The document discusses vision in older adults, describing age-related changes to vision, common eye diseases such as cataracts and glaucoma, and the importance of assessing vision in older patients. It covers topics like the anatomy of the eye, normal age-related changes to vision, visual impairments that increase with age, diseases affecting vision, associated signs and symptoms, and nursing considerations.
Aphakia and its causes. Correction of Aphakia. Advantages and disadvantages of different corrections. Surgeries and related signs and symptoms of aphakia. Complications related to Aphakia.
Aphakia and its causes. Correction of Aphakia. Advantages and disadvantages of different corrections. Surgeries and related signs and symptoms of aphakia. Complications related to Aphakia.
Management of visual problems of Aging by Ashith Tripathi Ashith Tripathi
This presentation contains headings - Visual performance in the ageing eye
Routine optometric and ocular examination of an older adult:
History
Ocular health examination
Visual acuity measurement
Refraction
Binocular vision
Visual field measurement
Colour vision
Management of vision problems in older adults
Frame requirement
Lens requirements
And special instructions etc.
Management of visual problems of Aging by Ashith Tripathi Ashith Tripathi
This presentation contains headings - Visual performance in the ageing eye
Routine optometric and ocular examination of an older adult:
History
Ocular health examination
Visual acuity measurement
Refraction
Binocular vision
Visual field measurement
Colour vision
Management of vision problems in older adults
Frame requirement
Lens requirements
And special instructions etc.
From International Life Sciences Institute discussion organized by ILSI Europe: "The Aging Brain" by Dr. S. Kergoat, 19 ~ 20 January 2015 in Chandler, Phoenix, Arizona
It extends from the etiology to the management measures. A little effort to make people understand LOW VISION. Vivek Chaudhary, Christian College BSc Optometry, Bangalore. Frm NEPAL, LAHAN
This was a lecture in the course "Significant Medical Conditions in Seniors" presented at Peer Learning in Chapel Hill, NC, USA in 2016 by Michael C. Joseph, MD, MPH.
Macular degeneration is an eye disease and is the most common type of macular damage in adults. Because the disease develops as a person ages, it is often known as age-related macular degeneration (AMD).
Optometric examination and management of geriatric problems.pptxAnisha Heka
Normal age related changes
Common pathological changes with age
Optometric examination of geriatric population
Complications in examination of older patient
Vision Corrections in older patient
This Module will help the learners to understand the best about Low vision in General.This will also help and guide Educators to make up more things regarding Low Vision and its introduction.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
1. Vision in Older Adults
NURS 4100 Care of the Older Adult
Spring 2014
Joy A. Shepard, PhD(c), MSN, RN, CNE
1
2. Objectives
Describe assessment of vision in the older adult
Explain the importance of sensory function and the impact
of sensory deficits on older adults
Describe the effects of aging on visual function
List measures to promote healthy visual function in older
adults
Identify signs and symptoms and nursing interventions for
older adults with cataracts, glaucoma, macular
degeneration, and detached retina
2
3. Key Terms
Cataracts - Opacity of eye lens that reduces visual acuity
Glaucoma – Eye disorder characterized by increased
intraocular pressure; can lead to irreversible damage to
optic nerve with loss of peripheral vision
Macular Degeneration- Atrophy of cells in central macular
region of retina
Presbyopia - Universal age-related change in lens of eye
involving loss of accommodation. Objects held closer than
1 or 2 ft become difficult to see
3
5. Introduction: Sensory Function
Taken for granted
Protection from harm
Accurate perception of environment
Essential to communication
Sensory deficits compound other problems that
threaten health, well-being, and independence
5
6. Sensory Dysfunction: Personal
Cost
Functional impairment
Loss of independence
Injury
Social isolation
Depression
Decreased quality of life
6
10. Interview
Adequacy of vision
Recent changes vision
Date of last exam
Inspection
Movement of eyelids
Abnormally colored sclera
Unequal or absent pupillary
response
10
11. Interview – Visual Problems
Red eye
Excessive tearing/ discharge
Foreign body sensation
Headache, eyestrain when reading or
doing close work
New onset
Double vision, rapid deterioration visual acuity
Haziness, flashing lights, moving spots
Loss central/ peripheral vision
Trauma or eye injury
11
15. Normal Age-Related Changes of
the Eye
Changes are gradual
Over time can limit functional
ability
Common eye disorders in the
elderly are NOT normal:
cataracts, glaucoma, macular
degeneration, & retinopathy
15
16. Normal Age-Related Changes of the
Eye: External Changes
Graying and thinning eyebrows
and eyelashes
Subcutaneous tissue atrophy
wrinkling + thinning of skin around eyes
Decreased orbital fat sunken eye
appearance + sagging eyelids
Atrophy lacrimal glands Dry eyes
(saline drops)
16
17. Normal Age-Related Changes of the
Eye: Internal Changes
Reduced elasticity of lens; decreased ability of the lens
to accommodate
Decreased ability to focus on close objects (presbyopia)
Accommodation is the process by which the eye changes
optical power to maintain a clear image (focus) on an object
as its distance changes
17
22. Normal Age-Related Changes of the
Eye
Visual acuity (sharpness of vision)
Diminishes gradually after age 50
Decreases rapidly after age 70
Light sensitivity declines
Brightness contrast
Dark adaptation
Recovery from glare
22
23. Clinical Implications
Difficulty reading small print
Narrowing of field of vision
Decreased light to retina
Sensitivity to glare
Decreased night vision
Difficulty with depth
perception (going down stairs)
Increased risk for FALLS!
23
27. Question
The nurse is assessing a patient who has just been
tested for visual acuity and was told his vision is 20/50.
The patient asks what this means, and the nurse
answers:
A. “You can see approximately 2/5 as well as the normal person.”
B. “You can see at 20 feet what a person with normal vision sees at 50
feet.”
C. “Your vision is the same as a 20-year-old man, even though you are
50.”
D. “You can see at 50 feet what a person with normal vision can see at
20 feet.”
27
30. Cataracts
NOT a normal part of aging process
(though very common with aging)
Most cataracts are related to aging
Lens clouding decreased light to
retina limited vision
Oxidative damage or cross linking
Slow and painless
Leading cause of low vision in older
adults
> 50% of adults > 65 years have
cataracts visual problems
30
32. Cataracts: Symptoms
No pain or discomfort
Hazy or blurred vision (most
likely)
Glare, photosensitivity
Halos around objects
Double vision
Lack of color contrast or
faded colors
Poor night vision
The Symptoms of Cataracts
32
37. Cataracts: Risk Factors
Increased age
Smoking and alcohol
Diabetes, hyperlipidemia
Trauma to the eye
Exposure to the sun and UVB rays
Corticosteroid medications
Risks of Cataracts
37
38. A. Simulated vision with cataracts.
B. Normal vision.
(From National Eye Institute, National Institutes of Health, 2004.)
38
39. Cataracts: Tx & Nursing
Strategies
Surgery only cure
Outpatient procedure: relatively few
complications
Removal of lens
Insertion of intraocular lens implant (distorts
vision less than special cataract glasses do)
Cataracts Treatment
39
41. Cataract Surgery – Postoperative
Instructions
Day of surgery
Eye shield
First 2 weeks
HOB 30°, lie on back or
unaffected side
Eye shield at night
Eye drops
Mild aches, scratchiness,
itchiness
Tylenol; NO aspirin, ibuprofen
Do not rub, touch area
Avoid bright sunlight
Avoid activities ↑ IOP
Caring for Eyes after Cataract Surgery
Wrap-around sunglasses
Sneezing, coughing, vomiting,
straining, bending, lifting > 5 lbs
Prevent constipation (fiber,
fluids, mobility, stool softener)
Avoid heavy work, such as
gardening, mowing the lawn, or
moving furniture
Avoid water in eye (tap water,
shower, tub, etc)
41
42. Cataract Surgery – Postoperative
Instructions
Symptoms to report
Pain not relieved by Tylenol
Changes in vision
Decreased vision, redness, cloudiness, drainage, floaters or light flashes,
curtain over vision, severe eye pain or pressure
Complications
Infection
Wound dehiscence
Hemorrhage
Severe pain
Uncontrolled, elevated intraocular pressure
Cataracts Surgery Complications
42
43. Education Regarding Cataract
Prevention
Wearing hats and
sunglasses when in
sun
Smoking cessation
Avoid steroids
Low-fat diet
Avoid ocular injury
How to Prevent Cataracts
43
44. Question
Which of the following statements indicates that
the client has understood home care instructions
following cataract surgery?
