Neurosesnsory

Mae G. Marcojos, RN

Anatomy and Physiology EYES

Visual System Eyes Accessory structures
Eyebrows Eyelids Conjunctiva Lacrimal apparatus Extrinsic eye muscles

Sensory neurons

Function of the Eye

Light refraction Focusing of Images on the Retina

Anatomy and Physiology EYES

Eyeball hollow filled sphere Wall of eye
Fibrous tunic Vascular tunic Nervous tunic

Anatomy and Physiology EYES

Layers: SCLERAE/ CORNEA CHOROID Ciliary Body Iris RETINA Rods Cones Blue Green Red

Chambers of the Eye

Anterior Posterior Vitreous

Anatomy and Physiology

LENS VITREOUS HUMOR AQUEOUS HUMOR Anterior Chamber Posterior Chamber

Anatomy and Physiology

CONJUNCTIVAE LACRIMAL GLAND EYE MUSCLES Rectus Oblique

CRANIAL NERVES CN II, III, IV, VI

Anatomy and Physiology

L Eye R Eye Both Eyes OS OD OU

Anatomy and Physiology EYES

Muscles of the eyes 7 extrinsic muscles:
4 rectus 2 oblique
superior oblique for medial rotation so that it looks downward and laterally inferior oblique which turns eyeball upward and laterally.

1 elevator palpatrae

Conjuctiva highly vascular Lacrimal apparatus tears

 Test Vision:
Snellen Chart 20/20 numerator denoting the distance in ft. at which the test is conducted usually 20 ft. and the denominator, the distance at which the smallest letters read on the Snellen Chart should be seen by and average normal eye Opthalmoscope usually the pupil has to be dilated with mydriatic. Changes in the optic nerve head may indicate IOP

Test Vision:
Biomicroscope/Slit lamp- an instrument used to examine the anterior segment of the eye under great magnification by means of binocular microscope with a brillian beam of light for illumination. Tonometer accurate measurement of intraocular pressure (Normal = 11-21mmHg) Perimeter for measuring the boundary of the field of vision. Normal field of vision is 90 degrees.

 *Tunnel vision sign of increased IOP glaucoma

Bjerrums Tangent Screen to test central field of vision Ishihara color plate test for color blind people to identify 3 primary colors RBG Gonioscopy- angle of the anterior chamber can be seen

Planning: Care of EYES

rise of drops should be diagnosed, tears containing upozone (beta-lysine) IgA, IgG all odd which inhibit bacterial growth printed matter should be held at least 14 inches from the eye. When watching TV, stay 10-12 ft away from the screen. read in an environment illuminated by bulbs of 100-150 watts. Light should come from behind and should not reflect a glare

Planning: Care of EYES

client should be informed about danger signals of visual disorders
Persistent redness of eyes Continued discomfort or pain around the eyes especially following an injury Crossing of eyes esp in children Visual disturbances such as blurred vision or spots before eyes Continual discharge, crusting, or tearing of the eye Pupil irregularities

Planning: Care of EYES

conjunctivitis- highly infectious pinpoint pupil - pontine disorder Normal pupil size 2-6 mm, PERRLA anisocoria unequal pupils due to Planning of health maintenance and restoration

Nursing Treatments:
Installation of eye drops head of pt should be tilted backward and inclined slightly to the site, ask the pt to look up, pull down his lower lid and drop the medicine in the center of the lower cul-de-sac or space bet the eyeball and inner surface of the lower lid

Nursing Treatments:
Installation of eye ointments same as above. Expel a small quantity of ointment from the top of the tube without coming in contact with the lid, beginning at the inner canthus and then moving outward

Nursing Treatments:
Hot compress ordered for the effect of heat, unless specified use NSS and temp should beat or slightly above body temp 46oC to 49oC Cold compress to help control bleeding and edema

Nursing Treatments:
Eye irrigation done to remove secretions to cleanse the eye preop and to supply warmth Massage of the eyeball used in treating glaucoma esp following certain operations

Meds
Ocular Meds: Local anesthesia act to anesthetize the eyes and then prevent pain during various ocular procedures Topical Pontocaine 0.5% Injectable Local Anesthetic Novocaine 1-2%, Xylocaine 1-2% Parasympathetics produce effects resembling stimulations of parasympathomimetic nerve. Used as miotics, which causes the pupils to contract (used to control IOP in glaucoma by widening the filtration angle and permitting outflow of aqueous humor)

Meds
mydriatic dilate miotiocs for glaucoma Group 1 Cholinergic drugs which acts directly on the myoneural junction; produced strong contraction of iris (miosis) and cilairy body musculature (accommodation); ex. Pilocartine HCl 0.5-10% Group 2 Cholidesterase Inhibitors anticholinesterase drugs; ex. Eserine

