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Vision in older adults spring 2012 abridged

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  • Good sensory function is an extremely valuable asset that often is taken for granted. For instance, people are better able to protect themselves from harm when they can see, hear, smell, touch, and communicate. The reduced ability to protect oneself from hazards because of sensory deficits can result in serious falls from unseen obstacles, missed alarms and warnings, ingestion of hazardous substances from not recognizing bad tastes, an inability to detect the odor of smoke or gas, and burns and skin breakdown because of decreased skin sensation of excessive temperature and pressure. Intact senses also facilitate accurate perception of the environment. When sensory function is impaired, perception of the environment is distorted (e.g., people might suspect they are being talked about if they are unable to hear the conversation of those around them). Impaired sensory function affects everyday experiences. For example, poor eyesight can hamper reading the newspaper and recognizing a familiar face on the street. Food tastes bland without properly functioning taste buds. The pleasant experience of smelling freshly cut flowers is low when olfactory functioning is poor. Finally, sensory function is essential to communication. Social interaction, the sharing of experiences, and the exchange of feelings are more complete when all the senses can participate. Through communication, people share joys and burdens, derive feelings of normalcy, validate perceptions, and maintain a link with reality. Sensory deficits compound other problems that threaten the health, well-being, and independence of older persons – their increased vulnerability to accidents, their social isolation and declining physical function, and many other limitations regarding self-care activities.
  • A variety of intrinsic and extrinsic factors, including alterations during the aging process, excessive use and abuse of certain medications, and the disease processes that affect all age groups, contribute to the sensory problems of older adults. Changes in vision, hearing, smell, taste, and touch occur naturally throughout the aging process. Gerontological nurses must be aware of the factors that influence sensory function in older adults and help to ensure that sensory problems are properly evaluated and corrected when possible. Older persons with sensory dysfunction may suffer functional impairment, loss of independence, injury, social isolation, depression, and decreased quality of life. Impairments in sensory functioning in sensory functioning can greatly alter the capabilities of older adults to complete everyday activities, affecting quality of life and safety. Intact senses allow the older person to accurately perceive the environment and remain appropriately involved with other people, places, and objects. Safety is compromised when the older person cannot see fall hazards on the floor, cannot smell a natural gas leak from a stove, cannot recognize the taste of spoiled milk, cannot hear a signaling fire alarm, and cannot fell a pebble in the shoe that could lead to a blister or foot ulcer. A loss of independence, social isolation, depression, and a decreased quality of life can be associated with visual impairment in the older population. Visual impairment increases the risk of falls and fractures, making it more likely that an older person will be admitted to a hospital or nursing home, be disabled, or die prematurely. It is important for the nurse to understand normal versus abnormal changes and how to assist the older adult to improve safety and well-being.
  • Careful observation of the person’s appearance is the first step when assessing the vision of an older person. When assessing the vision of an older person, the nurse should first observe the patient’s appearance. Older persons with stains on their clothing, older women with too much or poorly applied makeup, or patients with multiple bumps and bruises may be exhibiting signs of visual impairment.
  • Older patients should be questioned regarding adequacy of vision, recent changes in vision, visual problems, and the date of their last complete visual examination. Open ended questions are best. “ Has there been any change in your vision? Please describe?” “ Are your glasses as useful to you as they were when you first obtained them?” “ Do you experience pain, burning, or itching in the eyes?” “ Do you ever see spots floating across your eyes? How often does this happen and how large and numerous are the spots?” “ Do you ever see flashes of light or halos?” “ Are your eyes ever unusually dry or watery?” “ Do you have difficulty with vision at night, in dimly lit areas, or in bright areas?” “ Does anyone in your family have glaucoma or other eye problems?” The gerontological nurse should inspect the eyes for unusual structure, drooping eyelids, discoloration, and abnormal movement. Abnormalities: including movement of the eyelids, abnormal discharge, excessive tearing, abnormally colored sclera, and abnormal or absent pupillary response. Black-skinned persons may normally have a slight yellow discoloration of the sclera. Note any lesions on the eyelids.
  • In addition to annual or biennial examinations, the gerontological nurse should urge all older persons who complain of a visual problem to seek a visual evaluation if they experience any of the following problems: Red eye Excessive tearing or discharge Headache or feeling of eyestrain when reading or doing close work Foreign body sensation in the eye New-onset double vision or rapid deterioration of visual acuity New-onset haziness, flashing lights, or moving spots Loss of central or peripheral vision. A blind spot in the visual field (i.e., scotoma) can occur with macular degeneration. A narrowing of the peripheral field may be associated with glaucoma. Blindness in the same half of both eyes (i.e., homonymous hemianopia) can be present in persons who have experienced a cerebrovascular accident. Trauma or eye injury
  • The Snellen chart, used to measure visual acuity. A Snellen chart can be used to measure visual acuity, or the patient can be asked to read from a magazine or newspaper with various print sizes. Visual field testing can detect blind spots or loss of peripheral vision. If the patient is unable to see letters on the chart or newspaper, estimate the extent of the visual limitation by determining if the patient is able to see fingers held up before him or can merely make out figures. Ask the patient to follow your fingers as they move from point to point without changing the head position to check extraocular movements. Have the patient follow your finger as you move it to various points horizontally and vertically. Irregular, jerking eye movements can result from disturbances in cranial nerves III, IV, or VI. The older person with glasses should wear them during the vision assessment.
  • The healthy older adult should schedule a complete eye examination every year to check visual acuity, the retina, and intraocular pressure. During this examination, visual acuity should be evaluated, pupils should be dilated with examination of the retina, and intraocular pressure should be tested.
  • Normal age-related changes in vision occur gradually; however, over time these changes can limit the functional ability of the older adult. Approximately 1.8 community-dwelling older people report some difficulty with basic activities such as bathing, dressing, and walking around the house, in part because they are visually impaired. Unfortunately, visual impairment increases with age. Visual impairment is defined as visual acuity of 20/40 or worse while wearing corrective lenses, and legal blindness or severe visual impairment is 20/200 or more as measured by a Snellen wall chart at 20 feet. The prevalence of blindness also increases with age, reaching its peak at about the age of 85. Fortunately, the prevalence of blindness in both eyes in the United States is low, about 1% among persons 70 to 74 years of age and 2.4% in persons 85 and older. Approximately half of all individuals who are identified as legally blind each year are 65 years of age or older. Visual impairment and blindness in the older person is the result of four main causes: cataracts, age-related macular degeneration (ARMD), glaucoma, and diabetic retinopathy. Visual impairment can lead to loss of independence, social isolation, depression, and a decreased quality of life. Visual limitations can make communication problematic because facial expressions and gestures, which are as important as the words themselves, may be missed or misinterpreted. Visual impairment increases the risk of falls and fractures, making it more likely that an older person will be admitted to a hospital or nursing home, be disabled, or die prematurely. It is important for the nurse to understand normal versus abnormal changes and how to assist the older adult to improve safety and well-being. Remaining aware of current events through newspapersand socializationnthrough playin cards and other games may be hampered.
  • Age-related changes in the eye can impact safety or have no effect on functional capacities in daily life. Normal changes of the eye related to age including graying and thinning of the eyebrows and eyelashes. Wrinkling of the skin surrounding the eyes occurs as a result of subcutaneous tissue atrophy. The eyes may appear sunken as orbital fat decreases and the eyelids sag. Darkening and wrinkling of skin around orbits. Atrophy of lacrimal glands results in dry eyes. Stinging, burning, scratchiness, and stringy mucous are some of the symptoms. Although this may seem surprising, increased tearing may be a symptom of dry eyes. If tear secretion is below normal, excess tears are produced by the lacrimal gland in response to irritation. If no foreign body is found, the condition is called dry eye syndrome. Tear production decreases with age, and menopausal women are most often afflicted. Also, dry eyes may be associated with arthritis and the use of certain medications. Treatment consists of tear replacement or conservation. Tears can be replaced by instilling an over-the-counter artificial tear preparation to lubricate the eyes and replace missing moisture. Other interventions include use of a humidifier and avoidance of smoke. Saline drops can bring relief.
  • One of the most significant areas of changes that occur with age are those affecting vision. The reduced elasticity of the lens that begins in the fourth decade of life interferes with the ability to adequately focus on close objects. As the lens of the eye becomes less flexible, it is less able to focus. It is the factor responsible for most older people’s requiring some form of corrective lenses; this condition is known as presbyopia. It is harder to read fine print or see close objects clearly. This is correctable with reading glasses or bifocals. The diagram shows how light from afar is bent by the stretched lens to strike the retina, and how light from a closer source is bent even more sharply by the relaxed lens to strike the retina.