A. “I should not bend over to pick up objects from the floor.”
B. “I can sleep on whichever side I want as long as my head
is raised.”
C. “I may not watch television for 6 weeks.”
D. “I should keep the protective eye shield in place 24 hours
a day.”
44
46. Glaucoma
Degenerative eye disease
Second leading cause of blindness in U.S.
10% vision loss in U.S.
Primary cause of blindness among AA
What is Glaucoma
Glaucoma Prevalence
46
47. Glaucoma
Optic nerve damaged by pressure
Increase in intraocular pressure (IOP)
optic
nerve damage peripheral vision loss
IOP > 21 mm Hg
“Sneaky thief of sight”
Causes of Glaucoma
47
50. Simulated Vision with Glaucoma
(From National Eye Institute, National Institutes of Health, 2004.)
50
51. Chronic (Open-Angle) vs Acute
(Angle-Closure) Glaucoma
Chronic (also called open-angle)
More common than acute, 90%
Slowed flow of aqueous humor through trabecular
meshwork build up increased IOP damage
to optic nerve loss of vision
Painless vision loss
Peripheral
visual field loss
Types of Glaucoma
51
55. Chronic Glaucoma: S/S
Peripheral vision slowly impaired
Tired eyes
Headaches
Misty vision
Colored rings/ halos around lights
Worse symptoms in morning
Usually involves one eye, but may be both
Glaucoma Symptoms
55
59. Topical Eyedrops
Beta-blockers (Betagan, Timoptic, Ocupress) – Bottles
with blue or yellow caps
1st line therapy for glaucoma
Lowers IOP by decreasing formation of aqueous humor
SEs: Bradycardia, hypotension, bronchospasm, confusion
Prostaglandin analogues (Xalatan, Lumigan)
Increases outflow of aqueous humor
SEs: Stinging, burning, darkening of eye
Glaucoma Help In A Drop
59
60. Topical Eyedrops
Alpha-Adrenergic Agonists (Iopidine,
Alphagan, Epinal) – Bottles with purple caps
Lowers IOP by decreasing formation of
aqueous humor
Avoid use in acute angle-closure glaucoma
SEs: Palpitation, hypertension, tremor,
sweating
60
61. Topical Eyedrops
Miotics/ cholinesterase inhibitors (pilocarpine,
Humorsol) – Bottles with green caps
Facilitates outflow of aqueous humor
SEs: Decreased night vision, bronchospasm,
sweating, salivation, lacrimation, diarrhea
Carbonic anhydrase inhibitors (Trusopt, Azopt) –
Bottles with orange caps
Decreased formation of aqueous humor
61
62. Question
A client with open-angle glaucoma is receiving
brinzolamide (Azopt) for treatment. When assessing the
client’s response to the medication, the nurse expects
therapeutic effects to be the result of the following?
A. A decrease in the outflow of aqueous humor
B. An increase in the outflow of aqueous humor
C. A decrease in aqueous humor production
D. An increase in aqueous humor production
62
63. Acute (Angle-Closure) Glaucoma
Acute (angle-closure, closed-
angle, narrow-angle)
Not as common
Angle of iris obstructs drainage
of aqueous humor through
trabecular meshwork
increased IOP visual
changes
May occur suddenly
Ophthalmic emergency!
63
65. Acute Glaucoma: S/S
Severe unilateral eye pain or headache
Blurred vision
Nausea and vomiting
Photophobia
Colored halos around light
Red eye
65
66. Acute Glaucoma
Sudden S/S: eye pain,
HAs, halos around lights,
dilated pupils, vision loss,
red eyes, N & V
May last for a few hours,
return again
Each attack takes part of
field of vision
66
67. Acute Glaucoma: Tx & Nursing
Strategies
Diagnosis
Tonometer to measure IOP
Normal IOP is 20 mm Hg or below
Gonioscopy (direct exam)
Medications (to decrease pressure)
Permanent vision loss within 2 – 5 days if untreated
Surgery: iridotomy (lowers IOP) to prevent future
episodes
67
68. Risk Factors for Glaucoma
Increased intraocular pressure
Older than 60 years of age
Female gender
Family history of glaucoma
Personal history of myopia, diabetes,
hypertension, or migraines
African American ancestry
Who's at Risk of Developing Glaucoma
68
70. Glaucoma: Contraindicated
Medications
Cold remedies with Pseudoephedrine or Phenylephrine
(Neo-Synephrine)
Antihistamines such as Chlorpheniramine (ChlorTrimeton) or Diphenhydramine (Benadryl)
Overactive bladder remedies – Tolterodine tartrate
(Detrol)
Tricyclic antidepressants – Amitriptyline (Elavil)
Cyclobenzaprine (Flexeril)
70
71. Question
Is the following statement true or false?
Patient adherence with treatment for glaucoma
can be a problem in the older adult population.
71
73. Age-Related Macular
Degeneration (ARMD)
Most common cause of
blindness adults > 65
Degeneration of macula,
(sharpest central vision)
Scotoma – central vision
Visual acuity
Central vision
Seeing objects clearly
Common daily tasks (reading
and driving)
Managing Macular Degeneration
73
74. ARMD: Symptoms
Painless
More light required for
reading
Central scotomas – blind
spots
Blurry
Bent, warped images
Words on a page may
appear distorted or
incomplete
Metamorphopsia –
images look smaller
(micropsia) or larger
(macropsia) than they
actually are
Dark, foggy or light spots
The Signs of AMD
74
75. A. Simulated loss of vision with age-related macular
degeneration (AMD). B. Normal vision.
(From National Eye Institute, National Institutes of Health, 2004.)
Helping Macular Degeneration
75
77. ARMD: Two Types –
Dry & Wet
Dry (atrophic,
nonexudative form)
10-20% severe vision loss
Atrophy
Retinal pigment
degeneration
Drusen accumulations
90% ARMD this type
Better prognosis, slower
progression
77
78. ARMD: Two Types –
Dry & Wet
Wet (Neovascular exudates)
Blood or serum leak from newly
formed blood vessels beneath
retina scar formation + visual
problems
10% this type
More sudden onset
More severe vision loss
Learn about Wet AMD
78
80. Risk Factors for ARMD
Age (above 50)
Female gender
Caucasian race and light (blue) colored eyes
Family history of ARMD
Cigarette smoking
Ultraviolet light (sunlight)
HTN, high cholesterol, cardiovascular disease
Lack of dietary intake of lutein; antioxidants and zinc
How to Prevent Macular Degeneration
The Risks of Smoking and Macular Degeneration
80
81. ARMD: Tx
No cure at present
New research:
Photodynamic therapy uses a special laser to seal
leaking blood vessels in the eye
Antioxidant vitamins (C, D, E, and Beta-carotene),
lutein, & zinc may slow progress of disease
Retinal cell transplantation or regeneration
New Macular Degeneration Treatment (just an example)
81
82. Age-Related Macular Degeneration
(ARMD) Preventive Measures
Nurses should encourage
Routine ophthalmic examinations
Wearing UV protective lenses in sun
Smoking cessation
Exercising routinely
Eating a healthy diet consisting of fruits
and vegetables
82
83. ARMD: Nursing Strategies
(p.365, Box 26-2)
Magnifying glasses
Reading lamps
Low-vision assistive devices
Modify environment
Avoid glare
Use contrasting colors
More auditory input (books on tape, etc.)
Decrease controllable risk factors
(smoking, UV exposure)
How to Deal with Losing Sight
83
84. Question
Which type of visual problem is
associated with macular degeneration?
A. Loss of peripheral vision
B. Loss of central vision
C. Perception of spots moving across the eye
D. Pain with movement of the eye
84
91. Promoting Visual Safety in Home
Provide adequate lighting in high-traffic areas
Stair rails, non skid surfaces
Use contrast when painting
Avoid reflective floors
Signs – bright colors such as red, orange, yellow
Use red-colored tape or paint on edges of stairs and
entryways
Avoid complicated rug patterns
91
93. Nursing Diagnoses Associated with
Visual Impairment (Table 26-1)
Sensory/Perceptual Alterations: Visual with a
variety of nursing goals and interventions
Communication
Safety
Mobility
Self-care activities
Mood
93
Editor's Notes
Good sensory function is an extremely valuable asset that often is taken for granted. For instance, people are better able to protect themselves from harm when they can see, hear, smell, touch, and communicate.
