Eye disorders: Treatments

For eye disorders, treatments consist of drug therapy and surgery.

Eye disorders: Drug therapy

Topical medications are commonly used to treat eye disorders; however, the practitioner may also prescribe systemic medications. These medications include anti-infectives, anti-inflammatories, miotics, mydriatics, vasoconstrictors, and other medications. It’s essential to provide proper patient teaching on instillation of these topical agents. (See Instilling eye ointment and eyedrops.)

Instilling eye ointment and eyedrops

To teach the patient how to instill eye ointment, tell him to follow these steps:

  • Hold the tube for several minutes to warm the ointment.
  • Squeeze a small amount of ointment 1/4 to 1/2 (0.5 to 1.5 cm) inside the lower lid.
  • Gently close the eye and roll the eyeball in all directions.
  • Wait 10 minutes before instilling other ointments.

To teach the patient how to instill eyedrops, tell him to follow these steps:

  • Tilt the head back and pull down on the lower eye lid.
  • Drop the medication into the conjunctival sac.
  • Apply pressure to the inner canthus for 1 minute after administration of drops to prevent systemic absorption.
  • Wait 5 minutes before instilling a second drop.

Eye disorders: Surgery

Surgical treatments for eye disorders include cataract removal, iridectomy, laser surgery, scleral buckling, and trabeculectomy.

Cataract removal

Two techniques allow the removal of cataracts: intracapsular cataract extraction (ICCE) and extracapsular cataract extraction (ECCE).

Eye disorders: Intra is out

In ICCE, the entire lens is removed, most commonly with a cryoprobe. However, this technique isn’t widely used today.

In ECCE, the patient’s anterior capsule, cortex, and nucleus are removed, leaving the posterior capsule intact. This is the primary treatment for congenital and traumatic cataracts.

Eye disorders: In with the implant

Immediately after removal of the natural lens, many patients receive an intraocular lens implant. An implant works especially well for elderly patients who can’t use eyeglasses or contact lenses (because of arthritis or tremors, for example). (See Bilateral cataract surgery: Simultaneous or staggered?)

Patient preparation

Tell the patient he’ll need to:

  • temporarily wear an eye patch after surgery to prevent traumatic injury and infection
  • get help when getting out of bed
  • sleep on the unaffected side to reduce IOP

Bilateral cataract surgery: Simultaneous or staggered?

Eye disorders

 

Monitoring and aftercare

After the patient returns from surgery, follow these important steps:

  • Notify the practitioner if the patient has severe pain. Also, report increased IOP.
  • Because of the change in the patient’s depth perception, assist him with ambulation and observe other safety precautions.
  • Make sure the patient wears the eye patch for 24 hours, except when instilling eyedrops as ordered, and have him wear an eye shield, especially when sleeping.
  • Instruct the patient to continue wearing the shield at night or whenever he sleeps for several weeks, as ordered.

Home care instructions

Before discharge, teach the patient:

  • how to administer eyedrops or ointments
  • to contact the practitioner immediately if sudden eye pain, red or watery eyes, photophobia, or sudden vision changes occur
  • to avoid activities that raise IOP, including heavy lifting, straining during defecation, and vigorous coughing and sneezing
  • not to exercise strenuously for 6 to 10 weeks
  • to wear dark glasses to relieve glare
  • that changes in his vision can present safety hazards if he wears eyeglasses
  • how to use up-and-down head movements to judge distances to help compensate for loss of depth perception
  • how to insert, remove, and care for contact lenses, if appropriate, or how to arrange to visit a practitioner routinely for removal, cleaning, and reinsertion of extended-wear lenses
  • when to remove the eye patch and when to begin using his eyedrops

Iridectomy

Performed by laser or standard surgery, an iridectomy reduces IOP by easing the drainage of aqueous humor. This procedure makes a hole in the iris, creating an opening through which the aqueous humor can flow to bypass the pupil. An iridectomy is commonly performed to treat acute angle-closure glaucoma.

 

Eye disorders: Another angle

Because glaucoma usually affects both eyes eventually, patients commonly undergo preventive iridectomy on the unaffected eye. It may also be indicated for a patient with an anatomically narrow angle between the cornea and iris. An iridectomy is also used for chronic angle- closure glaucoma, with excision of tissue for biopsy or treatment, and sometimes with other eye surgeries, such as cataract removal, keratoplasty, and glaucoma-filtering procedures.

Patient preparation

Make it clear to the patient that an iridectomy doesn’t restore vision loss caused by glaucoma but that it may prevent further loss.

Monitoring and aftercare

After an iridectomy, take the following steps:

  • Watch for hyphema (hemorrhaging into the anterior chamber of the eye) with sudden, sharp eye pain or the presence of a small half-moon-shape blood speck in the anterior chamber when checked with a flashlight. If either occurs, have the patient rest quietly in bed, with his head elevated, and notify the practitioner.
  • Administer a topical corticosteroid to decrease inflammation and medication to dilate the pupil.
  • Administer a stool softener to prevent constipation and straining during bowel movements, which increases venous pressure in the head, neck, and eyes. This increased pressure can led to increased IOP or strain on the suture line or blood vessels in the affected area.

