Question

1. What is the principal treatment for patients with open-angle glaucoma and the types of drugs used to control IOP?

2. What are signs and symptoms of glaucoma and appropriate nursing interventions.

3. A patient comes to the emergency department (ED) complaining of sudden headache, blurred vision, eye pain, and halos seen around white lights. He denies previous treatment of this problem. He states that he hit his head yesterday while fixing a bathroom sink. The nurse triages the patient and sends him immediately to the ED for further evaluation by the health care provider. What type of assessment should the nurse perform on this patient? Why does the nurse evaluate this patient’s complaint as a true emergency?

4. A patient with acute closed-angle glaucoma is prescribed IV mannitol, an analgesic, and an antiemetic. What should the nurse caring for the patient look for after the mannitol is administered? Why did the health care provider order an analgesic and antiemetic? What type of environment should the nurse set up for this patient?

Answer 1

1.PRINCIPAL TREATMENT-Slowing disease progression and preservation of quality of life are the main goals for glaucoma treatment. Reduction of intraocular pressure is the only proven method to treat glaucoma.Results from several multicenter clinical trials have demonstrated the benefit of lowering intraocular pressure in preventing the development and slowing the disease’s progression.The most common treatments for glaucoma are eye drops and, rarely, pills. Doctors use a number of different categories of eye drops to treat glaucoma. They either decrease the amount of fluid (aqueous humor) in the eye or improve its outward flow, and some do both. Sometimes doctors will prescribe a combination of eye drops.

Types of Medications

1. Alpha Adrenergic Agonists

This medication both reduces aqueous humor production and increases its outflow. Allergic reactions frequently occur with this class of medication.

Examples include:

• Apraclonidine (Iopidine®)
• Brimonidine (Alphagan®)
• Epinepherine (Gluacon® and Epifrin®)
• Dipivefrin (Propine®)

2. Beta blockers

This type of medication works to lower eye (intraocular) pressure by reducing aqueous humor production and decreasing the rate at which the fluid flows into the eye.

Examples include:

• Timolol (Timoptic XE Ocumeter® and Timoptic®)
• Levobunolol (Betagan®)
• Carteolol (Ocupress®)
• Metipranolol (OptiPranolol®)
• Betatoxol (Betoptic®)

3.Biodegradable Drug-delivery Implant

In March 2020, the FDA has approved Durysta™, a new long-term, biodegradable eye implant, containing bimatoprost (prostaglandin analog) to reduce eye pressure in people with ocular hypertension or open-angle glaucoma. Durysta is currently indicated as a single-use implant, and patients who receive thee implant would not be able to be re-administered a second time.

The most common side effect involving the eyes reported in patients using Durysta^™ was eye redness. Other common side effects reported were: feeling like something is in your eye, eye pain, being sensitive to light, a blood spot on the white of your eye, dry eye, eye irritation, increased eye pressure, a loss of cells on the inner layer of the cornea, blurry vision, inflammation of the iris, and headache.

4.Carbonic Anhydrase Inhibitors

These are eye drops or pills that reduce fluid production in the eye. Examples include:

• Dorzolamide (Trusopt®)
• Brinzolamide (Azopt®)
• Acetazolamide (Diamox®): an oral medication
• Methazolamide (Neptazane®): an oral medication

5.Miotics

This type of medication is a cholinergic agent, which causes the pupil to become much smaller in diameter and helps increase fluid drainage from the eye. Examples include:

• Pilocarpine (Isopto Carpine®, Pilocar® and Pilopine HS® ointment)
• Echothiophate (Phospholine Iodide®)

6.Prostaglandin Analogs

This medication reduces eye pressure by increasing the outward flow of fluid from the eye. Examples include:

• Tafluprost ophthalmic solution (Zioptan™)
• Latanoprost (Xalatan®)
• Bimatoprost (Lumigan®)
• Travoprost (Travatan®)
• Unoprostone isopropyl ophthalmic solution (Rescula®)
• Latanoprostene bunod ophthalmic solution (Vyzulta™)

7.Rho Kinase Inhibitors

• Netarsudil ophthalmic solution (Rhopressa®)

8.Combinations

Combinations of eye drops may also be used to achieve better results. Examples include:

• Dorzolamide and timolol (Cosopt®)
• Latanoprost and timolol (Xalacom®)
• Brimonidine and timolol (Combigan™)
• Brinzolamide and brimonidine (Simbrinza®)
• Netarsudil and latanoprost (Rocklatan™)

2.SIGNS AND SYMPTOMS OF GALUCOMA

With open-angle glaucoma, there are no warning signs or obvious symptoms in the early stages. As the disease progresses, blind spots develop in your peripheral (side) vision.