  • Accommodation is the ability of the lens to change its focus from distant to near objects. It is achieved through the action of the ciliary muscles that change the shape of the lens. Distant image – flat. Close image – rounded.
  • The term presbyopia means "old eye" and is a vision condition involving the loss of the eye's ability to focus on close objects. It is a normal change of aging and it happens to everyone as they get older. It is not considered to be an eye disease, like cataracts or glaucoma. Presbyopia occurs without regard to other eye conditions. It generally occurs around age 40.The process stabilizes or peaks some 10-20 years later, by approximately age 63 to 65. At that age, there is the need for maximum correction. One loses the ability to see near objects without corrective lenses or corrective surgery. The cause of presbyopia is a change in the ability of the human lens to change its shape (a process called accommodation) which results in the inability to focus on objects close at hand. As the lens hardens, it is unable to focus the rays of light that come from nearby objects. Individuals typically have difficulty reading small print, such as that in telephone directories and newspaper advertisements, and may need to hold reading materials at arm's length.The loss of pliability in the lens contributes to presbyopia or the decrease in near vision. The process of the lens losing its elasticity (accommodative ability) begins around age 10, but vision changes aren't noticeable to a person until he/she reaches approximately 40 years of age. Hardening impedes accommodation, the ability of the lens to change shape and focus images clearly.
  • The eyes' pupils become less able to take in light and less able to adapt to changes in light. By the time a person reaches 60, his pupils decrease to about one-third of the size of when he was 20. Visual acuity (sharpness) progressively declines due to reduced pupil size and loss of photoreceptor cells in the retina. The light perception threshold decreases causing difficulty with vision at night and in dimly lit areas. Dark and light adaptation takes longer. Instruct the elder to take the extra time to adjust to the dim light. Visual changes cause depth perception to become distorted, making the ability to judge the height of walking surfaces more challenging. The yellowing or slightly cloudiness(opacification) of the lens causes difficulty in distinguishing between blue, green, and violet. Sensitivity to glare increases.
  • A decrease in endothelial cells on the cornea reduces ocular sensitivity and pain, which may delay awareness for treatment of injuries and infections. Arcus senilis is a grayish or whitish arc or circle visible around the peripheral part of the cornea in many older adults. It develops due to lipid deposits. It typically is not associated with a serious underlying condition and doesn't require treatment. T his condition is unrelated to hypercholesterolemia or lipid abnormalities except in rare cases. Increased opacity of lens with yellowing. The lenses thicken and harden and with age and appear yellowish and opaque. Thickening of the lenses can cause light to scatter, and opaqueness of the lenses will interfere with color discrimination. This greatly increases the risk for falls and can make night driving dangerous for the older adult. Lens thickness also reduces the space for aqueous humor to drain and increases the risk for glaucoma.
  • Visual acuity is sharpness of vision, especially as tested with a Snellen chart. Normal visual acuity based on the Snellen chart is 20/20. Visual acuity tends to diminish gradually after 50 years of age and then more rapidly after the age of 70. Visual acuity – decreased reading and color discrimination ability. Wear corrective lenses and use extra light. Light sensitivity, or the ability to adapt to varying degrees of light, declines with age. With increased age, there is a need for increased light. Three functions are associated with light sensitivity: Brightness contrast: This is the ability to discriminate between objects in varying degrees of light. Starting at about age 50, more light is needed to see dimly lit objects in shadows on a sunny day. Dark adaptation: This is the ability to see objects upon entering a dimly lit room after entering from daylight. An older person will not see objects at first, but with time, outlines will become more discernible. Recovery from glare: Glare is excessive light reflected back into the eye. Glare will obliterate normal vision for a period of time (for example, after a flash picture is taken). With age, recovery from glare takes more time.
  • Alterations in vision not only reduce the ability to perform ADLs, but can also be a significant health hazard.
  • Visual impairment is defined as visual acuity of 20/40 or worse while wearing corrective lenses, and legal blindness or severe visual impairment is 20/200 or more as measured by a Snellen wall chart at 20 feet. Common visual disturbances in older adults include presbyopia, glaucoma, macular degeneration, and cataracts. In 2004, 2.4 million Americans (1.98 percent) had low vision. Cataracts were the leading cause of low vision. These vision-reducing conditions will affect approximately 70 million Americans by 2030, and can result in significant visual impairment and blindness.
  • Legal blindness is defined as a visual acuity of 20/200 or less on the Snellen chart. This means that a person standing 20 feet from an object with see with the same degree of clarity as a normally sighted person could from 200 feet away. The prevalence of blindness also increases with age, reaching its peak at about the age of 85. The prevalence of blindness in both eyes in the United States is low, about 1% among persons 70 to 74 years of age and 2.4% in persons 85 and older. In 2004, an estimated 937,000 (0.78 percent) Americans older than 40 were blind. The leading cause of blindness among white persons was age-related macular degeneration (54.4 percent of the cases), while among black persons, cataracts and glaucoma accounted for more than 60 percent of blindness. Among Hispanics, the leading cause of blindness was glaucoma. The authors project that the number of blind persons in the United States will increase by 70 percent to 1.6 million by 2020.
  • “B”
  • A cataract is a cloudy area in the lens of the eye that causes the lens to lose its transparency. The lens becomes opaque or yellow. A normal lens is clear and focuses light into the back of the eye or retina. When a cataract develops, some of this light is blocked out or scattered.  As this cataract develops, it becomes harder for a person to see. Cataracts cloud the lens, decrease the amount of light able to reach the retina, and inhibit vision. Cataracts are common in older people because everyone develops some degree of lens opacity as they age, with or without the presence of other eye disorders. However, since cataracts are considered an eye disorder, they are not considered to be a normal aging process. They develop gradually and without pain, and may be unilateral or bilateral. Most people with cataracts have a cataract in both eyes. However, one eye may be worse than the other because each cataract develops at a different rate. Etiology thought to be from oxidative damage to lens protein and fatty deposits in the lens that occurs with aging. And cross-linking. Clumps of protein reduce the sharpness of the image reaching the retina. The lens consists mostly of water and protein. When the protein clumps up, it clouds the lens and reduces the light that reaches the retina. The clouding may become severe enough to cause blurred vision. Most age-related cataracts develop from protein clumpings. Cataracts are more severe in persons who have had significant exposure to sunlight. When tasks become increasingly difficult and fatiguing because of the vision changes that cataracts produce, the patient should be instructed to seek medical attention. In fact, cataracts are the leading cause of low vision in older adults. More than 50% of adults over the age of 65 years have visual problems as a result of cataracts. Most common in age over 75. After age 75, as many as 70-90% of Americans have cataracts that are significant enough to impair their vision. No ethic or gender variations Eventually, lens opacity and vision loss are complete. Cataracts are the leading cause of blindness in the world.
  • The lens of the eye becomes yellow or yellow-brown; eventually the color of the pupil changes from black to a cloudy white.
  • Patients with cataracts may experience blurry vision, glare, halos around objects, double vision, lack of color contrast or faded color, and poor night vision. Symptoms – No discomfort or pain is associated with cataracts. A cataract starts out small and at first has little effect on your vision. At first visual acuity is not affected, but as opacification continues, vision is distorted, night vision is decreased, and objects appeared blurred. You may notice that your vision is blurred a little, like looking through a cloudy piece of glass or viewing an impressionist painting. People may have trouble seeing street signs while driving and feel that there is a film over the eye. Glare from sunlight and bright lights is extremely bothersome to the affected person; this is due to the cloudy lens causing light to scatter more than it would in a clear lens. A cataract may make light from the sun or a lamp seem too bright or glaring. Or you may notice when you drive at night that the oncoming headlights cause more glare than before. Some individuals may report an improvement in the ability to see small print and objects (“second sight”), which is due to changes in the lens that increase nearsightedness. Colors may not appear as bright as they once did. They may need more light or illumination when reading, and repeated alterations of the corrective lens prescriptions. Hallmark symptoms – Blurry vision, glare, appearance of halos around objects as light is diffused
  • Exposure to ultraviolet light increases the risk of developing cataracts, emphasizing the importance of wearing proper sunglasses to protect the eyes. Risk factors for the development of cataracts include the following: Increased age Smoking and alcohol Diabetes, hyperlipidemia Trauma to the eye Exposure to the sun and UVB rays Corticosteroid medications
  • Surgery to remove the lens is the only cure. The need for surgery is assessed on an individual’s unique situation.For most patients, surgery improves vision. The simple surgical procedure and several weeks of rehabilitation can result in years of improved vision and, consequently, a life of higher quality. Surgical removal of the affected lens is generally the treatment of choice because there are no medications to treat this problem. Corrective lenses that filter out glare may be effective in managing symptoms in the early phases, but do not stop progression of vision loss. Surgical recommendations are made when vision problems interfere with daily activities such as reading and driving. Cataract surgery is recommended in the following circumstances: Visual acuity is 20/50 or less with symptoms of loss of functional ability. Visual acuity is 20/40 or better with disabling glare or frequent exposure to low light situations, diplopia, disparity between eyes, or occupational need. Cataract removal will treat another lens-induced disease such as glaucoma. Cataract exists with other diseases of the retina, such as diabetic retinopathy, requiring unrestricted monitoring. The outpatient surgical procedure involves removal of the affected lens and insertion of an artificial lens or intraocular lens. Cataract surgery is generally a nonemergency procedure. Newer surgical procedures with laster photolysis and sonic phacoemulsification have shown to be valuable in making smaller surgical incision. Cataract surgery is contraindicated when the patient wishes to avoid surgery, glasses or visual aids provide satisfactory vision, the patient’s lifestyle is not compromised, or the patient has been diagnosed with medical problems that make surgery a high-risk procedure.
