Tumors of the Eye, Cataract, Glaucoma, Retinal Detachment

Tumors of the Eye

Tumors of the Eye

Overview:

• May be benign or malignant; can form in or metastasize to the eye

• Retinoblastoma, a congenital malignant neoplasm found in children; spreads easily by extension to the brain

• Melanoma in the iris and choroid; grows slowly, metastasizes to liver and lungs

Tumors of the Eye

Clinical findings:

• Headache, visual complaints

• Redness and swelling of the conjunctiva; decreased vision; increased intraocular pressure

• In Retinoblastoma, white pupillary reflex, strabismus, retinal detachment

Tumors of the Eye

Therapeutic Management:

• Chemotherapy

• Radiation therapy

• Enucleation (surgical removal of the eye) when tumor is malignant

Tumors of the Eye

Nursing Care

Assessment:

• Description of onset and progression of symptoms

• Visual acuity

• Client’s coping mechanisms and support system

Tumors of the Eye

Nursing Care:

Nursing Diagnoses:

• Body image disturbance related to enucleation

• Risk for injury related to visual disturbance

Tumors of the Eye

Nursing Care:

Planning/Implementation:

• Support client and family as they attempt to cope with diagnosis; support adaptation to changes in body image

• Observe for side effects of medical therapy and attempt to limit their effects

Tumors of the Eye

Nursing Care:

Planning/Implementation:

• Provide care in post enucleation period…

• Maintain pressure dressings on eye for 1-2 days to minimize hemorrhage

• Watch for signs of meningitis, which occurs as a complication, including headache or pain on operative side

• Explain that monocularity results in loss of depth perception; activities that require this should be performed cautiously; turning head from side to side

Tumors of the Eye

Nursing Care:

Planning/Implementation:

d. Explain that the artificial eye may be inserted when healing is complete, usually 1-2 months; instruct about care of the eye socket and prosthesis; cleanse eye prosthesis with warm water or saline

Tumors of the Eye

Nursing Care:

Planning/Implementation:

• Support natural defense mechanisms; encourage intake of nutrient dense foods, especially those rich in the immune-stimulating mineral selenium and vitamins A, C, and E, as well as protein

Tumors of the Eye

Nursing Care:

Evaluation/Outcomes:

• Adapts to loss of eye while maintaining a positive body image

• Remains free from injury

• Cares for eye socket and prosthesis appropriately

Cataract

Cataract

Overview:

• Opacity of the crystalline lens or its capsule

• Results from injury, exposure to heat, heredity, aging, or congenital factors that cause a diminution of sight

Cataract

Clinical findings:

• Distortion of vision (e.g., haziness, cloudiness, diplopia); photophobia

• Progressive loss of vision; black pupil appears clouded, progressing to milky white appearance

Cataract

Therapeutic interventions:

• Mydriatics and ophtalmic antibiotics

• Corrective lenses until surgery is needed

• Surgical intervention to remove the opaque lens

(a.) surgery most frequently performed in ambulatory surgery

(b.) extracapsular extraction involves removing the anterior capsule and lens through a small incision after the lens has been fragmented through a phacoemulsification technique; most common procedure

(c.) intracapsular extraction involves removal of the entire lens as a unit with a cryoprobe

(d.) intraocular lens implantation usually done at the time of cataract extraction

(e.) corrective lenses following cataract surgery

(f.) anti-emetics, analgesics, and stool softeners postoperatively

Cataract

Nursing Care:

Assessment:

• Description of onset and progression of symptoms

• Visual acuity

• Characteristic of lens

• Red reflex via ophthalmoscopic examination

Cataract

Nursing Care:

Nursing Diagnoses:

• Sensory/perceptual alteration (visual) related to clouding of lens

• Risk for injury related to change in depth perception and decreased visual acuity

Cataract

Nursing Care:

Planning/Implementation:

• Provide thorough orientation to environment

• Place call bell, phone and other items on unaffected side

• Avoid glaring lights

• Provide auditory stimulation such as television, radio, and talking books

• Remove environmental hazards

Cataract

Nursing Care:

Planning/Implementation:

• Provide care after cataract removal

(a) Instruct the client to prevent pressure on eye by avoiding: touching, rubbing, or tightly closing the eyes; coughing, sneezing, or bending from the waist (teach the client to open the mouth when coughing); rapid head movements; straining at stool or lifting; lying on the affected side

Cataract

Nursing Care:

Planning/Implementation:

(b) Instruct the client to request prescribed analgesics, anti-emetics, and stool softeners as required

(c) Reduce the amount of light and encourage the use of sunglasses when the eye patch is removed

(d) Teach signs of increased intraocular pressure (e.g., pain, restlessness, increased pulse rate) and infection (e.g., pain, changes in vital signs)

(e) Explain that vision may be altered but will clear and lenses will help to compensate for distortion

