2. OVERVIEW
Ophthalmology is the branch of medicine which
deals with the diseases of the eye and their
treatment. The word ophthalmology comes
from the Greek roots ophthalmos meaning
eye and logos meaning word; ophthalmology
literally means "The science of eyes."
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3. As a discipline it applies to animal eyes also,
since the differences from human practice are
surprisingly minor and are related mainly to
differences in anatomy or prevalence, not
differences in disease processes.
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4. By convention the term ophthalmologist is
more restricted and implies a medically
trained specialist. Since ophthalmologists
perform operations on eyes, they are
generally categorized as surgeons.
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5. The branch of medicine concerned with the
study and treatment of disorders and
diseases of the eye (Wikipedia, 2011).
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6. Ophthalmology helps nurses (students) in
their basic training as they may spend time in
the eye hospital or out-patient.
It also helps nurses to appropriately nurse
patients admitted to general wards with eye
conditions.
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7. The aim is therefore to provide an
introduction to some common eye disorders
and the principle which underlie their
treatment and nursing care.
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8. Refer to your procedure manuals
(Pg. 225-235)
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9. Aphakia: absence of the crystalline lens
Contact lens: a very thin soft refractive
medium which is worn on the cornea
Entropion: the in turning (inversion) of the
eyelid resulting into trichiasis (rubbing of the
eyelashes on the cornea)
Ectropion: the outward turning (eversion) of
the eyelid
Enucleation: is the removal of the eyeball but
leaving the muscles and the eyelids behind
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10. Evisceration: removal of the contents of the
eyeball but not the sclera
Hypermetropia: long sightedness i.e. can
see far more clearly than nearer
Hyphaema: blood in the anterior chamber of
the eye
Hypopyon: pus in the anterior chamber of
the eye
Keratitis: the inflammation of the cornea
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11. Keratomalacia: corneal softening usually
associated with vitamin A deficiency
Myopia: short sightedness i.e. can see near
more clear than far away
Presbyopia (old sight): physiological blurred
near vision commonly evident soon after age
of 40 due to reduction in the power of
accommodation (poor accommodation)
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12. Pterygium: an encroachment of a tissue into
the cornea possibly due to irritation
Ptosis: drooping of the upper eyelid
Strabismus (squint): one eye turned in or
outwards
Tonometer: an instrument used to measure
intra ocular pressure
Uveitis: the inflammation of the uveal tract
(iris, ciliary body and choroid)
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13. VA: visual acuity
CF: counting fingers
HM: hand movement
LP: light perception
N-LP: Non-light perception
OD: Right eye
OS: Left eye
OU: Both eyes
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14. The anatomy of the eye can be considered
under two main headings, the anatomy of the
globe and the anatomy of the orbit.
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20. Muscle Action Nerve supply
Orbicularis oculi Closes the eye Facial (7)
Levator palpebrae superioris Opens the eye Oculomotor (3)
Superior rectus Looks up Oculomotor (3)
Medial rectus Looks in Oculomotor (3)
Inferior rectus Looks down Oculomotor (3)
Lateral rectus Looks out Abducens (6)
Superior oblique Looks down and in Trochlear (4)
Inferior oblique Looks up and in Oculomotor (3)
Ciliary muscle Accommodates Oculomotor (3)
Pupil constrictor Constricts pupil Oculomotor (3)
Pupil dilator Dilates pupil Sympathetic
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21. Visual Acuity: the ability to see near and far
objects clearly. The test is done using the
snellen’s chart where one is asked to stand at
a distance (6 meters) and asked to read the
letters on the chart.
Physical Examination: general impression of
the patient and the appearance of both eyes
together, followed by examination of each
eye on its own
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22. Conjuctival Swab: is used to screen for
presence of infection of the conjunctiva
Flourescein Staining: it is used to check for
corneal ulcers where a dye (Flourescein) is put
on the cornea which will change colour and
allows you to see the ulcerated areas of the
cornea
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23. Tonometry: it is used to measure the intra ocular
pressure of the eye (normal btwn 10 and 20 mmHg)
Fundoscope: is a device used for examining the
intra ocular structures i.e. the lens, retina, vitreous
humor, etc.
Pupil Reaction test: involves shinning light on the
pupil with the torch. It allows for testing the integrity
of the sensory and motor functions of the eye. Under
normal conditions . Normally, pupils react (i.e.
constrict) equally.
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24. Slit lamp examination: A microscope that
projects a linear slit beam of light onto the
eye; allows viewing of the conjunctiva,
cornea, iris, aqueous humor, lens, and eyelid.
Pin-hole Test: a test performed on a person
who has diminished visual acuity to
distinguish a refractive error from organic
disease. If visual acuity is improved, the
defect is refractive; if not, it is organic.
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45. Definition:
this is a chronic inflammation of the lid
margins of the eye characterised by redness of
the eye, itching and burning sensation.
Types:
1. ulcerative Blepharitis caused usually by
staphylococcus
2. squamous Blepharitis associated with
seborrhoea (dandruff) of the scalp
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50. IEC
Hygiene: wash eyes regularly to prevent gluing
of eyes and avoid dust areas
Drug compliance
Nutrition: vitamin A containing foods like
mangoes for good sight, proteins like beans to
build up worn out tissues and Vitamin C to
boast up immunity
Regular eye check
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51. Definition:
This is the drooping of the upper or lower
eyelid due to loss of control by the third cranial
nerve.
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52. Causes:
Congenital loss of function or weak eyelid
muscles
Old age due to loss lid muscle strength
Trauma to eyelid muscles
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53. 3rd cranial nerve (oculomotor) damage
Inflammation of the lid margins
Neoplasms of the eyelids
Drugs like high dose opioids such as
morphine
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54. S/S
Visual disturbances
Weakness of the superior rectus muscles
Encroachment of the lid on the pupil
Thinning of the lid
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55. Treatment:
Treatment includes surgical and non surgical
Non-Surgical: use of glasses or special scleral
contact lenses to support the eyelid
Surgery
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56. Definition:
This is a condition in which the eyelid is turned
outward and doesn’t come in contact with the
eyeball characterised by tearing and thickening
of the conjunctiva.
