Diseases Affecting Vision and Hearing

Chapter 19

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Diseases Affecting Vision and Hearing

Visual impairment has a negative impact on the quality of life
More than two-thirds of those with visual impairment are older than 65 years of age
Those older than 80 years of age account for 70% of the cases of severe visual impairment
Significant racial and cultural disparities in vision impairment

Vision Impairments

Glaucoma
Cataracts
Diabetic retinopathy
Diabetic macular edema
Macular degeneration
Detached retina
Dry eye

Diseases of the Eye

A clouding of the eye’s normally clear crystalline lens, causing the lens to lose transparency or scatter light
Most common causes are heredity and advancing age
Categorized by their location
Nuclear cataract

Most common type

Incidence increases with age and cigarette smoking

Cortical cataract

More common with age

Related to a lifetime exposure to ultraviolet light

Posterior subcapsular

Cataracts

Most common symptom is cloudy or blurred vision
Other symptoms include glare, halos around lights, poor night vision, perceiving that colors are faded or that objects are yellowish, and the need for brighter light when reading
Red reflex may be absent or may appear as a black area

Signs and Symptoms

Surgery is the most common
Involves removing the lens and placing a plastic intraocular lens (IOL)
Usually done on an outpatient basis
Nursing interventions include
Teaching

Avoid heavy lifting, straining, or bending at the waist

Wear glasses during the daytime and a shield at night

Administer eye drops to aid the healing process and to prevent infection

Treatment

Natural fluids of the eye are blocked by ciliary muscle rigidity, pressure builds, and damage to the optic nerve occurs
Second leading cause of blindness in the United States
Types include congenital glaucoma, primary open-angle glaucoma, low-tension or normal-tension glaucoma, secondary glaucoma, and acute angle-closure glaucoma (medical emergency)

Glaucoma

Most common form
Risk varies by race and age
Other high-risk groups include those with diabetes, hypertension, history of corticosteroid use, and family history of glaucoma
Usually affects side vision first and may go unnoticed for years

Primary Open-Angle Glaucoma

Headaches
Poor vision in dim lighting
Increased sensitivity to glare
Complaints of “tired eyes”
Impaired peripheral vision
A fixed and dilated pupil
Frequent changes in prescriptions for corrective lenses

Signs and Symptoms

Occurs when the angle of the iris causes obstruction of the aqueous humor through the trabecular network
Medical emergency; blindness can occur in 2 days
Those with smaller eyes, Asians, and women are most susceptible
May occur with infection or trauma
Symptoms include redness and pain in and around the eye, severe headaches, nausea and vomiting, and blurred vision

Angle-Closure Glaucoma

Adults older than 65 years of age need annual eye examinations
Those with medication-controlled glaucoma should be examined every 6 months
Those with a family history of glaucoma and African Americans should be screened annually after age 40 years

Glaucoma Screening

Oral or topical eye drops that lower eye pressure
Either decrease the amount of aqueous fluid produced within the eye or improve the flow through the drainage angle
Beta blockers are the first-line therapy followed by prostaglandin analogs
Second-line agents include topical carbonic anhydrase inhibitors and α2-agonist
Laser surgery treatments may be recommended

Treatment

- Complication of diabetes
- Leading cause of blindness in the United States
- Blood and lipid leakage leads to macular edema and hard exudates
- No symptoms occur in the early stages
- Early findings observed in funduscopic examination are microaneurysms, flamed-shaped hemorrhages, cotton-wool spots, hard exudate, and dilated capillaries

Diabetic Retinopathy

- Annual dilated fundoscopic examination should begin 5 years after diagnosis of diabetes type 1 and at the time of diagnosis of diabetes type 2
- Laser treatment can reduce vision loss
- Strict control of blood glucose, cholesterol, and blood pressure

Screening and Treatment

Thickening of the center of the retina
Leading cause of legal blindness
Affects 1 in 25 adults age 40 years and older with diabetes
Incidence is higher in African Americans and Hispanics
Treatments include medications (cortisone-type drugs), laser therapy, and anti-VEGF therapy (Lucentis)

Diabetic Macular Edema

Leading cause of vision loss in Americans who are 60 years of age and older
Age is the greatest risk factor
Other risk factors include genetic predisposition, smoking, hypertension, obesity, and a family history
Causes progressive loss of central vision, leaving only peripheral vision intact

Macular Degeneration

Geographic atrophy (dry age-related macular degeneration [AMD])
Rapid, severe loss of central vision
Many will be legally blind within 2 years of diagnosis
Neovascular AMD (wet AMD)
Occurs when abnormal blood vessels behind the retina start to grow under the macula
These new blood vessels often leak blood and fluid, which raise the macula from its normal place at the back of the eye

