papilloma
7. Sclera
- Note color of sclera.
- Reddish sclera diffuse
episcleritis
- Icteric (yellow) sclera at the
limbus: elevated bilirubin
(jaundice)
8. Cornea and lenses
- Shine a light on the cornea from
an oblique angle.
- Note clarity and abrasions.
- Corneal reflex: to test the
corneal reflex take a wisp of
rolled cotton and gently touch
the cornea, or take a needle
less syringe filled with air and
shoot a ff of air over the cornea,
note blinking and tearing.
- Blinking reflex: brush your index
finger across patient’s
eyelashes and note blinking.
- Cloudy cornea; Vitamin A
deficiency
- Lens Opacities: cataract
9. Iris
- note for color and shape
- bloodshot appearance or
vessels; Iritis
10.Pupils
- note pupil size and equality
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 - test papillary reaction to light;
have patient look straight ahead
while you bring light in from the
side over the eyes.
- Note reaction and speech in
both eyes.
- Small, pinpoint pupils (miosis):
brain injury to the pons.
- Larger, dilated pupils
(mydriasis): use of marijuana,
mydriatic eye drops.
11.Accommodation
- hold your finger or an object in
font of patient from a distance
of about 1 inches from patient.
- Instruct patient to focus on
finger or object while you move
finger or object closure to
patient.
- Note convergence of eyes and
constriction of pupils as object
gets closer.
- Poor convergence –
exophthalmus
12.Anterior chamber
- have patient look straight ahead
as you shine a light from the
side across the eye.
- Note clarity and shadowing from
iris.
- Hypopyon – pus
PALPATING THE EXTERNAL STRUCTURES
1. Eyeball
- gently palpate below eyebrow
and note firmness or eyeball.
- Excessively firm or tender
globe: Glaucoma
2. Lacrimal Glands and Nasolacriminal
Duct
- to palpate glands, gently
palpate below eyebrows on
brows.
- To palpate ducts, glands, gently
palpate inner canthus of eyes.
- Swelling and tenderness;
inflammation
PERFORMING AN OPTHALMIC
EXAMINATION
1. Red Reflex
- Stand about ft from patient at a
15-degree angle from patient’s
line of vision.
- Place index finger on lens wheel
and turn wheel as needed to
focus.
- Keep free hands on patient’s
forehead to determine distance/
closeness to patient.
2. Optic Disc
- Move closer within inches from
patient, turning the lens wheel
to focus as needed.
- Identify structures.
3. Blood Vessels
- Arteries and veins originate from disc
in pairs, so make sure to note size,
color and crossings.
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DIAGNOSTIC EVALUATION:
• Direct Opthalmoscopy: Hand-held
instruments with variousplus and
minus lenses.
• Indirect Opthalmoscopy: Used by
the opthalmologist to see larger areas
of the retina, although in an
unmagnified state.
• Slit- Lamp Examination: Binocular
microscope mouted ona table with a
magnification of 10-40 times the real
image.
• Color Vision: ability to differentiate
colors has a dramatic effect on the
activities of daily living.
• Amsler Grid: Used for patients with
macular problems, such as macular
degeneration.
• Ultrasonography: is a ver valuable
diagnostic technique, especially when
the view of the retina is obscured by
opaque media such as cataract or
hemorrhage.
• OptiacalCoherence Tomography:
emerging technology that involves low
coherence interferometry.
• Fluorescein Angioraphy: clinically
significant macular edema, documents
macular capillary non perfusion and
identifies retinal and choroidal
neovascularization in age-related
macular degeneration.
• Indocyanine Green Angiography:
Used to evaluate abnormalities in the
choroidal vasculature.
• Tonometry: Measures IOP by
determining the amount of force of
pressure necessary to indent or flatten
a small anterior area of the global of
the eye.
• Perimetry Testing: evaluates the
field of vision.
CATARACT
• Derived from the greek word
cataractos, which means running
water.
• Lens opacity or cloudiness.
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 • Changes in the clarity of the natural
lens inside the eye that gradually
degrade visual quality.
