The document provides information about ophthalmic nursing and eye anatomy. It discusses the three layers of the eye wall, structures of the human eye like the iris, pupil, lens, sclera, cornea, choroid, ciliary body, retina, vitreous body and aqueous humour. It also describes visual assessment techniques including history taking, physical assessment of extraocular structures and the use of tools like the Snellen chart, tonometer and phoropter. Common refractive errors like myopia, hyperopia, presbyopia and astigmatism are also summarized.

1. OPHTHALMIC NURSING
By Laurenzia Njeru

2. The structures of the Eye
•The wall of the eye has 3 layers of tissue which
includes;
a). The outer fibrous layer: sclera and cornea
b). The middle vascular layer or uveal tract
consists of choroid, ciliary body and iris
c). The inner nervous tissue: Retina

3. The human eye
http://www.virtualcancercentre.com

4. Anatomy of the human eye

5. Lashes—protection from foreign material
Glands—lubricate anterior surface
Meibomian/tarsal glands
Lacrimal glands
Conjunctiva
Thin, transparent, vascular layer lining
Eye lids and sclera
Anatomy

6. Anatomy
•Iris-Iris is composed of the pigment cells, and
two layers of smooth muscles
Iris gives eye color and the muscles control the
size of the pupil (dilate or constrict)and
regulate the light entry
•Lies behind the cornea and infront of the lens
•Presents the circular opening called the pupil

7. Anatomy
•Pupil
Allows light to enter and enables view to
back of eye and eye health
evaluation

8. LENS
A transparent biconvex elastic structure and
opaque in cataract
Lies behind the iris
Suspended from the ciliary body by the
suspensory ligaments
The ciliary muscles controls its thickness
The lens then refracts the light and focuses it
on the retina

9. LENS CONT;
•The refractory power is controlled by changes
in thickness
•With age the lens flexibility becomes hard
and accommodation power is lost

10. Sclera
•It is opaque and forms the 5/6th of the
posterior eyeball
•It is firm to maintain the shape of the eyeball
•Anteriorly it continues as cornea at the
limbus( sclerocorneal junction)
•It gives attachment to the extraoccular
muscles

11. cornea
•It is transparent and forms the anterior 1/6 of
the eyeball
•It is convex and avascular. It is sensitive to pain
•It is separated from the iris by a space called
anterior chamber
•It is involved in light refraction to the retina
•Nourished from lacrimal fluid and the aquoeos
humor

12. choroid
•It is chocolate brown in colour
•It has rich blood supply
•Covers the posterior inner surface of the
sclera
•It separates the sclera from the retina
•Anteriory it ends at the ciliary body

13. Ciliary body
•Thickened part of the uveal tract
•Anteriorly it continues with the iris while
posteriorly with the choroid
•Consists of the ciliary muscles and secretory
epithelial cells
•The lens is attached to the ciliary body
through the suspensory ligaments
•Secretory cells secrets the aqueos fluid to the
anterior and the posterior chambers of the
eye

14. CONT’
•Contraction and relaxation of the ciliary
muscles controls the shape of the lens for
adjustment for near vision
•Ciliary muscles are responsible for the
accomodation reflex
•They are supplied by the parasympathetic
branches of occulomotor nerve (CN III)
•When the ciliary muscles contracts, the
suspensory ligaments relax
•This allow the lens to bulge to adjust for near
vision

15. Retina
•Innermost layer of the eyeball
•Attached to the choroid posteriory
•It extends anteriory upto to ora serrata
•It consist of many sensory neurons and
supporting cells which are arranged in ten
layers
•Rods and cones are the photoreceptors of the
retina
•Retina is the light sensitive part of the eye

16. CONT’
•They convert the light rays to nerve impulse
•Rods are concerned with dim light
•Cones are concerned with bright light and
colour vision
•They receive an inverted image of the object

17. Interior of the eye
•Has an anterior and posterior chamber. Both
chambers contain aqueous humour

18. Aqueous humour
•Protein free plasma clear fluid
•Secreted by the glands in the ciliary body
•It is secreted into the posterior chamber then
circulates to the anterior chamber through the
pupil
•It is then drained to the veins through the scleral
venous sinus (canal of schlemm) and this cleans
the eyeball
•The production and drainage is continous

19. Aqueous humour CONT’
•Aqueous humour nourishes the cornea and the
lens and removes the wastes
•It maintains the normal intraocular pressure
(10-21mmhg)
•An increase in this pressure causes glaucoma

20. Vitreous body
•A colourless jelly like transparent substance
•99% is water
•Supports the retina against choroid
•Prevent the walls of the eyeball from
collapsing
•Eye shape is maintained.

