Vision in older adults spring 2014 abridged

1

Vision in Older Adults

NURS 4100 Care of the Older Adult Spring 2014

Joy A. Shepard, PhD(c), MSN, RN, CNE

2

Objectives

Describe assessment of vision in the older adult Explain the importance of sensory function and the impact

of sensory deficits on older adults Describe the effects of aging on visual function List measures to promote healthy visual function in older

adults Identify signs and symptoms and nursing interventions for

older adults with cataracts, glaucoma, macular degeneration, and detached retina

3

Key Terms

Cataracts - Opacity of eye lens that reduces visual acuity Glaucoma – Eye disorder characterized by increased

intraocular pressure; can lead to irreversible damage to optic nerve with loss of peripheral vision

Macular Degeneration- Atrophy of cells in central macular region of retina

Presbyopia - Universal age-related change in lens of eye involving loss of accommodation. Objects held closer than 1 or 2 ft become difficult to see

4

Anatomy of the Eye

Anatomy of the Eye Video

5

Introduction: Sensory Function

Taken for grantedProtection from harmAccurate perception of environmentEssential to communicationSensory deficits compound other problems that

threaten health, well-being, and independence

6

Sensory Dysfunction: Personal Cost Functional impairmentLoss of independence InjurySocial isolationDepressionDecreased quality of life

7

Assessment of Vision

8

Assessing Sensory Problems

Skilled assessment of sensory functionAssessment Guide 26-1 (pp. 362-363):

Sensory FunctionSensory Function (Review!)Assistive techniques: Correct

implementation to promote sensory function

9

Assessment of Vision

Appearance?Clothing CleanlinessSelf-careBumps and bruises

10

InterviewAdequacy of visionRecent changes visionDate of last examInspection

Movement of eyelidsAbnormally colored scleraUnequal or absent pupillary

response

11

Interview – Visual Problems Red eye Excessive tearing/ discharge Foreign body sensation Headache, eyestrain when reading or

doing close work New onset

Double vision, rapid deterioration visual acuity Haziness, flashing lights, moving spots

Loss central/ peripheral vision Trauma or eye injury

12

Vision

Snellen chart or reading from print

Visual field testingExtraocular

movements

13

Eye ExaminationsHealthy older adults

Complete eye examination every yearVisual acuityRetinaIntraocular pressure (IOP)

14

Normal Visual Changes with Aging

15

Normal Age-Related Changes of the EyeChanges are gradualOver time can limit functional

abilityCommon eye disorders in the

elderly are NOT normal: cataracts, glaucoma, macular degeneration, & retinopathy

16

Normal Age-Related Changes of the Eye: External Changes

Graying and thinning eyebrows and eyelashes

Subcutaneous tissue atrophy wrinkling + thinning of skin around eyes

Decreased orbital fat sunken eye appearance + sagging eyelids

Atrophy lacrimal glands Dry eyes (saline drops)

17

Normal Age-Related Changes of the Eye: Internal Changes Reduced elasticity of lens; decreased ability of the lens to

accommodate Decreased ability to focus on close objects (presbyopia) Accommodation is the process by which the eye changes optical power to

maintain a clear image (focus) on an object as its distance changes

18

Changes During Accommodation

19

Presbyopia: Normal Change

Flexible lens of eye gradually loses elasticity, affecting ability to change shape to focus on close objects

20

Normal Age-Related Changes of the Eye: Internal Changes

Decreased pupil size, decreased retinal illumination Decreased visual acuity (sharpness of vision) Decreased light sensitivity (difficulty seeing in dim areas/ at night) Dark and light adaptation takes longer Distortion in depth perception

Lens: Yellowed/ Slightly cloudy (opacification) Increased difficulty in distinguishing between blue, green, & violet Increased sensitivity to glare

21

Internal Changes: Cornea & Lens Lipid deposits around

peripheral cornea arcus senilis (normal change)

Lenses thicken/ hardenYellowish appearance +

opacityCataracts (not a normal

change)

22

Normal Age-Related Changes of the EyeVisual acuity (sharpness of vision)

Diminishes gradually after age 50Decreases rapidly after age 70

Light sensitivity declinesBrightness contrastDark adaptationRecovery from glare

23

Clinical Implications Difficulty reading small print Narrowing of field of vision Decreased light to retina Sensitivity to glare Decreased night vision Difficulty with depth perception

(going down stairs) Increased risk for FALLS!