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57. S/S
Tearing
Irritation due to dryness of the conjunctiva
Redness in the eyelids
Light sensitivity or decreased vision and pain
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58. Causes
Relaxation of the orbicular muscles associated
with aging
Scarring
Congenital
Allergies
Severe burns of the face
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59. Types
There are 7 types:
Involutional: age iduced horizontal elongation
of the eyelid
Cicatrical: tumour, scar or trauma induced
contracture of the outer layers of the skin and
muscles in the outer layers of the eyelid
Paralytic: resulting from 7th cranial nerve palsy
such as Bell’s palsy.
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60. Punctal: eversion of the medial portion of
the eyelid where resides the punctal opening
or the tear drainage system.
Mechanical: eversion of the lower lid due to
the weight of the tumour or inflammation
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61. Congenital: ectropion evident in a child at or
soon after birth
Mixed Mechanism: A combination of two or
more causes usually involutional and
cicatricial.
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62. Management
Treatment will depend on the causes and
severity:
No need of treatment when there is mild
symptoms of facial palsy such as Bell’s palsy it
fixes itself
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63. Simple self help measures to reduce
symptoms are keeping any exposed areas of
cornea moist and lubricated using eyedrops
and taping the eyelid upwards with surgical
tape.
Surgery
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65. Prevention
Use of artificial tears or lubricating ointments
prevent corneal complications
Early seeking of medical advice when you have
prolonged signs and symptoms of dry eyes,
including red, irritated, tired and painful eyes.
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66. Definition
This is a condition in which the eyelid is turned
in against the eyeball
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68. Causes
Muscle weakness: As one ages muscles
including tendons of the eye may become weak
and cause entropion
Scars or previous surgeries: scarred from
chemicals, burns, trauma or surgery on the face
can distort the normal curve of the eyelid
causing entropion
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69. Skin infections: previous skin diseases or
infections such as ocular herpes can result in
entropion
Trachoma can cause scarring of the inner
eyelid leading to entropion and even
blindness from the corneal complications
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70. Eye surgery: an eyelid problem called
spastic entropion affects some people
temporarily after eye surgery usually lasting
only until the eye is completely healed.
Abnormal foetal development: very rarely
entropion is present at birth (congenital)
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71. Management
Surgery by tightening orbicular muscles and
also directly preventing inward rotation of the
eyelid margin
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73. Definition
This is the inability to close or poor closure of
the upper eyelids. It is a form of facial paralysis
affecting the orbicularis muscle in the eyelids.
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74. Causes
Bell’s palsy: paralysis of facial nerve causing
weakness of the muscle of one side of the face
Trauma: causing paralysis of the cranial nerve
(7) which controls eyelid function
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75. Neuro-surgery: surgery carried out to the
brain, spinal cord and nerves causing damage
to the nerves supplying the eyes leading to
paralysis of the muscles of the face.
Bacterial infection: this damages facial
nerves causing eyelids not to function
properly
Heredity: it runs in families
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76. Tumours: abnormal growth of tissues or
cells causing reduced blood supply to the
nerves leading to inability of eyelids to
function properly
CVAs: This causes paralysis of the cranial
nerve 7 which controls eye and the eyelid
function.
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78. Treatment
This depends on the extent of the facial nerve
paralysis:
Eye ointments or drops only for paralysis
lasting for less than 6 months
Surgery: when paralysis is deemed permanent
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79. Complication
Severe dry eye and discomfort
Corneal ulceration
Decreased or loss of vision
Unsatisfactory appearance
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80. Definition
The term trichiasis describes the misdirection
of eyelashes such that instead of them growing
outwards normally, they point inwards and
touch the eyeball causing irritation, watering
and discomfort
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84. Treatment
This depends on the number of lashes
involved, the cause and patient’s preference:
Epilation: if 1 or 2 lashes are involved plucking
them out is done though this is temporal as
they will grow again usually within 6 weeks
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85. Electrolysis: more permanent treatment
where small number of abnormally growing
eyelashes are destroyed by applying a small
electric current using a needle electrode next
to hair follicle bulb.
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86. Surgery: to change direction of growth or
permanently remove the eyelashes hair
bearing skin.
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87. It is also known as hordeolum
Definition
An acute localised pyogenic infection of one
or more of the glands of Zeis or moll
(external hordeolum) or of the meibomian
gland (internal hordeolum, myebomian stye)
caused by staphylococcal bacterial infection
characterised by swelling and tenderness.
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89. S/S
Painful lump on the lid margin
Tenderness
Swelling
Redness
Irritation of the eye
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90. Treatment
Incision & drainage (I & D) will be done
Warm compress 3-4 times a day for 10-15
minutes
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91. Apply Vaseline around the to keep it moist
Tretracycline hydrocortisone eye ointment
1% 8hourly for 5 days
Procain penicillin 300, 000 IU IM for 5 days
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92. It is also known as tarsal or chalazion
It is a chronic granulomatous enlargement
of a meibomian gland from occlusion of its
duct often following inflammation of the
gland characterised by painless localised
swelling that develops over a period of
weeks.
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93. CAUSE
Occlusion of the meibomian gland duct often
following its inflammation
S/S
Swelling of the eyelid
Eyelid tenderness
Sensitivity to light
Increased tearing
Heaviness of the eyelid
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94. Treatment
Warm compress 3-4 times a day for 10-15
minutes
Tetracycline HCL Eye Ointment 1% 8hourly for
5 days
Procaine penicillin 300, 000 IU IM OD for 5
days
Surgery
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98. Also called pink eye or madras eye is
inflammation of the conjunctiva (the
outermost layer of the eye and the inner
surface of the eyelids). It is most commonly
due to an infection (usually viral, but
sometimes bacterial) or an allergic reaction
(Wikipedia, 2011).
