Glaucoma and cataract :

Nursing PPT - for Msc nursing students and Bsc Nursing students

1. Glaucoma & cataract Mathew Varghese V MSN(RAK ),FHNP (CMC Vellore),CPEPC Nursing officer AIIMS Delhi 1 [email protected]

2. Glaucoma Epidemiology Leading causes of irreversible blindness in the world More prevalent among people older than 40 years of age Incidence increases with age. More prevalent among men than women More common in African American and Asian populations. There is no cure for glaucoma, but research continues 2 [email protected]

3. What is Glaucoma Glaucoma is a complex disease in which damage to the optic nerve due to increased IOP leads to progressive, irreversible vision loss.  3 [email protected]

4. Normal physiology of Aqueous Humor Aqueous humor flows between the iris and the lens, nourishing the cornea and lens. Most (90%) of the fluid then flows out of the anterior chamber, draining through the spongy trabecular meshwork into the canal of Schlemm and the episcleral veins. About 10% of the aqueous fluid exits through the ciliary body into the suprachoroidal space and then drains into the venous circulation of the ciliary body, choroid, and sclera. 4 [email protected]

5. Normal physiology of Aqueous Humor The outflow of aqueous fluid depends on an intact drainage system and an open angle (about 45 degrees) between the iris and the cornea. A narrower angle places the iris closer to the trabecular meshwork, diminishing the angle. The amount of aqueous humor produced tends to decrease with age, in systemic diseases such as diabetes, and in ocular inflammatory conditions. 5 [email protected]

6. IOP IOP is determined by the rate of aqueous production, the resistance encountered by the aqueous humor as it flows out of the passages, and the venous pressure of the episcleral veins that drain into the anterior ciliary vein. When aqueous fluid production and drainage are in balance, the IOP is between 10 and 21 mm Hg. When aqueous fluid is inhibited from flowing out, pressure builds up within the eye. Fluctuations in IOP occur with time of day, exertion, diet, and medications. 6 [email protected]

7. Risk Factors Family history of glaucoma African American race Older age Diabetes Cardiovascular disease Migraine syndromes Nearsightedness (myopia) Eye trauma Prolonged use of topical or systemic corticosteroids 7 [email protected]

8. Pathophysiology There are two accepted theories regarding how increased IOP damages the optic nerve in glaucoma. The direct mechanical theory The indirect ischemic theory 8 [email protected]

9. Stages 1 . Initiating events 2. Structural alterations in the aqueous outflow system 3. Functional alterations: 4. Optic nerve damage : 5 . Visual loss: 9 [email protected]

10. Types of Glaucoma Open-angle glaucoma (OAG) Narrow angle glaucoma. 10 [email protected]

11. Variations of OAG include Primary open angle glaucoma (POAG) Normal-tension glaucoma (NTG), Pigmentary glaucoma Pseudo exfoliation glaucoma Secondary glaucoma Congenital glaucoma. 11 [email protected]

12. Variations of narrow angle glaucoma Acute angle closure glaucoma Chronic angle closure glaucoma Neovascular glaucoma. 12 [email protected]

13. Primary open-angle glaucoma.(POAG) This common type of glaucoma gradually reduces your peripheral vision without other symptoms. By the time you notice it, permanent damage already has occurred. If your IOP remains high, the destruction caused by POAG can progress until tunnel vision develops , and you will be able to see only objects that are straight ahead. Ultimately, all vision can be lost, causing blindness 13 [email protected]

14. Acute angle-closure glaucoma Also called narrow-angle glaucoma , acute angle-closure glaucoma produces sudden symptoms such as eye pain, headaches, halos around lights, dilated pupils, vision loss, red eyes, nausea and vomiting. These signs constitute a medical emergency. The attack may last for a few hours, and then return again for another round, or it may be continuous without relief. Each attack can cause progressively more vision loss. 14 [email protected]

15. Normal-tension glaucoma. Like POAG, normal-tension glaucoma (also called normal-pressure glaucoma, low-tension glaucoma or low-pressure glaucoma) is a type of open-angle glaucoma that can cause visual field loss due to optic nerve damage . But in normal-tension glaucoma, the eye's IOP remains in the normal range. Also, pain is unlikely and permanent damage to the eye's optic nerve may not be noticed until symptoms such as tunnel vision occur. The cause of normal-tension glaucoma is not known. But many doctors believe it is related to poor blood flow to the optic nerve. Normal-tension glaucoma is more common in those who are Japanese, are female and/or have a history of vascular disease. 15 [email protected]

16. Secondary glaucoma.  Symptoms of chronic glaucoma following an eye injury could indicate secondary glaucoma Which also may develop with presence of eye infection, inflammation, a tumor or enlargement of the lens due to a cataract. 16 [email protected]

17. Congenital glaucoma This inherited form of glaucoma is present at birth , with 80 percent of cases diagnosed by age one. These children are born with narrow angles or some other defect in the drainage system of the eye. It's difficult to spot signs of congenital glaucoma, because children are too young to understand what is happening to them. If you notice a cloudy, white, hazy, enlarged or protruding eye in your child, consult your eye doctor . Congenital glaucoma typically occurs more in boys than in girls. 17 [email protected]

