Ophthalmological Nursing

Retinal Disorders
Retina
 Is composed of multiple microscopic layers:
o Sensory retina = innermost layer that contains photoreceptor cells (rods and cones)
o Retinal pigment epithelium (PRE) = the outermost layer that captures impulses
generated by the photoreceptor cells

1. Retinal detachment = refers to separation of the RPE from the sensory layer.
 4 types:
o Rhegmatogenous = the most common form
 A hole, or tear develops in the sensory retina, allowing some of the liquid vitreous
to seep through the sensory retina, and detach it from the RPE
 People at risk:
 With Myopia
 Aphakia after cataract surgery
 Trauma
o Traction = the tension, or pulling force is responsible for traction retinal detachment
 There is development of fibrous scar tissue from conditions such as diabetic
retinopathy, vitreous hemorrhage, or retinopathy of prematurity.
 The fibrous scar proliferation exerts a pulling force on the delicate retina.
o Combination of rhegmatogenous and traction
o Exudative = is the result of the production of serous fluid under the retina from the
choroid.
 Cause: conditions such as uveitis and macular degeneration may cause the
production of this serous fluid.

 Predisposing Factors:
o Aging
o Cataract extraction
o Degeneration of the retina
o Trauma
o Severe myopia
o Previous retinal detachment
o Family history

 Clinical Manifestations:
o Sensation of a shade or “veil” or curtain coming across the vision of on eye
o Presence of cobwebs, shadows or black areas in the field of vision
o Bright flashing lights
o Sudden onset of a great number of floaters

 Diagnostic Tests:
o Slit-lamp biomicroscopy
o Fundus examination through ophthalmoscopy

 Surgical Managements:
o Scleral buckling = the retinal surgeon compresses the sclera (often with a scleral buckle
or a silicone band) to indent the scleral wall from the outside of the eye and bring the two
retinal layers in contact with each other.
 Advantages:
 High success rate
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 Less damage to the lens of the eye in phakic patients

 Low risk of endophthalmitis
 Disadvantages:
 Increased incidence of diplopia and myopia
 Increased postoperative pain
o Pars plana vitrectomy
 Is an intraocular procedure in which 1- to 4-mm incisions are made at the pars
plana (sclera)
 One incision allows the introduction of a light source, and another incision
serves as portal of for the vitrectomy instrument.
 The vitreous gel of the eye is removed and replaced with a gas to refill the
eye and reposition the retina. The gas eventually is absorbed and is
replaced by the eye's own natural fluid.
 A scleral buckle is usually also performed with the vitrectomy.
 Pneumatic retinopexy
 The technique is used for the repair of a rhegmatogenous retinal
detachment.
 A gas bubble, silicone oil, or perfluorocarbon and liquids may be injected
into the vitreous cavity to help push the sensory retina up against the
RPE.
 Argon laser photocoagulation or cryotherapy is also used to “spotweld”
small holes.
o Transconjuctival sutureless vitrectomy
 A less invasive 25-gauge technique allows for self-sealing transconjunctival pars
plana sclerotomies.
 Procedure:
 Infusion of fluid through a 25-gauge needle secured by passing through a
block of plastic sutured to the eye.
 Balanced salt solution is fed into the eye by gravity.
 Illumination and observation are provided with the indirect
ophthalmoscope.
 The vitreous is aspirated into the port of the sharp-tipped vitreous cutter.

 Nursing Managements:
o Instruct the patient to maintain a prone position to allow the gas bubble to float onto the
position overlying the area of detachment, providing consistent pressure to reattach the
sensory retina. – pneumatic retinopexy
o Teaching about complications:
 Increased IOP
 Endophthalmitis
 Development of other retinal detachments
 Development of cataracts
 Loss of turgor of the eye

2. Age-Related Macular Degeneration (AMD) = is the most common cause of visual loss in people
older than 60 years.
 Clinical Manifestations:
o Characterized by tiny, yellowish spots called “drusen” beneath the retina
 Drusen = are small clusters of debris or waste material that lie deep within the
RPE.
o Central vision loss, but retaining peripheral vision

 Types of AMD:
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o Dry type (nonneovascular, nonexudative)

 Accounts for 85% to 90% of all cases of AMD
 The outer layers of the retina slowly break down, and come the appearance of
drusen.
o Wet type (neovascular, exudative)
 Has an abrupt onset
 There is proliferation of abnormal blood vessels growing under the retina, within
the choroid layer of the eye, a condition known as choroidal neovascularization
 The affected vessels can leak fluid and blood, elevating the retina.
 Patients may report that straight lines appear crooked and distorted or
that letters in words appear broken.

 Medical Management:
o No known cure for the dry type of AMD.
o Use of antioxidants (Vit. C, Vit. E, betacarotene, and zinc oxide, lutein and zeaxanthin
[carotenoids]) have shown slow progression of AMD
o Antiangiogenic therapy:
 Agents that inhibit the ability of vascular endothelial growth factor (VEGF) to bind
to cellular receptors.
 Vascular endothelial growth factor = a stimulus for the development and
progression of angiogenesis (abnormal blood vessel formation).
 VEGF antagonist
 Ranibizumab (Lucentis)
o Monoclonal antibody:
 Bevacizumab (Avastin)

 Nursing Managements:
o After patient discharge, instruct them to monitor for a sudden onset of distortion of vision.
 Amsler grids = this may provide the earliest sign that macular degeneration is
getting worse
 Encourage patients to look at these grids, one eye at a time, several
times each week with glasses on.
 If the lines or squares appear distorted or faded, notify the
ophthalmologist immediately.

3. Diabetic Retinopathy
 A complication of diabetes that affects the eyes caused by damage to the blood vessels of the
retina.
 Ocular manifestation of systemic disease (DM)
 The longer you have DM, & the less controlled your blood sugar is, the more likely you are to
develop the disease.

 Manifestations:
o At first, no symptoms or only mild vision problems.
o Eventually, can result in blindness.
o To protect vision; careful control blood sugar level & yearly eye exams

 2 types (stages):
o Nonproliferative (NPDR)
 Early
 New blood vessels aren't growing
 Walls of BV in retina weaken
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 Microaneurysms protrude from the vessel walls, sometimes leaking or oozing

fluid & blood
 Macula begins to swell (macular edema)
o Proliferative (PDR)
 Advanced & severe form
 New BV begin to grow in the retina
 BV are abnormal. May grow or leak into the clear, jelly-like substance that fills the
center of your eye (vitreous).

 Pathophysiology:
Inc. sugar in the blood
↓
tiny BV become blocked/damaged
↓
Bld. supply to retina is cutoff
(vision loss)
↓
Eye attempts to grow new blood vessels (abnormal BV)
↓
Leaking BV & hemorrhage
↓
Vision loss

 Symptoms:
o Has no symptom until the damage is severe. 
o Blurred vision & slow vision loss over time
o Floaters
o Shadows or missing areas of vision
o Trouble seeing at night

 Management:
o Control of blood sugar (glucose), blood pressure, & cholesterol levels
o Stop smoking
o Nonproliferative type may not need treatment but closely monitored
o Treatment does not reverse damage but it can help keep the disease from getting
worse.

 Complications:
o Vitreous hemorrhage
o Retinal detachment; abnormal BV associated with diabetic retinopathy stimulate the
growth of scar tissue
o Glaucoma
o Blindness