Meds
Parasympatholytic drugs (anticholinergic drugs)-produce effects resembling those of interruption of parasympathetic nerve supply to a part. Used to facilitate eye exam and refraction. They cause smooth muscle of ciliary body and iris to relax thus producing mydriasis which causes the pupils to dilate &

Meds
Cycloplegia-paralysis of muscles, resulting in paralysis of accomadation Mydriatics Meo-synjephrine 2.5%+10%; eupthalmine 2%-5% Cyclophegics atropine sulfate-0.5% hyosein .25% homatropine hydrobromite 2-5% cyclogyll

Meds
Sympathomimetic drugs used primarily to produce mydriasis and vasoconstriction, doent cause cycloplegia, vasoconstriction increases outflow of aqueous humor, thus reducing IOP (Adrenaline) (1:1000) ex; Neosynephrine 1.125-10% Antibiotics Chloromycetin, Neosporin, polymycin (?) B sulfate, bacitracin Sulfonamides Gantrisin 4% Carbonic Anhydrase Inhibitors the enzyme is necessary for the production of aqueous humor. Used as a tx for glaucoma to reduce formation of aqueous humor and thus reduce IOP. Diuresis is produced. Eg. Oratol, diamox

 Care of Contact Lenses: May be hard of soft (hydrophilic). They tend to absorb chemicals, therefore instructions are usually given not to wear them while they swim unless using goggles.

EYE MEDICATIONS
Eye medications refer to drops, ointment, and disks. PURPOSES: Therapeutic Purposes to lubricate the eye or socket for a prosthetic eye to prevent or treat eye conditions and infections

EYE MEDICATIONS
Diagnostic Purposes Eyedrops can be used to anesthetize the eye Dilate the pupil Stain the cornea to identify abrasions and scars. Cross contamination is a potential problem with eyedrops. The pt. should adhere to the following safety measures to prevent cross contamination:
each client should have his or her own bottle of eyedrops discard any solution remaining in the dropper after installation discard the dropper if the tip is accidentally contaminated, as by touching the bottle or any part of the clients eye

EYE MEDICATIONS
ASSESSMENT: Assess the five rights: right client, medication, route, dose, and time. (prevent errors in medication administration) Assess the condition of the clients eye. Are there any contraindications to administering the medication? (reassessing the client prior to every medication dose prevents possibly injuring the client) Assess the medication order. (prevent errors in medication administration)

EYE MEDICATIONS
DIAGNOSIS: Risk for injury Knowledge deficit, related to medication regime Sensory/ perceptual alterations due to the effects of eye medications

EYE MEDICATIONS
PLANNING: Expected Outcomes The right client will receive the right dose of the right medication via the right route at the right time. The client will encounter the minimum of discomfort during the medication administration procedure. The client will receive the maximum benefit from the medication.

EYE MEDICATIONS
Equipment Needed: Medication Administration Record (MAR) Eye medication Tissue or cotton ball Nonsterile gloves (if needed)

EYE MEDICATIONS
CLIENT EDUCATION NEEDED Educate the client regarding the reason for this medication, including the importance of taking the right dose at the right time. Instruct the client in ways to prevent contamination and cross contamination especially when using the eyedrops. Teach the client to gently press the tear duct closed while administering the eyedrops to prevent loss of the medication and possible systemic complications.

EYE MEDICATIONS
IMPLEMENTATION 1. Check with the client and the chart for any known allergies or medical conditions that would contraindicate use of the drug. 2. Gather the necessary equipments. 3. Follow the five rights of drug administration. 4. Take the medication to the clients room and place on a clean surface.

EYE MEDICATIONS
IMPLEMENTATION 5. Check clients identification. 6. Explain the procedure to the client; inquire if the client wants to instill medication. If so, assess the clients ability to do so. 7. Wash hands, use nonsterile gloves if needed. 8. Place client in a supine position with the head slightly hyperextended.

INSTILLING EYEDROPS
1.Remove cap from eye bottle and place cap on its side. 2.Squeeze the prescribed amount of medication into the eyedropper. 3.Place a tissue below the lower lid. 4. With dominant hand, hold eyedropper - inch above the eyeball, rest hand on clients forehead to stabilize.

INSTILLING EYEDROPS
5. Place hand on cheekbone and expose lower conjunctival sac by pulling down on cheek. 6.Instruct the client to look up and drop prescribed number of drops into center of conjunctival sac. 7.Instruct client to gently close eyes and move eyes. Briefly place fingers on either side of the clients nose to close the tear ducts and prevent the medication from draining out of the eye.

