VISUAL FUNCTION EYELASHES

DISORDERS • Located along edges of eyelids

• Help protect eyeball by preventing foreign
Transcribed by: John Cyril A. Roquete materials and/or insects from coming in contact
with surface of eyeball.
OVERVIEW OF THE EYE
SCLERA
• The eye acts much like a camera:
o Lens of eye adjusts to bring object into • “White of the eye”
focus o Tough, fibrous membrane
o Pupil of eye constricts to allow less light o Maintains shape of eyeball
to enter in bright setting or dilates to o Serves as protective covering for eye
allow more light to enter in darker setting • Thinnest over anterior surface of the eye
o Through bending of light rays, image • Thickest at the back of the eye, near opening for
reaches the retina optic nerve
o Sensitive nerve cell layer of eye
o Image is transmitted to brain for
interpretation
• 70 percent of all sensory receptors are in the
eyes
• Each eye has over a million nerve fibers
• Protection for the eye:
o Most of the eye is enclosed in a bony
orbit made up of the lacrimal (medial),
ethmoid (posterior), sphenoid (lateral),
frontal (superior), and zygomatic and
maxilla (inferior)
o A cushion of fat surrounds most of the
eye

CORNEA

• Continuous with anterior portion of sclera

• Transparent, nonvascular layer covering colored
part of the eye

IRIS

• Colored portion of the eye

o Composed of circular and radial
muscles reflex
STRUCTURES OF THE EYE (FRONT VIEW) o Contraction of circular muscle in bright
light (pupil constrict)
o Reflex contraction of radial muscle in
dim light (pupil dilate)
o Regulates entry of light into the eye

PUPIL

• Rounded opening in the iris

• Controls amount of light entering eye

LENS

• Colorless biconvex structure that aids in

focusing images clearly on retina.
EYELIDS LIGHT ACCOMODATION:
• Continuous with skin and cover the eyeball • Light must be focused to a point on the retina for
• Keep surface of eyeball lubricated and protected optimal vision
from dust and debris through blinking motion. • The eye is set for distance vision (over 20 ft
away)
• 20/20 vision at 20 feet, you see what a normal
• Eye would see at 20 feet (20/100 at 20, normal
person would see at 100)
 • The lens must change shape to focus for closer LATERAL CROSS SECTION OF THE EYE AND
objects STRUCTURES OF THE EYE (CROSS SECTION)

CHOROID

• Vascular middle layer of eye

CONJUNCTIVA o Just beneath sclera
o Contains extensive capillaries that
• Thin mucous membrane layer that lines anterior
provide blood supply and nutrients to
part of eye and inner part of eyelids.
eye
o Colorless, but appears white because it
o Contains the iris, ciliary body, and
covers sclera
suspensory ligaments
• Connects to the surface of the eye - forms a seal
• Secretes mucus to lubricate the eye CILIARY BODY

LACRIMAL APPARATUS • Located on each side of the lens

• Contains muscles responsible for adjusting lens
• Lacrimal Gland: Produces lacrimal fluid
to view near objects
• Lacrimal Canals: Drains lacrimal fluid from eyes
• Lacrimal Sac: Provides passage of lacrimal fluid SUSPENSORY LIGAMENTS
towards nasal cavity
• Nasolacrimal Duct: Empties lacrimal fluid into • Radiate from ciliary body and attach to lens
the nasal cavity • Hold lens in place
• Assist in adjusting shape of lens for proper
FUNCTION OF THE LACRIMAL APPARATUS: focusing of eye
• Properties of lacrimal fluid:
o Dilute salt solution (tears) CILIARY GLANDS
o Contains antibodies (fight antigen
• Modified sweat glands between the eyelashes
foreign substance) and lysozyme
secrete acidic sweat to kill bacteria, lubricate
(enzyme that destroys bacteria)
eyelashes.
• Protects, moistens, and lubricates the eye
• Empties into the nasal cavity RETINA

SENSITIVE NERVE CELL LAYER:

• Changes energy of light rays into nerve impulses
• Transmits nerve impulses via optic nerve to
brain for interpretation of image seen by eye.

NERVE CELLS OF RETINA:

• Rods are responsible for vision in dim light and
for peripheral vision
• Cones responsible for visualizing colors, central
vision, and vision in bright light

MACULA LUTEA:
• Oval, yellowish spot near center of retina

FOVEA CENTRALIS:
• Small depression located within macula lutea
• Sharpest image is obtained when image focuses
directly on fovea centralis = central vision
 OPTIC NERVE PROCESS OF VISION

• Receives impulses from retina and transmits PROCESS BEGINS AS LIGHT RAYS ENTER THE
them to the brain EYE:
• Images are then interpreted as vision
• Transmitted through cornea, aqueous humor,
OPTIC DISC pupil, lens, and vitreous humor to retina.
o Sensitive nerve cells of retina transmit
• Contains no rods or cones image through optic nerve to brain
• Known as the “blind spot” of the eye o Brain interprets image as vision
• Center of optic disc serves as point of entry for
artery that supplies retina REFRACTION:
• Process of bending of light rays as they pass
ANTERIOR CAVITY OF THE EYE through the various structures of the eye to
produce a clear image on the retina.
ANTERIOR CHAMBER:
ERRORS OF REFRACTION:
• Located in front of lens
• Filled with clear, watery fluid called aqueous • Occur when eyeball is abnormally shaped
humor • Occur when lens has lost ability to
accommodate to near vision
POSTERIOR CHAMBER: o Vision will be blurred Can be adjusted
• Located behind lens with corrective lenses
• Also filled with aqueous humor
• Flows back and forth between both chambers ASSESSMENT OF THE EYE
HEALTH ASSESSMENT INTERVIEW
POSTERIOR CAVITY OF THE EYE

• Posterior to lens • Ask about the patient’s chief complaint such as:
o Blurred vision
• Filled with vitreous humor
o Eye infection
o Clear, jellylike substance that gives
o Halos
shape to the eyeball
o Difficulty reading
o Not constantly reproduced
o Blindness can result if vitreous humor
PHYSICAL ASSESSMENT
escapes from eye

SNELLEN’S EYE CHART:

EXTRINSIC EYE MUSCLES
• A test for vision.
• Muscles attach to the outer surface of the eye • Assessment of the pupils.
• Produce eye movements
• Extra movements of the eyes nystagmus or non-
parallel movements known as strabismus, may
indicate disease, cranial nerve dysfunction or
muscle weakness and should be reported.