21. VISUAL ASSESSMENT
Aim of visual assessment:-
•Establish cause of vision problem
•Establish response to treatment
•Know whether problem is unilateral or
bilateral
•As a routine to provide health education

22. History (Hx) taking;
•Collect both objective and subjective data
•Chief compliants
•Hx of present illness
•Past medical-surgical hx
•Family hx
•Psychosocial hx

23. History
•Sudden/gradual
•Uni/Bilateral
•Haloes around lights
•Floaters
•Flashes
•Hallucinations
•Micropsia / macropsia
•Diplopia
•Blurring
•Pain
•Foreign sensation
•Photophobia
•Vomiting
•Headache
•Discharge
•Colour
•Swelling
•Hx – DM, hypertension

24. Ophthalmic Instrument list and their use
•Contact lenses- use to correct refractive
errors of the eye;a little invasive
•Phoropter -used in refraction testing
•Tonometers –used to determine the
intraoccular pressure (IOP) - useful in
glaucoma;
•Speculum- used to keep the eyes open during
any operation
•Search others

25. Charts for vision
• Snellen's distant vision chart.....
• Regional language charts...........
• E Chart.......................................
• Landolt's broken ring chart.......
• Toys picture chart......................
• Snellen's near chart (1/17
reduction of distant chart)...........
• Colour vision............................
• Ishihara's chart...........................
• Stenopaeic slit
for those who can read in English
for those who can read in their local language
for those who can not read
for those who can not read
for children
standard chart of alphabets
to test colour vision
to determine the type of colour blondness
• detection of axis of the cylindrical
(astigmatism) power of the eye; glaucoma
testing

26. PHYSICAL ASSESSMENT
Start with the non-invasive procedures;
i. Ass visual acuity and visual field
ii. Ass muscle balance and eye movement
iii. Check the extraoccular structures
iv. Use of an ophthalmoscope and other
techniques

27. Assessment of extraoccular structures
Eyelids
•Check for erythema, edema, any scalling on the
edges.
•Ass their position-they should be vertical i.e
not drooping when open, closed or blinking to
confirm function of cranial nerve No. 7.
•They should act in uniform and this rules out
pulsy of the nerve.

28. Eye lashes
•Ass direction of their growth, loss or abnormal
growth.
•Lacrimal apparatus-ass for prescence of tears
and discharge.
•Conjuctiva- it’s transparent, ass for discharge,
edema, any foreign body, pallor
•Cornea-it’s clear, check for clarity, thickness. If
cloudy it could be a sign of cataracts

29. Iris
•Check for colour, any structural defects, check
the depth of the anterior chamber. (important
because of drainage of aqueous humour)

30. VISUAL ACUITY
•This is the ability of the eye to see fine
details/sharpness of vision.
•It is used to ass both distant and near vision.
•Done using a snellen chart;
•The pt stands 20 ft (6m) away from the chart
which is fixed on the wall in a well lit area.

31. CONT’
•Each eye is assessed separately by covering the
other eye with a palm or an opaque card
•The examiner points to a line and have the pt
read from left to right.
•It is expressed in a ratio that relates to what a
normal person sees from the same distance as
what the pt sees e.g 6/60, 6/18, 6/6, 6/12,
20/200
•When the numerator is smaller than the
denominator it means there is a defect

32. Questions
• What does it mean if you have 20/ 10 vision?
In the rare instances where vision may test better than normal on
a Snellen chart, a value of 20/10 vision means that you can see
clearly from a distance of 20 feet, what a person with normal
vision sees well at a distance of 10 feet
• What does it mean if you have 20/20 vision?
20/20 simply means your vision is "normal." 20/15 vision is slightly
better than 20/20. 20/10 is even better, and 20/5 is sharp as a
tack.
• How to score a snellen chart?
Top number equates to the distance (in metres) at which the test
chart was presented (usually 6m), Bottom number identifies the
position on the chart of the smallest line read by the 'patient'. Eg;
6/60 means the subject can only see the top letter when viewed at
6m.

33. CONT’
If pt is not able to see from the chart at all, move
to;
Counting fingers- CF/4 then
Hand motion- HM then
Light perception- LP then
No light perception-NLP

34. Snellen Chart
•Series of letters

35. SNELLEN CHART
•The snellen eye chart is the eye testing chart used by
eye care professionals to measure visual acuity (
clearness/ sharpness of vision)
•Or how well the patient can see without glasses or
contacts, measured at a distance of 20 feet.
•Dr, Hermann Snellen developed the eye chart in 1862.
•If some one has 20/20 vision, it means they can see the
same amount of details from 20 feet away as the average
person.
•If 20/40 vision, it means they can see the same amount
of details from 20 feet away as the average person would
see from 40 feet away.
•It can detect refractive errors e.g. myopia and hyperopia.

