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Sensory Disorders: Vision & Hearing. Chapter 27 Cristen Walker, MS, CRNP. Refractive Errors. Refraction = bending of light rays Emmetropia - normal vision Light rays are bent to focus precisely on macula (retina) Ammetropia - refractive error, image not clearly focused on retina

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Sensory disorders vision hearing

Sensory Disorders: Vision & Hearing

Chapter 27

Cristen Walker, MS, CRNP

Refractive errors

Refractive Errors

  • Refraction = bending of light rays

  • Emmetropia - normal vision

    • Light rays are bent to focus precisely on macula (retina)

  • Ammetropia - refractive error, image not clearly focused on retina

    • Hyperopia – farsighted, light rays focus behind retina, short eyeball

    • Myopia – nearsighted, distance vision blurred, long eyeball

    • Astigmatism - blurred vision w/ distortion, unequal shape of cornea

    • Presbyopia - older age, loss of ability to focus on close objects, lenses lose elasticity

Refractive errors1

Refractive errors

  • Signs & Symptoms

    • difficulty reading or seeing objects, headaches

  • Diagnosis: Snellen chart; exam of retina w/ dilation

  • Treatment: corrective lenses; surgical

    • Incisional radial keratectomy – incision on cornea to reshape

    • Photorefractive keratectomy - becoming more common, use of laser to reshape

    • Intrastromal corneal rings (Intacs) – flexible ring to change cornea shape

      • for MYOPIA



  • Laser assisted in-situ keratomileusis

  • Laser used to create thin, circular flap in cornea, folded back, damaged corneal tissue removed, cornea reshaped

  • Allows light to properly focus on retina

  • For near-, farsightedness, and astigmatism

  • Procedure: 5-10 minutes, pt. awake, eye anesthetic used, mild oral sedative, minimal pain



  • Post-operative teaching:

    • Rest 4-6 hours post procedure

    • No driving same day

    • No exercise for 1 week

    • No eye rubbing

    • Vision corrected to 20/20 – 20/40

    • May still need “reading glasses” (bifocals)

    • Improved vision within 1-3 days

    • Complications: Infection, night glare

Disorders of the eye infection

Disorders of the Eye: Infection

  • Conjunctivitis - inflammation of conjunctiva

Conjunctivitis pink eye

Conjunctivitis: “Pink eye”

Infection inflammation

Infection & Inflammation

  • Blepharitis -inflammation of the eyelid margins (chronic)

    • Seborrheic

      • Redness & flaking at base of lashes

    • Ulcerative

      • Crusting at lashes, redness of eyes and inflammation of cornea

    • Tx - long-term daily cleansing

      • cu-tips & baby shampoo or special eye cleanser

  • May require antibiotic ointment

  • Usually caused by staph or effect of rosacea



Infection inflammation1

Infection & Inflammation

  • Hordeolum - “sty” - external

    • Small abcess at base of eyelash (red, raised)

    • Forms in sebaceous gland

    • Usually resolve spontaneously without treatment

    • Warm compresses

  • Chalazion - internal hordeolum

    • Larger and more problematic

    • More painful

    • May require I & D w/ antibiotics







  • Keratitis - inflammation of the cornea.

    • Acute or chronic

    • Caused by infection or irritation

    • Causes – bacterial conjunctivitis, improper contact lens care, herpes virus, tuberculosis, syphilis, inability of eyelid to close properly

    • Symptoms:

      • Pain with eye movement, vision changes, photophobia (sensitivity to light)

    • Diagnosis: during corneal exam

    • Treatment: antibiotics or antivirals, artificial tears

    • If severe, may need corneal transplant (keratoplasty)

      • Corneal tatoo ?



  • Treatment

    • Corneal infections are serious and can result in loss of sight.

    • May be associated w/ contact lens use

    • Overnight wearing of contact lens increases risk – can lead to pseudomonas

    • Must dispose of lenses





  • Complete or almost complete absence of sight.

