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Case study activity: Gonioscopy

what is it: type of an eye examination that evaluates the internal drainage system of the eye.
- Because the angle is inside the eye, essentially around a corner on the interior, it needs to be seen with a big contact lens called a gonioscope.

also referred to as Anterior Chamber Angle

A special contact lens prism is placed on the eye which allows visualization of the angle and drainage system.

Why is it done?

The procedure is done to evaluate the pressure in the eyes. BEcause the the pressure in the eye is maintained by constant production of fluid called Aqueous humor. High pressure in the eyes can cause damage to the optic nerve. Damage of the optic nerve is called Glaucoma, second leading cause of blindness worldwide.

How is it done:

it is performed with the head positioned in the slit lamp.

The eyes are numbed prior to examination using an eye drop then a special contact lens is placed directly on the eye and a beam of light is used to illuminate an the angle.

When to go for eye exam:
If you don’t have any symptoms or vision problems, doctors recommend getting regular eye exams based on your age:

Ages 20 to 39: Every 5 years

Ages 40 to 54: Every 2 to 4 years

Ages 55 to 64: Every 1 to 3 years

Ages 65 and up: Every 1 to 2 years

Grading Scale :
Shaffer System: commonly used grading system. It describes the degree to which the angle is open rather than closed.
- the Shaffer system approximates the angle at which the iris inserts relative to the trabecular meshwork.
- if the angle angle b/t the iris and the meshwork is 20 degree to 45 degrees. The angle is assessed at no capable of closure.
- if angles of 20 degree or less= possible closure.

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Ms. Santos was working in her yard today when she experienced an immediate sensation of something in her left eye. As she rubbed it, she noticed that she had a “gritty” feeling and now states that she seems to have a slight blurring of vision. Her right eye is unaffected.

1.) What type of diagnostic testing may be used to diagnose Ms. Santos’s condition and who would perform the testing?

Slit-lamp examination, corneal staining, ophthalmoscopic assessment. An ophthalmologist would perform the assessments.

- Rationale:

Slit-lamp examination magnifies the anterior eye structures. Corneal staining uses dye to outline irregularities of the corneal surface that are not easily visible. Ophthalmoscopy allows viewing of the eye’s external and interior structures. All of these diagnostic tests could assist in a more conclusive diagnosis. The ophthalmologist is a medical or osteopathic doctor specializing in eye/vision assessments, diagnosis, and treatments of eye alterations including surgery.

2.) After ophthalmoscopic assessment and corneal staining, the nurse practitioner diagnoses Ms. Santos with a corneal abrasion. Ms. Santos tells the nurse that she is unsure about how to instill the eyedrops that were prescribed. What patient teaching should the nurse provide to Ms. Santos?
- Rationale:
When teaching a patient about instillation of eyedrops, focus should be placed on infection control and correct technique.

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-patient should be informed and have consent signed, eye should be prepared, patient must have a mode of transportation post-operation, know what signs and symptoms to look out for that are considered abnormal
-proper eye treatment before surgery such as drops several times a day for 2-4 weeks, make sure there is a ride prepared for after surgery
-"gritty" feeling is considered normal but to continue to monitor, also look for other signs such as nausea and vomiting

fluorescein angiography:
fluorescent dye is injected into the blood stream; highlighting the eyes the blood vessels at the back of the eye for visualization and photography

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1. Pre-op teaching should be done; the pt. should be informed this is an out-patient surgery so they will be able to leave the same day. Someone must drive them home from the appointment.
2. The pt. will still need to have eyedrops after the surgery. If she can not administer them herself, she needs to find someone to help her.
3. After catarac removal, it is normal for the eye to feel itchy and "gritty".

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1.) preop pt teaching should include the need for eye drops before surgery as prescribed by surgeon. The need for a ride home after surgery. As well as the information about the actual events that will take place on day of surgery. This ensures that the pt can plan ahead accordingly.

2.) Eye drops will still need to be used  several times a day for 2-4 weeks; daily assessments will be needed and if any visual changes occur she will need transportation. Pt will need to learn how to instill eyedrops or have someone assist her.

3.) Pt should be reminded that gritty feeling and mild itching is normal. She should also be reminded to report pain and N/V.  She should also be educated on what symptoms to expect following the cataract removal surgery.