36. Assess for Near vision
•You use a Rosenbaum chart. Pt sits a metre
away.

37. VISUAL FIELDS TEST
Done by confrontation test.
Examiner sits 2 ft away from the client at eye level.
Have the client cover his left eye while you cover
your right eye.
Looks directly at each other with the uncovered
eyes.
Examiner then fully extends the left arm at midline
and slowly moves one finger/ pencil from below
until the client sees it.
Ask the client to say now/ yes when they see the
finger/ pencil.
 Test the inferior, superior, temporal and nasal
visual fields.

38. Inspection of Extraocular Muscle Function
1) Corneal light reflex test
This test assesses the parallel alignment of the
eyes.
Hold a penlight about 30cm from the client’s
face. Shine the light towards the bridge of the
nose while the client stares straight ahead.
Note the light reflection on the corneas.
Normally the reflection of the light on the
corneas should be on the exact same spot on
each eye which indicate parallel alignment.

39. 2) Cover test/ uncover test
Ask the client to stare straight ahead and focus on a
distant object.
Cover one of the client’s eyes with an opaque card while
you observe the uncovered eye for any movements.
Then remove the opaque card and observe the previously
covered eye for any movement. Repeat the test on the
other eye.
Normally, uncovered eye should remain fixed straight
ahead while the covered eye should also remain fixed
straight ahead after being uncovered. Abnormal findings-
the uncovered eye will move to establish focus when the
opposite eye is covered; when the covered eye is
uncovered it moves to re-establish focus.

40. Testing the six cardinal fields of gaze
Instruct the client to focus on an object that you
are holding about 30cm from the clients face.
Move the object through the 6 cardinal
positions of gaze in a clock wise direction and
observe the client’s eye movements.
Normally the eye movements should be smooth
and symmetric throughout the 6 directions.
Abnormal findings- failure of the eyes to follow
the movements which indicate a weakness in
one or more muscles; nystagmus- shaking
movement of the eye.

41. Assessing for eye pressure
•Also known as intra-occular pressure (IOP).
•Done by use of a tonometer and procedure is
tonometry.
•Measured in mmHg.
•A topical anaesthetic eye drop is instilled in the
lower conjuctival sac and the tonometer is then
used to measure the IOP.

42. PERRLA TEST
•Specific to the pupils
•Check and note whether they are equal. Best
done in a dark room.
•Check if they are round and react to light.
•Then assess for accommodation(the ability of the
eye to focus on both near and distant objects)

43. Other Special Techniques
•Ophthalmoscope (hand-held)
•Tonometry
•Applanation tonometer
•Gonioscopy(ant chamber-angle)
•Binocular Indirect ophthalmoscope
•Slit lamp
•CT scan
•MRI
•Angiography(blood vessels)

44. Hand-held
•Ophthalmoscope-used to ass
the internal structures i,.e the
retina, optic disc and blood
vessels
•1% Cyclopentolate (Mydrilate) /
1% tropicamide (Mydriacyl)

45. Slit Lamp
•Binocular
microscope

46. Phoropter
•Refractor
•Millions of possible
lens combinations
•Pt views object to
determine which
corrective lens to use

47. What is refraction?
•Refraction is the bending of light rays as they pass
through one object to another. The cornea and
lens bend (refract) light rays to focus them on the
retina. When the shape of the eye changes, it also
changes the way the light rays bend and focus —
and that can cause blurry vision.
( Aug 2020)Refractive Errors | National Eye Institute
•https://www.nei.nih.gov › eye-conditions-and-diseases

48. What is accommodation?
•The ability of the eye to change its focus from
distant to near objects (and vice versa).
•Accommodation is the adjustment of the optics of
the eye to keep an object in focus on the retina as
its distance from the eye varies. It is the process of
adjusting the focal length of a lens.
•https://www.rxlist.com ›

49. REFRACTIVE ERRORS
•Myopia
•Hyperopia (Hypermetropia)
•Presbyopia
•Astigmatism

50. Myopia
•Near sightedness
•Rays of light brought
to focus infront of the
retina.
•Occurs when the
eyeball is elongated.
•It has hereditary
fashion
•Correct by Concave
lens

51. Hyperopia
Or Hypermetropia
•Farsightedness
•Rays focused behind the
retina.
•Caused by short eyeball.
It’s the most common
•Has a connection with
aging due to decreased
muscle power
•Correct by convex lenses