  • Often referred to as “visually impaired” to avoid negative connotation

  • Legal blindness = 20/200

    • With corrective lenses




  • Obstruction to ray of light to optic nerve

    • HTN, diabetes, glaucoma

  • Disease of optic nerve

  • Injury/Trauma to occipital lobe (area of sight)

    • stroke, tumor

  • Rarely occurs at birth



  • Nursing Interventions

    • Use normal tone of voice

    • Alert client when approaching

    • Orient client to environment

    • Use a focal point

    • Allow client to touch objects in room

    • Promote independence

    • Provide TV, radio, clocks (oral time)

    • Assist w/ ambulation – client should walk 1 step behind

      • Pg. 1258 Textbook: Care of Pt. w/ visual impairment



  • Opacity (cloudiness) of the lens - may cause loss of vision

    • Light rays unable to get through

  • Causes:

    • Age (>50), sunlight, diabetes, smoking, steroids, alcohol use, infections, congenital defects (rubella), chemical toxins

  • Painless

  • Symptoms:

    • Halos around lights, trouble reading fine print (newspaper), increased sensitivity to glare (sun, car lights), hazy vision, decreased color vision, poor night vision

    • Looking through a “sheet of falling water”





  • Surgical removal of cloudy lens, very common procedure

  • Rare complications – increased ICP, hemorrhage, retinal detachment

  • Pre-op

    • Teaching – takes 5-10 minutes, pt. awake (light sedation may be used), eye anesthesia used

    • Post-op expectations – same day surgery, clear vision within 2 days

    • Mydriatics may be given pre-op



  • Post-op care and education

    • Avoid eye rubbing and straining

    • Avoid rapid movements; sneezing/vomiting/coughing

    • Avoid bending, lifting objects >5 lb

    • Avoid constipation

    • Use eye drops as prescribed, 2-4 weeks

    • Use eye shield at bedtime

    • Contact MD for decrease in vision, severe eye pain, increase in eye discharge



  • 2 causes

  • 1. Diabetes – assoc. w/ excess glucose, constriction of blood vessels & microaneurysms (swell, rupture & hemorrhage)

  • 2. HTN – retinal vasoconstriction decreases blood supply to retina

  • Sx: blurred vision, red/black lines or spots, missing areas in field of vision (may be central)

  • Dx: requires exam of internal eye – annually !



  • Tx: Control glucose & BP; prevent further leakage of blood/fluid into retina

    • Laser surgery

    • Vitrectomy (vitreous fluid drained & replaced w/ saline)

  • Cannot reverse vision loss that has occurred, not a cure, may progress

  • Can progress to retinal detachment and/or blindness

Diabetic retinopathy

Diabetic Retinopathy

Retinal detachment

Retinal Detachment

  • Separation of the retina from the choroid layer allowing fluid to enter the space between the layers.

  • Caused by:

    • Hole or tear in the retina

      • either from degenerative changes or trauma

    • Fibrous tissue pulling on retina

      • related to diabetic or hypertensive retinopathy

    • Accumulation of fluid in the space

      • from conditions such as HTN, eclampsia, or tumors.

Retinal detachment1

Retinal Detachment

  • Symptoms:

    • Gradual or sudden change in vision

    • loss of peripheral vision or central vision

      • Depends of portion of retinal involved

    • flashing lights (colored lights)

    • floaters or black spots – caused by small hemorrhages

    • “looking through a veil or cobweb” or “curtain over eyes”

  • NO PAIN (retina w/o sensory nerves)

  • Requires prompt referral for treatment (laser reattachment, cryosurgery)

  • Ages 40-70, increased in Jewish descent (r/t to higher incidence of myopia)

Retinal detachment2

Retinal Detachment

  • Post op care

    • Eye patch

    • Eye shield during sleep to prevent injury

    • Improvement of vision weeks to months

      • Flashing lights common for few weeks post op

    • Antibiotic eyedrops/ointment post op

    • Pain meds may be prescribed

    • Wear sunglasses to decrease light sensitivity

    • No water in affected eye (showers not recommended)

    • Light activity/rest for several days post op

      • No sports 3-4 mos.

    • No driving until 20/40 vision restored

Sensory disorders vision hearing

Which finding would the nurse expect while caring for a patient with a detached retina ?

  • Blurred vision

  • Pain in the affected eye

  • Yellow discoloration of the sclera

  • A sense of a curtain falling across the field of vision



  • Abnormal pressure within eyeball

    • Increased intraocular pressure

    • Restricts blood flow to retina & optic nerve

  • Damages optic disc & optic nerve

  • Damage is usually silent and irreversible

  • 2nd leading cause of blindness

  • Sx: loss peripheral vision, reduction in central vision, possible blindness

  • Can occur at any age

    • May be genetically predisposed



  • Requires lifelong treatment

  • 3 common types:

    • AACG – acute angle-closure glaucoma

      • refers to angle width between cornea & iris

  • POAG – Primary open-angle glaucoma

    • chronic

    • 90%

    • often inherited

  • Associated (secondary) glaucoma

    • w/ DM, HTN, retinal detachment, extreme myopia

  • Glaucoma2


    • Primary open-angle

      • Most common

      • Aqueous fluid behind iris does not flow properly into anterior chamber

      • No symptoms ??