PUPILS, EQUAL ROUND REACTIVE TO LIGHT

AND ACCOMMODATION (PERRLA):
• Direct a beam of light into the pupil, look for
constriction
• Hold object a few feet from client, pupils should
WHEN EXTRINSIC EYE MUSCLE CONTRACT : dilate, move closer pupils should constrict
• Inspection: Sclera, iris, cornea and internal
• Superior Oblique: Rotates eye structures
counterclockwise
• Inferior Oblique: Rotates eye clockwise ELECTRONYSTAGMOGRAPHY:
• Superior Rectus: Rolls eye upward • Group of tests used in evaluating vestibule-
• Inferior Rectus: Rolls eye downward ocular reflex; normal reflex produced by
• Lateral Rectus: Turns eye outward, away from stimulation of vestibular apparatus in which eye
midline position compensates for motion of the head.
• Medial Rectus: Turn eye inward, toward midline
ELECTRORETINOGRAM (ERG):
• Recording of changes in electrical potential of
retina after stimulation of light.
FLUORESCEIN STAINING: LASER IN SITU KERATOMILEUSIS (LASIK):
• Application of a fluorescein-stained sterile filter • LASIK procedure is a form of laser vision
paper strip moistened with a few drops of sterile correction for nearsightedness (myopia).
saline or sterile anesthetic solution to the lower
cul-de-sac of the eye to visualize a corneal PHACOEMULSIFICATION:
abrasion. • Removing a lens by using ultrasound vibrations
to split up lens material into tiny particles that
GONIOSCOPY:
can be suctioned out of the eye.
• Process of viewing anterior chamber angle of
eye for evaluation, management, and PHOTO REFRACTIVE KERATECTOMY:
classification of normal and abnormal angle • Surgical procedure in which a few layers of
structures. corneal surface cells are shaved off by an
“excimer laser beam” to flatten cornea and
OPTHALMOSCOPY:
reduce myopia or nearsightedness.
• Examination of external and internal structures
of the eye; utilizes an ophthalmoscope. RETINAL PHOTOCOAGULATION:
• Surgical procedure using an argon laser to treat
PACHYMETRY:
conditions such as retinal detachment, and
• Measures thickness of cornea; patient’s eyes diabetic retinopathy.
are numbed; uses an ultrasonic-wave instrument • Retinal Detachment: Argon laser used to create
to gauge thickness of each cornea. an area of inflammation, which will develop
adhesions, causing a welding of the layers.
SLIT-LAMP EXAM: • Diabetic Retinopathy: Argon laser used to seal
• Examination of external and internal structures microaneurysms and areas of leakage, and to
of the eye using a low power microscope reduce risk of hemorrhage.
combined with a high intensity light source
focused to shine as a slit beam; also known as TRABECULECTOMY:
bio-microscopy. • Surgical excision of a portion of corneoscleral
tissue to decrease intraocular pressure in
TONOMETRY: persons with severe glaucoma.
• Process of determining intraocular pressure by
calculating resistance of eyeball to an applied TRABECULOPLASTY:
force causing indentation. • Surgical creation of a permanent fistula used to
drain fluid (aqueous humor) from the eye’s
CORNEAL TRANSPLANT: anterior chamber; usually performed under
• Surgical transplantation of a donor cornea general anesthesia.
(cadaver’s) into the eye of a recipient usually • Laser trabeculoplasty is an outpatient plastic
under local anesthesia. surgery approach used in management of
glaucoma.
EXTRACAPSULAR CATARACT EXTRACTION
(EECE):
DISORDERS OF THE EYE
• Surgical removal of anterior segment of lens
• The human eye is the sense organ that reacts to
capsule along with lens allowing for insertion of
light and allows vision. Rod and cone cells in
an intraocular lens implant.
the retina are photosensitive cells which are able
• Intraocular Lens Implant: Surgical process of
to detect visible light and convey this information
cataract extraction and insertion of an artificial
to the brain. Eyes signal information which is
lens in patient’s eye; restores visual acuity and
used by the brain to illicit the perception of color,
provides improved depth perception, light
shape, depth, movement and other features.
refraction, and binocular vision.
The eye is a part of the sensory nervous
IRIDECTOMY: system.

• Extraction of a small segment of the iris to open

an anterior chamber angle and permit the flow of
CATARACT
aqueous humor between the anterior and
posterior chambers; relieves person’s intraocular
pressure.

KERATOPLASTY:
• Transplantation of corneal tissue from one
human eye to another to improve vision in
affected eye; also called corneal grafting.
Figure: A cataract is a cloudy or opaque lens. On visual PHYSICAL FACTORS
inspection, the lens appears gray or milky.
• Blunt trauma, perforation of the lens with a sharp
• Clouding of a normally clear lens. object or foreign body, electric shock.
• Patients with cataract sees a cloudy lens which • Dehydration associated with chronic diarrhea,
is like looking through a frosty or fogged window. the use of purgatives in anorexia nervosa, and
• The lens in the eye becomes progressively the use of hyperbaric oxygenation.
cloudy losing its normal transparency. It alters • Ultraviolet radiation in sunlight and x-ray
perception of images due to interference of light
transmission to retina. SYSTEMIC DISEASES AND SYNDROMES
• Clouding of the lens of the eye that impairs
vision is common over 65 years old. It is the • Diabetes
leading cause of blindness in the world. • Disorders related to lipid metabolism
• As the lens ages, its cells become less clear • Down syndrome
• Mature cataract involves the entire lens • Musculoskeletal disorders
• Near and distant vision are affected • Renal disorders
• Details become obscured
SUMMARY OF RISK FACTORS
• Pupil appears cloudy gray or white rather than
black • Increasing age – senile cataracts
• Lens opacity or cloudiness • Diabetes
• Faded colors, blurry or double vision, halos • Excessive exposure to sunlight
around light, trouble with bright lights, and • Smoking
trouble seeing at night. • Obesity
• High blood pressure
RISK FACTORS
• Previous eye injury or inflammation
AGING • Previous eye surgery
• Prolonged use of corticosteroid medications
• Accumulation of a yellow-brown pigment due to • Drinking excessive amounts of alcohol
the breakdown of lens protein.
• Clumping or aggregation of lens protein (which
leads to light scattering).
• Decreased oxygen uptake
• Decrease in levels of vitamin C, protein, and
glutathione (an antioxidant)
• Increase in sodium and calcium PATHOPHYSIOLOGY
• Loss of lens transparency
• Cataracts can develop in one or both eyes at
ASSOCIATED OCULAR CONDITIONS any age. The three most common types are
traumatic, congenital, or senile cataract.
• Infection (e.g., herpes zoster, uveitis) There are a variety of risk factors, the most
• Myopia common one being age.
• Retinal detachment and retinal surgery
• Retinitis pigmentosa HOW DO CATARACTS FORM?
• The lens where cataract forms is position behind
TOXIC FACTORS the colored part of the iris.
• Alkaline chemical eye burns, poisoning • The lens focuses light that passes through the
eye produce a clear and sharp image on the
• Aspirin use
retina.
• Calcium, copper, iron, gold, silver, and mercury,
• The light sensitive membrane in the eye that
which tend to deposit in the pupillary area of the
functions like a film in the camera.
lens
• As you age, the lenses in the eyes becomes less
• Cigarette smoking
flexible, less transparent, and thicker. Age
• Corticosteroids, especially at high doses and in
related and other medical conditions causes
long-term use
tissues within the lens to break down and clump
• Ionizing radiation
together, clouding small areas within the lens.
NUTRITIONAL FACTORS
TYPES OF CATARACTS
• Obesity
• As the cataracts begins to develop, the clouding
• Poor nutrition
becomes denser and involves the bigger part of
• Reduced levels of antioxidants the lens. A cataract scatters and blocks the light
as it passes through the lens, preventing a
sharply defined image from reaching the retina.
As a result, the vision becomes blurred. Cataract
 develops in both eyes but not evenly. Cataract in LIGHT SCATTERING:
one eye, may be more advanced than the other,
• Light scattering is common, and the person
causing a difference of vision between the eyes.
experiences reduced contrast sensitivity,
sensitivity to glare, and reduced visual acuity.
NUCLEAR CATARACTS
OTHER EFFECTS:
• Cataracts affecting the center of the lens
• First Cause: Nearsightedness or temporary • Myopic shift (return of ability to do close work
improvement of reading visions. [e.g., reading fine print] without eyeglasses).
• With time, the lens turns into densely yellow and • Astigmatism (refractive error due to an
further clouds the vision. irregularity in the curvature of the cornea)
• As it progresses, it may turn brown. • Monocular diplopia (double vision)
• Advance yellowing or browning of the lens can • Color changes as lens becomes more brown in
be difficult in distinguishing between shapes or color.
colors.
ASSESSMENT AND DIAGNOSTIC FINDINGS
CORTICAL CATARACTS
• Decreased visual acuity is directly
• Affects the edges of the lens proportionate to cataract density. The
• Begins as whitish, wedge shaped, opacity or Snellen visual acuity test, ophthalmoscopy,
streaks on the outer edge of the lens’ cortex. and slit-lamp biomicroscopic examination are
• When progresses, the streaks extend to the used to establish the degree of cataract
center and interfere with the light pass into the formation. The degree of lens opacity does not
center of the lens. always correlate with the patient’s functional
status. Some patients can perform normal
POSTERIOR SUBCAPSULAR CATARACTS activities despite clinically significant cataracts.
Others with less lens opacification have a
• Affect the back of the lens disproportionate decrease in visual acuity;
• Starts a small, opaque area that usually forms hence, visual acuity is an imperfect measure of
near the back of the lens, right in the path of the visual impairment.
light.
• Often interferes with reading vision VISUAL ACUITY TEST
• Reduces vision in bright light and compasses
glare or halos around light at night. • Using eye chart to measure how well a person
can read a series of letters.
• Progress faster than the other.
• Eyes tested one at a time; one eye is covered
CONGENITAL CATARACT • Snellen’s chart test

