Increased intraocular pressure (IOP) is the result of inadequate drainage of aqueous humor from the anterior chamber of the eye. The increased pressure causes atrophy of the optic nerve and, if untreated, blindness. There are two primary categories of glaucoma: (1) open-angle and (2) closed-angle (or narrow angle). Chronic open-angle glaucoma is the most common type, accounting for 90% of all glaucoma cases. It develops slowly, may be associated with diabetes and myopia, and may develop in both eyes simultaneously. Chronic glaucoma has no early warning signs, and the loss of peripheral vision occurs so gradually that substantial optic nerve damage can occur before glaucoma is detected.
Narrow-angle, or angle-closure, glaucoma is the less common form and may be associated with eye trauma, various inflammatory processes, and pupillary dilation after the instillation of mydriatic drops. Acute angle-closure glaucoma is manifested by sudden excruciating pain in or around the eye, blurred vision, and ocular redness. This condition constitutes a medical emergency because blindness may suddenly ensue.
CARE SETTING
Community, unless sudden increase in IOP requires emergency intervention and close monitoring.
RELATED CONCERNS
Psychosocial aspects of care
Patient Assessment Database
ACTIVITY/REST
May report:Change in usual activities/hobbies due to altered vision
FOOD/FLUID
May report:Nausea/vomiting (acute glaucoma)
NEUROSENSORY
May report: Gradual loss of peripheral vision, frequent change of glasses, difficulty adjusting to darkened room, halos around lights, mild headache (chronic glaucoma)
Cloudy/blurred vision, appearance of halos/rainbows around lights, sudden loss of peripheral vision, photophobia (acute glaucoma)
Glasses/treatment change does not improve vision
May exhibit: Dilated, fixed, cloudy pupils (acute glaucoma)
Fixed pupil and red/hard eye with cloudy cornea (glaucoma emergency)
Increased tearing
Intumescent cataracts, intraocular hemorrhage (glaucoma secondary to trauma)
PAIN/DISCOMFORT
May report: Mild discomfort or aching/tired eyes (chronic glaucoma)
Sudden/persistent severe pain or pressure in and around eye(s), headache (acute glaucoma)
SAFETY
May report: History of hemorrhage, trauma, ocular disease, tumor (secondary to trauma)
Difficulty seeing, managing activities
May exhibit: Inflammatory disease of eye (glaucoma secondary to trauma)
TEACHING/LEARNING
May report: Family history of glaucoma, diabetes, systemic vascular disorders
History of stress, allergies, vasomotor disturbances (e.g., increased venous pressure),
endocrine imbalance, diabetes
History of ocular surgery/cataract removal; steroid use
Discharge plan
May require assistance with transportation, meal preparation, self-care, homemaker/ maintenance tasks
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Ophthalmoscopy examination: Assesses internal ocular structures, noting optic disc atrophy, papilledema, retinal hemorrhage, and microaneurysms. Slit-lamp examination provides three-dimensional view of eye structures, identifies corneal abnormalities/change in shape, increased IOP, and general vision deficits associated with glaucoma.
Visual acuity tests (e.g., Snellen, Jayer): Vision may be impaired by defects in cornea, lens, aqueous or vitreous humor, refraction, or disease of the nervous or vascular system supplying the retina or optic pathway.
Visual fields (e.g., confrontation, tangent screen, perimetry): Reduction of peripheral vision may be caused by glaucoma or other conditions such as cerebrovascular accident (CVA), pituitary/brain tumor mass, or carotid or cerebral artery pathology.
Tonography measurement: Assesses intraocular pressure (normal: 12–20 mm Hg). In acute angle-closure glaucoma,
IOP may be 50 mm Hg or higher.
Gonioscopy measurement: Helps differentiate open-angle from angle-closure glaucoma.
Provocative tests: May be useful in establishing presence/type of glaucoma when IOP is normal or only mildly elevated.
Glucose tolerance test/fasting blood sugar (FBS): Determines presence/control of diabetes, which is implicated at times in secondary glaucoma.