  • Cataract surgery is very successful in restoring vision. In fact, it is the most frequently performed surgery in the United States, with more than 3 million Americans undergoing cataract surgery each year. Nine out of 10 people who have cataract surgery regain very good vision, somewhere between 20/20 and 20/40. Cataract surgery is an outpatient procedure and older people usually withstand it well. The most common method of replacing the surgically removed lens is the insertion of an intraocular lens at the time of cataract surgery. For older patients, this method has been more successful than adjusting to a contact lens or special cataract glasses. The intraocular lens tends to distort vision less than cataract glasses do and does not require the care of a contact lens. During surgery, the surgeon will remove the clouded lens and in most cases replace it with a clear, plastic intraocular lens (IOL). The replacement for the cataract-damaged natural lens, the intraocular lens (IOL), is positioned in the capsular bag of the eye. Throughout the procedure, most patients are awake, relaxed, and feel no pain. Some patients do develop complications with a lens implant, such as eye infection, loss of vitreous humor, and slipping of the implant.
  • Patients typically can resume nonstrenuous activities within a day. He or she also will need to wear protective eye shields while sleeping or napping, for about 2 weeks after surgery. They also must avoid bright sunlight. The patient will be given sun shades to help protect eyes in bright light. These are wrap-arounds and will need to be worn for 2 weeks. The patient will need to administer eye drops, as prescribed by the eye surgeon, several times daily during the next few weeks after the procedure. Teach the patient to wash hands before instilling eyedrops and correct procedure for eyedrop instillation. Postsurgical education includes reinforcement not to life any heavy objects, strain at stool, or bend at the waist. Avoid anything that can increase intraocular pressure such as coughing or vomiting.
  • The patient will need to administer eye drops, as prescribed by the eye surgeon, several times daily during the next few weeks after the procedure. He or she also will need to wear protective eye shields while sleeping or napping, for about a week after surgery. They also must avoid bright sunlight. The patient will be given sun shades to help protect eyes in bright light. These are wrap-arounds and will need to be worn for a short-time. Teach the patient to wash hands before instilling eyedrops and correct procedure for eyedrop instillation. Postsurgical education includes reinforcement not to life any heavy objects, strain at stool, or bend at the waist. Avoid anything that can increase intraocular pressure such as coughing or vomiting. Complications of cataract surgery include eye infection, wound dehiscence, loss of vitreous humor, hemorrhage, severe pain, uncontrolled elevated intraocular pressure (IOP), and slipping of the implant. Patients with cognitive impairments such as Alzheimer’s disease must be carefully supervised for at least 24 hours after surgery to ensure that they do not remove the protective eye patch and do not rub the eye. When surgery is needed in both eyes, one eye is done first and the second procedure is scheduled a month or so later to allow healing and recovery. Adequate home care and support is needed to prevent complications.
  • Preventative measures should also be implemented in teaching, such as wearing hats and sunglasses when in the sun, smoking cessation, eating low-fat diets, and avoiding ocular injury. In addition, providing patients with information regarding support groups and other resources can provide added psychological and emotional support.
  • “A”
  • Another condition that can occur as we get older is glaucoma - a rise in pressure within the eye. If untreated, glaucoma results in a gradual and irreversible loss of vision, typically in the peripheral vision. Glaucoma is a disease of the optic nerve, which transmits the images you see from the eye to the brain. The optic nerve is made up of many nerve fibers (like an electric cable with its numerous wires). Glaucoma damages nerve fibers, which can cause blind spots and vision loss. Glaucoma has to do with the pressure inside the eye, known as intraocular pressure (IOP). When the aqueous humor (a clear liquid that normally flows in and out of the eye) cannot drain properly, pressure builds up in the eye. The resulting increase in IOP can damage the optic nerve and lead to vision loss The eye has an internal "plumbing" system that constantly circulates and drains fluid from the eyes. A blockage or too much fluid production can cause pressure build up and damage the optic nerve. If detected early, it can be controlled with special eye drops. Yearly eye exams are important because early stage glaucoma has no symptoms. In the United States and worldwide, it is the second leading cause of blindness. It is the first cause of blindness among blacks. Glaucoma accounts for about 10% of all blindness in the United States. It ranks after cataracts as a major eye problem in older persons. Glaucoma tends to occur in people over age 40 and increases in prevalence with age. Black individuals tend to develop glaucoma at earlier ages than whites and have a significantly higher incidence. Glaucoma accounts for 19% of all blindness among African Americans, compared with 6% of Caucasians. In fact, glaucoma is six to eight times more common in African Americans than in Caucasians. Although glaucoma can occur at any age, those most at risk are adults older than age 60. Glaucoma affects one in two hundred people aged fifty and younger, and one in ten over the age of eighty. Drugs with anticholinergic properties can exacerbate glaucoma due to their effects of dilating the pupil.
  • Another condition that can occur as we get older is glaucoma. Glaucoma is unusually high pressure inside the eye that damages the optic nerve and can result in permanent vision loss. If untreated, glaucoma results in a gradual and irreversible loss of vision, typically in the peripheral vision. Glaucoma refers to a category of eye disorders often associated with a dangerous buildup of internal eye pressure (intraocular pressure or IOP), which can damage the eye's optic nerve that transmits visual information to the brain. When the IOP is greater than 21 mm Hg, the optic nerve has the potential for atrophy and vision loss. Glaucoma has been nicknamed the "sneaky thief of sight" because the loss of visual field often occurs gradually over a long time and may only be recognized when it is already quite advanced. The most common form has few, if any, symptoms and may cause partial vision loss before it is detected. It is asymptomatic until very late in the disease, when there is a noticeable loss of peripheral vision, causing tunnel vision. Once lost, this damaged visual field can never be recovered. However, if detected early, glaucoma can usually be controlled and serious vision loss prevented.
  • To follow the flow of fluid inside the eye, follow the blue arrow. Internal eye fluids are produced by the ciliary body, which is a small, circular structure found behind the iris or colored portion of the eye. This fluid within the eye, known as the aqueous humor, serves as nourishment for surrounding tissues. The aqueous humor flows behind the iris and through the pupil or central opening in the middle of the iris. Fluid then fills the anterior chamber, a space between the back of the clear cornea and the front of the iris. The aqueous humor escapes from the eye through a spongy tissue at the front of the eye called the trabecular meshwork into a drainage canal (dark blue region next to the trabecular meshwork). This drainage canal is known as the filtration angle, which is the angle formed inside the anterior chamber between the iris and the peripheral cornea. The aqueous filters through this angle and through the sclera or white part of the eye and then joins with the network of veins outside the eye. The cause of glaucoma is generally a failure of the eye to maintain an appropriate balance between the amount of internal (intraocular) fluids produced and the amount that drains away. An average or normal IOP is 15 mm Hg (normal range 10 to 20 mm Hg). IF the outflow of aqueous fluid is obstructed, aqueous humor accumulates, increasing the pressure within the eye and damaging the optic nerve.
  • Simulated vision loss from the effects of glaucoma is pictured above.
  • The most common form of glaucoma is primary open-angle glaucoma, in which the aqueous fluid is blocked from flowing back out of the eye at a normal rate through a tiny drainage system. Most people who develop primary open-angle glaucoma notice no symptoms until their vision is impaired. Ocular hypertension is often a forerunner to actual open-angle glaucoma. When ocular pressure is above normal, the risk of developing glaucoma increases. In open-angle glaucoma, the fluid in the eye's front (anterior) chamber between the clear cornea and the colored iris (aqueous humor) can't filter through an area where it needs to pass (filtration angle). This occurs because the drainage channels (trabecular meshwork) are blocked, causing internal eye pressure (IOP) to rise. As IOP increases, the pressure pushes harder against the nerve fibers of the optic nerve, which transmits images to the brain. This increased pressure reduces the blood supply to the optic nerve, depriving it of oxygen and nutrients. Over time, high IOP can cause irreversible optic nerve damage and vision loss. Open-angle glaucoma is more common that acute (90% of cases are this type), affecting over 2 million people in the United States. This type of glaucoma occurs gradually and insidiously. Peripheral vision is slowly impaired. This type of glaucoma can damage vision so gradually and painlessly that a person is unaware of a problem until the optic nerve is badly damaged. Visual loss begins with deteriorating peripheral vision. Vision loss is painless and gradual with peripheral visual field loss being the classic symptom. About half of Americans with open-angle glaucoma don't even know they have it.
