Session 20:

ASSESSMENT AND DIAGNOSTIC EVALUATION

OF THE EYE AND VISION, REFRACTIVE ERRORS
AND REFRACTIVE SURGERIES , GLAUCOMA,
CATARACT, RETINAL DETACHMENT, MACULAR
DEGENERATION, DRY EYE SYNDROME,
CONJUNCTIVITIS
NUR 149 - MEDICAL SURGICAL NURSING
P3W2
Learning Outcome:
On completion of this session, students will be able to:

1. Explain disorders according to causes, manifestations, medical

care, and nursing management.
2. Describe the pathophysiology, clinical manifestations, and
medical and nursing management of REFRACTIVE ERRORS
AND REFRACTIVE SURGERIES , GLAUCOMA, CATARACT,
RETINAL DETACHMENT, MACULAR DEGENERATION, DRY EYE
SYNDROME, CONJUNCTIVITIS
3. Use the nursing process as a framework for care of the patient
with REFRACTIVE ERRORS AND REFRACTIVE SURGERIES ,
GLAUCOMA, CATARACT, RETINAL DETACHMENT, MACULAR
DEGENERATION, DRY EYE SYNDROME, CONJUNCTIVITIS
4. DISCUSS ASSESSMENT AND DIAGNOSTIC EVALUATION OF
THE EYE AND VISION
EYE ASSESSMENT
ENGAGING ACTIVITY: IDENTIFY WHAT ASSESSMENT IS BEING PERFORMED
AND EXPLAIN RATIONALE AND RESULTS OF THE PROCEDURE
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REFRACTIVE ERRORS
ANATOMY REVIEW
HYPEROPIA /
FARSIGHTEDNESS
● vision is blurry at a close range and clear at a far range.
MYOPIA /
NEARSIGHTEDNESS
occurs when light rays focus anterior to the retina,
causing objects that are far away to be unfocused.
LASER IN SITU KERATOMILEUSIS
(LASIK) and PHOTOREFRACTIVE
KERATECTOMY (PRK)
1. Laser Vision Correction Photorefractive Keratectomy (PRK)

- Is used to treat myopia and hyperopia with or without astigmatism . A

bandage contact lens is placed over the cornea to promote epithelial
healing and reduce pain. - The major limitations of this procedure are
postoperative pain, corneal haze, and prolonged recovery of vision.

2. Laser-Assisted In Situ Keratomileusis (LASIK)

An improvement over PRK, particularly for correcting high (severe) myopia,
LASIK involves flattening the anterior curvature of the cornea by removing
a stromal lamella or layer.
- LASIK causes less postoperative discomfort, has fewer side
effects, and is safer than PRK. The patient has no corneal haze
and requires less postoperative care.
- However, with LASIK, the cornea has been invaded at a deeper
level, and any complications are more significant than those that
can occur with PRK.
- With the increasing success and popularity of LASIK, PRK is now
reserved for patients who are unsuitable for LASIK, such as
people with very thin corneas.
Perioperative Complications:
a. Surgically Induced Abnormalities
- Corneal surface irregularities: central islands (central
areas of stiff- ness or elevation), decentered ablations
resulting from misalignment of the laser treatment or
from involuntary eye movement during laser treatment,
and forms of irregular astigmatism. Symptoms of
central islands and decentered ablations include
monocular diplopia or ghost images, halos, glare, and
decreased visual acuity.
b. Diffuse Lamellar Keratitis (DLK)
- DLK is a peculiar, noninfectious, inflammatory reaction
in the lamellar interface after LASIK. - DLK seems to be
strongly associated with a decrease of contrast
sensitivity up to 6 months postoperatively.
- Treatment: Corticosteroid drops
CATARACT
PHACOEMULSIFICATION
In this method of extracapsular cataract surgery, a portion of
the anterior capsule is removed, allowing extraction of the
lens nucleus and cortex while the posterior capsule and
zonular sup- port are left intact.
INTRAOCULAR LENS
IMPLANT
 NURSING MANAGEMENT
A Provide Preoperative Care
1. Withhold any anticoagulant therapy (aspirin, warfarin [Coumadin])
to reduce the risk of retrobulbar hemorrhage (after retrobulbar
injection) for 5 to 7 days.
The researchers speculated that regular users of aspirin or
warfarin are already at higher risk for transient ischemic attacks
or angina and suggest that patients may not need to discontinue
these medications prior to surgery.
2. Administer dilating drops every 10 minutes for four doses at least 1
hour.
3. May administer additional dilating drops in the operating room
(immediately before surgery).
4. May administer antibiotic, corticosteroid, and anti- inflammatory
drops prophylactically to prevent postoperative infection and
inflammation.
NURSING MANAGEMENT
B. Provide Postoperative Care
1. Before discharge: provide the patient with
verbal and written instructions about how to
protect the eye, administer medications,
recognize signs of complications, and obtain
emergency care.
2. Explain that there should be minimal
discomfort after surgery and instruct the patient
to take a mild analgesic agent, such as
acetaminophen, as needed.
3. Administer antibiotic, anti-inflammatory, and
corticosteroid eye drops or ointments.
 NURSING MANAGEMENT
C. Promote Home and Community-Based Care