      • Hazy vision, rainbow colored rings around lights, gradual loss peripheral vision, tunnel vision advanced stages

      • Treatment

        • Eye drops **

        • Laser surgery

        • Microsurgery – to unblock drainage canals

    Glaucoma medications

    Glaucoma: Medications



    • Acute angle closure (narrow angle)

      • Iris pushes against drainage channels of anterior chamber

      • Drainage canals blocked

      • Increased intraocular pressure – rises suddenly

      • Symptoms = severe

        • Intense eye pain, N/V, sudden vision loss, halos around lights

      • Medical emergency – prompt treatment

      • Treatment: laser or surgical iridectomy, to relieve pressure

        • Failure to treat immediately may cause blindness



    • At risk (AACG):

      • People w/ hyperopia

      • Asian

      • Woman >45AACG

      • AACG:

        • Requires strict bedrest

        • Strict avoidance of anticholinergic meds

          • Mydriatics – dilate pupil



    Nursing Interventions:

    1. instruct client to wear medic-alert bracelet

    2. instruct client to avoid anticholinergic meds

    3. Educate re: symptoms

    *pain in eye, blurred vision, halo w/ lights

    4. inform pt. of AACG symptoms – emergency

    5. Discuss importance of medication compliance

    6. Prevention: low sodium diet, limit caffeine,

    prevent constipation, decrease stress

    Sensory disorders vision hearing

    A teaching plan for the client with glaucoma should include:

    • Decrease amount of salt in diet

    • Decrease fluid intake to control IOP

    • Avoid reading the newspaper and watching TV

    • Eye medications will need to be administered for the rest of your life

    Macular degeneration

    Macular Degeneration

    • Leading cause of visual impairment in U.S.

      • >50.

    • Deterioration in macula

      • center of retina

      • light rays converge, color vision occurs

    • 2 types

      • Dry – age related, more common, formation of yellow

        deposits (drusen), causes drying/thinning

      • Wet – leaky blood vessels, swelling; more severe

    • High risk:

      • >60 yrs, family history of MD, diabetes, smoking, exposure to UV light, caucasian, female, obese, high BP,

        high cholesterol

    Macular degeneration1

    Macular Degeneration

    • Symptoms

      • blurred vision, distortion straight lines, dark spot in central vision, loss can be progressive (dry) or sudden (wet)

    • Treatment

      • Antioxidants/Zinc – may slow progression

        • Vit. C, Vit. E, Beta Carotene (Vit. A)

      • Possible laser surgery to seal leaking blood vessels

        • Not highly effective

      • Telescopic lens implant

    Macular degeneration2

    Macular Degeneration

    Macular degeneration3

    Macular Degeneration

    Ocular melanoma

    Ocular Melanoma

    • Malignant eye tumor

    • Adults

    • May change color of iris

    • Diagnosis: routine exam, ultrasound

    • Treatment: enucleation

      radiation therapy

    Eye trauma

    Eye Trauma

    • Foreign body most common cause of corneal injury (worsened by rubbing eyes)

    • Corneal abrasions/lacerations from nails or clothing

    • Chemical burns

      • Immediate flushing necessary

      • Water or saline, 15-20 minutes

    • Penetrating wounds = most serious

    Disorders of the ear

    Disorders of the Ear

    • Hearing Loss

    • External disorders

    • Middle Disorders

    • Internal Disorders.