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99. Classification can be either by cause or by
extent of the inflamed area.
1. By cause
Allergic conjunctivitis
Bacterial conjunctivitis
Viral conjunctivitis
Chemical conjunctivitis
Neonatal conjunctivitis is often defined
separately due to different organisms.
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100. 2. By extent of involvement
Blepharoconjunctivitis is the dual
combination of conjunctivitis with blepharitis
(inflammation of the eyelids).
Keratoconjunctivitis is the combination of
conjunctivitis and keratitis (corneal
inflammation).
NB: Depending on the time taken
conjunctivitis, maybe said to acute or chronic.
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101. Definition
An acute Conjunctival inflammation, usually
caused by viruses, bacteria, or allergy.
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102. Microorganisms: viruses or bacteria
Allergy
Irritants: from wind, dust, smoke, intense
ultraviolet light, etc
Infections: common cold, measles
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103. Etiology Discharge;
cell type
Lid swelling Node
involvement
Itching
Bacteria Purulent;
polymorphon
uclear
leukocytes
Moderate No No
Viral Clear;
mononuclear
cells
Minimal Yes No
Allergic Clear, mucoid,
ropy;
eosinophils
Moderate to
severe
No Intense
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104. Bacterial: TEO 1%, CEO 1%, or GED 0.3% qid x 7 to
10 days. This treatment can be used for all forms
of conjunctivitis. A poor clinical response after 2
or 3 days indicates an intensive bacterial, viral or
allergic conjunctivitis.
Allergy: topical corticosteroid therapy e.g.
predinisolone acetate 0.12% tid
Others
advise the patient to use his own towels
Keep the eyes free of discharge and not patched
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105. Definition
A chronic inflammation of the conjunctiva
characterized by exacerbations and
remissions that occur over months or years.
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106. Causal agents are similar to those of acute
conjunctivitis, ectropion, Entropion,
blepharitis, chronic dacryocystitis, chlamydia,
topical drug sensitivity and toxicity, and
chronic exposure to irritants.
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107. similar to those of acute conjunctivitis but
less severe and include:
Itching
irritation
Foreign-body sensation
Red eye (hyperemia)
Pain
Photophobia
Lid oedema
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108. Scant mucoid secretion may be present
Reddened palpebral conjunctiva, which is
thickened and velvety
the bulbar conjunctiva may be slightly
involved
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109. Specific therapy depends on the cause.
Irritating factors must be eliminated.
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113. Neisseria gonorrhoeae
chlamydia trachomatis
any other bacteria
silver nitrate
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114. Lid oedema (unilateral/bilateral infection)
copious discharge
sticky lid
chemosis (oedema of the conjunctiva)
+/- corneal ulcer
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115. Neisseria G. 1-5 days
Chlamydia T. 5-14 days
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116. Conjuctival Swab for mcs
vaginal swab for mcs
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117. This is in 2 parts i.e.:
1. Baby part;
Benzyl penicillin 30mg/kg bwt in 2 divided
doses x 5/7 IM
Gentamycin 0.3% eye drops/ointment hrly x
2/7, then 3 hrly x 2/7 and 6 hrly x 6/7
vigorous eye irrigation
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121. Also called granular conjunctivitis and
Egyptian ophthalmia
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122. It is chronic infectious disease/conjunctivitis
due to repeated reinfection by chlamydia
trachomatis causing a characteristic
roughening of the inner surface of the eyelids
(Wikipedia, 2011). It affects mainly the upper
tarsal conjunctiva and/or the cornea.
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123. Globally, 41 million people suffer from
active infection and nearly 8 million people
are visually impaired as a result of this
disease (Wikipedia, 2011).
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124. Chlamydia trachomatis: an organism half
way between the bacteria and virus.
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125. some cause severe and blinding condition
while others cause mild disease including
conjunctivitis
Nomenclature-Genus
it is chlamydae
Species
There are two main species:-
Chlamydia trachomatis
Chlamydia pstasi
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126. The bacterium has an incubation period of 5
to 12 days
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127. It ranges from mild with no symptoms to severe
blinding condition. Symptoms are like those
of conjunctivitis as follows:-
Irritable red eye (hyperemia)
Mucopurulent discharge (exudation)
Pain
Photophobia
Lid oedema
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128. The conjunctiva will have:-
Follicles in the upper fornix and around the
limbus
papillae over palpebral conjunctiva
The cornea will have:-
Superficial punctate Keratitis
pannus
sometimes ulceration
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129. TF-Trachoma follicles: Five or more follicles
of >0.5 mm on the upper tarsal conjunctiva
TI- Trachoma inflammation: Papillary
hypertrophy and inflammatory thickening of
the upper tarsal conjunctiva obscuring more
than half the deep tarsal vessels
TS- Trachoma scarring: Presence of scarring
in tarsal conjunctiva.
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130. TT- Trachoma trichiasis: At least one
ingrown eyelash touching the globe, or
evidence of epilation (eyelash removal)
TO- Trachoma opacification: Corneal
opacity blurring part of the pupil margin
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131. 1. Direct demonstration: Specimen used is
Conjuctival scraping
Giemsa stain: polymorphs are raised,
plasma cells are present, macrophages and
debris, there are follicle cells
(pathognomonic)
Iodine stain: It shows glycoproteins of cells
at their centres
Monoclonal antibody testing: It shows the
germ itself (chlamydia trachomatis)
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132. 2. Culture
This is done in special media where the cells
are grown (McCoil or Hella cells)
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133. 3. Serology
This is done on tears or on serum to isolate
one of the serotypes of chlamydia that cause
trachoma
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134. Trachoma is common in areas of low
immunity communities. It appears in hot dry
climates/environments. In dust environments,
dirt environments and where discharges are
frequently seen.
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135. it is spread by direct contact with eye, nose,
and throat secretions from affected
individuals, or contact with formites
(inanimate objects that carry infectious
agents, such as blankets and pillowcases),
such as towels and/or washcloths, that have
had similar contact with these secretions.
