Anatomy and Physiology Review

A. Location and Structure

The eyeball, a round, ball-shaped organ about 1 inch in diameter (2.3 cm in

diameter, 2.5cm long). It is located in the anterior portion of the orbit. The orbit is
the bony structure that surrounds the eye and offers protection to the eye along
with the attached muscles, nerves, vessels, and tear-producing glands.

B. Layers of the Eye

1. The external layer

a. The external layer is the fibrous coat that supports the eye.

b. It contains the sclera, which is an opaque white tissue making up the

“whites” of the eye, and cornea, which is a dense transparent layer on the
front of the eye.

2. The middle layer, or uvea, is vascular and heavily pigmented. It consists of the
choroid, the ciliary body, and the iris.

a. The choroid is the dark brown membrane located between the sclera and
the retina, lines most of the sclera. The choroid lines most of the sclera and
is attached to the retina but can detach easily from the sclera. The choroid
contains many blood vessels and supplies nutrients to the retina.

b. The ciliary body connects the choroid with the iris and secretes aqueous
humor that helps give the eye its shape

c. The iris is the colored portion of the eye, is located in front of the lens, and
has a central circular opening called the pupil. The muscles of the iris
contract and relax to control pupil size and the amount of light entering the
eye. The pupils control the amount of light that enters the eye and reaches
the retina. Darkness produces dilation. Light produces constriction.

3. The internal/innermost layer consists of the retina. It is a thin, delicate structure

in which the fibers of the optic nerve are distributed and is made up of sensory
receptors that transmit impulses to the optic nerve. It also contains blood
vessels and photoreceptors called rods and cones. Rods work at low light levels
and provide peripheral vision. The cones are active at bright light levels and
provide color and central vision.

• Optic fundus – Optic disk

o The optic fundus is the area at the inside back of the eye that can
be seen with an ophthalmoscope. This area contains the optic
disk, is a creamy pink to white depressed area in the retina. The
optic nerve enters and exits the eyeball at this area. This area is
called the blind spot because it contains only nerve fibers, lacks
photoreceptor cells, and is insensitive to light.

• Macula Lutea

o The macula lutea is a small, oval yellowish, pink area located

lateral and temporal to the optic disk. The central depressed part
of the macula is the fovea centralis, where most acute vision
occurs.

Refractive Structures and Media

 C. Vitreous body

The vitreous body contains a gelatinous substance that occupies the vitreous
chamber, which is the space between the lens and the retina.

D. Vitreous

It is a jell-like substance that maintains the shape of the eye. It also provides
additional physical support to the retina.

E. Aqueous humor

It is a clear watery fluid that fills the anterior and posterior chambers of the eye.
The anterior chamber lies between the cornea and the iris while the posterior
chamber lies between the iris and the lens. The aqueous humor is produced by the
ciliary processes, and passes from the posterior chamber, through the pupil, and
into the anterior chamber. The fluid drains into the canal of Schlemm.

F. Canal of Schlemm

The canal of Schlemm is a passageway that extends completely around the eye.
The canal permits fluid to drain out of the eye into the systematic circulation so a
constant intraocular pressure is maintained.

G. Lens

It is a transparent circular, convex structure behind the iris and in front of the
vitreous body. It bends rays of light so that the light falls/focus properly on the
retina.

External Structure

H. Eyelids

The eyelids are thin, movable folds of skin that protect the eyes, shut out light
during sleep, and keep the cornea moist. The upper eyelid is larger than the lower
one. The canthus is the place where the two eyelids meet at the corner of the eye.

I. Conjunctivae

The conjunctivae are thin transparent mucous membranes. The palpebral

conjunctiva is a thick membrane with many blood vessels that lines the under
surface of each eyelid. Located over the sclera is the thin, transparent bulbar
conjunctiva.

J. Lacrimal gland

It produces tears and is located in the upper part of each orbit. Tears flow across
the front of the eye, toward the nose, and into the inner canthus. They drain
through the punctum (an opening at the nasal side of the lid edges), into the
lacrimal duct and sac, and then into the nose through the nasolacrimal duct.

K. Eye Muscles

Six voluntary muscles rotate the eye and coordinate eye movements.

Rectus muscles exert their pull when the eye turns temporally

Oblique muscles exert their pull when the eye turns nasally.

Functions of the Eye Muscles:

a. Superior Rectus Muscle

 Together with the lateral rectus, this muscle moves the eye
diagonally upward toward the side of the head

Together with the medial rectus, this muscle moves the eye
diagonally upward toward the middle of the head

b. Lateral Rectus Muscle

Together with the medial rectus, contraction of this muscle holds

the eye in a straight position

Contracting alone, the muscle turns the eye toward the side of the
head

c. Medial Rectus Muscle

Contracting alone, this muscle turns the eye toward the nose.

d. Inferior Rectus Muscle

Together with the lateral rectus, this muscle moves the eye
diagonally downward toward the side of the head

Together with the medial rectus, this muscle moves the eye
diagonally downward toward the middle of the head

e. Superior Oblique Muscle

Contraction pulls the eye downward

f. Inferior Oblique Muscle

Contraction pulls the eye upward

L. Nerves

The muscles around the eye are innervated by:

Cranial nerve II: optic nerve (nerve of sight), connecting the optic disc to the brain

Cranial nerve III: oculomotor

Cranial nerve IV: trochlear

Cranial nerve VI: abducens

Cranial nerve V: trigeminal (stimulates the blink reflex when the cornea is
touched)

Cranial nerve VII: facial (innervates the lacrimal glands and muscles controlling lid
closure)

M. Blood vessels

1. Ophthalmic artery is the major artery supplying the structures in the eye. This
artery branches to supply blood to the retina. The ciliary arteries supply the
sclera, choroid, ciliary body and iris.