52. Presbyopia
When elasticity of the lens
is reduced thus eye cannot
accommodate for near
vision.
The cilliary muscles that
support the lens become
weak so the lens becomes
less flexible thus more
convex.
Associated with the aging
process
Near vision not complete

53. Clinical manifestations (CM)
Causes difficulty with close vision
Eye strain
Headache
Fatigue
These disappear with eye rest and
use of reading glasses

54. Astigmatism (strabismus)
•A condition where parallel rays of light do not focus
on one point because of the irregular surfaces of
the cornea.
•This makes light to be refracted to focus on two
different points.
•This can result to myopia or hyperopia.
•Causes-can be inherited, can result from corneal
surgery, edema

55. CMs
•Blurred vision,
headache, eye strain,
fatigue
•Problems with both
near and distant
vision
• Corrective measures
•Attempt to make the
surface regular e.g
through reconstructive
surgery
•If not possible, use of
corrective lenses

56. INFLAMMATORY EYE DISORDERS
•Conjunctivitis
•Hordeolum (internal-chalazion & external-stye)
•Trachoma
•Corneal ulcer
•Uveitis
•Blepharitis

57. Conjunctivitis
Inflammation of Conjunctiva caused by:-
Irritants eg smoke, dust, wind, cold, dry air
Microbial eg staph, strep, pneumococci,
herpes, viral
Allergy eg dust, animal, cosmetics, soaps
They are two types:
Infectious
Allergic
In neonates?..............

58. Conjunctivitis – s/s
•Photophobia
•Redness
•Pain
•Itching
•Edema
•Tearing
•Feeling of a foreign body
•Discharge (Purulent/mucoid / both)

59. Bacterial Conjunctivitis
• Common, especially
in children
Lids stuck shut in
morning

60. Adenoviral Conjunctivitis
•Highly contageous
•Lymphadenopathy
•Causes Keratitis

61. Allergic Conjunctivitis
• Lid edema

62. Conjunctivitis - Rx
•Ass the cause to form the base of mgt
•R/o FB (foreignbody)
•For bacterial A/b – systemic/local depending on
severity. E.g Moxiclucloxacillin, Bacitracin and
Erythromycin
•Swab = c/s
•Viral – it’s highly contagious but self limiting
(epidemics)
•Hygiene measures

63. External Hordeolum (Stye)
Infection of the sebaceous gland of the eyelid
and could also affect an eyelid follicle.
Caused by Staph aureus

64. CONT’
CMs
Affected eye swells,
acute pain, Reddens,
edema of localized
area and localized
itchness
Untreated ruptures
to release the pus
then resolve
spontaneously
• MX
•Warm compressions of
saline to promote
comfort and decrease
edema-this may initiate
drainage
•Topical A/bs BD is
important
•Analgesics

65. Mx-CONT;
When failed I &D
can be done to non-
resolving lesions i.e if
stayed for more than
48 hrs

66. Internal hordeolum (Chalazion)
•Deeper, chronic, painless granulomatuous (cyst-
like) swelling of eyelid. It is benign
•Due to blocked sebaceous gland

67. CONT;
•If due to infection, Staph aureus– it is presents
with reddens and inflammation.
•It can cause blockage of the tear gland because it
is deeper-rooted. When it swells it presses on
the cornea which can result to blurred vision

68. MX
•Resolves spontaneously, but removed (I & D)
Surgically under Local anesthesia if severe
•Conservative mx i.e warm compressions to
increase blood circulation
•Topical antibiotics

69. Blepharitis
•Inflammation of
eyelids (anterior or
posterior)
•Cause-
Staphylococcal
infection

70. CONT’
Symptoms
•Itching
•Burning
•Crusting
•Dry eye sensation
•Foreign body sensation

71. Signs
•Crusts on lid
margins
•Thickened,
reddened eyelids
•Plugged or
inspisated(thicken
ed) meibomian
glands along
eyelid
Treatment
•Warm compresses,
10 minutes 1-2
x/day-relieves
inflammation,
removes debris
•Artificial tears
•Erythromycin
ointment
•If infection persists,
use topical steroid to
relieve the
inflammation

72. TRACHOMA
•Chronic inflammatory condition of the conjunctiva &
cornea caused by Chlamydia trachomatis (subtype A, B,
C) (D-K in newborns)
•Fibrous tissue forms in the conjunctiva & cornea, leading
to eyelid deformity & blindness
•Transmission – Flies, Fingers, Formites (towels etc)
•In Dry, Dusty & Dirty and in crowded areas
•It is the leading cause of preventable blindness in the
world
•Causes 10% of all blindness in Kenya