24

Visual Impairments with Aging

25

Visual Impairment Visual impairment = visual acuity 20/40 by Snellen

chart at 20 feet Increases with age

Common visual disturbances in older adults: Presbyopia Age-Related Macular Degeneration Cataracts Glaucoma

Will affect 70 million Americans by 2030

26

Legal blindness

Visual acuity 20/200 by Snellen chart at 20 feetIncreases with

agePeaks at 85 years

27

Question The nurse is assessing a patient who has just been

tested for visual acuity and was told his vision is 20/50. The patient asks what this means, and the nurse answers: A. “You can see approximately 2/5 as well as the normal person.” B. “You can see at 20 feet what a person with normal vision sees at 50

feet.” C. “Your vision is the same as a 20-year-old man, even though you are

50.” D. “You can see at 50 feet what a person with normal vision can see at

20 feet.”

28

Diseases Affecting Vision

29

Cataracts

30

Cataracts NOT a normal part of aging process

(though very common with aging) Most cataracts are related to aging Lens clouding decreased light to

retina limited vision Oxidative damage or cross linking Slow and painless Leading cause of low vision in older

adults > 50% of adults > 65 years have

cataracts visual problems

31

Cataracts: Signs

Yellowing of lensPupil changes color

to cloudy white or gray

32

Cataracts: Symptoms No pain or discomfort Hazy or blurred vision (most

likely) Glare, photosensitivity Halos around objects Double vision Lack of color contrast or

faded colors Poor night vision

The Symptoms of Cataracts

33

34

Cataracts: Blurry Vision

35

Cataracts: Yellowing of Images

36

Cataracts: Decrease in Color Intensity

37

Cataracts: Risk FactorsIncreased ageSmoking and alcoholDiabetes, hyperlipidemiaTrauma to the eyeExposure to the sun and UVB raysCorticosteroid medications

Risks of Cataracts

38

A. Simulated vision with cataracts.

B. Normal vision.

(From National Eye Institute, National Institutes of Health, 2004.)

39

Cataracts: Tx & Nursing Strategies

Surgery only cureOutpatient procedure: relatively few

complications Removal of lensInsertion of intraocular lens implant (distorts

vision less than special cataract glasses do)Cataracts Treatment

40

Cataract Surgery (Outpatient): Intraocular Lens

Learn About Cataract Surgery - Very graphic!

Say Good-Bye to Cataracts & Glasses

41

Cataract Surgery – Postoperative Instructions Day of surgery

Eye shield First 2 weeks

HOB 30°, lie on back or unaffected side

Eye shield at night Eye drops Mild aches, scratchiness,

itchiness Tylenol; NO aspirin, ibuprofen Do not rub, touch area

Avoid bright sunlight Wrap-around sunglasses

Avoid activities IOP Sneezing, coughing, vomiting,

straining, bending, lifting > 5 lbs Prevent constipation (fiber,

fluids, mobility, stool softener) Avoid heavy work, such as

gardening, mowing the lawn, or moving furniture

Avoid water in eye (tap water, shower, tub, etc)

Caring for Eyes after Cataract Surgery

42

Cataract Surgery – Postoperative Instructions Symptoms to report

Pain not relieved by Tylenol Changes in vision

Decreased vision, redness, cloudiness, drainage, floaters or light flashes, curtain over vision, severe eye pain or pressure

Complications Infection Wound dehiscence Hemorrhage Severe pain Uncontrolled, elevated intraocular pressure

Cataracts Surgery Complications

43

Education Regarding Cataract Prevention Wearing hats and

sunglasses when in sun

Smoking cessationAvoid steroidsLow-fat dietAvoid ocular injuryHow to Prevent Cataracts

44

Question

Which of the following statements indicates that the client has understood home care instructions following cataract surgery? A. “I should not bend over to pick up objects from the floor.” B. “I can sleep on whichever side I want as long as my head

is raised.” C. “I may not watch television for 6 weeks.” D. “I should keep the protective eye shield in place 24 hours

a day.”

45

Glaucoma

46

Glaucoma

Degenerative eye disease Second leading cause of blindness in U.S.

10% vision loss in U.S.Primary cause of blindness among AA

Glaucoma Prevalence

What is Glaucoma

47

Glaucoma

Optic nerve damaged by pressureIncrease in intraocular pressure (IOP) optic

nerve damage peripheral vision lossIOP > 21 mm Hg

“Sneaky thief of sight”Causes of Glaucoma

48

49

Aqueous Humor

50

(From National Eye Institute, National Institutes of Health, 2004.)

