Vicki Notes

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• Normal aging changes the eye, which affects the functional level (sight) and increases the potential for pathologic (disease) conditions that affect vision.
• 95% of older adults wear glasses.
• Of those over 85 years old glasses only help 45% to correct their vision problems. 12% are legally blind.
• Early intervention and rehabilitation is important. Nurses help in prevention through education and screening (now you know why you have to learn this!).

• The external eye changes due to - loss of orbital fat & elastic tissue & a decrease in muscle tone. Also skin around the eye darkens & wrinkles (crow's feet). There may be loss of lateral aspect of the eyebrows.
• Xanthomas - deposits of lipid material around the inner lid may occur (may mean ↑ blood lipids)
• Senile entropion - is where the lid margin turns inward (remember 'en' as 'in') This may cause eyelashes to irritate the eye conjunctiva. Tx: with surgery.
• Senile ectropion - is where the eyelid turns outward (remember 'ect' as 'out'). This may lead to inflammation.
• With age the cornea flattens, limiting its protective function.
• The sclera becomes more transparent & may yellow (due to dehydration).
• The pupils become smaller & response to light lessens because of poor dilation & constriction.
• The retina becomes thinner & receives on 1/3 of the light of a younger person's retina. Therefore, older adults need more light to read & adaptation to the dark is slower & lesser.
• The ability to perceive colors decreases, especially with blue/green distinction.
• The lens loses elasticity & becomes denser (thicker) Both eyes usually change at the same time. Decreased ability of the lens to accommodate is the reason there is decreased ability to focus on near objects. Thus, the need for glasses to read fine print, this is called presbyopia & is common.
• Changes in the lens also make glare a problem, increasing the need for sunglasses.
• Depth perception is affected.
• Floaters - opacities in the vitreous humor appear in the person's field of vision. While this is considered part of normal aging it could also indicate retinal detachment & should be determined in an eye exam.
• Arcus senilis - is a common change in the cornea with those over 65 y/o, it is a grayish-yellow ring around the iris & caused by a fatty invasion. This usually causes no problems.
• There is decreased tear secretion, decreasing the ability to defend the eye from environmental population. Leading to increased infections of the conjunctiva. Decrease tearing can be supplemented with OTCs such as Artificial Tears.

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• Is the most frequent ocular disease of aging & 50% of adults over 40 show some lens clouding.
• 95% of people over 65 have some degree of cataracts & only a few progress to the advanced stage & lead to a slow decrease in vision.
• Signs & symptoms:
• Decreased ability to see detail (because of decreased light to the retina).
• Increased difficulty adjusting to glare & decreased ability to adjust between light & dark.
• At first, there may be improvement in near vision but that will fade.
• There are three ways to restore vision - Eyeglasses, contact lenses & intraocular implant.
• Eyeglasses - are rarely used after surgery, and are thick & heavy. They increase object size by 25% (that is a change hard to adjust to), provide excellent central vision but impair peripheral vision (person must turn their head more). If one eye is normal eyeglasses can't be used to restore vision.
• Contact lenses - correct the focus of the eye & provide both central & peripheral vision. They only increase object size by 6%. However, insertion, handling & care of contacts may be a problem for the older adults (only 50-60% are capable).
• Intraocular implantation of an artificial lens is the most frequent cataract surgery (done outpatient with a local anesthesia. Postop care usually consists of eye drops & restriction in activities (such as bending & lifting). Important considerations: can the older person tolerate surgery & will they have social support to monitor and/or care for them if needed postsurgery.

• Is the leading cause of blindness throughout the world.
• With this there is increased intraocular pressure, optic nerve damage & loss in vision field.
• There are two types of glaucoma:
• Primary open-angle glaucoma - is more often seen in the elderly, who may present with no symptoms, this is usually discovered in a routine eye exam). This develops slowly over time & is subtle. Assess for family hx of glaucoma, increased intraocular pressure, blurred vision not corrected with lenses & a halo effect around lights. This patient will have loss of peripheral vision, which can cause problems driving a car (another reason nursing physical assessment is so vital & you carry the assessment tools right on your hand!). Medical tx: includes eye drops to decrease intraocular pressure or decrease aqueous formation (Diamox). Surgical tx: is reserved for those difficult-to-control situations.
• Primary closed-angel glaucoma - is often an acute, rapid onset, pain attack of increased pressure with a marked decrease in vision. Tx: Consists of normalizing intraocular pressure with eye drops followed by surgery. Application of eye drops may be difficult for the older adult. Eye drops can also cause systemic & adverse effects.

• Involves the loss of central vision & occurs over time. Onset is usually at about 65. Begins with only one eye & involves the second eye in about four years. Little hope for a cure. The disease is thought to be caused by leakage of retinal membranes & some tx is being done with laser photocoagulation. Sign & symptoms: reports of loss of visual acuity or distorted vision. Tx: with visual rehabilitation, which attempts to magnify the central vision defect area with ocular lenses, or with video enlargement.

