Angelite Nurses

• Cataracts
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• Glaucoma
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• Detached Retina
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• Eye Injuries/Emergency Care
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• Blindness
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• Conjunctivitis

1. General information: infection of membrane covering anterior surface of eye globe and inner surface of eyelid due to multiple causes (bacterial, viral, allergic)
2. Medical management: ophthalmic antibiotics, steroids, anesthetics
3. Assessment findings: weeping eye, reddened conjunctiva, sensitivity to light, eyelid stuck shut with exudate
4. Nursing interventions
1. Administer medications as ordered: apply ophthalmic antibiotic ointments from inner to outer canthus (do not let container touch eye).
2. Provide client teaching and discharge planning concerning measures to prevent spread of infection
1. Very contagious if bacterial or viral; no school until antibiotics have been taken for 24-48 hours
2. Should not share pillows, tissues, toys
3. Good hand-washing technique
4. Medication regimen: schedule, dosage, desired and side effects

1. Causes
1. Genetic disorders: Tay-Sach's disease, inborn errors of metabolism
2. Maternal infections during pregnancy: TORCH syndrome
3. Perinatal: prematurity, retrolental fibroplasia
4. Postnatal: trauma, childhood infections
2. Medical management: treatment of causative disorders
3. Assessment findings
1. Vacant stare; obvious failure to look at objects
2. Rubbing eyes, tilting head, examining objects very close to the eyes
3. Does not reach for objects (over 4 months)
4. Does not smile when mother smiles (over 3 months), but does smile in response to mother's voice
5. Crawls or walks into furniture (over 12 months)
6. Does not respond to the motions of others
7. No concept of the look of an object, no concept of color or reflection of self
8. Other senses become more keenly developed to compensate
9. Unable to copy the actions of others; delayed motor milestones in accomplishing tasks but are not mentally handicapped
10. Various degrees (20/200 O.U. and worse)
4. Nursing interventions
1. For hospitalized child, find out parents' usual method of care.
2. Encourage infant to be active; use multisensory stimulation (rocking, water play, musical toys, touch).
3. From ages 2-5 arrange environment for maximum autonomy and safety (e.g., avoid foods with seeds and bones).
4. Speak before you touch the child, announce what you plan to do.
5. Do not rearrange furniture without first telling child.
6. For a partially sighted child
1. Encourage child to sit in front of classroom.
2. Speak directly to child's face; do not look down or turn back.
3. Use large print and provide adequate nonglare lighting.
4. Use contrasting colors to help locate areas.
7. Provide client teaching and discharge planning concerning
1. General child care, with adaptations for safety and developmental/ functional level
2. Availability of support groups/community agencies
3. Special education programs
4. Interaction with peers; assist child as necessary

1. Removal of loose foreign body from conjunctiva
1. Foreign bodies, e.g., sand, dust, may cause pain and lacrimation.
2. Instruct client to look upward.
3. Evert lower lid to expose the conjunctival sac.
4. Gently remove the particle with a cotton applicator dipped in sterile normal saline using a twisting motion.
5. If particle is not found, examine the upper lid.
6. Place cotton applicator stick or tongue blade horizontally on outer surface of upper lid; grasp under eyelashes with fingers of other hand and pull the upper lid outward and upward over the applicator stick.
7. Gently remove the particle as above.
2. Penetrating injuries to the eye
1. Examples: darts, scissors, flying metal
2. Do not attempt to remove object.
3. Do not allow client to apply pressure to the eye.
4. Cover eye lightly with sterile eye patch for embedded objects, e.g., metal; apply protective shield, e.g., paper cup, for impaled objects such as darts.
5. Cover uninjured eye to prevent excessive movement of injured eye.
6. Refer the client to an emergency room immediately.
3. Chemical burns
1. Flush eye immediately with copious amounts of water for 15-20 minutes.
1. Have client hold head under faucet to let water run over eye to thoroughly wash it out; may need to forcibly separate eyelids during flush
2. If available, flush eye with syringe
2. After flushing, refer client to an emergency room immediately

