MENNONITE COLLEGE OF NURSING
AT
ILLINOIS STATE UNIVERSITY
Family Nurse Practitioner I
471
Screening
Recommendations:
·
Healthy
People 2000 – 80% of healthcare providers screen for vision, hearing, speech
·
For
eyes, recommend screen begin at 3-4 years of age
·
American
Optometric Association: Comprehensive
eye and vision exam q 1-2 years (ages 20-64), annually thereafter
·
American
Academy of Ophthalmology: q 2-4 years
(ages 40-64), then q 1-2 years thereafter
More
than 90% of older persons use corrective lenses at some point in time.
Age
appropriate tests for visual acuity:
·
Birth-3
years: red reflex, corneal &
pupillary reflexes, tracking of visual stimuli
·
At
6 weeks, should demonstrate eye to eye contact, track slowly
·
At
3 months, should fix and follow at 2-3 feet
·
At
6 months, should show interest in objects, etc., across the room
·
2,5-3
years: Allen cards (identify familiar
objects: star, boat, heart)
·
3
years +: HOTV at 10 or 20 feet, Snellen
E
·
HOTV
(match hand held set of cards with one held by examiner)
·
Snellen
E (point in the direction the “E” is pointing)
·
5
years +: Snellen letter chart, copies
line, circle, cross
·
Color
vision: Ishihara
Screening
Basics:
·
Snellen
chart – 20 feet away (may use E for illiterate)
·
Test
each eye separately
·
Pass
for the line if majority are identified.
·
May
wear corrective lenses during screen.
·
If
less than 20/40, refer to eye doctor.
·
If
unable to see chart, then document as CF – counting fingers, HM – hand
movement, LP – light perception
Visual
Impairment:
·
20/80
or less is considered visually impaired
·
20/200
is considered legally blind
·
In
most states, you need 20/40 (corrected) to obtain driver’s license
·
Most
visual loss in adults is attributed to refractive error.
·
Other
causes include diabetic retinopathy, optic nerve disorders, etc.
·
Definition: inflammation involving the structures of the
lid margin with redness, scaling and crusting.
·
Etiology: May be staphyloccocal or seborrheic.
·
Epidemiology: Tends to be chronic with acute flare-ups and
is more common in fair-skinned people.
·
S/Sx: If staphylococcal, dry scales, lash loss,
sometimes conjunctivitis; If seborrheic, greasy scales and less redness
·
Treatment: Usually responds to lid hygiene measures and
topical antibiotics
·
Can
instruct patient to dilute Johnson’s baby shampoo 50:50 with water and use a
cotton ball to scrub the lids well with the eyes closed.
·
After
rinsing with water, a hot compress is applied to the closed lids for 5-10
minutes, and then erythromycin or bacitracin ophthalmic ointment is instilled
in the inferior fornix.
·
The
excess is rubbed into the eyelash base.
·
Do
this 3-4 times/day
·
After
improvement is obtained, the lids can be maintained by nightly lid hygiene and
warm compresses.
Hordeolum (stye)
·
Definition: a small, pus-filed abscess involving the
hair follicle of the eyelid
·
Etiology: usually caused by staphylococcal infection;
may be a secondary infection.
·
Epidemiology: occurs most commonly in children and
adolescents; occurs equally in men and in women
·
Contributing
factors: recurrent blepharitis, makeup,
contact lens, poor eyelid hygiene, eye irritation from smoking
·
S/Sx: papule on lid margin, erythematous, tender
to palpation,
·
Physical
exam (using gloves) reveals the head of the stye on the outside of the lid or
when the eyelid is everted, on the underside
·
Tx:
·
Warm,
moist compresses to the eyes several times a day. Allow to open and drain spontaneously; do not squeeze. (Pain decreases when stye opens and drains).
·
Erythromycin
ophthalmic ointment tid thinly applied to area with a cotton-tipped applicator
·
Try
gentamicin ophthalmic ointment if refractive to treatment
·
F/U: 2-3 weeks
·
Complications: cellulitis of eyelid, repeated styes (if
occurs, evaluate for DM)
·
Refer: if draining of abscess needed
·
Definition: a sterile granulomatous inflammation/mass of
a meibomian (oil-secreting) gland on the upper or lower eyelid
·
Etiology: Blockage in a duct leading to the eyelid
surface from the gland or obstruction of a meibomian gland results in
inflammation, the formation of a hard mass, and/or infection (usually from Staphylococcus).
·
Epidemiology: occurs at any age; occurs equally in men and
in women
·
S/Sx: slow-developing, painless, hard mass with
inflammation of the meibomian gland and possible involvement of the surrounding
tissue.
·
Physical
exam with eversion of the eyelid reveals a red, elevated mass that may become
quite large and press against the eye, causing nystagmus
·
Dx.
Tests: visual exam (to R/O other
problems), culture of drainage (if I & D is done), biopsy of recurrent
chalazion to R/O malignancy
·
Tx: warm compresses to area
·
Sulfacetamide
sodium 10% ophthalmic ointment qid for 7 days thinly applied to the lid margin
with a cotton-tipped applicator.
·
Antibiotic
eye drops may be used to prevent secondary bacterial infection in other parts
of the eye
·
F/U: 1 week; may take several weeks to months for
complete resolution. Recurrences common
·
Refer: to ophthalmologist if visual change, pain or
impairment to the eye; or if surgical removal needed.
