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Trauma, infection, neoplasm, degeneration

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Trauma, infection, neoplasm, degeneration

  1. 1. Trauma, Infection, Neoplasm Degeneration Gauri S. Shrestha, M.Optom, FIACLE Assistant Lecturer BPKLCOS
  2. 2. <ul><li>Degeneration </li></ul><ul><li>Neoplasm </li></ul><ul><li>Trauma </li></ul><ul><li>Infection </li></ul>
  3. 3. Age related Macular degeneration <ul><li>bilateral disease of the macular area, </li></ul><ul><li>apparent after 50 years of age. </li></ul><ul><li>most common cause of irreversible visual loss </li></ul><ul><li>Atrophic (dry, non-exudative) : </li></ul><ul><li>90% of cases. </li></ul><ul><li>slowly progressive </li></ul><ul><li>drusen and geographic atrophy of the RPE. </li></ul><ul><li>Exudative (wet, neovascular) : </li></ul><ul><li>less common but devastating </li></ul><ul><li>choroidal neovascularization (CNV) enventually subretinal scarring, and </li></ul><ul><li>rapidly progressive and marked loss of vision. </li></ul>
  4. 5. Age related Macular degeneration <ul><li>Risk factors </li></ul><ul><ul><li>Genetic factor, Smoking, Exposure to UV </li></ul></ul><ul><ul><li>Hypertension, cardiovascular diseases </li></ul></ul><ul><ul><li>Glycemic diet </li></ul></ul><ul><li>Symptoms </li></ul><ul><ul><li>Gradual loss of central vision, distortion of straight lines or edges, black spot in front of the fixation </li></ul></ul><ul><li>Signs </li></ul><ul><ul><li>Macular drusen, clump of pigment in the outer retina, </li></ul></ul><ul><ul><li>RPE atrophy and detachment, </li></ul></ul><ul><ul><li>subretinal neovascularization, haemorrhage, scarring </li></ul></ul>
  5. 6. NURSING ASSESSMENT <ul><li>Subjective </li></ul><ul><ul><li>History: smoking, excessive outdoor activities, cardiovascular diseases and hypertension as well as occurrence in family. </li></ul></ul><ul><li>Objective </li></ul><ul><ul><li>Visual acuity: decreased </li></ul></ul><ul><ul><li>Refraction: vision may not be restored even if there is a refractive error corrected. </li></ul></ul><ul><ul><li>Dilated fundus examination+BP </li></ul></ul><ul><ul><li>Amsler grid: a central or paracentral scotoma, metamorphosia, macropsia, micropsia </li></ul></ul><ul><ul><li>Investigation </li></ul></ul><ul><ul><ul><li>Intra-venous fluorescein angiography (IVFA) to detect choroidal neovascular membrane </li></ul></ul></ul>
  6. 7. Age related Macular degeneration <ul><li>NURSING DIAGNOSIS </li></ul><ul><ul><li>Disturbed sensory perception related to visual impairment. </li></ul></ul><ul><ul><li>Risk for injury related to impairment vision. </li></ul></ul><ul><ul><li>Self care deficit related to impaired vision. </li></ul></ul><ul><li>EXPECTED OUTCOME </li></ul><ul><ul><li>Further loss of vision will be prevented by appropriate therapy. </li></ul></ul><ul><ul><li>Progression will be halted by improving food habit and make patient stopping smoking. </li></ul></ul><ul><ul><li>Residual vision will be optimally utilized to prevent impairment. </li></ul></ul>
  7. 8. Intervention <ul><li>Advise patient to improve food habit (high antioxidants & beta carotenes) </li></ul><ul><li>Advise immediate stopping of smoking. </li></ul><ul><li>Laser photocoagulation or photodynamic therapy is applied within 72 hours of the IVFA in case of treatable CNV is formed </li></ul><ul><li>Caution patient to avoid exposure to direct sunlight for 5 days after the photodynamic therapy. </li></ul><ul><li>Patient is treated with a high dose combination of vitamin C (500mg), Vitamine E (400IU), Beta carotene (15mg), and zinc (80mg) in dry AMD. </li></ul>