EYE OINTMTENT APPLICATION

Lower Lid: 1.With non dominant hand, gently separate clients eyelids with thumb and finger and grasp lower lid near margin immediately below the lashes; exert pressure downward over the bony prominence of the cheek. 2.Instruct the client to look up. 3.Apply ointment along inside edge of the entire lower eyelid, from inner to outer canthus.

EYE OINTMTENT APPLICATION

Upper Lid: 1.Instruct the client to look down. 2.With nondominant hand, gently grasp clients lashes near center of upper lid with thumb and index finger, and draw lid up and away from eyeball. 3.Squeeze ointment along upper lid starting at inner canthus.

EYE IRRIGATION
Sterile Equipment: Eyedropper Asepto bulb syringe or plastic bottle with prescribed solution For copious use: sterile normal saline or prescribed solution IV set up with tubing

EYE IRRIGATION
IMPLEMENTATION PREPARATORY PHASE 1.Verify the eye to be irrigated and the solution and amount of irrigant. 2.The patient may sit with head tilted back or lie in a supine position. 3.Instruct the patient to tilt head toward the side of the affected eye.

EYE IRRIGATION
PERFORMANCE PHASE 1.Wash eyelashes and lids with prescribed solution at room temperature; a curve basin should be placed on the affected side of the face to catch the outflow. 2.Evert the lower conjunctival sac. 3.Instruct the patient to look up; avoid touching eye with equipment.

EYE IRRIGATION
PERFORMANCE PHASE 4.Allow irrigating fluid to flow from the inner canthus to the outer canthus along the conjunctival sac. 5.Use only enough force to flush secretions from conjunctiva. 6.Ocassionally, have patient close eyes.

THE PUPILS
PERRLA P upils E qually R ound R eactive to L ight and A ccommodation

Assessing Accommodation
Hold an object (pen or pencil) about 10 cms from the bridge of the clients nose. Instruct client to look at the top of the object and then shift to distant object. Pupils should constrict when looking at near object and dilate when looking at far object.

Assessing direct reaction to light

Partially darken the room. Let patient look straight ahead. Using a penlight, shine a light from the side of one eye to the inner. Pupil should constrict in response to light. Repeat the process on the other eye.

Assessing consensual reaction to light

Assessed by passing light on one eye while observing for constriction of the pupil on the other eye.

DIAGNOSTIC ASSESSMENT
1. Snellen s Chart Tests visual acuity Normal is 20/20 20/200 legal blindness bottom to up reading test eyes separately 20 feet distance from the chart 20/20 at 20 feet person can read what an average person can read also 20/60 a person can read at 20 feet what an average person can read at 60 feet

DIAGNOSTIC ASSESSMENT
2. Ishihara Plate Tests color vision Uses series of plates with printed round colors and patterns Normal color vision: person who are able to discern specific numbers or patterns Color perception deficiency: Inability to identify a number or pattern

Normal Color Vision

Red-Green Color Blind

Left Top 25

Right 29 Top

Left 25

Right Spots

Middle

45

56

Middle Spots

56

Bottom

Bottom Spots

Spots

DIAGNOSTIC ASSESSMENT
3. Retinoscopy Determines refractive error of an eye Examiner shines a light into the pupillary opening Note the movements of reflex which will vary the type of refractive error

DIAGNOSTIC ASSESSMENT
4. Cover-Uncover Test Differentiates various types of strabismus Types of Strabismus Concomitant (Heterotropia)eye adopt an abnormal position in relation to each other Paralytic- shows limited movement; diplopia is always present

DIAGNOSTIC ASSESSMENT
5. Tonometry Indirect measure of IOP Normal is 11-21 mm Hg

Measuring of IOP by determining the resistance of the eyeball to indentation by an applied force

Noncontact tonometry (pneumotonometry). Applanation (Goldmann) tonometry Indentation (Schiotz) tonometry. Electronic indentation tonometry

Nursing Care
Anesthetic eyedrops are used for the methods that involve touching a tonometer to your eye. The eyedrops prevent you from feeling the instrument touch your eye. No numbing eyedrops are needed when an air-puff (noncontact) tonometer is used. Results from tonometry are most accurate when you: Avoid drinking more than 2 cups of fluid 4 hours before the test. Avoid drinking alcohol for at least 12 hours before the test. Avoid smoking marijuana for at least 24 hours before the test.