Flies can also be a route of mechanical
transmission.
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136. Flies: Flies can also be a route of mechanical
transmission.
Fingers/hand shaking: it is spread by direct
contact with eye, nose, and throat secretions
from affected individuals
Formites: contact with formites (inanimate
objects that carry infectious agents, such as
blankets and pillowcases), such as towels
and/or washcloths, that have had similar
contact with these secretions.
Overcrowding/big Families
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139. You should have an aim in delivery of your
service to the target group e.g. “promiscuity
prevention”.
Method
Posters
ZNBC
Generally talk about the following:-
Face washing
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140. Fecal disposal
Pit latrine construction
Digging rubbish pits
Hand washing
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141. This is determined by the level of the disease. The
principle is:-
Assess the patient after screening. WHO-
recommended SAFE strategy, which includes:
1. Surgery: to correct advanced stages of the
disease
2. Antibiotics: to treat active infection using TEO
1% qid x 6/52 and Cap tetracycline qid x 1/52 or
azithromycin (single oral dose of 20 mg/kg)
3. Fly control/face hygiene: to reduce disease
transmission
4. Environmental change: to increase access to
clean water and improved sanitation
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142. If not treated properly with oral antibiotics,
the symptoms may escalate and cause
blindness, which is the result of ulceration
and consequent scarring of the cornea.
Surgery may also be necessary to fix eyelid
deformities.
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143. Scarring of the inner eyelid
Eyelid deformities (Ptosis)
Inward folding of the eyelid (Entropion)
Ingrown eyelashes (Trichiasis)
Corneal scarring or cloudiness (Pannus)
Partial or complete vision loss (Blindness)
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146. It is an inflammatory or more seriously,
infective condition of the cornea involving
disruption of its epithelial layer with
involvement of the corneal stroma (Wikipedia,
2011).
OR
It is a local necrosis of corneal tissue due to
invasion by bacteria, fungi, viruses, or
acanthamoeba (Berkow R. et al, 1992).
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147. Trauma e.g. direct corneal injury by contact
lenses, Chemicals, etc
Other eye conditions e.g. entropion,
distichiae, corneal dystrophy,
keratoconjunctivitis sicca (dry eye), chronic
blepharitis, conjunctivitis, trachoma,
dacryocystitis, etc
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148. Infections by micro-organisms i.e. bacteria,
fungi, viruses, protozoa, and Chlamydia
Poor corneal nutrition e.g. vitamin A or
protein malnutrition
Corneal exposure due to eyelid injuries or
lagophthalmos
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149. Pain in the eye: this is due to nerve
exposure
Photophobia due to nerve exposure and
irritation
Tearing (lacrimation) due to pain and
irritations
Pus in the anterior chamber (hypopyon) due
to bacterial infection
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150. Squinting
Blood vessels may grow in from the limbus
(pannus)
Vision loss due to opaque scarring of the
cornea
Signs of uveitis such as miosis (small pupil),
aqueous flare (protein in the aqueous
humour), and redness of the eye. Stimulation
of pain receptors in the cornea results in
release inflammatory mediators such as
prostaglandins, histamine, and acetylcholine.
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151. Slit lamp done by direct observation under
magnified view reveal the ulcer on the cornea
Fluorescein stain which is taken up by
exposed corneal stroma and appears green,
helps in defining the margins of the corneal
ulcer
Swab for gram stain and m/c/s may reveal
the causative organism
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152. Corneal scraping and examining under the
microscope with stains like Gram's may reveal
the bacteria and fungi respectively
Schirmer's test for keratoconjunctivitis sicca
and an analysis of facial nerve function for
facial nerve paralysis
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153. Proper diagnosis is essential for optimal treatment:
Bacterial/Traumatic-Antibiotics
Fungal- intensive application of topical anti-
fungal agents such as Natamycin, Econazole, and
Miconazole eye drops and Sporanox capsules is
helpful.
Viral- those caused by herpes virus may
respond to antivirals like topical acyclovir 3% eye
ointment instilled at least five times a day/400-
800mg 5x o.d for 14/7 or Idouxuridine (IDU)
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154. Pain medications are given
Topical cycloplegics like atropine or
homatropine to dilate the pupil and thereby
stop spasms of the ciliary muscle
Deep ulcers may require conjunctival grafts
or conjunctival flaps, soft contact lenses, or
corneal transplant.
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155. Proper nutrition including protein intake
and Vitamin C are usually advised
Where the corneal ulceration is due to a
deficiency of Vitamin A supplementation by
oral or intramuscular route is given.
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156. Opaque scarring of the cornea
Decreased vision
Iritis
Iridocyclitis
Corneal perforation with iris prolapse
Hypopyon
Panophthalmitis
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159. It is a disorder of the eye characterized by
increased intra ocular pressure that may cause
impaired vision, ranging from slight loss to
absolute blindness (Berkow R. et al, 1992). OR
It is an eye disorder in which the optic nerve
suffers damage, permanently damaging vision in
the affected eye(s) and progressing to complete
blindness if untreated. It is often, but not always,
associated with increased pressure of the fluid in
the eye (aqueous humour).
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160. 1. Primary Glaucoma
Etiology and Pathogenesis
The causes are unknown
Predisposing factors
Vasomotor and emotional instability
Hyperopia
Heredity
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161. The intra ocular tension/pressure is created
because of the imbalance between production
and outflow of the aqueous humor.
Obstruction to outflow appears to be mainly
responsible for this imbalance.
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162. Primary glaucoma is divided into chronic
open angle glaucoma (COAG) which has a
wide angle and acute/chronic closure angle
glaucoma (with closed angle, narrow-angle,
congestive, acute glaucoma attack).
Congenital (infantile) glaucoma is also
primary.
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163. a) Chronic Open Angle Glaucoma
(COAG)/Chronic, Simple or Wide Angle
Glaucoma
Definition
A disorder characterized by a gradual rise in
intraocular pressure, causing slowly
progressive loss of peripheral vision and
when uncontrolled, late loss of central vision
and ultimate blindness (Berkow R. et al,
1992).
