Glaucoma

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as an increased risk for developing primary open-angle glaucoma? Select all that apply.

• a.Blue eyes

• 
  b.Older age
  

• 
  c.African ethnicity
  

• 
  d.Diabetes mellitus
  

• 
  e. Use of contact lenses

Answer explanation

Choices B, C, and D are correct. Risk factors for primary open-angle glaucoma (POAG) include hypertension, African American ethnicity, family history, diabetes mellitus, and any condition that may cause an increase in intraocular pressure. Hypertension increases IOP. Because African Americans are at higher risk for developing hypertension, they are impacted by the condition's negative vascular impacts. Diabetes, especially if uncontrolled, may cause vascular damage, and the eyes are commonly affected. Annual eye examinations for a client with diabetes are recommended.

Choices A and E are incorrect. Eye color and using corrective lenses do not raise the risk of POAG.

The nurse is caring for a client with acute angle-closure glaucoma of the right eye. It would be correct to place the client in which position?

• A.Trendelenburg
  

• B.Supine
  

• 
  C.Right lateral decubitus with head end elevated
  

• D.Prone

Answer explanation

Choice B is correct. The client with acute angle-closure glaucoma should be placed supine, which will assist in the lens falling away from the iris, mechanically helping to relieve angle closure and decreasing the pupillary block. Clients with open-angle glaucoma (OAG) are advised to sleep with their heads elevated to about 30 degrees. However, there is insufficient evidence to recommend the same for angle closure glaucoma. The supine position is widely accepted for angle-closure glaucoma.

Choices A, C, and D are incorrect. Lateral decubitus, prone, and trendeleburg are all positions that can significantly increase the IOP. Therefore, they are unhelpful in the management of angle-closure glaucoma. Placing the client supine will enable the treatment (mannitol, acetazolamide) to achieve its objective of reducing the pupillary block by separating the lens from the iris.

Trendelenburg position can significantly increase the IOP. Surgeons should be aware of this effect in glaucoma clients that are placed in the Trendelenburg position during surgery (choice A)
The lateral decubitus position increases the IOP in the dependent eye. In this case, the right eye is affected, and lying in the right lateral position will exacerbate the angle closure of glaucoma (choice C).
In a prone position, the lens-iris diaphragm moves forward, tending to occlude an anatomically predisposed angle and further increasing intra-ocular pressure (choice D).

The nurse is caring for a client with angle-closure glaucoma.

Which prescription should the nurse anticipate from the primary healthcare provider (PHCP)?

• A.timolol

• B.hydroxyzine

• C.phenylephrine

• D.imipramine

Answer explanation

Choice A is correct. Timolol is an intraocular beta-blocker and is effective in treating angle-closure glaucoma. This medication is indicated for this ocular emergency as it lowers intraocular pressure (IOP).

Choice B is incorrect. Hydroxyzine is an anticholinergic medication intended to treat allergies. This anticholinergic medication would worsen glaucoma because of its propensity to increase IOP.

Choice C is incorrect. Phenylephrine is a medication intended to raise blood pressure. Raising blood pressure would not be helpful for a client with increased IOP.

Choice D is incorrect. Imipramine is a tricyclic antidepressant (TCA). This medication is strongly anticholinergic and should not be given to individuals with increased IOP.

The nurse is caring for a client with angle-closure glaucoma. Which prescription should the nurse anticipate from the primary healthcare provider (PHCP)?

• A.Acetazolamide
  

• B.Diphenhydramine
  

• C.Phenylephrine
  

• D.Nortriptyline

Answer explanation

Choice A is correct. Timolol is an intraocular beta-blocker and is effective in treating angle-closure glaucoma. This medication is indicated for this ocular emergency as it lowers intraocular pressure (IOP).

Choice B is incorrect. Hydroxyzine is an anticholinergic medication intended to treat allergies. This anticholinergic medication would worsen glaucoma because of its propensity to increase IOP.

Choice C is incorrect. Phenylephrine is a medication intended to raise blood pressure. Raising blood pressure would not be helpful for a client with increased IOP.

Choice D is incorrect. Imipramine is a tricyclic antidepressant (TCA). This medication is strongly anticholinergic and should not be given to individuals with increased IOP.

A nurse is assessing a 58-year-old client with blurred vision and reduced visual fields.  Which manifestation is of most concern to the nurse?