Most people with open-angle glaucoma do not notice any change in their vision until the damage is quite severe. This is why glaucoma is called the “silent thief of sight.”

• severe pain in the eye or forehead
• redness of the eye
• decreased vision or blurred vision
• seeing rainbows or halos
• headache
• nausea
• vomiting

NURSING INTERVENTIONS FOR GLAUCOMA

1. Remember to administer cycloplegic eyedrops in the affected eye only. In the affected eye, these drops may precipitate an attack of angle-closure glaucoma and threaten the patient’s residual vision.
2. After trabeculectomy, give medications as ordered to dilate pupila.
3. Apply topical corticostroids as ordered to rest the pupil.
4. After surgery, protect the affected eye by applying an eye patch and eye shield.
5. Position the patient on his back or unaffected side, and following general safety measures.
6. Administer pain medications as ordered.
7. Encourage ambulation immediately after surgery.
8. Encourage the patient to express his concerns related to having a chronic condition.
9. Monitor the patient’s ability to see clearly. Question the patient regularly about the occurrence of visual changes.
10. Monitor the patient’s intra-occular pressures.
11. Stress the importance of meticulous compliance with prescribed drug therapy.
12. Instruct the patient’s family how to modify the patient’s environment for safety.
13. Teach the patient the signs and symptoms that require immediate medical attention, such as sudden vision change or eye pain.

type of assessment should the nurse perform on this patient

Visual loss following head trauma is common, and the diagnosis can be challenging for the neurologist called to perform an emergency room assessment. The approach to the patient with post-traumatic visual loss is complicated by a wide range of potential ocular and brain injuries with varying pathophysiology. In addition to direct injuries of the eye and orbit, traumatic optic neuropathies, carotid cavernous fistulas, and damage to the intracranial visual pathways are classic causes of visual loss after head trauma

Unless the trauma is minimal and the visual loss is isolated, priority is given to assessment of vital functions in the emergency room. It is only once the patient is stabilized, and severe trauma to the head, face, spine, and other essential organs is ruled out, that attention is paid to visual function.¹

A basic ophthalmologic evaluation should be performed systematically in the emergency room. Trauma patients, especially those with decreased consciousness, or severe pain and anxiety, may not be aware of visual changes until they are specifically questioned. Examination should include external inspection of the eyes and periorbital region, measurement of visual acuity, pupillary examination, testing of extraocular movements, and funduscopic examination. Any abnormality should prompt an emergent ophthalmologic consultation.

In most cases, traumatic visual loss is related to direct ocular injury and occurs in the setting of severe head trauma associated with loss of consciousness.^3-6 Ocular trauma such as hyphema or ocular penetrating injuries and foreign body may require urgent ophthalmologic treatment (Figure 1). Less common is unilateral or bilateral visual loss with normal ocular appearance, suggesting trauma to the optic nerve or intracranial visual pathways, for which a neurologic or neurosurgical consultation is often requested.

• The nurse evaluated this patients complaint as a true emergency as it may be case of blunt glaucoma,As a result of an immediate injury, traumatic glaucoma is most commonly caused by blunt trauma, which is an injury that doesn’t penetrate the eye, such as a blow to the head or an injury directly on the eye.

  Normally, the eye fluid flows out of the front part of the eye through the pupil and then is absorbed into the bloodstream through a meshwork of drainage canals around the outer edge of the iris.

  When a blunt trauma occurs, damage to this system can occur. The most common cause is the ciliary body, the part of the eye that produces eye fluid, inside the eye tearing. This can cause bleeding inside the eye.

  The excess amount of blood, plasma and debris can accumulate and clog the drainage system. This can lead to an increase in eye pressure, which can damage the optic nerve.

  Elevated eye pressure due to blunt trauma is treated by keeping the eye pressure at safe levels while the eye drains the excess blood out. Glaucoma medications to control the eye pressure are usually tried first. If this is not sufficient to control the eye pressure, surgery may be necessary.

  The elevated eye pressure following blunt trauma is temporary in most cases. It is important, however, to make sure to get regular follow-up eye exams.

5.In the emergency treatment of acute glaucoma, intraocular pressure must be reduced urgently. This is done pharmacologically using osmotic diuretics such as mannitol or glycerol in combination with other topical and systemic drugs.

• the nurse should look for calmness and
• Helath care provider ordered an analgesic and antiemetic to avoid as most of the medicines causes the condition of vomitting and nausea, and headaches.
• Glaucomic patients hould lie with head elevated , take fluids frequently ,limit caffeine, eat healthy, should avoid light for sometime.