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Chapter 51
Eye and Vision
Disorders
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Learning Objectives
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Identify the data to be collected in the nursing assessment
of the eye and vision.
Identify the nursing responsibilities for patients having diagnostic
tests or procedures to diagnose eye disorders.
List measures to reduce the risk of eye injuries.
Describe the nursing care of patients who require common
therapeutic measures for eye disorders: irrigation,
application of ophthalmic drugs, and surgery.
Describe the pathophysiology, signs and symptoms, diagnosis,
and treatment of selected eye conditions.
Assist in developing a nursing care plan for the patient
with an eye disorder.
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Anatomy and Physiology
of the Eye
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External Structures
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Eyelids
Eyelashes
Conjunctiva
Cornea
Sclera
Extraocular muscles
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Figure 51-1
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The Eyeball
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Sclera
Choroid
Retina
Optic nerve
Fluid chambers
• Anterior chamber
• Posterior chamber
• Lens
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Figure 51-2
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Figure 51-3
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Visual Pathway
• Light enters eye, passes through transparent cornea, aqueous
humor, lens, and vitreous humor
• These structures are called refractive media
• Refract (bend) horizontal and vertical light rays so that the light rays
focus on the retina
• On retina, light rays are reversed and upside down
• Images carried as impulses through the optic nerve
• At optic chiasm, fibers from the left field from each eye join to form
the left optic tract
• Fibers from right field of eye join to form right optic tract
• Images transmitted to the brain by way of the optic tracts
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Figure 51-4
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Age-Related Changes in the Eye
• Skin around the eye becomes wrinkled and loose
• Eyelids usually have some excess tissue; not important unless it
interferes with vision
• The amount of fat around the eye decreases, permitting the
eyeball to sink deeper into the orbit
• Tear secretion diminishes; cornea less sensitive
• Grayish ring may be around the outer margin of the iris
• Pupil smaller and responds more slowly to light
• Presbyopia: ability to focus is impaired
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Health History
• History of present illness
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Record changes in vision
If pain, inquire about location and nature
Sensitivity to light (photophobia)
Discharge from the eyes
Complaints that the eyes feel dry and irritated
• Past medical history
• Diabetes, neurologic disorders, thyroid disease,
hypertension
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Health History
• Family history
• Any eye diseases as well as a history of
arteriosclerosis, diabetes, and thyroid disease
• Functional assessment
• Patient’s occupation, roles, usual activities
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Physical Examination
• Inspect the external eye, assess response of
the pupil to light, and evaluate gross visual
acuity
• If abnormalities suspected, inform physician or
advise patient to seek medical evaluation
• Acuity commonly tested with Snellen chart
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Figure 51-5
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Diagnostic Tests and Procedures
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Ophthalmoscopic examination
Refractometry
Visual fields
Tonometry
Measure of electrical potential
Fluorescein angiography
Corneal staining
Imaging procedures
• CT, ultrasonography, radioisotope scanning, or MRI
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Figure 51-6
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Figure 51-7
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Figure 51-8
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Figure 51-9
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Therapeutic Measures
• Eye irrigation
• Topical medications
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Miotics
Mydriatics
Anesthetics
Cycloplegics
Antibiotics
Anti-inflammatory drugs
• Eye surgery
• Surgical incisions, lasers, and cryotherapy
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Preoperative Nursing Care
• Assessment
• Patient’s emotional state, ability to perform self-care,
and knowledge of surgical routines and outcomes
• Be sure the patient understands the preoperative
routine
• Interventions
• Anxiety
• Self-Care Deficit
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Postoperative Nursing Care
• Assessment
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Vital signs and level of consciousness
Inspect dressing for bleeding or drainage
