aqueous humor moisturizes and nourishes the lens & cornea, made in the ciliary bodies

lens Separates the anterior and posterior chamber. Transparent, behind iris
- attached to ciliary muscle
ciliary muscle muscle that relaxes and contracts to change the shape of the lens
(accommodation)
10-21 mmHg What is the normal intraocular pressure?
Snellen chart What is a common tool used to test visual acuity?
slit-lamp This test magnifies the anterior eye structures. Patient leans on chin rest to
stabilize head. Narrow beam of light is aimed so that only a narrow segment of
the eye is brightly lighted. The examiner can then locate position of any
abnormality.
tonometry measurement of intraocular pressure
electroretinography The process of graphing the retina's response to light stimulation. Helpful in
detecting and evaluating blood vessel changes from disease or drugs. Graph is
obtained by placing a contact lens electrode on an anesthetized cornea. Lights
at varying speeds and intensities are flashed, and the neural response is
graphed. The measurement from the cornea is identical to the response that
would be obtained if electrodes were placed directly on the retina.
fluorescein Measures abnormal blood vessels in the eye. Have dye injected and watch
angiography blood flow in the eye. Can turn skin yellow and urine green/yellow for 12-24
hrs
corneal staining Blot some stain on the eye to see extent of scratching and injury. Use a blue
light after staining and any scratches/cuts will show up easily
snellen chart test Tests visual acuity.
- cover one eye and use one eye to read
- use both eyes
- stand 20 ft away
- read lines until 3 mistakes made
- move up to line that has less than 3 mistakes
- 20/20 = normal
- 20/70 = refractive errors
- 20/200 = legally blind
OS left eye
OD right eye
OU both eyes
topical anesthetics Proparacaine HCL, or proxymetacaine (AKTaine, Alcaine, Ocu-Caine,
Ophthetic), Tetracaine HCL, cocaine HCL (Pontacaine)
- remind pt not to rub or touch eye while it is anesthetized
- patch the eye if the patient leaves the facility before the anesthetic wears off
- instruct the patient not to use discolored solution
- teach the patient to store the bottle tightly closed
topical steroids Prednisolone acetate, Prednisolone phosphate, Dexamethasone,
Betamethasone, Fluorometholone
- tell the patient to shake the bottle vigorously before use
- teach the patient to check for corneal ulceration (pain, reduced vision,
secretions)
- warn the patient not to share eyedrops with others
anti-infective agents Gentamicin, Tobramycin, Ciprofloxacin, Erythromycin, Chlortetracycline,
Sulfisoxazole, Ofloxacin, Levofloxacin
- teach the patient the importance of using the drug exactly as prescribed,
even if he or she needs to use it hourly
- teach the patient how to clean exudate from the eyes before using drops
- reinforce the importance of completing the prescribed drug regimen
antibiotic-steroid Tobramycin with dexamethasone, Neomycin sulfate with polymyxin B sulfate
combinations and dexamethasone
- instructions are the same as for each component alone
topical antiviral agents Trifluridine, Vidarabine
- teach the patient to refrigerate the drug and protect it from light
- teach the patient to assess for itching lids and burning eyes
antifungal agents Amphotericin B, Natamycin
- teach the patient to assess for itching lids and burning eyes
nonsteroidal anti- Flurbiprofen, Diclofenac, Bromfenac, Ketorolac
inflammatory agents - teach the patient to check for bleeding in the eye
(NSAIDS) - teach the patient not to wear soft contact lenses during therapy with these
drugs
instillation of - check name, strength, expiration date
ophthalmic ointment - wash hands, check prescription, check name, explain procedure, put on
(chart 49-1) gloves,etc
- have pt sit and tilt head back, you stand behind them
- pull lower lid down forming small pocket
- without touching any part of the eye or lid with tip of tube, gently squeeze
tube and release about 1/4-1/2 in strip of ointment into pocket. move from
inner to outer canthus. release lower lid
- tell pt to close eye gently and gently wipe away any excess
- have pt keep eye closed for about 1 min
prostaglandin agonists Bimatoprost, Latanoprost, Travoprost, Unoprostone. Lower IOP by dilating
blood vessels in trabecular mesh of eye where aqueous humor is reabsorbed.