  • Intraocular pressure is maintained at normal levels when some of the fluid produced by the eye is allowed to flow out. The fluid (aqueous humor ) is produced by the ciliary body where it flows into the anterior chamber and then out through a spongy tissue at the front of the eye called the trabecular meshwork into a drainage canal. In open-angle glaucoma, fluid cannot flow effectively through the trabecular meshwork , and this causes an increase in intraocular pressure causing damage to the optic nerve and leading to vision loss.
  • Often no symptoms until late in the course of the disease.
  • Patients do not generally report symptoms of glaucoma until advanced stages of the disease, so monitoring of IOP during routine ophthalmic examinations for patients with any risk factors is essential. Diagnosis: tonometry (screen); gonioscopy (direct view) The goal of glaucoma treatment is to lower your eye pressure to prevent or slow further vision loss. Your ophthalmologist will recommend treatment if the risk of vision loss is high. Treatment often consists of eyedrops but can include laser treatment or surgery to create a new drain in the eye. Glaucoma is a chronic disease that can be controlled but not cured. Ongoing monitoring (every three to six months) is needed to watch for changes. Management of glaucoma involves lowering the IOP to stop the damage to the optic nerve and to prevent further vision loss. Therapy includes medications (usually topical eyedrops) to decrease IOP and/ or laser surgery to increase the flow of aqueous humor, by creating a new drainage exit. Open-angle glaucoma is usually managed with one or several of the following medications: beta-blockers, miotics, alpha-adrenergic agonists, prostaglandin analogues, and carbonic anhydrase inhibitors. Beta-blockers remain the first-line therapy for glaucoma because they decrease the rate of intraocular fluid production. If medications are unable to decrease IOP or are contraindicated, then laser surgery or surgery may be an option. P art of the thickened wall of the channels of the trabecular meshwork is shot with a laser light or cut with a scalpel; this makes them wider allowing the aqueous humour to drain more freely. These procedures can be performed in an outpatient setting.
  • In ophthalmology, tonometry is the procedure eye care professionals perform to determine the intraocular pressure (IOP), the fluid pressure inside the eye. A wisp of air is blown into the eye. Most tonometers are calibrated to measure pressure in mmHg. It is used to screen for glaucoma. Gonioscopy: used to directly examine the anterior chamber angle, the portion of the eye that directs aqueous humor (the fluid produced by the eye). A special mirrored contact lens is used during this evaluation. The angle is examined with a special lens called a gonioscopy lens (“gonio” means angle).
  • Beta-blockers – generic names end in “olol” Prostaglandins – generic names end in “prost” STORE UNOPENED BOTTLE of Xalatan in the refrigerator. AFTER THE BOTTLE IS OPENED, store this medicine in the refrigerator or in a cool place below 77 degrees F (25 degrees C) for up to 6 weeks.
  • MIOSIS – causes pupils to contract. Constriction of the pupils causes a drop in intraocular pressure. Reduces eye pressure by clearing fluid from the eyes. Pilocarpine has the fewest side effects and is usually prescribed first. Miotic agents typically cause a reduction in night vision acuity, darkening of the vision, irritation, and redness. STORE Pilocarpine at room temperature, away from heat and light. Keep the container tightly closed. Side effects of cholinergic agents: SLUDGE – salivation, lacrimation, urination, diarrhea, GI upset, emesis STORE Trusopt at room temperature, away from heat and light.
  • Various glaucoma eye drops are classified by the active ingredient chemical that helps make the drug work.
  • C
  • In angle-closure glaucoma, the iris (the colored part of the eye) may drop over and completely close off the drainage angle, abruptly blocking the flow of aqueous fluid and leading to increased IOP or optic nerve damage. In acute angle-closure glaucoma there is a sudden increase in IOP due to the buildup of aqueous fluid. This condition is considered an emergency because optic nerve damage and vision loss can occur within hours of the problem. Symptoms can include nausea, vomiting, seeing halos around lights, and eye pain Angle-closure glaucoma (also known as acute, closed-angle, or narrow-angle glaucoma) is not as common. In angle-closure glaucoma, the angle of the iris obstructs drainage of the aqueous humor through the trabecular meshwork. It may occur suddenly as a result of infection or trauma. Acute-closure glaucoma is an ophthalmic emergency requiring immediate attention by an ophthalmologist to preserve vision. Permanent vision loss within 2 to 5 days if left untreated.
  • Symptoms include unilateral headache, visual blurring, nausea, vomiting, and photophobia.
  • A photograph of an eye in acute angle closure glaucoma. The eye is very red and the patient was in pain. The intraocular pressure was 62 mmHg (normal 10 - 21). Notice the bleeding spot at 1 o’clock (arrow) where laser iridotomy surgery was performed.
  • A small opening is made at the base of the iris (iridotomy) to allow the IOP to equalize on either side and prevent the iris from obstructing the outflow channel. Iridotomy with a laser can be performed in the outpatient setting. A peripheral iridotomy is most often used to treat narrow angle or angle closure glaucoma. The laser beam creates a tiny hole in the colored part of the eye (the iris). This lets the pressure in front of the iris become the same as the pressure behind the iris. As a result, the iris moves away from the drainage angle and the aqueous fluid can resume draining normally
  • Unlike cataracts, there are some ethnic distinctions with the development of glaucoma. Blacks tend to develop it earlier than whites, and females more often than males. Glaucoma is more common in African Americans, Asian Americans, Hispanics, and Eskimos. Other contributing factors include eye trauma, small cornea, small anterior chamber, family history, cataracts, and some medications. Risk factors for glaucoma include the following: Increased intraocular pressure Older than 60 years of age Family history of glaucoma Personal history of myopia, diabetes, hypertension, migraines African American ancestry
  • The American Academy of Ophthalmology recommends that patients over the age of 65 be examined and screened for glaucoma at least every 1 to 2 years., every 6 months with prior diagnosis of glaucoma. A complete examination includes the patient’s visual acuity with corrective lenses, visual field test to assess peripheral vision, measurement of the IOP noting the time of day as pressures may vary throughout the day, slit lamp inspection of the iris to assess whether the anterior angle is open or closed, and a complete dilated examination to inspect the optic nerve and retina.
  • True. Compliance with the treatment regimen for glaucoma can be a challenge for the older adult. The silent nature of glaucoma—and potential difficulties with instilling eye drops — as well as the cost of the medications may contribute to a lack of adherence.
  • Age-related Macular Degeneration (or AMD) is another very common cause of sight problems in older people. It is the number one cause of severe vision loss and legal blindness in adults over 60 in the U.S. It is a degenerative disorder of the macula that affects both central vision (scotoma) and visual acuity. AMD is a deterioration or breakdown of the macula. The macula is a small area at the center of the retina in the back of the eye that allows us to see fine details clearly and perform activities such as reading and driving The macula is a a part of the inner lining of the eye. It is a small circular membrane situated in the central part of the retina at the back of the eye and it is dense with photoreceptor cells. This membrane is light sensitive and responsible for our clear central vision. The visual symptoms of AMD involve loss of central vision. While peripheral (side) vision is unaffected, with AMD, one loses the sharp, straight-ahead vision necessary for driving, reading, recognizing faces, and looking at detail. Macular degeneration is the gradual loss of vision caused by damage to the macula by thinning, atrophy, and in some cases, bleeding. When the macula degenerates, central vision deteriorates. This will result in seeing images as cloudy or distorted, decreased color vision, and sometimes a central scotoma (a large, dark spot in the center of vision). Age-related macular degeneration begins with reduced light sensitivity and distortion of central vision. The disease causes the progressive loss of central vision, leaving only peripheral vision intact. Central vision is needed for seeing objects clearly and for common daily tasks such as reading and driving. It usually starts in one eye, but with a high risk that the disease will affect the other eye within 5 years. As our population ages, and the "baby boomers" advance into their 60's and 70's, we will see a virtual epidemic of AMD.