74. Stages of Trachoma
TF – Trachomatuous Follicles
TI – Trachomatuous Inflammation
TT – Trachomatuous Trichiasis (eyelid invert, eyelashes
rub on the cornea leading to corneal ulcer)
TS – Trachomatuous Scar
CO – Corneal opacity (ulcers “healed”)
NB/ It is a poor man’s d’se that can ruin the economy of
a country.
Takes 10yrs+. Mild infection disappears in 3-4 wks.
It recurs causing scaring of the conjunctiva and cornea
thus visual impairment

75. Stages of Trachoma
TF TI
TT TS

76. S/S
•It’s bilateral
•Inflammation of conjunctiva, reddening
•Excessive tearing, irritation
•Sensitivity to light
•If not treated it causes thick discharge and pt
complains of pain
•Repeated episodes cause scarring and eventually
blindness

77. Trachoma – Mx
•Topical A/bs therapy e.g TEO
•Oral Azithromycin is the drug of choice as a
single dose given together with TEO or
Erythromycin ointment or drops
•Educate community
•↑↑↑ Hygiene
•↑↑↑ water supply since re-infection is
common
•May need medical screening and mass Rx
•Sergery( sx) -grafting of the cornea because
of scarring

78. Corneal Ulcers/Keratitis
•Breach in the corneal epithelium leading to
inflammation
•Superficial one heal fast without scar, but
deep lead to scarring + opacity
Dendritic (viral) ulcer

79. Causes
•Trauma – sergery, chemicals, injuries
•Infection (Bacterial most common) – central
ulcers, Fungal – central + satellite ulcers, Viral –
dendritic
•Inappropriate use of contact lenses
•Decrease in quality and quantity of tears
•Lowered immunity is a risk factor

80. CONT’
2 types of Corneal Ulcers/Keratitis;
Microbial
Exposure-develops when the cornea is
inadequately moistened leading to corneal
drying.
Risk factors; Exophthalmia, paralysis of the facial
nerve (bell’s palsy), comatose pts with their
eyelids open or even anaesthetized pts

81. Corneal Ulcers – S & S
Pain+++
Ulcer
Photophobia+++
Blepharospasm
Tearing
Sensation of a foreign body
Hypopyon ulcers – pus in the anterior chamber
due to an ulcer
Perforation of cornea in advanced stages
NB/ Perforation and scarring are the major causes
of blindness

82. Corneal Ulcers - Mx
•Prevention of foreign bodies
•Confirm ulcer/type
•Analgesics
•Pad eye - ↑epithelisation, pt can’t rub
•Antibiotics (a/b) – do c/s
•Atropine – paralyses ciliary muscles whose
spasms cause more pain
•Prompt Rx of corneal scratches
•Warm water compressions to relieve
inflammation

83. Cont;
•Encourage pt to wear dark glasses
•If has Hypopyon – give subconjunctivival a/b
•Sx - corneal transplant (Keratoplasty)
(Hypopyon is a medical condition involving
inflammatory cells in the anterior chamber of the
eye. It is an exudate rich in white blood cells, seen
in the anterior chamber, usually accompanied by
redness of the conjunctiva and the underlying
episclera).

84. KERATOPLASTY
Also known as corneal transplantation.
Involves removal of the damaged tissues of the
cornea and replacing it with a live human cornea
or a candever.
Indications
Severe visual impairment with irreversible
damage
Corneal opacity due to scarring, chemical burns

85. CONT’
There are two types;
1) Penetrating-a full thickness graft where all the
layers of the cornea are replaced
2) Lamellar graft-a partial thickness graft which is
done when only a small size of the cornea is
damaged.
It is an elective surgery.
Preop care
Preparation of the recipient’s eye; conjuctival
swabbing, instilling A/bs for prophylaxis, shaving or
cutting of the eye lashes

86. Intraop care
•Done under LA. Takes 1-2hrs
•A sterile field is created around the opacity and
cornea is removed.
•The donor’s cornea is then removed so that it
exactly fits the removed cornea
•Ultrafine sutures are then used to make tight
sutures for both donor and recipient

87. Postop care
•Monitor the pt and instruct them to avoid
activities that increase(intra occular pressure)
IOP as this can cause retinal damage and damage
the graft. Can also cause loss of aqueous humour
through the stitches
•The nurse should be cautious with this; e.g
coughing, sneezing, lifting heavy objects,
straining during defecation
•Encourage increase of fluid intake, give laxatives
sometimes

88. CONT’
•Encourage pt to rest the eye so that healing can
progress smoothly. Bed rest with assistance to the
washrooms is ideal
•Tell pt that healing is slow
•To prevent infection;
Observe asepsis during procedures
Provide pt with contact lenses to protect suture
lines
You can also provide eyeshields to protect the
suture lines while sleeping
Ct A/bs