1. General information
1. Detachment of the sensory retina from the pigment epithelium of the retina
2. Caused by trauma, aging process, severe myopia, postcataract extraction, severe diabetic retinopathy
3. Pathophysiology: tear in the retina allows vitreous humor to seep behind the sensory retina and separate it from the pigment epithelium
2. Medical management
1. Bed rest with eyes patched and detached areas dependent to prevent further detachment
2. Surgery: necessary to repair detachment
1. Photocoagulation: light beam (argon laser) through dilated pupil creates an inflammatory reaction and scarring to heal the area
2. Cryosurgery or diathermy: application of extreme cold or heat to the external globe; inflammatory reaction causes scarring and healing of area
3. Scleral buckling: shortening of sclera to force pigment epithelium close to retina
3. Assessment findings
1. Flashes of light, floaters
2. Visual field loss, veil-like curtain coming across field of vision
3. Diagnostic test: ophthalmoscopic examination confirms diagnosis.
4. Nursing interventions: preoperative
1. Maintain bed rest as ordered with head of bed flat and detached area in a dependent position.
2. Use bilateral eye patches as ordered; elevate side rails to prevent injury.
3. Identify yourself when entering the room.
4. Orient the client frequently to time, date, and surroundings; explain procedures.
5. Provide diversional activities to provide sensory stimulation.
5. Nursing interventions: postoperative (see also Cataract Surgery)
1. Check orders for positioning and activity level.
1. May be on bed rest for 1-2 days.
2. May need to position client so that detached area is in dependent position.
2. Administer medications as ordered: topical mydriatics, analgesics as needed.
3. Provide client teaching and discharge planning concerning
1. Technique of eyedrop administration
2. Use of eye shield at night
3. No bending from waist; no heavy work or lifting for 6 weeks
4. Restriction of reading for 3 weeks or more
5. May watch television
6. Need to check with physician regarding combing and shampooing hair and shaving
7. Need to report complications such as recurrence of detachment

1. General information
1. Characterized by increased intraocular pressure resulting in progressive loss of vision; may cause blindness if not recognized and treated
2. Risk factors: age over 40, diabetes, hypertension, heredity; history of previous eye surgery, trauma, or inflammation
3. Types
1. Chronic (open-angle) glaucoma: most common form, due to obstruction of the outflow of aqueous humor, in trabecular meshwork or canal of Schlemm
2. Acute (closed-angle) glaucoma: due to forward displacement of the iris against the cornea, obstructing the outflow of the aqueous humor; occurs suddenly and is an emergency situation; if untreated, blindness will result
3. Chronic (closed-angle) glaucoma: similar to acute (closed-angle) glaucoma, with the potential for an acute attack
4. Early detection is very important; regular eye exams including tonometry for persons over age 40 is recommended.
2. Medical management
1. Chronic (open-angle) glaucoma
1. Drug therapy: one or a combination of the following
1. miotic eyedrops (pilocarpine) to increase outflow of aqueous humor
2. epinephrine eyedrops to decrease aqueous humor production and increase outflow
3. acetazolamide (Diamox): carbonic anhydrase inhibitor to decrease aqueous humor production
4. timolol maleate (Timoptic): topical beta-adrenergic blocker to decrease intraocular pressure
2. Surgery (if no improvement with drugs)
1. filtering procedure (trabeculectomy, trephining) to create artificial openings for the outflow of aqueous humor
2. laser trabeculoplasty: noninvasive procedure performed with argon laser that can be done on an outpatient basis; produces similar results as trabeculectomy
2. Acute (closed-angle) glaucoma
1. Drug therapy (before surgery)
1. miotic eyedrops (e.g., pilocarpine) to cause pupil to contract and draw iris away from cornea
2. osmotic agents (e.g., glycerin [oral], mannitol [IV]) to decrease intraocular pressure
3. narcotic analgesics for pain
2. Surgery
1. peripheral iridectomy: portion of the iris is excised to facilitate outflow of aqueous humor
2. argon laser beam surgery: noninvasive procedure using laser that produces same effect as iridectomy; done on an outpatient basis
3. iridectomy usually performed on second eye later since a large number of clients have an acute attack in the other eye
3. Chronic (closed-angle) glaucoma
1. Drug therapy: miotics (pilocarpine)
2. Surgery: bilateral peripheral iridectomy to prevent acute attacks
3. Assessment findings
1. Chronic (open-angle) glaucoma: symptoms develop slowly; impaired peripheral vision (tunnel vision); loss of central vision if unarrested; mild discomfort in the eyes; halos around lights
2. Acute (closed-angle) glaucoma: severe eye pain; blurred, cloudy vision; halos around lights; nausea and vomiting; steamy cornea; moderate pupillary dilation
3. Chronic (closed-angle) glaucoma: transient blurred vision; slight eye pain; halos around lights
4. Diagnostic tests
1. Visual acuity: reduced
2. Tonometry: reading of 24-32 mm Hg suggests glaucoma; may be 50 mm Hg or more in acute (closed-angle) glaucoma
3. Ophthalmoscopic exam: reveals narrowing of small vessels of optic disk, cupping of optic disk
4. Perimetry: reveals defects in visual fields
5. Gonioscopy: examine angle of anterior chamber
4. Nursing interventions
1. Administer medications as ordered.
2. Provide quiet, dark environment.
3. Maintain accurate I&O with the use of osmotic agents.
4. Prepare the client for surgery if indicated.
5. Provide post-op care (see Cataract Surgery).
6. Provide client teaching and discharge planning concerning
1. Self-administration of eyedrops
2. Need to avoid stooping, heavy lifting, or pushing, emotional upsets, excessive fluid intake, constrictive clothing around the neck
3. Need to avoid the use of antihistamines or sympathomimetic drugs (found in cold preparations) in closed-angle glaucoma since they may cause mydriasis
4. Importance of follow-up care
5. Need to wear Medic-Alert tag