Home care instructions

Before discharge, teach the patient to:

  • report sudden, sharp eye pain immediately, because it may indicate increased IOP
  • refrain from strenuous activity for 3 weeks
  • refrain from coughing, sneezing, and vigorous nose blowing, which raise venous pressure
  • move slowly, keep his head raised, and sleep with two pillows under his head

Laser surgery

The treatment of choice for many ophthalmic disorders is laser surgery because it’s relatively painless and especially useful for elderly patients, who may be poor surgical risks. Depending on the type of laser, the finely focused, high-energy beam shines at a specific wavelength and color to produce various effects. Laser surgery can be used to treat retinal tears, diabetic retinopathy, macular degeneration, and glaucoma.

Patient preparation

Before the procedure, take these steps:

  • Tell the patient he’ll be awake and seated at a slit lamp–like instrument for the procedure.
  • Explain that his chin will be supported and that he’ll wear a special contact lens that will prevent him from closing his eye.
  • Explain that laser use requires safety precautions, including eye protection for everyone in the room.

Monitoring and aftercare

After the procedure, the patient may occasionally have eye pain. Apply ice packs as needed to help decrease the pain. The patient may be discharged after this office procedure.

Home care instructions

Instruct the patient to receive follow-up care as scheduled. Tell him that ice packs may ease eye discomfort.

Scleral buckling

Used to repair retinal detachment, scleral buckling involves applying external pressure to the separated retinal layers to bring the choroid into contact with the retina. Indenting (or buckling) brings the layers together so that an adhesion can form. It also prevents vitreous fluid from seeping between the detached layers of the retina, which could lead to further detachment and possible blindness. (See Scleral buckling for retinal detachment.)

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Eye disorders

 

Eye disorders: A frigid look

Another method of reattaching the retina is pneumatic retinopexy. This procedure involves sealing the tear or hole with cryotherapy and introducing gas to provide a tamponade of the retina and the layer beneath it.

Patient preparation

Depending on the patient’s age and the surgeon’s preference, advise him whether he’ll receive a local or general anesthetic.

Monitoring and aftercare

After the procedure, take these steps:

  • Notify the practitioner immediately if you observe eye discharge or if the patient experiences fever or sudden, sharp, or severe eye pain.
  • As ordered, administer mydriatic and cycloplegic eyedrops to keep the pupil dilated, an antibiotic to prevent infection, and a corticosteroid to reduce inflammation.
  • For swelling of the eyelids, apply ice packs.
  • Because the patient will probably have binocular patches in place for several days, institute safety precautions while he’s hospitalized. Raise the side rails of his bed, and help him when he walks.
  • Advise the patient to avoid activities that increase IOP, such as hard coughing or sneezing, or straining during defecation. If he’s nauseated, administer an antiemetic, because vomiting increases IOP.

Home care instructions

Before discharge, instruct the patient to:

  • notify the practitioner of signs of recurring detachment, including floating spots, flashing lights, and progressive shadow
  • report fever, persistent excruciating eye pain, or drainage
  • avoid activity that risks eye injury
  • avoid heavy lifting, straining, or any strenuous activity that increases IOP
  • use dilating, antibiotic, or corticosteroid drops as prescribed
  • avoid rapid eye movements

Trabeculectomy

Trabeculectomy is a surgical filtering procedure that removes part of the trabecular meshwork to allow aqueous humor to bypass blocked outflow channels and flow safely away from the eye. This procedure creates an opening under the conjunctiva. An iridectomy is then performed to prevent the iris from prolapsing into the new opening and obstructing the flow of aqueous humor. A trabeculectomy helps treat glaucoma that doesn’t respond to drug therapy.

Patient preparation

Inform the patient that this procedure will probably prevent further vision impairment but that it won’t restore vision that’s already lost.

Monitoring and aftercare

After a trabeculectomy:

  • Report excessive bleeding from the affected area.
  • Observe for nausea; if necessary, administer an antiemetic because vomiting can raise IOP.
  • Administer eyedrops (usually a miotic such as pilocarpine [Carpine]).
  • Immediately instill a cycloplegic such as atropine. If ordered, give a corticosteroid to reduce iritis, an analgesic to relieve pain, and a beta-adrenergic blocker to reduce pressure.
  • Continue previously prescribed eyedrops — a miotic such as pilocarpine or a beta-adrenergic blocker — in the unaffected eye.
  • Remind the patient that he should avoid all activities that increase IOP, including trying to avoid hard coughing or sneezing as well as straining during defecation.

Home care instructions

Instruct the patient to:

  • immediately report sudden onset of severe eye pain, photophobia, excessive tearing, inflammation, or vision loss
  • understand that glaucoma isn’t curable but can be controlled by taking prescribed drugs regularly to treat this condition
  • avoid constrictive clothing, coughing, sneezing, or straining because they can increase IOP
  • anticipate changes in his vision that present safety hazards and that to overcome the loss of peripheral vision, he should turn his head fully to view objects at his side
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