The reduced ability to protect oneself from hazards because of sensory deficits can result in serious falls from unseen obstacles, missed alarms and warnings, ingestion of hazardous substances from not recognizing bad tastes, an inability to detect the odor of smoke or gas, and burns and skin breakdown because of decreased skin sensation of excessive temperature and pressure.
Intact senses also facilitate accurate perception of the environment. When sensory function is impaired, perception of the environment is distorted (e.g., people might suspect they are being talked about if they are unable to hear the conversation of those around them).
Impaired sensory function affects everyday experiences. For example, poor eyesight can hamper reading the newspaper and recognizing a familiar face on the street. Food tastes bland without properly functioning taste buds. The pleasant experience of smelling freshly cut flowers is low when olfactory functioning is poor.
Finally, sensory function is essential to communication. Social interaction, the sharing of experiences, and the exchange of feelings are more complete when all the senses can participate. Through communication, people share joys and burdens, derive feelings of normalcy, validate perceptions, and maintain a link with reality.
Sensory deficits compound other problems that threaten the health, well-being, and independence of older persons – their increased vulnerability to accidents, their social isolation and declining physical function, and many other limitations regarding self-care activities.
A variety of intrinsic and extrinsic factors, including alterations during the aging process, excessive use and abuse of certain medications, and the disease processes that affect all age groups, contribute to the sensory problems of older adults.
Changes in vision, hearing, smell, taste, and touch occur naturally throughout the aging process.
Gerontological nurses must be aware of the factors that influence sensory function in older adults and help to ensure that sensory problems are properly evaluated and corrected when possible.
Older persons with sensory dysfunction may suffer functional impairment, loss of independence, injury, social isolation, depression, and decreased quality of life.
Impairments in sensory functioning in sensory functioning can greatly alter the capabilities of older adults to complete everyday activities, affecting quality of life and safety. Intact senses allow the older person to accurately perceive the environment and remain appropriately involved with other people, places, and objects.
Safety is compromised when the older person cannot see fall hazards on the floor, cannot smell a natural gas leak from a stove, cannot recognize the taste of spoiled milk, cannot hear a signaling fire alarm, and cannot fell a pebble in the shoe that could lead to a blister or foot ulcer.
A loss of independence, social isolation, depression, and a decreased quality of life can be associated with visual impairment in the older population. Visual impairment increases the risk of falls and fractures, making it more likely that an older person will be admitted to a hospital or nursing home, be disabled, or die prematurely. It is important for the nurse to understand normal versus abnormal changes and how to assist the older adult to improve safety and well-being.
Careful observation of the person’s appearance is the first step when assessing the vision of an older person.
When assessing the vision of an older person, the nurse should first observe the patient’s appearance. Older persons with stains on their clothing, older women with too much or poorly applied makeup, or patients with multiple bumps and bruises may be exhibiting signs of visual impairment.
Older patients should be questioned regarding adequacy of vision, recent changes in vision, visual problems, and the date of their last complete visual examination.
Open ended questions are best.
“Has there been any change in your vision? Please describe?”
“Are your glasses as useful to you as they were when you first obtained them?”
“Do you experience pain, burning, or itching in the eyes?”
“Do you ever see spots floating across your eyes? How often does this happen and how large and numerous are the spots?”
“Do you ever see flashes of light or halos?”
“Are your eyes ever unusually dry or watery?”
“Do you have difficulty with vision at night, in dimly lit areas, or in bright areas?”
“Does anyone in your family have glaucoma or other eye problems?”
The gerontological nurse should inspect the eyes for unusual structure, drooping eyelids, discoloration, and abnormal movement.
Abnormalities: including movement of the eyelids, abnormal discharge, excessive tearing, abnormally colored sclera, and abnormal or absent pupillary response. Black-skinned persons may normally have a slight yellow discoloration of the sclera.
Note any lesions on the eyelids.
In addition to annual or biennial examinations, the gerontological nurse should urge all older persons who complain of a visual problem to seek a visual evaluation if they experience any of the following problems:
Red eye
Excessive tearing or discharge
Headache or feeling of eyestrain when reading or doing close work
Foreign body sensation in the eye
New-onset double vision or rapid deterioration of visual acuity
New-onset haziness, flashing lights, or moving spots
Loss of central or peripheral vision. A blind spot in the visual field (i.e., scotoma) can occur with macular degeneration. A narrowing of the peripheral field may be associated with glaucoma. Blindness in the same half of both eyes (i.e., homonymous hemianopia) can be present in persons who have experienced a cerebrovascular accident.
Trauma or eye injury
The Snellen chart, used to measure visual acuity.
A Snellen chart can be used to measure visual acuity, or the patient can be asked to read from a magazine or newspaper with various print sizes.
Visual field testing can detect blind spots or loss of peripheral vision. If the patient is unable to see letters on the chart or newspaper, estimate the extent of the visual limitation by determining if the patient is able to see fingers held up before him or can merely make out figures.
Ask the patient to follow your fingers as they move from point to point without changing the head position to check extraocular movements. Have the patient follow your finger as you move it to various points horizontally and vertically. Irregular, jerking eye movements can result from disturbances in cranial nerves III, IV, or VI.
The older person with glasses should wear them during the vision assessment.
The healthy older adult should schedule a complete eye examination every year to check visual acuity, the retina, and intraocular pressure. During this examination, visual acuity should be evaluated, pupils should be dilated with examination of the retina, and intraocular pressure should be tested.
Normal age-related changes in vision occur gradually; however, over time these changes can limit the functional ability of the older adult. Approximately 1.8 community-dwelling older people report some difficulty with basic activities such as bathing, dressing, and walking around the house, in part because they are visually impaired. Unfortunately, visual impairment increases with age. Visual impairment is defined as visual acuity of 20/40 or worse while wearing corrective lenses, and legal blindness or severe visual impairment is 20/200 or more as measured by a Snellen wall chart at 20 feet.
The prevalence of blindness also increases with age, reaching its peak at about the age of 85. Fortunately, the prevalence of blindness in both eyes in the United States is low, about 1% among persons 70 to 74 years of age and 2.4% in persons 85 and older. Approximately half of all individuals who are identified as legally blind each year are 65 years of age or older.
Visual impairment and blindness in the older person is the result of four main causes: cataracts, age-related macular degeneration (ARMD), glaucoma, and diabetic retinopathy.
Visual impairment can lead to loss of independence, social isolation, depression, and a decreased quality of life.
Visual limitations can make communication problematic because facial expressions and gestures, which are as important as the words themselves, may be missed or misinterpreted.
Visual impairment increases the risk of falls and fractures, making it more likely that an older person will be admitted to a hospital or nursing home, be disabled, or die prematurely. It is important for the nurse to understand normal versus abnormal changes and how to assist the older adult to improve safety and well-being.
Remaining aware of current events through newspapersand socializationnthrough playin cards and other games may be hampered.
Age-related changes in the eye can impact safety or have no effect on functional capacities in daily life.
Normal changes of the eye related to age including graying and thinning of the eyebrows and eyelashes. Wrinkling of the skin surrounding the eyes occurs as a result of subcutaneous tissue atrophy. The eyes may appear sunken as orbital fat decreases and the eyelids sag.
Darkening and wrinkling of skin around orbits.
Atrophy of lacrimal glands results in dry eyes. Stinging, burning, scratchiness, and stringy mucous are some of the symptoms. Although this may seem surprising, increased tearing may be a symptom of dry eyes. If tear secretion is below normal, excess tears are produced by the lacrimal gland in response to irritation. If no foreign body is found, the condition is called dry eye syndrome. Tear production decreases with age, and menopausal women are most often afflicted. Also, dry eyes may be associated with arthritis and the use of certain medications.
Treatment consists of tear replacement or conservation. Tears can be replaced by instilling an over-the-counter artificial tear preparation to lubricate the eyes and replace missing moisture. Other interventions include use of a humidifier and avoidance of smoke.
Saline drops can bring relief.
One of the most significant areas of changes that occur with age are those affecting vision.