18. Diagnosis, Screening and Tests for Glaucoma Ocular History ocular examination Tonometer   imaging technology Scanning laser polarimetry (SLP) Optical coherence tomography (OCT) 18 [email protected]

19. Diagnosis, Screening and Tests for Glaucoma  Confocal scanning laser ophthalmoscopy  — to create baseline images and measurements of the eye's optic nerve and internal structures. Visual field testing   Gonioscopy  to evaluate the drainage angle. Ultrasound biomicroscopy is another technique that may be used to evaluate the drainage angle. 19 [email protected]

20. Medical Management The aim of all glaucoma treatment is prevention of optic nerve damage through medical therapy, laser or nonlaser surgery, or a combination of these approaches. Lifelong therapy is almost always necessary because glaucoma cannot be cured. Although treatment cannot reverse optic nerve damage, further damage can be controlled. The treatment goal is to maintain an IOP within a range unlikely to cause further damage. Treatment focuses on achieving the greatest benefit at the least risk, cost, and inconvenience to the patient. 20 [email protected]

21. Pharmacologic treatment 21 [email protected]

22. SURGICAL MANAGEMENT Laser trabeculoplasty In laser trabeculoplasty for glaucoma, laser burns are applied to the inner surface of the trabecular meshwork to open the intratrabecular spaces and widen the canal of Schlemm, thereby pro- moting outflow of aqueous humor and decreasing IOP. The procedure is indicated when IOP is inadequately controlled by medications ; it is contraindicated when the trabecular meshwork cannot be fully visualized because of narrow angles. A serious complication of this procedure is a transient rise in IOP (usually 2 hours after surgery) that may become persistent. IOP assessment in the immediate postoperative period is essential. 22 [email protected]

23. Laser iridotomy In laser iridotomy for pupillary block glaucoma, an opening is made in the iris to eliminate the pupillary block. Laser iridotomy is contraindicated in patients with corneal edema , which interferes with laser targeting and strength. Potential complications are burns to the cornea, lens, or retina; transient elevated IOP; closure of the iridotomy; uveitis ; and blurring. Pilocarpine is usually prescribed to prevent closure of the iridotomy. 23 [email protected]

24. Filtering procedures Filtering procedures for chronic glaucoma are used to create an opening or fistula in the trabecular meshwork to drain aqueous humor from the anterior chamber to the subconjunctival space, thereby bypassing the usual drainage structures. This allows the aqueous humor to flow and exit by different routes ( ie , absorption by the conjunctival vessels or mixing with tears).   24 [email protected]

25. Trabeculectomy Trabeculectomy is the standard filtering technique used to remove part of the trabecular meshwork. Complications include hemorrhage, an extremely low ( hypotony ) or elevated IOP, uveitis , cataracts, endophthalmitis . 25 [email protected]

26. Drainage implants or shunts Drainage implants or shunts are open tubes implanted in the anterior chamber to shunt aqueous humor to an attached plate in the conjunctival space. A fibrous capsule develops around the episcleral plate and filters the aqueous humor, thereby regulating the outflow and controlling IOP. 26 [email protected]

27. Nursing Management Disturbed Visual Sensory Perception related to increased ocular pressure as evident by progressive loss of visual field Anxiety related to Physiological factors, change in health status; presence of pain; possibility/reality of loss of vision Deficient Knowledge related to lack of exposure/unfamiliarity with resources 27 [email protected]

28. Cataracts What Is a Cataract? A cataract is a dense, cloudy area that forms in the lens of the eye. A cataract begins when proteins in the eye form clumps that prevent the lens from sending clear images to the retina. The retina works by converting the light that comes through the lens into signals. It sends the signals to the optic nerve, which carries them to the brain. It develops slowly and eventually interferes with your vision. 28 [email protected]

29. causes Ageing An overproduction of oxidants, which are oxygen molecules that have been chemically altered due to normal daily life Smoking Ultraviolet radiation The long-term use of steroids and other medications Certain diseases, such as diabetes Trauma Radiation therapy 29 [email protected]

30. Risk factors Aging • Loss of lens transparency • Clumping or aggregation of lens protein (which leads to light scattering) • Accumulation of a yellow-brown pigment due to the breakdown of lens protein • Decreased oxygen uptake • Increase in sodium and calcium • Decrease in levels of vitamin C, protein, and glutathione (an antioxidant) 30 [email protected]

31. Associated Ocular Conditions Retinitis pigmentosa • Myopia • Retinal detachment and retinal surgery • Infection ( eg , herpes zoster, uveitis ) 31 [email protected]

32. Toxic Factors Corticosteroids, especially at high doses and in long-term use Alkaline chemical eye burns, poisoning Cigarette smoking Calcium, copper, iron, gold, silver, and mercury, which tend to deposit in the pupillary area of the lens 32 [email protected]

33. Nutritional Factors Reduced levels of antioxidants • Poor nutrition • Obesity 33 [email protected]

34. Physical Factors Dehydration associated with chronic diarrhea, use of purgatives in anorexia nervosa, and use of hyperbaric oxygenation Blunt trauma, perforation of the lens with a sharp object or foreign body, electric shock Ultraviolet radiation in sunlight and x-ray 34 [email protected]