Patient comfort, including pain and nausea
If vision impaired, inspect environment for safety
hazards
• Before discharge, determine patient’s understanding
of and ability to administer prescribed medications
by having the patient demonstrate self-medication
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Postoperative Nursing Care
• Interventions
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Risk for Injury
Disturbed Sensory Perception
Acute Pain
Anxiety
Ineffective Therapeutic Regimen Management
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Protection of the Eyes
and Vision
• Patient teaching
• Adults younger than 40 years of age should have
their eyes examined every 3 to 5 years
• After the age of 40, examinations every 2 years and
should include testing for glaucoma
• When there are symptoms of eye problems, patients
should seek medical advice
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Protection of the Eyes
and Vision
• Prevention of injuries
• Teach young children the danger of throwing or
poking objects at the faces of playmates
• Assess toys for safety
• Adult activities that produce sparks or cause
fragments to be dispersed also cause injuries
• Advise protective eyewear for such potentially
dangerous activities
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Protection of the Eyes
and Vision
• Basic eye care
• Gently cleanse the eyelids each time the face is
washed; use a clean cloth without soap
• Wash eye from the inner canthus (near the nose)
toward the outer canthus
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Effect of Visual Impairment
• Mild losses may require only some adaptations
• Serious losses affect independence, mobility,
employment, and interpersonal relationships
• People grieve for the lost function just as they might
grieve after the death of a loved one
• Factors that affect a person’s response to this loss
include personality, usual coping style, effect of vision
loss on the person’s life, and the circumstances of the
loss
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Care of the Visually Impaired Patient
• Be aware of visually impaired person’s
thoughts and feelings about handicaps
• Assume that people with visual impairments
can be independent and productive
• The person needs help with some tasks but
should be treated as an adult
• The extent of vision loss determines the types
of assistance needed
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Care of the Visually Impaired Patient
• Interventions
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Disturbed Sensory Perception
Ineffective Coping
Self-Care Deficit
Ineffective Therapeutic Regimen Management
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Figure 51-11
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Figure 51-12
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Disorders Affecting the Eye or
Vision:
Inflammation and Infection
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Blepharitis
• Inflammation of hair follicles along eyelid margin
• Caused by bacteria, most often by staphylococci
• Symptoms include itching, burning, and photophobia;
scales or crusts on the lid margins
• Physician may prescribe an antibiotic ointment
• Be certain that any medication applied to the eye is an
ophthalmic preparation
• Eyelids can be gently cleansed with baby shampoo
solution
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Hordeolum
• Commonly called a stye
• Common acute staphylococcal infection of the eyelid
margin that originates in a lash follicle
• Affected area of lid is red, swollen, and tender
• Apply warm, moist compresses several times a day
• Repeated infections may be related to staphylococcal
infections at some other location on the body
• Physician may treat with ophthalmic antibiotics
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Chalazion
• Inflammation of the glands in the eyelids
• Swelling prevents fluid from leaving the glands,
causing tenderness
• Warm compresses may bring some relief
• Physician may order antibiotics if infection
• Surgical removal of the gland necessary if
condition persists
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Conjunctivitis
• Inflammation of the conjunctiva caused by
microorganisms, allergy, or chemical irritants
• Bacterial conjunctivitis commonly called
pinkeye
• Red conjunctiva, mild irritation, drainage
• Warm/cool compresses, topical vasoconstrictors
• Infected people should practice good hand washing
and should avoid sharing washcloths
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Conjunctivitis
• Viral conjunctivitis caused by herpes simplex
virus type 1, herpes zoster virus, or
adenoviruses
• Characterized by redness and drainage
• Round, raised white or gray areas on the
conjunctiva
• Infections caused by herpes simplex virus type 1
are treated with ointments or other topical
medications
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Keratitis
• Inflammation or infection, or both, of the cornea
• From bacteria, viruses, fungi; chemical or mechanical
injuries cause inflammation that may be followed by
infection
• No noticeable drainage, but considerable pain