89. Postop Cont’
•Pain control
•Cycloplegics can be used to dilate the pupils
which prevents formation of adhesions thus
promoting comfort
•Topical steroids to relieve inflammation and
promote comfort
•Comprehensive pt education to prevent foreign
bodies and activities that increase ICP/IOP

90. CONT’
•Use of lenses to protect cornea
•NB/ sutures are removed after 6 months
onwards and contact lenses or glasses are
prescribed

91. ASSIGNMENT
•Read and make notes on;
•Choroiditis
•Keratoconus

92. Uveitis
•Inflammation of the uveal tract (Iris, Ciliary
body, Choroid)
•Anterior uveitis – iris + cilliary body
•Posterior uveitis - choroid

93. Uveitis

94. Uveitis-causes
•Autoimmune disorders e.g ankylosing
spondylitis, sarcoidosis, toxoplasmosis
•Herpes zoster virus, ocular candidiasis,
histoplasmosis, herpes simplex virus, TB and
syphyllis

95. Uveitis – S & S
•Photophobia
•Pain
•Irritation
•Blurred vision
•Redness
•Complications – Glaucoma, cataracts, retinal
detachment, macular degeneration

96. Uveitis-MX
Wear dark glasses due to photophobia
Local corticosteroid drops to decrease
inflammation
If recurrent, a careful hx should be taken to
discover any underlying causes

97. Retinitis
Inflammation of the retina.
Most common cause is Cytomegalovirus.
Associated with AIDs
S/S
Floaters (spot in vision e.g.black/grey specks)
Decrease in peripheral vision
Paracentral or central scotoma (blind spot)
Fluctuations in vision
Retinal hemorrhage

98. MX
•Ganciclovir (cytovene)
•Foscarnet (Foscarvir)
•Cidofovir (Vistide)

99. OTHER EYE CONDITIONS
Retinal detachment
•This is the detachment of the retina from the
underlying choroid layer.
•It’s a medical emergency
•Risk for occurrence increases with age. More
common after 40 yrs
•When detached, blood vessel that supplies
nutrients to the retina will be cut and so retinal
cells will be deprived of oxygen & nutrients

100. CONT’
It’s painless but warning signs are;
Sudden appearance of floaters in the eyes
Sudden flashes of light in one or both eyes
A shadow or a cutting of a portion of a visual
field
If on the macular area, there is loss of central
vision and the client is emotionally distressed
Sudden blurring of vision
We’ve primary and secondary

101. Primary
This occurs when there is one or more breaks in
the neurosensory layer allowing the aqueous
humuor to collect between the pigmented layer of
the retina and the choroid.
This causes the photosensitive layer of the retina
not to function leading to loss of sight
Causes
Aphakia (missing lens) e.g, congenital, trauma or
surgery i.e. cataracts operation
Vascular diseases like HTN, Retinal degeneration

102. CONT’
Recent or previous trauma to the eye
High myopia (high degree nearsightedness)
Secondary
Occurs when there is separation of the layers
which results in pulling or pushing of the pigment
layer away from the neurosensory layer
Causes
Scar formation
Pressure from intraocular tumours or hemorrhages

103. CONT’
•Diabetic retinopathy
•Severe HTN
•Toximia in pgcy (PET)
•Intraoccular inflammation
•Previous retinal detachment even in one eye
•Family hx of retinal detachment

104. MX
Dx –is by use of an ophthalmoscope or U/S
Prompt care, surgery to repair
Bed rest to promote ocular rest, prevent
straining of the retina and further detachment
Bilateral eye patching-rests the eye

105. SX MX
The aim is to return retina to its position, seal
breaks and remove any fluid in layers.
1) Sclera buckling-silicon is inserted into the
sclera and it seals the break. This reduces
traction on the retina (Risk for diplopia,
myopia and post-op pain)
2) Laser photocoagulation-Seals the break
between the two layers (Laser- use of
electromagnetic radiation)
3) Pneumatic retinopexy-a gas bubble is inserted
into the vitrous cavity(middle of eyeball) using
LA

106. CONT;
The gas expands, pushing against the walls and
they are brought together. The gas will disappear
after several weeks(1-3)
4) Vitrectomy-a syringe is injected into the aquoes
humour and fluid is withdrawn and the two layers
come into apposition