35. Systemic Diseases and Syndromes Diabetes mellitus Down syndrome Disorders related to lipid metabolism Renal disorders Musculoskeletal disorders 35 [email protected]

36. Types of Cataracts Nuclear cataracts form in the middle of the lens and cause the nucleus, or the center, to become yellow or brown. Cortical cataracts are wedge-shaped and form around the edges of the nucleus. Posterior capsular cataracts form faster than the other two types and affect the back of the lens. Congenital cataracts , which are present at birth or form during a baby’s first year, are less common than age-related cataracts 36 [email protected]

37. Types of Cataracts Secondary cataracts are caused by disease or medications. Diseases that are linked with the development of cataracts include glaucoma and diabetes. The use of the steroid prednisone and other medications can sometimes lead to cataracts. Traumatic cataracts develop after an injury to the eye, but it can take several years for this to happen. Radiation cataracts can form after a person undergoes radiation treatment for cancer. 37 [email protected]

38. Symptoms of Cataracts blurry vision trouble seeing at night seeing colors as faded increased sensitivity to glare halos surrounding lights double vision in the affected eye a need for frequent changes in prescription glasses 38 [email protected]

39. Diagnosing Cataracts ocular history ocular examination snellen’s Chart Examination Tonometry to measure eye pressure. Slit-lamp exam Retinal exam Refraction and visual acuity test 39 [email protected]

40. Medical Management No nonsurgical treatment cures cataracts. Ongoing studies are investigating ways to slow cataract progression, such as intake of antioxidants ( eg , vitamin C, beta-carotene, vitamin E) Reducing glare with proper light and appropriate lighting can facilitate reading. Mydriatics can be used as short-term treatment to dilate the pupil and allow more light to reach the retina, although this increases glare. 40 [email protected]

41. Surgical Management Phacoemulsification ( Using an ultrasound probe to break up the lens for removal)   During a procedure called phacoemulsification ,surgeon makes a tiny incision in the front of eye (cornea) and inserts a needle-thin probe into the lens substance where the cataract has formed. Surgeon then uses the probe, which transmits ultrasound waves, to break up (emulsify) the cataract and suction out the fragments. The very back of lens (the lens capsule) is left intact to serve as a place for the artificial lens to rest. Stitches may or may not be used to close the tiny incision in cornea at the completion of the procedure. 41 [email protected]

42. Surgical Management Laser-assisted cataract surgery (Using an advanced laser technique to remove the cloudy lens.)   In laser-assisted cataract surgery, the surgeon uses a laser to make all incisions and soften the cataract for removal. 42 [email protected]

43. Surgical Management Extra capsular cataract extraction (Making an incision in the eye and removing the lens in one piece) A less frequently used procedure called extracapsular cataract extraction requires a larger incision than that used for phacoemulsification . Through this larger incision surgeon uses surgical tools to remove the front capsule of the lens and the cloudy portion of the lens comprising the cataract. The very back capsule of the lens is left in place to serve as a place for the artificial lens to rest. This procedure may be performed if patient has certain eye complications. With the larger incision, stitches are required. Once the cataract has been removed by either phacoemulsification or extracapsular extraction, the artificial lens is implanted into the empty lens capsule. 43 [email protected]

44. Potential Complications of Cataract Surgery Inflammation Infection Bleeding Swelling Drooping eyelid Dislocation of artificial lens Retinal detachment Glaucoma Secondary cataract Loss of vision 44 [email protected]

45. Nursing Management Disturbed Sensory Perception: Visual: related to cataracts Risk for Injury related to Decreased vision 45 [email protected]

46. Conclusion Prevention of cataract includes risk factors reduction such as UVB exposure and smoking can be addressed. Although no means of preventing cataracts has been scientifically proven, wearing sunglasses that counteract ultraviolet light may slow their development. While adequate intake of antioxidants (such as vitamins A, C, and E) has been thought to protect against the risk of cataracts, clinical trials have shown no benefit from supplements; though evidence is mixed, but weakly positive, for a potential protective effect of the nutrients  lutein  and  zeaxanthin .  Statin  use is somewhat associated with a lower risk of nuclear sclerotic cataracts 46 [email protected]

47. ? 47 [email protected]

48. Bibliography Field D, Tillotson J, Whittingham E (2015) Eye Emergencies - The Practitioners Guide. Second edition. M&K Publishing, Keswick. Grasso J, Long J, McCulloch J, Moore C (2008) Eye Examination. tinyurl.com/qgaw49o (Last accessed: October 30 2015.) Marsden J (2002) Ophthalmic trauma in the emergency department. Accident and Emergency Nursing. 10, 3, 136-142. Marsden J (2006) Ophthalmic Care. Wiley-Blackwell, Chichester . Patient (2013) Examination of the Eye. www.patient. co.uk/doctor/examination-of-the-eye (Last accessed: October 30 2015.) 48 [email protected]

49. Thank You 49 [email protected]