The Eye and Vision

Vision is the sense that has been studied most; of all the sensory receptors in the body 70% are in
the eyes.
Anatomy of the Eye
Vision is the sense that requires the most “learning”, and the eye appears to delight in being
fooled; the old expression “You see what you expect to see” is often very true.

External and Accessory Structures

The accessory structures of the eye include the extrinsic eye muscles, eyelids, conjunctiva, and
lacrimal apparatus.

 Eyelids. Anteriorly, the eyes are protected by the eyelids, which meet at the medial
and lateral corners of the eye, the medial and lateral commissure (canthus), respectively.
 Eyelashes. Projecting from the border of each eyelid are the eyelashes.
 Tarsal glands. Modified sebaceous glands associated with the eyelid edges are the tarsal
glands; these glands produce an oily secretion that lubricates the eye; ciliary glands,
modified sweat glands, lie between the eyelashes.
 Conjunctiva. A delicate membrane, the conjunctiva, lines the eyelids and covers part of
the outer surface of the eyeball; it ends at the edge of the cornea by fusing with the
corneal epithelium.
 Lacrimal apparatus. The lacrimal apparatus consists of the lacrimal gland and a number
of ducts that drain the lacrimal secretions into the nasal cavity.
  Lacrimal glands. The lacrimal glands are located above the lateral end of each eye; they
continually release a salt solution (tears) onto the anterior surface of the eyeball through
several small ducts.
 Lacrimal canaliculi. The tears flush across the eyeball into the lacrimal
canaliculi medially, then into the lacrimal sac, and finally into the nasolacrimal duct,
which empties into the nasal cavity.
 Lysozyme. Lacrimal secretion also contains antibodies and lysozyme, an enzyme that
destroys bacteria; thus, it cleanses and protects the eye surface as it moistens and
lubricates it.
 Extrinsic eye muscle. Six extrinsic, or external, eye muscles are attached to the outer
surface of the eye; these muscles produce gross eye movements and make it possible for
the eyes to follow a moving object; these are the lateral rectus, medial rectus, superior
rectus, inferior rectus, inferior oblique, and superior oblique.

Internal Structures: The Eyeball

The eye itself, commonly called the eyeball, is a hollow sphere; its wall is composed of three
layers, and its interior is filled with fluids called humors that help to maintain its shape.
Layers Forming the Wall of the Eyeball
Now that we have covered the general anatomy of the eyeball, we are ready to get specific.

 Fibrous layer. The outermost layer, called the fibrous layer, consists of the protective
sclera and the transparent cornea.
 Sclera. The sclera, thick, glistening, white connective tissue, is seen anteriorly as the
“white of the eye”.
  Cornea. The central anterior portion of the fibrous layer is crystal clear; this “window” is
the cornea through which light enters the eye.
 Vascular layer. The middle eyeball of the layer, the vascular layer, has three
distinguishable regions: the choroid, the ciliary body, and the iris.
 Choroid. Most posterior is the choroid, a blood-rich nutritive tunic that contains a dark
pigment; the pigment prevents light from scattering inside the eye.
 Ciliary body. Moving anteriorly, the choroid is modified to form two smooth muscle
structures, the ciliary body, to which the lens is attached by a suspensory ligament
called ciliary zonule, and then the iris.
 Pupil. The pigmented iris has a rounded opening, the pupil, through which light passes.
 Sensory layer. The innermost sensory layer of the eye is the delicate two-layered retina,
which extends anteriorly only to the ciliary body.
 Pigmented layer. The outer pigmented layer of the retina is composed pigmented cells
that, like those of the choroid, absorb light and prevent light from scattering inside the
eye.
 Neural layer. The transparent inner neural layer of the retina contains millions of
receptor cells, the rods and cones, which are called photoreceptors because they respond
to light.
 Two-neuron chain. Electrical signals pass from the photoreceptors via a two-neuron
chain-bipolar cells and then ganglion cells– before leaving the retina via optic nerve as
nerve impulses that are transmitted to the optic cortex; the result is vision.
 Optic disc. The photoreceptor cells are distributed over the entire retina, except where
the optic nerve leaves the eyeball; this site is called the optic disc, or blind spot.
 Fovea centralis. Lateral to each blind spot is the fovea centralis, a tiny pit that contains
only cones.
Lens
Light entering the eye is focused on the retina by the lens, a flexible biconvex, crystal-like
structure.

 Chambers. The lens divides the eye into two segments or chambers; the anterior
(aqueous) segment, anterior to the lens, contains a clear, watery fluid called aqueous
humor; the posterior (vitreous) segment posterior to the lens, is filled with a gel-like
substance called either vitreous humor, or the vitreous body.
 Vitreous humor. Vitreous humor helps prevent the eyeball from collapsing inward by
reinforcing it internally.
 Aqueous humor. Aqueous humor is similar to blood plasma and is continually secreted
by a special of the choroid; it helps maintain intraocular pressure, or the pressure inside
the eye.
 Canal of Schlemm. Aqueous humor is reabsorbed into the venous blood through the
scleral venous sinus, or canal of Schlemm, which is located at the junction of the sclera
and cornea.
Eye Reflexes
Both the external and internal eye muscles are necessary for proper eye function.
  Photopupillary reflex. When the eyes are suddenly exposed to bright light, the pupils
immediately constrict; this is the photopupillary reflex; this protective reflex prevents
excessively bright light from damaging the delicate photoreceptors.
 Accommodation pupillary reflex. The pupils also constrict reflexively when we view
close objects; this accommodation pupillary reflex provides for more acute vision.
Pathway of Light through the Eye and Light Refraction

When light passes from one substance to another substance that

has a different density, its speed changes and its rays are bent, or
refracted.