  • AMD Impaired Vision
  • Although it never causes total blindness by itself, age-related macular degeneration robs those affected of their sharp central vision and can dim contrast sensitivity and color perception. It destroys the clear, "straight ahead" central vision necessary for reading, driving, identifying faces, watching television, doing fine detailed work, safely navigating stairs and performing other daily tasks we take for granted. Patients with ARMD often require more light for reading. They often experience blurry vision, central scotomas (blind spots within the visual field), and metamorphosia in which images are distorted to look smaller (micropsia) or larger (macropsia) than they actually are. Peripheral vision may not be affected, and it is possible to see "out of the corner of your eye". 
  • Another symptom typical of wet ARMD is that straight lines appear crooked or wavy. The Amsler grid was developed as a screening tool to assess for ARMD; patients with this condition experience visual distortions of the lines and central scotomas. A sample grid and the appearance of the grid to a patient with normal vision and ARMD are depicted in this slide.
  • There are two types of AMD – the more common dry version, which can’t be treated, and the aggressive, but less common wet version that, if caught early enough, can be halted or slowed or, using the very latest drugs, even reversed. There are two types of ARMD: a dry and wet form. Nine out of 10 people who have AMD have atrophic or “dry” AMD, which results in thinning of the macula. Dry AMD takes many years to develop. A specific vitamin regimen has been shown to slow progression of dry AMD. The dry form, or atrophic form, occurs as a result of atrophy, retinal pigment degeneration, and drusen accumulations. Drusen are deposits of cellular debris and appear as yellow spots on ophthalmic examination. Visual loss as a result of this type of ARMD is generally slow in progression, and accounts for only 10% to 20% of severe vision loss. Dry AMD is an early stage of the disease and may result from the aging and thinning of macular tissues, depositing of pigment in the macula or a combination of the two processes. Dry macular degeneration is diagnosed when yellowish spots known as drusen begin to accumulate from deposits or debris from deteriorating tissue primarily in the area of the macula. Gradual central vision loss may occur with dry macular degeneration but is not nearly as severe as symptoms associated with the wet form of AMD. No FDA-approved treatments are available for the dry form of macular degeneration. A major National Eye Institute study (AREDS) has produced strong evidence that certain nutrients such as beta carotene (vitamin A) and vitamins C and E may help prevent or slow progression of dry macular degeneration. The AREDS study indicates that taking high dose formulas of certain nutritional supplements can reduce risk of early stage AMD progression by 25 percent. Some eye doctors also recommend that dry AMD patients wear sunglasses with UV protection against potentially harmful effects of the sun. [
  • In about 10 percent of cases, dry AMD progresses to a more advanced and damaging form of the eye disease known as wet macular degeneration. With wet AMD, new blood vessels grow (neovascularization) beneath the retina and leak blood and fluid. This leakage causes permanent damage to light-sensitive retinal cells, which die off and create blind spots in central vision. Exudative or “wet” AMD is less common (occurring in one out of 10 people with AMD) but is more serious. In the wet form of AMD, abnormal blood vessels may grow in a layer beneath the retina, leaking fluid and blood and creating distortion or a large blind spot in the center of your vision. If the blood vessels are not growing directly beneath the macula, laser surgery is usually the treatment of choice. The procedure usually does not improve vision but tries to prevent further loss of vision. For those patients with wet AMD whose blood vessels are growing directly under the center of the macula, a procedure called photodynamic therapy (PDT), which causes fewer visual side effects, is sometimes used. Intravitreal injections of certain medications can also be used in these cases In the wet form, also known as neovascular ARMD, blood or serum leaks from newly formed blood vessels beneath the retina. This seepage of fluid ultimately leads to scar formation and visual problems. Although less prevalent than the dry form, the wet form of ARMD is responsible for the majority of severe vision loss. Neovascularization, the underlying process causing wet AMD and abnormal blood vessel growth, is the body's misguided way of attempting to create a new network of blood vessels to supply more nutrients and oxygen to the eye's retina. But the process instead creates scarring, leading to sometimes severe central vision loss.
  • Risk factors for ARMD include the following: Age above 50 Cigarette smoking Family history of ARMD Increased exposure to ultraviolet (sunlight) light Caucasian race and light-colored eyes Hypertension or cardiovascular disease Lack of dietary intake of antioxidants and zinc AMD is more common in women, people with blue eyes, and Caucasians. While age is the most significant risk factor for developing AMD, heredity, blue eyes, high blood pressure, cardiovascular disease, and smoking have also been identified as risk factors. AMD accounts for 90% of new cases of legal blindness in the United States
  • To prevent age related macular degeneration (ARMD) nurses should teach prevention and safety measures. Due to the severity of vision loss as a result of ARMD nurses can play an important role in patient education. According to the American Academy of Ophthalmology, people over the age of 65 should be examined every 1 to 2 years. Routine ophthalmic examinations are important to detect early signs of this disease. Nurses should encourage preventive measures such as wearing ultraviolet protective lenses in the sun, smoking cessation, and exercising routinely. In addition, a healthy diet consisting of fruits and vegetables may be helpful not only to increase consumption of antioxidants, but also to reduce the risk of cardiovascular disease. The role of vitamins is being studied, and current recommendations for those with ARMD include zinc oxide 80 mg, cupric oxide 2 mg, beta-carotene 15 mg, vitamin C 500 mg, and vitamin E 400 IU taken in divided doses twice a day to slow the risk of progression.
  • Low-vision assistive devices Technological advances in the last decade have produced some low-vision assistive devices that may be used successfully to improve the quality of life for the visually impaired elder. Use large-print reading material. People with severe visual impairment may qualify for disability and financial and social services assistance through government and private programs including vision rehabilitation programs. An array of low-vision devices are now available, including insulin delivery and glucose-monitoring equipment, talking watches, large-print books, magnifiers, and computers with low-vision devices. Modify environment – Use several soft indirect lights instead of a single glaring one. Avoid glare from windows by using sheer curtains or stained windows. Place frequently used items within the visual field. Avoid the use of low-tone colors and attempt to use bright ones. Use contrasting colors on doorways and stairs and for changes in levels. Eyeglasses, once heavy and bulky, are now cosmetically appealing. Sunglasses are designed to filter out ultraviolet rays that may be harmful to sensitive retinas.
  • “B” Loss of central vision Macular degeneration is the most common cause of blindness in people over age 65 and involves damage or breakdown of the macula, which results in loss of central vision.
  • A retinal detachment occurs when the retina is pulled away from its normal position in the back of the eye. The retina sends visual images to the brain through the optic nerve. When detachment occurs, vision is blurred. A detached retina is a very serious problem that almost always causes blindness unless it is treated. The retina normally lies smoothly and firmly against the inside back wall of the eyeball (or choroid) and functions much like the film in the back of a camera. Millions of light-sensitive retinal cells receive optical images, instantly "develop" them, and send them on to the brain to be seen. If any part of the retina is lifted or pulled from its normal position, it is considered detached and will cause some vision loss. The vitreous is the clear collagen gel that fills the back of the eye between the retina and the lens. As we get older the vitreous may pull away from its attachment to the retina at the back of the eye. Usually the vitreous separates from the retina without causing a problem. But sometimes the vitreous pulls hard enough to tear the retina in one or more places. Fluid may pass through the retinal tear and lift the retina off the back of the eye like wallpaper can peel off a wall. Retinal detachment can occur at any age, but it is more common in midlife and later. Older persons are more prone to detachment of the retina. Retinal detachment can occur at any age, but it is more common in midlife and later. Conditions that can increase the chance of a retinal detachment include nearsightedness; previous cataract surgery; glaucoma; severe trauma; previous retinal detachment in your other eye; family history of retinal detachment; or weak areas in your retina that can be seen by your ophthalmologist. The symptoms, which can be gradual or sudden, include the perception of spots moving across the eye, blurrred vision, flashes of light, and the feeling that a coating is developing over the eye. Blank areas of vision progress to complete loss of vision. The severity of symptoms depends on the degree of retinal detachment. There is no pain.
  • With age the vitreous, the gel which fills the cavity in front of the retina, begins to liquefy and shrink. This normal for age process usually starts between 45 and 55 years of age. Individuals who are undergoing this process may briefly see floaters and even flashing lights in their vision. These symptoms usually subside and may leave a small residual floater in the vision. Rarely, a PVD may lead to a retinal tear or hole.