- teach to check cornea for abrasions or other signs of trauma
- remind that, over time, eye color darkens & eyelashes elongate in eye
receiving drug
- if only one eye is to be treated, teach pt NOT to place drops in other eye to
try to make eye colors similar
- warn pt that using higher doses than prescribed can reduce effectiveness in
controlling glaucoma
adrenergic agonists Apraclonidine, Brimonidine tartrate, Dipivefrin hydrochloride, Epinephryl
borate. Bind to receptors in eye, reducing amount of aqueous humor
produced. In addition, pupil is dilated and flow of fluid through pupil is
improved.
- ask whether pt is taking any MAOI's
- teach to wear dark glasses outdoors and indoors when lighting is bright
- teach not to use eye drops with contact lenses in place and wait 15 min after
using drug to put in the lenses
beta-adrenergic Betaxolol hydrochloride, Carteolol, Levobetaxolol, Levobunolol, Metipranolol,
blockers Timolol. By selectively blocking beta-adrenergic receptors in eye, less aqueous
 humor is produced. Fluid appears to be absorbed slightly faster as well.
- ask whether pt has moderate-severe asthma or COPD
- warn diabetic pts to check blood glucose levels more often when on this drug
- teach pts who also take oral beta blockers to check pulse at least twice per
day and notify physician if pulse consistently below 58 bpm
cholinergic drugs Carbachol, Echothiophate, Pilocarpine. Lower IOP by decreasing amount of
aqueous humor produced and improving flow of fluid. Make pupil smaller
(miosis) but, at same time, make more room between iris and lens, allowing
fluid to flow through pupil better even though it's small.
- teach not to use more eyedrops than are prescribed and to report increased
salivation or drooling to physician
- teach to use good light when reading and take care in darker rooms
carbonic anhydrase Brinzolamide, Dorzolamide. Reduce IOP by directly inhibiting production of
inhibitors aqueous humor. Do not affect flow or absorption of the fluid.
- ask whether pt has allergy to sulfonamide antibacterial drugs
- teach to shake drug before applying
- teach not to use eyedrops with contact lenses in place and wait 15 minutes
after using drug to put in the lenses
combination drugs Brimonidine tartrate and timolol maleate.
- instructions same as for each drug alone
5 minutes How long do you need to wait between instilling different eye drops in the
same eye?
miotics constricts the pupil
mydriatics dilates the pupil
anesthetics numbs the eye and surface of the eye
- can help with discomfort
- local
cycloplegics temporarily paralyzes your accommodation
adrenergics dries eye out, decreases IOP
beta-blockers decreases aqueous humor
- can have real side effects if it goes systemic i.e. decreased BP and HR, induce
hypoglycemia (apply punctal pressure to inner canthus to avoid this)
refractive errors Refraction is the ability of the eye to bend light rays so that they fall on the
retina. Errors are when they fall on the retina in the wrong places
strabismus Inability to focus both eyes at same time on same object
- lack of coordination between the extraocular muscles
- can cause double vision, can be adult onset
- Treatment: surgery, eye glasses - prisms
screening for - Cover test: person focuses on near object, cover is placed over eye for short
strabismus moment and then removed, eye is observed for movement, strabismus eye
will wander inward or outward trying to focus
- Hirschberg test: shining light in eyes and observing whether light centers in
the pupils at the same place

amblyopia "Lazy eye". No transmission or poor transmission of the visual image to the
brain - poor depth perception
- usually unilateral but still a problem
 - can often be corrected with use of an eye patch on the dominant eye and/or
vision therapy
- detecting condition in early childhood increases chance of successful
treatment, but can still be adult onset
- vision therapy: use atropine to dilate the "good" eye which helps to stimulate
the "lazy" eye
astigmatism Unevenly curved surfaces on the eye especially the cornea
- because light rays aren't refracted equally in all directions, a focus point on
the retina is not achieved
- increases with age
- treatment: eye glasses
presbyopia As people age, the crystalline lens loses its elasticity and is less able to alter its
shape to focus the eye for close work
- "presby" is latin for old man, has to do with age
- symptoms: eye strain, poor night vision, blurred vision, squinting, fatigue,
headaches
- * = cardinal signs for all refractive errors
- onset of symptoms occurs in 40's
- treatment: reading glasses - bifocals - multifocal contact lenses
myopia Nearsightedness.
- Eye over bends the light resulting in images focused in front of the retina
- near vision is normal, but distance vision is poor
- treatment: biconcave lens or contact lens
hyperopia Farsightedness.