2. Two Ophthalmic veins drain the blood from the eye

Functions
Four eye function that provides clear images of near and far objects:
A. Refraction
 The different curved surfaces and refractive media of the eye allow light to pass
through to the retina. Each surface and media bends (refracts) light differently to
focus an image on the retina
Emmetropia is the perfect refraction of the eye: with the lens at rest, light rays
from a distant source (6m or more) are focused into a sharp image on the retina.
Errors of refraction:
Hyperopia (hypermetropia or farsightedness) occurs when the eye does not refract
light enough. As a result, images actually fall (converge) behind the retina. It is
corrected with a convex lens in eyeglasses or contact lenses.
Myopia (Nearsightedness) occurs when the eye overrefracts or overbends the
light. As a result, images are focused in front of the retina. It is corrected with a
biconcave lens in eyeglasses or contact lenses.
Astigmatism is a refractive error caused by unevenly curved surfaces on or in the
eye, especially of the cornea. These uneven surfaces distort vision.
B. Pupillary Constriction
The pupil controls the amount of light that enters the eye. If the level of light to
one of both eyes is increased, both pupils constrict (become smaller). The amount
of constriction depends on how much light is available and how well the retina can
adapt to light changes.
Pupillary constriction is called miosis, and papillary dilatation is called mydriasis.
C. Accommodation
The process of maintaining a clear visual image when the gaze is shifted from a
distant to a near object is known as accommodation. The eye is able to adjust its
focus by changing the curve of the lens.
D. Convergence

Circulation of Aqueous Humor

Ciliary body

Posterior chamber

Pupil

Anterior chamber

Canal of Schlemm

Blood

Balanced intraocular pressure

Assessment of Vision

A. Acuity

1. Visual Acuity tests measure both distance and near vision

• Snellen’s chart (eye chart) – simple tool that measures distance vision. The
clients stands 20 feet from the chart and covers one eye and uses the other
eye to read the line that appears most clearly.

o Have the client stand 20 feet from the chart, cover an eye, and use
the other eye to read the line that appears most clear. If the client
can do this accurately, ask him/her to read the next lower line.
Repeat the procedure with the other eye. Record findings as a
comparison between what the client can read at 20 feet and the
distance at which a person with normal vision can read the same line.
For example, 20/50 means that the client is able to see at 20 feet
from the chart what a “healthy eye” can see at 50 feet.
 • Near Vision Testing – is test for clients who have difficulty reading and n
clients over 40 years of age. Use a small, handled Snellen chart called a
Rosenbaum Pocket Vision Screener or a Jaeger card. Ask the client to hold
the card 14 inches away from his or her eyes and read the characters. Test
each eye separately and then together. Record the value of the lowest line
on which the client can identify more than half the characters.

B. Confrontational test – to examine visual fields or peripheral vision

• During the test, sit facing the client and ask him or her to look directly into
your eyes while you look into the client’s eyes. Cover your right eye, and
have the client cover hor or her left eye so that you both have the same
visual field. Then move a finger or an object from the nonvisible area into
the client’s line of vision. The client with normal peripheral vision should
notice the object at about the same time to you. Repeat this examination by
covering your left eye and the client covering his or her right eye.

o Hemianopia –blindness in one half the field of vision

o Quadranopia – blindness in one fourth of the field or vision

o Scotomas – blind spots in the visual field

C. Extraocular muscle function

1. Corneal light reflex – determines alignment of the eyes. Ask the client to stare
straight ahead, shine a penlight at both corneas from a distance of 12 to 15
inches. The bright dot of light reflected from the shiny surface of the cornea
should be in a symmetric position. An asymmetric reflex indicates a deviating
eye and possible muscle imbalance.

2. Six cardinal positions of gaze - client holds head still and is asked to move eyes
and to follow a small object

3. Cover-uncover test – ask the client to use both eyes to look at a specific fixed
point, such as your nose. Then place a card over one of the client’s eyes, and
observe the uncovered eye to see if it moves to fix on the object. If muscle
function is normal, the eye does not move.

D. Color vision

1. Tests for color vision involve picking numbers or letters out of a complex and
colourful picture

2. Ishihara chart consists of numbers that are composed of colored dots located
within a circle of colored dots. The test is sensitive for the diagnosis of red

E. Ophthalmoscopy

This is to examine the external structures and the interior of the eye.

Procedure

a. Performing ophthalmoscopy, hold the instrument with your right hand when
examining the right eye and with your left hand when the examining the
left. Stand on the same side as the eye being examined. Tell the client to
look straight ahead at an object on the wall behind you.

b. When using the ophthalmoscope, move towards the client’s eye from about
12 to 15 inches away and to the side of his or her line of vision. As you
direct the ophthalmoscope at the pupil, a red glare (red reflex) should be
 seen in the pupil. The red reflex is a reflexion of the light of the retina. An
absent red reflex may indicate a lens opacity or cloudiness of the vitreous.

Diagnostic Test for the Eye

1. Fluorescein angiography – it is the detailed imaging and recording of ocular

circulation by a series of photographs after the administration of a dye
intravenously. This test is useful for assessing problems of retinal circulation
(diabetic retinopathy, retinal hemorrhage, and macular degeneration) or for the
diagnosis of intraocular tumors.
Preprocedure Interventions
a. Explain the procedure to the client
b. Assess the client for allergies and previous reactions to dyes
c. Obtained informed consent
d. A mydriatric medication is instilled in the eye 1 hour before the test. Warn the
client that the dye may cause the skin to appear yellow for several hours after
the test. The stain is eliminated through the urine, which also changes color.
e. The client may experience nausea, vomiting, sneezing, parasthesia of the
tongue, or pain at the injection site
Procedures
c. Intravenous access must be obtained.
d. After the needle is in the vein, 5 ml of a 10% solution of fluorescein is
injected.
e. A digital camera is set up with equipment to photograph retinal and
choriodal blood vessels as the dye passes through them. The results can be
viewed immediately on a computer screen.
f. The procedure takes only minutes because the vessels fill quickly.
Postprocedure Interventions
a. Encourage fluid intake to assist in eliminating the dye from the clients system
b. Remind the client that the yellow skin appearance will disappear
c. Instruct the client that urine will appear bright green until the dye is excreted.
d. Instruct to avoid direct sunlight for a few hours after the test
e. Photophobia will continue until pupil size returns to normal
2. Computed tomography – a beam of x-rays scans the skull and orbits of the eye.
Also used for detecting tumors in the orbital space. Usually two sets of CT scans
are performed, one set taken in the supine position (axial images) and one set
taken with the head tipped back as far possible (coronal images)

Intervention

a. Instruct the client that he or she will be positioned in a confined space and will
need to keep their heads still during the procedure

3. Magnetic Resonance Imaging

a. It has replaced CT in many settings for looking at the orbits and the optic
nerves.

b. MRI is also useful for evaluating ocular tumors

c. Metal in the eye is an absolute contraindication for MRI

4. Radioisotopic Scanning – are used to locate tumors and lesions in various body
organs. Isotope studies differentiate an intraocular tumor from a hemorrhage,
especially in the choroid layer.

