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Advanced Clinical Nursing Theory > Ophthalmology > Flashcards

Ophthalmology Flashcards

1
Q

what are the main signs of eye pain?

A

blepharospasm
reduced palpebral fissure
ocular discharge/epiphora
hyperaemia

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2
Q

what is blepharospasm?

A

increased blink rate

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3
Q

what is epiphora?

A

watery eyes

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4
Q

what is hyperaemia?

A

redness

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5
Q

what are the local signs of occular pain?

A

photophobia
miosis
third eyelid protrusion
head shy
self trauma

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6
Q

what is miosis?

A

constricted pupil

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7
Q

what are the systemic signs of occular pain?

A

reduced appetite
quiet
subdued
depressed
lethargic
headache

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8
Q

how should occular cases be triaged?

A

systemic signs
brief outline of occular signs
speed of onset
duration

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9
Q

when should patients with occular pain/issues be seen in practice?

A

same day wherever possible

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10
Q

what is the downside of using standard pain scoring to assess occular pain?

A

it is influenced by blepharospasm

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11
Q

what are the 3 sections of the ophthalmic patient pain score?

A

overall demenour
observation of blepharospasm
rubbing of the eye

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12
Q

what score on the ophthalmic patient pain score suggests analgesia is required?

A

> 3

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13
Q

what are the main methods of management of ophthalmic pain?

A

medical - topical and systemic
surgical

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14
Q

who must advocate for the patient?

A

veterinary team

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15
Q

what must be treated?

A

cause of the pain

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16
Q

what may be causing an animal occular pain?

A

scratchy dry lids
acute ulcer
uveitis
chronic glaucoma
orbital swelling
unknown - unable to open eye to see

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17
Q

how may dry eyelids be treated?

A

lubrication with HA drops

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18
Q

how may pain from acute ulcers be treated?

A

bandage contact lens

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19
Q

how do bandage contact lenses prevent pain?

A

covers nerve endings

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20
Q

how may pain from uveitis be treated?

A

atropine or Cyclopentolate drops to relax muscle

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21
Q

how may pain from chronic glaucoma be treated?

A

enucleation

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22
Q

how may pain from orbital swelling be treated?

A

NSAIDs
opioids

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23
Q

how may an eye that cannot be opened be treated?

A

LA
sedation
GA

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24
Q

how should blind or partially sighted patients be handled?

A

go slowly
hand on chest initially
talk to them
guide then whilst walking
avoid bumping into things

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25
Q

why is avoiding bumping into things essential if the eye is fragile?

A

could lead to rupture

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26
Q

how should patients be handled for occular exam?

A

assessment of temperament - is muzzle needed
keep steady
keep calm
placed at the table edge
reward and reassure

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27
Q

what are some of the main causes of vision loss?

A

cataract
glaucoma
SARDS
toxins
PRA
brain disease or trauma

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28
Q

what are the 2 main reasons that cateracts develop?

A

inherited
diabetic

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29
Q

how is glaucoma caused?

A

inherited genetic defect
secondary to intraocular neoplasia, uveitis or lens luxation

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30
Q

how is glaucoma treated?

A

medically managed initially
surgical shunt implant
laser TSCP/ECP
ultimately enucleation

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31
Q

what is SARDS?

A

sudden acquired retinal degeneration syndrome

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32
Q

how is SARDS confirmed?

A

flat line on electroretinogram

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33
Q

how is SARDS treated?

A

no treatment

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34
Q

what toxins can cause blindness?

A

ivermectin poisoning
enrofloxacin in cats

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35
Q

what is PRA?

A

progressive retinal atrophy

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36
Q

what breeds is PRA common in?

A

cocker spaniels

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37
Q

what type of vision is lost first with PRA?

A

night and then day

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38
Q

how can PRA be diagnosed?

A

simple maze test with lights on and off
ERG can show if rods not responding and so night vision lost

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39
Q

how important is sight to animals?

A

scent and hearing most important
adjust very well to blindness

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40
Q

how can owners support their blind pets at home?

A

online forums for blind pet owners
RSPCA
buster collars
guide leads
doggles
voice commands for stairs etc
behaviour training
lead walks offer more support

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41
Q

will eye ulcers heal if we do nothing?