 Refraction. The refractive, or bending, power of the

cornea and humors is constant; however, that of the lens
can be changed by changing its shape- that is, by making
it more or less convex, so that light can be properly
focused on the retina.
 Lens. The greater the lens convexity, or bulge, the more it
bends the light; the flatter the lens, the less it bends the
light.
 Resting eye. The resting eye is “set” for distant vision; in
general, light from a distance source approaches the eye
as parallel rays and the lens does not need to change
shape to focus properly on the retina.
 Light divergence. Light from a close object tends to scatter and to diverge, or spread out,
and the lens must bulge more to make close vision possible; to achieve this, the ciliary
body contracts allowing the lens to become more convex.
 Accommodation. The ability of the eye to focus specifically for close objects (those less
than 20 feet away) is called accommodation.
 Real image. The image formed on the retina as a result of the light-bending activity of
the lens is a real image- that is, it is reversed from left to right, upside down, and smaller
than the object.

Visual Fields and Visual Pathways to the Brain

Axons carrying impulses from the retina are bundled together at the posterior aspect of the
eyeball and issue from the back of the eye as the optic nerve.

 Optic chiasma. At the optic chiasma, the fibers from the medial side of each eye cross
over to the opposite side of the brain.
 Optic tracts. The fiber tracts that result are the optic tracts; each optic tract contains
fibers from the lateral side of the eye on the same side and the medial side of the opposite
eye.
  Optic radiation. The optic tract fibers synapse with neurons in the thalamus, whose
axons form the optic radiation, which runs to the occipital lobe of the brain; there they
synapse with the cortical cells, and visual interpretation, or seeing, occurs.
 Visual input. Each side of the brain receives visual input from both eyes-from the lateral
field of vision of the eye on its own side and from the medial field of the other eye.
 Visual fields. Each eye “sees” a slightly different view, but their visual fields overlap
quite a bit; as a result of these two facts, humans have binocular vision, literally “two-
eyed vision” provides for depth perception, also called “three-dimensional vision” as
our visual cortex fuses the two slightly different images delivered by the two eyes.

Application of the Nursing Process

A. Assessment
1. Subjective Data
a. Nursing History
 Pain - An unpleasant sensation that can range from mild localized discomfort to
agony. Pain has both physical and emotional components. The physical part of pain
results from nerve stimulation. Pain may be contained to a discrete area, as in an
injury, or it can be more diffuse, as in disorders like fibromyalgia. Pain is mediated by
specific nerve fibers that carry the pain impulses to the brain where their conscious
appreciation may be modified by many factors.
 Photophobia - Painful oversensitivity to light. For example, photophobia is often
seen in measles and iritis. Keeping lights dim and rooms darkened is helpful when a
patient has photophobia. Sunglasses may also help.
 Blurred Vision - Lack of sharpness of vision with, as a result, the inability to see fine
detail. Blurred vision can occur when a person who wears corrective lens is without
them. Blurred vision can also be an important clue to eye disease.
 Spots, Floaters - Also known as "floaters", blurry spots that drift in front of the eyes
but do not block vision. The blur is the result of debris from the vitreous casting a
shadow on the retina. The spot is the image formed by a deposit of protein drifting
about in the vitreous, the clear jelly-like substance that fills the middle of the eye.
 Dryness - A deficiency of tears. The main symptom is usually a scratchy or sandy
feeling as if something is in the eye. Other symptoms may include stinging or burning
of the eye; episodes of excess tearing that follow periods of very dry sensation; a
stringy discharge from the eye; and pain and redness of the eye. Sometimes people
with dry eye experience heaviness of the eyelids or blurred, changing, or decreased
vision, although loss of vision is uncommon.
 Diplopia - A condition in which a single object appears as two objects. Also known
as double vision.
 Ptosis - Downward displacement. For example, ptosis of the eyelids is drooping of
the eyelids.
 Proptosis - downward displacement of the eyeball resulting from an inflammatory
condition of the orbit or a mass within the orbital cavity
 Vision Loss - Loss of vision can occur suddenly or develop gradually over time.
Vision loss may be complete (involving both eyes) or partial, involving only one eye
 or even certain parts of the visual field. Vision loss is different from blindness that
was present at birth, and this article is concerned with causes of vision loss in an
individual who previously had normal vision. Vision loss can also be considered as
loss of sight that cannot be corrected to a normal level with eyeglasses. The causes of
loss of vision are extremely varied and range from conditions affecting the eyes to
conditions affecting the visual processing centers in the brain. Impaired vision
becomes more common with age. Common causes of vision loss in the elderly
include diabetic retinopathy, glaucoma, age-related macular degeneration,
and cataracts.
 Visual Field Loss - Visual field loss occurs when an individual experiences damage
to any part of his or her visual pathway, which is the path that signals travel from the
eye to the brain.