Client preparation:

a. Informed consent. The client receives a tracer dose of the radioactive isotope,
either orally or by injection

Procedure:
 a. The client is asked to lie still and breathe normally. The scanner measures the
radioactivity emitted by the radioactive atoms concentrated in the area being
studied. Clients who are anxious or agitated may require sedation

Postprocedure

a. Assure the client that the amount of radioisotope used is small and that he or
she is not radioactive. No other special follow-up care is required.
5. Slit lamp – it allows examination of the anterior ocular structures under
microscopic magnification. The client leans on a chin rest to stabilize the head
while a narrowed beam of light is aimed so that it illuminates only a narrow
segment of the eye is brightly lighted.
Intervention
a. Advise the client about the brightness of the light and the need to look forward
at point over the examiner’s ear
6. Corneal staining – a topical dye is instilled into the conjuctival sac to outline
irregularities of the corneal surface that are not easily visible. The eye is viewed
through a blue filter, and a bright green color indicates areas of a non-intact
corneal epithelium. Is used for corneal trauma, problems caused by contact lens,
or the presence of foreign bodies, abrasion, ulcers or other corneal disorders.
Procedure
a. Noninvasive and performed under aseptic conditions.
b. The dye is applied topically to the eye, and then viewed through a blue filter.
Nonintact areas of cornea stain a bright green color.

Interventions

a. If the client wears contact lenses, the lenses must be removed

b. The client is instructed to blink after the dye has been applied to distribute the
dye evenly across the cornea

7. Tonometry – the test is used primarily to assess for an increase of intraocular

pressure and potential glaucoma. Normal ocular pressure is 10 to 21 mmHg.
Indicated for all clients older than 40 years of age. For adults with a family history
of glaucoma should have their IOP measured once or twice a year. IOP varies
throughout the day. It is often higher in the morning but may peak at any time of
the day.

Interventions

a. Each eye is anesthetized

b. The client is asked to stare forward at a point above the examiner’s ear

c. A flattened cone is brought in contact with the cornea

d. The amount of pressure needed to flatten the cornea is measured

e. The client must be instructed to avoid rubbing the eye following the
examination if the eye has been anesthetized because the potential for
scratching the cornea exists.

8. Ultrasonography – used to examine the orbit and eye with high-frequency sound
waves. This noninvasive test aids in the diagnosis of trauma, intraorbital tumors,
proptosis, and choriodal or retinal detachments/
Client Preparation:
a. Explain the test to the client and instill the anesthetic drops into the lower lid
b. Caution the client to avoid rubbing the eye.
c. Seat the client upright with his or her chin in the chin rest
Procedure
a. The probe is touched against the client’s anesthesized cornea and sound waves
are bounced through the eye.
 b. The sound waves return to the transducer when they strike a non-fluid filled
structure. Structures that reflect sound waves are the cornea, anterior, and
posterior lens capsule, and retina.
c. When these reflected sound waves return to the transducer, a “spike” pattern
appears on the screen
Postprocedure
a. Remind the client not to rub or bump the eye until the effects of the anesthetic
drops have worn off
9. Electroretinography – is the process of graphing the retina’s response to light
stimulation. This test is helpful in detecting and evaluating blood vessel changes
from a disease or drugs. The graph is obtained by placing a contact lens electrode
on an anesthesized cornea. Lights at varying speeds and intensities are flashed,
and the neural response is graphed.
Preparation
a. Includes instilling an anesthetic into the eye
b. Remind the client to avoid rubbing the eye until the effects of the anesthetic
have disappeared.

PRIORITY NURSING DIAGNOSIS

1. Disturbed sensory perception: visual

2. Self-care deficit: bathing, hygiene, dressing, grooming, feeding

3. Knowledge deficit

4. Grieving

5. Disturbed self-esteem

6. Hopelessness

OPHTHALMIC AND OTIC MEDICATIONS

Guidelines for the use of eye medications

1. Eye medications are usually in the form of drops or ointments.

2. To prevent overflow of medication into the nasal and pharyngeal passages, thus
reducing systemic absorption, instruct the client to apply pressure over the inner
canthus next to the nose for 30 seconds to 1 minute following administration of
the medication

3. If both an eye drop and an eye ointment are scheduled to be administered at the
same time, administer the eye drop first.

4. Wash hands before administering eye medications to avoid contaminating the eye
or medication dropper or applicator and after administering eye medications to
rinse off any residue

5. Use a separate bottle or tube of medication for each client to avoid accidental
cross-contamination

6. Place prescribed dose of eye medication in the lower conjunctival sac, never
directly onto the cornea

7. Avoid touching any part of the eye with the dropper or applicator

8. Administer glucocorticoid preparations before other medications

9. Monitor the pulse of the client receiving an ophthalmic β-blocker, and instruct the
client to do the same; if the pulse is less than 50 to 60 beats per minute (adult),
withhold the next dose of eye medication and notify the physician

10.Instruct the client how to instill medication until the client can do it safely

11.Instruct the client to read the medication labels carefully to ensure administration
of the correct medication and strength.

12.Remind the client to keep these medications out of reach of children

13.Instruct the client to avoid driving or operating hazardous equipment of vision is

blurred

14.Inform the client that he or she may be unable to drive home after eye
examinations when medications to dilate the pupil (mydriatics) or medications to
paralyze the ciliary muscle (cycloplegics) are used

15.If photophobia occurs, instruct the client to wear sunglasses and avoid bright lights

16.Instruct the client to administer a missed dose of the eye medication as soon as
remembered, unless the next dose is scheduled to be administered in 1 to 2 hours

17.Inform the client with glaucoma that the disorder cannot be cured, only controlled

18.Reinforce the importance of using medications to treat glaucoma as prescribed

and not to discontinue these medications without consulting the physician

19.Inform the client that medications used to treat glaucoma may cause pain and
blurred vision, especially when therapy is begun

20.Instruct the client to report the development of any eye irritation

21.Instruct the client using eye gel to store the gel at room temperature or in the
refrigerator but not to freeze it

22.Instruct the client to discard unused eye gel kept at room temperature after 8
weeks

23.Inform the client that soft contact lenses may absorb certain eye medications and
that preservatives in eye medications may discolour the contact lenses.