The reduced elasticity of the lens that begins in the fourth decade of life interferes with the ability to adequately focus on close objects. As the lens of the eye becomes less flexible, it is less able to focus. It is the factor responsible for most older people’s requiring some form of corrective lenses; this condition is known as presbyopia.
It is harder to read fine print or see close objects clearly. This is correctable with reading glasses or bifocals.
The diagram shows how light from afar is bent by the stretched lens to strike the retina, and how light from a closer source is bent even more sharply by the relaxed lens to strike the retina.
Accommodation is the ability of the lens to change its focus from distant to near objects.
It is achieved through the action of the ciliary muscles that change the shape of the lens.
Distant image – flat.
Close image – rounded.
The term presbyopia means "old eye" and is a vision condition involving the loss of the eye's ability to focus on close objects. It is a normal change of aging and it happens to everyone as they get older. It is not considered to be an eye disease, like cataracts or glaucoma.
Presbyopia occurs without regard to other eye conditions.
It generally occurs around age 40.The process stabilizes or peaks some 10-20 years later, by approximately age 63 to 65. At that age, there is the need for maximum correction. One loses the ability to see near objects without corrective lenses or corrective surgery.
The cause of presbyopia is a change in the ability of the human lens to change its shape (a process called accommodation) which results in the inability to focus on objects close at hand. As the lens hardens, it is unable to focus the rays of light that come from nearby objects. Individuals typically have difficulty reading small print, such as that in telephone directories and newspaper advertisements, and may need to hold reading materials at arm's length.The loss of pliability in the lens contributes to presbyopia or the decrease in near vision.
The process of the lens losing its elasticity (accommodative ability) begins around age 10, but vision changes aren't noticeable to a person until he/she reaches approximately 40 years of age. Hardening impedes accommodation, the ability of the lens to change shape and focus images clearly.
The eyes' pupils become less able to take in light and less able to adapt to changes in light. By the time a person reaches 60, his pupils decrease to about one-third of the size of when he was 20.
Visual acuity (sharpness) progressively declines due to reduced pupil size and loss of photoreceptor cells in the retina.
The light perception threshold decreases causing difficulty with vision at night and in dimly lit areas. Dark and light adaptation takes longer. Instruct the elder to take the extra time to adjust to the dim light.
Visual changes cause depth perception to become distorted, making the ability to judge the height of walking surfaces more challenging.
The yellowing or slightly cloudiness(opacification) of the lens causes difficulty in distinguishing between blue, green, and violet.
Sensitivity to glare increases.
A decrease in endothelial cells on the cornea reduces ocular sensitivity and pain, which may delay awareness for treatment of injuries and infections.
Arcus senilis is a grayish or whitish arc or circle visible around the peripheral part of the cornea in many older adults. It develops due to lipid deposits. It typically is not associated with a serious underlying condition and doesn't require treatment. This condition is unrelated to hypercholesterolemia or lipid abnormalities except in rare cases.
Increased opacity of lens with yellowing. The lenses thicken and harden and with age and appear yellowish and opaque. Thickening of the lenses can cause light to scatter, and opaqueness of the lenses will interfere with color discrimination. This greatly increases the risk for falls and can make night driving dangerous for the older adult.
Lens thickness also reduces the space for aqueous humor to drain and increases the risk for glaucoma.
Visual acuity is sharpness of vision, especially as tested with a Snellen chart. Normal visual acuity based on the Snellen chart is 20/20.
Visual acuity tends to diminish gradually after 50 years of age and then more rapidly after the age of 70. Visual acuity – decreased reading and color discrimination ability. Wear corrective lenses and use extra light.
Light sensitivity, or the ability to adapt to varying degrees of light, declines with age. With increased age, there is a need for increased light. Three functions are associated with light sensitivity:
Brightness contrast: This is the ability to discriminate between objects in varying degrees of light. Starting at about age 50, more light is needed to see dimly lit objects in shadows on a sunny day.
Dark adaptation: This is the ability to see objects upon entering a dimly lit room after entering from daylight. An older person will not see objects at first, but with time, outlines will become more discernible.
Recovery from glare: Glare is excessive light reflected back into the eye. Glare will obliterate normal vision for a period of time (for example, after a flash picture is taken). With age, recovery from glare takes more time.
Alterations in vision not only reduce the ability to perform ADLs, but can also be a significant health hazard.
Visual impairment is defined as visual acuity of 20/40 or worse while wearing corrective lenses, and legal blindness or severe visual impairment is 20/200 or more as measured by a Snellen wall chart at 20 feet.
Common visual disturbances in older adults include presbyopia, glaucoma, macular degeneration, and cataracts.
In 2004, 2.4 million Americans (1.98 percent) had low vision. Cataracts were the leading cause of low vision.
These vision-reducing conditions will affect approximately 70 million Americans by 2030, and can result in significant visual impairment and blindness.
Legal blindness is defined as a visual acuity of 20/200 or less on the Snellen chart. This means that a person standing 20 feet from an object with see with the same degree of clarity as a normally sighted person could from 200 feet away.
The prevalence of blindness also increases with age, reaching its peak at about the age of 85. The prevalence of blindness in both eyes in the United States is low, about 1% among persons 70 to 74 years of age and 2.4% in persons 85 and older.
In 2004, an estimated 937,000 (0.78 percent) Americans older than 40 were blind. The leading cause of blindness among white persons was age-related macular degeneration (54.4 percent of the cases), while among black persons, cataracts and glaucoma accounted for more than 60 percent of blindness. Among Hispanics, the leading cause of blindness was glaucoma.
The authors project that the number of blind persons in the United States will increase by 70 percent to 1.6 million by 2020.
“B”
A cataract is a cloudy area in the lens of the eye that causes the lens to lose its transparency. The lens becomes opaque or yellow. A normal lens is clear and focuses light into the back of the eye or retina. When a cataract develops, some of this light is blocked out or scattered. As this cataract develops, it becomes harder for a person to see.
Cataracts cloud the lens, decrease the amount of light able to reach the retina, and inhibit vision.
Cataracts are common in older people because everyone develops some degree of lens opacity as they age, with or without the presence of other eye disorders. However, since cataracts are considered an eye disorder, they are not considered to be a normal aging process. They develop gradually and without pain, and may be unilateral or bilateral. Most people with cataracts have a cataract in both eyes. However, one eye may be worse than the other because each cataract develops at a different rate.
Etiology thought to be from oxidative damage to lens protein and fatty deposits in the lens that occurs with aging.
And cross-linking. Clumps of protein reduce the sharpness of the image reaching the retina. The lens consists mostly of water and protein. When the protein clumps up, it clouds the lens and reduces the light that reaches the retina. The clouding may become severe enough to cause blurred vision. Most age-related cataracts develop from protein clumpings.
Cataracts are more severe in persons who have had significant exposure to sunlight.
When tasks become increasingly difficult and fatiguing because of the vision changes that cataracts produce, the patient should be instructed to seek medical attention.
In fact, cataracts are the leading cause of low vision in older adults.
More than 50% of adults over the age of 65 years have visual problems as a result of cataracts. Most common in age over 75. After age 75, as many as 70-90% of Americans have cataracts that are significant enough to impair their vision.
No ethic or gender variations
Eventually, lens opacity and vision loss are complete.
Cataracts are the leading cause of blindness in the world.
The lens of the eye becomes yellow or yellow-brown; eventually the color of the pupil changes from black to a cloudy white.
Patients with cataracts may experience blurry vision, glare, halos around objects, double vision, lack of color contrast or faded color, and poor night vision.
Symptoms – No discomfort or pain is associated with cataracts. A cataract starts out small and at first has little effect on your vision. At first visual acuity is not affected, but as opacification continues, vision is distorted, night vision is decreased, and objects appeared blurred.
You may notice that your vision is blurred a little, like looking through a cloudy piece of glass or viewing an impressionist painting.
People may have trouble seeing street signs while driving and feel that there is a film over the eye.
Glare from sunlight and bright lights is extremely bothersome to the affected person; this is due to the cloudy lens causing light to scatter more than it would in a clear lens. A cataract may make light from the sun or a lamp seem too bright or glaring. Or you may notice when you drive at night that the oncoming headlights cause more glare than before.
Some individuals may report an improvement in the ability to see small print and objects (“second sight”), which is due to changes in the lens that increase nearsightedness.