• Cataracts you’re born with SLIT-LAMP EXAMINATION

• Develops during childhood; genetic or
associated with intrauterine infections or trauma. • Allows doctor to see the anterior structure of the
• May be due to: Myotonic dystrophy, eye under magnification.
galactosemia, neurofibromatosis type 2, rubella. • Microscope called slit-lamp because it uses an
intense lamp of light to view the structural small
• Can be removed soon after detection
section.
PREVENTION
RETINAL EXAM
• Have regular eye examinations
• To prepare, doctor puts eyedrops to open and
• Quit smoking
dilate the pupils for easier examination of the
• Manage other health problems
back of the eyes, especially retina.
• Choose a healthy diet that includes plenty of
• Using a slit-lamp or ophthalmoscope
fruits and vegetables
• Antioxidant in pill form
MEDICAL MANAGEMENT
• Wear sunglasses – UV rays one causative
agent • No nonsurgical treatment (e.g., medications, eye
drops, eyeglasses) cures cataracts or prevents
CLINICAL MANIFESTATIONS age-related cataracts. Optimal medical
management is prevention. Patients should be
PAINLESS, BLURRY VISION: educated by primary providers about risk
• Painless, blurry vision is characteristic of reduction strategies such as:
cataracts. The person perceives that o Smoking cessation
surroundings are dimmer, as if their glasses o Weight reduction
need cleaning. o Optimal blood sugar control for patients
with diabetes
 o Should be advised to wear sunglasses TYPES OF CATARACT SURGERY
outdoors to prevent early cataract
formation. INTRACAPSULAR CATARACT EXTRACTION
• Nonsurgical (medications, eyedrops,
eyeglasses) treatment, vitamins C and E, beta- • Entire lens (nucleus, cortex, and capsule)
carotene, and selenium removed and fine sutures are used to close the
incision.
• Cataract Surgery: Performed on an outpatient
basis and usually takes less than 1 hour
EXTRACAPSULAR CATARACT EXTRACTION
injection-free topical and intraocular anesthesia,
such as 1% lidocaine gel. • Involves smaller incisional wounds (less trauma
to the eye)
SURGICAL MANAGEMENT • Maintains the posterior capsule of the lens
• In general, if reduced vision from cataract does • Portion of the anterior capsule is removed,
not interfere with normal activities, surgery may allowing extraction of the lens, nucleus, and
not be needed. In deciding when cataract cortex.
surgery is to be performed, the patient’s • Most common surgery for cataract
functional and visual status should be a primary
consideration. Cataract removal is common, with PHACOEMULSIFICATION
more than 1 million such surgeries performed in
• Uses an ultrasonic device that liquefies the
the United States each year. Surgery is
nucleus and cortex, which are then suctioned
performed on an outpatient basis and usually
out through a tube.
takes less than 1 hour, with the patient being
• Posterior capsule left intact
discharged in 30 minutes or less afterward.
• Minimally invasive
Although complications from cataract surgery
are uncommon, they can have significant effects In this method of extracapsular cataract surgery, a
on vision. Restoration of visual function through portion of the anterior capsule is removed, allowing
a safe and minimally invasive procedure is the extraction of the lens nucleus and cortex while the
surgical goal, which is achieved with advances posterior capsule and zonular support are left intact. An
in topical anesthesia, smaller wound incision ultrasonic device is used to liquefy the nucleus and
(i.e., clear cornea incision), and lens design cortex, which are then suctioned out through a tube. An
(i.e., foldable and more accurate intraocular lens intact zonular–capsular diaphragm provides the
[IOL] measurements). needed safe anchor for the posterior chamber IOL. The
• Injection-free topical and intraocular pupil is dilated to 7 mm or greater. The surgeon makes
anesthesia, such as 1% lidocaine gel applied a small incision on the upper edge of the cornea and a
to the surface of the eye, eliminates the hazards viscoelastic substance (clear gel) is injected into the
of regional (retrobulbar and peribulbar) space between the cornea and the lens. This prevents
anesthesia, such as the space from collapsing and facilitates insertion of the
o Ocular perforation IOL. Because the incision is smaller than the manual
o Retrobulbar hemorrhage extracapsular cataract extraction, the wound heals more
o Optic injuries rapidly, and there is early stabilization of refractive error
o Diplopia, and ptosis, and is ideal for and less astigmatism.
patients receiving anticoagulants.
• Furthermore, patients can communicate and LENS REPLACEMENT
cooperate during surgery. IV moderate
sedation may be used to minimize anxiety and • After removal of the crystalline lens, the patient
discomfort. is referred to as aphakic (i.e., without lens). The
• When both eyes have cataracts, one eye is lens, which focuses light on the retina, must be
treated first, with at least several weeks, replaced for the patient to see clearly.
preferably months, separating the two
APHAKIC GLASSESS:
procedures. Because cataract surgery is
performed to improve visual functioning, the • Aphakic glasses, although effective, are rarely
delay for the other eye gives time for the patient used. Objects are magnified by 25%, making
and the surgeon to evaluate whether the results them appear closer than they actually are. This
from the first surgery are adequate to preclude magnification creates distortion. Peripheral
the need for a second operation. The delay also vision is also limited, and binocular vision (i.e.,
provides time for the first eye to recover; if there ability of both eyes to focus on one object and
are any complications, the surgeon may decide fuse the two images into one) is impossible if the
to perform the second procedure differently. other eye is aphakic (without a natural lens).