24.Advise the client wearing contact lenses to question the physician carefully about
special precautions to observe

25.In infants, inform the parents that atrophine sulphate eye drops may contribute to
abdominal distention

26.Instruct the parents to keep a record of the infant’s bowel movements of atrophine
sulphate eye drops are being administered

27.Auscultate bowel sounds of the infant or child receiving atrophine sulphate eye
drops

MYDRIATIC/CYCLOPLEGIC AND ANTICHOLINERGIC MEDICATIONS

A. Description
1. Mydriatics and cycloplegic dilate the pupils (mydriasis) and relax the ciliary
muscles (cycloplegia)
2. Anticholinergics block responses of the sphincter muscle in the ciliary body,
producing mydriasis and cyclopegia
 3. These medications are used preoperatively or for eye examinations to
produce mydriasis
4. These medications are contraindicated in clients with glaucoma because of
the risk of increased intraocular pressure
5. Mydriatics are contraindicated in cardiac dysrhythmias and cerebral
atherosclerosis and should be used with caution in the older client and in
clients with prostatic hypertrophy, diabetes mellitus, or parkinsonism
B. Side Effects
1. Tachycardia
2. Photophobia
3. Conjunctivitis
4. Dermatitis
C. Atrophine Toxicity
1. Dry mouth
2. Blurred vision
3. Photophobia
4. Tachycardia
5. Fever
6. Urinary retention
7. Constipation
8. Headache, brow pain
9. Confusions
10.Hallucinations, delirium
11.Coma
12.Worsening of narrow-angle glaucoma
D. Systemic reactions of anticholinergics
1. Dry mouth
2. Fever
3. Thirst
4. Confusion
5. Hyperactivity
E. Interventions
1. Monitor for allergic response
2. Assess for risk of injury
3. Assess for constipation and urinary retention
4. Instruct the client that a burning sensation may occur on instillation
5. Instruct the client not to drive or perform hazardous activities for 24 hours
after instillation of the medication unless otherwise directed by the
physician
6. Instruct the client to wear sunglasses until the effects of the medication
wear off
7. Instruct the client to notify the physician if blurring of vision, loss of sight,
difficulty breathing, sweating, or flushing occurs
8. Instruct the client to report eye pain to the physician
F. Alpha-Adrenergic blocker
1. Medication: dapiprazole hydrochloride (Rev-Eyes)
2. Use: to counteract mydriasis

Mydriatric/Cycloplegic Eye Medications

Atropine sulphate (Isopto Atropine, Ocu-Tropine, Atropair,
Atropisol)
Cyclopentolate and phenylephrine (Cyclomydril)
Cyclopentolate hydrochloride (Cyclogyl, AK-Pentolate,
Pentolair)
Homatropine hydrobromide (Isopto Homatrine, AK-
Homatropine, Spectro-Homatrine)
Scopolamine phenylephrine (Murocoll 2)
Scopolamine hydrobromide (Isopto-Hyoscine)
Tropicamide (Mydriacyl, I-Piramide, Tropicacyl)
Tropicamide and hydroxyamphetamine (Paremyd)

ANTIINFECTIVE EYE MEDICATIONS

 A. Description: Antiinfective medications kill or inhibit the growth of bacteria, fungi,
and viruses

B. Side effects

Superinfection

2. Global irritation

C. Interventions

1. Assess for risk of injury

2. Instruct the client how to apply the eye medication

3. Instruct the client to continue treatment as prescribed

4. Instruct the client to wash hands thoroughly and frequently

5. Advise the client that if improvement does not occur to notify the physician

Antiinfective Eye Medications

AMINOGLYCOSIDES
Gentamycin sulphate
(Garamycin, Genoptic)
Tobramycin (Nebcin, Tobrex)

ANTIBACTERIAL
Chloramphenicol
(Chloromycetin, Chloroptic)
Erythromycin (Ilotycin)

ANTIFUNGAL
Natamycin (Natacyn)

ANTIVIRAL
Idoxuridine (Stoxil, Herplex)
Trifluridine (Viroptic)
Vidarabine (Vira-A)

SULFONAMIDES
Sulfacetamide (Bleph-10,
Sulamyd)
Sulfisoxadole (Gantrisin)

ANTIINFLAMMATORY EYE MEDICATIONS

A. Description

1. Antiinflammatory medications control inflammation, thereby reducing vision

loss and scarring

2. Antiinflammatory medications are used for uveitis, allergic conditions, and

inflammation of the conjunctiva, cornea, and lids

B. Side Effects

1. Cataracts

2. Increased IOP
 3. Impaired healing

4. Making signs and symptoms of infection

C. Interventions

1. Interventions are the same as for antiinfective medication

2. Note that dexamethasone (Maxidex) should not be used for eye abrasions
and wounds

Antiinflammatory Eye Medications

ANTIALLERGIC AGENTS
Cromolyn sodium (Opticrom)
Ketotifen fumarate (Zaditor)
Levocabastine (Livostin)
Lodoxamide (Alomide)

CORTICOSTERIODS
Betamethasone (Betnesol)
Dexamethasone (Maxidex)
Fluorometholene (FML-S Ophthalmic
Suspension, FML)
Medrysone (HMS Liquifilm)
Prednisolone (Pred-Forte, Predair-A)

NONSTEROIDAL ANTIINFLAMMATORY
AGENTS
Diclofenac (Voltaren)
Flurbiprofen sodium (Ocufen)
Ketorolac tromethamine (Acular)