Colors may not appear as bright as they once did.
They may need more light or illumination when reading, and repeated alterations of the corrective lens prescriptions.
Hallmark symptoms – Blurry vision, glare, appearance of halos around objects as light is diffused
Exposure to ultraviolet light increases the risk of developing cataracts, emphasizing the importance of wearing proper sunglasses to protect the eyes.
Risk factors for the development of cataracts include the following:
Increased age
Smoking and alcohol
Diabetes, hyperlipidemia
Trauma to the eye
Exposure to the sun and UVB rays
Corticosteroid medications
Surgery to remove the lens is the only cure. The need for surgery is assessed on an individual’s unique situation.For most patients, surgery improves vision. The simple surgical procedure and several weeks of rehabilitation can result in years of improved vision and, consequently, a life of higher quality.
Surgical removal of the affected lens is generally the treatment of choice because there are no medications to treat this problem. Corrective lenses that filter out glare may be effective in managing symptoms in the early phases, but do not stop progression of vision loss. Surgical recommendations are made when vision problems interfere with daily activities such as reading and driving. Cataract surgery is recommended in the following circumstances:
Visual acuity is 20/50 or less with symptoms of loss of functional ability.
Visual acuity is 20/40 or better with disabling glare or frequent exposure to low light situations, diplopia, disparity between eyes, or occupational need.
Cataract removal will treat another lens-induced disease such as glaucoma.
Cataract exists with other diseases of the retina, such as diabetic retinopathy, requiring unrestricted monitoring.
The outpatient surgical procedure involves removal of the affected lens and insertion of an artificial lens or intraocular lens. Cataract surgery is generally a nonemergency procedure. Newer surgical procedures with laster photolysis and sonic phacoemulsification have shown to be valuable in making smaller surgical incision. Cataract surgery is contraindicated when the patient wishes to avoid surgery, glasses or visual aids provide satisfactory vision, the patient’s lifestyle is not compromised, or the patient has been diagnosed with medical problems that make surgery a high-risk procedure.
Cataract surgery is very successful in restoring vision. In fact, it is the most frequently performed surgery in the United States, with more than 3 million Americans undergoing cataract surgery each year. Nine out of 10 people who have cataract surgery regain very good vision, somewhere between 20/20 and 20/40.
Cataract surgery is an outpatient procedure and older people usually withstand it well.
The most common method of replacing the surgically removed lens is the insertion of an intraocular lens at the time of cataract surgery.
For older patients, this method has been more successful than adjusting to a contact lens or special cataract glasses. The intraocular lens tends to distort vision less than cataract glasses do and does not require the care of a contact lens.
During surgery, the surgeon will remove the clouded lens and in most cases replace it with a clear, plastic intraocular lens (IOL). The replacement for the cataract-damaged natural lens, the intraocular lens (IOL), is positioned in the capsular bag of the eye.
Throughout the procedure, most patients are awake, relaxed, and feel no pain.
Some patients do develop complications with a lens implant, such as eye infection, loss of vitreous humor, and slipping of the implant.
Patients typically can resume nonstrenuous activities within a day.
He or she also will need to wear protective eye shields while sleeping or napping, for about 2 weeks after surgery.
They also must avoid bright sunlight. The patient will be given sun shades to help protect eyes in bright light. These are wrap-arounds and will need to be worn for 2 weeks.
The patient will need to administer eye drops, as prescribed by the eye surgeon, several times daily during the next few weeks after the procedure. Teach the patient to wash hands before instilling eyedrops and correct procedure for eyedrop instillation.
Postsurgical education includes reinforcement not to life any heavy objects, strain at stool, or bend at the waist.
Avoid anything that can increase intraocular pressure such as coughing or vomiting.
The patient will need to administer eye drops, as prescribed by the eye surgeon, several times daily during the next few weeks after the procedure. He or she also will need to wear protective eye shields while sleeping or napping, for about a week after surgery.
They also must avoid bright sunlight. The patient will be given sun shades to help protect eyes in bright light. These are wrap-arounds and will need to be worn for a short-time.
Teach the patient to wash hands before instilling eyedrops and correct procedure for eyedrop instillation.
Postsurgical education includes reinforcement not to life any heavy objects, strain at stool, or bend at the waist.
Avoid anything that can increase intraocular pressure such as coughing or vomiting.
Complications of cataract surgery include eye infection, wound dehiscence, loss of vitreous humor, hemorrhage, severe pain, uncontrolled elevated intraocular pressure (IOP), and slipping of the implant.
Patients with cognitive impairments such as Alzheimer’s disease must be carefully supervised for at least 24 hours after surgery to ensure that they do not remove the protective eye patch and do not rub the eye.
When surgery is needed in both eyes, one eye is done first and the second procedure is scheduled a month or so later to allow healing and recovery. Adequate home care and support is needed to prevent complications.
Preventative measures should also be implemented in teaching, such as wearing hats and sunglasses when in the sun, smoking cessation, eating low-fat diets, and avoiding ocular injury. In addition, providing patients with information regarding support groups and other resources can provide added psychological and emotional support.
“A”
Another condition that can occur as we get older is glaucoma - a rise in pressure within the eye. If untreated, glaucoma results in a gradual and irreversible loss of vision, typically in the peripheral vision.
Glaucoma is a disease of the optic nerve, which transmits the images you see from the eye to the brain. The optic nerve is made up of many nerve fibers (like an electric cable with its numerous wires). Glaucoma damages nerve fibers, which can cause blind spots and vision loss.
Glaucoma has to do with the pressure inside the eye, known as intraocular pressure (IOP). When the aqueous humor (a clear liquid that normally flows in and out of the eye) cannot drain properly, pressure builds up in the eye. The resulting increase in IOP can damage the optic nerve and lead to vision loss
The eye has an internal "plumbing" system that constantly circulates and drains fluid from the eyes. A blockage or too much fluid production can cause pressure build up and damage the optic nerve. If detected early, it can be controlled with special eye drops. Yearly eye exams are important because early stage glaucoma has no symptoms.
In the United States and worldwide, it is the second leading cause of blindness. It is the first cause of blindness among blacks. Glaucoma accounts for about 10% of all blindness in the United States.
It ranks after cataracts as a major eye problem in older persons.
Glaucoma tends to occur in people over age 40 and increases in prevalence with age.
Black individuals tend to develop glaucoma at earlier ages than whites and have a significantly higher incidence.
Glaucoma accounts for 19% of all blindness among African Americans, compared with 6% of Caucasians. In fact, glaucoma is six to eight times more common in African Americans than in Caucasians.
Although glaucoma can occur at any age, those most at risk are adults older than age 60. Glaucoma affects one in two hundred people aged fifty and younger, and one in ten over the age of eighty.
Drugs with anticholinergic properties can exacerbate glaucoma due to their effects of dilating the pupil.
Another condition that can occur as we get older is glaucoma. Glaucoma is unusually high pressure inside the eye that damages the optic nerve and can result in permanent vision loss.
If untreated, glaucoma results in a gradual and irreversible loss of vision, typically in the peripheral vision.
Glaucoma refers to a category of eye disorders often associated with a dangerous buildup of internal eye pressure (intraocular pressure or IOP), which can damage the eye's optic nerve that transmits visual information to the brain. When the IOP is greater than 21 mm Hg, the optic nerve has the potential for atrophy and vision loss.
Glaucoma has been nicknamed the "sneaky thief of sight" because the loss of visual field often occurs gradually over a long time and may only be recognized when it is already quite advanced. The most common form has few, if any, symptoms and may cause partial vision loss before it is detected. It is asymptomatic until very late in the disease, when there is a noticeable loss of peripheral vision, causing tunnel vision.
Once lost, this damaged visual field can never be recovered.
However, if detected early, glaucoma can usually be controlled and serious vision loss prevented.
To follow the flow of fluid inside the eye, follow the blue arrow.
Internal eye fluids are produced by the ciliary body, which is a small, circular structure found behind the iris or colored portion of the eye. This fluid within the eye, known as the aqueous humor, serves as nourishment for surrounding tissues. The aqueous humor flows behind the iris and through the pupil or central opening in the middle of the iris. Fluid then fills the anterior chamber, a space between the back of the clear cornea and the front of the iris. The aqueous humor escapes from the eye through a spongy tissue at the front of the eye called the trabecular meshwork into a drainage canal (dark blue region next to the trabecular meshwork). This drainage canal is known as the filtration angle, which is the angle formed inside the anterior chamber between the iris and the peripheral cornea. The aqueous filters through this angle and through the sclera or white part of the eye and then joins with the network of veins outside the eye.