• Topical antibiotics and topical corticosteroids
• Systemic antibiotics after culture and sensitivity
• Sometimes physician injects antibiotics directly into the
conjunctiva
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Entropion
• The lower lid turns inward
• Eyelashes rub against the eye, causing pain
and possibly scratching the cornea
• Surgical correction usually recommended
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Ectropion
• The lower lid droops and turns outward
• The eye does not close completely, causing it
to become dry and irritated
• The dry cornea is easily injured
• Requires surgical correction
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Foreign Body
• Blinking/tearing wash small irritants from eye
• If foreign body remains, evert the upper and lower lids
• If object is clearly visible and does not appear to be
embedded, you may attempt to remove it
• Use sterile cotton swab to touch object gently
• If object not embedded, it usually clings to swab and
can be removed
• If object is embedded, it should be removed only by a
physician
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Figure 51-13
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Corneal Opacity
• Inflammation and infection
• When cornea injured by infection or trauma, scar tissue may
form
• If scar tissue prevents light from entering the eye, varying
degrees of vision impairment occur
• Only treatment is keratoplasty (removal of the scarred cornea
and replacement with a healthy cornea)
• During keratoplasty, damaged cornea removed first
• An identically sized graft then taken from the donor eye and
secured to the recipient’s eye with very fine suture
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Figure 51-14
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Figure 51-15
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Care of the Patient Having
Keratoplasty
• After surgery, the keratoplasty patient has an
eye pad and a metal shield over the operative
eye
• Corticosteroid eye drops may be ordered to
reduce inflammation
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Care of the Patient Having
Keratoplasty
• Assessment
• Inspect dressing for drainage and ask if patient has pain or
nausea
• After dressing is removed, inspect for corneal opacity
• Also evaluate the patient’s visual acuity
• Interventions
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Risk for Injury
Pain
Impaired Sensory Perception
Ineffective Therapeutic Regimen Management
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Disorders Affecting the Eye or Vision:
Errors of Refraction
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Myopia
• The medical term for nearsightedness
• The lens is situated too far from the retina
• Light rays come together to focus in front of the
retina
• People with myopia have difficulty seeing
distant images clearly
• New glasses needed approximately every 2
years
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Hyperopia
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Commonly known as farsightedness
The lens is too close to the retina
Light rays come together behind the retina
The hyperopic person sees clearly in the
distance but has difficulty focusing on close
objects
• Convex corrective lenses needed
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Figure 51-16
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Astigmatism
• Irregularities in the cornea or lens
• If condition is mild, the natural lens can correct
for the abnormality
• If severe, vision is distorted, and corrective
lenses are needed
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Presbyopia
• Poor accommodation due to loss of elasticity of
the ciliary muscles
• Accommodation: adjustment of the lens for near and
distant vision
• Contraction or relaxation of the ciliary muscles,
which causes the lens to change shape
• It most often develops after age 40 years
• Corrective lenses are needed
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Medical Treatment
• Corrective lenses for errors of refraction
• Eyeglasses
• Contact lenses
• Surgical treatment
• Photorefractive keratectomy (PRK)
• Laser in situ keratomileusis (LASIK)
• Nursing care
• Encourage periodic examinations and know if the
patient uses corrective lenses
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Disorders Affecting the Eye or
Vision
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Cataract
• Lens opaque (cloudy); no longer transparent
• Causes: congenital, traumatic, degenerative
• Pathophysiology
• Injuries cause opacity rapidly, whereas age-related
opacity progresses slowly
• Signs and symptoms: cloudy vision, seeing
spots or ghost images, and floaters
• Medical treatment
• Cataract extraction
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Figure 51-17
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Cataract
• Complications
• Leakage of vitreous humor, hemorrhage into the eye,
and opening of the incision
• Lens replacement
• Cataract eyeglasses
• Contact lenses
• Intraocular lenses
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Care of the Patient with Cataracts
• Preoperative care
