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Visual and Auditory Problems
Zoya Minasyan, RN, MSN-Edu
Structures and Functions of Visual System
Assessment of Visual Systems
Magnified view of retina through the ophthalmoscope.
Structures and Functions of Visual System
External eye and lacrimal apparatus. Tears produced in the lacrimal gland pass over the surface of theeye and
enter the lacrimal canal. From there the tears are carried through the nasolacrimal duct to the nasal cavity.
Structures and Functions of Visual System
• External Structures and Functions, continued
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Conjunctiva
Sclera
Cornea
Lacrimal apparatus
Extraocular muscles
• Internal Structures and Functions
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Iris
Lens
Ciliary body
Choroid
Retina
Gerontologic Considerations:
Effects of Aging on Visual Systems
Arcus senilis. Age-related degeneration of the cornea.
• Opacity within lens
– The patient may have a cataract in one or both
eyes.
• Leading cause of blindness
• Most common surgical procedure for those
aged over 65
• Influencing factors
– Age
– Blunt trauma
– Congenital factors
– Radiation/UV light exposure
– Long-term corticosteroid use
– Ocular inflammation
• Senile cataract
– Most common type
– Altered metabolic processes cause
• Accumulation of water
• Altered lens fiber structure
• Decrease in vision
• Abnormal color perception
• Glaring of vision
– Glare is due to light scatter caused by lens
opacities, and it may be significantly worse at
night when the pupil dilates.
• Secondary glaucoma can also occur if the
enlarging lens causes increased intraocular
pressure (IOP).
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History and physical examination
Visual acuity measurement
Ophthalmoscopy
Glare testing
• Nonsurgical therapy
•The patient may be willing to adjust his or her
lifestyle to accommodate for visual decline. For
example, if glare makes it difficult to drive at night,
a patient may elect to drive only during daylight
hours or to have a family member drive at night.
•Visual aids (palliative)
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Changing eyewear prescription
Reading glasses
Magnifiers
Increased lighting
• Preoperative phase
– History and physical assessment
– Antibiotic eyedrops
– Dilating eyedrops
• Surgical Therapy
•The patient’s occupational needs and lifestyle changes
are factors affecting the decision to have surgery.
• Preoperative Phase
•local anesthesia,
•most cataract patients are older adults and may have
several medical problems that should be evaluated and
controlled before surgery.
•Almost all patients with cataracts are admitted to a surgical
facility on an outpatient basis.
•Dilating drops and a nonsteroidal antiinflammatory eyedrop
are used to reduce inflammation and to help maintain pupil
dilation.
• for dilation -mydriatic, an α-adrenergic agonist that produces
pupillary dilation by contraction of the iris dilator muscle.
• Another type of drug is a cycloplegic, an anticholinergic agent that
produces paralysis of accommodation (cycloplegia) by blocking the
effect of acetylcholine on the ciliary body muscles.
• Intraoperative phase
– Corneoscleral incision
– Cataract extracted and sutured
– Cortex irrigated and aspirated
– Corticosteroid ointment applied with protective
shield
Surgical Therapy
•Cataract extraction is an intraocular procedure. Rarely, intracapsular
extraction is performed, in which the entire lens is removed with the capsule
intact (this procedure may be necessary in instances of trauma). More
commonly, extracapsular extraction is done, in which the anterior capsule is
opened and the lens nucleus and cortex are removed, leaving the remaining
capsular bag intact.
•In extracapsular extraction, the surgeon can remove the lens nucleus by
“scooping” it out with a lens loop, or by phacoemulsification, in which the
nucleus is fragmented by ultrasonic vibration and is aspirated from inside
the capsular bag.
•In either case, the remaining cortex is aspirated with an irrigation and
aspiration instrument. Placement and type of incision vary among surgeons.
•At the end of the procedure, additional medications such as antibiotics and
corticosteroids may be administered.16 Depending on the type of anesthesia,
the patient’s eye may be covered with a patch or protective shield. If used,
the patch/protective shield usually is worn overnight and is removed during
the first postoperative visit.
Implementation of Intraocular Lens
Intraocular lens implant after cataract surgery. Almost all patients now have an intraocular lens implanted at the
time of cataract extraction surgery. Because most patients have an extracapsular procedure, the lens of choice is a
posterior chamber lens that is implanted in the capsular bag behind the iris.
• Postoperative phase
– Outpatient procedure unless complications occur
– Antibiotic and corticosteroid eyedrops
• to prevent infection and to decrease the postoperative
inflammatory response.