  • Retinal Detachment is a separation of the retina (the inner nervous tunic of the eye) from the choroid in the back of the eye. The retina is the light-sensitive tissue that lies smoothly against the inside back wall of your eye and sends messages to your brain through your optic nerve. Underneath the retina is the choroid — a thin layer of blood vessels that supplies oxygen and nutrients to the retina. Retinal detachment occurs when the retina separates from the choroid. Usually this happen when there is a small tear or hole in the retina that allows the vitreous humor (fluid) to leak between the choroid and the retina. Most retinal detachments are caused by the presence of one or more small tears or holes in the retina. Normal aging can sometimes cause the retina to thin and deteriorate, but more often shrinkage of the vitreous body, the clear gel-like substance which fills the center of the eye, is responsible for deterioration and retinal tears. The vitreous is firmly attached to the retina in several places around the back wall of the eye. As the vitreous shrinks, it may pull a piece of the retina away with it, leaving a tear or hole in the retina. This allows fluid to perculate thru the tear, with subsequent detaching of the retina (analogous to wall paper coming off a wall). Though some shrinkage of the vitreous body occurs naturally with aging and usually causes no damage to the retina, abnormal growth of the eye (sometimes a result of nearsightedness), inflammation or injury, may also cause the vitreous to shrink. In most cases, a significant change in the structure of the vitreous body occurs before the development of a retinal detachment. Once a retinal tear is present, watery fluid from the vitreous space may pass through the hole and flow between the retina and the back wall of the eye. This separates the retina from the back of the eye and causes it to “detach.” The part of the retina that is detached will not work properly and there will be a blindspot in vision. It is not known why some people get retinal detachments however, there are many risk factors including increasing age (with liquefication of the vitreous gel), diabetes, high myopia (near sightness), inflammation, and of course trauma.
  • Prompt treatment is required to prevent continued damage and eventual blindness. Initial measures most likely to be prescribed, bed rest and the use of bilateral eye patches, can be frightening to the older patient, who may react with confusion and unusual behavior. The nurse should help the patient feel secure as possible; frequent checks and communication, easy access to a call light or other means of assistance, and full, honest explanations will help provide a sense of well-being. After time has been allowed for the maximum amount of “reattachment” of the retina to occur, surgery may be planned. Several surgical techniques are used in the treatment of detached retinas. Electrodiathermy and cryosurgery cause the retina to adhere to its original attachment; scleral buckling and photocoagulation decrease the size of the vitreous space. Laser surgery (photocoagulation). During photocoagulation your surgeon directs a laser beam through a special contact lens or through a special ophthalmoscope to make burns around the retinal tear. The burns cause scarring, which usually “welds” the retina to the underlying tissue. This procedure requires no surgical incision, and it causes less irritation to your eye than does cryopexy. Freezing (cryopexy). With cryopexy your surgeon uses intense cold to freeze the retina around the retinal tear. After a local anesthetic numbs your eye, a freezing probe is applied to the outer surface of the eye directly over the retinal defect. This freezes the area around the hole, and the resulting delicate scar helps secure the retina to the eye wall. Cryopexy is used in instances where the tears are more difficult to reach with a laser, generally along the retinal periphery. Your eye may be red and swollen for some time after cryopexy. If Retinal Detachment Has Occurred – The Surgery Doctors commonly use one of these surgical procedures to repair a retinal detachment. Some of these procedures are done in conjunction with photocoagulation or cryopexy. The purpose of these treatments is to close any retinal holes or tears and to reduce the tug on the retina from a shrinking vitreous. The type, size and location of any retinal detachment will determine which procedure your eye surgeon recommends. In general, these surgeries can successfully treat more than 90 percent of cases of retinal detachment, although a second treatment is sometimes necessary. Pneumatic Retinopexy.    This surgical technique is generally used for a relatively uncomplicated detachment when the tear is located in the upper half of the retina. It’s usually done on an outpatient basis under local anesthesia. The retina is reattached by injection of a bubble of expandable gas into the vitreous cavity. Over the next several days, the gas bubble expands, sealing the retinal tear by pushing against it and the detached area that surrounds the tear. With no new fluid passing through the retinal tear, fluid that had previously collected under the retina is absorbed, and the retina is able to reattach itself to the back wall of your eye. Once the retina is reattached, the retinal tear can be sealed by laser photocoagulation or cryotherapy. Scleral buckling. This is the most common surgery for repairing retinal detachment. It’s usually done in an operating room under local or general anesthesia. If you have an uncomplicated retinal detachment, this surgery may be done on an outpatient basis. First your surgeon treats the retinal tears or holes with cryopexy. Then he or she attaches a tiny silicone band (buckle) to the white of your eye (sclera) over the affected area. The silicone material is in the form of either a soft sponge or a solid piece. The buckle closes the tear and helps reduce the traction on the retina, which prevents further vitreous pulling and separation. When you have several tears or holes or an extensive detachment, your surgeon may create an encircling scleral buckle around the entire circumference of your eye. The scleral buckling material is stitched to the outer surface of the sclera. Before tying the sutures that hold the buckle in place, the surgeon may make a small cut in the sclera and drain any fluid that has collected under the detached retina. The buckle usually remains in place for the rest of your life. Some surgeons may choose a temporary buckle for simple retinal detachments, using a small rubber balloon that’s inflated and later removed. Vitrectomy Operation.   A vitrectomy operation involves making 3 very tiny holes in the eye through which instruments can be put to help remove the jelly inside the eye. The surgeon accomplishes this with a variety of delicate instruments passed into the eyeball through small openings in the sclera. These instruments include a light probe that illuminates the inside of your eye, a cutter to remove vitreous or scar tissue, and an infusion tube that replaces the volume of removed tissue with a balanced salt solution to maintain the normal pressure and shape of the eye. After completing the vitrectomy, your surgeon may perform a scleral buckling procedure or pneumatic retinopexy procedure by filling the inside of your eye with air, expandable gas or silicone oil to help seal the retina against the wall of your eye. Vitrectomy surgery typically lasts more than an hour but may take several hours in more complex cases. The complex cases are often done under general anesthesia, but shorter procedures are usually performed under local anesthesia. Eye patches remain on the patient for several days after surgery. Specific routines vary according to the type of surgery performed.The patient needs frequent verbal stimuli to minimize anxiety and enhance psychological comfort. Physical and emotional stress must be avoided. Approximately two weeks after surgery, the success of the operation can be evaluated. A minority of patients must undergo a second procedure. It is important for the patient to understand that periodic examination is important, especially because some patients suffer a detached retina in the other eye.
  • p. 389, Box 14-1 – KNOW INTERVENTIONS for safety

Vision in  older adults spring 2012 abridged Vision in older adults spring 2012 abridged Presentation Transcript

  • Vision in Older Adults NURS 4100 Care of the Older Adult Spring 2012 Joy A. Shepard, PhD(c), MSN, RN, CNE
  • Objectives
    • Describe assessment of vision in the older adult
    • Explain the importance of sensory function and the impact of sensory deficits on older adults
    • Describe the effects of aging on visual function
    • List measures to promote healthy visual function in older adults
    • Identify signs and symptoms and nursing interventions for older adults with cataracts, glaucoma, macular degeneration, and detached retina
  • Key Terms
    • Cataracts - Opacity of eye lens that reduces visual acuity
    • Glaucoma – Eye disorder characterized by increased intraocular pressure; can lead to irreversible damage to optic nerve with loss of peripheral vision
    • Macular Degeneration - Atrophy of cells in central macular region of retina
    • Presbyopia - Universal age-related change in lens of eye involving loss of accommodation. Objects held closer than 1 or 2 ft become difficult to see
  • Anatomy of the Eye Anatomy of the Eye Video
  • Introduction: Sensory Function
    • Taken for granted
    • Protection from harm
    • Accurate perception of environment
    • Essential to communication
    • Sensory deficits compound other problems that threaten health, well-being, and independence
  • Sensory Dysfunction: Personal Cost
    • Functional impairment
    • Loss of independence
    • Injury
    • Social isolation
    • Depression
    • Decreased quality of life
  • Assessment of Vision
  • Assessing Sensory Problems
    • Skilled assessment of sensory function
    • Assessment Guide 26-1 (pp. 335-336): Sensory Function
    • Assistive techniques: Correct implementation to promote sensory function
  • Assessment of Vision
    • Appearance?