CATARACT: PATHOPHYSIOLOGY
• Cataract formation is characterized
chemically by the reduction in oxygen
uptake and an initial increase in water
content followed by dehydration of the
lens. Sodium and calcium contents are
increased: potassium, ascorbic acid
and protein content decreased. The
protein in the lens undergoes
numerous age- related changes,
including yellowing from formation of
fluorescent compounds molecular
change. These change, along with
photoabsorption of violet radiation
throughout life, suggest that cataract
maybe caused by photo chemical
process.
CATARACT: STAGE OF DEVELOPMENT
• Immature Cataract - incomplete
opaque, and some light is transmitted
through them, allowing useful vision.
• Mature Cataract – completely
opaque
• Intumescent Cataract – the lens
absorbs water and increases size.
CATARACT: TYPES
• Congenital Cataracts or infantile –
occurs at birth
• Nuclear Cataract – the central
portion of the lens is mostly affected
• Cortical Cataract - Opacities at the
lens cortex ( outside of the lens.)
• Subcapsular Cataract - Opacity
develops immediately to the lens
capsule(common in posterior portion.)
• Senile Cataract - commonly occurs
with aging
• Aphakia - absence of crystalline lens
CATARACT: RISK FACTORS
• Aging: Loss of lens transparency,
Clumping or aggregation of the lens,
Accumulation of yellow – brown
pigment due to the breakdown of the
lens protein, Decrease oxygen uptake,
Increase in sodium and calcium,
Decrease in levels of Vit. C, protein
and glutathione.
• Associated Ocular Conditions:
Retinitis pigmentosa, Myopia, Retinal
detachment and retinal surgery,
Infection
• Toxic Factors: Corticosteroids,
especially at high doses and in long
term use, Alkaline chemical eye burns,
positioning, Cigarette smoking,
Calcium. Copper, iron, gold and
mercury, which tent to deposit in the
papillary area of the lens
• Nutritional Factor: Reduced levels of
antioxidants, Poor nutrition, Obesity
• Physical Factors: Dehydration
associated with chronic diarrhea, use
of purgatives in anorexia nervosa, and
use of hyperbaric oxygenation, Blunt
trauma, perforation of the lens with a
sharp object or foreign body, electric
shock, ultraviolent radiation in sunlight
and x-ray.
• Systemic Disease and Syndromes:
DM, Down Syndrome. d/o r/t lipid
metabolism, Renal d/o,
Musculoskeletal d/o.
CATARACT: CLINICAL MANIFESTATION
• Painless, blurry vision
• Person perceives that surroundings
are dimmer, as if his or her glasses
need cleaning.
• Light scattering
• Reduced contrast sensiitvity
• Sensitivity to glare
• Reduces visual acuity
• Myopic shift
• Astigmatism
• Monocular diplolia
• Brunescens
CATARACT: COMPLICATION
• Secondary Glaucoma
• Postoperative Infections
• Bleeding
• Macular edema
• Wound leaks
CATARACT: ASSESSMENT AND
DIAGNOSTIC FINDINGS
• Decreased visual acuity
• DIANOSTIC EVALUATION:
– Slit-lamp exam
– Tonometry
– Direct and indirect
opthalmoscopy
– Perimetry
CATARACT: NSG. DX & PLANNING
• Disturbed visual secondary perception
r/t altered sensory reception, status of
sense organs and therapeutically
restricted.
• Risk for injury: Risk factor may include
poor vision, reduced hand/ eye
coordination.
• Planning: The client will gain
improved vision and will adapt to
change in visual correction.
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CATARACT: INTERVENTIONS
• Surgical Interventions:
– Intracapsular Cataract
Extraction: Entire lens is
removed and fined sutures are
used to close the incision.
– Extracapsular Cataract
Extraction: Involves smaller
incisional wounds and maintains
the posterior capsule of the
lens.
– Phacoemulsification: Method
of extracapsular surgery uses
an ultrasonic device that
liquefies the nucleas and cortex,
which are then suctioned out
through tubing.
– Lens Replacements
• Nursing Interventions:
– Administer dilating drops every
10 min for 4 doses atleast 1
hour before surgery.
– Antibiotic, corticosteriod and
anti-inflammatory drops amy be
administered prophylactically to
prevent postoperative infection
and inflammations.
– After the surgery the patient
receives verbal and written
instruction about how to protect
eye, administer medications,
recognize complications and
obtain emergency care.