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164. The anterior chamber and its anatomic
structures appear normal but drainage of the
aqueous humor is impeded.
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165. Prevalent after age 30 but may occur in
early childhood
It is usually familiar. Rarely, it’s unilateral.
Individuals of High Risk
Age > 35 years
Diabetes (also those with positive glaucoma
tolerance tests)
Myopia
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166. Pigment dispersion syndrome (Krukenberg’s
spindle)
Family history of glaucoma
Race: 4-5 times higher in blacks developing
glaucoma than whites
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167. Frequent mild headache
Vague visual disturbances
Sees halos around electric lights
Impaired dark adaptation
Eye ache
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169. Aim
to reduce the increased IOP
Medical
Beta blockers e.g. timolol maleate
Pupil dilators e.g. Epinephrine, etc
Miotics e.g. Pilocarpine 0.5%,
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170. Laser Trabeculoplasty (ALT) or
Trabeculectomy
Iridencleisis
Cyclodiathermy
Corneal sclera trephine
Filtering surgery to improve aqueous
drainage
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171. Others
Avoidance of fatigue, emotional upsets, use
of tobacco, and drinking large quantities of
fluids
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172. b) Chronic Angle-ClosurenGlaucoma
Definition
A disorder characterized by recurrent
attacks usually unilateral, of increased intra
ocular pressure, pain, and impaired vision-
similar to those of acute angle-closure
glaucoma but less severe (Berkow R. et al,
1992).
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173. The anterior chamber is shallow, the
filtration angle is narrowed, and the iris may
obstruct the trabecular meshwork at the
entrance of the canal of schlemn.
Dilatation of the pupil may push the root of
the iris forward against the angle, which may
produce angle closure, thus precipitating an
acute attack.
Eyes with narrow anterior chamber are
predisposed to acute angle-closure glaucoma
attacks of varying degrees of severity.
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174. About 10% of patients with closed angles
present with acute angle closure crises
characterized by:
Sudden ocular pain
Seeing halos around lights
Red eye
Very high intraocular pressure (>30 mmHg)
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175. Nausea and vomiting
Sudden decreased vision, and
A fixed, mid-dilated pupil
NB: Acute angle closure is an ocular emergency.
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176. Darkroom test after Tonometry: A rise of
pressure of 6 mmHg during the test is a
positive result.
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177. Eye drops i.e Pilocarpine 1 or 2 % 3-6
times/day
Timolol Maleate 1 drop 0.25 or 0.5%
solution 1 or 2 times/day can be added
Oral glycerine/mannitol IV
Early laser iridotomy or peripheral
iridectomy
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178. Definition
This Glaucoma which is secondary to an
intraocular disorder, usually anterior uveitis
(Berkow R. et al, 1992).
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179. Secondary glaucoma is caused by any
interference with the flow of aqueous humour
from the posterior chamber through the pupil
into the anterior chamber canal of schlemm.
inflammmatory disease of the anterior
segment may prevent aqueous escape by
causing complete posterior synechia and iris
bombe and may plug the drainage channel
with exudates.
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180. other common causes are intraocular
tumours, intumescent cataracts, central
retinal vein occlusion, trauma to the eye,
operative procedures, and intraocular
haemorrhage.
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184. Opacity of the lens
Clouding that develops in the crystalline
lens of the eye or in its envelope, varying in
degree from slight to complete opacity and
obstructing the passage of light.
Causes/Predisposing Factors
Senile cataract due to old age causing
degeneration of the lens
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185. Nutritional cataract due to lack of Vitamin B
& C
Systemic cataract due to diabetes
Inflammatory due to iritis
Traumatic due to penetrating injuries
Congenital due to rubella/TORCH from
mother
Toxic due to steroids (systemic/topical)
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186. Reduced V/A, painless vision loss, blurred
visual disturbance, double vision, glares at
bright light, poor reading vision, seeing
better in dim light (nuclear cataract), Pupil
changes from black to white (whitish opacity)
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187. Described according to the cause, location or
level of maturity of the cataract i.e:
Cause
Senile, Traumatic, Diabetic, Congenital,
Secondary cataract, Familial, and Toxic
cataracts.
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188. Nuclear found in the anterior pole
Corticol found in the posterior pole
Subcapsular found in the lamellar
Maturity
Immature only part of the lens is opaque
Mature when whole lens is opaque &
swollen (intumescent)
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189. Hypermature when there is an opaque &
wrinkled lens with dehydration
Phakolytic lens when the lens matter leaked
out causing uveitis & secondary raised IOP.
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192. Loss of vitreous, wound dehiscence, iris
prolapse, hyphema, glaucoma, retinal
detachment, infection.
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193. Advise the following:
moving slowly & cautiously
avoid straining
eye will be bandaged for some days
wearing metal shield at night for several
weeks
patient may be given cataract glasses when
sitting after bandage is removed as it may be
difficult to adjust to distortions of objects
avoid driving/swimming
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194. wearing ultraviolet-protecting sunglasses
may slow the development of cataracts
Regular intake of antioxidants (such as
vitamins A, C and E) is helpful
Give others considering the causes
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197. This is a separation/detachment of the
neural retina from the underlying retinal
pigment epithelium (RPE) by the subretinal
fluid (SRF) (Berkow et al, 1992).
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198. 1. Rhegmatogenous
This implies a break through and through in
the retina
A rhegmatogenous retinal detachment
occurs due to a break in the retina that allows
fluid to pass from the vitreous space into the
subretinal space between the sensory retina
and the retinal pigment epithelium.
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199. Retinal breaks are divided into three types -
holes, tears and dialyses.
Holes form due to retinal atrophy especially
within an area of lattice degeneration.
Tears are due to vitreoretinal traction.
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200. Dialyses which are very peripheral and
circumferential may be either tractional or
atrophic, the atrophic form most often
occurring as idiopathic dialysis of the young.