TOPICAL ANESTHETICS FOR THE EYE

A. Description

1. Topical Anesthetics produce corneal anesthesia

2. Topical anesthetics are used for anesthesia for eye examinations and
surgery or to remove foreign bodies from the eye

B. Side Effects

1. Temporary stinging or burning of the eye

2. Temporary loss of corneal reflex

C. Interventions

1. Assess for risk of injury

2. Note that the medications should not be given to the client for home use
and are not to be self-administered by the client

3. Note that the blink reflex is lost temporarily and that corneal epithelium
needs to be protected

4. Provide an eye patch to protect the eye from injury until the corneal reflex
returns
Topical Anesthetics for the Eye
Proparacaine hydrochloride
(Ophthaine, Ophthetic)
Tetracaine hydrochloride
(Pontocaine)

EYE LUBRICANTS

A. Description

1. Eye lubricants replace tears or add moisture to the eyes

2. Eye lubricants moisten contact lenses or an artificial eye

3. Eye lubricants protect the eyes during surgery or diagnostic procedures

4. Eye lubricants are used for keratitis, during anesthesia, or in a disorder that
results in unconsciousness or decreased blinking

B. Side Effects

1. Burning on instillation

2. Discomfort or pain on instillation

C. Interventions

1. Inform the client that burning may occur on instillation

2. Be alert to allergic responses to the preservatives in the lubricants

Eye Lubricants
Hydroxypropyl methylcellulose (Lacril,
Isopto Plain)
Petroleum-based ointment (artificial
tears, Liquifilm Tears

MIOTICS

A. Description

1. Miotics reduce intraocular pressure by constricting the pupil and contracting

the ciliary muscle, thereby increasing the blood flow to the retina and
decreasing retinal damage and loss of vision

2. Miotics open the anterior chamber angle and increase the outflow of
aqueous humor

3. Miotic cholinergic medications reduce intraocular pressure by mimicking the

action of acetylcholine

4. Miotic acetylcholine inhibitors reduce intraocular pressure by inhibiting the

action of cholinesterase
 5. Miotic are used for chronic open-angle glaucoma or acute and chronic
closed-angle glaucoma

6. Miotics are used to achieve miosis during eye surgery

7. Miotics are contraindicated in clients with retinal detachment, adhesions

between the iris and lens, or inflammatory diseases

8. Use miotics with caution in clients with asthma, hypertension, corneal

abrasion, hyperthyroidism, coronary vascular disease, urinary tract
obstruction, gastrointestinal obstruction, ulcer diseases, parkinsonism and
bradycardia

B. Side Effects

1. Myopia

2. Headache

3. Eye pain

4. Decreased vision in poor light

5. Local irritation

6. Systemic effects

a. Flushing

b. Diaphoresis

c. Gastrointestinal upset and diarrhea

d. Frequent urination

e. Increased salivation

f. Muscle weakness

g. Respiratory difficulty

7. Toxicity

a. Vertigo and syncope

b. Bradycardia

c. Hypotension

d. Cardiac dysrhythmias

e. Tremors

f. Seizures

C. Interventions

1. Assess vital signs

2. Assess for risk of injury

3. Assess the client for the degree of diminished vision

4. Monitor for side effects and toxic effects

 5. Monitor for postural hypotension and instruct the client to change positions
slowly

6. Assess breath sounds for wheezes and rhonchi because cholinergic

medications can cause bronchospasms and increased bronchial secretions

7. Maintain oral hygiene because of the increase in salivation

8. Have atrophine sulphate available as an antidote for pilocarpine

9. Instruct the client or family regarding the correct administration of eye

medications

10.Instruct the client not to stop the medication suddenly

11.Instruct the client to avoid activities such as driving while vision is impaired

12.Instruct clients with glaucoma to read labels on over-the-counter

medications and to avoid atropine-like medications because atropine will
increase IOP.

Miotics
Carbachol (Carboptic)
Demecarium bromide
(Humorsol)
Echothiophate (Phospholine
Iodide)
Isoflurophate (Floropryl)
Pilocarpine hydrochloride
(Isopto Carpine

OCULAR SYSTEM

A. Description

1. Ocusert is a thin eye wafer (disk) impregnated with a time-release dose of

pilocarpine

2. Ocusert is devised to overcome the frequent application of pilocarpine

3. Ocusert is placed in the upper or lower cul-de-sac of the eye

4. The pilocarpine is released over 1 week

5. The disk s replaced every 7 days

6. Drawbacks of its use include sudden leakage of pilocarpine, migration of the

system over the cornea, and unnoticed loss of the system

B. Interventions

1. Assess the client’s ability to insert the medication disk

2. Store the medication in the refrigerator

3. Instruct the client to discard damaged or contaminated disks

4. Inform the client that temporary stinging is expected but to notify the
physician of blurred vision or brow pain occurs
 5. Instruct the client to check for the presence of the disk in the conjunctival
sac daily at bedtime and on arising

6. Because vision may change in the first few hours after the eye system is
inserted, instruct the client to replace the disk at bedtime

β – ADRENERGIC BLOCKING EYE MEDICATIONS

A. Description

1. These medications reduce IOP by decreasing sympathetic impulses and

decreasing aqueous humor production without affecting accommodation or
pupil size

2. These medications are used to treat chronic open-angle glaucoma

3. These medications are contraindicated in the client with asthma because

systemic absorption can cause increased airway resistance

4. Use these medications with caution in the client receiving oral β-blockers

B. Side Effects

1. Ocular irritation

2. Visual disturbances

3. Bradycardia

4. Hypotension

5. Bronchospasm

C. Interventions

1. Monitor vital signs, especially blood pressure and pulse, before

administering medication

2. If the pulse is 60 or less or if the systolic blood pressure is less than

90mmHg, withhold the medication and contact the physician

3. Monitor for shortness of breath

4. Assess for risk of injury

5. Monitor intake and output

6. Instruct the client to notify the physician if shortness of breath occurs

7. Instruct the client not to discontinue the medication abruptly

8. Instruct the client to change positions slowly because of the potential for
orthostatic hypotension

9. Instruct the client to avoid hazardous activities

10.Instruct the client to avoid over-the-counter medications without the

physician’s approval

D. Adrenergic medications
 1. Adrenergic medications decrease the production of aqueous humor and lead
to a decrease in IOP