    Hearing loss

    Hearing Loss

    • Conductive – interference w/ conduction of sound impulses through external canal & eardrum

      • Causes – cerumen, foreign body, trauma, fluid, tumor, otosclerosis

        • Otosclerosis: middle ear bones harden & fuse

    • Hearing devices most effective for this type *

    • Can affect speech, language development, academic achievement, behavior

  • Sensorineural - originates in cochlea, involves hair cells & nerves, may also originate in brainstem

    • Caused by disease, trauma, infections, ototoxic drugs, aging

  • Hearing loss1

    Hearing Loss

    • Most common disability in the US

    • Ranges from difficulty to total deafness

    • Can be mixture of both types of hearing loss

      • conductive + sensorineural

    • Management is to improve hearing

    • Hearing aids may be necessary

    • Presbycusis

      • hearing loss caused by aging process, degenerative changes to organ of corti (hair cells), over 50, high-pitch frequency decreases

    Hearing loss2

    Hearing Loss

    Communicating w/ child or adult:


    • Face patient, eye level

    • Talk slowly and clearly

    • Lower your voice (avoid high-pitch)

    • Use nonverbal cues

    • Allow time don’t rush

    • Don’t avoid speaking to the patient

    • Write it down if needed

      Pg. 1271, textbook: Communicating w/ Person who has a hearing impairment

    Hearing aids


    • Amplify sounds

      • Microphone hearing aids

      • Digital hearing aids (more $$)

      • Inside-ear fit or behind-the-ear fit (most common)

      • Remove battery when not in use

      • Clean weekly w/ dry or damp cloth

    • Cochlear Implant

      • Electrode for cochlear implant is surgically placed

      • Used for profoundly deaf

    Hearing aids video

    Hearing aids Video


    • Right click, open hyperlink

    External ear disorders

    External ear disorders

    Infection – most common disorder.

    • Localized abscess from hair follicle– furuncle

    • If involves several hair follicles – carbuncle

    • Usually open and drain spontaneously

    • Otitis Externa = most common infection

    • Bacterial or fungal

    • “swimmer’s ear”

    External otitis

    External Otitis

    • Most common complaint is PAIN

      • especially when pulling the pinna or moving the jaw

    • Symptoms: ear canal (outer) swollen and red, possible fever

    • Treatment: topical and/or systemic antibiotics

      • May treat with combination meds (steroid + antibiotic) Cortisporin, Floxin (otic drops)

      • Warm compresses

    External ear disorders1

    External Ear Disorders

    • Impacted cerumen

      • work in dirty areas or improper cleaning

      • prevalent with hearing aids

      • s/s – hearing loss, “blocked ear”

      • Treatment:

        • cerumen softeners (Debrox)

        • ear flushing (NOT used with a perforated TM)

    External ear disorders2

    External Ear Disorders

    • Insects

      • Mineral oil or diluted alcohol instilled

      • Will suffocate insect

      • Removal with ear forceps

    • Trauma – blunt trauma to head, auto accident, burns, foreign bodies

      • Lacerations, contusions, abrasions, blistering, hematoma

      • Repeated trauma can result in cauliflower ear (swelling, scarring) or hearing loss

    Middle ear disorders

    Middle Ear Disorders

    • Otitis media

      • Inflammation of the middle ear—mastoid—eustachian tube

      • May be bacterial or viral

        • Haemophilus influenzae, strep pneumoniae

      • TM appears red, swollen on exam

      • Acute or chronic (>3 months)

      • w/ or w/o effusion (fluid)

    • Cause

      • inflammation of the nasopharynx, causing build up of fluid or pus

      • Eustachian tube become blocked

      • Infants/young children more prone

    Otitis media

    Otitis Media

    • Signs & Symptoms

      • Fever

      • Earache

      • Fullness in ear

      • Purulent drainage is possible

      • If mastoid involvement will have pain in the mastoid area

      • Infants/children: rubbing/pulling at ear, rolling head side to side, loud/problematic speech, inattentive behavior

    Otitis media1

    Otitis Media


    • Perforation – ruptured TM – pain before & relief afterwards - hearing loss may result

    • Cholesteatoma – cyst that spreads through a perforation, resulting in permanent damage & conductive hearing loss

    • Tympanosclerosis – calcification of TM, deposits of collagen, chalky white plaques, lead to conductive hearing loss

    • Mastoiditis– severe infection of mastoid process if OM left untreated, can usually treat w/ antibiotics - may require mastoidectomy

    Otitis media2

    Otitis Media

    • Treatment:

      • Antibiotics – Amoxicillin, Penicillin,

        Azithromycin (Zithromax), Cefaclor (Ceclor), Bactrim

      • Oral analgesics – Aspirin, Tylenol, Ibuprofen

      • Eardrops – to relieve pain ??