CONTACT LENSES:
• Contact lenses provide patients with almost
normal vision, but because contact lenses need
to be removed occasionally, the patient also
needs a pair of aphakic glasses. Contact lenses
 are not advised for patients who have difficulty • Before discharge, the patient receives verbal
inserting, removing, and cleaning them. and written education regarding eye protection,
Frequent handling and improper disinfection administration of medications, recognition of
increase the risk of infection. complications, activities to avoid, and obtaining
emergency care. An eye shield is usually worn
INSERTION OF IOL’S” at night for the first week to avoid injury. The
• Insertion of IOLs during cataract surgery is the nurse also explains that there should be minimal
most common approach to lens replacement. discomfort after surgery and educates the
After cataract extraction, or phacoemulsification, patient about taking a mild analgesic agent, such
the surgeon implants an IOL. Cataract extraction as acetaminophen, as needed. Antibiotic, anti-
and posterior chamber IOLs are associated with inflammatory, and corticosteroid eye drops or
a relatively low incidence of complications (e.g., ointments are prescribed postoperatively.
eye infection, loss of vitreous humor, and Patients prescribed anti-inflammatory or
slipping of the implant) (Eliopoulos, 2018). corticosteroid eye drops are monitored for
• IOL implantation is contraindicated in patients possible increases in IOP.
with recurrent uveitis, proliferative diabetic
retinopathy, neovascular glaucoma, or rubeosis AFTER CATARACT SURGERY
iridis.
• Withhold any anticoagulant therapy (e.g.
o Single-Focus Lens: Eyeglasses are still
aspirin, warfarin [Coumadin]) – can cause
needed for distant or close vision
bleeding after surgery.
o Multifocal IOLs: Reduce the need for
• Dilating drops are administered every 10
eyeglasses but patients can experience
minutes for four (4) doses at least 1 hour
halos and glare.
before surgery.
• Antibiotic, corticosteroid, anti-inflammatory
NURSING MANAGEMENT
drops are given
PROVIDING PREOPERATIVE CARE • Patient wears a protective eye patch for 24
hours after surgery, followed by eyeglasses
• The patient with cataracts receives the usual worn during the day and a metal shield worn at
preoperative care for ambulatory surgical night for 1 – 4 weeks.
patients undergoing eye surgery. The standard • Sunglasses should be worn while outdoors
battery of preoperative tests (e.g., complete during the day because the eye is sensitive to
blood count, electrocardiogram, and urinalysis) light.
commonly performed for most surgeries is • Slight morning discharge, some redness, and
prescribed only if indicated by the patient’s scratchy feeling may be expected for a few days,
medical history. clean, damp washcloth may be used to
remove it.
ALPHA-ANTAGONISTS:
• Notify the surgeon if new floaters (dots) in vision,
• Alpha-antagonists (particularly Tamsulosin flashing lights, decrease in vision, pain, or
[Flomax], which is used for treatment of increase in redness occurs (medical
enlarged prostate) are known to cause a emergency).
condition called intraoperative floppy iris • IOL implants have functional vision on the first
syndrome. Alpha antagonists can interfere with day after surgery
pupil dilation during the surgical procedure, • Avoid straining, bending down or lifting heavy
resulting in miosis and iris prolapse and objects (may cause rupture of the suture lines).
leading to complications. Intraoperative floppy • Avoid touching the operated eye
iris syndrome can occur even though a patient • Lie on supine position or on the side opposite
has stopped taking the drug. The nurse needs to the affected eye when sleeping.
ask patients about a history of taking alpha-
antagonists. Surgical team members are then
alerted to the risk of this complication.
RETINAL DETACHMENT
• A partial or complete splitting away of the
DILATING DROPS: retina from the pigmented vascular layer called
• Dilating drops are given prior to surgery. Nurses the choroid, interrupting vascular supply to the
in the ambulatory surgery setting begin patient retina and thus creating a medical emergency.
education about eye medications (antibiotic, • Once signs and symptoms occur, bring the
corticosteroid, and anti-inflammatory drops) that patient immediately to ER (emergency room).
will need to be self-administered to prevent • Retinal detachment refers to the separation of
postoperative infection and inflammation. the RPE (retinal pigment epithelium) from the
neurosensory layer.
• The four types of retinal detachment are:
o Rhegmatogenous
o Traction
o A combination of rhegmatogenous and
traction
 o Exudative • Retinal detachment itself is painless
• Rhegmatogenous detachment is the most • The sudden appearance of many floaters –
common form. In this condition, a hole or tear tiny specks that seem to drift through your field
develops in the sensory retina, allowing some of of vision
the liquid vitreous to seep through the sensory • Complaints of a burst of black spots or
retina and detach it from the RPE. floaters – hallmark sign
• People at risk for this type of detachment include • Flashes of light in one or both eyes (photopsia)
those with high myopia or those who have • Blurred vision
aphakia (absence of the natural lens) after • Gradually reduced side (peripheral) vision
cataract surgery. • A sense of curtain falling across the field of
• Trauma may also play a role in rhegmatogenous vision – hallmark sign
retinal detachment. Between 5% and 10% of all
rhegmatogenous retinal detachments are TYPES OF RETINAL DETACHMENT
associated with proliferative retinopathy—a
retinopathy associated with diabetic RHEGMATOGENOUS RETINAL DETACHMENT
neovascularization.
• Common cause is aging since the gel-like
material that fills the inside of the eye (vitreous
humor) change its consistency, shrink, and
become more liquid.
• Cause by a hole or tear in the retina that allows
fluid to pass through and collect under the retina,
pulling the retina away from the underlying
tissues.
• The area which the retina detaches losses its
blood supply and stop working, causing loss of
vision.
• Normally, the vitreous choroid from the surface
of the retina without any complication.
• A condition called posterior vitreous
detachment (PVD) is one complication of this
• Tension, or a pulling force, is responsible for condition, which is a tearing of the retina.
traction retinal detachment. An
ophthalmologist must ascertain all of the areas TRACTIONAL RETINAL DETACHMENT
of retinal break and identify and release the • Detachment can occur when scar tissue grows
scars or bands of fibrous material providing on the retina’s surface, causing the retina to pull
traction on the retina. In general, patients with away from the back of the eye.
this condition have developed fibrous scar tissue • Commonly seen to pts with poorly controlled
from conditions such as: diabetes.
o Diabetic retinopathy
o Vitreous hemorrhage EXUDATIVE RETINAL DETACHMENT
o Retinopathy of prematurity
• The hemorrhages and fibrous proliferation • Fluid accumulates beneath the retina, but there
associated with these conditions exert a pulling are no holes or tears in the retina.
force on the delicate retina. • Exudative detachment can be caused by age-
• Patients can have both rhegmatogenous and related macular degeneration, injury to the eye,
traction retinal detachment. tumors or inflammatory disorders.
• Exudative retinal detachments are the result
of the production of a serous fluid under the RISK FACTORS
retina from the choroid. Conditions such as
• Aging – common over age 50
uveitis and macular degeneration may cause
• Previous retinal detachment in one eye
the production of this serous fluid.
• Family history of retinal detachment
CLINICAL MANIFESTATIONS • Extreme nearsightedness (myopia)
• Previous eye surgery, such as cataract removal
• Patients may report the sensation of a shade or • Previous severe eye injury
curtain coming across the vision of one eye, • Previous other eye disease or disorder,
cobwebs, bright flashing lights, or the sudden including:
onset of a great number of floaters. Patients do o Retinoschisis
not complain of pain but retinal detachment is an o Uveitis or thinning of the peripheral
ocular emergency, requiring immediate surgical retina (lattice degeneration)
intervention for optimal outcomes.
ASSESSMENT AND DIAGNOSTIC FINDINGS VIRECTOMY