A

if simple will heal in 7 days with no intervention

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42
Q

what must be done if ulcers are lasting more than 7 days?

A

investigation of underlying issue

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43
Q

what is the issue with not treating ulcers?

A

pain
infection risk
delayed healing
risk of keratomalacia

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44
Q

how does keretomalacia occur?

A

enzymes in tears break down cornea which can lead to globe perforation

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45
Q

what may happen if ulcers are not correctly managed?

A

perforation
endophthalmitis
glaucoma
phthisis
blindness

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46
Q

what typeof epithelium is the cornea formed from?

A

transparent stratified squamous epithelium

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47
Q

what is an integral part of the cornea?

A

tear film on upper surface

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48
Q

what is the limbus of the eye?

A

transition zone to sclera

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49
Q

what is the sclera?

A

fibrous tunic

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50
Q

what is the role of the sclera?

A

gives globe rigidity

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51
Q

what are the different ulcer depths?

A

superficial
deep
descemetocoele
perforation

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52
Q

how can ulcers be classified?

A

depth of stroma affected
size
type

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53
Q

what is the effect on the stroma of a descemetocoele ulcer?

A

all stroma is lost

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54
Q

when is an eye classed as fragile?

A

> 50% stromal loss

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55
Q

what layer of the eye can ulcers reach that makes the eye extremely fragile?

A

Descemet’s layer

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56
Q

what can cause eye rupture if eye is fragile?

A

any increase in IOP

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57
Q

what may cause increased IOP?

A

barking
jugular samples
coughing
vomiting
collar
firm restraint

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58
Q

what breeds are commonly affected by severe ulcers?

A

brachycephalic breeds

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59
Q

how should animals with fragile eyes be treated?

A

avoid pressure on neck/lids
keep venous pressure low to keep IOP low
avoid stress
caution with occular tests used
ensure meds given regularly
keep eye area clean

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60
Q

what ulcer types are there?

A

SCCED
stromal ulcers
melting ulcers
descemetocoeles
perforation

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61
Q

what is SCCED?

A

spontaneous chronic corneal epithelial defect

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62
Q

how can SCCED be treated?

A

algar brush
grid
superficial keratectomy

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63
Q

what is a superficial keratectomy?

A

top layer of the cornea removed

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64
Q

how are stromal ulcers / feline sequestrum treated?

A

medical
surgical graft

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65
Q

how are melting ulcers treated?

A

intense medical management initially
corneal cross linking if cornea unstable
corneal graft

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66
Q

how are descemetoceles treated?

A

structural support imperative
corneal-conjunctival transposition

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67
Q

how is eye perforation treated?

A

suture closed
graft
corneal transplant

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68
Q

how should patients with fragile eyes be managed around anesthesia?

A

low stress
smooth pre-med (IV) and induction
smooth recovery
consider not reversing premed

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69
Q

where should horses be kept following eye surgery?

A

dark stables to allow atropine to be used

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70
Q

what is involved in post occular surgery care?

A

harness only
no jugular samples
buster collar needed
monitor and treat pain
administer meds
keep wounds clean and dry
keep patient calm

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71
Q

what types of trauma are ocular emergancies?

A

sharp trauma
blunt trauma
proptosis
penetrating FB

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72
Q

what is proptosis?

A

eyelids trapped behind the globe which pushes the eye out of the orbit

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73
Q

what are the priorities for occular emergencies?

A

CVS stability
analgesia
occular surface support
eye lubrication
prevent further trauma
stabilise any FB
buster collar to prevent self-trauma

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74
Q

when do puppies develop a menace response?

A

between 8-12 weeks

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75
Q

what can be caused by cat claw injury to the eye?

A

corneal laceration
lens puncture
capsular tear
cataract formation
lens induced uveitis

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76
Q

what may be needed to treat cat claw injuries?

A

cataract surgeries with phaecoemulsification
corneal laceration repair
medical treatment of uveitis

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77
Q

how can risk of cat claw injury be reduced?

A

ensure owners with cats and puppies are aware of when mencae response develops

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78
Q

what visually about the eye can indicate glaucoma?