107. Preop care
Complete bed rest to avoid disturbing the eye
Eye patching to avoid movement
Mydriatics /to dilate the pupil( e.g. atropine,
mydrilate, homatropine, phenylephrine) etc.
Prophylactic A/bs and antianxiety drugs
Postop care
Ct A/bs, Cycloplegics to prevent adhesion. e.g
altafrin,cyclogyl, cyclomydril etc.
Analgesics
Compressions over the eye

108. CONT;
Encourage progressive ambulation
Pt teaching-avoidance of activities that
increase ICP/IOP, hygiene, need for ambulation
Complications
Eye could fail to reattach and eventually
blindness
Secondary infection
Increased IOP which can result to glaucoma

109. Cataracts
Partial/complete opacification of the lens
Cause 50% of blindness in Kenya and is the
leading cause of blindness in the world. Not
preventable but can be corrected


110. CONT’
•Congenital – in utero !!infection (esp Rubella).
Most common. Also cause Microphthalmos
•Acquired – (senile cataract) after 50yrs+. 20 to
uveitis, DM, Trauma, UV, steroids

111. Classification
Nucleic cataract-forms in the nucleus at the
center of the lens. Most common. Common in the
elderly
Cortisol cataract- starts at the cortex but extends.
Common among DM pts
Subcapsular cataract- begins at the back of the
lens. Common in HTN, DM, retinitis, and in
prolonged use of corticosteroids
Causes/risk factors
Congenital, Aging process, trauma, systemic d’ses
e.g DM, Lifestyle e.g alcohol and smoking, long use
of corticosteroids

112. Cataract – S & S
•Painless and so very gradual loss of vision (3
yrs+)
•Vision is distorted, blurred & hazy
•Glare with bright lights
•Change in colour perception

113. Cataract - Mx
The ultimate mx is surgical removal of the
cataracts. There are two types;
•Intracapsular Cataract Extraction (ICCE)
•Extracapsular Cataract Extraction (ECCE)
•PhacoEmulsification

114. ICCE
•Removal of the whole lens. Vision corrected
by thick glasses / contact lenses

115. ECCE
•Removal of part of the lens material then
put an artificial (intraocular) lens implant

116. ECCE

117. PhacoEmulsification
Carried out through a small (2.5mm to 3mm),
self-sealing incision.
A high frequency ultra-sonic probe emulsifies or
breaks the nucleus into small fragments and sucks
the microscopic particles of the nucleus material
out of the eye.
A specially designed foldable intra-ocular lens
(IOL) is then inserted, providing a permanent and
safe replacement for the natural lens.
This surgery is performed under local
anesthesia.

118. Complications
•Loss of vision
•Double vision
•Retinal detachment-occurs when fluid sips
through a tear in the retina. The sippage causes
the retina to detach from the back of the eye

119. Glaucoma
•Increased Intraocular pressure
(IOP) within the eye ball,
causing gradual loss of sight.
•Damage done to the IO
structures esp the optic nerve &
arteries due to increased
Intraocular pressure
•Causes 20% of blindness in
Kenya. It’s the 3rd leading cause
of blindness after cataracts and
trachoma
•It’s a silent thief of sight

120. Cardinal s/s
•Increased IOP ( measered using Goldmann
application tonometry)
•Cupping and atrophy of the optic nerve
•Visual field loss

121. Congenital Glaucoma
•Malfunction of the angle (b/w iris & cornea)
•Ciliary body continues to produce aqueous
humour, but the trabecular meshwork does not
absorb it into the canal of schlemm then to the
venous flow
•Eyeball ballons & appears grey/blue –
buphthalmos (bull’s eye)
•Photophobia, Tearing, Pressure >25mmHg

123. Adult Glaucoma
•Primary (idiopathic)-Open / Closed angle
•Secondary
•Trauma
•Uveitis
•Tumour
•Haemorrhage
•DM
•Old age

124. Open Angle Glaucoma
•The angle is open and so there is free flow
•Due to sclerosis of the trabecular meshwork – no
absorption of aqueous humour

125. CONT;
•Occurrence increases with age
•Gradual and painless, unilateral
•↓ peripheral visual acuity (tunnel vision
hence stab into objects)
•↓ visual fields-
•↑ IOP
•Damage to the optic nerve

126. Closed Angle Glaucoma/angle closure
glaucoma
•The angle b/w the iris & cornea is narrowed or
blocked.
•It’s an emergency
•No absorption → ↑ IOP
•Sudden
•Painful - +/- N/V
•Cornea oedematuous, red
•Headache

127. Causes/ risk factors
•Iris plateau-iris is attached to the ciliary body
too close to the trabecular meshwork
•Hyperopic pts (have shallow ant chambers &
narrow angles)
•Age-lens tends to enlarge putting pressure on
the iris
•People who work in dark envis
•Gender-common in men
•Race-eskimos have narrow ant chambers