Types of Age-Related Macular Degeneration

Causes the progressive loss of central vision, leaving only peripheral vision intact
Awareness of a blurry spot in the middle of vision; blurred areas grow larger, and blank spots develop, leading to difficulty reading and writing
Increased need for bright light
Colors appear dim and gray

Signs and Symptoms

Amsler grid is used to determine the clarity of vision
In early AMD, exercise, avoiding smoking and a diet high in green leafy vegetables and fruits may help keep vision longer
Treatment includes photodynamic therapy, laser photocoagulation, and anti-VEGF therapy

Screening and Treatment

Medical emergency
Can occur spontaneously or after recent cataract surgery or eye trauma
Exhibits a “curtain coming down” over the line of vision and a gradual increase in floaters or light flashes
Small holes or tears are treated with laser surgery or cryopexy
Retinal detachments treated with surgery

Detached Retina

Not a disease but a frequent complaint among older adults
Causes can include medications such as antihistamines, diuretics, beta blockers, and sleeping pills
Common treatment is artificial tears or saline gel
Management includes using a home humidifier and avoiding wind and hair dryers

Dry Eye

Which disorder would the nurse suspect in a patient complaining of intense headaches, bloodshot eyes, and blurred vision?

Cataracts

Detached retina

Macular degeneration

Angle-closure glaucoma

Question

D—Symptoms of acute angle-closure glaucoma include redness and pain in and around the eye, severe headaches, nausea and vomiting, and blurred vision.

Answer

Use warm incandescent lighting
Increase the intensity of lighting
Control glare by using shades and blinds
Use yellow-to-amber lenses to decrease glare
Wear sunglasses to block out ultraviolet light
Use reading materials in large, dark print
Choose sharply contrasting colors

Interventions to Enhance Vision

Financial and social governmental programs
Insulin-delivery systems
Talking clocks and watches
Large print books
Magnifiers
Telescopes with handheld devices or attached to eye glasses
Electronic magnification

Low-Vision–Assisted Devices

Vision deficiencies affect communication, functional abilities, safety, and quality of life
Nursing concerns
Appropriate assessment
Environmental adaptation to enhance vision and safety
Communicating appropriately
Providing appropriate health teaching
Providing appropriate referrals for prevention and treatment

Implications for Gerontology Nurses and Healthy Aging

Third most chronic condition in U.S. older adults
Of those who are 80 years of age and older, 80% have hearing loss
Racial and gender disparities exist in hearing impairment
Risk factors include noise exposure, ear infections, smoking, and chronic disease (e.g., diabetes, chronic kidney disease, heart disease)

Hearing Impairments

Diminishes the quality of life
Increases social isolation
Decreases function
Increases likelihood of hospitalizations, miscommunication, depression, falls, loss of self-esteem, and safety risks
Increases cognitive decline and dementia

Consequences

Conductive loss
Involves abnormalities of the external and middle ear, which reduces the ability of sound to be transmitted to the middle ear
Is caused by otosclerosis, infection, perforated eardrum, fluid in the middle ear, or cerumen accumulation
Sensorineural loss
Result of damage to any part of the inner ear or the neural pathways to the brain
Includes presbycusis and noise-induced hearing loss

Types of Hearing Loss

Perception of sound in one or both ears or in the head when no external sound is present
Described as a “ringing in the ears”
May be described as buzzing, hissing, whistling, cricket chirping, bells, roaring, clicking, pulsating, humming, or swishing sounds
May be constant or intermittent

Tinnitus

Exact cause can be unknown
Exposure to loud noises is the leading cause
Exacerbated by caffeine, alcohol, smoking, stress, and fatigue
High-pitched tinnitus common with sensorineural loss
Low-pitched tinnitus reported in Meniere disease
Maintain a diary for times when noise is heard
Assess medication history
Lifestyle modifications and treatments

Assessment and Treatment

Hearing aids to amplify sound
Cochlear implants to bypass damaged portions of the ear and stimulate the auditory nerve in those with sensorineural hearing loss
Assisted listening and adaptive devices

Interventions to Enhance Hearing

What information will the nurse include when teaching a patient about using a hearing aid?

“This amplifies sound and directs it into the ear canal.”

“You will be able to hear better in noisy or crowded rooms.”

“It will assist you to interpret the incoming sounds more effectively.”

“This will bypass damaged portions of the ear and stimulate the auditory nerve.”

Question

A—Hearing aids amplify sound in part by directing sound into the ear canal.

Answer

- Hearing impairment affects communication, safety, and quality of life
- Nursing concerns
- Appropriate assessment
- Communicating appropriately
- Properly caring and maintaining hearing aids
- Providing appropriate health teaching
- Providing appropriate referrals for prevention and treatment

Implications for Gerontology Nurses and Healthy Aging

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