Rhegmatogenous retinal detachment are
seen more frequently in myopia, after
cataract surgery, or following ocular trauma.
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201. 2. Non-Rhegmatogenous
Not caused by a retinal break but can be
produced by vitreoretinal traction (e.g.
proliferative retinopathy of diabetes or sickle
cell disease) or by transudation of fluid into
the subretinal space (e.g. severe uveitis
especially in vogtkoyanagi-Harada disease, or
primary or metastatic choroidal tumours).
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202. An exudative retinal detachment occurs due
to inflammation, injury or vascular
abnormalities that results in fluid
accumulating underneath the retina without
the presence of a hole, tear, or break.
In evaluation of retinal detachment it is
critical to exclude exudative detachment as
surgery will make the situation worse, not
better.
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203. Although rare, exudative retinal detachment
can be caused by the growth of a tumor on
the layers of tissue beneath the retina,
namely the choroid.
This cancer is called a choroidal melanoma.
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204. A tractional retinal detachment occurs when
fibrous or fibrovascular tissue, caused by an
injury, inflammation or neovascularization,
pulls the sensory retina from the retinal
pigment epithelium.
A minority of retinal detachments result
from trauma, including blunt blows to the
orbit, penetrating trauma, and concussions to
the head.
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205. primary detachment occurs spontaneously
because of a change in retina or vitreous
Intraocular inflammation
Trauma
Hole/tear in the retina
Degenerated changes related to aging
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206. Myopia (High)
Cataract surgery (esp. after aphakia)
Traction on the retina by vitreous bands or
membranes resulting from proliferative DM,
retinopathy, posterior uveitis or traumatic
intraocular foreign body.
Retinopathy of prematurity, tumours
It can be inherited, usually in association
with myopia
uveitis
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207. Pt c/o flashes of light (photopsia) or
blurred, ‘sooty’ vision due to stimulation of
the retina by vitreous pull
Foreign body sensation in the line of vision
a sudden dramatic increase in the number
of floaters
a slight feeling of heaviness in the eye
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208. Gradual, painless vision loss
A sensation of a vein like coaling coming
down, up or sideways in front of the eyes
a dense shadow that starts in the peripheral
vision and slowly progresses towards the
central vision
the impression that a veil or curtain was
drawn over the field of vision
central visual loss
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209. Direct Ophthalmoscopy-shows folds or
discoloration in the usually transparent retina
Indirect Ophthalmoscopy-shows retinal
tears
Ocular U/S-to examine the retina if the pt
has an opaque lens
Pt describes like looking directly into the
sun if examined by ophthalmoscope
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210. Total bedrest to prevent further detachment
of the retina. Both eyes may be padded
according to Doctor’s orders
Psychological Care-Explain the condition,
procedure to be done. Tell pt that he is going
to have a patch on his eyes after surgery &
that the arm orbital area will be black & blue
but it will fade away.
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211. Patient should wash the face with a
detergent germicide pre-op to reduce risk of
infection
Administer sedatives and traquilisers for
comfort & relief of anxiety
Give prescribed antibiotics (Sulphonamides,
Gentamycin eye drops) & mydriatics.
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212. Electrodiathermy-An electrode needle is
passed in the sclera to allow subretinal fluid
to escape. An exudate forms from the
pigment epithelium & adheres to the retina.
Cryosurgery-A supercooled probe is
touched to the sclera, causing minimal
damage, as a result of scarring, the sclera
adheres to the retina.
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213. Photocoagulation-A light beam is passed in
the dilated pupil causing a small burn &
producing an exudate from the pigment
epithelium & adheres to the retina.
Sclera Buckling-One or more silicone bands
(bands, tyres) are sewn to the sclera. The
bands push the wall of the eye inward against
the retinal hole, closing the break.
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214. Pneumatic retinopexy: a gas bubble is
injected into the eye after which laser or
freezing treatment is applied to the retinal
hole. The surface tension of the air interface
seals the hole in the retina
Vitrectomy: It involves the removal of the
vitreous gel and is usually combined with
filling the eye with either a gas bubble or
silicon oil.
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215. Proper positioning of the pt as ordered. Pt is
allowed out of bed on the 2nd day.
discourage activities that would rise the IOP
& administer antiemetics
take precautions to avoid bumping pt’s
head this causing the retina to detach further
pt is encouraged to breath deeply but not to
cough since this may cause increase in IOP,
further detachment of the retina.
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216. Observe for slight localized corneal edema
& perilimbal congestion. to reduce edema &
discomfort, apply ice packs & administer
acetaminophen as ordered for headache.
If patient receives a retrobulbar injection,
apply a protective eye patch because the eye
lid will remain open
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217. After removing the protective patch give
cyclople (to dilate pupil) as ordered. apply
cold compress to decrease swelling & pain.
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218. Instruct him to rest & to avoid driving,
bending, heavy lifting or any other activities
that may affect IOP for several days.
Discharge activities that may cause the pt to
bump his eye.
Take analgesics for pain & apply ice to his
eye to reduce swelling & alleviate discomfort
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219. Review S/S of infection, emphasizing those
requiring immediate attention.
Show Pt how to instill eyedrops properly
Pt can watch TV
Emphasize on review dates usually after 2
weeks
Stay home for several weeks to avoid
accidental injuries
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220. Increased IOP
Endophthalmitis (inflammation of the
endoepithelial layer in the retina)
Development of other retinal detachment
Cataracts
Loss of turgor of the eye (phthisis)
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223. Blindness is not a disease. It is a
complication of other eye diseases and
trauma.
WHO states that if you are blind you are 60%
dead.
There are a number of myths associated
with blindness in Zambia.
These myths try to explain the cause of
blindness.
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224. Blindness is the inability to see, usually
defined as best corrected visual acuity (BCVA)
of 20/400 or less, or a visual field of no more
than 20 degrees in the better eye to no light
perception (Smeltzer and Bare, 2009).