a. Functional Health Problems

1. Objective Data
a. Physical Assessment of Visual System
a.1 Eye Structure

 Eye position
 Lids
 Blink
 Eyeball
 Lacrimal Apparatus
 Conjunctiva
 Cornea
 Anterior Chamber
 Iris, Pupil

a.2 Test of the Eye

 Corneal Reflex
 Corneal Light Reflex
 Cover-uncover Test
a.3 Vision Testing

 Visual Acuity
 Visual Fields
 Special Test
 Color Vision
 Central Area blindness
b. Diagnostic Assessment
b.1 Non-invasive

 Fundus Photography – A digital fundus camera is used to take an image of the

fundus — the back portion of the eye that includes the retina, macula, fovea, optic
 disc and posterior pole. A digital fundus camera normally consists of a camera with a
specialized microscope attached. Either a lamp or flash provides the light necessary
for photo taking, or depending on the camera photos at different angles of view —
from narrow to wide — can be taken. The resulting image can then be used by an
ophthalmologist for diagnosis and treatment.

 Ophthalmometry - the measuring of the corneal curvatures of the eye and of their
deviations from normal (as in astigmatism) usually by means of an ophthalmometer.

 Ophthalmic Radiography - Retinal imaging takes a digital picture of the back of

your eye. It shows the retina (where light and images hit), the optic disk (a spot on
the retina that holds the optic nerve, which sends information to the brain),
and blood vessels. This helps your optometrist or ophthalmologist find certain
diseases and check the health of your eyes

 MRI - An MRI scan uses a magnetic field and pulses of radio wave energy to make
pictures of your body. During an MRI to check for optic neuritis, you might receive
an injection of a contrast solution to make the optic nerve and other parts of your
brain more visible on the images.

An MRI is important to determine whether there are damaged areas (lesions) in your
brain. Such lesions indicate a high risk of developing multiple sclerosis. An MRI can
also rule out other causes of visual loss, such as a tumor.

 Ultrasonography - Ultrasound is acoustic energy with frequencies above the audible

limit. Very high frequency, low energy and short duration ultrasonic pulses are
transmitted into the ocular and orbital structures from a ‘probe’ 1 via a coupling
agent. In the time intervals between pulse transmissions, reflections from tissues are
received by the same probe and the signals can be used to produce various types of
detailed images of the eye and orbit.

o A-Scan - It can be used to measure the length of the eye in the presence of a
dense cataract when measurement by optical means is not possible. A small
single transducer typically with a frequency of 10MegaHertz (MHz) is placed
on the central cornea and aimed along the visual axis. It emits pulses of sound
and in the time interval between pulses; the echoes are received by the same
single transducer.

o B-Scan - The B-scan technique produces a cross-sectional image of the eye

and obit. The B-scan is created by moving an individual transducer, via a
coupling agent, across the eye. Each transducer position generates an A-scan
line of data but instead of plotting echoes as spikes, they are plotted as spots,
the brightness of the spots indicating the amplitude of the echo. These spots
are plotted in accordance with the transducer position and so the image
generated resembles an anatomical cross-section through the eye and orbit.
  Ophthalmodynamometer – the measurement of the blood pressure in the retinal
vessels.

 Electroretinography – ERG measures the function of your retina – the light-

sensitive layer at the back of your eye. When light from an image enters the eye, it is
converted into electrical energy by specialized cells in the retina. These cells send
electrical impulses through the optic nerve to the brain where the image is
processed. The ERG records how well the cells of the retina are conveying
electrical impulses within the eye. Studies have shown that ERG results aid in the
diagnosis and treatment planning of many vision-related disorders

 Visual Evoked Response - VEP is a painless, safe, non-invasive vision test used to
objectively measure neurological responses of the entire visual pathway. VEP
measures neurological responses by measuring the electrical activity in the vision
system. When light from an image enters your eye, it is converted into electrical
energy at the retina and travels through the optic nerve to the visual cortex of the
brain which processes vision. The VEP test measures the strength of the signal
reaching your visual cortex and how fast it gets there.

 Slit-Lamp Examination - The slit lamp exam is usually performed during eye
checkups. It looks for any diseases or abnormalities in the anterior portion of the eye,
which includes the eyelids, lashes, lens, conjunctiva, cornea, and iris.
Eye drops will be administered and the technician and the doctor will use a low-
powered microscope and a high-intensity light to look closely at your eyes. The light
focuses into a single intense beam that shows the eye structures in great detail.

 Amsler Grid test - The Amsler grid is a tool that eye doctors use to detect vision
problems resulting from damage to the macula (the central part of the retina) or
the optic nerve.