• Experienced by those with diabetes mellitus & the leading cause of blindness in the adult population. Signs & symptoms include transient blurring (comes & goes), loss of central vision & significant shifts in vision. The retina of the diabetic eye has irregular small hemorrhages and yellow-white exudates. Usually occurs 10-15 years after onset of diabetes. Some laser photocoagulation treatment may be helpful but there is otherwise no current treatment.

• Is a vascular & inflammatory disease of older age, of the temporal arteries. Signs and symptoms include headache, preauricular tenderness, enlarged temporal artery & c/o of malaise. One half of those affected suffer visual loss. Tx: Steroids.

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• History - Impairment of vision is usually slow & may go unnoticed by the older patients. While some people are excellent historians others may require more time & more direct questioning. Use also open-ended approach (Tell what is different now about your vision…) & conclusion (Is there anything else you can tell me about your vision?). Examples of direct questions include: When was the last time the prescription for your glasses were changed?
• Visual Acuity - The most common test for far vision is the Snellen chart (you know the one with letters & numbers we've all taken). The patient stands or sits 20 feet from the chart (thus the first 20 in 20/20). Exam is performed first without then with glasses. Visual acuity is recorded as a fraction. The higher the denominator (or second number in 20/20 for example 20/200) the more impaired the vision.
• Physical Examination of the Eye - First observe the skin & tissue around the eye, the eyelids, the conjunctiva (any irritation?), the pupils (unusually small or slowed reflex response?). A mature cataract will impair the ability to visualize the red reflex with an opthalmoscope.
• Psychosocial Assessment - This should focus on the strengths of the older person. Ask patients how they perceive themselves coping with their impairments & what strengths they use to adjust to their levels of sensory impairment. Ask them to describe a normal day.
• Family Assessment - Establish significant family members that can provide additional information. Identify any primary caregivers, as they are an important part of the patient's milieu & should always be included in assessment.
• Environmental Assessment
• Living Arrangement Assessment - Older adults in need of nursing care may be found in private or family homes, the hospital or nursing home. The most difficult to assess is the private home. Assessment should include the actual area & the surroundings (neighborhood or areas around an apartment). An issue for example may be the use of an elevator - being able to see the numbers, getting off at the correct place, or getting on before the doors close, or deciding if there is room to get in. Nursing needs to be sure environments are supportive of the visually impaired older adult & serve as an advocate to promote & protect their safety.
• Resources Assessment - Assess for adequate lighting for the aging eye. Teach: Use one light source in a work area which should be out of the visual field, the strongest light should be directed at the work & farther areas should be well lighted but not as strongly lit, avoid luminous ceiling lights & watching television in the dark.

• Alteration in sensory/visual perception r/t pathologic or other conditions.
• Impaired social interaction and/or social isolation r/t visual impairment.
• Risk for injury r/t impaired vision.

• Establish realistic short & long term goals. Whenever possible include the patient in this phase.

• In the acute care setting - In the hospital setting be alert to the older patient without glasses due to the fact that this population usually wears glasses - glasses may be left at home or at the nursing home. Make sure glasses are readily available, clean & used by the patient. It is important that they be able to see clearly to decrease the already present fear or strangeness of hospital surroundings. Do your pre or postop teaching in a slower manner & include the caregiver.
• In the nursing home - The nurse must be sure the resident has yearly eye exams, understand the significance of medication & their potential for side effects. Eyeglasses should be cared for properly, cleaned & wore. It may be wise to label the glasses with the resident's name in case the eyeglasses are lost.
• In the private or family home - Assist to create a barrier-free environment that is safe. Vision should always be assessed on the home visit. This is also a good time to teach.

• Determine if outcomes have been met. Has the plan of care made a difference?

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• That they have trouble seeing under low light (dim light) or viewing rapidly changing displays. Difficulty focusing on things close-up, problems with glare and searching for things in the environment, and decreased night vision.

• The cornea flattens, sclera becomes yellow & less elastic, intraocular pressure increases, accommodation of the lens decreases, retina receives less light, capability for tearing diminishes, ability to gaze upward decreases, ability to maintain convergence diminishes, vitreous floaters may appear, arcus senilis may appear, visual acuity decreases & night vision decreases.

• Wear eyeglasses, increase the amount of light when reading, allow extra time for eyes to accommodate to darkness, avoid nighttime driving of vehicles & wear dark glasses to reduce the impact of sun's glare.

 Patient Teaching: What are the steps for self-administration of eye drops?

• Wash your hands, use adequate light; sit, stand or lie down in front of a mirror, tilt your head back, extend your lower lid outward to make a 'pocket' into which the drops can fall & look up, insert the drops into the pocket & release your eyelid, and close your eye.

• Cataracts, glaucoma, senile macular degeneration, diabetic retinopathy & temporal arteritis.

• That adequate lighting is available, light switches are conveniently located, stairways are well lighted, night-lights are used (especially in bathrooms) & bedrooms, handrails are available where there could be a sudden change of light (such as outside step), glare from windows is controlled by use of drapes and/or shades, no furniture is placed in entryways, bright nonskid tape is on the top & bottom steps to indicate beginning and end of stairs, shiny surfaces such as shiny waxed floors are avoided & contrasting colors are used in decorating (very dark colors or very light pastels are avoided).