• After visual acuity is determined, the patient • A vitrectomy is an intraocular procedure that
must have a dilated fundus examination using allows the introduction of a light source through
an indirect ophthalmoscope as well as slit- an incision; a second incision serves as the
lamp bio-microscopy. portal for the vitrectomy instrument. The surgeon
• Stereo fundus photography and fluorescein dissects preretinal membranes under direct
angiography are commonly used during the visualization while the retina is stabilized by an
evaluation. intraoperative vitreous substitute.
• Increasingly, optical coherence tomography • Traction on the retina may be relieved through
and ultrasound are used for the complete vitrectomy and may be combined with scleral
retinal assessment, especially if the view is buckling to repair retinal detachments. A gas
obscured by a dense cataract or vitreal bubble, silicone oil, or perfluorocarbon and
hemorrhage. All retinal breaks, all fibrous bands liquids may be injected into the vitreous cavity
that may be causing traction on the retina, and to help push the sensory retina up against the
all degenerative changes must be identified. RPE. Argon laser photocoagulation or
cryotherapy is also used to hold the retina in
RETINAL EXAMINATION place.

• The doctor uses an instrument with a bright light MEDICAL MANAGEMENT

and special lenses to examine the back of the
eye, including retina. RETINAL TEARS
• Device provide a highly detailed view of the
whole eye, allowing doctor to see any retinal
hole, tear, or detachment. LASER SURGERY (PHOTOCOAGULATION)
• The surgeon directs a laser beam into the eye
ULTRASOUND IMAGING through the pupil. The laser makes burn around
the retina tear creating scarring that usually well
• May use this if bleeding has occurred, making it
the retina to the underlying tissues.
difficult to see the retina.
• The doctor will examine both eyes regardless if
only one eye is affected. FREEZING (CRYOPEXY)
• If a tear is not identified at first visit, the doctor • After giving local anesthetic, the surgeon applies
would ask the patient to come back after a few the freezing probe to the outer surface of the
weeks after to confirm that there is no delayed eye, directly over the tear.
tear as a result of vitreous separation.
FREEZING CAUSES A SCAR THAT HELPS CURE
SURGICAL MANAGEMENT THE RETINA:

• In rhegmatogenous detachment, an attempt is • Both done in the outpatient basis; walk in basis.
made to surgically reattach the sensory retina to • After procedure, the patient is advised to avoid
the RPE. In traction retinal detachment, the activities that might dry the eyes, such as
source of traction must be removed and the running for a couple of weeks.
sensory retina reattached. The most commonly
used surgical interventions are the scleral RETINAL DETACHMENT
buckle and vitrectomy. • Needing surgery to repair the disorder,
preferably, within days of the diagnosis.
SCLERAL BUCKLE

• The retinal surgeon compresses the sclera PNEUMATIC RETINOPEXY

(often with a scleral buckle or a silicone band) to
• Injecting air or gas into the eye
indent the scleral wall from the outside of the
• Injecting a bubble of air or gas into the center of
eye and bring the two retinal layers in contact
eyes, the vitreous cavity.
with each other.
• If position properly, the bubble pushes the area
of retina containing the hole or hose against the
eye, stopping the flow of liquid into the space
behind retina.
• The doctor uses cryopexy during procedure to
repair retinal break.
• The fluid collected by the retina is absorbed by
itself, and retina can then adhere to the wall of
the eye.
• The patient may hold the hand in certain position
for up to several days to keep the bubble in the
proper position.
• The bubble eventually will absorb on its own. • Glaucoma is estimated to affect 3 million
Americans, approximately 50% of whom are
SCLERAL BUCKLING undiagnosed. Glaucoma is more prevalent in
people older than 40 years, and it is the third
• Indenting the surface of the eye that relieves most common age-related eye disease in the
some of the forces caused by vitreous clogging United States. There is no cure for glaucoma,
on the retina but the disease can be controlled.
• Involves surgeon sewing or suturing a piece of
silicone material to the white of the eye (sclera) RISK FACTORS
over the affected area.
• High internal eye pressure (intraocular pressure)
• Over age 60 (older age)
VIRECTOMY
• Black, Asian or Hispanic
• Draining and replacing the fluid in the eye • Family history of glaucoma
• Surgeon removes the vitreous along with any • Certain medical conditions, such as diabetes
tissue tagging in the retina. Air, gas, and silicone mellitus, heart disease, high blood pressure, and
oil is injected into the vitreous space to help sickle cell anemia.
flatten the retina. • Corneas that are thin in the center
• May be combined with scleral buckling • Extremely nearsighted or farsighted
• Vision takes several months to improve • Previous eye injury or certain types of eye
• May be needing second surgery for a successful surgery
treatment • Corticosteroid medications, especially eyedrops
taken for a long time
NURSING MANAGEMENT • Migraine syndrome
• Nursing management consists of educating the • Nearsightedness (myopia)
patient and providing supportive care. • Prolonged use of topical or systemic
Postoperative positioning of the patient is corticosteroids
critical when a gas bubble is used because the
injected bubble must remain in position overlying PATHOPHYSIOLOGY
the area of detachment, providing consistent
• Aqueous humor flows between the iris and the
pressure to reattach the sensory retina. The
lens, nourishing the cornea and lens. Most
patient must maintain a prone position that
(90%) of the fluid then flows out of the anterior
would allow the gas bubble to act as a
chamber, draining through the spongy trabecular
tamponade for the retinal break. Patients and
meshwork into the canal of Schlemm and the
family members should be made aware of these
episcleral veins. About 10% of the aqueous
needs beforehand so that the patient can be
fluid exits through the ciliary body into the
made as comfortable as possible.
suprachoroidal space and then drains into the
• In most cases, vitreoretinal procedures are venous circulation of the ciliary body, choroid,
performed on an outpatient basis, and the and sclera. Unimpeded outflow of aqueous fluid
patient is seen the next day for a follow-up depends on an intact drainage system and an
examination. Postoperative complications may open angle (about 45 degrees) between the iris
include: and the cornea. A narrower angle places the iris
o Increased IOP closer to the trabecular meshwork, diminishing
o Endophthalmitis the angle. The amount of aqueous humor
o Retinal detachment produced tends to decrease with age, in
o Development of cataracts systemic diseases such as diabetes, and in
• Patients must be educated about the signs and ocular inflammatory conditions.
symptoms of complications, particularly of
increasing IOP and postoperative infection. A.) Normally, aqueous humor, which is secreted in the
Contact details for the ophthalmic team are posterior chamber, gains access to the anterior chamber
provided and the patient is encouraged to call by flowing through the pupil. In the angle of the anterior
immediately if complications occur. chamber, it passes through the canal of Schlemm into
the venous system.
GLAUCOMA
B.) In wide-angle glaucoma, the outflow of aqueous
• The term glaucoma is used to refer to a group humor is obstructed at the trabecular meshwork.
of ocular conditions characterized by elevated
IOP. If left untreated, the increased IOP C.) In narrow-angle glaucoma, the aqueous humor
damages the optic nerve and nerve fiber layer, encounters resistance to flow through the pupil.
but the degree of harm is highly variable. The Increased pressure in the posterior chamber produces a
optic nerve damage is related to the IOP caused forward bowing of the peripheral iris so that the iris
by congestion of aqueous humor in the eye. A blocks the trabecular meshwork.
range of IOPs are considered “normal,” but
these may also be associated with vision loss in
some patients.
 • Some glaucomas appear as exclusively
mechanical, and some are exclusively ischemic
types.
• Typically, most cases are a combination of both.

