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Nursing assessment of eye part 2
 

Nursing assessment of eye part 2

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    Nursing assessment of eye part 2 Nursing assessment of eye part 2 Presentation Transcript

    • Nursing Assessment Part II Gauri S. Shrestha, M.Optom, FIACLE
    • Tonometry
      • Tonometry refers to a clinical technique that provides a measurement of intraocular pressure.
      • Indentation tonometry (Schiotz tonometer) is rarely used nowadays.
      • Goldmann applanation tonometry- a gold standard.
      • Purpose
        • To measure intraocular pressure.
      • Assessment of patient
        • Note age of patient on the record. Age above 40 years is a general indication.
        • Assess anterior chamber angle depth, iris pattern, neovasularization, and surgery.
        • Assess internal eye structures especially optic nerve head to find out glaucomatous changes.
      • Required instrument:
        • Slit lamp.
        • Applanation tonometer
        • Topical anesthetics
        • Fluorescein strips
        • Sterile cotton bud
        • Sterile saline solution
      • Patient preparation
        • Explain patient about the nature of the test to seek his or her confidence and co-operation.
        • Seat patient comfortably in dimly illuminated room in front of slit lamp.
        • Check the diagnosis and purpose of the test.
        • Make sure removal of patient's spectacle or contact lenses, if he or she is wearing them.
    • (Schiotz tonometry)
      • Weight of plunger= force required to flatten cornea
      • Amount of pressure exerted is directly read on scale as indicated by needle
      • Exact amount of pressure is read from scale nomogram adjusted for weight
      Gauri S Shrestha, M.Optom
    • Goldmann applanation tonometry
      • Imbert ficks law:
        • Pressure inside the sphere (P)= Force required to flatten its surface/area of flattening
      • Diameter of indented area= 3.06mm
      • Variation: perkins applanation tonometer
      • Pulse air tonometer
      Gauri S Shrestha, M.Optom
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    • Findings
      • However, it has to be understood that the IOP is not static, but undergoes a diurnal variation.
      • Single observation of intraocular pressure can't justify as the suspicion of glaucoma.
      • However, mean intraocular pressure of 15mmHg is considered normal.
      • Intraocular pressure above 21mmHg is considered elevated.
      • Abnormally high intraocular pressure over along period, suggest the presence of glaucoma.
    • Refraction
      • Refraction pertains to determination of the refractive status of the eye.
      • In objective refraction, the examiner determines the refractive state of the eye on the basis of instrumental finding.
        • Retinoscope and autorefractor
      • In subjective refraction, the examiner determines the refractive state entirely on the basis of the patient's response.
      • Cycloplegic refraction is performed in non-verbal, non-communicative, infants, toddlers, and squint patients.
      • Purpose
        • To determine refractive error of patient.
        • To help evaluate the cause for non-improvement of vision in some ocular pathology.
        • To act as primary treatment for correction of squint, amblyopia, and binocular vision problem
      • Required Instruments
        • Retinoscope
        • Trail frame
        • Lens rack
        • Lens bar
      • Assessment of patient
        • Assess visual acuity without glasses, with glasses, and with pinhole.
        • Ascertain any media opacity in the eye that obscures viewing of internal structure of the eye such as cataract, corneal opacity.
        • Assess any redness in eye, haziness in the media, patient's complaint of eyeball pain, squint, and asthenopia.
        • Assess that retina is normal to confirm possibility of vision improvement.
      • Patient preparation
        • Explain the importance and sequences of procedure to patient to seek his confidence and co-operation.
        • Make patient sit comfortably in examination room in front of nurse with eyes at same level as nurse.
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    • Findings
      • Concave lens is required in myopic ametropia
      • Convex lens is required in hyperopic ametropia.
      • Cylindrical power is required to correct astigmatism which could be either convex or concave.
      • The refractive error and visual acuity should be recorded in patient record form as (RE/LE/BE)/ (±Spherical power in DS)/ (±Cylindrical power in DC) X (axis in degree). e.g., RE -2.00DS/ -1.25DC X 180; LE +0.50DS/ -0.75DC X 180.
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    • Color vision test
      • Introduction
        • the part of every basic eye examination.
        • Normal color vision is said to be trichromatic
        • Missing or abnormalities in any one of the receptors which detect these primary colors result in color vision defect.
      • Pseudoisochromatic plates
      • Farnsworth D-15 test
      • Purpose
        • To detect red-green deficiency.