A

blue cornea
red sclera
conjunctiva

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79
Q

what can be caused by glaucoma?

A

blindness and pain

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80
Q

what can chronic glaucoma cause?

A

buphthalmic eye

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81
Q

what is a buphthalmic eye?

A

eyeball is bigger as globe is stretched

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82
Q

does the eyeball move from its position in the orbit if glaucoma is seen?

A

no - remains in it’s normal position inside the orbit

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83
Q

what is normal IOP?

A

10-25 mmHg

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84
Q

what IOP can be seen with glaucoma?

A

> 30 mmHg

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85
Q

what can a IOP of >40mmHg cause?

A

blindness in 24-28 hours

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86
Q

what can cause exophthalmos?

A

FB causing retrotubular abscess or cellulitis
elevator slip trauma if recent dental work
stick injuries

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87
Q

what are the signs of retrotubular masses?

A

pain on opening mouth
exophthalmus
excessive conjunctiva visible - especially third eyelid

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88
Q

what is exophthalmus?

A

eye is pushed forwards

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89
Q

what is the role of lubricant eye drops?

A

protect
soothe
support healing
provide nutrients to eye

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90
Q

what is the role of antibiotic eye drops?

A

treatment
prophylaxis

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91
Q

what types of anti-inflammatory eye drops are available?

A

NSAIDs
steroids

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92
Q

what is the role of immune modulator eye drops?

A

treatment of immune mediated disease

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93
Q

what is the role of anti-glaucoma eye drops?

A

lower IOP

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94
Q

what is the role of mydriatic eye drops?

A

dilation of the pupil

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95
Q

what mydriatic is commonly used?

A

atropine

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96
Q

what is the role of LA eye drops?

A

diagnostic procedure
pre-op

97
Q

what LA is commonly used for eyes?

A

proxymetacaine

98
Q

what can serum eye drops be made from?

A

FFP
serum (patients own or donor)

99
Q

how can serum eye drops be made?

A

defrost frozen plasma
place needle free spike into plasma bag
draw up 3 mls plasma and transfer into bottles
store bottles or syringes of plasma in the freezer
defrost on day of use

100
Q

how long can serum eye drops be kept in the fridge for?

A

max 3 days

101
Q

when should serum drops be applied?

A

every 1-2 hours

102
Q

what is essential when making serum eye drops?

A

process should be as sterile as possible

103
Q

what can serum eye drops be used for?

A

melting ulcers
prevention of keratomalacia

104
Q

what must be checked before administering eye drops?

A

correct meds for the correct eye

105
Q

how much eye drops are needed?

A

one drop sufficient

106
Q

how much time should be left between each drop?

107
Q

how much time should be left between gel drops and ointment?

108
Q

what must not touch the surface of the eye?

A

nozzle
finger

109
Q

what determines order of drop administration?

110
Q

in what order should drops be applied?

A

watery/aqueous drops
suspensions
gel
ointment

111
Q

what is the role of lubricants?

A

support healing in all ocular surface disease
nutrition of cornea
reduce evaporation
prevent perioperative ulceration
KCS management
comfort

112
Q

when will lubricants not be used in ocular surface disease?

A

if the eye has ruptured

113
Q

look at eye drops table

114
Q

what are the main patient factors to consider when preparing for ophthalmic surgery?

A

mobility
systemic health
is pre-op testing needed
BOAS?
will eye drops be needed prior to surgery
when and where should catheter be placed
many are diabetic - insulin needs

115
Q

how can induction for ophthalmic patients be made smoother?

A

waiting with owner
ensure adequate depth before intubation

116
Q

how should patients be positioned for ophthalmic surgery?

A

vacuum bags to prevent movement
op vet usually to position

117
Q

where should monitoring equipment be placed during ophthalmic surgery?

A

towards the back wherever possible

118
Q

what type of ET tube may be used during ophthalmic surgery?

A

armoured ET tube

119
Q

what additional anaesthesia may be used in ophthalmic surgery?

120
Q

what is required if NMBAs are used?

A

ventilation

121
Q

what is the benefit of NMBA for ophthalmic surgery?