      • Clothing
      • Cleanliness
      • Self-care
      • Bumps and bruises
  • Interview
    • Adequacy of vision
    • Recent changes vision
    • Date of last exam
    • Inspection
      • Movement of eyelids
      • Abnormally colored sclera
      • Unequal or absent pupillary response
  • Interview – Visual Problems
    • Red eye
    • Excessive tearing/ discharge
    • Foreign body sensation
    • Headache, eyestrain when reading or doing close work
    • New onset
      • Double vision, rapid deterioration visual acuity
      • Haziness, flashing lights, moving spots
    • Loss central/ peripheral vision
    • Trauma or eye injury
  • Vision
    • Snellen chart or reading from print
    • Visual field testing
    • Extraocular movements
  • Eye Examinations
    • Healthy older adults
      • Complete eye examination every year
        • Visual acuity
        • Retina
        • Intraocular pressure (IOP)
  • Normal Visual Changes with Aging
  • Normal Age-Related Changes of the Eye
    • Changes are gradual
    • Over time can limit functional ability
    • Common eye disorders in the elderly are NOT normal: cataracts, glaucoma, macular degeneration, & retinopathy
  • Normal Age-Related Changes of the Eye: External Changes
    • Graying and thinning  eyebrows and eyelashes
    • Subcutaneous tissue atrophy  wrinkling + thinning of skin around eyes
    • Decreased orbital fat  sunken eye appearance + sagging eyelids
    • Atrophy lacrimal glands  Dry eyes (saline drops)
  • Normal Age-Related Changes of the Eye: Internal Changes
    • Reduced elasticity of lens; decreased ability of the lens to accommodate
      • Decreased ability to focus on close objects (presbyopia)
      • Accommodation is the process by which the eye changes optical power to maintain a clear image (focus) on an object as its distance changes
  • Changes During Accommodation
  • Presbyopia: Normal Change
    • Flexible lens of eye gradually loses elasticity, affecting ability to change shape to focus on close objects
  • Normal Age-Related Changes of the Eye: Internal Changes
    • Decreased pupil size, decreased retinal illumination
      • Decreased visual acuity (sharpness of vision)
      • Decreased light sensitivity (difficulty seeing in dim areas/ at night)
      • Dark and light adaptation takes longer
      • Distortion in depth perception
    • Lens: Yellowed/ Slightly cloudy (opacification)
      • Increased difficulty in distinguishing between blue, green, & violet
      • Increased sensitivity to glare
  • Internal Changes: Cornea & Lens
    • Lipid deposits around peripheral cornea  arcus senilis (normal change)
    • Lenses thicken/ harden
      • Yellowish appearance + opacity
      • Cataracts (not a normal change)
  • Normal Age-Related Changes of the Eye
    • Visual acuity (sharpness of vision)
      • Diminishes gradually after age 50
      • Decreases rapidly after age 70
    • Light sensitivity declines
      • Brightness contrast
      • Dark adaptation
      • Recovery from glare
  • Clinical Implications
    • Difficulty reading small print
    • Narrowing of field of vision
    • Decreased light to retina
    • Sensitivity to glare
    • Decreased night vision
    • Difficulty with depth perception (going down stairs)
    • Increased risk for FALLS!
  • Visual Impairments with Aging
  • Visual Impairment
    • Visual impairment = visual acuity 20/40 by Snellen chart at 20 feet
      • Increases with age
    • Common visual disturbances in older adults:
      • Presbyopia
      • Age-Related Macular Degeneration
      • Cataracts
      • Glaucoma
    • Will affect 70 million Americans by 2030
    Understanding the Visually Impaired
  • Legal blindness
    • Visual acuity 20/200 by Snellen chart at 20 feet
      • Increases with age
      • Peaks at 85 years
  • Question
    • The nurse is assessing a patient who has just been tested for visual acuity and was told his vision is 20/50. The patient asks what this means, and the nurse answers:
      • A. “You can see approximately 2/5 as well as the normal person.”
      • B. “You can see at 20 feet what a person with normal vision sees at 50 feet.”
      • C. “Your vision is the same as a 20-year-old man, even though you are 50.”
      • D. “You can see at 50 feet what a person with normal vision can see at 20 feet.” 
  • Diseases Affecting Vision
  • Cataracts
  • Cataracts
    • NOT a normal part of aging process (though very common with aging)
    • Most cataracts are related to aging
    • Lens clouding  decreased light to retina  limited vision
    • Oxidative damage or cross linking
    • Slow and painless
    • Leading cause of low vision in older adults
    • > 50% of adults > 65 years have cataracts  visual problems
    What is Cataracts? Cataracts Explained
  • Cataracts: Signs
      • Yellowing of lens
      • Pupil changes color to cloudy white or gray
  • Cataracts: Symptoms
    • No pain or discomfort
    • Hazy or blurred vision (most likely)
    • Glare , photosensitivity
    • Halos around objects
    • Double vision
    • Lack of color contrast or faded colors
    • Poor night vision
    The Symptoms of Cataracts
  •  
  • Cataracts: Blurry Vision
  • Cataracts: Yellowing of Images
  • Cataracts: Decrease in Color Intensity
  • Cataracts: Risk Factors
    • Increased age
    • Smoking and alcohol
    • Diabetes, hyperlipidemia
    • Trauma to the eye
    • Exposure to the sun and UVB rays
    • Corticosteroid medications
    Risks of Cataracts
  • A. Simulated vision with cataracts. B. Normal vision. (From National Eye Institute, National Institutes of Health, 2004.)
  • Cataracts: Tx & Nursing Strategies
      • Surgery only cure
      • Outpatient procedure: relatively few complications
      • Removal of lens
      • Insertion of intraocular lens implant (distorts vision less than special cataract glasses do)
    Cataracts Treatment
  • Cataract Surgery (Outpatient): Intraocular Lens Learn About Cataract Surgery - Very graphic! Say Good-Bye to Cataracts & Glasses
  • Cataract Surgery – Postoperative Instructions
    • Day of surgery
      • Eye shield
    • First 2 weeks
      • HOB 30°, lie on back or unaffected side
      • Eye shield at night
      • Eye drops
      • Mild aches, scratchiness, itchiness
        • Tylenol; NO aspirin, ibuprofen
        • Do not rub, touch area
      • Avoid bright sunlight
        • Wrap-around sunglasses
      • Avoid activities  IOP
        • Sneezing, coughing, vomiting, straining, bending, lifting > 5 lbs
        • Prevent constipation (fiber, fluids, mobility, stool softener)
        • Avoid heavy work, such as gardening, mowing the lawn, or moving furniture
      • Avoid water in eye (tap water, shower, tub, etc)
    Caring for Eyes after Cataract Surgery
  • Cataract Surgery – Postoperative Instructions
    • Symptoms to report
      • Pain not relieved by Tylenol
      • Changes in vision
        • Decreased vision, redness, cloudiness, drainage, floaters or light flashes, curtain over vision, severe eye pain or pressure
    • Complications
      • Infection
      • Wound dehiscence
      • Hemorrhage
      • Severe pain
      • Uncontrolled, elevated intraocular pressure
    Cataracts Surgery Complications
  • Education Regarding Cataract Prevention
    • Wearing hats and sunglasses when in sun
    • Smoking cessation
    • Avoid steroids
    • Low-fat diet
    • Avoid ocular injury
    How to Prevent Cataracts
  • Question
    • Which of the following statements indicates that the client has understood home care instructions following cataract surgery?
      • A. “I should not bend over to pick up objects from the floor.”
      • B. “I can sleep on whichever side I want as long as my head is raised.”
      • C. “I may not watch television for 6 weeks.”
      • D. “I should keep the protective eye shield in place 24 hours a day.”
  • Glaucoma
  • Glaucoma
    • Degenerative eye disease
    • Second leading cause of blindness in U.S.
      • 10% vision loss in U.S.
    • Primary cause of blindness among AA
    Glaucoma Prevalence What is Glaucoma
  • Glaucoma
    • Optic nerve damaged by pressure
      • Increase in intraocular pressure (IOP)  optic nerve damage  peripheral vision loss
      • IOP > 21 mm Hg
    • “ Sneaky thief of sight”
    Causes of Glaucoma
  •  
  • Aqueous Humor
  • Simulated Vision with Glaucoma (From National Eye Institute, National Institutes of Health, 2004.)