– Limiting activities
• avoid activities that increase the IOP, such as bending
or stooping, coughing, or lifting.
– Follow-up visits
• The ophthalmologist usually will see the patient 2 to 3
times throughout the 6 to 8 weeks following surgery
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Visual acuity
Psychosocial impact of visual disability
Level of knowledge of disease
Comfort and ability to comply with postop
treatment
• Self-care deficits
• Anxiety
• Preoperative goals
– Make informed decisions regarding therapeutic
options.
– Experience minimal anxiety.
• Postoperative goals
– Understand and comply with postoperative
therapy.
– Maintain level of comfort.
– Remain free of infection and other complications.
• Health promotion
– Wear sunglasses.
– Avoid unnecessary radiation.
– Adequate antioxidant vitamins (e.g., vitamins C
and E)
– Ensure good nutrition.
• Acute intervention
– Educate about disease process and treatment options.
• the patient needs to know that without surgery, some degree of visual
disability will occur. Be available to give the patient and the family information
to help them make an informed decision about appropriate treatment.
– Administer medication.
• Photophobia is common; therefore decreasing the room lighting is helpful.
These medications produce transient stinging and burning.
– Inform those with patch that they will not have depth perception until
their patch is removed.
• This necessitates special considerations to avoid possible falls or other injuries.
The patient with significant visual impairment in the un-operated eye requires
more assistance while the operative eye is patched. Once the patch is
removed (usually within 24 hours), most patients with visual impairment in the
un-operated eye will have adequate vision for necessary activities
– Ensure little to no pain.
– Teach signs and symptoms of infection.
• of increased or purulent drainage, increased redness, or any decrease in visual
acuity.
• Ambulatory and home care
– Activity restrictions
– Medications
– Follow-up visits
– Signs and symptoms of possible complications
– Educate on postoperative visual acuity.
– Instruct family to modify activities and
environment.
• Remove area rugs.
• Prepare frozen meals.
• Provide audio books.
• Expected outcomes
– Improved vision
– Ability to care for self
– Minimal to no pain
– Optimistic expectations
• A group of disorders characterized by
– Increased IOP and consequences of elevated
pressure
– Optic nerve atrophy
– Peripheral visual field loss
• Balance between aqueous production and
reabsorption needed for normal level of IOP
• Glaucoma related to elevation of IOP
• Primary open-angle glaucoma (POAG)
– Most common type of glaucoma
– Outflow of aqueous humor is ↓, the drainage
channels become clogged, like a clogged kitchen
sink. Damage to the optic nerve can then result.
• Primary angle-closure glaucoma (PACG)
– Angle closure ↓ the flow of aqueous humor
– Caused by age, pupil dilation(it causes peripheral iris
bulging forward and blocking the outflow channels
– Possibly drug induced
•An acute attack may be precipitated by situations in which the
pupil remains in a partially dilated state long enough to cause
an acute and significant rise in IOP. This may occur because of
drug-induced mydriasis (dilation), emotional excitement, or
darkness.
•Check drug records and documentation before administering
medications to the patient, and instruct the patient not to take
any mydriatic-producing medications.
• Secondary glaucoma
– Results from other ocular or systemic conditions
that block outflow
– Associated with inflammatory processes
• POAG
– Develops slowly
– No symptoms
– Unnoticed until all peripheral vision is lost“tunnel
vision,” in which only a small center field can be
seen and all peripheral vision is absent.
• Acute angle-closure glaucoma
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Sudden excruciating pain around eyes
Nausea and vomiting
Seeing colored halos around lights
Blurred vision
Ocular redness
Corneal edema
IOP elevated in glaucoma
• Normal IOP 10 to 21 mm Hg
• Open-angle glaucoma 22 to 32 mm Hg
• Acute angle-closure glaucoma >49 mm Hg
• Gonioscopy (allows better visualization of the
anterior chamber angle)
• Peripheral and central vision test
• Ophthalmoscopy (The optic disc becomes
wider, deeper, and paler (light gray or white).
This is visible with direct or indirect
ophthalmoscopy)
Ophthalmoscopy
In the normal eye, the optic cup is pink with little cupping. B, In glaucoma, the optic disc is bleached and optic
cupping is present. (Note the appearance of the retinal vessels, which travel over theedge of the optic cup and
appear to dip into it.)