A

central and still eye

122
Q

how should eyelids be prepared for surgery?

A

wear gloves
apply large volume of lubricating gel to the eyes
small sharp clippers used
clip area as close as possible without causing trauma or irritation
flush hairs and lubricant away with saline

123
Q

is clipping required for globe surgery?

124
Q

what should be placed in the eye before clipping for eyelid surgery?

A

lubricating gel to catch hairs

125
Q

what must always be used to surgically prep the eye?

A

povidine iodine solution

126
Q

what must never be used for eye prep?

A

hibi
iodine scrub or tincture

127
Q

what ratio of povidine iodine to sterile saline should be used for the globe?

A

1:50 iodine:saline

128
Q

what ratio of povidine iodine to sterile saline should be used for the eyelids?

A

1:10 iodine:saline

129
Q

what length of contact time is required for povidine iodine solution?

130
Q

what should be done once the povidine iodine has had its 2 minute contact time?

A

flush out with saline

131
Q

what should be used to remove gel and hair from the eye following clipping?

A

gauze swabs and sterile saline

132
Q

can povidine iodine solution be made up in advance?

A

yes can keep for up to a week

133
Q

what amount of povidine iodine to saline will make a 1:50 solution?

A

2ml in 98ml saline

134
Q

what order should the globe and lids be prepped?

A

globe first (1:50)
then eyelids (1:10)

135
Q

why must the globe be flushed with sterile saline after the 2 minutes povidine iodine contact time?

A

prevents corneal toxicity

136
Q

what surgical equipment may be needed for ophthalmic surgery?

A

patient drapes
surgeons chair with arm rests
gown and gloves
equipment and chair drapes
pre-drawn saline flush

137
Q

what equipment may be used for ophthalmic surgery at referral level?

A

operating microscope with sterile cover
ventilator
muscle stim if NMBA used
phaecoemulsification machine if cateract surgery

138
Q

what is essential when cleaning and packing ophthalmic kit?

A

extreme care taken
very fragile and expensive
no towels!

139
Q

what are the main types of eye surgical kits?

A

lid
corneal
phaeco

140
Q

what suture material is often used for lids?

A

5-0 or 6-0 vicryl

141
Q

what suture material is often used for cornea?

A

8-0 or 9-0 vicryl

142
Q

what type of needle is used for corneal suture?

A

spatulated

143
Q

what drapes may be used for ophthalmic surgery?

A

fenestrated
sticky
may have pouch to catch fluid

144
Q

what block may be used for enucleation?

A

retrotubular

145
Q

what are the 2 main methods of enucleation?

A

trans-conjunctival
transpalpebral

146
Q

how does transconjunctival enucleation work?

A

2 phase
incision around limbus and eye removed
then lids and conjunctiva follow

147
Q

what may be used instead of NMBAs during occular surgery to stabilise the eye?

A

stay sutures

148
Q

what happens during transpalpebral enucleation?

A

en block removal
eyelids sutured closed first
lids and eyeball removed all in one

149
Q

when would trans-palpebral enucleation be used?

A

tumour or infection

150
Q

what are some specific anaesthetic considerations relating to enucleation?

A

stimulation of oculo-cardiac reflex
excessive traction on chiasm
haemorrhage

151
Q

what is the oculo-cardiac reflex caused by?

A

pressure on the eye stimulating the vagus nerve

152
Q

what happens during the oculo-cardiac reflex?

A

reflex bradycardia due to vagal stimulation

153
Q

what is the effect of traction on the optic chiasm?

A

optic nerves are linked
avulsion from excessive traction can lead to blindness in other eye

154
Q

what animals are more at risk from blindness following traction on chiasm?

155
Q

what are the options for haemorrhage during enucleation?

A

collagen pads
powders
adrenaline
pressure

156
Q

where may owners see mild post op haemorrhage following enucleation?

157
Q

what are some general surgeries seen in the eye area?

A

entropian
mass removal
rhytidecomy
distichasis
medial canthoplasty
cherry eye
lid to lid transposition
parotid duct transposition

158
Q

what techniques may be used for entropion correction?