  • Chronic (Open-Angle) vs Acute (Angle-Closure) Glaucoma
    • Chronic (also called open-angle)
    • More common than acute, 90%
      • Slowed flow of aqueous humor through trabecular meshwork  build up  increased IOP  damage to optic nerve  loss of vision
      • Painless vision loss
        • Peripheral visual field loss
    Types of Glaucoma
  • Chronic (Open-Angle) Glaucoma
  • Chronic (Open-Angle) Glaucoma
  • Chronic Glaucoma
  • Chronic Glaucoma: S/S
      • Peripheral vision slowly impaired
      • Tired eyes
      • Headaches
      • Misty vision
      • Colored rings / halos around lights
      • Worse symptoms in morning
      • Usually involves one eye, but may be both
    Glaucoma Symptoms
  •  
  • Chronic: Tx & Nursing Strategies
    • Diagnosis and Treatment
      • Dx: tonometry; gonioscopy
    • Treatment (Care Plan 26-1; pp. 340-341):
      • No cure, requires life-long management
      • Reduce IOP
        • Medications to decrease IOP (topical eyedrops)
        • Avoid stress, coughing, sneezing, bending over, or straining with bowel movements
        • Laser trabeculoplasty, Surgery – trabeculectomy
    Glaucoma Treatments Glaucoma Treatment Developments Glaucoma Laser
  • Tonometry & Gonioscopy
  • Topical Eyedrops
    • Beta-blockers (Betagan, Timoptic, Ocupress) – Bottles with blue or yellow caps
      • 1st line therapy for glaucoma
      • Lowers IOP by decreasing formation of aqueous humor
      • SEs: Bradycardia, hypotension, bronchospasm, confusion
    • Prostaglandin analogues (Xalatan, Lumigan)
      • Increases outflow of aqueous humor
      • SEs: Stinging, burning, darkening of eye
    Glaucoma Help In A Drop
  • Topical Eyedrops
    • Alpha-Adrenergic Agonists (Iopidine, Alphagan, Epinal) – Bottles with purple caps
      • Lowers IOP by decreasing formation of aqueous humor
      • Avoid use in acute angle-closure glaucoma
      • SEs: Palpitation, hypertension, tremor, sweating
  • Topical Eyedrops
    • Miotics/ cholinesterase inhibitors (pilocarpine, Humorsol) – Bottles with green caps
      • Facilitates outflow of aqueous humor
      • SEs: Decreased night vision, bronchospasm, sweating, salivation, lacrimation, diarrhea
    • Carbonic anhydrase inhibitors (Trusopt, Azopt) – Bottles with orange caps
      • Decreased formation of aqueous humor
  •  
  • Question
    • A client with open-angle glaucoma is receiving brinzolamide (Azopt) for treatment. When assessing the client’s response to the medication, the nurse expects therapeutic effects to be the result of the following?
      • A. A decrease in the outflow of aqueous humor
      • B. An increase in the outflow of aqueous humor
      • C. A decrease in aqueous humor production
      • D. An increase in aqueous humor production
  • Acute (Angle-Closure) Glaucoma
    • Acute (angle-closure, closed-angle, narrow-angle)
      • Not as common
      • Angle of iris obstructs drainage of aqueous humor through trabecular meshwork  increased IOP  visual changes
      • May occur suddenly
      • Ophthalmic emergency!
  • Acute (Angle-Closure) Glaucoma
  • Acute (Angle-Closure) Glaucoma
  • Acute Glaucoma: S/S
    • Severe unilateral eye pain or headache
    • Blurred vision
    • Nausea and vomiting
    • Photophobia
    • Colored halos around light
    • Red eye
  • Acute Glaucoma
    • Sudden S/S: eye pain, HAs, halos around lights, dilated pupils, vision loss, red eyes, N & V
    • May last for a few hours, return again
    • Each attack takes part of field of vision
  • Acute Glaucoma: Tx & Nursing Strategies
    • Diagnosis
      • Tonometer to measure IOP
      • Normal IOP is 20 mm Hg or below
      • Gonioscopy (direct exam)
    • Medications (to decrease pressure)
    • Permanent vision loss within 2 – 5 days if untreated
    • Surgery: iridotomy (lowers IOP) to prevent future episodes
  • Risk Factors for Glaucoma
    • Increased intraocular pressure
    • Older than 60 years of age
    • Female gender
    • Family history of glaucoma
    • Personal history of myopia, diabetes, hypertension, or migraines
    • African American ancestry
    Who's at Risk of Developing Glaucoma
  • Education Regarding Glaucoma Screening
    • Complete ophthalmic examination
    • Adults 65+ should be evaluated annually
    • Every 6 months with glaucoma controlled by medication
  • Glaucoma: Contraindicated Medications
    • Cold remedies with Pseudoephedrine or Phenylephrine (Neo-Synephrine)
    • Antihistamines such as Chlorpheniramine (Chlor-Trimeton) or Diphenhydramine (Benadryl)
    • Overactive bladder remedies – Tolterodine tartrate (Detrol)
    • Tricyclic antidepressants – Amitriptyline (Elavil)
    • Cyclobenzaprine (Flexeril)
  • Question
    • Is the following statement true or false?
    • Patient adherence with treatment for glaucoma can be a problem in the older adult population.
  • Age-Related Macular Degeneration (ARMD)
  • Age-Related Macular Degeneration (ARMD)
    • Most common cause of blindness adults > 65
    • Degeneration of macula, (sharpest central vision)
      • Scotoma – central vision
      • Visual acuity
    • Central vision
      • Seeing objects clearly
      • Common daily tasks (reading and driving)
    Managing Macular Degeneration
  •  
  • ARMD: Symptoms
    • Painless
    • More light required for reading
    • Central scotomas – blind spots
      • Blurry
      • Bent, warped images
      • Dark, foggy or light spots
    • Words on a page may appear distorted or incomplete
    • Metamorphopsia – images look smaller (micropsia) or larger (macropsia) than they actually are
    The Signs of AMD
  • A. Simulated loss of vision with age-related macular degeneration (AMD). B. Normal vision. (From National Eye Institute, National Institutes of Health, 2004.) Helping Macular Degeneration
  • Macular degeneration: distortion of center vision; normal peripheral vision Amsler Grid
  • ARMD: Two Types – Dry & Wet
    • Dry (atrophic, nonexudative form)
      • 10-20% severe vision loss
        • Atrophy
        • Retinal pigment degeneration
        • Drusen accumulations
      • 90% ARMD this type
      • Better prognosis, slower progression
  • ARMD: Two Types – Dry & Wet
    • Wet (Neovascular exudates)
      • Blood or serum leak from newly formed blood vessels beneath retina  scar formation + visual problems
      • 10% this type
      • More sudden onset
      • More severe vision loss
    Learn about Wet AMD
  • Normal Macula vs Dry & Wet ARMD
  • Risk Factors for ARMD
    • Age (above 50)
    • Female gender
    • Caucasian race and light (blue) colored eyes
    • Family history of ARMD
    • Cigarette smoking
    • Ultraviolet light (sunlight)
    • HTN, high cholesterol, cardiovascular disease
    • Lack of dietary intake of lutein; antioxidants and zinc
    How to Prevent Macular Degeneration The Risks of Smoking and Macular Degeneration
  • ARMD: Tx
    • No cure at present
    • New research:
      • Photodynamic therapy uses a special laser to seal leaking blood vessels in the eye
      • Antioxidant vitamins (C, D, E, and Beta-carotene), lutein, & zinc may slow progress of disease
      • Retinal cell transplantation or regeneration
    New Macular Degeneration Treatment (just an example)
  • Age-Related Macular Degeneration (ARMD) Preventive Measures
    • Nurses should encourage
      • Routine ophthalmic examinations
      • Wearing UV protective lenses in sun
      • Smoking cessation
      • Exercising routinely
      • Eating a healthy diet consisting of fruits and vegetables
  • ARMD: Nursing Strategies (p.337, Box 26-2)
    • Magnifying glasses
    • Reading lamps
    • Low-vision assistive devices
    • Modify environment
    • Avoid glare
    • Use contrasting colors
    • More auditory input (books on tape, etc.)
    • Decrease controllable risk factors (smoking, UV exposure)
    How to Deal with Losing Sight
  • Question
    • Which type of visual problem is associated with macular degeneration?
      • A. Loss of peripheral vision
      • B. Loss of central vision
      • C. Perception of spots moving across the eye
      • D. Pain with movement of the eye
  • Detached Retina
  • Detached Retina
    • Forward displacement of retina
    • Gradual or sudden
    • Risk factors: nearsightedness (myopia), cataract surgery, glaucoma, trauma, previous retinal detachment, family hx
    • Symptoms: spots, blurred vision, flashes of light, curtain over visual field
    • Blank areas of vision
    • Painless
    Causes of Retinal Detachment
  • Posterior Vitreous Detachment
  • Retinal Detachment
  • Detached Retina: Tx & Nursing Strategies
    • Prompt treatment
    • Bed rest, bilateral eye patches
      • Reason: Reduce rapid eye movements
    • Safety concerns
    • Surgery: electrodiathermy & cryosurgery
    • Scleral buckling & photocoagulation
    Detached Retina (or Retinal Detachment)
  • Promoting Visual Safety
  • Promoting Visual Safety in Home
    • Provide adequate lighting in high-traffic areas
    • Stair rails, non skid surfaces
    • Use contrast when painting
    • Avoid reflective floors
    • Signs – bright colors such as red, orange, yellow
    • Use red-colored tape or paint on edges of stairs and entryways
    • Avoid complicated rug patterns
  • Nursing Diagnoses
  • Nursing Diagnoses Associated with Visual Impairment
    • Sensory/Perceptual Alterations: Visual with a variety of nursing goals and interventions
      • Communication
      • Safety
      • Mobility
      • Self-care activities
      • Mood