2. Adrenergic medications may be used to treat glaucoma

β Adrenergic Blocking Eye

Medications
Betaxolol hydrochloride
(Betoptic)
Carteolol hydrochloride
(Ocupress)
Levobunolol hydrochloride
(Betagan)
Metipranolol (Optipranolol)
Timolol maleate (Timoptic)

Adrenergic Medications
Epinephrine (Epifrin,
Glaucon)
Hydroxyamphetamine
(Paradrine)
Naphazoline (Allerest,
Vasoclear)
Oxymethazoline (OcuClear)
Phenylephrine (AK-Nephrin,
Prefin)
Tetrahydrozoline (Murine
Plus, Visine)

CARBONIC ANYHYDRASE INHIBITORS

A. Description
1. Carbonic Anhydrase inhibitors interfere with the production of carbonic acid,
which leads to decreased aqueous humor formation and decreased IOP
2. These medications are used for long-term treatment of open-angle
glaucoma
3. These medications are contraindicated in the client allergic to sulfonamides
B. Side Effects
1. Appetite loss 5. Hypokalemia
2. GI upset 6. Renal calculuses
3. Paresthesias in the fingers, 7. Photosensitivity
toes, and face 8. Lethargy and drowsiness
4. Polyuria 9. Depression
C. Interventions
1. Monitor vital signs
2. Assess visual acuity
3. Assess for risk of injury
4. Monitor intake and output
5. Monitor weight
6. Maintain oral hygiene
7. Monitor for side effects such as lethargy, anorexia, drowsiness, polyuria,
nausea and vomiting
8. Monitor electrolytes for hypokalemia
9. Increase fluid intake unless contraindicated
10.Advise the client to avoid prolonged exposure to sunlight
11.Encourage the use of artificial tears for dry eyes
12.Instruct the client not to discontinue the medication abruptly
13.Instruct the client to avoid hazardous activities while vision is impaired

Carbonic Anhydrase Inhibitors: Eye

Medications
Acetazolamide (Diamox)
Dichlorphenamide (Daranide)
Dorzolamide hydrochloride
(Trusopt)
Methazolamide (Neptazane)

OSMOTIC MEDICATIONS

A. Description

1. Osmotic medications lowers IOP

2. Are used in emergency treatment of acute closed-angle glaucoma

3. Are used preoperatively and postoperatively to decrease vitreous humor

volume

B. Side Effects

1. Headache

2. Nausea, vomiting, diarrhea

3. Disorientation

4. Electrolyte imbalances

C. Interventions

1. Assess vital signs

2. Assess visual acuity

3. Assess for risk of injury

4. Monitor intake and output

5. Monitor weight

6. Monitor electrolyte imbalances

7. Increase fluid intake unless contraindicated

8. Monitor for changes in level of orientation

Osmotic Medications
for the Eye
Glycerin (Osmoglyn)
Mannitol (Osmitrol)

Anatomy and Physiology of the Ear

A. Functions

1. Hearing

2. Maintenance of balance
B. External Ear

a. The External ear is embedded in the temporal bone bilaterally at the level of
the eyes

b. The external ear extends from the auricle through the external canal to the
tympanic membrane or eardrum

c. The external ear includes the mastoid process, which is the bony ridge
located over the temporal bone

C. Middle Ear

a. The Middle ear consists of the medial side of the tympanic membrane

b. The middle ear contains three bony ossicles:

1. Malleus

2. Incus

3. Stapes

c. The tympanic membrane is a thick transparent sheet of tissue that provides

a barrier between the external and the middle ear

d. The middle ear is protected from the inner ear by the round and the oval
window membranes.

e. The Eustachian tube opens into the middle ear and allows for equalization of
pressure on both sides of the tympanic membrane

D. Inner Ear

a. The inner ear contains the semicircular canals, the cochlea, and the distal
end of the eighth cranial nerve

b. The semicircular canals contain fluid and hair cells connected to sensory
nerve fibers of the vestibular portion of the eighth cranial nerve

c. The inner ear maintains sense of balance or equilibrium

d. The cochlea is the spiral-shaped organ of hearing

e. The organ of Corti (within the cochlea) is the receptor and organ of hearing

f. Eighth cranial nerve

a. The cochlear branch of the nerve transmits neuroimpluses from the

cochlea to the brain where they are interpreted as sound

b. The vestibular branch maintains balance and equilibrium.

E. Hearing and Equilibrium

a. The external ear conducts sound waves to the middle ear.

b. The middle ear, also called the tympanic cavity, conducts sound waves to
the inner ear

c. The middle ear is filled with air, which is kept at atmospheric pressure by
opening of the Eustachian tube

d. The inner ear contains sensory receptors for sound and for equilibrium
 e. The receptors in the inner ear transmit sound waves and changes in body
position to the nerve impulses

Assessment of the Ear

A. Otoscopic examination

1. The speculum is never introduced blindly into the external canal because of the
risk of perforating the tympanic membrane

2. The client’s head is titled slightly away and the ostoscope is held upside down
as if it were a large pen, for this permits the examiner’s hand to lay against the
client’s head for support

3. Pull the pinna up and back to straighten the external canal in adult

4. Visualize the external canal while slowly inserting the speculum

5. The normal external canal is pink and intact without lesions and with various
amounts if cerumen and fine little hairs

6. Assess the tympanic membrane for intactness; the normal tympanic membrane
is intact, without perforations, and should be free from lesions.

7. The tympanic membrane is transparent, opaque, pearly gray, and slightly

concave.

B. Auditory assessment

1. Sound is transmitted by air conduction and bone conduction

2. Air conduction takes 2 to 3 times longer than bone conduction

3. Hearing loss is categorized as conductive, sensorineural, and mixed conductive

and sensorineural.

4. Conductive hearing loss is due to any physical obstruction to the transmission

of sound waves.