A

holtz-celcus - crescent shaped incision on eyelid

159
Q

what technique may be used for eyelid mass removal?

A

wedge excision

160
Q

what is rhytidectomy?

A

removal of excess skin that may be impacting eyes/vision
(droopy dog facelift)

161
Q

what is distichasis?

A

extra lashes that rub against eye due to their position on the eyelid

162
Q

how can distichasis be treated?

A

cryosurgery
electrolysis

163
Q

what is a medial canthoplasty?

A

reshaping of medial canthus to prevent rubbing on the cornea

164
Q

what dogs is medial canthoplasty often performed in?

165
Q

what are lid to lid transpositions used for?

A

replace defects

166
Q

what can parotid duct transposition be used for?

167
Q

what position must the eye be in for corneal surgery?

A

horizontal and still
ideally central

168
Q

how can eye position be stabilised for corneal surgery?

A

NMBA and ventilation
stay sutures

169
Q

what is involved in corneal surgery?

A

removal of damaged cornea
free or advancement graft to cover deficit

170
Q

what is a common cause of blindness?

171
Q

what are the main causes of cataracts?

A

inherited
acquired through diabetes mellitus

172
Q

how should patients be assessed before cataract surgery?

A

gonioscopy
ERG
US for tumour
check if giving post op meds is practical for O
are their financial constraints

173
Q

what is the purpose of gonioscopy?

A

assess eye drainage angle

174
Q

what condition is indicated by gonioscopy?

A

inherited glaucoma

175
Q

how is gonioscopy performed?

A

patient conscious
LA drops used
placed on eye

176
Q

what is the purpose of ocular ultrasound?

A

assess structures of the eyes

177
Q

what may be diagnosed through ocular ultrasound?

A

lens structure
cataracts
retinal detachment
retrotubular mass
FB

178
Q

can ocular ultrasound be performed conscious?

179
Q

how is the patient prepped for ocular US?

A

proxymetacaine to desensitise cornea
lots of gel used

180
Q

what is ERG used for?

A

assessment to see if retina is functional

181
Q

what is recorded by ERG?

A

retinal electrical response to light stimulus

182
Q

does the patient need to be anaesthetised for ERG?

A

can be conscious or sedated

183
Q

how many diabetic patients develop cataracts within 6 months of diagnosis?

184
Q

how many diabetic patients develop cataracts within 12 months of diagnosis?

185
Q

what are the risks associated with untreated diabetic cataracts?

A

lens capsule rupture
lens induced uveitis

186
Q

do diabetics need to be well controlled for surgery?

187
Q

what is the overall aim of cataract surgery?

A

restores vision

188
Q

what type of surgery is cataract surgery?

A

intra-ocular

189
Q

what is the success rate of cataract surgery?

190
Q

what is essential pre cataract surgery?

A

pre-op work up to check eye health

191
Q

what is involved in pre-cataract surgery work-up?

A

ERG
US of drainage angle
gonioscopy
full bloods and urinalysis

192
Q

what is the purpose of pre-cataract ultrasound?

A

drainage angle of eye
assess for detached retina / masses

193
Q

what is the average cost of cataract surgery?

A

£4-5k depending on one or both eyes

194
Q

how often may meds be needed post cataract op?

A

up to 12 times daily in the first week

195
Q

how long should patients be kept quiet for following cataract surgery?

196
Q

what eye drops are needed post cataract surgery?

A

steroids
NSAIDs
glaucoma meds
antibiotics
lubricants

197
Q

what is the role of steroid and NSAID eyedrops following cataract surgery?

A

topical control of uveitis

198
Q

what is the role of glaucoma eyedrops following cataract surgery?

A

minimisation of IOP spike

199
Q

how long will antibiotic drops be given post glaucoma surgery?

A

until wounds heal

200
Q

what are the main risk factors of ophthalmic surgery anaesthesia?

A

patients tend to be older
co-morbidities likely
BOAS common
cardiac issues

201
Q

what analgesia is likely used for ophthalmic surgery?

A

local - skin line or retrotubular
systemic NSAID/opioids

202
Q

what is a commonly used drug for NMBA?