Cataract

Nursing Care:

Evaluation/Outcomes:

• Remains free from injury

• Demonstrates increased visual acuity

Glaucoma

Glaucoma

Overview

• The pressure within the eyeball is higher than normal

• Open angle glaucoma

• Close angle glaucoma

Glaucoma

• Open angle glaucoma:

• Occurs when aqueous fluid does not drain properly from the eye; related to pathologic changes in the trabecular meshwork of Schlemm’s canal

• The intraocular pressure increases and destroys retinal nerve fibers, causing progressive vision loss in affected areas

• Most common type of glaucoma

Glaucoma

• Close angle glaucoma:

• Occurs when the iris lies close to drainage channels, creating a mechanical blockage of the trabecular meshwork that interferes with the exit of aqueous humor from the anterior chamber

• Trapped aqueous humor causes the intraocular pressure to rise suddenly

• Occurs most commonly in African Americans and people older than 60

Glaucoma

Clinical Findings:

Open Angle Glaucoma:

• Halos around lights

• Gradual loss of peripheral vision; increased intraocular pressure (24-32 mmHg) as measured by a tonometer

Glaucoma

Clinical Findings:

Close Angle Glaucoma:

• Nausea; halos around lights; severe frontal headache

• Loss of peripheral vision; steamy cornea; redness and swelling of the conjunctiva; increased intraocular pressure (50-70 mmHg) as measured with a tonometer

Glaucoma

Therapeutic Interventions:

• Lowering the intraocular pressure with miotics or carbonic anhydrase inhibitors

• Surgical intervention to facilitate drainage of the aqueous humor is called a peripheral iridectomy; a surgical incision is made through the cornea to remove a portion of the iris to facilitate aqueous drainage

• Laser iridotomy

Glaucoma

Nursing Care:

Assessment:

• Description of onset and progression of symptoms

• Visual acuity, peripheral vision

• Characteristics of sclera, pupil and anterior chamber

Glaucoma

Nursing Care:

Nursing Diagnoses:

• Sensory/perceptual alteration (visual) related to increased intraocular pressure

• Risk for injury related to decreased peripheral vision

• Anxiety related to decreased vision and potential for blindness

Glaucoma

Nursing Care:

Planning/Implementation:

• Explain the importance of continued use of eye medications as ordered to prevent further visual loss

• Explain the need for continued medical supervision for observation of intraocular pressure to ensure control of the disorder

Glaucoma

Nursing Care:

Planning/Implementation:

• Teach avoidance of exertion, stooping, straining for a bowel movement, coughing, or heavy lifting because these increase intraocular pressure

• Instruct reporting severe eye or brow pain and nausea to the physician

Glaucoma

Nursing Care:

Evaluation/Outcomes:

• Maintains present level of visual acuity

• Remains free from injury

Retinal Detachment

Retinal detachment

Overview:

• Retina separates from the choroid, and vitreous humor seeps behind the retina

• May result from trauma, the aging process, or cataract surgery; also seen in clients with myopia or diabetes mellitus

Retinal detachment

Clinical findings:

• Flashes of light; floaters; sensation of a veil in the line of sight

• Loss of vision; retinal separation noted on ophthalmoscopy

Retinal detachment

Therapeutic Interventions:

• Bed rest, with area of detachment in a dependent position to promote healing

• Tranquilizers for rest and to reduce anxiety

Retinal detachment

Therapeutic Interventions:

• Surgical intervention:

• Cryosurgery: supercooled probe causes retinal scarring and healing of area

• Photocoagulation: laser beam through the pupil produces a retinal burn, which causes scarring of the involved area

• Scleral buckling: shortening of the sclera to force choroid closer to retina

Retinal detachment

Nursing Care:

Assessment:

• Description of onset and progression of symptoms; history to identify contributing factors such as trauma ore recent surgery of the eye

• Visual acuity

• Status of retina via ophthalmoscopic examination

Retinal detachment

Nursing Care:

Nursing Diagnoses:

• Sensory/perceptual alteration (visual) related to disease process

• Risk for injury related to decreased vision

• Anxiety related to decreased vision and potential for blindness

Retinal detachment

Nursing Care:

Planning/Implementation:

• Provide accurate information in a calm voice; client’s anxiety is high as a result of the sudden, unexpected vision loss

• Keep on bed rest in position as ordered

• Provide a call bell and answer promptly

• Maintain protective eye patch

Retinal detachment

Nursing Care:

Planning/Implementation:

• Instruct client to avoid activities that increase intraocular pressure such as coughing, straining, and stooping

• Observe for signs of hemorrhage postoperatively (severe pain, restlessness)

• Diminish lights in the room

Retinal detachment

Nursing Care:

Evaluation/Outcomes:

• Reports improved vision

• Remains free from injury