1. Teaching Patients Self-Care

a. 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.
b. Instruct the patient and family in applying and caring for the eye
shield.

c. Wear sunglasses while outdoors during the day because the eye is
sensitive to light.
d. Inform the patient that there may be slight morning discharge,
some redness, and a scratchy feeling may be expected for a few
days. A clean, damp washcloth may be used to remove slight
morning eye discharge.
e. Notify the surgeon if new floaters (dots) in vision, flashing lights,
decrease in vision, pain, or increase in redness occurs (because
cataract surgery increases the risk of retinal detachment)
 NURSING MANAGEMENT
D. Continuing Care
1. Inform the patient:
a. Eye patch is removed after the first follow-up appointment.
b. May experience blurring of vision for several days to weeks.
c. Sutures, if used, are left in the eye but alter the curvature of the
cornea, resulting in temporary blurring and some astigmatism.
d. Vision gradually improves as the eye heals.
2. Patients with IOL implants:
a. Have functional vision on the first day after surgery.
b. Vision is stabilized when the eye is completely healed, usually
within 6 to 12 weeks, when final corrective prescription is
completed.
3. Patients who choose multifocal IOLs should be aware that there may be
increased night glare and contrast sensitivity.
NURSING MANAGEMENT
E. Intraocular Lens Implant
1. Wear glasses or metal eye shield at all times following surgery as
instructed by the physician. 2. Always wash hands before touching or
cleaning the postoperative eye.
3. Clean postoperative eye with a clean tissue; wipe the closed eye with a
single gesture from the inner canthus outward.
4. Bathe or shower; shampoo hair cautiously or seek assistance.

5. Avoid lying on the side of the affected eye the night after surgery.
6. Keep activity light (walking, reading, watching television). Resume the
following activities only as directed by the physician: driving, sexual
activity, unusually strenuous activity.
7. Avoid lifting, pushing, or pulling objects heavier than 15 lb.

8. Avoid bending or stooping for an extended period.

9. Be careful when climbing or descending stairs.

10. Know when to contact the physician.

GLAUCOMA
Clinical Manifestations
1. Blurred vision or
“halos” around lights

2. Difficulty focusing

3. Difficulty adjusting
eyes in low lighting

4. Loss of peripheral
vision

5. Aching or discomfort
around the eyes

6. Headache
TYPES OF GLAUCOMA
Pharmacologic Management
a. Miotics - medications that cause pupillary constriction

Cholinergics (Pilocarpine, Carbachol)

- Increases aqueous fluid outflow by contracting the ciliary muscle and causing miosis (constrictio
of the pupil) and opening of trabecular meshwork.