• Drops used before cataract surgery are mydriatics,
cycloplegics, antibiotics, and nonsteroidal antiinflammatory agents
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Care of the Patient with Cataracts
• Postoperative care
• Assessment
• Pain and nausea
• Patient is likely to wear a patch and shield over operative
eye
• Note any drainage
• Also note level of consciousness and orientation
• Interventions
• Risk for Injury
• Impaired Sensory Perception
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Glaucoma
• Pathophysiology
• Intraocular pressure is above normal
• Caused by interference with outflow of aqueous
humor
• Although glaucoma may follow trauma, exact cause
is often unknown
• Peripheral vision is lost first
• Field of vision gradually narrows until tunnel vision
• Complete blindness eventually occurs
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Types of Glaucoma
• Open-angle glaucoma
• Prevents the normal passage of aqueous humor through the
trabecular meshwork
• Usually there are no signs and symptoms at first
• Tired eyes, blurred vision, and halos around lights
• Need for frequent changes in eyeglass prescriptions
• Treated first with drug therapy
• Beta-adrenergic blockers, adrenergics, cholinergics, carbonic
anhydrase inhibitors, and hyperosmotic agents
• Surgical procedures: trabeculoplasty, trabeculectomy, and
cyclocryotherapy
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Glaucoma
• Angle-closure glaucoma
• Flow of aqueous humor through the pupil is blocked
• Pressure forces iris forward; blocks trabecular meshwork
• Rapid rise in intraocular pressure; if not lowered promptly,
permanent blindness can result
• Signs and symptoms: sudden, acute pain; blurred vision, halos
around lights, nausea and vomiting, and headache on the
affected side
• Drugs for treatment: miotics and oral or intravenous carbonic
anhydrase inhibitors
• After pressure lowered, iridotomy or iridectomy usually
recommended to prevent recurrence
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Glaucoma
• Assessment
• Collect data about patient knowledge of the disease
and treatment and patient ability to carry out selfcare
• Interventions
• Risk for Injury
• Fear and Ineffective Therapeutic Regimen
Management
• Pain
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Retinal Detachment
• Pathophysiology
• Separation of sensory layer from pigmented layer
• Begins when a tear in the retina allows fluid to collect between the
sensory and the pigmented layers
• The fluid causes the two layers to separate
• Separation deprives sensory layers of nutrients and oxygen that
normally are supplied by the blood vessels in the choroid
• Leads to damage to the nerve tissue in the sensory layer and
resultant partial or complete loss of vision
• Retinal tears may occur spontaneously or as a result of trauma
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Retinal Detachment
• Signs and symptoms
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Depend on location and extent of detachment
Patients report seeing light flashes or floaters
Vision may be cloudy
If area of detachment is large, vision may be lost
completely
• Some patients say it seems as if a curtain has come
down or across the line of vision
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Figure 51-18
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Retinal Detachment
• Medical and surgical treatment
• Laser photocoagulation
• Cryotherapy
• Scleral buckling
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Retinal Detachment
• Nursing care
• Before corrective measures, the patient usually is placed on
strict bed rest with the head elevated
• Postoperative care essentially the same as for other patients
undergoing eye surgery
• Positioning orders may be specific for these patients
• Surgeon prescribes activity limitations; length of hospitalization
depends on location and severity of the tear, the type of repair,
and the surgeon’s routines
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Figure 51-19
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Senile Macular Degeneration
• Changes in the eye cause the macula to degenerate
• Both eyes usually affected
• Two types
• Dry (strophic)
• Abnormal blood vessels develop in or near the macula resulting in
loss of vision in a specific area
• Wet (exudative)
• Central vision gets gradually worse
• Special telescopic lenses may be helpful
• Laser treatments may offer hope to some patients
• Nurse needs to help the patient and family members learn to cope
with declining vision
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Figure 51-20
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Enucleation
• Removal of the eye
• From injury, infection, sympathetic ophthalmia, and
some glaucomas and malignancies
• Postoperative observe for excessive bleeding or
increasing pain
• Report any temperature elevation
• After pressure dressing removed, physician may order wound
care and topical medications
• Approximately 1 month after the enucleation, a prosthesis can
be fitted by an optician
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Figure 51-21
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