        • To detect blue-yellow color vision deficiency.
        • Identify hereditary and acquired color deficiencies.
        • Evaluate macula function.
      • Assessment of patient
        • Assess visual acuity and refraction.
        • Observe involuntary to and fro eye movement (nystagmus)
        • Assess history of any congenital anomalies in children.
        • Review the report of ophthalmologic report on any acquired retinal and optic nerve diseases.
        • Review the patient's medication such as ethanbutol, tranquillizers, etc, that can cause color vision alteration.
      • Instrumentation
        • Ishihara color vision test (pseudoisochromatic plates) or
        • Farnsworth D-15 test
        • Color vision record sheet for Farnsworth D-15 test.
        • Occluder
      • Patient preparation
        • Provide the comfortable sitting arrangement to patient.
        • Ask to remove tinted glasses before administering the test.
        • Refractive correction should be there or visual acuity should be better than 6/60.
        • Ask the patient to avoid color naming.
        • Give a fixed, verbal and clear instruction to patient.
    • Isihara for Anomalous Trichromate
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    • Normal Color Perception Red Color Blind Green Color Blind
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    • How the World look? Red green defect Blue yellow defect Normal
    • TEST OF STEREOPSIS
      • Stereopsis is the ability to perceive depth or disparity.
      • The Titmus stereo test.
        • Stereofly in used to test gross stereopsis of 3000 seconds.
        • Pictures or figure of different disparity ranging from 400 seconds to 40seconds.
      • Purpose
        • To grade level of depth perception in strabismus, amblyopia, and ocular diseases.
      • Assessment of Patient
        • Assess history of asthenopia, ocular pain associated with near work, especially in computer operators.
        • Review the ophthalmologic and optometric report of strabismus and diplopia.
        • Assess best corrected visual acuity to ascertain amblyopia.
        • Review the ophthalmologic and optometric record of ocular diseases that causes decrease in vision
      • Instrumentation
        • Titmus stereo test booklet
        • Polarized glasses.
      • Patient preparation
        • Check the diagnosis and purpose of the test.
        • Assess patient's level of consciousness and ability to follow directions.
        • Seat patient comfortably in adequately illuminated room.
    • Tests for Stereopsis: Titmus test
      • TNO Random dot test
      Tests for Stereopsis:
    • Findings
      • Patient can't read any of the disparity cards, means stereopsis is absent, and cause will usually establish the finding.
      • When the patient is able to read, the stereo threshold is recorded as the smallest disparity perceived by the patient.
      • In general, one can read stereopsis of as fine as 30 seconds of arc.
    • VISUAL FIELD
      • Every basic eye examination should include some form of visual field evaluation.
        • When there is a reason to suspect the presence of a field loss.
        • glaucoma, lesions of choroid, retina, and visual pathway.
      • Goldman hemispherical projection perimeter and automated field analyzers
      • Here, the discussion is limited to visual field testing in confrontation and amsler chart.
      • Purpose
        • To detect visual field defect in periphery as well as central area of field of vision.
        • To detects constriction and hemianopia of peripheral field by confrontation.
        • To detect alteration in central visual field such as scotoma, blur, distrotion, or spots.
        • To refer really necessary cases for a detailed examination of the visual field.
      • Assessment of patient
        • Check patient’s name, bed number, and identification.
        • Check the diagnosis and purpose of the test.
        • Assess the need for any restraints.
        • Assess patient's level of consciousness and ability to follow directions.
    • Anatomy of visual field
    • Visual field testing devices Goldmann VF Automated VF Bernal disc
    • Automated and goldmann reading
    • THE AMSLER CHARTS
      • This chart is used for central visual field screening.
      • Helpful in screening macular lesions, and vision is reduced without knowing the cause.
      • Instrumentation
        • Amsler Chart.
        • Occluder with head band.
      • Patient preparation
        • Explain the importance and sequences of procedure to patient to seek his confidence and co-operation.
        • A patient is sited comfortably in adequately lit room .
        • Arrange uniform background behind the examiner.
    • Amsler grid test: central visual field test
    • Micropsia Metamorphopsia Macropsia
    • Findings
      • When patient notice any distortion, scotoma, interruption or blur, his or her central vision should be considered affected.
      • This finding warrants further examination and evaluation.
    • Field defect Orientation and mobility Reading performance Difficulty identifying faces
    • VF Loss: Simulations:
    • Thank you