– The nurse also explains that
there should be minimal
discomfort after surgery.
– Instruct patient self care to
prevent accidental rubbing of
the eye.
– Teach patient self care to
prevent accidental rubbing of
the eye.
– Patient should wear a protective
eye patch for 24 hours after
surgery, followed by eyeglasses
worn during the day and a
metal shield worn at night for 1
to 4 weeks.
– Teach client eye patch is
removed after first follow – up
appointment.
CATARACT: EVALUATION
• Adaption to restored normal vision is
usually rapid.
• Adaption to limited vision requires
more time based on individual
variations.
What is GLAUCOMA?
 Glaucoma is a group of eye diseases
which in most cases produce
increased pressure within the eye.
This elevated pressure is caused by a
backup of fluid in the eye. Over time,
it causes damage to the optic nerve
and result in vision loss and
blindness.
Types of GLAUCOMA
1. Primary Open-Angle Glaucoma
( Chronic Glaucoma)
1. Normal Tension Glaucoma
2. Ocular Hypertension
2. Close-Angle Glaucoma (Acute
Glaucoma)
1. Subacute angle-closure
glaucoma
2. Chronic angle-closure glaucoma
Who’s at Risk?
 People who have a family history of
glaucoma
 Older age
 People with diabetic
 Myopia (nearsightedness)
 Cardiovascular disease
 Migraine syndrome
 Eye trauma
 Race: more common in blacks (African
American)
Continuation
 Among African-American, studies
shows that glaucoma is:
 Five times more likely to occur in
African American than in Caucasians
 About four times more likely to cause
blindness in African Americans than in
Caucasians
 Fifteen times more likely to cause
blindness in African Americans
between the ages of 45 and 64 than in
Caucasians of the same age group
Sign and Symptoms
 Loss of side (peripheral) vision
 Cloudy or haloed vision
 Nausea or headaches
 Light sensitivity (photophobia)
 Excessive blinking (blepharospasm)
 Crossed or out-turned eyes
(strabismus)
 One eye becoming larger than the
other
 Excessive tearing (epiphora)
 Decreased vision (amblyopia)
Diagnosing Glaucoma
Glaucoma can be diagnosed through
different kinds of test/procedure. And these
are some of the test/procedure for glaucoma:
1. Tonometer
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 2. Pachymeter 6. notify physician for signs of
3. Visual Field Test increase iop (severe eye pain,
4. Ophthalmoscopy photophobia, nd excessive
5. Imaging Technology lacrimation)
6. Ginioscopy Prevention
Medical Management  Get regular eye care. Regular
 Eye drops: comprehensive eye exams can help
 Timolol detect glaucoma in its early stages
 Levobunolol before irreversible damage occurs. As
 Metipranol a general rule, have comprehensive
 Betaxolol eye exams every three to five years
 Epinephrine after age 40 and every year after age
60. You may need more frequent
 Pilocarpine (not used by itself)
screening if you have glaucoma risk
 Acetazolamide for more severe cases
factors. Ask your doctor to recommend
while awaiting laseer surgery
the right screening schedule for you.
 Eye drops:
 Treat elevated eye
 Timolol
pressure. Glaucoma eyedrops can
 Levobunolol significantly reduce the risk that
 Metipranol elevated eye pressure will progress to
 Betaxolol glaucoma. To be effective, these drops
 Epinephrine must be taken regularly even if you
 Pilocarpine (not used by itself) have no symptoms.
 Acetazolamide for more severe cases  Control your weight and blood
while awaiting laseer surgery pressure. Studies have shown that
insulin resistance — which may result
Nursing Management from hypertension and obesity — is
 chronic glaucoma: linked to elevated intraocular
1. provide information about pressure.
glaucoma  Wear eye protection. Serious eye
2. teach client about the action of injuries can lead to glaucoma. Wear
the drug. eye protection when you use power
3. discuss visual defects and ways tools or play high-speed racket sports
to compensate on enclosed courts, or otherwise risk
4. elevate patient head after being hit in the eye.
surgery.
5. alert to avoid circumstances
that may increase IOP RETINAL DETACHMENT
6. continuous daily use of eye • a medical emergency requiring prompt
medications surgical treatment to preserve vision.