DIAGNOSTIC ASSESSMENT
6. Gonioscopy Microscopic examination of the anterior chamber angle Gonioscope- mirrored optic instrument it permits visualization of the angle by means of a reflected image Diagnoses congenital and secondary glaucoma

DIAGNOSTIC ASSESSMENT
7. Bjerrum Tangent Screen Measures central vision

DIAGNOSTIC ASSESSMENT
8. Ophthalmoscopy Examines the fundus of the eye For visualization of the structure of the eye at any depth Ophthalmoscope- includes a light, a mirror with a single aperture, and a dial holding several lenses of varying strength

DIAGNOSTIC ASSESSMENT
9. Slit Lamp Biomicroscopy Examines the anterior portion of the eye Can diagnose astigmatism

10. Red Reflex Test A red reflex test will be one of the first eye tests your baby receives, when an eye doctor examines reflections from the inner back of the eye (retina) to test for possible presence of eye disease.

 The red reflex test is used to screen for abnormalities of the back of the eye (posterior segment) and opacities in the visual axis, such as a cataract or corneal opacity. An ophthalmoscope held close to the examiners eye and focused on the pupil is used to view the eyes from 12 to 18 inches away from the subjects eyes. To be considered normal, the red reflex of the 2 eyes should be symmetrical. Indications for referral to an ophthalmologist.
Dark spots in the red reflex a blunted red reflex on 1 side lack of a red reflex or the presence of a white reflex (retinal reflection)

CommonlyRelated Disorders

Injuries and trauma Infections Pterygium Cataract Glaucoma Detachment of Retina

INJURIES AND TRAUMA

In general, when an eye injury is present, it is advisable to treat patient but leave the eye alone unless chemical injury has occurred and the eye itself must immediately be flushed with water Remove foreign particles: dont touch cornea Irrigation: 15 mins before stopping to move the patient or to get a doctor. If water is not available, use beer or carbonated beverages

INFECTIONS
Hordeolum or sty infection of the zeis gland in the follicle of a lash Chalazion involves a meibomian gland, locate dint he lateral plate of the lid, Rx: I&D; an anti-bacterial ointment Conjunctivitis caused by a wide variety of bacteria, often called pink eye. May result also from bacterial infection, allergy, trauma as in sunburn and viruses

INFECTIONS
Uveitis inflammation of iris Keratitis Inflammation of cornea PTERYGIUM A triangular fold of membrane which forms in conjunctiva which tend from white of the eye to the cornea - outgrowth

CATARACT

opacity of the crystalline lens or of its capsule which interferes with transparency Signs and symptoms: dimness of visual acuity rapid and marked changes or refraction error

CATARACT
Classifications:
Primary or senile begins first in one eye and then the other eye from 45 years on, it is rare that this becomes unilateral; occur as degenerative changes with age Secondary or traumatic due to some disease or injury of the eye; ex. DM, traumatic cataract due to direct blow or due to exposure to intense light Congenital not seen at time of birth but when defective vision comes evident during childhood. Associated with attack of German measles in the mother during 1st trimester of pregnancy

CATARACT TREATMENT
Intracapsular extraction lens is removed within its capsule Extracapsular extraction lens capsule is excised and the lens is expressed by pressure in the eye from below with a metal spoon Cryoextraction cataract is lifted from the eye by a small probe that has been cooled to temperature below zero to the next surface of the cataract

CATARACT TREATMENT
Phacoemulsification - incision just large enough to insert a needle probe that vibrates 40,000 times per sec to break up the lens and flush it out in tiny suction

CATARACT TREATMENT
Enzymatic zonumolysis a technique that invoves injecting alpha-chymotrypsin, a fibrinolytic and proteolytic enzyme into the anterior chamber. The enzyme frees the attachment of the monules to the lens capsule and thereby facilitate removal of the lends without tearing the lens in the process of removing it

CATARACT TREATMENT
Intraocular lens implantation of a synthetic lens designed for distance upon, the patient wears prescribed glasses for reading and near vision. It is an alternative to sight correction with glasses or contact lenses for the aphakic patient

Pre-Op Nursing Care:

orient the pt to his new environment begin rehab as soon after admission deep-breathing exercises, instruct how to close eyes without squeezing the lids reduce conjunctival edema use of antibiotics prepare affected eye for surgery, instill mydriatics if ordered *use sterile technique

Post-Op Nursing Care:

reorient pt to surroundings prevent inc IOP and stress on the suture line promote pt comfort: mild analgesic to control pain observe and treat for complications:
nausea and vomiting use of anti-emetic drugs and cold compress hemorrhage notify physician if pt complains of sudden pain in the eye prolapse of the iris most common post-op complication and can precipitate acute glaucoma

Post-Op Nursing Care:

promote the rehab of the pt:
encourage pt to become independent walk with pt when first become ambulatory health teachings

use dark glasses temporary corrective glasses may be prescribed 1-4 weeks after surgery

Post-Op Nursing Care:

permanent lenses will be prescribed 6-8wks after the surgery the glasses will take the place of the crystalline lens. In 6mos time the eyes have made the necessary adjustment pt should know that it will take time to learn to judge distance, climb stairs, and do other simple things

Post-Op Nursing Care:

color of objects seen with lens removed is slightly changed ambulatory pt should have slip-on slippers to avoid bending/stooping. Peripheral vision is decreased, so that the pt needs to be taught to turn his head and utilize central vision provided by the lenses.

