Eye Disorders

BLEPHARITIS
* It is a common chronic bilateral infection of the eyelids. The lids are rimmed with scales or crust on the lid margin and lashes. Signs and symptoms:
* Swelling
* Redness
* Crust of dried mucus on the lids
* Individual report foreign sensation on the eye
* There are red eyelids margins, flaking and itching, burning sensation, and loss of lashes.
* Light sensitivity, conjunctivitis and possible corneal inflammation may occur. Causes:
* Bacteria (staphylococcus aureus)
* Seborrhic skin condition such as flaking, redness, and irritation * Recurrent styes of the upper of lower lid

Types
* Ulcerative blepharitis- is caused by bacterial infection * Non-ulceratice blepharitis- may be caused by psoriasis, seborrhea, or an allergic response. Diagnosis is made by clinical examination and laboratory test may be done to isolate the causative agent. Individual;s with chronic disease such as diabetes, gout, anemia, and chronic infections of the mouth and or throat are at great risk. -it is stubborn to treat and is often resistant to various therapies. – topical anti-infective ointments and drops are used but by mainstay of treatment is by the used of eyelid scrubs. * STAPHYLOCOCCAL BLEPHARITIS

* Ulcerative and more serious due to involvement of the base of hair follicles. Permanent scarring may result. * SEBORRHEIC BLEPHARITIS
* Eyelids are erythematous and the margins are covered with granular crust.

Medical Management:
* In mild cases, it is treated with eyelid margin scrub at least once daily(baby shampoo may be used) * If caused by bacteria, antibiotic ointment is prescribed 1-4 times per day to eyelid margin. Nursing intervention

* Teach patient to scrub eyelid margin with cotton to removed flaking and then apply ointment with cotton swab as directed.

HORDEOLUM (STY)
* It is an infection of the sebaceous glands, and follicles of the lid margin. * EXTERNAL HORDEOLUM involves the hair follicles of the eyelid margin. Signs and symptoms:
* Rapid development of red, swollen, circumscribed and acutely tendered area. * Pain, foreign body sensation, and pustule may be present. Causes:
* Bacteria such as staphylococcus and seborrhea

Management :
* Treatment usually consists of warm soaks to help promote drainage four times a day until it improves, good hand washing and eyelid hygiene, and possible application of ointment antibiotic. * In some cases incision and drainage in the office with local anesthesia may be necessary. Nursing intervention:

* Teach patient how to clean eyelid margins and not to squeeze the stye. * If there is tendency of recurrence teach the patient to perform lid scrub daily.

CHALAZION
* It is a chronic inflammatory granuloma of the meibomian (sebaceous) glands in the lid. Causes:
* It may evolve from hordoleum
* It may also occur as a response to material released in the lid when a blocked gland ruptures. Signs and symptoms:
* Appear on the upper lid as swollen, tender, reddened area that may be painful. Management:
* Initial treatment is similar to that of hordoleum.
* If warm, moist compresses are ineffective in causing spontaneous drainage, the ophthalmologist may surgically removed the lesion, or may inject the lesion with corticosteroids.

UVEITIS
* Is the inflammation of uveal tract of the eye, including the iris, ciliary body, and choroid. Signs and symptoms:
* Characterized by irregular shaped pupil that does not react briskly * inflammation round the cornea
* pus in the anterior chamber
* Opaque deposits on the cornea
* Deep eye pain
* Lacrimation
* Ciliary flush(redness around limbus)
* Decreased visual acuity
* Conjuctival redness

Causes:
* Bacteria
* Viruses
* Fungi
* Parasites
* Infections
* Autoimmune-mediated disorder such as ankylosing spondylitis, chron’s disease, reiter’s syndrome and lupus * Trauma
* Idiopathic
Classification according to the structures involved:
* Anterior evuitis- involves the iris (iritis) or iris and ciliary bosy(iridocyclitis). It is the most common and usually unilateral. * Intermediate uveitis- structures posterior to the lens (pars plantis or peripheral evuitis * Posterior uveitis- involves choroid (choroiditis), retina (retinitis) or vitreous near the optic nerve and macula. It is usually bilateral Types:

* Non-granulomatous type
* Manifest as an acute condition with pain, photopobia, and a pattern of conjunctival injection, especially around the cornea. * The pupil is small or irregular, and vision is blurred. * There may be small, fine precipitates on the posterior corneal surface and cells in the aqueous humor. * If th uveitis is severe, a hypopyon (accumulation of pus in the anterior chamber) develops. * The condition may be unilateral and bilateral and may be recurrent * Repeated attacks of nongranulomatous anterior uveitis can cause anterior synechiae (peripheral iris adheres to the cornea and impedes outflow of aqueous humor). Posterior syncechiae (adherence of the iris and lens) block aqueous outflow of the posterior chamber. * Secondary glaucoma can result from either anterior or posterior synechiae. * Cataracts may also occur as a sequel to uveitis.

* Granulomatous Uveitis
* Can have a more insidious onset and can involve any portion of the uveal tract. * Tends to be chronic
* Photophobia and pain may be minimal.
* Vision is markedly and adversely affected.
* Conjunctival injection is diffuse, and there may be a vitreous clouding. * In sever posterior uveitis, such as chorioretinitis, there may be retinal and choroidal hemorrhages. Management:

* Because photophobia is present, patient should wear dark glasses outdoor. * Ciliary spasm and synechia are best avoided through mydriasis; cyclopentolate (cyclogyl) and atropine are commonly used. * Local corticosteroid drops such as Spedfork 1% and Flarex 0.1% instilled 4 to 6 x a day are also used to decreased inflammation. * In very severe cases, may have systemic corticosteroids, as well as intravitreal corticosteroids. * Daclizemab (Zenapax) a monoclonal antibody is designed to prevent a specific chemical interaction needed by immune cells, such as lymphocytes, to produce inflammation. * If the uveitis is recurrent, a careful history should be initiated to discover any underlying causes. This evaluation should include a complete physical examination, a diagnosis, including CBC count, ESR, antinuclear antibosies, and veneral disease research laboratory(VDRL) and lyme disease titers. * Underlyin causes include autoimmune disorders, such as ankulosing spondylitis and sarcoidosis as well as toxoplasmosis, herpes zoster virus, ocular candidiasis, histoplasmosis, herpes simplex virus, tuberculosis and syphilis.

KERATITIS
* It is an inflammation or infection of the cornea that can be caused by a variety of microorganisms or by other factors. * It may involve the conjunctiva and/or the cornea. When it involved both, it is termed keratoconjunctivitis. * Corneal abrasion and inflammation

* Loss of epityhelial layer of cornea due to some type of trauma- contact with finger nail, tree branch, spark or other projectile, or over wearing contact lens. * May lead to corneal ulceration and secondary infection into cornea, which may lead to blindness. Symptoms:

* Pain
* Redness
* Foreign body sensation
* Photophobia
* Increased tearing
* Difficulty opening eye
There are two kinds of keratitis.
* The superficial kind affects the outer layers of the cornea and normally heals without leaving a scar. * Deep keratitis infects the deeper layers of the cornea, and may cause scarring and impaired vision. If left untreated, keratitis can cause permanent damage and loss of eyesight. Pathogens:

* Bacterial keratitis
* The intact kornea provides an effective defense against infection. When the epithelial layer is disrupted, the cornea can become infected by a variety of bacteria. * It is caused y staphylococcus aureus, streptococcus pnuemonae, pseusomonas aeruginosa * There is a disruption of epithelial layer which may result to pain, redness, and sifficulty opening the eyes. * Topical antibiotics are generally effective, but eradicating the infection may require subconjunctival antibiotic injection, or in severe cases, intravenous antibiotics. * Risk factor involves mechanical or chemical corneal epithelial damage, contact lens wear, debilitation, nutritional deficiencies, immunosuppressed states, and contaminated products (lens care solutions and cases, topical medications, cosmetics). * Viral keratitis

* Herpes simplex virus (HSV) keratitis or dendritic keratitis is the most frequently occurring infections causes of corneal blindness(in the western hemisphere) * It may be caused by HSV-1 or HSV-2(genital herpes). The resulting corneal ulcer has a characteristics dendritic(tree-branching) appearance, and it is often, although not always, preceded by infection of the conjunctiva or eyelids. Pain and photophobia are common. * Collaborative therapy includes corneal debridement followed by topical therapy with vidarabine (vira-A) or trifluridine (Viroptic) used for 2-3 weeks. Topical corticosteroids are usually contraindicated because they contribute to a longer course and possible deeper ulceration or the cornea. Drug theraphy may include oral acyclovir (Zovirax). * Varacilla-zoster virus (VZV) causes both chickenpox and herpes zoster opthalmicus (HZO). HZO may occur by reactivation of an endogenous infection that has persisted in latent form after an ealier attack of varicella or by direct or indirect contact with a patient with chickenpox or herpes zoster.