• Chronic open-angle glaucoma
– Drug therapy
– Argon laser trabeculoplasty
• Therapeutic option to lower IOP
– Laser stimulates scarring and contraction of trabecular
meshwork
– Trabeculectomy
• removal of part of iris and trabecular meshwork
– Implant
– Reserved for patients in whom filtration surgery has failed
– Permanent surgical placement of small drainage tube and
reservoir
• General glaucoma
•The primary focus of glaucoma therapy is to keep the IOP low
enough to prevent the patient from developing optic nerve
damage. This damage is manifested by increasing visual field loss
and progressive optic disc cupping. Specific therapies vary with
the type of glaucoma.
• Acute angle-closure glaucoma
– Miotics ( constriction of the pupils of the eyes)
– Oral/IV hyperosmotic
– Laser peripheral iridotomy
– Surgical iridectomy
• These procedures allow the aqueous humor to flow
through a newly created opening in the iris and into
normal outflow channels. One of these procedures may
also be performed on the other eye as a precaution,
because many patients often experience an acute
attack in the other eye.
• Secondary glaucoma
– Managed by treating underlying problems
– Antiglaucoma medication
– If treatment fails, glaucoma can progress to
absolute glaucoma, resulting in a hard, sightless,
and usually painful eye requiring enucleation
(surgical removal of the eye).
Health Promotion
– Teach patient and family risks of glaucoma.
• Loss of vision due to glaucoma is a preventable
problem.
– Stress importance of early detection.
• the incidence of glaucoma increases with age
– Provide ophthalmologic examination.
• The current recommendation is for an ophthalmologic
examination every 2 to 4 years for persons between
ages 40 and 64 years, and every 1 to 2 years for persons
age 65 years or older.
Acute Intervention
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Administer medication to lower IOP.
Darken the environment.
Apply cool compresses to the patient’s forehead.
Provide quiet space.
For surgical patients
 Provide postop instructions.
 Relieve discomfort.
Ambulatory and Home Care
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Encourage patient to follow therapy.
Educate on disease process and treatments.
Discuss follow-up appointments.
Provide verbal and written instructions.
Expected Outcomes
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No further loss of vision
Compliance with recommended therapy
Safe functioning in the environment
No pain from disease and surgery
Retinal Detachment
• Is a separation of retina and epithelium with
fluid accumulation between the two layers.
• Risk factors: increasing age, eye trauma,
cataract or glaucoma, family Hx
• Symptoms: photopsia-light flashes, floaters,
ring in the field of vision, painless loss of
peripheral or central vision, “ like a curtain”
coming across the field of vision.
• Care: Surgical therapy
Inflammation and Infection
• Hordeolum (sty)
– Staph aureus- infection of the sebaceous glands in the lid margin
• Chalazion
– Inflammation in meibomian (sebaceous) glands in the lid, can be b/c
of sty
• Blepharitis
– Scales or crusts on the lid and lashes. Burning, irritation photophobia,
caused by staph infections
• Conjunctivitis (infection or inflammation)
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Bacterial infections (pink eye-influenza and pneumonia)
Viral infections ( foreign body sensation, redness)
Chlamydial infections
Allergic conjunctivitis
Inflammation and Infection
Hordeolum (sty) on the upper eyelid caused by staphylococcal infection.
Inflammation and Infection
• Keratitis- involved conjunctiva and/or the cornea
– Bacterial infections
– Viral infections
– Other causes of keratitis
– Corneal ulcer
Inflammation and Infection
Corneal ulcer. Infection associated with poor contact lens care.
Strabismus
Is a condition in which patient cannot focus two eyes simultaneously on the same object.
• Myopia- nearsightness; light rays to be focused in
front of the retina (distant objects cannot be seen
sharply)
• Hyperopia- farsightness; light rays to be focus
behind the retina (difficulty focusing on near
objects, and in extreme cases unable to focus on
objects at any distance)
• Presbyopia- by aging less elastic lens and
decrease eye accomodation (difficulty seeing in
dim light, problems focusing on small objects
and/or fine print )
• Astigmatism-irregular corneal curvature, blurred
vision
Structures and Functions of Auditory System
External, middle, and inner ear.
Structures and Functions of
Auditory System
• External Ear
• Middle Ear
• Inner Ear
– Transmission of sound
Assessment of Auditory System
Normal Physical Assessment of Auditory System.
Assessment of Auditory System
The tympanic membrane. A, Landmarks of right tympanic membrane. B, Normal-appearing
tympanic membrane. C, Perforated tympanic membrane.
• Presbycusis: hearing loss due to aging
• Tinnitus: ringing in the ears- due to aging
• Vertigo: person or objects around the person
are moving or spinning or stimulated by the
movement of the head