Simulated Vision with Glaucoma

51

Chronic (Open-Angle) vs Acute (Angle-Closure) Glaucoma Chronic (also called open-angle)More common than acute, 90%

Slowed flow of aqueous humor through trabecular meshwork build up increased IOP damage to optic nerve loss of vision

Painless vision lossPeripheral visual field loss

Types of Glaucoma

52

Chronic (Open-Angle) Glaucoma

53

Chronic (Open-Angle) Glaucoma

54

Chronic Glaucoma

55

Chronic Glaucoma: S/SPeripheral vision slowly impairedTired eyesHeadachesMisty visionColored rings/ halos around lightsWorse symptoms in morningUsually involves one eye, but may be both

Glaucoma Symptoms

56

57

Chronic: Tx & Nursing Strategies Diagnosis and Treatment

Dx: tonometry; gonioscopy

Treatment (Care Plan 26-1; pp. 366-368): No cure, requires life-long management Reduce IOP

Medications to decrease IOP (topical eyedrops) Avoid stress, coughing, sneezing, bending over, or straining with bowel

movements Laser trabeculoplasty, Surgery – trabeculectomy

Glaucoma TreatmentsGlaucoma Treatment DevelopmentsGlaucoma Laser

58

Tonometry & Gonioscopy

59

Topical Eyedrops Beta-blockers (Betagan, Timoptic, Ocupress) – Bottles

with blue or yellow caps 1st line therapy for glaucoma Lowers IOP by decreasing formation of aqueous humor SEs: Bradycardia, hypotension, bronchospasm, confusion

Prostaglandin analogues (Xalatan, Lumigan) Increases outflow of aqueous humor SEs: Stinging, burning, darkening of eye

Glaucoma Help In A Drop

60

Topical Eyedrops Alpha-Adrenergic Agonists (Iopidine,

Alphagan, Epinal) – Bottles with purple capsLowers IOP by decreasing formation of

aqueous humorAvoid use in acute angle-closure glaucomaSEs: Palpitation, hypertension, tremor,

sweating

61

Topical Eyedrops Miotics/ cholinesterase inhibitors (pilocarpine,

Humorsol) – Bottles with green capsFacilitates outflow of aqueous humorSEs: Decreased night vision, bronchospasm,

sweating, salivation, lacrimation, diarrheaCarbonic anhydrase inhibitors (Trusopt, Azopt) –

Bottles with orange capsDecreased formation of aqueous humor

62

Question A client with open-angle glaucoma is receiving

brinzolamide (Azopt) for treatment. When assessing the client’s response to the medication, the nurse expects therapeutic effects to be the result of the following? A. A decrease in the outflow of aqueous humor B. An increase in the outflow of aqueous humor C. A decrease in aqueous humor production D. An increase in aqueous humor production

63

Acute (Angle-Closure) Glaucoma Acute (angle-closure, closed-

angle, narrow-angle) Not as common Angle of iris obstructs drainage

of aqueous humor through trabecular meshwork increased IOP visual changes

May occur suddenly Ophthalmic emergency!

64

Acute (Angle-Closure) Glaucoma

65

Acute Glaucoma: S/S Severe unilateral eye pain or headacheBlurred visionNausea and vomitingPhotophobiaColored halos around lightRed eye

66

Acute Glaucoma

Sudden S/S: eye pain, HAs, halos around lights, dilated pupils, vision loss, red eyes, N & V

May last for a few hours, return again

Each attack takes part of field of vision

67

Acute Glaucoma: Tx & Nursing Strategies Diagnosis

Tonometer to measure IOP Normal IOP is 20 mm Hg or below Gonioscopy (direct exam)

Medications (to decrease pressure) Permanent vision loss within 2 – 5 days if untreated Surgery: iridotomy (lowers IOP) to prevent future

episodes

68

Risk Factors for Glaucoma

Increased intraocular pressureOlder than 60 years of ageFemale genderFamily history of glaucomaPersonal history of myopia, diabetes,

hypertension, or migrainesAfrican American ancestryWho's at Risk of Developing Glaucoma

69

Education Regarding Glaucoma ScreeningComplete ophthalmic examinationAdults 65+ should be evaluated

annuallyEvery 6 months with glaucoma

controlled by medication

70

Glaucoma: Contraindicated Medications Cold remedies with Pseudoephedrine or Phenylephrine

(Neo-Synephrine) Antihistamines such as Chlorpheniramine (Chlor-

Trimeton) or Diphenhydramine (Benadryl) Overactive bladder remedies – Tolterodine tartrate

(Detrol) Tricyclic antidepressants – Amitriptyline (Elavil) Cyclobenzaprine (Flexeril)

71

Question

Is the following statement true or false?