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225. Cataract
Glaucoma
Trachoma
Cornea opacities due to:
Measles, etc
Vitamin A Deficiency
Traditional eye practices
Ophthalmic neonatorum
Ocular injuries
-
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226. Systematic diseases such as Diabetic
mellitus, HTN, etc
Onchocerciasis identified in some countries
like Malawi, Congo DR and Tanzania
Age related macular degeneration, Cone rod
dystrophy , cataract, etc
Congenital :Structural or functional defect in
the eye or extra ocular structures or Retinitis
pigmentosa
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227. Iatrogenic e.g. Retinopathy of prematurity
resulting from fluctuating PaO2 to which the
retina of the premature baby does not react
well leading to retrolental fibroplesia and
visual loss
Tumours -May infiltrate the eyes and result
in poor innervations and function. E.g.
retinoblastoma
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228. Lack of knowledge: Blindness may be due to
inadequate knowledge about the factors that
contribute to the preservation of good vision.
(e.g. nutrition, protection of eyes in
potentially hazardous situations).
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229. Total blindness: Is defined as blindness in
which the person has no perception of light
and no usable vision (Lewis et al, 2007).
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230. Functional blindness : Is defined as the
ability of a person to perceive light Can also
be classified according to the number of eyes
affected these are: unilateral blindness or
bilateral blindness.
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231. Visual loss when attempting to ambulate
Structural changes on exam e.g. cataract,
corneal opacifications
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232. History will reveal loss of vision
visual acuity testing in each eye
measuring the visual field or peripheral
vision.
Ophthalmoscopy: helps to detect pathology
in the lens, vitreous and retina
Slit lump examination to examine the
structures of the eye. Causes of blindness
such as retinal detachment, new growths
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233. The treatment of blindness depends on the
cause of blindness:
Refractive error, merely prescribing and
giving glasses will alleviate the problem
Nutritional causes of blindness can be
addressed by dietary changes
Cataract: surgery
Inflammations & Infections: medication in
the form of drops or pills
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234. The prognosis for blindness again is
dependent on its cause.
In patients with blindness due to optic-
nerve damage or a stroke of indeterminate
age, visual acuity can usually not be restored.
Patients who have corneal scarring or
cataract have a good prognosis if they are
able to access surgical care of their condition
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235. Maintenance of a safe environment
Psychological
Nutrition
Communication
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236. Diet- vitamin A, B and C are considered
important
Protective wear
Regular/periodical eye examinations
Promote good environmental sanitation
Monitoring intra arterial oxygen or blood
gasses in premature babies will help prevent
retrolental fibroplesia
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237. Recognition and appropriate care of
individuals certain conditions e.g. measles,
malnutrition and diarrhoea.
Immunizations against measles
Screening of antenatal mother for sexually
transmitted infections and health education
Treatment of eye conditions such as
trachoma, removal of cataract.
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238. Rehabilitation is re-education, particularly
of one who has been ill or injured, so that he
or she may become capable of useful activity
(Weller, 2007).
These skills include:
Mobility using the cane and other guides.
Communication, the blind are taught
various communication styles. An
independent blind person must develop a
variety of skills these include:-
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239. Braille,
Effective listening,
Note taking techniques
Typing
The centre has Braille printing and
transcription facilities.
Use of a computer with synthetic speech or
electronic Braille display.
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240. Talk about presence of the following:
federation for the blind
Cultural centre for the blind which provides
the blind people with resources on various
issues including
Schools for the visually impaired and the
blind around the country
The blind are also taught how to use aids
such as canes, guide dogs
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244. Read about them
Superior & inferior rectus
Medial & Lateral rectus
Superior & inferior oblique
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245. Deviation of one eye from parallelism with
the other (Berkow et al, 1992)
Strabismus (squint, cross-eyes) is a
wandering or misalignment of one eye so
that its line of vision isn’t parallel with that of
the other eye and both eyes aren’t pointed at
the same object at the same time (Berkow et
al, 1997).
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246. Normally, both eyes move together so that a
single, fused image from both eyes is
produced by the brain
Because each eye has a slightly different
viewpoint, this image is three dimensional
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247. If the eyes aren’t aligned properly, the brain
may receive images from each eye that are
too different to be fused, resulting in double
vision (diplopia)
To avoid double vision, the brain may
suppress the image from the deviating eye
which is done constantly vision in that eye is
lost
Because the image produced by a single eye
isn’t 3-dimensional, depth perception is also
lost.
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248. Paralytic (nonconcomitant) strabismus: This
result from paralysis of one or more ocular
muscles may be caused by a specific
oculomotor nerve lesion or damage to the
nerve supplying those muscles.
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249. Nonparalytic (concomitant) strabismus:
Usually results from unequal ocular muscle
tone caused by a supranuclear abnormality
within the CNS (brain). This type of a squint is
not caused by a lesion reducing innervations.
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250. Farsightedness in children: this is because
eyes have to turn inward (accommodative
esotropia) when looking at distant objects in
order for accommodation to take place.
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252. Misalignment of the eye which maybe may
be Convergent (esotropia), divergent
(exotropia), or vertical (hyper- or hypotropia)
Diplopia due to different images from each
eye
Limitation of eye motion in paralytic
deviation
Loss of vision in one eye
Loss of depth perception
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253. VA: may show amblyopia (reduced VA due
to an abnormal visual experience early in life)
Eye Fixation Exam/Cover Test: Done by
having the patient fix on a pencil or flashlight
held in front of the examiner while covering
the normal eye, in exotropia the eye turns in
and in esotropia it turns out to fixate.
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254. Ophthalmoscopy: Strabismus may be due to
serious ocular or neurological disease hence
the need for complete evaluation of the
corneas, lenses, retinas, and optic nerves.
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255. Patching of the normal eye to treat early
amblyopia may result in improved vision in the
deviating eye
Corrective Glasses/Contact
Lenses/Miotics/Orthoptic training e.g. eye
exercises or surgical restoration in muscle
imbalance.