1. General information
1. Opacity of the ocular lens
2. Incidence increases with age
3. May be caused by changes associated with aging ("senile" cataract); may be congenital; or may develop secondary to trauma, radiation, infection, certain drugs (corticosteroids)
2. Assessment findings
1. Blurred vision
2. Progressive decrease in vision
3. Glare in bright lights
4. Pupil may develop milky-white appearance
5. Diagnostic test: ophthalmoscopic exam confirms presence of cataract
3. Nursing interventions: prepare client for cataract surgery.

Cataract Surgery

1. General information
1. Performed when client can no longer remain independent because of reduced vision
2. Surgery performed on one eye at a time; usually in a same-day surgery unit
3. Local anesthesia and intravenous sedation usually used
4. Types
1. Extracapsular extraction: lens capsule is excised and the lens is expressed; posterior capsule is left in place (may be used to support new artificial lens implant).
2. Phacoemulsification: a type of extracapsular extraction; a hollow needle capable of ultrasonic vibration is inserted into lens, vibrations emulsify the lens, which is then aspirated.
3. Intracapsular extraction: lens is totally removed within its capsule, may be delivered from eye by cryoextraction (lens is frozen with a metal probe and removed).
5. Peripheral iridectomy may be performed at the time of surgery; small hole cut in iris to prevent development of secondary glaucoma
6. Intraocular lens implant often performed at the time of surgery.
2. Nursing interventions: preoperative (see also Perioperative Nursing)
1. Assess vision in the unaffected eye since the affected eye will be patched post-op.
2. Provide pre-op teaching regarding measures to prevent increased intraocular pressure post-op.
3. Administer medications as ordered.
1. Topical mydriatics and cycloplegics to dilate the pupil
2. Topical antibiotics to prevent infection
3. Acetazolamide (Diamox) and osmotic agents (oral glycerin or IV mannitol) to decrease intraocular pressure to provide a soft eyeball for surgery
3. Nursing interventions: postoperative
1. Reorient the client to surroundings.
2. Provide safety measures: elevate side rails, provide call bell, assist with ambulation when fully recovered from anesthesia.
3. Prevent increased intraocular pressure and stress on the suture line.
1. Elevate head of bed 30°-40°.
2. Have client lie on back or unaffected side.
3. Avoid having client cough, sneeze, bend over, or move head too rapidly.
4. Treat nausea with antiemetics as ordered to prevent vomiting.
5. Give stool softeners as ordered to prevent straining.
6. Observe for and report signs of increased intraocular pressure: severe eye pain, restlessness, increased pulse.
4. Protect eye from injury.
1. Dressings are usually removed the day after surgery.
2. Eyeglasses or eye shield used during the day.
3. Always use eye shield during the night.
5. Administer medications as ordered.
1. Topical mydriatics and cycloplegics to decrease spasm of ciliary body and relieve pain
2. Topical antibiotics and corticosteroids
3. Mild analgesics as needed
6. Provide client teaching and discharge planning concerning
1. Technique of eyedrop administration
2. Use of eye shield at night
3. No bending, stooping, or lifting
4. Report signs or symptoms of complications immediately to physician: severe eye pain, decreased vision, excessive drainage, swelling of eyelid.
5. Cataract glasses/contact lenses
1. if a lens implant has not been performed, the client will need glasses or contact lenses.
2. temporary glasses are worn for 1-4 weeks, then permanent glasses fitted.
3. cataract glasses magnify objects by 1/3 and distort peripheral vision; have client practice manual coordination with assistance until new spatial relationships become familiar; have client practice walking, using stairs, reaching for articles.
4. contact lenses cause less distortion of vision; prescribed at one month.