* In occurs frequently in the older adult and in the immunosuppressed patient * Collaborative care of the patient with acute HZO may include opiod or nonopiod analgesics for the pain, topicl corticosteroids to reduced inflammation, antiviral agents such as acyclovir (Zovirax) to reduced viral replication, mydriatic agents to dilate the pupil and rlieve paind, and topical antibiotics to combat secondary infection. * The patient may apply warm compress and povidone-iodine gel to the effected skin(gel not be applied near the eye). * Epidemic keratoconjunctivitis (EKC) is the most serious ocular adenoviral disease. EKC is spread by direct contact, incusing sexual activity. * In the medical setting, contaminated hands and instruments may be a cause of spread. * The patient may complain of tearing, redness, photophobia and foreign body sensation. * Treatment is primarily palliative and includes icepacks and dark glasses. * In severe cases, therapy can include mild topical corticosteroids to temporarily relieved symptoms and topical antibiotic ointment. * Fungal keratitis

* Keratitis may also caused by fungi (most commonly Aspergillus, Candida, and Fusarium species), especially in the case of ocular trauma in an outdoor setting hen fungi are prevalent in the soil and moist organic matter. * Acanthamoeba keratitis is caused by a parasite that is associated with contact lens care solution and cases. * Medical treatment of fungal and acanthamoeba keratitis is difficult. The acathamoeba microorganisms are resistant to most drugs. Only one antifungal eyedrop (natamycin [natacyn]) is approved by the FDA. If antimicrobial therapy fails, the patient may require corneal transplant. * Exposure keratitis occurs when the patient cannot adequately close the eyelids. The patient with exopthalmos (protruding eyeball) from thyroid eye disease or masses posterior to the globe is susceptible to this condition. * Infectious keratitis

* Tissue loss caused by infection of the cornea produces a corneal uncle. * The infection may be due to bacteria, viruses or fungi. * Corneal ulcer are often very painful, the patient may feel as if there is a foreign body in their eye. * Other symptoms can include tearing, purulent or watery discharge, redness and photophobia. * Treatment is generally aggressive to avoid permanent loss of vision. Antibiotic, antiviral, or antifungal eye drops may be prescribed as frequently as every hour, night and day for the first 24 hours. * An untreated corneal ulcer/infectious keratitis can result in corneal scarring and perforation (hole in the cornea). A corneal transplant may be indicated. Nursing management for inflammation and infection

* Nursing assessment
* The nurse should assess ocular changes, such as edema, redness, decreasing visual acuity, feeling that a foreign object is present, or discomfort, and documents the findings in the patient’s record. The nurse’s assessment should also consider the psychosocial aspects of the patient’s condition, especially when the patient has visual impairment associated with the condition. * Nursing diagnosis

* Acute pain related to irritation or infection of the external eye * Anxiety related to uncertainty of cause of disease and outcome of treatment * Disturbed sensory perception (visual) related to diminished or absent vision * Planning

* The overall goals are that the patient with inflammation or infection of the external eye will
* avoid spread of infection
* maintain an acceptable level or comfort and functioning during the course of the specific ocular problem
* maintain and improve vision acuity
* comply with the prescribed therapy
* promote appropriate health-seeking behavior
* nursing implementation
* health promotion.