 Refractometry - Refractometry is the method of measuring the refractive index of

substances.
b.2 Invasive Test

 Fluorescein angiography - This is a diagnostic procedure that allows the study of the
circulation of the retina and choroid in normal and diseased states. A special camera is
used to take a series of photographs of the retina after a small amount of yellow dye
(fluorescein) is injected into a vein in your arm.

 Corneal Staining - This is a test that uses orange dye (fluorescein) and a blue light to
detect foreign bodies in the eye. This test can also detect damage to the cornea.

B. ANALYSIS/NURSING DIAGNOSIS (Visual and Auditory Function)

 1. Disturbed Sensory Perception as evidenced by blurred vision, seeing halos, black spots or
floaters, difficulty hearing, altered sense of balance.
2. Impaired Verbal Communication as evidenced by difficulty comprehending and
maintaining communication, inability to articulate speech, absence of eye contact.
3. Deficient Knowledge: Vision/Hearing Assisting Devices as evidenced by expressions of
helplessness, lack of health-seeking behaviour.
4. Nausea as evidenced by complaints of queasiness, discomfort associated with movement
of head.
5. Risk for injury ineffective health maintenance.

C. PLANNING

1. Planning for Health Promotion

Care of the Eyes
a. Use of medications
 Use of drops should be discouraged since tears contain a lysozyme (beta lysin). IgA,
and IgG, which inhibit bacterial growth.
b. Eye Fatigue
 Printed matter should be held at least 14 inches from the eye.
 When watching television, stay 10-12 feet away from the screen.
c. Illumination
 Read in an environment illuminated by a bulb of 100-150 watts.
 Light should come from behind and not reflect a glare.
d. Use of dark glasses
 Dark glasses protect the eyes of an individual who changes environments by
becoming lighter as the individual enters a dark environment and darker as
sunlight is entered.
e. Danger signals of eye problems
 Persistent redness of the eye
 Continued discomfort or pain around the eye, especially following an injury
 Crossing of the eyes, especially in children
 Visual disturbances, such as blurred vision or spots before the eyes.
 Growth in the eye or eyelid or opacities visible in the normally transparent part of
the eyes.
 Continuous discharge, crusting, or tearing of the eye
 Pupil irregularities
Eye Specialists
a. Optometrist – a licensed non-medical practitioner qualified to measure refractive errors
and eye muscle disturbances. This professional does not treat or diagnose eye conditions.
b. Optician – a technician who prepares and grinds lenses, fits them into proper frame, and
adjusts the frames to the wearer.
 c. Ophthalmologist (MD) – specializes in diagnosis and treatment of defects and diseases
of the eyes, performs surgery when necessary, and prescribes other types of treatment,
including glasses and care for refractive problems.
d. Orthoptist – a medical technician who assists the oculist in the examination and care of
clients with disorders of ocular movements.
e. Ocularist – a person who makes and fits artificial eye(s).

2. Planning for Health Maintenance and Restoration

Nursing Management
a. Installation of eye drops – client tilts head backward and inclined slightly to the site.
Ask the client to look up, pull his lower lid down and drop the medicine in the center of
the lower cul-de-sac or space between the eyeball and inner surface of the lower lid.
Allow the medicine to enter the conjunctival sac by capillary attraction. Excess fluid can
be wiped off. Tell the patient to close his/her eyes. Do not squeeze for even distribution
of the medicine.
b. Installation of eye ointments – same as above. Expel a small amount of ointment from
the tip of the tube without coming in contact with the lid, beginning at the inner canthus
moving outward to prevent the spread of contaminants into the lacrimal duct.
c. Glasses
 For adults: suggest attractive frames and encourage proper fitting of glasses.
 For children: Have glasses changed as recommended by the ophthalmologist to
keep pace with growth changes and shifts in visual acuity
d. Hot compresses – unless specified, use NSS. Also, temperature should be at or slightly
above temperature, 46-49℃ (115-120℉)
e. Cold compress – helps control bleeding and edema
f. Eye irrigations – done to remove secretion, to cleanse the eye preoperatively into supple
warmth. NSS is often used because it is more soothing and less likely to cause pain.
g. Massage of the eyeball – used in treating glaucoma especially following certain
operations.
h. Contact lenses
Types:
 Sclera: fits over the cornea and the conjunctiva covering the sclera; it is used in
pathological conditions.
 Corneal: tiny disks that are contoured to fit the anterior cornea.
Common Ocular Medications
a. Local anesthetic – acts to anesthetize the eye and thus prevent pain during various ocular
procedures.
 Topical anesthetic (Pontocaine, 0.5%)
 Injectable local anesthetics (Novocaine – 1-2%; Xylocaine – 1-2%)
b. Parasympathomimetic drugs – produces effects resembling stimulation by the
parasympathetic nerve. Used as miotic, this causes the pupils to contract and is used to
control intra-ocular pressure in glaucoma by widening the filtration angle and permitting
outflow of aqueous humor.
  Group I (cholinergic drugs) – acts directly on the myoneural junction; produces
strong contraction of iris (e.g. miosis) and ciliary body musculature
(accommodation); e.g., Pilocarpine HCl (0.5 – 10%)
 Group II (cholinesterase inhibitors) – 0.25 – 0.5%
c. Parasympatholytic drugs (anticholinergics drugs) – e.g., those which produce effects
resembling those of the interruption of parasympathetic nerve supply to a body part. It is
used to facilitate eye exam and refraction. They cause smooth muscles of the ciliary body
and iris to relax thus producing mydriasis which causes the pupil to dilate and cyloplegia
(paralysis of the ciliary muscles, resulting in paralysis of accommodation).
 Mydriatics (Neo-Synephrine 2.5 +10%; Euphthalmine 2-5%)
 Cycloplegics (atropine sulfate – 0.5%; hyoscine 0.25% homatropine
hydrobromide – 2.5%; cyclogyl – 1.0-2%; hydriacyl – 0.5+1%)
d. Sympathomimetic drugs (adrenergic drugs) – used primarily to produce mydriasis and
vasoconstriction; do not cause cycloplegia. Vasoconstriction increases outflow of
aqueous humor, thus reducing intraocular pressure; e.g., adrenaline (1:1000);
neosynephrine 1.125-10%
e. Antibiotics (e.g., chloromycetin; Neosporin; polymixin B sulfate; bacitracin)
f. Sulfonamide – Gantrisin 4%
g. Adrenal corticosteroids – for the treatment of nonpyrogenic inflammation and allergic
reactions (e.g., cortison acetate; prednisone)
h. Carbonic anhydrase inhibitors – an enzyme carbonic anhydrase is one of the
substances necessary for production of aqueous humor; for the treatment of glaucoma to
reduce formation of aqueous humors and thus reduce intraocular pressure. Diuresis is
produced, e.g., Oratrol; Diamox
Common Ophthalmic symbols:

 OD – oculus dexter (right eye, RE)

 OS – oculus sinister (left eye, LE)
 OU – oculus uterque (both eyes)
 EOM – extra ocular muscles
 Gtt(s) – gutta, guttae (drop, drops)
 IOP – intraocular pressure
Visual Impairment
Variations
a. The individual who is considered partially sighted may have a visual acuity ranging from
20/70 to 20/200.
b. An individual with a visual acuity of 20/70 generally requires special services because of
the impairment invasion.
c. An individual whose vision is 20/200 or less in the better eye with corrective lenses is
considered legally blind.
d. An individual who has totally loss his ability to see is considered blind. Blindness is of 2
types:
 Congenital blindness – infants born blind
  Acquired blindness – individuals who lose their sight during infancy, childhood,
adolescence, adulthood, or during the aging process.
Factors

 Age – onset at which individual becomes blind may totally affect the adjustment
 Suddenness of onset – another factor that may affect adjustments such as traumatic
injury or accident.
Grief Process

 Stage:
o Shock – first stage experience. It is characterized by an inability of the person to
think or feel emotionally.
o Depression – the individual goes through a period of grieving in which he/she
actually mourns for the eyes.
Nursing Care

 Support systems
 Give ample time to work through the client’s feelings.
 Provide opportunities for the client to verbalize his/her thoughts, fears and inadequacies.
 Assist for rehabilitation, which is the essential factor.
Assessment
a. Neonate’s eyes are anatomically larger in comparison with body size.
 Eyes function immaturely
 Pupils: constricted and unequal (until the first week of life)
 Cornea: larger and flatter than adults
 Eyelids: edematous, so the neonate opens his/her eyes infrequently, respond to
flash or light by closing eyelids (eye movement uncoordinated)
 Lacrimal glands: do not function until 2 weeks of age
b. Infant’s eyes are smaller than at birth
 Tears may flow in response to emotions (3 months)
 1 month: focuses on stationary object
 2 months: able to follow moving object
 3 months: focuses on object within easy reach; active blink reflex
 4 – 6 months: 20/200 visual acuity, recognizes strangers, develops eye-hand
coordination
 5 – 7 months: preference for bright (light) colors
 9 months: pick up tiny objects
 1 – year – old: visual acuity 20/100; mature eye muscles
c. Toddler
 Visual acuity: 20/60 (2 years old)
 3 years old visual acuity: 20/30. Attention span increased to 1 minute
d. Pre-school
  20/30 visual acuity, readiness for reading
 Lacrimal glands are fully developed
 5 years old: color recognition establish
e. School age
 Visual acuity: 20/20
 Attention span increased to 20 mm
f. Adolescent
 Emmetropia is well-established
 Eyeball attains adult size
g. Adult
 Increased lens elasticity
 Ability to focus upon near objects
 42 – 45 years old: gradual loss of accommodation
Planning and Implementation – the goal of care is to help each client to lead a normal life as
much as possible.
a. Developmental Considerations
 Physical maturation
 Motor development
 Neuromuscular coordination
b. Guidelines for communication with a blind person
 Talk in a normal tone of voice
 Do not try to avoid common phrases in speech, such as “see what I mean.”
 Introduce yourself with each contact. If in a hospital, knock on the door before
entering.
 Explain any activity occurring in the room or what you’ll be doing
 Announce when you are leaving the room so the person is not put in a position of
talking to someone who is no longer there.
c. Guidelines for facilitating independence in activities of daily life for blind persons
 Place clothing in specific locations in drawers and closets
 Place food and cooking utensils in specific locations in cupboards and/or
refrigerator
 Encourage use of cane when walking
 Keep furniture and household objects in specific places
 When assisting a blind person in walking, let the person take your arm
 Provide description of foods on the plate using clock placement of food client,
e.g., put peas at 7 o’clock.
 Always permit blind persons to pull out their own chair and seat themselves.
d. Visual impairments aids
 Aids for the blind
o Cane – useful instrument in assisting the blind client in orientation and
mobility. The client can explore by touching objects within the immediate
environment.
 o Seeing Eye dog or guide dog – permits blind individuals to travel and
explore areas where he/she would otherwise be hesitant to venture into.
 Aids for the partially blind
o Books and newspapers in large print to enable the partially blind client to
cope with the condition, as well as to continue contact with the outside
world of pleasure and companionship
e. Recreation
 Leisure time activities; special toys, such as a soft ball, should be available.
 Special checkers and checkboards, chess, scrabble and Braille cards.
 Blind people may also engage in arts and crafts
 Films, plays and lectures are great sources of stimulation
 Fishing is an excellent outdoor sport
 Young clients should be encouraged to engage in physical sports to relieve
aggression and hostility.
f. Education
 Instruct families about an educational setting. The nurse should encourage the
client’s family to enrol the child in the kind of educational setting from which
he/she can benefit the most.
 Resources such as Braille books, talking book tapes, recorder lectures, and other
services are provided for the legally blind.
g. The hospitalized client
 Client should always be oriented to the environment
 The nurse should encourage the use of tactile senses by allowing locating the call
light, furniture, windows, bathroom, and other objects within the environment.