The cause of glaucoma is generally a failure of the eye to maintain an appropriate balance between the amount of internal (intraocular) fluids produced and the amount that drains away. An average or normal IOP is 15 mm Hg (normal range 10 to 20 mm Hg). IF the outflow of aqueous fluid is obstructed, aqueous humor accumulates, increasing the pressure within the eye and damaging the optic nerve.
Simulated vision loss from the effects of glaucoma is pictured above.
The most common form of glaucoma is primary open-angle glaucoma, in which the aqueous fluid is blocked from flowing back out of the eye at a normal rate through a tiny drainage system. Most people who develop primary open-angle glaucoma notice no symptoms until their vision is impaired.
Ocular hypertension is often a forerunner to actual open-angle glaucoma. When ocular pressure is above normal, the risk of developing glaucoma increases.
In open-angle glaucoma, the fluid in the eye's front (anterior) chamber between the clear cornea and the colored iris (aqueous humor) can't filter through an area where it needs to pass (filtration angle). This occurs because the drainage channels (trabecular meshwork) are blocked, causing internal eye pressure (IOP) to rise.
As IOP increases, the pressure pushes harder against the nerve fibers of the optic nerve, which transmits images to the brain. This increased pressure reduces the blood supply to the optic nerve, depriving it of oxygen and nutrients. Over time, high IOP can cause irreversible optic nerve damage and vision loss.
Open-angle glaucoma is more common that acute (90% of cases are this type), affecting over 2 million people in the United States. This type of glaucoma occurs gradually and insidiously. Peripheral vision is slowly impaired. This type of glaucoma can damage vision so gradually and painlessly that a person is unaware of a problem until the optic nerve is badly damaged. Visual loss begins with deteriorating peripheral vision.
Vision loss is painless and gradual with peripheral visual field loss being the classic symptom. About half of Americans with open-angle glaucoma don't even know they have it.
Intraocular pressure is maintained at normal levels when some of the fluid produced by the eye is allowed to flow out. The fluid (aqueous humor) is produced by the ciliary body where it flows into the anterior chamber and then out through a spongy tissue at the front of the eye called the trabecular meshwork into a drainage canal. In open-angle glaucoma, fluid cannot flow effectively through the trabecular meshwork, and this causes an increase in intraocular pressure causing damage to the optic nerve and leading to vision loss.
Often no symptoms until late in the course of the disease.
Patients do not generally report symptoms of glaucoma until advanced stages of the disease, so monitoring of IOP during routine ophthalmic examinations for patients with any risk factors is essential.
Diagnosis: tonometry (screen); gonioscopy (direct view)
The goal of glaucoma treatment is to lower your eye pressure to prevent or slow further vision loss. Your ophthalmologist will recommend treatment if the risk of vision loss is high. Treatment often consists of eyedrops but can include laser treatment or surgery to create a new drain in the eye. Glaucoma is a chronic disease that can be controlled but not cured. Ongoing monitoring (every three to six months) is needed to watch for changes.
Management of glaucoma involves lowering the IOP to stop the damage to the optic nerve and to prevent further vision loss. Therapy includes medications (usually topical eyedrops) to decrease IOP and/ or laser surgery to increase the flow of aqueous humor, by creating a new drainage exit.
Open-angle glaucoma is usually managed with one or several of the following medications: beta-blockers, miotics, alpha-adrenergic agonists, prostaglandin analogues, and carbonic anhydrase inhibitors. Beta-blockers remain the first-line therapy for glaucoma because they decrease the rate of intraocular fluid production.
If medications are unable to decrease IOP or are contraindicated, then laser surgery or surgery may be an option. Part of the thickened wall of the channels of the trabecular meshwork is shot with a laser light or cut with a scalpel; this makes them wider allowing the aqueous humour to drain more freely. These procedures can be performed in an outpatient setting.
In ophthalmology, tonometry is the procedure eye care professionals perform to determine the intraocular pressure (IOP), the fluid pressure inside the eye. A wisp of air is blown into the eye. Most tonometers are calibrated to measure pressure in mmHg. It is used to screen for glaucoma.
Gonioscopy: used to directly examine the anterior chamber angle, the portion of the eye that directs aqueous humor (the fluid produced by the eye). A special mirrored contact lens is used during this evaluation.
The angle is examined with a special lens called a gonioscopy lens (“gonio” means angle).
Beta-blockers – generic names end in “olol”
Prostaglandins – generic names end in “prost”
STORE UNOPENED BOTTLE of Xalatan in the refrigerator. AFTER THE BOTTLE IS OPENED, store this medicine in the refrigerator or in a cool place below 77 degrees F (25 degrees C) for up to 6 weeks.
MIOSIS – causes pupils to contract. Constriction of the pupils causes a drop in intraocular pressure. Reduces eye pressure by clearing fluid from the eyes. Pilocarpine has the fewest side effects and is usually prescribed first.
Miotic agents typically cause a reduction in night vision acuity, darkening of the vision, irritation, and redness.
STORE Pilocarpine at room temperature, away from heat and light. Keep the container tightly closed.
Side effects of cholinergic agents: SLUDGE – salivation, lacrimation, urination, diarrhea, GI upset, emesis
STORE Trusopt at room temperature, away from heat and light.
C
In angle-closure glaucoma, the iris (the colored part of the eye) may drop over and completely close off the drainage angle, abruptly blocking the flow of aqueous fluid and leading to increased IOP or optic nerve damage. In acute angle-closure glaucoma there is a sudden increase in IOP due to the buildup of aqueous fluid. This condition is considered an emergency because optic nerve damage and vision loss can occur within hours of the problem. Symptoms can include nausea, vomiting, seeing halos around lights, and eye pain
Angle-closure glaucoma (also known as acute, closed-angle, or narrow-angle glaucoma) is not as common.
In angle-closure glaucoma, the angle of the iris obstructs drainage of the aqueous humor through the trabecular meshwork. It may occur suddenly as a result of infection or trauma.
Acute-closure glaucoma is an ophthalmic emergency requiring immediate attention by an ophthalmologist to preserve vision. Permanent vision loss within 2 to 5 days if left untreated.
Symptoms include unilateral headache, visual blurring, nausea, vomiting, and photophobia.
A photograph of an eye in acute angle closure glaucoma. The eye is very red and the patient was in pain. The intraocular pressure was 62 mmHg (normal 10 - 21). Notice the bleeding spot at 1 o’clock (arrow) where laser iridotomy surgery was performed.
A small opening is made at the base of the iris (iridotomy) to allow the IOP to equalize on either side and prevent the iris from obstructing the outflow channel. Iridotomy with a laser can be performed in the outpatient setting.
A peripheral iridotomy is most often used to treat narrow angle or angle closure glaucoma. The laser beam creates a tiny hole in the colored part of the eye (the iris). This lets the pressure in front of the iris become the same as the pressure behind the iris. As a result, the iris moves away from the drainage angle and the aqueous fluid can resume draining normally
Unlike cataracts, there are some ethnic distinctions with the development of glaucoma. Blacks tend to develop it earlier than whites, and females more often than males. Glaucoma is more common in African Americans, Asian Americans, Hispanics, and Eskimos. Other contributing factors include eye trauma, small cornea, small anterior chamber, family history, cataracts, and some medications.
Risk factors for glaucoma include the following:
Increased intraocular pressure
Older than 60 years of age
Family history of glaucoma
Personal history of myopia, diabetes, hypertension, migraines
African American ancestry
The American Academy of Ophthalmology recommends that patients over the age of 65 be examined and screened for glaucoma at least every 1 to 2 years., every 6 months with prior diagnosis of glaucoma. A complete examination includes the patient’s visual acuity with corrective lenses, visual field test to assess peripheral vision, measurement of the IOP noting the time of day as pressures may vary throughout the day, slit lamp inspection of the iris to assess whether the anterior angle is open or closed, and a complete dilated examination to inspect the optic nerve and retina.
True.