Ophthalmoscopy: also called funduscopy, is a test that allows a health professional to see inside the fundus of the eye and other structures using an ophthalmoscope (or funduscope). It is done as part of an eye examination and may be done as part of a routine physical examination. The physician performs this by shining a beam of light into the patient's eye.

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Group 1- Case Study Answers Ch. 46 (Adriana, Delaney, Alisha, Allie) -____-

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Group 1- Case Study Answers Ch. 46 (Adriana, Delaney, Alisha, Allie) -____-

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Slit-lamp examination, corneal staining, ophthalmoscope assessment. An ophthalmologist would perform the assessments

.When teaching a patient about instillation of eye drops, focus should be placed on infection control and correct technique

SLIT LAMP
is an instrument that uses high intensity light that is focused to shine a thin sheet of light into the eye.

Doctor may administer eye drops to make any abnormalities more visible (fluorescein). Additional drops can be used to help dilate the eye.

Can Help Diagnose: macular degeneration, detached retina, cataracts, injury to the cornea, blockages of the retinal vessel or obstructions

Depending on the results, it can determine infection, inflammation, increased pressure of the eye, or degeneration of arteries/veins of eye

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1. Patient would need to be assessed by an Opthamologist

3 assessment types:
-Slit/Lamp examination
-corneal staining
-Ophthalmoscopic assessment

2. • Check the eyedrop name, strength, expiration date, color, and clarity. • If both eyes are to receive the same drug and one eye is infected, use two separate bottles and label each bottle with “right” or “left” for the correct eye. • Wash your hands. • Remove the cap from the bottle. • Tilt your head backward, open your eyes, and look up at the ceiling. • Using your nondominant hand, gently pull the lower lid down against your cheek, forming a small pocket. • Hold the eyedrop bottle (with the cap off) like a pencil, with the tip pointing down, with your dominant hand. • Rest the wrist holding the bottle against your mouth or upper lip. • Without touching any part of the eye or lid with the tip of the bottle, gently squeeze the bottle and release the prescribed number of drops into the pocket of your lower lid. • Release the lower lid and gently close your eye without squeezing the lids. • Gently press and hold the corner of the eye nearest the nose to close off the punctum and prevent the drug from being absorbed systemically. • Gently blot away any excess drug or tears with a tissue. • Keep the eye closed for about 1 minute. • Place the cap back on the bottle and store it as prescribed. • Wash your hands again.

Corneal Staining:
https://www.webmd.com/eye-health/corneal-staining

-Remove your eyeglasses or contact lenses. Ophthalmologist will usually numb your eye and then blot your eye's surface with paper soaked with colored dye. You’ll blink a few times to spread the dye over your cornea.

-If you don’t have any abrasions, the stain floats on the cornea and doesn’t stick to your eye. If there is damage on your cornea, your doctor can rate it using a score or grade, usually from 0 (normal) to 5 (serious). Corneal abrasions in grades of 2 or lower may heal on their own.

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This test measures the intraocular pressure of the eye. This test can help determine if the patient is at risk of glaucoma (eye disease with increased fluid pressure, due to not being able to drain properly)

WHO IS AT RISK
-are over 60 years old

-have a family history of glaucoma

-have diabetes

-have hypothyroidism

-have other chronic eye conditions or injuries are nearsighted

-have used corticosteroid medications for prolonged periods of time
SIGNS OF GLAUCOMA
-a gradual loss of peripheral vision

-tunnel vision

-severe eye pain

-blurred vision

-halos around lights

-reddening of your eye

HOW IT WORKS
The eye doctor will start by putting numbing eye drops in the eye. Once your eye is numb, your doctor may touch a tiny, thin strip of paper that contains orange dye to the surface of your eye to stain it. This helps increase the accuracy of the test. Your doctor will then put a machine called a “slit-lamp” in front of you. You will rest your chin and forehead on the supports provided. The lamp will then be moved toward your eyes until just the tip of the tonometer probe touches your cornea. By flattening your cornea just a bit, the instrument can detect the pressure in your eye.

WHAT THE RESULTS TELL US
-Normal eye pressure is 12- 22 mm Hg. A normal test result means that the pressure in your eye is within the normal range and you don’t have glaucoma or other pressure-related eye problems.
-A pressure reading exceeding 20 mm Hg, you may have glaucoma or pre-glaucoma or you had an eye injury, or if you have bleeding in the front of your eye caused by blood vessel problems, inflammation, or other issues.