 The client should stand behind the nurse who is guiding him/her; the approach
affords an added sense of balance and security.
 The nurse should walk in a straight line
 When leading up and down stairs, the nurse should pause for a brief moment and
then inform the client.
 If handrails are available, the client should be encouraged to use them.
 Doors must never be left partially open, they should always be open or closed.

D. COMMON RELATED DISORDERS

 Injuries and Trauma – In general, when an eye injury is present, it is advisable
to treat the patient but leave the eye alone. The exception to this rule is when a
chemical injury has occurred and the eye itself must be immediately flushed with
water. When removing foreign particles, do not touch the cornea. Irrigation is
done for at least 15 minutes before stopping to move the patient or get a doctor. If
water is not available, use beer or carbonated beverages.

 Infections
o Hordeolum or Stye: infection of the Zeis gland in the follicle of a lash.
o Chalazion: involves a meibomian gland, located in the tarsal plate of the
lid. Rx: I & D; an antibacterial ointment
 o Conjunctivitis: can be caused by a wide variety of bacteria; often called
“pink eye”. May result from a bacterial infection, allergy and trauma, as in
sunburn and viruses.
o Uveitis: inflammation of the cornea.
o Pterygium: a triangular fold of membrane which forms in the conjunctiva
which tends from the white of the eye to the cornea

 Cataract – opacity of the crystalline lens or of its capsule which interfered with
transparency.
o Signs and Symptoms: dimness of visual acuity, rapid and marked
changes of refraction error.
o Classification
 Primary or senile – begins first in one eye and then the other eye
from 45 years on. It is rare that this becomes unilateral. It occurs
with other degenerative changes as person ages.
 Secondary or traumatic – due to some disease or injury of the
eye, e.g., diabetes mellitus; traumatic cataract due to a direct blow
or due to exposure of intense light.
 Congenital – not seen at the time of birth, but when defective
vision becomes evident during childhood it is associated with
attack of German measles in the mother during the first trimester
of pregnancy.
o Management
 Intracapsular extraction – lens is removed within its capsule.
 Extracapsular extraction – lens capsule is excised and the lens id
expressed by pressure in the eye from below with a metal spoon.
 Cryoextraction – cataract is lifted from the eye by a small probe
that has been cooled to a temperature below zero to the wet surface
of the cataract. All these procedures usually are preceded by an
iridectomy that is performed to create an opening to the flow of
aqueous humor which may become blocked post-op when the
vitreous humor moves forward.
 Phacoemulsification – requires an incision just large enough to
insert a needle probe that vibrates 40,000 times per second to break
up the lens and flush it out in tiny suction units.
 Enzymatic Zonumolysis – a technique that involves injecting
alpha-chymotrypsin (a fibrinolytic and proteolytic enzyme) into
the anterior chamber. This enzyme frees the attachment of the lens
capsule and thereby facilitates removal of the lens without tearing
the lens in the process of removing it.
 Intraocular lens – implantation of a synthetic lens designed for
distance vision. The patient wears prescribed glasses for reading
and near vision. It is an alternative to sight correction with glasses
or contact lenses for the aphasic patient.
o Nursing Care
 Pre-op:
  Orient the patient to his/her environment.
 Begin rehabilitation soon after admission. Deep breathing
exercise should be taught. Instruct how to close eyes
without squeezing the lids. ‘
 Reduce the conjunctival count: use of antibiotics
 Prepare the affected eye for surgery: Instill mydriatics if
ordered.
 Post-op:
 Reorient the patient to his/her surroundings
 Prevent increase in IOP and stress on the suture line.
o Activities that tend to increase IOP and are
therefore restricted during the early postoperative
period are coughing, brushing the teeth, shaving,
vomiting, bending, and stooping.
o Bathroom privileges and ambulation are permitted
but constipation should be avoided.
 Promote the comfort of the patient: mild analgesic to
control pain.
 Observe and treat complications:
o Nausea and vomiting of anti-emetics drugs and cold
compress to the throat.
o Hemorrhage: Notify physicians if patient complains
of sudden pain in the eye.
o Prolapse of the Iris is the most common post-op
complication and it can precipitate acute glaucoma.
 Promote the rehabilitation of the patient: Encourage the
patient to become independent: walk with him/her when
he/she first becomes ambulatory
 Health teachings:
o Dark glasses may be prescribed 1-4 weeks after
surgery
 Temporary corrective lenses may be prescribed 1-4 weeks after
surgery
 Permanent lenses may be prescribed 6-8 weeks after surgery. The
glasses will take the place of the crystalline lens. In six months’
time, the eye will have made their adjustment. However, the power
of accommodation is lost so that a bifocal lens is used.
 Patients should know that it will take time to learn to judge
distances, climb stairs and do other simple things.
 Colors of objects seen with the lens removed is slightly changed
and that if they have had the lens removed from one eye only they
will use only one eye at a time nut not together, unless a contact
lens is fitted on the operated eye.
 Ambulatory patient should have slip-on footwear to avoid bending
or stooping.
  Peripheral vision is decreased, so that the patient needs to be taught
to turn his/her head and utilize the central vision provided by the
lenses.