·
Definition: duct fails to canalize at birth
·
S/Sx: mucoid discharge, tearing in inner canthus
·
Tx.: massage with expression toward nose
·
If
purulent discharge, antibiotic ointment
·
May
probe…usually after 1 year of age
·
Definition: inflammation of the conjunctiva (mucous
membranes) covering the front of the eye.
May also involve the palpebral and/or bulbar conjunctiva.
·
Etiology
·
Bacteria
(Staph aureus, Strep pneumoniae, H flu, n. gonorrhea [usually 2-4 days after
birth], or Branhamella catarrhalis)
·
Viruses
(adenoviruses, herpes simplex, herpes zoster)
·
Allergens
(linked to a humoral response and some autoimmune disorders)
·
Chlamydia
(inclusion conjunctivities)
·
Association
with certain systemic diseases, such as thyroid disorders and Reiter’s syndrome
(idiopathic conjunctivitis)
·
Chronic
use of eye medications over a long period of time (noninfectious
conjunctivitis)
·
S/Sx:
(use gloves for exam)
·
General: burning and/or feeling of something being in the eye; may have
itching, tearing, lid matting, and exudate.
Physical examination reveals a diffusely injected conjunctiva
·
Bacterial: minimal pruritus, moderate tearing, and purulent exudates and
matted lids in mornings; usually begins unilaterally, and then evolves into a
bilateral process.
·
Viral: usually bilateral, with copious tearing with little exudate and
minimal pruritus. Systemic viral
symptoms such as preauricular adenopathy, fever, and malaise may also be present
·
Allergic: presents bilaterally with severe itching, redness, and no
exudate, clear tears.
·
Inclusion: photosensitivity, swollen
eyelids (usually develops 5-10 days after exposure)
·
Differential
diagnosis: foreign body, corneal
abrasion, herpes simplex, acute glaucoma, iritis, blepharitis, lacrimal duct
obstruction
·
Tx:
·
Bacterial: sulfacetamide 10-30%
ophthalmic solution or 10% ointment for 3-7 days or gentamicin sulfate topical
3 mg/ml for 3-7 days
·
Allergic: naphazoline HCl, phenylephrine HCl, ketorolac tromethamine
(NSAID)
·
Viral: idoxuridine 0.1% solution, 1 gtt q 1 h during day and q 2 hours
during night or adenine arabinoside 3% ointment five times a day
·
F/U: As needed
·
Complications: blindness if not treated properly
·
Refer: ophthalmologist as needed
·
Definition: inflammation of the uveal tract, including
the iris, ciliary body, and choroid
·
Diagnosis
suggested by pain, photophobia, redness, and ciliary flush
·
Anterior
uveitis = iritis
·
With
posterior uveitis, inflammation is usually confined to the posterior choroid,
which quickly spreads to the sensory retina, resulting in potential destruction
of vision.
·
REFER
Iritis (anterior uveitis)
·
Definition: Intraocular inflammation of the iris; most
common form of uveitis
·
With
iritis, the iris, ciliary body, and anterior choroid are usually all involved
because of a common blood supply
·
Presents
with eye pain, photophobia, redness, and pupillary contraction, slightly cloudy
anterior chamber (note: constricted
[miotic] pupil does not react to light)
·
REFER
Keratitis (corneal
inflammation or foreign body)
·
Corneal
ulcers detected by fluorescein staining may be sterile or caused by bacteria,
viruses, or fungi; staining in a fine, branching pattern or broader defects
with herpes simplex or herpes zoster
·
Corneal
abrasions: stain with fluorescein but
have no infiltrate unless they are untreated for several days
·
Corneal
foreign body – may cause tearing and hyperemia with little sensation of a
foreign body; particularly true of rust rings left by ferrous foreign bodies
·
Dry
eyes can cause intense reactions secondary to superficial keratitis, as does
overwearing of contact lenses (corneal hypoxia) and ultraviolet keratitis.
Acute Glaucoma
·
Ocular
emergency that presents as painful, red eye with prominent ciliary flush, pupil
mid-dilated and fixed, cornea cloudy secondary to edema.
·
IOP
> 40 mm Hg and may reach 70-80 mm Hg
·
Cloudy
vision, colored rings around lights (due to corneal edema) and unilateral
headache, often accompanied by N/V
Red Eye
Decision Tree
Lid or lacrimal sac swelling
or proptosis (downward displacement of eyeball)?
( * potentially dangerous
red eyes requiring prompt, specialized care)
_______________________|_________________________
| |
YES: NO:
·
Chronic
blepharitis Subnormal
visual acuity,
·
Stye foreign-body sensation,
·
Chalazion severe pain, or
·
Dacryocystitis circumcorneal injection
·
Orbital
cellulitis* (ciliary flush)?
·
Orbital
inflammation* |
·
Orbital
tumor* |
________________________________________________|
YES: NO:
·
Keratitis* Focal conjunctival redness?
·
Anterior
uveitis* |
·
Acute
angle-closure glaucoma* |
·
Epscleritis
and scleritis* |
________________________________________________|
YES: NO:
·
Inflamed
pingueculum Purulent discharge?
·
Pterygium |
·
Subconjunctival
hemorrhage |
________________________________________________|
YES: NO:
·
Bacterial
conjunctivitis* Itching?
________________________________________________|
YES: NO:
·
Allergic
conjunctivitis Topical ocular medications,
cosmetics, environmental
pollutants?
________________________________________________|
YES: NO:
·
Contact
dermatoconjunctivitis - Viral conjunctivitis
·
Toxic
conjunctivitis -
Chlamydial conjunctivitis
- Immunogenic conjunctivitis
- Cavernous
sinus arteriovenous fistula