CAUSES

• Glaucoma is the result of damage to the optic

nerve.
o As it deteriorates blind spots develop in
the visual fields.
o Related to increased pressure in the eye
• Elevated eye pressure is due to a buildup of a
fluid (aqueous humor) that flows throughout the
inside of your eye.
o The internal fluid will normally drain out
in a tissue called the trabecular
meshwork at the angle where the iris
and cornea meet.
o When fluid is overproduced or the
draining system doesn’t work properly,
the fluid can’t flow out at its normal rate
and eye pressure increases.
• IOP: between 10 to 21 mmHg
• It is genetic

TYPES AND CLASSIFICATIONS

• There are several types of glaucoma.

• Forms of glaucoma are identified as wide-angle
glaucoma; narrow-angle glaucoma;
congenital glaucoma; and glaucoma
associated with other conditions, such as
developmental anomalies or corticosteroid use.
• IOP is determined by the rate of aqueous • Glaucoma can be primary or secondary
production, the resistance encountered by the depending on whether associated factors
aqueous humor as it flows out of the passages, contribute to the rise in IOP.
and the venous pressure of the episcleral veins • The two common clinical forms of glaucoma in
that drain into the anterior ciliary vein. When adults are wide- and narrow angle glaucoma,
aqueous fluid production and drainage are in which are differentiated by the mechanisms that
balance, the IOP is between 10 and 21 mmHg. cause impaired aqueous outflow.
When aqueous fluid is inhibited from flowing out,
pressure builds up within the eye. Fluctuations in OPEN-ANGLE GLAUCOMA
IOP occur with time of day, exertion, diet, and
medications. IOP tends to increase with blinking, • Common form
tight lid squeezing, and upward gazing. Systemic • The drainage angle formed by the cornea and
conditions such as diabetes and intraocular the iris remains open, but the trabecular
conditions such as uveitis and retinal meshwork is partially blocked.
detachment have been associated with elevated • This causes pressure in the eye to gradually
IOP. Glaucoma may not be recognized in people increase.
with thin corneas because measurement of the • This pressure damages the optic nerve and it
IOP may be falsely low as a result of this happens so slowly that the vision may be loss
thinness. before the patient is even aware of the problem.

PATHOPHYSIOLOGY ANGLE-CLOSURE GLAUCOMA

• There are two theories regarding how increased • Also called closed-angle glaucoma
IOP damages the optic nerve in glaucoma. • Occurs when the iris bulges forward to narrow or
• The direct mechanical theory suggests that block the drainage angle formed by the cornea
high IOP damages the retinal layer as it passes and the iris.
through the optic nerve head. • As a result, fluid can’t circulate through the eye
• The indirect ischemic theory suggests that and pressure increases.
high IOP compresses the microcirculation in the • Some patients with narrow drainage angle put
optic nerve head, resulting in cell injury and them at risk of angle closure glaucoma.
death. • May occur suddenly (acute), gradually, or
chronic
 • Acute form is a medical emergency and require OCULAR HYPERTENSION
immediate treatment.
MANIFESTATIONS:
NORMAL-TENSION GLAUCOMA • Elevated IOP
• The optic nerve becomes damage even if the • Possible ocular pain or headache
pressure of the eye is within normal range.
TREATMENT:
• Exact reason is unknown; one may have
sensitive optic nerve or less blood being • The best management for normal tension
supplied into the optic nerve (may be due to glaucoma management is yet to be established.
atherosclerosis). Goal is to lower the IOP by at least 30%.

GLAUCOMA IN CHILDREN NARROW-ANGLE GLAUCOMA

• Possible for infants and children • Obstruction in aqueous humor outflow due to the
• May be present at birth or develop withing the complete or partial closure of the angle from the
first few years of life. forward shift of the peripheral iris to the
• Optic nerve damage may be caused by drainage trabecula.
blockage or underlying medical condition. • The obstruction results in an increased IOP.