- eyes does not refract light enough
- images fall behind the retina
- vision beyond 20 feet is normal, but near vision is poor
- treatment: corrected with convex lens or contact lens
surgical treatment of - photorefractive keratectomy (PRK)
refraction errors - laser in situ kerotomileusis (LASIK)
- outcomes are very positive
- need to teach pt about meds
c A 44-yr-old pt tells the nurse she recently bought reading glasses because they
helped her see better at close range. When she asks the nurse what is
happening to her eyes, the nurse explains that this change occurs as a result
of...
A) retinal thinning
B) degeneration of the cornea
C) loss of lens elasticity
D) loss of cones
blindness Clients are legally blind if their best visual acuity with corrective lenses is
20/200 or less
- can occur in one or both eyes
- can be functional or total
functional blindness Have light perception. Can make out shapes but no details
risk factors of - glaucoma
blindness - cataracts
 - diabetic retinopathy
- atherosclerosis
- trauma
goals of blindness - promote independence and provide emotional support
treatment - facilitate activities of daily living
- health teaching
- communication
- safety
- ambulation
- self-care
- support
communication - identify yourself when entering room
enhancement for - not pt's reaction to diminished vision
visual deficit (chart - accept pt's reaction to diminished vision
49-10) - assist pt in setting new goals to learn how to "see" with other senses
- build on remaining vision, as appropriate
- walk 1-2 steps ahead of pt, with pt's hand on your elbow
- describe environment to patient
- don't move items in pt's room without informing patient
- read mail, newspaper, etc. to pt
- identify items on food tray in relation to numbers on a clock
- fold paper money in different ways for easy identification
- inform where to locate radio or talking books
- provide magnifying glass or prism eyeglasses, as appropriate, for reading
- provide braille reading material
- initiate occupational therapy referral
- refer pt to appropriate agency
B A nurse orients a visually impaired client to his hospital room. Choose an
appropriate action...
A) assure client that the nurse tech will helps feed him meals
B) orient client to furniture placement
C) speak in louder tones to facilitate communication
D) do not speak when entering room so that client will not be startled
trauma - MVA (motor vehicle accidents)
- sports
- falls
- assaults
- work-related
- hobbies
- children: propulsive objects - fire crackers, scissors
hematoma/contusion "Black eye". Most black eye injuries are minor and will heal themselves
in about one week.
- pain and nausea main symptoms that something isn't right
- some common signs of more serious injury may include: double vision,
loss of sight or fuzzy vision, loss of consciousness, inability to move the
eye or large swelling, blood or clear fluid from the nose or ears, blood on
surface of eye, persistent headache
chemical burns - S&S: pain, redness, irritation, tearing, inability to keep eye open,
sensation of something in the eye, swelling of eyelids, blurred vision
- tx: begin washing eye before taking any other action and continue for
at least 20 min. The longer a chemical is in your eye, the more damage
will occur. Irrigate from inner canthus to outer, no need to pull sclera
down
- using sterile flush is best but use what you have (i.e. water hose)
- don't give anything to eat or drink (might have to have surgery right
away)
- keep head at least 45 degree angle because of swelling
ocular irrigation (chart 1) assemble equipment
49-8) 2) quickly obtain history from pt while flushing the tubing with normal
saline
3) evaluate pt's visual acuity BEFORE treatment
4) put on gloves
5) place strip of pH paper in cul-de-sac of pt's effected eye to test pH of
agent splashed into eye and know when it has been washed out
6) instill proparacaine hydrochloride eye drops as prescribed
7) place pt in supine position with head turned slightly toward effected
eye
8) have pt hold effected eye open, or position an eyelid speculum
9) direct flow of normal saline across affected eye from inner to outer
canthus
10) assess pt's comfort during procedure
11) if both eyes effected, irrigate them simultaneously using separate
personnel and equipment
penetrating wounds Poorest chance of retaining vision in the injured eye
- common causes: glass, high-speed metal or wood particles, BB pellets
and bullets
- lodge in or behind the eyeball
- s&s: pain, possible loss of vision
- x-ray and CT scan to see extent of injury
- MRI contraindicated: may be metal piece in eye and MRI can move it
around
- treatment: surgery, IV antibiotics before surgery, tetanus booster if
needed
A An unconscious patient is admitted to the emergency department
with multiple injuries following a motorcycle accident. While
assessing the pupillary reflexes, the nurse notes the presence of
contact lenses. Which action should the nurse take next?
A) remove the contact lens from the eye
B) call the physician to evaluate client's eyes
C) determine what lens type is present in the eyes
D) apply artificial tears to lubricate the eyes