128. Glaucoma - Mx
Type!!-goals to maintain IOP at normal levels
Drugs - ↑ drainage or ↓ production eg
 Blockers(preffered initial therapy)-decrease the
amount of aquoues humour produced eg Timolol
Miotics(cholinergics)-cause constriction of the
pupil and open the trabecular meshwork thus
increase outflow of aquoes humour eg
pilocarpine

129. CONT’
Adrenergic agonists-reduces production of
aqueous humour & increases outflow e.g
adrenaline(epinephrine)
Carbonic anhydrase inhibitors decrease the
amount of aquoeos humour produced eg
Acetazolamide
Analgesics
Osmotic diuretics- draw fluid from eye by
osmosis e.g mannitol

130. CONT’
Sx- done when others have failed
•Trabeculectomy (open)- a small part of
trabecular meshwork is removed
•Cyclophotocoagulation-it’s laser surgery
where some parts of the ciliary body are
frozen and so reduced production
•Iridectomy (closed) or
•Iriodotomy (closed) removal of the part of the
iris ( therapy for closed glaucoma).
Complications; Blindness

131. Tumours of the Eye
•Retinoblastoma – congenital malignant
neoplasm found in children. Spreads easily to
the brain
•Malignant Melanoma – in Iris & choroid.
Grows slowly but metastasizes to the liver &
lungs
•Basal cell carcinoma-It’s malignant found on
the eyelid margin. Spreads to the surrounding
tissues and grows slowly but does not
metastasize

132. Tumours - S & S
•Headache
•Visual Complaints
•↓ vision
•Retinoblastoma – white pupillary reflex,
strabismus(misalignment), retinal
detachment

133. Tumours - Mx
•Cytotoxics
•Radiation
•Enucleation…? means

134. Nursing Management
Educate on proper eye care
Hand wash
Avoid rubbing
Rx as prescribed
Post-op
Avoid valsalva maneuver ?
Educate!!
Enucleation – pressure dress, artificial eye
Support + family therapy

135. CONT’
•Nystagmus
•Constant involuntary movt of the eye
•Read and make short notes……..

136. CONGENITAL ABNORMALITIES
•Strabismus/misaligned eyes
•squint / cross eye. Eyes unable to be
directed to the same object. Weakness of
Extra-ocular muscles or defective nerve
supply esp. CN III but also IV , VI

137. CONT’
one or both eyes turn in, out, up or down
caused by muscle imbalance
• 3 Kinds of Strabismus
–Esotropia
–Exotropia
–Hypertropia
–hypotropia

138. i) Esotropia
Eye turns in towards nose

139. Types of Esotropia
Infantile (congenital)
Develops in first 3 months of life
Surgery usually recommended along with
vision therapy and glasses
Accommodative
Usually noted around age 2yrs
Child typically farsighted
focusing to make images clear can cause eyes to
turn inward.
Treated with glasses and vision therapy may also
be needed

140. ii) Exotropia
•Eye turns outward; Congenital; Surgery usually
needed to re-align. Many exotropias are
intermittent
•May occur when patient is tired or not paying
attention
•Concentration can force eyes to re-align
•Vision therapy and/or glasses can help

141. iii) Hypertropia
•One eye vertically misaligned usually from
paresis of an extra-ocular muscle

142. BLINDNESS
•Anything that disrupts the passage of light from
the envi to the back of the eye and from the
back of the eye (retina) to the brain.
•Visual acuity of 20/200 and use of corrective
glasses and contact lenses have failed.

143. CAUSES
When light cannot reach the retina e.g in
damage of the cornea, infections that cause
corneal scarring, vit A deficiency which causes
dryness of the cornea and consequently
opacities
When light rays don’t focus on the retina
properly e.g in severe myopia
When retina cannot sense the light rays e.g in
retinal detachment
When nerve impulses from the retina are not
transmitted to the brain e.g in brain tumors

144. CONT’
•When there is inadequate blood supply to the
retina e.g retinal detachment
•Inflammation of the optic disc
• When the eye could be normal but the brain
cannot interprete information sent by the eye
e.g in brain tumor, SOLs

145. SAFETY MEASURES/HEALTH EDUCATION
FOR PREVENTION OF BLINDNESS
•Educate the community on good eye hygiene like
use of tissues on both eyes together
•Routine eye check up to detect problems early
•Prevention or mgt of conditions that may
complicate or are risks for eye problems e.g DM,
HTN
•Community screening
•Proper use and care of contact lenses

146. CONT’
•Occupational safety
•Prevention of eye trauma
•Taking a balanced diet

147. •END