NB: Permanent loss of vision can occur if
strabismus and its attendant amblyopia are not
treated before age 4-6 yrs, with intermittent
follow-up examinations at least until age 10
years.
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256. Amblyopia (reduced VA) early in life
Permanent loss of vision
Loss of self esteem especially in children
due to poor appearance of eyes
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259. a) The admission routine
b) Pre-op pt education
c) Pre-op eye drops
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260. When a pt is admitted for surgery, the
admission routine should include:
i) Bathing the pt:
there is an increased risk of infection
(Endophthalmitis) following the operation if the
pt is dirty.
Wash the pt with soap and water, particularly
the face and hair.
Before they are admitted they should then be
given clean hospital clothes to wear whilst they
are in the ward.
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261. ii) BP checking:
most pts admitted for eye surgeries e.g.
cataract extraction are elderly and most of them
have HTN.
It is important for the BP to be controlled
before the eye operation.
Measure and record the BP and inform the
ophthalmologist if it is raised.
He will refer the pt for Tx and will decide
whether or not to carry on with the surgery or
postpone it until the BP is controlled (raised BP
leads to bleeding a lot).
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262. iii) Urinalysis:
Check the urine sugar.
Diabetic pts have an increased risk of
developing age related cataract and significant
numbers of pts admitted for lens extraction have
diabetes.
Record whether or not there is sugar in the
urine and inform the ophthalmologist if it is
present. (if present pt is referred to the physician
for further mgt.
The ophthalmologist will decide on whether to
operate or to wait until sugar is controlled.
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263. Pts are starved pre op (depends on type of
anesthesia), to prevent hypoglycemia in
diabetics IVL 5% Dextrose is commenced.
The pt may also have diabetic retinopathy
and it is important for the fundus to be
examined after cataract extraction.
If there is no retinopathy the pt should visit
your clinic regularly for fundoscopy.
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264. iv) Chest Examination:
Check if the pt is coughing. It is important for
the pt to lie still and not to cough during the
operation (L/anesthesia).
This is to avoid intraocular contents coming out
once the incision has been made.
Ask the pt if he is coughing and ask him to
cough for you.
if the pt is coughing and has a productive
cough, record this and inform the
ophthalmologist who will decide when to
postpone or do the pt under GA or refer to the
physician.
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266. This education can be given to all the pts in
the ward who are going for surgery a day
before and on the morning of surgery.
Health education helps to relieve anxiety
and you may need to repeat it several times
for some of them because they are elderly
and have hearing problems too.
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267. The points to explain include:
i) The nature of their condition/cataract,
glaucoma, the principles of the operation
they are going to have and the visual result
they should expect from.
ii) The routine in the ward, pre and post op
instillation of eye drops, applications of eye
pad and shield, meals, toilet, bathing, etc
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268. iii) The routine in theatre (L/A injection, drapes,
the importance of lying still and not
coughing).
iv) The prevention of infection following
operation (No sniffing, no smoking, no
touching the eye with dirty fingers or wiping
the eye with a dirty cloth).
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269. v) The prevention of mechanical injury to the
eye following operation (No bending over, no
rubbing the eye, no lifting heavy weights,
care not to bump the eye).
Allow them to ask where they have not
understood, evaluate and finally pts made to
sign the consent.
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270. i) Antibiotic drops: E.g. CEDs 1 drop qid to both
eyes from admission to theatre day. this is
prophylaxis against the developing of
infection e.g. post-op Endophthalmitis
ii) Mydriatic drops: Pts for lens extraction
require pre-op mydriatic drops to dilate the
pupil adequately for easy extraction.
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271. You must be aware of the systemic side
effects of phenyl epinephrine drop BP (Punctal
occlusion and no more than 4 drops should
be given over the space of 2 hours).
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272. a) The 1st 24 hours
b) Day 1-2 mgt
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273. i) Receiving of pt from recovery room (general)
ii) Specific Mgt
-Pt will have eye pad and shield applied over
the operated eye, which should not be
removed until following day
-Remind the pt about do’s and don’ts (to stay
in bed and lie on his back or opposite side of
the operated side)
-The pt may sit up for meals and get up with
assistance to the toilet
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274. -No smoking or sniffing
-Not touching the operated eye or rubbing to
prevent infection
-Prevent mechanical injury-not leaving out bed to
pick up anything on the floor or lifting of heavy
objects
-No straining on stool and coughing
-If pt had an IOL and visco plastic applied in the
anterior chamber of the eye and not washed out,
pt should be given diamox 250mg qid x 24
hours orally (to prevent increase of IOP)
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275. -Assist the ophthalmologist to remove the shield
and eye pad to examine the eye
-When eye pad and shield are removed remind pt
not to touch or rub the eye, advise him/her to
blink if it is itching
-Discard eye pad but wash shield with soap and
water. Apply stripes on to it and place it on to
pt’s bedside locker (optional).
-Educate pt that if s/he goes to sleep should
reapply the shield to affected eye to avoid
bumping the eye thereby applying pressure
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276. -After examining of the eye, antibiotic steroid
combination eye drops 1 drop qid prescribes
e.g. Prednisolone and Gentamycin
-Ensure that eyes are swabbed applying aseptic
technique before instillation of eye drops
-Ensure that each pt has his/her own medicine
and kept at his/her bedside locker, and this is
the same medicine he will take home when
discharged.
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277. -If ECCE had been done and no IOL inserted
issue pt with +10 lens aphasic glasses and
educate pt on how to put them on and care
for them
-If pt had trabeculectomy, keep eye open no
need for eye pad
-After day 1, pt may get out of bed, walk
around, bath and not splash water into the
eye, sit up no bending over, no heavy lifting,
no smoking.
-If no complications pt may be discharged or if
he is to stay general Nsg care routine
continues
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278. Mukumbi J, (2015), Kalene school of
nursing, Zambia.
Cook C., (1999), A Manual for Ophthalmic
Nursing in Kwa Zulu, RSA.
Sandford John, (1995), Eye Diseases in Hot
Climates, 2nd Edition, RSA.
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