  8. 9. Intervention <ul><li>Instruct patient to visit to Ophthalmologist for appropriate therapy. </li></ul><ul><li>Instruct patient to visit to Optometrist for visual rehabilitation. </li></ul><ul><li>Provide amsler grid to take at home to use on daily basis. </li></ul><ul><li>Instruct patient to take preventive measures </li></ul><ul><li>Advise patient to visit for follow up every 6-12 months in dry AMD, 2 weeks, 6 weeks, 3 months, and 6 months after therapy. </li></ul>
  9. 10. Ocular Tumour Capillary haemangioma Basal cell carcinoma Congenital granuloma Conjunctival Naevus Melanoma Lymphangioma
  10. 11. Ocular tumours Neurofibroma Squamous papilloma Retinoblastoma Papilloma
  11. 12. Retinoblstoma <ul><li>most common congenital primary intraocular malignancy arising from neurosensory retina. </li></ul><ul><li>one in 20,000 live births and accounts for about 3% of all childhood cancers. </li></ul><ul><li>ages of 1-2 years of life. </li></ul><ul><li>no sex predisposition. </li></ul><ul><li>usually unilateral but bilateral cases are reported in 25-30% cases. </li></ul>
  12. 13. Presentation <ul><li>Leukocoria: White pupillary reflex in 60% cases. </li></ul><ul><li>Strabismus: Deviation of eye in 20% cases. </li></ul><ul><li>Secondary glaucoma: Uncommon/present </li></ul><ul><li>Nystagmus: rare/present </li></ul><ul><li>Orbital inflammation: It mimicks orbital or preseptal cellulites in necrotic tumours. </li></ul><ul><li>Children can present with orbital invasion and proptosis in neglected cases. </li></ul><ul><li>Metastatic diseases involve regional lymph nodes. </li></ul>
  13. 14. NURSING ASSESSMENT <ul><li>Subjective </li></ul><ul><ul><li>History: white pupillary reflex and strabismus in children </li></ul></ul><ul><li>Objective </li></ul><ul><ul><li>Detailed Retina examination. </li></ul></ul><ul><ul><li>Investigation </li></ul></ul><ul><ul><ul><li>Ultrasonography: tumour size and calcification. </li></ul></ul></ul><ul><ul><ul><li>CT scan: involvement of the optic nerve and orbital; and CNS extension </li></ul></ul></ul><ul><ul><ul><li>MRI: optic nerve evaluation and detection of pinealoblastoma. </li></ul></ul></ul><ul><ul><ul><li>Aqueous humour: raised lactic dehydrogenase level. </li></ul></ul></ul>
  14. 15. Leukocoria mass of tumour
  15. 16. Nursing Diagnosis <ul><li>Vision loss due to disease condition. </li></ul><ul><li>Deficient knowledge about treatment regimen of retinoblastoma. </li></ul><ul><li>Potential for metastasis to lymph nodes, optic nerves, and brain. </li></ul>
  16. 17. Expected Outcome <ul><li>Family members especially parents will be informed about treatment regimen of retinoblastoma. </li></ul><ul><li>In early stage, child’s vision loss will be prevented. </li></ul><ul><li>Child’s life is saved. </li></ul><ul><li>Metastasis to lymph nodes, optic nerve and brain will be prevented. </li></ul>
  17. 18. Intervention <ul><li>Advise patient’s parents or family members properly about its need of emergency treatment. </li></ul><ul><li>Instruct the child’s parents about treatment plan or about requirement of whole eyeball removal. </li></ul><ul><li>Perform dressing of wound and bandage of orbit of enucleated eye. </li></ul><ul><li>Later, the enucleated eye can be fitted with ocular prosthesis. </li></ul>
  18. 19. Trauma <ul><li>Ocular injuries can be occurred by various modes. According to mode of infection, ocular injury can be classified into following types. </li></ul><ul><li>Mechanical injury </li></ul><ul><ul><li>Extraocular foreign body </li></ul></ul><ul><ul><li>Blunt trauma </li></ul></ul><ul><ul><li>Penetrating and perforating injury </li></ul></ul><ul><ul><li>Intraocular foreign body </li></ul></ul><ul><li>Chemical Injury </li></ul><ul><ul><li>Alkali burn </li></ul></ul><ul><ul><li>Acid burn </li></ul></ul><ul><li>Thermal injury </li></ul><ul><li>Electrical injury </li></ul><ul><li>Radiational injury </li></ul>