7. moderate use of eye • The retina is the light-sensitive tissue
8. unrestricted fluid intake: alcohol that lines the inside back wall of your
and coffee may be permitted eye. In retinal detachment, the retina
unless they are noted to caused is pulled away from the underlying
iop. choroid – a thing layer of blood vessels
9. maintenance of regular bowel that supplies oxygen and nutrients to
habits to decrease straining the retina.
10.wearing medical identification • Retinal detachment leaves retinal cells
tag indicating the patient has deprived of oxygen. The longer the
glaucoma. retina and choroid remain separated,
 Acute glaucoma the greater the risk of permanent
vision loss in the affected eye.
1. administer opioid analgesics as
directed. RETINAL DETACHMENT: SYMPTOMS
2. explain procedure and goal of
iop reduction. • Retinal detachment is painless, but
3. provide reassurance and calm visual symptoms almost always
presence to reduce anxiety appear before it occurs. Warning signs
4. inform client that after of retinal detachment include:
procedure, d client will 1. The sudden appearance of
experience blurring of vision for many floaters – small bits of
first few days debris in your field of vision that
5. wear sunglasses to help with look like spots, hairs or string
photophobia and seem to float before your
eyes
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 2. Sudden flashes of light in one or
both eyes
3. A shadow or curtain over a
portion of your visual field
4. A sudden blur in your vision
RETINAL DETACHMENT: CAUSES
1. Trauma
2. Advanced diabetes
3. An inflammatory disorder, such as
sarcoidosis or cytomegalovirus retinitis
4. Sagging or shrinkage of the jelly-like
vitreous that fills the inside of your eye
RETINAL DETACHMENT:
PATHOPHYSIOLOGY
• Retinal detachment occurs when
vitreous liquid (vitreous humor) leaks
through a retinal tear and
accumulates underneath the retina.
Leakage can also occur through tiny
holes where the retina has thinned
due to aging or other retinal disorders.
Less commonly, fluid can leak directly
underneath the retina, without a tear
or break. As liquid collects underneath
it, the retina can peel away from the
underlying layer of blood vessels
(choroid). Over time these detachment
areas may expand, like wallpaper that,
once torn, slowly peels off a wall. The
areas where the retina is detached
lose their blood supply and stop
functioning, leading to loss of vision.
RETINAL DETACHMENT: RISK FACTORS
• Aging – retinal detachment is more
common in people older than age 40
• Previous retinal detachment in one
eye
• A family history of retinal detachment
• Extreme nearsightedness (myopia)
• Previous eye surgery, such as cataract
removal
• Previous severe eye injury or trauma
• Weak areas on the sides (periphery) of
your retina
RETINAL DETACHMENT: TEST AND
DIAGNOSIS
• An ophthalmologist may be able to see
a retinal hole, tear or detachment by
looking at the retina with an
ophthalmoscope.
• If blood in your vitreous cavity blocks
the view of your retina, ultrasound
examination may be useful.
• Photocoagulation – a light beam is
passed through the pupil, causing a
small beam and producing an
exudates between the pigments
epithelium and retina.
RETINAL DETACHMENT: NURSING
DIAGNOSIS
• Anxiety r/t visual deficit and surgical
outcome
• Risk for injury r/t eye surgery
RETINAL DETACHMENT: TREATMENTS
AND DRUGS
• Surgery is the only effective therapy
for a retinal tear, hole or detachment.
• Pneumatic retinopexy – for a
relatively uncomplicated detachment
with the tear located in the upper half
of the retina; usually done under local
anesthesia.
• Scleral buckling – this is one of the
most common surgeries for repairing
retinal detachment.
• Vitrectomy - removing portions of
the vitreous itself is occasionally
necessary when vitreous clouding
blocks the surgeon’s view of the
detached retina or retinal scarring
limits the effectiveness of pneumatic
retinopexy or scleral buckling.
• Electrodiathermy – an electrode
needle is passed through the sclera to
allow subretinal fluid to escape
• Retinal cryopexy – supercooled
porbe is touched to the sclera.
RETINAL DETACHMENT: NURSING
MANAGEMENT
• Provide supportive care
• Promote comfort
• Teach about complication
• Sedation, bed rest, and eye patch to
restrict eye movements