Compliance with the treatment regimen for glaucoma can be a challenge for the older adult. The silent nature of glaucoma—and potential difficulties with instilling eye drops—as well as the cost of the medications may contribute to a lack of adherence.
Age-related Macular Degeneration (or AMD) is another very common cause of sight problems in older people. It is the number one cause of severe vision loss and legal blindness in adults over 60 in the U.S.
It is a degenerative disorder of the macula that affects both central vision (scotoma) and visual acuity.
AMD is a deterioration or breakdown of the macula. The macula is a small area at the center of the retina in the back of the eye that allows us to see fine details clearly and perform activities such as reading and driving
The macula is a a part of the inner lining of the eye. It is a small circular membrane situated in the central part of the retina at the back of the eye and it is dense with photoreceptor cells. This membrane is light sensitive and responsible for our clear central vision.
The visual symptoms of AMD involve loss of central vision. While peripheral (side) vision is unaffected, with AMD, one loses the sharp, straight-ahead vision necessary for driving, reading, recognizing faces, and looking at detail.
Macular degeneration is the gradual loss of vision caused by damage to the macula by thinning, atrophy, and in some cases, bleeding. When the macula degenerates, central vision deteriorates. This will result in seeing images as cloudy or distorted, decreased color vision, and sometimes a central scotoma (a large, dark spot in the center of vision).
Age-related macular degeneration begins with reduced light sensitivity and distortion of central vision. The disease causes the progressive loss of central vision, leaving only peripheral vision intact. Central vision is needed for seeing objects clearly and for common daily tasks such as reading and driving.
It usually starts in one eye, but with a high risk that the disease will affect the other eye within 5 years.
As our population ages, and the "baby boomers" advance into their 60's and 70's, we will see a virtual epidemic of AMD.
Although it never causes total blindness by itself, age-related macular degeneration robs those affected of their sharp central vision and can dim contrast sensitivity and color perception. It destroys the clear, "straight ahead" central vision necessary for reading, driving, identifying faces, watching television, doing fine detailed work, safely navigating stairs and performing other daily tasks we take for granted.
Patients with ARMD often require more light for reading. They often experience blurry vision, central scotomas (blind spots within the visual field), and metamorphosia in which images are distorted to look smaller (micropsia) or larger (macropsia) than they actually are.
Peripheral vision may not be affected, and it is possible to see "out of the corner of your eye".
Another symptom typical of wet ARMD is that straight lines appear crooked or wavy. The Amsler grid was developed as a screening tool to assess for ARMD; patients with this condition experience visual distortions of the lines and central scotomas. A sample grid and the appearance of the grid to a patient with normal vision and ARMD are depicted in this slide.
There are two types of AMD – the more common dry version, which can’t be treated, and the aggressive, but less common wet version that, if caught early enough, can be halted or slowed or, using the very latest drugs, even reversed.
There are two types of ARMD: a dry and wet form.
Nine out of 10 people who have AMD have atrophic or “dry” AMD, which results in thinning of the macula. Dry AMD takes many years to develop. A specific vitamin regimen has been shown to slow progression of dry AMD.
The dry form, or atrophic form, occurs as a result of atrophy, retinal pigment degeneration, and drusen accumulations. Drusen are deposits of cellular debris and appear as yellow spots on ophthalmic examination. Visual loss as a result of this type of ARMD is generally slow in progression, and accounts for only 10% to 20% of severe vision loss.
Dry AMD is an early stage of the disease and may result from the aging and thinning of macular tissues, depositing of pigment in the macula or a combination of the two processes.
Dry macular degeneration is diagnosed when yellowish spots known as drusen begin to accumulate from deposits or debris from deteriorating tissue primarily in the area of the macula. Gradual central vision loss may occur with dry macular degeneration but is not nearly as severe as symptoms associated with the wet form of AMD.
No FDA-approved treatments are available for the dry form of macular degeneration. A major National Eye Institute study (AREDS) has produced strong evidence that certain nutrients such as beta carotene (vitamin A) and vitamins C and E may help prevent or slow progression of dry macular degeneration.
The AREDS study indicates that taking high dose formulas of certain nutritional supplements can reduce risk of early stage AMD progression by 25 percent. Some eye doctors also recommend that dry AMD patients wear sunglasses with UV protection against potentially harmful effects of the sun. [
In about 10 percent of cases, dry AMD progresses to a more advanced and damaging form of the eye disease known as wet macular degeneration. With wet AMD, new blood vessels grow (neovascularization) beneath the retina and leak blood and fluid. This leakage causes permanent damage to light-sensitive retinal cells, which die off and create blind spots in central vision.
Exudative or “wet” AMD is less common (occurring in one out of 10 people with AMD) but is more serious. In the wet form of AMD, abnormal blood vessels may grow in a layer beneath the retina, leaking fluid and blood and creating distortion or a large blind spot in the center of your vision. If the blood vessels are not growing directly beneath the macula, laser surgery is usually the treatment of choice. The procedure usually does not improve vision but tries to prevent further loss of vision. For those patients with wet AMD whose blood vessels are growing directly under the center of the macula, a procedure called photodynamic therapy (PDT), which causes fewer visual side effects, is sometimes used. Intravitreal injections of certain medications can also be used in these cases
In the wet form, also known as neovascular ARMD, blood or serum leaks from newly formed blood vessels beneath the retina. This seepage of fluid ultimately leads to scar formation and visual problems. Although less prevalent than the dry form, the wet form of ARMD is responsible for the majority of severe vision loss.
Neovascularization, the underlying process causing wet AMD and abnormal blood vessel growth, is the body's misguided way of attempting to create a new network of blood vessels to supply more nutrients and oxygen to the eye's retina. But the process instead creates scarring, leading to sometimes severe central vision loss.
Risk factors for ARMD include the following:
Age above 50
Cigarette smoking
Family history of ARMD
Increased exposure to ultraviolet (sunlight) light
Caucasian race and light-colored eyes
Hypertension or cardiovascular disease
Lack of dietary intake of antioxidants and zinc
AMD is more common in women, people with blue eyes, and Caucasians.
While age is the most significant risk factor for developing AMD, heredity, blue eyes, high blood pressure, cardiovascular disease, and smoking have also been identified as risk factors. AMD accounts for 90% of new cases of legal blindness in the United States
To prevent age related macular degeneration (ARMD) nurses should teach prevention and safety measures.
Due to the severity of vision loss as a result of ARMD nurses can play an important role in patient education. According to the American Academy of Ophthalmology, people over the age of 65 should be examined every 1 to 2 years. Routine ophthalmic examinations are important to detect early signs of this disease.
Nurses should encourage preventive measures such as wearing ultraviolet protective lenses in the sun, smoking cessation, and exercising routinely.
In addition, a healthy diet consisting of fruits and vegetables may be helpful not only to increase consumption of antioxidants, but also to reduce the risk of cardiovascular disease.
The role of vitamins is being studied, and current recommendations for those with ARMD include zinc oxide 80 mg, cupric oxide 2 mg, beta-carotene 15 mg, vitamin C 500 mg, and vitamin E 400 IU taken in divided doses twice a day to slow the risk of progression.
Low-vision assistive devices
Technological advances in the last decade have produced some low-vision assistive devices that may be used successfully to improve the quality of life for the visually impaired elder.
Use large-print reading material.
People with severe visual impairment may qualify for disability and financial and social services assistance through government and private programs including vision rehabilitation programs.
An array of low-vision devices are now available, including insulin delivery and glucose-monitoring equipment, talking watches, large-print books, magnifiers, and computers with low-vision devices.
Modify environment – Use several soft indirect lights instead of a single glaring one. Avoid glare from windows by using sheer curtains or stained windows. Place frequently used items within the visual field. Avoid the use of low-tone colors and attempt to use bright ones. Use contrasting colors on doorways and stairs and for changes in levels.
Eyeglasses, once heavy and bulky, are now cosmetically appealing. Sunglasses are designed to filter out ultraviolet rays that may be harmful to sensitive retinas.
“B”
Loss of central vision
Macular degeneration is the most common cause of blindness in people over age 65 and involves damage or breakdown of the macula, which results in loss of central vision.
A retinal detachment occurs when the retina is pulled away from its normal position in the back of the eye. The retina sends visual images to the brain through the optic nerve. When detachment occurs, vision is blurred. A detached retina is a very serious problem that almost always causes blindness unless it is treated.