NURSING PRIORITIES
1. Prevent further visual deterioration.
2. Promote adaptation to changes in/reduced visual acuity.
3. Prevent complications.
4. Provide information about disease process/prognosis and treatment needs.
DISCHARGE GOALS
1. Vision maintained at highest possible level.
2. Patient coping with situation in a positive manner.
3. Complications prevented/minimized.
4. Disease process/prognosis and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
Narrow-angle, or angle-closure, glaucoma is the less common form and may be associated with eye trauma, various inflammatory processes, and pupillary dilation after the instillation of mydriatic drops. Acute angle-closure glaucoma is manifested by sudden excruciating pain in or around the eye, blurred vision, and ocular redness. This condition constitutes a medical emergency because blindness may suddenly ensue.
CARE SETTING
Community, unless sudden increase in IOP requires emergency intervention and close monitoring.
RELATED CONCERNS
Psychosocial aspects of care
Patient Assessment Database
ACTIVITY/REST
May report:Change in usual activities/hobbies due to altered vision
FOOD/FLUID
May report:Nausea/vomiting (acute glaucoma)
NEUROSENSORY
May report: Gradual loss of peripheral vision, frequent change of glasses, difficulty adjusting to darkened room, halos around lights, mild headache (chronic glaucoma)
Cloudy/blurred vision, appearance of halos/rainbows around lights, sudden loss of peripheral vision, photophobia (acute glaucoma)
Glasses/treatment change does not improve vision
May exhibit: Dilated, fixed, cloudy pupils (acute glaucoma)
Fixed pupil and red/hard eye with cloudy cornea (glaucoma emergency)
Increased tearing
Intumescent cataracts, intraocular hemorrhage (glaucoma secondary to trauma)
PAIN/DISCOMFORT
May report: Mild discomfort or aching/tired eyes (chronic glaucoma)
Sudden/persistent severe pain or pressure in and around eye(s), headache (acute glaucoma)
SAFETY
May report: History of hemorrhage, trauma, ocular disease, tumor (secondary to trauma)
Difficulty seeing, managing activities
May exhibit: Inflammatory disease of eye (glaucoma secondary to trauma)
TEACHING/LEARNING
May report: Family history of glaucoma, diabetes, systemic vascular disorders
History of stress, allergies, vasomotor disturbances (e.g., increased venous pressure),
endocrine imbalance, diabetes
History of ocular surgery/cataract removal; steroid use
Discharge plan
May require assistance with transportation, meal preparation, self-care, homemaker/ maintenance tasks
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Ophthalmoscopy examination: Assesses internal ocular structures, noting optic disc atrophy, papilledema, retinal hemorrhage, and microaneurysms. Slit-lamp examination provides three-dimensional view of eye structures, identifies corneal abnormalities/change in shape, increased IOP, and general vision deficits associated with glaucoma.
Visual acuity tests (e.g., Snellen, Jayer): Vision may be impaired by defects in cornea, lens, aqueous or vitreous humor, refraction, or disease of the nervous or vascular system supplying the retina or optic pathway.
Visual fields (e.g., confrontation, tangent screen, perimetry): Reduction of peripheral vision may be caused by glaucoma or other conditions such as cerebrovascular accident (CVA), pituitary/brain tumor mass, or carotid or cerebral artery pathology.
Tonography measurement: Assesses intraocular pressure (normal: 12–20 mm Hg). In acute angle-closure glaucoma,
IOP may be 50 mm Hg or higher.
Gonioscopy measurement: Helps differentiate open-angle from angle-closure glaucoma.
Provocative tests: May be useful in establishing presence/type of glaucoma when IOP is normal or only mildly elevated.
Glucose tolerance test/fasting blood sugar (FBS): Determines presence/control of diabetes, which is implicated at times in secondary glaucoma.
NURSING PRIORITIES
1. Prevent further visual deterioration.
2. Promote adaptation to changes in/reduced visual acuity.
3. Prevent complications.
4. Provide information about disease process/prognosis and treatment needs.
DISCHARGE GOALS
1. Vision maintained at highest possible level.
2. Patient coping with situation in a positive manner.
3. Complications prevented/minimized.
4. Disease process/prognosis and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
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