  19. 20. NURSING ASSESSMENT <ul><li>Subjective </li></ul><ul><ul><li>History: nature of injury including the circumstances, time and likely objects. </li></ul></ul><ul><li>Objective </li></ul><ul><ul><li>A thorough ocular examination from lids to retina. </li></ul></ul><ul><ul><li>Palpate orbital rim for stepoffs or integrity of bony structure. </li></ul></ul><ul><ul><li>EOM in all gazes: restriction in movement </li></ul></ul><ul><ul><li>Pupil examination: size, shape and reaction </li></ul></ul><ul><ul><li>Visual acuity: normal to reduced </li></ul></ul><ul><ul><li>Intraocular pressure: Elevated, normal or hypotony </li></ul></ul><ul><ul><li>Hess chart: monitor progression of diplopia, identify paralysis or restriction of extraocular muscles. </li></ul></ul>
  20. 21. Nursing Assessment <ul><li>Investigation </li></ul><ul><ul><li>CT scan and MRI of orbit and brain: extent of the fracture, foreign body, damage to ocular structures, prolapse of orbital fat, extra-ocular muscles, haematoma, integrity of intracranial and facial nerves. </li></ul></ul><ul><ul><li>Plain radiography or X-ray: detect foreign body and damage to orbit. </li></ul></ul><ul><ul><li>USG B-scan: extent of damage, retinal detachment, vitreous detachment, foreign body. </li></ul></ul><ul><ul><li>Seidel test: detect wound leak from laceration. </li></ul></ul>
  21. 22. NURSING DIAGNOSIS <ul><li>Loss of vision secondary to rupture or perforation of globe, foreign body, laceration, inflammation, and infection. </li></ul><ul><li>Anxiety due to loss of vision. </li></ul>
  22. 23. EXPECTED OUTCOME <ul><li>Foreign body and chemicals will be removed without causing significant tissue loss thus sight loss will be prevented. </li></ul><ul><li>Sight loss will be prevented by repairing globe rupture and laceration, and removing intraocular foreign body. </li></ul><ul><li>Associated ocular inflammation and complications will be freed. </li></ul>
  23. 24. Intervention <ul><li>Review the treatment plan and instruction </li></ul><ul><li>Remove superficial foreign body or chemical by swab stick or sterile hypodermic needle. </li></ul><ul><li>Follow the irrigation procedure thoroughly in chemical burn. </li></ul><ul><li>Remove contaminant. </li></ul><ul><li>Remove contaminated and necrotic tissues. </li></ul><ul><li>Check the record of prescription and administer accordingly. </li></ul>
  24. 25. Intervention <ul><li>Instruct patient to apply therapeutic contact lens for corneal laceration which is about to break </li></ul><ul><li>Apply patch if it is indicated. </li></ul><ul><li>Treat associated inflammation and infection. </li></ul><ul><li>Refer patient to neurosurgery for orbital roof fracture or intracranial haemorrhage. </li></ul><ul><li>Administer prescribed systemic antibiotics for ruptured globe and penetrating ocular injuries. </li></ul><ul><li>Educate patient to use special protective glasses at work. </li></ul>
  25. 27. Infection Ulcerative blepharitis, Gray white nodules on conjunctiva, scleritis, keratitis, uveitis, syphilitic retinitis, neuroretinitis, chorioretinitis, papillitis, and oculomotor nerve palsy. Syphilis Subconjunctival haemorrhage, retinal haemorrhage. Malaria Ocular manifestation in 1-2% cases: multiple uveal granulomas formation, keratitis, granulomatous uveitis, retinal vasculitis. Tuberculosis Decreased corneal sensitivity, corneal thickening, keratitis, and corneal opacity; chronic iridocyclitis and iris atrophy; scleral thinning; cataract, lagophthalmos, madarosis, districhiasis, entropion, trichiasis, blepharochalasis. Leprosy
  26. 28. Infection Major complication is retinochoroiditis, papillitis, papilloedema, vitritis, and retinal detachment. Toxoplasmosis Uveitis, cataract are the common consequences. Leukocoria, decreased vision, and retinal detachment. Toxocariasis Vasculopathy of uncertain cause, opportunistic infection, neoplasm, and neuro-ophthalmic abnormalities. Cytomegalovirus retinitis, hepes simplex virus retinitis, Kaposi’s sarcoma, cranial nerve palsy, papilledema, optic atrophy. AIDS

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