PIGMENTARY GLAUCOMA ACUTE ANGLE-CLOSURE GLAUCOMA

• The pigment granules from the iris buildup in the MANIFESTATIONS:
drainage channels, slowing or blocking fluid
exiting the eye. • Rapidly progressive visual impairment,
• Activities like jogging can sometimes tear up the periocular pain, conjunctival hyperemia and
pigment granules. Depositing them on the congestion.
trabecular meshwork and causing intermittent • Pain may be associated with nausea, vomiting,
pressure elevation. bradycardia and profuse sweating.
• Reduced central visual acuity, severely elevated
CLINICAL MANIFESTATIONS IOP, and corneal edema.
• Pupil is vertically oval, fixed in a semi-dilated
• Glaucoma is often called the “silent thief of position and unreactive to light and
sight” because most patients are unaware that accommodation.
they have the disease until they have
experienced visual changes and vision loss. TREATMENT:
• The patient may not seek health care until he or • Ocular emergency; administration of
she experiences blurred vision or “halos” around hyperosmotic, acetazolamide, and topical ocular
lights, difficulty focusing, difficulty adjusting eyes hypotensive agents, such as Pilocarpine and
in low lighting, loss of peripheral vision, aching beta-blockers (Betaxolol).
or discomfort around the eyes, and headache. • Possible laser incision in the iris (iridotomy) to
release blocked aqueous and reduce IOP.
TYPES OF GLAUCOMA
• Other eye is also treated with pilocarpine eye
drops and/or surgical management to avoid a
WIDE-ANGLE GLAUCOMA
similar spontaneous attack.
• Usually bilateral, but one eye may be more
severely affected than the other. In wide-angle SUBACUTE ANGLE-CLOSURE GLAUCOMA
glaucoma, the anterior chamber angle is open
and appears normal. MANIFESTATIONS:
• Transient blurring of vision, halos around lights;
NORMAL TENSION GLAUCOMA temporal headaches and/or ocular pain; pupil
may be semi-dilated.
MANIFESTATIONS:
• IOP ≤21mmHg TREATMENT:
• Optic nerve damage • Prophylactic peripheral laser iridotomy.
• Visual field deficits • Can lead to acute or chronic angle- closure
glaucoma if untreated.
TREATMENT:
• If medical treatment is unsuccessful, LT can CHRONIC ANGLE-CLOSURE GLAUCOMA
decrease IOP by 20%. Glaucoma filtering
surgery if continued optic nerve damage despite MANIFESTATIONS:
medication therapy and LT.
• Progression of glaucomatous cupping and
• The best management for normal tension
significant visual field loss; IOP may be normal
glaucoma management is yet to be established. or elevated; ocular pain and headache.
Goal is to lower the IOP by at least 30%.
TREATMENT:
• Management includes laser iridotomy and
medications.

PREVENTION

• Get regular dilated eye examinations

• Know your family’s eye health history
• Exercise safely – regular moderate exercise
reduces eye pressure
• Take prescribed eyedrops regularly – can
significantly reduce risk of high pressure
• Wear eye protection

ASSESSMENT AND DIAGNOSTIC FINDINGS

• The purpose of a glaucoma workup is to

establish the diagnostic category, assess the MEDICAL MANAGEMENT
optic nerve damage, and formulate a treatment
plan. The patient’s ocular and medical history • The aim of all glaucoma treatment is prevention
must be detailed to investigate the history of of optic nerve damage. Lifelong therapy is
predisposing factors. The types of examinations necessary because glaucoma cannot be cured.
used in glaucoma include tonometry to measure Treatment focuses on pharmacologic therapy,
the IOP, ophthalmoscopy to inspect the optic laser procedures, surgery, or a combination of
nerve, and central visual field testing. these approaches, all of which have potential
complications and side effects. The object is to
• The changes in the optic nerve related to
achieve the greatest benefit at the least risk,
glaucoma are pallor and cupping of the optic
cost, and inconvenience to the patient. Although
nerve disc. The pallor of the optic nerve is
treatment cannot reverse optic nerve damage,
caused by a lack of blood supply. Cupping is
further damage can be controlled. The goal is to
characterized by exaggerated bending of the
maintain an IOP within a range unlikely to cause
blood vessels as they cross the optic disc,
further damage.
resulting in an enlarged optic cup that appears
more basin like compared with a normal cup. • The initial target for IOP among patients with
The progression of cupping in glaucoma is elevated IOP and those with low-tension
caused by the gradual loss of retinal nerve fibers glaucoma with progressive visual field loss is
and the loss of blood supply. typically set at 30% lower than the current
pressure. The patient is monitored for changes
• As the optic nerve damage increases, visual
in the appearance of the optic nerve. If there is
perception decreases. The localized areas of
evidence of progressive damage, the target IOP
visual loss (i.e., scotomas) represent loss of
is again lowered until the optic nerve shows
retinal sensitivity and nerve fiber damage and
stability.
are measured and mapped on a graph. In
patients with glaucoma, the graph has a distinct • The damage caused can’t be reversed, but
pattern that is different from other ocular treatment and regular check-ups can help slow
diseases and is useful in establishing the or prevent vision loss. Glaucoma is treated by
diagnosis. lowering the eye pressure, depending on the
situation, may include the prescription of the
following:

• Review of medical history and comprehensive EYE DROPS

eye examination
• Helps decrease eye pressure by improving fluid
• Measuring intraocular pressure (tonometry)
drain in the eye or by decreasing the normal
• Testing for optic nerve damage with a dilated
amount of fluid in the eye.
eye examination and imaging tests
• Checking for areas of vision loss (visual field PROSTAGLANDINS:
test)
• Increases the outflow of fluid (aqueous humor) in
• Measuring corneal thickness (pachymetry)
the eye by reducing eye pressure.
• Inspecting the drainage angle (gonioscopy)
• Medicine: Latanoprost (Xalatan)
• Possible side effects include difficulty breathing,
slowed heart rate, lower blood pressure,
impotence, and fatigue.
• This class of drug can be prescribed for once- or
twice-daily use depending on your condition.
ALPHA-ADRENERGIC AGONISTS: FILTERING SURGERY:
• Reproduce aqueous humor and increase outflow • With trabeculectomy, the surgeon creates an
of the fluid in the eye. opening in the sclera and removes part of the
• Medicine: Iopidine and Alphagan trabecular meshwork.
• Possible side effects include an irregular heart
rate, high blood pressure, fatigue, red, itchy or DRAINAGE TUBES:
swollen eyes, and dry mouth. • Surgeon inserts a small tube, shunt in the eye to
• This class of drug is usually prescribed for twice- drain away excess fluid to lower eye pressure.
daily use but sometimes can be prescribed for
use three times a day. MINIMALLY INVASIVE GLAUCOMA SURGERY
(MIGS):
CARBONIC ANHYDRASE INHIBITORS:
• Doctor may suggest to lower eye pressure
• Reduce fluid production in eyes • Require less immediate post operative care and
• Medicine: Trusopt and Azopt have less risk than trabeculectomy or instilling
• Possible side effects include metallic taste, drainage device.
frequent urination, and tingling in the fingers and • Often combined with cataract surgery
toes.
• This class of drug is usually prescribed for twice- LASER PERIPHERAL IRIDOTOMY:
daily use but sometimes can be prescribed for • Opening made in the iris
use three times a day. • Treating acute angle-closure glaucoma, a
medical emergency.
RHO-KINASE INHIBITOR:
• Require both medical, laser, and other surgical
• Lowers eye pressure by suppressing the rho- procedure
kinase enzymes responsible for fluid increase. • Doctor creates a small opening in the iris using a
• Medicine: Rhopressa laser to allow aqueous humor to flow through it,
• Possible side effects include eye redness, eye relieving eye pressure.
discomfort, and deposits forming on the cornea • Usually done during EMERGENCY cases
• Prescribed for once-daily use (acute ACG)
• Pilocarpine: Prevent closure and widen the
MITOTIC OR CHOLINERGIC AGENTS: angle in patients with narrow angle if the
• Increase the outflow of fluid from the eye iridotomy fails.
• Medicine: Pilocarpine and Isopto carpine
• Side effects include headache, eye ache, PHARMACOLOGIC THERAPY
smaller pupils, possible blurred or dim vision,
• Medical management of glaucoma relies on
and nearsightedness.
systemic and topical ocular medications that
lower IOP. Periodic follow-up examinations are
NOTE: When prescribed multiple eye drops, allow 5 essential to monitor IOP, the appearance of the
minutes before administering the other drops. optic nerve, the visual fields, and side effects of
medications. Therapy takes into account the
patient’s health and stage of glaucoma. Comfort,
ORAL MEDICATIONS
affordability, convenience, lifestyle, and
• If eyedrops alone don’t bring your eye pressure functional ability are factors to consider in the
down to the desired level, your doctor may also patient’s adherence to the medical regimen.
prescribe an oral medication, usually a carbonic • The patient is usually started on the lowest dose
anhydrase inhibitor. of topical medication and then advanced to
• Possible side effects include frequent urination, increased concentrations until the desired IOP
tingling in the fingers and toes, depression, level is reached and maintained. Beta-blockers
stomach upset, and kidney stones. are the preferred initial topical medications
because of their efficacy, minimal dosing (can be
SURGERIES used once each day), and low cost. One eye is
treated first, with the other eye used as a control
LASER TRABECULOPLASTY: in determining the efficacy of the medication;
once efficacy has been established, treatment of
• Option if the patient has open-angle glaucoma
the other eye is started. If the IOP is elevated in
• Done in a clinic using a small laser beam to
both eyes, both are treated. When results are
open clogged channels in the trabecular
not satisfactory, a new medication is substituted.
meshwork.
The main markers of the efficacy of the
• May take a few weeks before a full effect of this
medication in glaucoma control are lowering of
procedure becomes apparent.
the IOP to the target pressure, stable
appearance of the optic nerve head, and the
visual field.
• Many ocular medications are used to treat
glaucoma, including miotics, beta-blockers,
 alpha2-agonists (i.e., adrenergic agents), • Trabeculectomy is the standard filtering
carbonic anhydrase inhibitors, and technique used to remove part of the trabecular
prostaglandins. meshwork.
• Cholinergics (i.e., miotics) increase the outflow • Complications include hemorrhage, an
of the aqueous humor by affecting ciliary muscle extremely low (hypotony) or extremely elevated
contraction and pupil constriction, allowing flow IOP, uveitis, cataracts, bleb failure, bleb leak,
through a larger opening between the iris and and endophthalmitis (i.e., intraocular infection).
the trabecular meshwork.
• Beta-blockers and carbonic anhydrase DRAINAGE IMPLANTS OR SHUNTS:
inhibitors decrease aqueous production. • Drainage implants or shunts are tubes implanted
• Prostaglandin analogs reduce IOP by in the anterior chamber to shunt aqueous humor
increasing aqueous humor outflow. to the episcleral plate in the conjunctival space.
Implants are used when failure has occurred
SURGICAL MANAGEMENT with one or more trabeculectomies in which
antifibrotic agents were used. A fibrous capsule
• Surgery is reserved for patients in whom
develops around the episcleral plate and filters
pharmacologic treatment has not controlled the
the aqueous humor, thereby regulating the
IOP. This minimally invasive procedure is
outflow and controlling IOP.
specifically designed to improve fluid drainage
from the eye to balance IOP. By restoring the
eye’s natural fluid balance, trabeculectomy MEDICATIONS
surgery stabilizes the optic nerve and minimizes
CHOLINERGIC (MIOTICS)
further visual field damage. The surgery is
performed through a small incision and does not • Pilocarpine
require creation of a permanent hole in the eye • Carbachol
wall or an external filtering bleb or an implant.
ACTION:
LASER TRABECULOPLASTY:
• Increase aqueous fluid outflow by contracting
• In laser trabeculoplasty for glaucoma, a laser the ciliary muscle and causing miosis
beam is applied to the inner surface of the (constriction of the pupil) and opening of
trabecular meshwork to open the intertrabecular trabecular meshwork.
spaces and widen the canal of Schlemm,
promoting outflow of aqueous humor and SIDE EFFECTS:
decreasing IOP. • Periorbital pain, blurry vision, difficulty seeing the
• The procedure is indicated when IOP is dark.
inadequately controlled by medications, and it is
contraindicated when the trabecular meshwork NURSING IMPLICATIONS:
cannot be fully visualized because of a narrow
• Caution patients about diminished vision in dimly
angle.
lit areas.
PERIPHERAL IRIDOTOMY:
BETA-BLOCKERS
• In peripheral iridotomy for pupillary block
glaucoma, an opening is made in the iris to • Timolol maleate
eliminate the pupillary blockage. Laser
iridotomy is contraindicated in patients with ACTION:
corneal edema, which interferes with laser • Decrease aqueous humor production
targeting and strength.
• Potential complications include burns to the SIDE EFFECTS:
cornea, lens, or retina; transient elevated IOP; • Can have systemic effects, including
closure of the iridotomy; uveitis; and blurring. bradycardia, exacerbation of pulmonary disease,
and hypotension.
FILTERING PROCEDURES:
• Filtering procedures for glaucoma are used to NURSING IMPLICATIONS:
create an opening or fistula in the trabecular • Contraindicated in patients with asthma, chronic
meshwork to drain aqueous humor from the obstructive pulmonary disease, 2nd- or 3rd
anterior chamber to the subconjunctival space degree heart block, bradycardia, or cardiac
into a bleb (fluid collection on the outside of the failure; educate patients about punctal occlusion
eye), thereby bypassing the usual drainage to limit systemic effects.
structures.
• This allows the aqueous humor to flow and exit
by different routes (i.e., absorption by the
conjunctival vessels or mixing with tears).
 ALPHA-ADRENERGIC AGONISTS

• Apraclonidine
• Brimonidine

ACTION:
• Decrease aqueous humor production

SIDE EFFECTS:
• Eye redness, dry mouth and nasal passages

NURSING IMPLICATIONS:
• Educate patients about punctal occlusion to limit
systemic effects

CARBONIC ANHYDRASE INHIBITORS

• Acetazolamide
• Dorzolamide

ACTION:
• Decrease aqueous humor production

SIDE EFFECTS:
• Oral medications (acetazolamide) are
associated with serious side effects including
anaphylactic reactions, electrolyte loss,
depression, lethargy, gastrointestinal upset,
impotence, and weight loss
• Side effects of topical form (dorzolamide) include
topical allergy

NURSING IMPLICATIONS:
• Do not administer to patients with sulfa-allergies;
monitor electrolyte levels

PROSTAGLANDIN ANALOGS

• Latanoprost
• Bimatoprost

ACTION:

• Increase uveoscleral outflow

SIDE EFFECTS:
• Darkening of the iris, conjunctival redness,
possible rash

NURSING IMPLICATIONS:
• Instruct patients to report any side effects