 Glaucoma – eye disease characterized by increase IOP associated with

progressive loss of peripheral vision

Cause: Obstruction to the circulation of aqueous humor through the meshwork at

the angle of the anterior chamber of the eye where the peripheral iris and the
cornea meet.

Types:
a. Chronic Simple or wide or open-angle glaucoma
Cause: hereditary predisposition to the thickening of the meshwork.
Signs and Symptoms: loss of peripheral vision (tunnel vision) before central
vision; frequent changes of glasses; difficulty in adjusting to darkness; failure to
detect changes in color; tearing; misty vision; headache; pain behind the eyeball;
nausea and vomiting; halos.

Rx: Miotics, e.g. Pilocarpine to constrict the pupil and draw the smooth muscle
of the iris away from the canal of schlema to permit aqueous humor to drain out.
Drops are prescribed in early AM since IOP is usually higher on arising on AM.
 Acetazolamide (Diamox) to reduce formation of aqueous humor
 Avoid fatigue or stress
 Avoid drinking large quantities of fluid
 Certain limitations are not necessary. May drink normal amounts of coffee and tea
(1-2 cups) and alcoholic beverages.
 Surgery: the principle is to improve the drainage of the intraocular fluid or
aqueous humor thereby lessening the pressure of the eye.
Iridecleisis – the formation of fistula between the anterior chamber and the subconjunctival
space.
Corneoscleral trephining (Elliot’s operation) – small opening is made at the junction of the
cornea and sclerae leaving a permanent opening through which aqueous humor may drain.
Langrange’s operation (sclerectomy) – sclera is excised combined with iridectomy
Trabeculoctomy and Trabeculotomy – excision of a rectangle of the sclerae that includes the
trabeculae sclerae canal and sclera spur.
Cyclodialysis – a new passage within the eye itself is made from the anterior chamber to the
suprachoroidal space. The principle of operation employing low voltage and high-frequency
currents (cyclodiathermy or cycloelectrolysis) is to cause atrophy or destruction of the ciliary
process, since one of their functions is the recreation of the aqueous humor.
Non-surgical and Laser therapy – approximately 50-100 beams are applied to the pigmented
band of the tubular meshwork resulting in permanent increase in tension on the trabeculum and
opening of the outflow channel.
b. Acute Angle Closure Glaucoma
Cause: the result of an abnormal displacement of iris against the angle of the anterior
chamber. It is a relatively rare disease. Dilation of the pupil is caused by darkness,
excitement or s mydriatic drug, which may cause blockage of the outflow mechanism of the
eye with a narrowed peripheral angle of the anterior chamber.
Signs and Symptoms: severe eye pain, nausea, vomiting and abdominal pain; blurred vision
colored halos around the lights, dilated pupils, and increased IOP
Rx: Miotics. Diamox: osmotic agents such as glycerol also act to reduce the pressure of acute
glaucoma.
Surgery: Iridectomy – removal of portion of the iris.
c. Congenital glaucoma – rare, may be present at birth
d. Secondary glaucoma – because of some other eye condition such as uveitis or trauma or
post-op complication
e. Absolute glaucoma – the end result of uncontrolled glaucoma. Enucleation if often
necessary.
Therapeutic management
a. Eye Surgery Terms
 Enucleation – removal of the eye. Rectus muscle is attached to the implant to
provide movement of the prosthetic eye.
 Exenteration – removal of the eye plus the surrounding structure
 Evisceration – removal of the content of the eye except the sclera

b. General Nursing Care after Glaucoma Surgery

Pre-op: Patient must realize that the vision lost cannot be restored but that further loss can
usually be prevented. Administration of miotics is done at this point.
Post-op

