CATARACTS

People with diabetes are predisposed to cataracts. Sorbitol, a byproduct of

excess glucose, can accumulate within the lens and damage it. People with
diabetes develop cataracts at a younger age than persons without diabetes.
When cataracts appear, they quickly progress. Cataracts may also be
associated with hypothyroidism, exposure to radiation, retinal detachment,
electrical shock, eye trauma, glaucoma surgery, and long-term corticosteroid
use
As the crystalline lens becomes increasingly opaque as a consequence of a
cataract, the color of the pupil changes from black to a greyish-white.
With a cataract, chemical changes in the lens (alteration of metabolism and
transport of nutrients) create a cloudiness that causes the lens to no longer
be transparent.
Persons with detached retinas may report seeing floating particles. Persons
with cataracts do not.
Normally, the lens changes shape to focus rays of light on the retina. With a
cataract, the lens loses its transparency. Entry of light into the eye is
impeded and vision becomes cloudy, especially at night or in bright light.
Phacoemulsification, which is more common, involves a small incision in the
side of the cornea and ultrasonic fragmentation of the lens nucleus before it
is removed with suction.
Extracapsular extraction involves a longer incision in the side of the cornea
and removal of the lens nucleus in one piece. Vision recovery time is longer
with extracapsular extraction
During sx: patient is awake, anesthesia is localized in the eye, blood pressure
is checked frequently due to Mydriatic topical medication which can elevate
BP In the elderly, theyll still need reading glasses, and vision will be normal
in a few weeks.
Mydriatic eye drops cause the pupil to dilate.
Mydriatic eye drops dilate the pupil and allow extra entry of light, which can
be uncomfortable. An eye patch placed over the left eye would enable Mrs.
Hoffman to see more clearly from her right eye and avoid any left eye
discomfort from the room lights. Mydriatics dilate the pupil and pull the iris
away from the lens. This facilitates removal of the lens and helps prevent
injury to the iris.

Elevating the head of the bed slightly would promote eye drainage by
gravity, prevent eye swelling and discomfort, and reduce the likelihood of
eye trauma.
Dont position on operative side. No coughing or any activity that may
increase intraocular pressure.
Bending at the waist and lifting (anything over five pounds initially) increase
intraocular pressure and should be avoided to prevent injury to the healing
surgical site. Straining with bowel movements should also be avoided.
Macular degeneration usually starts in one eye, but the other eye may become affected as well. The
"dry" nonexudative form of macular degeneration usually develops gradually. With the "wet"
exudative form of macular degeneration, sudden onset of blurred vision with central vision loss is
more common.
Various treatments (laser photocoagulation, eye injections) may be useful in arresting vision loss
associated with exudative macular degeneration. Prompt treatment with onset of symptoms is very
important in arresting vision loss.
Measures to prevent macular degeneration include vitamin supplements, although these may be of
limited value. An Amsler grid can be used to detect changes in vision between eye exams.

Macular degeneration is a major cause of legal blindness in the elderly.

Macular degeneration results in painless loss of vision that may be gradual,
or happen abruptly.
Macular degeneration involves central vision loss.
GLAUCOMA
In persons with glaucoma, an increase in intraocular pressure in the anterior
chamber (from an excess of aqueous humor) is usually responsible for the optic
nerve and visual field damage that can occur.
Aqueous humor supplies essential nutrients to the eye. Secreted by the ciliary body, aqueous humor
circulates from the posterior chamber through the pupil to the anterior chamber. Outflow of aqueous
humor from the anterior chamber occurs through the trabecular meshwork into the canal of
Schlemm, and eventually to venous circulation.
Normal intraocular pressure is maintained when aqueous humor is produced and drained in equal
amounts.

In angle-closure glaucoma, flow of aqueous humor out of the eye is restricted (the iris is pushed
against the trabecular meshwork). Symptoms appear when a triggering factor causes an acute rise
in intraocular pressure.