GLAUCOMA
eye disease characterized by inc IOP assoc with progressive loss of peripheral vision Cause: obstruction to the circulation of aqueous humor through the meshwork at the angle of the anterior chamber of the eye where the peripheral iris and cornea meet

GLAUCOMA
Types: Chronic simple or wide open angle glaucoma
Cause: heredity predisposition to the thickening of the meshwork Signs and Symptoms:
Loss of peripheral vision (tunnel vision) before central visions Difficulty in adjusting to darkness Failure to detect changes in color Tearing Misty visions Headache Pain behind the eye Nausea and vomiting

GLAUCOMA: Treatment
Miotics eg. Pilocarpine to construct the pupil and to draw the smooth muscle of the iris away from the canal of schlema to permit aqueous humor to drain out. Drops are prescribed at early AM since IOP is usually higher on arising on AM. Acetazolamide (Diamox) to reduce formation of aqueous humor Avoid fatigue/stress Avoid drinking large quantities of fluid

GLAUCOMA: Treatment
Certain limitations are not necessary-may drink normal amounts of coffee and tea Surgery the principle is to drain the drainage of the intraocular fluid or aqueous humor thereby lessening the pressure of the eye Iridecleisis formation of the fistula bet the anterior chamber and the subjunctival space Corneoscleral trephening of Elliots operation small opening is made at the junction of the cornea and sclera leaving a permanent opening through which aqueous humor may drain

GLAUCOMA: Treatment
Langranges operation sclerectomy sclera is excised combined with irridectomy Dyclodialysis new passage within eye itself is made from the anterior chamber to the supracholoidal space. The principle of operation employing low voltage and high frequency Trabeculectomy and trabeculotomy excision of a rectangle of the sclera that includes the trabeculae sclemas and scleral spur Non surgical laser therapy approx 50-100 beams are applied to the pigmented band of the tubular meshwork resulting to permanent increase in tension on the trabeculum and open the outflow channel

Acute angle closure glaucoma

result of abnormal displacement of iris against the angle of the anterior chamber; rare
May be
Congenital Secondary - from other existing eye problems like uveitis or trauma or post op complications Absolute end-result of uncontrolled glaucoma

Signs and Symptoms:

severe eye pain nausea and vomiting abdominal pains blurred vision colored halos around the lights dilated pupils inc IOP

Acute angle closure glaucoma

Treatments:
Myotics Diamox Glycerol to reduce pressure Iridectomy portion of iris is removed *iridotomy-butas para madrain yung abnormal accumulation of aqueous fluid

 Terms:
Enucleation removal of the eye, rectus muscle are attached to implant to provide most of prosthetic Exenteration- removal of eye plus surrounding structures Evisceration-removal of contents of the eye except sclera

Care after glaucoma surgery:

Miotics Flat and quiet for 24 hrs prevents prolapse of iris (like putting trochanter roll for head) Use of narcotics or sedatives to keep patient quiet and comfortable Liquid diet until first dressing Turn on non-operative side *drug of choice: Demerol

DETACHMENT OF RETINA
Occur when layers accumulate excessively and elevation of both retinal layer away fro the choroids as in the presence of tumor Causes: myopic degeneration

DETACHMENT OF RETINA
Signs and Symptoms: floating spots of opacities before the eye dt blood and retinal cells that are freed at the time of the tear cast shadows on the retina as they seem to drift about the eye, flashes of light progressive obstruction of vision in one eye

Treatment:
Conservative quiet in bed with eyes covered to try to prevent further detachment Non-surgical method employed to seal retinal breaks before retina becomes detached Photocoagulation small burn made in retina by shining very bright light Cyrotherapy cold probe Surgical methods aimed at sealing the retinal break, reattaching the retina and preventing the retina from detaching Scleral buckling - fluid that has an accumulation under the retina and the wall of the eye is buckled

Post-Op Care
Eyes are covered to prevent ocular movement Positioned so that the area of detachment is dependent Pupils dilated by mydriatics Discharge instructions:
avoid strenuous exercise and activity for 6 mos