5. Sensorineural hearing loss is due to a defect in the organ of hearing, in the

eighth cranial nerve, or in the brain itself

6. A mixed conductive/sensorineural hearing loss results in profound hearing loss.

C. Voice Test

1. Ask the client to block one external canal

2. The examiner stands 1 to 2 feet away and whispers a statement

3. Client is asked to repeat the whispered statement

4. Each ear is tested separately

D. Watch test

1. A ticking watch is used to test for high frequency sounds

2. The examiner holds a ticking watch about 5 inches from each ear and asks the
client if the ticking is heard

E. Tuning fork tests

1. Weber tuning fork test

 a. Place the vibrating tuning fork stem in the middle of the client’s head, at the
midline of the forehead, or above the upper lip over the teeth

b. Hold the fork by the stem only

c. The client is asked whether the sound is heard equally in both ears or
whether the sound is louder in one ear

d. Normal test result is hearing the sound equally in both ears

e. If the client hears the sound louder in one ear, the term lateralization is
applied to the side hearing the loudest.

f. Such a finding may indicate that the client has a conductive hearing loss in
the ear to which the sound is lateralized or that sensorineural hearing loss
has occurred in the opposite ear

2. Rinne tuning fork test

a. The test compares the client’s hearing by air conduction and bone
conduction.

b. Air conduction is 2 to 3 times longer than bone conduction

c. The vibrating tuning fork stem is placed on the client’s mastoid process and
the client is asked to indicate when he or she no longer hears the sound

d. The examiner quickly brings the tuning fork in front of the pinna without
touching the client and asks the client to indicate if he or she still hears the
sound

e. The client normally continues to hear the sound 2 times longer in front of
pinna; such results are a positive Rinne Test

f. The examiner records the duration of both phases, bone conduction

followed by air conduction and compares the times.

g. If the client is unable to hear the sound through the ear in front of the pinna,
the client may have a conductive hearing loss on the side tested; in this
situation, the bone conduction is greater than the air conduction (negative
Rinne test)

h. The Rinne test is of no value in determining sensorineural hearing loss

F. Vestibular assessment

g. Test for falling

a. The examiner asks the client to stand with the feet together
and arms hanging loosely at the side and eyes closed

b. The client normally remains erect with only slight swaying

c. A significant sway is a positive Romberg’s sign

h. Test for past pointing

a. The client sits in front of the examiner

b. The client closes the eyes and extends the arms on front,
pointing both index fingers at the examiner
 c. The examiner holds and touches his or her own extended index
fingers under the extended index fingers of the client to give the client
a point of reference.

d. The client is instructed to raise both arms and then lower them,
attempting to return to the examiner’s extended index fingers

e. The normal test response is that the client can easily return to
the point of reference

f. The client with a vestibular function problem lacks a normal sense of

position and is unable to return the extended fingers to the point of
reference; instead, the fingers deviate to the right or the left of the
reference point.

i. Gaze nystagmus evaluation

a. The client’s eyes are examined as the client looks straight

ahead, 30 degrees to each side, upward and downward

b. Any spontaneous nystagmus, an involuntary, rhythmic, rapid

twitching of the eyeballs, represents a problem with the vestibular
system

j. Hallpike’s manuever

a. Assesses for positional vertigo or induced dizziness

b. The client assumes a supine position

c. The head is rotated to one side for 1 minute

d. A positive test results in nystagmus after 5 to 10 seconds

Diagnostic Tests for the Ear

A. Tomography

1. Description

a. Tomography may be performed with or without contrast medium

b. Tomography assesses the mastoid, middle ear, and inner ear structures

c. Multiple radiographs of the head are made

d. Tomography is especially helpful in the diagnosis of acoustic tumors

2. Interventions

a. All jewelry is removed

b. Lead eye shields are used to cover the cornea to diminish the radiation
dose to the eyes

c. The client must remain still in a supine position

d. No follow-up care is required

B. Audiometry

1. Description
 a. Audiometry measures hearing acuity

b. Audiometry uses two types, pure tone audiometry and speech

audiometry

c. Pure tone audiometry is used to identify problems with hearing, speech,

music, and other sounds in the environment

d. In speech audiometry, the client’s ability to hear spoken words is

measured

e. After testing, audiogram patterns are depicted on graph to determine

the type and level of the hearing loss.

2. Interventions

a. Inform the client regarding the procedure

b. Instruct the client to identify the sounds as they heard

C. Electronystagmography

1. Description

a. Electronystagmography is a vestibular test that evaluates spontaneous

and induced eye movement known as nystagmus.

b. Electronystagmography is used to distinguish between normal

nystagmus and medication-induced nystagmus or nystagmus caused by
a lesion in the central or peripheral vestibular pathway

c. Electronystagmography records changing electrical fields with the

movement of the eye, as monitored by electrodes placed on the skin
around the eye

2. Interventions

a. The client is instructed to remain NPO for 3 hours before testing

b. Unnecessary medications are omitted for 24 hours before testing

c. Instruct the client that this is a long and tiring procedure

d. The client should bring the prescription eyeglass to the examination.

e. Client sits and is instructed to gaze at lights, focus on a moving pattern,

focus on a moving point, and then close the eyes

f. While sitting in a chair, the client may be rotated to provide information

about vestibular function.

g. In addition, the client’s ears are irrigated with cool and warm water,
which may cause nausea and vomiting.

h. Following the procedure, the client begins taking clear fluids slowly and
cautiously because nausea and vomiting may occur

i. Assistance with ambulation may also be necessary following the

procedure.

OTIC MEDICATIONS
Administration of drops

1. In an adult, pull the pinna up and back to straighten the external canal to instill ear
drops

2. Pull the pinna down and back for infants and children younger than 3 years of age;
up and back for older children

Irrigation of the ear

1. Irrigation of the ear needs to be prescribed by the physician

2. Ensure direct visualization of the tympanic membrane

3. Warm irrigating solution to 98⁰F because solutions that are not close to the client’s
body temperature will cause ear injury, nausea, and vertigo

4. Irrigation must be done gently to avoid damage to the eardrum

5. When irrigating, do not direct irrigation solution directly toward the eardrum

6. If a perforation of the eardrum is suspected, do not perform irrigation

Medications that Affect Hearing

ANTIBIOTICS
Amikacin (Amikin)
Chloramphenicol (Chloromycetin, Chloroptic,
Ophthoclor)
Erythromycin (E-Mycin, ERYC, Ery-Tab, PCE
Dispertabs, Ilotycin)
Gentamycin (Garamycin)
Streptomycin sulphate
Tobramycin sulphate (Nebcin)
Vancomycin (Vancocin)