Most persons with glaucoma have open-angle glaucoma. In open-angle glaucoma,

flow of aqueous humor out of the eye is not restricted, but aqueous humor
increases and intraocular pressure rises. Increase in intraocular pressure occurs
gradually, and symptoms may not occur, despite damage to the eye from increasing
pressure.
Eye medications can be absorbed systemically and have systemic effects. Timoptic
(timolol) and Betoptic (betaxolol) are beta-blockers. Beta-blockers can cause
bronchospasm. Therefore, these drugs (in particular Timoptic) are often not
prescribed for persons with asthma or chronic obstructive pulmonary disease
(COPD). Beta-blockers can decrease the heart rate. Blood pressure should be
followed. These drugs should be used with caution in any patient with heart disease.
Systemic absorption of eye medication can be reduced with occlusion of the
nasolacrimal duct (application of slight finger pressure) after the medication is
administered.
The Fowler's position (45 degrees or higher) is preferred for patients with acute
angle-closure glaucoma. It promotes drainage by gravity and should help control
intraocular pressure.
In patients with acute angle-closure glaucoma, greatly increased intraocular
pressure around the iris prevents normal pupil response to light.
MENIEREs disease
Symptoms:
Symptoms of Meniere's disease occur during recurrent attacks. A low buzzing or
ringing sound heard in the ear, called tinnitus, often occurs during attacks. Ear
"fullness" may also be described
Symptoms of Meniere's disease occur during recurrent attacks. Vertigo, a sense of
dizziness, spinning, and lack of balance, is a primary symptom in Meniere's disease.
It is present during attacks.
Symptoms of Meniere's disease occur during recurrent attacks. Hearing loss is
common during attacks, and may persist between attacks.
Nausea and vomiting, pallor, and sweating may also occur during Meniere's attacks.
Episodes may be brief (20 minutes) or last a few hours, and are often followed by
sleepiness.
As Meniere's disease progresses, tinnitus, unsteadiness, and hearing loss may
persist and become constant.
The Rinne test is done to determine if a person hears sound better by air conduction
or bone conduction. Normally, sound produced by conduction through air (tuning

fork adjacent to the external ear) is audible twice as long as sound produced by
conduction through bone (tuning fork on the mastoid process). If a person hears
sound longer through bone, a conductive hearing loss is present. If a person hears
sound longer through air, but not at the normal 2:1 ratio, a sensorineural hearing
loss is present.
Dysfunction of the labyrinth system in the inner ear causes Meniere's disease. The
inner ear includes the cochlea, vestibule, and semicircular canals, which are
collectively referred to as the labyrinth system. Increased volume of endolymph in
the labyrinth causes rupture of the membranous labyrinth and degeneration of the
cochlea and vestibule
This is a good description of the inner ear. The inner ear contains the cochlea,
vestibule, and semicircular canals, sense organs for hearing and balance. The
vestibular and cochlear nerves carry impulses from these structures to the brain,
where they are interpreted. The vestibular and cochlear nerves are each part of the
acoustic nerve, the eighth cranial nerve
Safety is a major concern for all persons with symptoms of Meniere's disease. The
vertigo and imbalance that accompany Meniere's disease often occur suddenly and
without warning. If these occur while Mr. Lee is driving a bus, the consequences
could be serious.
Audiometry is done to assess hearing and identify and define any hearing loss (such
as high-frequency hearing loss and/or low-frequency hearing loss). In persons with
Meniere's disease, low-frequency unilateral sensorineural hearing loss is typical,
although some persons with Meniere's disease have bilateral involvement. You
advise Mr. Lee that no special preparations are necessary for the hearing test. The
test involves the use of earphones and is not painful.
Electronystagmography (ENG) is also scheduled. This test is often ordered for
persons with complaints of dizziness to determine if damage to the vestibular part
of the acoustic nerve is responsible for dizziness. ENG involves a number of tests
during which involuntary eye movements (nystagmus) are recorded. These tests
may induce vertigo, nausea, and vomiting
Before electronystagmography (ENG) : no alcohol, meds for dizziness, or sedatives
A low salt diet is often useful in controlling symptoms of Meniere's disease.
Meniere's disease involves increased amount of endolymph in the inner ear. A low
salt diet can help minimize fluid pressure within the inner ear by avoiding fluid
retention. Diuretics are sometimes prescribed to decrease overall body fluid.
Nicotine is a vasoconstrictor that diminishes blood flow to the inner ear. This can
exacerbate symptoms such as dizziness by interfering with the absorption of
endolymph
The most comfortable position for one person may not be best for another. There is
no one recommended position to alleviate dizziness in persons with Meniere's
disease, although avoiding movement of the head may be helpful. A calm
environment is important