- Caution patients about diminished vision in dimly lit areas.

b. Adrenergic agonists - sympathomimetic agents

Dipivefrin, Epinephrine - reduces production of aqueous humor and increases outflow

c. Beta-blockers

Betaxolol, Timolol - decreases aqueous humor production

d. Alpha2-agonists (adrenergic agents)

Apraclonidine, Brimonidine - decreases aqueous humor production

e. Carbonic anhydrase inhibitors

Acetazolamide, Methazolamide, Dorzolamide - decreases aqueous humor production

f. Prostaglandins

Latanoprost, Bimatoprost - increases uveoscleral outflow

Surgical Management
1. Laser Trabeculoplasty

- Laser burns are applied to the inner surface of the trabecular meshwork to open the intratrabecular
spaces and widen the canal of Schlemm, thereby promoting outflow of aqueous humor and
decreasing IOP.
- A serious complication: transient increase in IOP (usually 2 hours after surgery) that may become
persistent.
2. Laser Iridotomy - for pupillary block glaucoma

- An opening is made in the iris to eliminate the pupillary block.

- Potential complications: burns to the cornea, lens, or retina; transient elevated IOP; closure of the
iridotomy; uveitis; and blurring.

- Pilocarpine (Pilocar) is usually prescribed to prevent closure of the iridotomy.

3. Filtering Procedures - for chronic glaucoma

- Used to create an opening or fistula in the trabecular meshwork to drain aqueous humor from the
anterior chamber to the subconjunctival space into a bleb (fluid collection on the outside of the
eye), thereby bypassing the usual drainage structures.
- Trabeculectomy is the standard filtering technique used to remove part of the trabecular meshwork.
- Complications: hemorrhage, an extremely low (hypotony) or extremely elevated IOP, uveitis,
cataracts, bleb failure, bleb leak, and endophthalmitis.
- Scarring is inhibited by using antifibrosis agents such as the antimetabolites fluorouracil (Efudex)
and mitomycin (Mutamycin).
Surgical Management
4. Drainage Implants or Shunts
- Are open tubes implanted in the anterior chamber to shunt aqueous humor
to the episcleral plate in the conjunctival space.
- These implants are used when failure has occurred with one or more
trabeculectomies in which antifibrotic agents were used.
5. Trabectome Surgery
- Is reserved for patients in whom pharmacologic treatment and/or laser
trabeculoplasty do not control the IOP sufficiently.
- This minimally invasive procedure is specifically designed to improve fluid
drainage from the eye to balance IOP.
- By restoring the eye’s natural fluid balance, trabectome surgery stabilizes
the optic nerve and minimizes further visual field damage.
RETINAL DETACHMENT
Assessment and Diagnostic Findings

1. Visual acuity
2. Indirect ophthalmoscopy
3. Slit-lamp biomicroscopy

4. Stereo fundus photography

and fluorescein angiography –
commonly used

5. Optical coherence
tomography and ultrasound –
used for the complete retinal
assessment, especially if the
view is obscured by a dense
cataract or vitreal hemorrhage
SURGICAL MANAGEMENT
- The retinal surgeon compresses the
sclera (often with a scleral buckle or
a silicone band; to indent the scleral
wall from the outside of the eye and
bring the two retinal layers in
contact with each other. - Has a high
success rate in the hands of
experienced retinal surgeons.
- Causes less damage to the lens of
the eye in phakic patients, and there
is a low risk of endophthalmitis.
- However, there is an increased
incidence of diplopia and other
complications, such as induced
myopia and increased postoperative
pain.
- A vitrectomy is an intraocular
procedure in which 1- to 4- mm
incisions are made at the pars plana.
- The surgeon dissects preretinal
membranes under direct
visualization while the retina is
stabilized by an intraoperative
vitreous substitute.
- The techniques of vitreoretinal
surgery can be used in various
procedures, including the removal of
foreign bodies, vitreous opacities
such as blood, and dislocated lenses.
- Traction on the retina may be
relieved through vitrectomy and may
be combined with scleral buckling to
repair retinal breaks.
3. Pneumatic Retinopexy
- This technique is used for the repair of a
rhegmatogenous retinal detachment.
- It is the least invasive of the three
procedures described.