A

atracurium

203
Q

how long does atracurium last for?

A

15-35 mins

204
Q

what can be caused by atracurium when given IV?

A

histamine release - give slowly

205
Q

what conditions of the patient must be avoided to prevent prolonging NMB?

A

hypothermia
acidosis
hypokalaemia

206
Q

why is NMBA safe in renal and hepatic patients?

A

non-cumulative

207
Q

what is seen with brachycephalic ocular syndrome?

A

lower medial entropian
shallow orbit
macropalpebral fissure
lagophthalmos
medial caruncular trichiasis
pigmentary ketatitis
epiphora

208
Q

what does a shallow orbit in brachycephalic dogs lead to?

A

relative exophthalmus

209
Q

what is lagophthalmos?

A

sleeping with lids incompletely closed

210
Q

what is medial caruncular trichiasis?

A

hairs rubbing on the eye

211
Q

what is pigmentary ketatitis?

A

pigment forming on cornea

212
Q

what can cause epiphora in brachycephalic dogs?

A

kinking of nasolacrimal canaliculi and obscuring punctum

213
Q

what can brachycephalic ocular syndrome be exacerbated by?

A

concurrent issues such as KCS or distichiasis

214
Q

how can the compromised airway of brachycephalic breeds be managed?

A

preoxygenate
O2 in recovery
manage hyperthermia
reduce stress
home ASAP
URT obstruction a risk
delayed extubation

215
Q

what can reduce regurgitation risk?

A

shorter starve time

216
Q

what drugs may increase regurgitation risk?

A

opioids due to reduction in GI motility and so delayed gastric emptying

217
Q

what can be done to stimulate peristalsis in BOAS dogs?

A

paracetamol if liver ok
visceral analgesia
lidocaine
get walking and moving
ensure hydrated
low fat food to speed gastric emptying

218
Q

how should diabetic patients be managed before surgery?

A

starve in the morning and withhold glucose

219
Q

what are diabetic patients at increased risk of during eye surgery?

A

systemic hypertension
dry eye
delayed healing
infection risk increased

220
Q

why do diabetics have increased fluid requirements?

A

glucoseuria

221
Q

what is involved in client communication around eye surgery?

A

manage expectations
train to give eye drops
train dog to receive drops
clarity around high bills
monitoring tests for at risk breeds
habituation of puppies to eyedrops

222
Q

how much more likely than the normal dog are brachycephalic breeds to get KCS?

223
Q

how much more likely than the normal dog are brachycephalic breeds to get corneal ulcers?

224
Q

what are the main benefits of ocular nurse clinics?

A

monitor normal patients for subclinical disease
O education
support medication compliance
positive reinforcement training for receiving eyedrops
STT in high risk breeds

225
Q

what are the layers of the tear film?

A

lipid
aqueous
mucus

226
Q

what is the function of the lipid layer of the tear film?

A

prevents evaporation
aids distribution

227
Q

what is the function of the aqueous layer of the tear film?

A

supplies corneal nutrition
antibacterial properties
removal and remodelling through proteases and antiproteases

228
Q

what is the role of the mucus layer of the tear film?

A

lubrication
reflective properties
anchors aqueous layer to cornea

229
Q

what is required for a functional lacrimal unit?

230
Q

what are the majority of cases of KCS caused by?

A

immune mediated adenitis

231
Q

what is KCS?

A

deficiency of aqueous tear

232
Q

what dogs are predisposed to KCS?

A

WHWT
yorkie
bulldogs
pugs
ESS
CKCS

233
Q

what is used to diagnose KCS?

A

schirmer tear test and concurrent clinical signs

234
Q

what mm/min STT reading is normal?

235
Q

what is indicated by 10-14 mm/min STT reading?

A

early / suspicion of KCS

236
Q

what is indicated by 6-10 mm/min STT reading?

A

moderate KCS

237
Q

what is indicated by 0-5 mmmin STT reading?

A

severe KCS

238
Q

what are the common clinical signs of KCS?

A

strings of adherent mucus
poor corneal clarity
poor corneal shine
poor Purkinjie reflex
low STT reading

Advanced Clinical Nursing Theory (36 decks)

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