DIURETICS
Acetazolamide (Diamox)
Ethacrynic acid (Edecrin)
Furosemide (Lasix)

OTHERS
Cisplatin (Platinol, Platinol-AQ)
Nitrogen mustard
Quinine (Quinamm)
Quinidine (Cardioquin, Quinaglute, Quinidex)

ANTIINFECTIVE EAR MEDICATIONS

A. Description

1. Antiinfective medications kill or inhibit the growth of bacteria

2. Antiinfective medications are used for otitis media or otitis externa

 3. Antiinfective medications are contraindicated if a prior hypersensitivity
exists

B. Side Effects

1. Overgrowth of nonsusceptible organisms

C. Interventions

1. Monitor vital signs

2. Assess for allergies

3. Assess for pain

4. Monitor for nephrotoxicity

5. Instruct the client to report dizziness, fatigue, fever, or sore throat, which
may indicate a superimposed infection

6. Instruct the client to complete the entire course of the medication

7. Instruct the client to keep ear canals dry

Antiinfective Ear Medications

Acetic Acid and aluminium acetate (Otic
Domeboro)
Amoxicillin (Amoxil)
AMpicillin Trihydrate (Polycillin)
Cefaclor (Ceclor)
Chloramphenicol (Chloromycetin Otic)
Clarithromycin (Biaxin)
Clindamycin hydrochloride (Cleocin)
Erythromycin (Ilotycin, E-Mycin)
Gentamicin sulphate otic solution (Garamycin)
Loracarbef (Lorabid)
Penicillin V potassium (Pen-V)
Polymyxin B sulphate (Aerosporin)
Tetracycline hydrochloride (Achromycin)
Trimethoprim and sulfamethoxazole (Bactrim,
Cotrim, and Septra)

ANTIHISTAMINES AND DECONGESTANTS

A. Description

1. These medications produce vasoconstriction

2. These medications stimulate the receptors of the respiratory mucosa

3. Reduce respiratory tissue hyperaemia and edema to open obstructed

eustachian tubes

4. Used for acute otitis media

B. Side Effects
 1. Drowsiness

2. Blurred vision

3. Dry mucosa membranes

C. Interventions

1. Inform the client that drowsiness, blurred vision, and a dry mouth may occur

2. Instruct the client to increase fluid intake unless contraindicated and to suck
on hard candy to alleviate dry mouth

3. Instruct the client to avoid hazardous activities if drowsiness occurs

Antihistamine and
Decongestants
Astemizole (Hismanal)
Brompheniramine (Bromphen,
Dimetan)
Cetirizine (Zyrtec)
Chlorpheniramine (Chlor-
Trimeton, Teldrin)
Clemastine (Tavist)
Naphazoline hydrochloride
(Allerest, Albalon)
Terfenadine (Seldane)
Triprolidine and
pseudoephedrine (Actifed)

LOCAL ANESTHETICS

A. Description

1. Block nerve conduction at or near the application site to control pain

2. Are used for pain associated with ear infections

B. Side Effects

1. Allergic reaction

2. Irritation

C. Interventions

1. Monitor for effectiveness if used for pain relief

2. Assess for irritation or allergic reaction

Local Anesthetic
Benzocaine (Americaine Otic,
Tympagesic)

CEREMINOLYTIC MEDICATIONS
 A. Description

1. Emulsify and loosen cerumen deposits

2. Used to loosen and removed impacted wax from the ear canal

B. Side Effects

1. Irritation

2. Redness or swelling of the ear canal

C. Interventions

1. Instruct the client not to use drops more often than prescribed

2. Moisten cotton plug with medication before insertion

3. Keep the container tightly closed and away from moisture

4. Avoid touching the ear with the dropper

5. Thirty minutes after instillation, gently irrigate the ear as prescribed with
warm water using a soft rubber bulb ear syringe

6. Irrigation may be done with hydrogen peroxide solution as prescribed to

flush cerumen deposits out of the ear canal

7. For a chronic cerumen impaction, 1 to 2 drops of mineral oil will soften the
wax

8. Instruct the client to notify the physician if redness, pain or swelling

persists.

Ceruminolytic Medications
Boric Acid (Ear-Dry)
Carbamide peroxide (Debrox)
Trolamine polypeptide oleate-
condensate (Cerumenex)

Did you know.....?

• The resolution of the human eye is equivalent to a 81 MP (megapixel) camera and a hawk's is 8 times better than that!

• The human eye actually sees everything upside-down and it's the brain that actually inverts the image right-way-up again

• The visual pathway contributes up to 65% of all brain pathways and is responsible for up to 85% of our knowledge

• Humans have a 200 degree horizontal binocular field of view

• We blink on average over 10 thousand times a day

• The eye is the second most complex organ in the body after the brain

• The eye has over 2 million working parts and processes 36,000 bits of information every hour

In the term "20/20 vision", the numerator refers to the distance in feet between the subject and the chart. The denominator is the distance at which the lines that
make up those letters would be separated by a visual angle of 1 arc minute, which for the lowest line that is read by an eye with no refractive error (or the errors
corrected) is usually 20 feet. The metric equivalent is 6/6 vision where the distance is 6 metres. This means that at 20 feet or 6 metres, a typical human eye,
able to separate 1 arc minute, can resolve lines with a spacing of about 1.75mm. 20/20 vision can be considered nominal performance for human distance
vision; 20/40 vision can be considered half that acuity for distance vision and 20/10 vision would be twice normal acuity. The 20/x number does not directly relate
to the eyeglass prescription required to correct vision, because it does not specify the nature of the problem with the lens, only the resulting performance.
Instead an eye exam seeks to find the prescription that will provide at least 20/20 vision
Hermann Snellen

Vernier acuity measures the ability to align two line segments. Humans can do this with remarkable accuracy. Under optimal conditions of good illumination, high
contrast, and long line segments, the limit to vernier acuity is about 8 arc seconds or 0.13 arc minutes, compared to about 0.6 arc minutes (20/12) for normal
visual acuity or the 0.4 arc minute diameter of a foveal cone. Because the limit of vernier acuity is well below that imposed on regular visual acuity by the "retinal
grain" or size of the foveal cones, it is thought to be a process of the visual cortex rather than the retina.