4. Transconjunctival Sutureless Vitrectomy

- Sutureless system is both safe and
effective with decreased surgical times,
reduced postoperative inflammation, and
more rapid recovery.
AGE-RELATED MACULAR
DEGENERATION
Medical
Management

Dry Type: no known cure

1. Use of antioxidants
(vitamin C, vitamin E, and
beta- carotene) and minerals
(zinc oxide)
- Slow the progression of AMD
and vision loss.
2. Lutein and Zeaxanthin
(Carotenoids) or fish oils
- Protect the macula and
prevent the progression of
AMD.
Wet Type
Antiangiogenic Therapy – prevents
progression of angiogenesis (abnormal
blood vessel formation) and slows
progression of visual loss
1. Pegaptanib sodium (Macugen) - visual
acuity has improved in only a limited
number of patients as a result of this
treatment
2. Ranibizumab (Lucentis) - patients may
gain one to two lines of vision on the
Snellen chart after a year of treatment
3. Monoclonal Antibody Bevacizumab
(Avastin) - helps in the treatment of
neovascular AMD
Nursing Management

1. Encourage the
patient to use
amsler grids at
home.
2. Advise to
report
ophthalmologist
immediately if
there is a change
in the grid.
DRY EYE SYNDROME
Assessment and Diagnostic Findings
Slit-lamp examination - shows an absent or interrupted tear meniscus
at the lower lid margin, and the conjunctiva is thickened, edematous,
and hyperemic and has lost its luster
Management
1. Instillation of artificial tears during the day and an ointment at night -
hydrates and lubricates the eye and preserve a moist ocular surface
2. Cyclosporine ophthalmic emulsion (Restasis) – increases tear
production
3. Anti-inflammatory medications – provides additional relief
4. Use of moisture chambers (moisture chamber spectacles, swim
goggles)
5. Concurrent treatment of infections, such as chronic blepharitis and
acne rosacea
6. Treatment of the underlying systemic disease, such as Sjögren
syndrome (an autoimmune disease)
Surgical Management
1. Punctal occlusion
- Punctal plugs are made of silicone material for the temporary or
permanent occlusion of the puncta. - This helps preserve the
natural tears and prolongs the effects of artificial tears.
- Short-term occlusion is performed by inserting punctal or silicone
rods in all four puncta. - Permanent occlusion is performed only in
severe cases in adults who do not develop tearing after partial
occlusion and who have results on a repeated Schirmer’s test of 2
mm or less (filter paper is used to mea- sure tear production).
2. Grafting procedures
3. Lateral tarsorrhaphy – uniting the edges of the lids
CONJUNCTIVITIS
Conjunctivitis (inflammation
of the conjunctiva) is the
most common ocular
disease worldwide. It is
characterized by a pink
appearance (hence the
common term pink eye)
because of subconjunctival
blood vessel congestion.
Conjunctivitis may be
unilateral or bilateral, but
the infection usually starts
in one eye and then spreads
to the other eye by hand
contact.
Assessment and Diagnostic
Findings
1. Evaluate the type of discharge
(watery, mucoid, purulent, or
mucopurulent), type of conjunctival
reaction (follicular or papillary),
presence of pseudomembranes or
true membranes, and presence or
absence of lymphadenopathy
(enlargement of the preauricular
and submandibular lymph nodes
where the eyelids drain). 2. Positive
results of swab smear preparations
and cultures confirm the diagnosis.
Management
1. Bacterial Conjunctivitis: Antibiotics
2. Viral Conjunctivitis: not responsive to any treatment
- Cold compresses
- Hand hygiene
- Avoid sharing of hand towels, face cloths, eye drops, and other
belongings
- Directly discard tissues into a covered trash can
- Stay at home
- Wear dark glasses for bright lights
- May use artificial tears and mild analgesics, Acetaminopen (Tylenol)
- Use new tissue/cloth every time when wiping the discharge
- May wash face and take a shower regularly
- Discard all of makeup articles, do not apply makeup until the infection
has resolved
3. Allergic
Conjunctivitis:
Ophthalmic
Corticosteroids in
ophthalmic
preparations, Topical
Epinephrine solution,
cold compresses, ice
packs, and cool
ventilation
4. Toxic Conjunctivitis:
immediately irrigate
the eyes profusely with
saline or sterile water