Careful asepsis and frequent, thorough hand washing are essential to prevent spreading organism from one eye to the other, to other patients, to family members, and to the nurse. * The nurse should dispose any contaminated dressings in the proper waste container. * The patient and family need information about avoiding sources or ocular irritation or infection and responding appropriately if an ocular problem occur. * The patient with infective disorder that may have sexual mode of transmission or an associated sexually transmitted disease needs specific information about those disorders. * The patient needs information about appropriate use and care of lenses and lens care products. * The nurse should encourage the patient to follow the recommended regimen. * Acute intervention

* The nurse must apply warm or cool compress if indicated for the patient’s condition. Darkening the room and providing appropriate analgesics are the other comfort measure. * If the patient’s visual acuity is decreased, the nurse may need to modify patient’s environment or activities for safety. * The patient may require eye drops as frequents as every hour. If the patient receives two or more different drops, the nurse should stagger the eye drops to promote maximum absorption. The patient who needs frequent eye drops administration may experience sleep deprivation.

CONJUCTIVITIS
* it is an infection or inflammation of conjunctiva.
* Conjunctival infection may be caused by bacteria or viral microorganisms. * Conjunctival inflammation may result from exposure to allergens or chemical irritants (including cigarette smoking). * The tarsal conjunctiva (lining the interior surface of the lids) may become inflames as a result of chronic foreign body in the eye, such as contact lens or an ocular prosthesis. * Careful hand washing ad using individual or disposable towels help prevent spreading of infection. Bacterial conjunctivitis

* May be acute or chronic, and symptoms are from mild to severe. * Acute bacterial conjunctivitis(pink eye) is a common infection. Although it occur in every age group, epidemics commonly occur in children because of their poor hygiene habits. In adults and children the most common causative microorganism is S. aureus. * Chronic bacterial conjunctivitis is seen in patients with lacrimal duct obstruction, chronic dacryocystitis and chronic blepharitis. * Streptococcus pneumonia, and hemophilus influenzae are the other common causative agents, but they are seen more often in children than adults. Streptococcus aerues may also cause bacterial conjunctivitis. * There is early onset of redness, burning, and discharge * Papillary formation, conjunctival irritation and injection of fornices are present. * Presence of exudates upon waking up in the morning. Eyes are difficult to open due to adhesion caused by exudates. * The patient with bacterial conjunctivitis may complain of irritation, tearing, redness, and mucopurulent drainage. * Purulent discharges occurs in severe acute bacterial infection, while mucopurulent discharges appears in mild cases. * Although this typically occurs initially in one eye, it spreads rapidly to the unaffected eye. Gonococcal conjunctivitis

* Symptoms are acute, exudate is profuse and purulent and there is a presence of lymphadenopathy. Pseudomembranes may also appear. Chlamydial conjunctivitis
* Icludes trachoma and inclusion conjunctivitis.
* Trachoma may be acute or subacute. Initial symptoms include red, inflamed eyes, tearing. Photophobia, ocular pain, purulent exudates, preauricular lymphadenopathy and lid edema. * Initial ocular signs includes follicular and papillary formations. * Middle stage is characterized by acute inflammation with papillary hypertrophy and follicular necrosis, then trichiasis and entropion develops. * Lashes that turned to rub against cornea and prolonged irritation results to corneal erosion and ulceration. * During late stage, the conjunctiva will be scarred, sunepithelial keratitis, abnormal vascularization of cornea (pannus) occurs. There is a resisual scars from the follicles that look like depressions in the conjunctiva. * Severe corneal ulceration may lead to perforation and blindness.

* Trachoma is a chronic conjunctivitiscaused by chlamysia trachomatis (serotype A through C).It is a major cause of blindness worldwide. * This preventable eye disease is transmitted mainly by the hands and by flies. Adult inclusion conjunctivitis (AIC) is caused by C. Trachomatis (serotype D through K). AIC is becoming more prevalent because of the increase in sexually transmitted chalamydial disease. * Manifestations for are both trachoma and AIC are mucopurulent ocular discharge, irritation, redness, and lid swelling. * Although antibiotic therapy is successful in adult with AIC, this patient has high risk of concurrent chlamydial genital infection, as well as other sexually transmitted disease. Viral conjunctivitis

* May be chronic or acute
* The patient may complain of tearing, foreign body sensation, redness and mild photophobia. * Discharge is watery and follicles are prominent. In severe cases it includes pseudomembranes. * Causative organisms are adenovirus and herpes simplex virus. * This condition is usually mild and self-limiting. However, it can be severe, with increased discomfort and subconjunctival hemorrhage. Adenoviral conjunctivitis