The retina normally lies smoothly and firmly against the inside back wall of the eyeball (or choroid) and functions much like the film in the back of a camera. Millions of light-sensitive retinal cells receive optical images, instantly "develop" them, and send them on to the brain to be seen. If any part of the retina is lifted or pulled from its normal position, it is considered detached and will cause some vision loss.
The vitreous is the clear collagen gel that fills the back of the eye between the retina and the lens. As we get older the vitreous may pull away from its attachment to the retina at the back of the eye. Usually the vitreous separates from the retina without causing a problem. But sometimes the vitreous pulls hard enough to tear the retina in one or more places. Fluid may pass through the retinal tear and lift the retina off the back of the eye like wallpaper can peel off a wall.
Retinal detachment can occur at any age, but it is more common in midlife and later. Older persons are more prone to detachment of the retina.
Retinal detachment can occur at any age, but it is more common in midlife and later. Conditions that can increase the chance of a retinal detachment include nearsightedness; previous cataract surgery; glaucoma; severe trauma; previous retinal detachment in your other eye; family history of retinal detachment; or weak areas in your retina that can be seen by your ophthalmologist.
The symptoms, which can be gradual or sudden, include the perception of spots moving across the eye, blurrred vision, flashes of light, and the feeling that a coating is developing over the eye.
Blank areas of vision progress to complete loss of vision.
The severity of symptoms depends on the degree of retinal detachment.
There is no pain.
With age the vitreous, the gel which fills the cavity in front of the retina, begins to liquefy and shrink. This normal for age process usually starts between 45 and 55 years of age. Individuals who are undergoing this process may briefly see floaters and even flashing lights in their vision. These symptoms usually subside and may leave a small residual floater in the vision. Rarely, a PVD may lead to a retinal tear or hole.
Retinal Detachment is a separation of the retina (the inner nervous tunic of the eye) from the choroid in the back of the eye. The retina is the light-sensitive tissue that lies smoothly against the inside back wall of your eye and sends messages to your brain through your optic nerve. Underneath the retina is the choroid — a thin layer of blood vessels that supplies oxygen and nutrients to the retina. Retinal detachment occurs when the retina separates from the choroid.
Usually this happen when there is a small tear or hole in the retina that allows the vitreous humor (fluid) to leak between the choroid and the retina.
Most retinal detachments are caused by the presence of one or more small tears or holes in the retina. Normal aging can sometimes cause the retina to thin and deteriorate, but more often shrinkage of the vitreous body, the clear gel-like substance which fills the center of the eye, is responsible for deterioration and retinal tears.
The vitreous is firmly attached to the retina in several places around the back wall of the eye. As the vitreous shrinks, it may pull a piece of the retina away with it, leaving a tear or hole in the retina. This allows fluid to perculate thru the tear, with subsequent detaching of the retina (analogous to wall paper coming off a wall).
Though some shrinkage of the vitreous body occurs naturally with aging and usually causes no damage to the retina, abnormal growth of the eye (sometimes a result of nearsightedness), inflammation or injury, may also cause the vitreous to shrink. In most cases, a significant change in the structure of the vitreous body occurs before the development of a retinal detachment.
Once a retinal tear is present, watery fluid from the vitreous space may pass through the hole and flow between the retina and the back wall of the eye. This separates the retina from the back of the eye and causes it to “detach.” The part of the retina that is detached will not work properly and there will be a blindspot in vision.
It is not known why some people get retinal detachments however, there are many risk factors including increasing age (with liquefication of the vitreous gel), diabetes, high myopia (near sightness), inflammation, and of course trauma.
Prompt treatment is required to prevent continued damage and eventual blindness.
Initial measures most likely to be prescribed, bed rest and the use of bilateral eye patches, can be frightening to the older patient, who may react with confusion and unusual behavior.
The nurse should help the patient feel secure as possible; frequent checks and communication, easy access to a call light or other means of assistance, and full, honest explanations will help provide a sense of well-being.
After time has been allowed for the maximum amount of “reattachment” of the retina to occur, surgery may be planned. Several surgical techniques are used in the treatment of detached retinas. Electrodiathermy and cryosurgery cause the retina to adhere to its original attachment; scleral buckling and photocoagulation decrease the size of the vitreous space.
Laser surgery (photocoagulation). During photocoagulation your surgeon directs a laser beam through a special contact lens or through a special ophthalmoscope to make burns around the retinal tear. The burns cause scarring, which usually “welds” the retina to the underlying tissue. This procedure requires no surgical incision, and it causes less irritation to your eye than does cryopexy.
Freezing (cryopexy). With cryopexy your surgeon uses intense cold to freeze the retina around the retinal tear. After a local anesthetic numbs your eye, a freezing probe is applied to the outer surface of the eye directly over the retinal defect. This freezes the area around the hole, and the resulting delicate scar helps secure the retina to the eye wall. Cryopexy is used in instances where the tears are more difficult to reach with a laser, generally along the retinal periphery. Your eye may be red and swollen for some time after cryopexy.
If Retinal Detachment Has Occurred – The SurgeryDoctors commonly use one of these surgical procedures to repair a retinal detachment. Some of these procedures are done in conjunction with photocoagulation or cryopexy. The purpose of these treatments is to close any retinal holes or tears and to reduce the tug on the retina from a shrinking vitreous. The type, size and location of any retinal detachment will determine which procedure your eye surgeon recommends. In general, these surgeries can successfully treat more than 90 percent of cases of retinal detachment, although a second treatment is sometimes necessary.
Pneumatic Retinopexy. This surgical technique is generally used for a relatively uncomplicated detachment when the tear is located in the upper half of the retina. It’s usually done on an outpatient basis under local anesthesia.
The retina is reattached by injection of a bubble of expandable gas into the vitreous cavity. Over the next several days, the gas bubble expands, sealing the retinal tear by pushing against it and the detached area that surrounds the tear. With no new fluid passing through the retinal tear, fluid that had previously collected under the retina is absorbed, and the retina is able to reattach itself to the back wall of your eye.
Once the retina is reattached, the retinal tear can be sealed by laser photocoagulation or cryotherapy.
Scleral buckling. This is the most common surgery for repairing retinal detachment. It’s usually done in an operating room under local or general anesthesia. If you have an uncomplicated retinal detachment, this surgery may be done on an outpatient basis.
First your surgeon treats the retinal tears or holes with cryopexy. Then he or she attaches a tiny silicone band (buckle) to the white of your eye (sclera) over the affected area. The silicone material is in the form of either a soft sponge or a solid piece. The buckle closes the tear and helps reduce the traction on the retina, which prevents further vitreous pulling and separation. When you have several tears or holes or an extensive detachment, your surgeon may create an encircling scleral buckle around the entire circumference of your eye.
The scleral buckling material is stitched to the outer surface of the sclera. Before tying the sutures that hold the buckle in place, the surgeon may make a small cut in the sclera and drain any fluid that has collected under the detached retina. The buckle usually remains in place for the rest of your life. Some surgeons may choose a temporary buckle for simple retinal detachments, using a small rubber balloon that’s inflated and later removed.
Vitrectomy Operation. A vitrectomy operation involves making 3 very tiny holes in the eye through which instruments can be put to help remove the jelly inside the eye. The surgeon accomplishes this with a variety of delicate instruments passed into the eyeball through small openings in the sclera. These instruments include a light probe that illuminates the inside of your eye, a cutter to remove vitreous or scar tissue, and an infusion tube that replaces the volume of removed tissue with a balanced salt solution to maintain the normal pressure and shape of the eye. After completing the vitrectomy, your surgeon may perform a scleral buckling procedure or pneumatic retinopexy procedure by filling the inside of your eye with air, expandable gas or silicone oil to help seal the retina against the wall of your eye. Vitrectomy surgery typically lasts more than an hour but may take several hours in more complex cases. The complex cases are often done under general anesthesia, but shorter procedures are usually performed under local anesthesia.
Eye patches remain on the patient for several days after surgery. Specific routines vary according to the type of surgery performed.The patient needs frequent verbal stimuli to minimize anxiety and enhance psychological comfort. Physical and emotional stress must be avoided. Approximately two weeks after surgery, the success of the operation can be evaluated.
A minority of patients must undergo a second procedure. It is important for the patient to understand that periodic examination is important, especially because some patients suffer a detached retina in the other eye.