 Position – flat and quiet for 24 hours to prevent prolapse of the iris through the
incision.
 Use of narcotics or sedatives to keep patient quiet and comfortable.
 Liquid diet until the first dressing
 Turning on his unoperated side.
Long-term Care

 There is usually no restriction on the use of the eyes

  Fluid intake generally is not curtailed and exercise is permitted.
 Neither bright lights nor darkness are harmful to the eyes of patient with glaucoma
and there is apparently no relationship between vascular hypertension and ocular
hypertension.
 Medical care for the rest of their lives.

 Detachment of the retina: this occurs when:

o A separation of the two primitive layers of the retina occurs because of
accumulation of fluid between them.
o An elevation of both retinal layers away from the choroid occurs because of the
presence of a tumor.
Causes: myopic degeneration, trauma and aphakia (absence of the crystalline lens)
Signs and Symptoms: floating spots or opacities before the eye due to blood and retinal cells that
are freed at the time of the tear and cast shadows on the retina as they seem to drift about the eye;
flashes of light and progressive constriction of vision in one eye.
Management
a. Conservative: keep the client quiet in bed with eyes covered to try to prevent further
detachment; head is positioned so that the retinal holes are the lower part of the eye.
b. Non-surgical methods: employed to seal retinal breaks before the retina becomes
detached
 Photocoagulation – a small burn is made in the retina by shining a very bright
light through the pupil.
 Cryotherapy: a cold probe is applied to the outer wall of the eye to “freeze” the
retina.
c. Surgical methods: aimed at sealing at the retinal break, reattaching the retina from
redetaching, e.g., scleral buckling

Post-op Care:
 Eyes are covered to prevent ocular movement.
 Position so that the area of detachment is dependent.
 Pupils are dilated by use of mydriatic, e.g., neosynephrine and cycloplegic, e.g.,
Cyclogyl to facilitate visualization of the retina to decrease movement of the
intraocular structures.
Discharge instructions: Avoid strenuous exercise and activity for at least 6 months.
Contact sports are restricted for the remainder of the client’s life. Client must avoid
sudden movement or jarring of the head. Movements of the eyes do not precipitate
recurrence and therefore no restrictions are placed on the use of the eyes.
 Refraction Errors of the Eyes
Terms
a. Emmetropia – refers to the normal eye
 b. Ametropia – indicates that a refraction error is present
c. Refraction – bending on the rays of light as they pass from one medium to another
d. Accommodation – ability of the eye to adjust from near to far objects
e. Adaptation – ability of the eye to see light from darkness
Common Refraction Errors
a. Myopia or near-sightedness – usually long anterior-posterior dimensions of the eyeball
which causes light rays to focus in front of the retina.
Cause: hereditary (an important cause), faulty posture, poor nutrition
Signs and Symptoms: good vision for near distances
Rx: use of concave lenses or minus lenses, proper diet

b. Hyperopia (also, hypermetropia or far-sightedness) – anterior-posterior dimension is

too short so that light rays focus on behind the retina
Cause: principally hereditary
Signs and Symptoms: eyestrain or asthenopia; good vision for far distances
Rx: convex lenses or positive lenses

c. Presbyopia or old sight or far-sightedness in advanced age – affects all persons past
the age of 45 years and is due to gradual loss of accommodation, which is due to loss of
elasticity of the lens and only partly weakening of the ciliary muscles.
Signs and Symptoms: inability to read without holding the reading material more than 13
feet from the eye
Rx: Use of bifocal lens

d. Astigmatism – condition caused by asymmetry or irregular curvature of the cornea so

that rays in the horizontal and perpendicular plane do not focus at the same point.
Cause: congenital in nearly all cases of regular astigmatism. Heredity is the only known
etiological factor.
Rx: use of cylindrical lenses. In higher degrees, glasses will be worn at all times; in lower
degrees, glasses are worn only for tasks causing eyestrain.

e. Anisometropia – condition in which the refractions of the two eyes are not alike.
f. Aniselkonia – condition in which there are difference in the size of the retinal images
independent of the reactive condition of the eye.
g. Blindness – the legal definition of blindness is 20/200 or less in the better eye with
corrective lenses.
 References
Layug, E., (2009). Client with Visual Disorders, Pages 1059-1073, Comprehensive Reviewer for

the Nurse Licensure Exam (NLE), 839 EDSA, South Triangle, Quezon City, C & E

Publishing, Inc.

MedTerms Medical Dictionary, retrieved on June 3, 2020 from

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Special Senses Anatomy and Physiology, Nurseslabs. Retrieved on June 3, 2020 from

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