* Conjunctivitis caused by adenovirus is highly contagious. It is preceded by symptoms of upper respiratory infection. * Corneal involvement causes extreme photophobia.
* Symptoms include extreme tearing, redness and foreign body sensation that involve one or both eyes. * Lid edema, ptosis and conjunctival hyperemia is present. * May be contracted with contaminated swimming pool and trough direct contact with an infected patient. Epidemic keratoconjunctivitis

* It is a highly contagious viral conjunctivitis that is easily transmitted from one person to another. * It is often seasonal, prevalent during summer, especially from using the swimming pool. * It is accompanied with preauricl lymphadenopathy and occasional periorbital pain. There is marked follicular and papillary formations. * May lead to keratopathy.

Allergic conjunctivitis
* It occur as a part of allergic rhinitis or it can be an independent allergic reaction. * May have history of allergy to pollens and other environmental allergens. * There is extreme pruritos, epiphoria injection and usually severe photophobia. * Conjunctivitis caused by exposure to allergen can be mild and transitory, or it can be severe enough to cause significant swelling, sometimes ballooning the conjunctiva beyond the eyelids. * The patient may also complain of burning, redness and tearing. Acutely, the patient may also have white or clear exudates. If the condition is chronic, the exudates is thicker and becomes mucopurulent. * Stringlike mucoid discharge is usually associated with rubbing the eyes because of sever pruritus. * In addition to pollens, the patient may develop the allergic conjunctivitis in response to animal dander, ocular solutions and medications, or even contact lenses. * Appears mostly in warm weather. There is large formation of papillae that have a cobble stone appearance. * Occurs mostly in children and young adults.

* Affects mostly, the population that have history of asthma, or eczema * Symptoms are intense itching, crusting discharge and springlike inflammation. Toxic conjunctivitis
* Chemical conjunctivitis can result from medications, chlorine from swimming pools, e exposures to toxic fumes among industrial workers, exposure to other irritants such as smoke, hairspray, acids and alkalis.

Management of conjunctivitis
* If the conjunctivitis is left untreated, may lead to a systemic complications: meningitis and generalized septicemia. * Management
depends upon the type of conjunctivitis. Mild viral conjunctivitis are self-limiting, benign condition that may not require treatment and laboratory procedures. In severe cases, topical antibiotics, eyedrops, and ointment are indicated. Gonococcal conjunctivitis requires urgent antoniotic therapy. If left untreated this ocular disease leads to corneal perforation and blindness. Management of bacterial conjunctivitis

* Acute bacterial conjunctivitis is self limiting lasting 2 weeks, if left untreated. If treated with antibiotics last few days, except from gonococcal and staphylococcal conjunctivitis. * For trachoma, usually broad spectrum antibiotics administered topically or systemically. * Surgical management includes correction of trichiasis to prevent conjunctival scarring. * In adult inclusion conjunctivitis, requires one week of antibiotics. Prevention of reinfection is important, and affected person and their sexual partners must seek treatment for sexually transmitted disease, as indicated. Management of viral conjunctivitis

* Viral conjunctivitis is not responsive to any treatment. * Cold compress may used to alleviate some symptoms.
* Emphasize hand hygiene and avoiding sharing of hand towels, face clothes, and eyedrops. Tissue directly discarded into covered trashcan. * Treatment is usually palliative(adenoviral conjunctivitis). If the patient is severely symptomatic, topical corticosteroids provide temporary relief but have no benefit in the final outcome. Antiviral drops are ineffective and therefore not indicated. Management for allergic conjunctivitis

* Corticosteroids in ophthalmic preparation is usually indicated. * Depending on the severity of the disease, they may be given oral preparation. * Use of vasoconstrictors, such as topical epinephrine solution, cold compresses, icepacks and cool ventilation usually provide comfort by decreasing swelling. * Artificial tears can be effective in diluting the allergen and washing it from the eye. * Effective topical medications include antihistamines, and corticosteroids. Management of toxic conjunctivitis

* If it is caused y chemical irritants, eye must be irrigated immediately and profusely by saline or sterile water.