Patient adherence with treatment for glaucoma can be a problem in the older adult population.

72

Age-Related Macular Degeneration (ARMD)

73

Age-Related Macular Degeneration (ARMD) Most common cause of

blindness adults > 65 Degeneration of macula,

(sharpest central vision) Scotoma – central vision Visual acuity

Central vision Seeing objects clearly Common daily tasks (reading

and driving)Managing Macular Degeneration

74

ARMD: Symptoms

Painless More light required for

reading Central scotomas – blind

spots Blurry Bent, warped images Dark, foggy or light spots

Words on a page may appear distorted or incomplete

Metamorphopsia – images look smaller (micropsia) or larger (macropsia) than they actually are

The Signs of AMD

75

A. Simulated loss of vision with age-related macular degeneration (AMD). B. Normal vision.

(From National Eye Institute, National Institutes of Health, 2004.)

Helping Macular Degeneration

76

Macular degeneration: distortion of center vision; normal peripheral vision

Amsler Grid

77

ARMD: Two Types – Dry & Wet Dry (atrophic,

nonexudative form) 10-20% severe vision loss

Atrophy Retinal pigment

degeneration Drusen accumulations

90% ARMD this type Better prognosis, slower

progression

78

ARMD: Two Types – Dry & Wet Wet (Neovascular exudates)

Blood or serum leak from newly formed blood vessels beneath retina scar formation + visual problems

10% this type More sudden onset More severe vision loss

Learn about Wet AMD

79

Normal Macula vs Dry & Wet ARMD

80

Risk Factors for ARMD Age (above 50) Female gender Caucasian race and light (blue) colored eyes Family history of ARMD Cigarette smoking Ultraviolet light (sunlight) HTN, high cholesterol, cardiovascular disease Lack of dietary intake of lutein; antioxidants and zincHow to Prevent Macular DegenerationThe Risks of Smoking and Macular Degeneration

81

ARMD: TxNo cure at presentNew research:

Photodynamic therapy uses a special laser to seal leaking blood vessels in the eye

Antioxidant vitamins (C, D, E, and Beta-carotene), lutein, & zinc may slow progress of disease

Retinal cell transplantation or regeneration

New Macular Degeneration Treatment (just an example)

82

Age-Related Macular Degeneration

(ARMD) Preventive Measures Nurses should encourage

Routine ophthalmic examinationsWearing UV protective lenses in sun Smoking cessationExercising routinely Eating a healthy diet consisting of fruits

and vegetables

83

ARMD: Nursing Strategies (p.365, Box 26-2) Magnifying glasses Reading lamps Low-vision assistive devices Modify environment Avoid glare Use contrasting colors More auditory input (books on tape, etc.) Decrease controllable risk factors

(smoking, UV exposure)How to Deal with Losing Sight

84

QuestionWhich type of visual problem is

associated with macular degeneration?A. Loss of peripheral visionB. Loss of central visionC. Perception of spots moving across the eyeD. Pain with movement of the eye

85

Detached Retina

86

Detached Retina

Forward displacement of retina Gradual or sudden Risk factors: nearsightedness (myopia), cataract surgery,

glaucoma, trauma, previous retinal detachment, family hx Symptoms: spots, blurred vision, flashes of light, curtain

over visual field Blank areas of vision PainlessCauses of Retinal Detachment

87

Posterior Vitreous Detachment

88

Retinal Detachment

89

Detached Retina: Tx & Nursing StrategiesPrompt treatmentBed rest, bilateral eye patches

Reason: Reduce rapid eye movementsSafety concernsSurgery: electrodiathermy & cryosurgeryScleral buckling & photocoagulationDetached Retina (or Retinal Detachment)

90

Promoting Visual Safety

91

Promoting Visual Safety in Home Provide adequate lighting in high-traffic areas Stair rails, non skid surfaces Use contrast when painting Avoid reflective floors Signs – bright colors such as red, orange, yellow Use red-colored tape or paint on edges of stairs and

entryways Avoid complicated rug patterns

92

Nursing Diagnoses

93

Nursing Diagnoses Associated with Visual Impairment (Table 26-1)

Sensory/Perceptual Alterations: Visual with a variety of nursing goals and interventionsCommunicationSafetyMobilitySelf-care activitiesMood