•   1. Difficulty adjusting to dimmed lights  
  

•   2. Extreme eye pain  
  

•   3. Gradual loss of peripheral vision  

•   4. Opaque appearance of lens  

Answer explanation

Acute angle-closure glaucoma is a form of glaucoma that requires immediate medical intervention.  Glaucoma disorders are characterized by increased intraocular pressure (IOP) due to decreased outflow of the aqueous humor, resulting in compression of the optic nerve that can lead to permanent blindness.  In acute angle-closure glaucoma, IOP increases rapidly and drastically, which can lead to the following manifestations:

Sudden onset of severe eye pain
Reduced central vision
Blurred vision
Ocular redness
Report of seeing halos around lights
(Options 1 and 3)  Gradual loss of peripheral vision and difficulty adjusting to different lighting are manifestations of chronic open-angle glaucoma.  Although further evaluation and treatment are necessary, this condition develops slowly and is not considered an emergency situation.

(Option 4)  Opaque lenses are characteristic of cataracts, which are not a medical emergency.

Which medication, if prescribed for the client with
glaucoma, would the nurse question?

•  1. Betaxolol
  

• 2. Pilocarpine
  

• 3. Erythromycin
  

• 4. Atropine sulfate

Answer explanation

 Rationale: Options 1 and 2 are miotic agents used to treat glau
coma. Option 3 is an antiinfective medication used to treat bacte
rial conjunctivitis. Atropine sulfate is a mydriatic and cycloplegic
(also anticholinergic) medication, and its use is contraindicated
in clients with glaucoma. Mydriatic medications dilate the pupil
and can cause an increase in intraocular pressure in the eye.
 Test-Taking Strategy: Focus on the subject, the medication
that the nurse would question. Recalling the classifications of
the medications identified in the options will assist in answer
ing the question. Remember that mydriatics dilate the pupil
and that these medications are contraindicated in glaucoma.

 A miotic medication has been prescribed for the
client with glaucoma, and the client asks the nurse
about the purpose of the medication. Which re
sponse would the nurse provide to the client?

•  1. “The medication will help dilate the eye to pre
  vent pressure from occurring.”
  

• 2. “The medication will relax the muscles of the  the muscles of the eyes
  and prevent blurred vision.”

• 3. “The medication causes the pupil to constrict and
  will lower the pressure in the eye.”
  

• 4. “The medication will help block the responses
  that are sent to the muscles in the eye.”

Answer explanation

 Rationale: Miotics cause pupillary constriction and are used
to treat glaucoma. They lower the intraocular pressure, thereby
increasing blood flow to the retina and decreasing retinal
damage and loss of vision. Miotics cause a contraction of the
ciliary muscle and a widening of the trabecular meshwork.
Options 1, 2, and 4 are incorrect.
 Test-Taking Strategy: Note that the client has glaucoma.
Recall that prevention of increased intraocular pressure is
the goal in the client with glaucoma. Options 1, 2, and 4 are
comparable or alike and describe actions related to mydriatic
medications, which primarily dilate the pupils and relax the
ciliary muscles.

Nausea and vomiting in which client is of greatest concern to the nurse?

•   1. Client postoperative ophthalmic surgery  
  

•   2. Client receiving chemotherapy  
  

•   3. Client with Ménière disease  
  

•   4. Client with severe gastroenteritis  

Answer explanation

Increased intraocular pressure can cause damage to the blood vessels and retina and cause potential permanent vision loss.  Coughing, vomiting, straining to lift objects (>5 lb), and bending at the waist temporarily increase intraocular pressure and must be avoided after eye surgery.  Antiemetic medication is administered as needed following ophthalmic surgery to prevent vomiting.

(Options 2 and 4)  Nausea and vomiting are expected side effects of chemotherapy and severe gastroenteritis.

(Option 3)  Ménière disease affects the inner ear.  Vertigo, nausea, and vomiting are expected manifestations of this disease.

A nurse is reinforcing discharge teaching with a client who is postoperative following laser surgery for open- angle glaucoma. Which of the following statements by the client indicates an understanding of the instructions?

• A. I will take a stool softener to prevent constipation

• B. I will ask to work the night shift, so I will not be driving in bright sunlight

• C. I will need to use my eye drops for 1 year

• D. I will need to follow a low-protein diet

Answer explanation

The statement that indicates an understanding of the instructions is "I will take a stool softener to prevent constipation."

This statement is incorrect. The need to work the night shift to avoid bright sunlight does not relate to the discharge instructions for a client postoperative following laser surgery for open-angle glaucoma. The primary focus of discharge teaching for this condition would be related to eye care, medication administration, and follow-up appointments.

This statement is incorrect. While eye drops are commonly prescribed for open-angle glaucoma, the duration of their use can vary based on the individual's condition and the healthcare provider's instructions. The client should follow the specific instructions given by their healthcare provider regarding the frequency and duration of eye drop use.

This statement is incorrect. A low-protein diet is not typically part of the discharge instructions for a client postoperative following laser surgery for open-angle glaucoma. The focus of dietary recommendations for open-angle glaucoma is on maintaining a healthy diet and managing other health conditions that may affect intraocular pressure, such as high blood pressure or diabetes.