      • Heating pad



    • Incision made in TM

    • Fluid drained

    • Tube placed to prevent further accumulation of fluid & to aerate the middle ear

      • Tympanostomy tubes, myringotomy tubes

    • Tubes eventually fall out at 3-12 months post-op

    Middle ear disorders1

    Middle ear disorders

    • Otosclerosis

      • Hardening of ear, from formation of bone along the stapes

      • Stapes becomes fixed to oval window, unable to vibrate

      • Causes conductive hearing loss

    • Cause

      • unknown but may be hereditary; 0.5% population

    • Symptoms

      • hearing loss, usually bilateral

    • Treatment:

      • Hearing aid

      • Stapedectomy – removal w/ prosthetic implant

      • Beethoven

    Inner ear disorders

    Inner Ear Disorders

    • Vertigo

      • Illusion of motion

      • Loss of balance

      • Causes: cold virus, trauma, menieres disease

      • Medications: antihistamines

        • Meclizine (Antivert), Diphenydramine (Benadryl)

    • Benign Positional Vertigo = vertigo symptoms w/ change of position

      *standing to sitting/lying to sitting

      *Treatment: Epley maneuver (to adjust particles inj

      semicircular canals

    Inner ear disorders1

    Inner Ear Disorders

    Labrynthitis – inflammation or infection of the inner ear

    *can be viral or bacterial

    *can last 6 months

    * may occur following complicated OM

    • Signs/Symptoms

      • Vertigo

      • Tinnitus

      • Sensorineural hearing loss

      • Ear pain, fever, nausea, vomiting

      • Nystagmus on affected side




    • Antibiotics if infected

    • Antihistamines – for relief of dizziness, may or may not help ?

      • Meclizine (Antivert)

    • Antiemetics

    • Pt. may need bedrest (dark room)

    • Avoid abrupt head turning, to avoid vertigo

    Inner ear disorders2

    Inner Ear Disorders

    Acoustic neuroma

    • Most common

    • Benign tumor of 8th cranial nerve

    • Grows slow

    • Occurs at any age

    • Compresses nerve & adjacent structures

    Acoustic neuroma

    Acoustic Neuroma


    • Progressive unilateral hearing loss

    • Usually loss of high-pitch sounds

    • Unilateral tinnitus

    • headache

    • balance disorders (vertigo)

    • Treatment

      • Surgical removal of tumor

      • Steroids, radiation possible

    Inner ear disorders3

    Inner Ear Disorders

    Meniere’s disease – balance disorder with unknown cause, overproduction of lymphatic fluid

    • 40-60 yrs.

    • mild or severe.

    • Triad of symptoms

      • Vertigo—hearing loss—tinnitus

        • Sensorineural hearing loss

      • May include nausea & vomiting

      • Symptoms may be severe & incapacitating

      • May take weeks for symptoms to resolve

      • May be chronic

    Meniere s disease

    Meniere’s Disease

    • Acute episodes can last for 2-4 hours

    • Warning signs of headache and unsteadiness may be present

    • Occurs 2-3 times per year

    • Safety is main concern

    • Treatment

      • symptomatic and prophylactic.

    Meinere s disease

    Meinere’s Disease

    • Symptomatic treatment

      • Tranquilizers (antianxiety meds) during acute attacks

      • Meclizine (Antivert)

      • antiemetics

      • bedrest

      • fall prevention

    • Prophylactic treatment

      • salt-restricted diet

      • fluid restriction

      • diuretics

      • avoid alcohol

      • stop smoking

    Cochlear implantation

    Cochlear Implantation

    • Surgically implanted device

      • External transmitter w/ magnet

      • Internal receiver w/ magnet

  • For severe to profound hearing loss (nerve deafness)

    • Sensorineural hearing loss

  • Goal = to produce hearing sensation

  • Hearing may improve immediately post-op or within 3 months

  • Sound is DISTORTED, “mechanical”, “static”, difficult to hear TV, radio, phone, music

  • Covered by 90% insurances, very $$$

  • Cochlear implant

    Cochlear Implant

    • Complications

      • Meningitis

      • Infection

      • Injury to facial nerve

      • CSF leakage from inner ear

      • Taste disturbance (nerve injury during surgery)

      • Numbness around ear

      • Tinnitus

      • **may set off metal detectors

    Cochlear implants

    Cochlear Implants

    Cochlear implant video

    Cochlear Implant Video


    • Right click, open hyperlink

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