Retinal Detachment

Description
  • Results from separation of the sensory layer of the retina containing the rod and cones from the pigmented epithelial layer beneath.Retinal Detachment
  • It may occur spontaneously because of degenerative changes in the retina (as in diabetic retinopathy) or vitreous humor, trauma, inflammation, tumor, or loss of a lens to a cataract.
  • It is rare in children, the disorder most commonly occurs after age 40.
  • Untreated retinal detachment results in loss of a portion of the visual field.
Causes/Risk factors
Modifiable
  • Trauma
  • Hemorrhage
  • Exudates that occur in front of or behind the retina
  • Sudden, severe physical exertion especially in persons who are debilitated.
Non-modifiable
  • Myopic degeneration
  • Aphakia (absence of crystalline lens)
Assessment
  1. Initially, the patient complains of flashes of light, floating spots or filaments in the vitreous, or blurred, “sooty” vision. Most of these phenomena result from traction between the retina and vitreous.
  2. If detachment progresses rapidly, the patient may report a veil-like curtain or shadow obscuring portions of the visual field. The veil appears to come from above, below, or from one side; the patient may initially mistake the obstruction for a drooping eyelid or elevated cheek.
  3. Straight-ahead vision may be unaffected in early stages but, as detachment progresses, there will be loss of central as well as peripheral vision.
Diagnostic Evaluation
  • Ophthalmoscopy or slit-lamp examination with full pupil dilation shows retina as gray or opaque in detached areas. The retina is normally transparent.
Primary Nursing Diagnosis
  • Sensory-perceptual alterations (visual) related to decreased sensory reception
Medical Management
  • Surgical intervention aims to reattach the retinal layer to the epithelial layer and has a 90% to 95% success rate.
Techniques include:
  1. Photocoagulation, in which a laser or xenon are “spot welds” the retina to the pigment epithelium.
  2. Electrodiathermy, in which a tiny hole is made in the sclera to drain subretinal fluid, allowing the pigment epithelium to adhere to the retina.
  3. Cryosurgery or retinal cryopexy, another “spot weld” technique that uses a super cooled probe to adhere the pigment epithelium to the retina.
  4. Scleral buckling, in which the sclera is shortened to force the pigment epithelium closer to the retina; commonly accompanied by vitrectomy.

scleral buckle

Pharmacologic Intervention
  • Drops as prescribed of Cyclopentolate hydrochloride (Cyclogyl) a cycloplegic agent that causes dilation of the pupil and rest of the muscles of accommodation
  • Drops as prescribed of antibiotics Gentamicin; prednisolone acetate to prevent eye infections
  • Other Drugs: Antiemetics and analgesics are ordered to manage nausea, vomiting, and pain.
Nursing Intervention
  1. Prepare the patient for surgery.
    • Instruct the patient to remain quiet in prescribed (dependent) position, to keep the detached area of the retina in dependent position.
    • Patch both eyes.
    • Wash the patient’s face with antibacterial solution.
    • Instruct the patient not to touch the eyes to avoid contamination.
    • Administer preoperative medications as ordered.
  2. Take measures to prevent postoperative complications.
    • Caution the patient to avoid bumping head.
    • Encourage the patient no to cough or sneeze or to perform other strain-inducing activities that will increase intraocular pressure.
  3. Encourage ambulation and independence as tolerated.
  4. Administer medication for pain, nausea, and vomiting as directed.
  5. Provide quiet diversional activities, such as listening to a radio or audio books.
  6. Teach proper technique in giving eye medications.
  7. Advise patient to avoid rapid eye movements for several weeks as well as straining or bending the head below the waist.
  8. Advise patient that driving is restricted until cleared by ophthalmologist.
  9. Teach the patient to recognize and immediately report symptoms that indicate recurring detachment, such as floating spots, flashing lights, and progressive shadows.
  10. Advise patient to follow up.
Documentation Guidelines
  • Visual acuity
  • Reaction to activity restrictions; ability of patient to participate in activities of daily living independently
  • Complications such as bleeding,infection,decreased visual acuity,falls
  • Response to medications and ability of the patient to instill eye drops
  • Understanding of eye care at home
Discharge and Home Healthcare Guidelines
  • Have the patient or significant others demonstrate the correct technique for instilling eye drops. Instruct the patient to wash her or his hands before and after removing the dressing; using a clean washcloth, cleanse the lid and lashes with warm tap water; tilt the head backward and inclined slightly to the side, so the solution runs away from the tear duct and other eye to prevent contamination; depress the lower lid with the finger of one hand. Tell the patient to look up when the solution is dropped on the averted lower lid; do not the place drop directly on the cornea.
  • Do not touch any part of the eye with the dropper; close the eye after instillation, and wipe off the excess fluid from the lids and cheeks. Close the eye gently so the solution stays in the eye longer.
  • Teach the patient to use warm or cold compresses for comfort several times a day. Note that the patient should wear either an eye shield or glasses during the day, during naps, and at night.
  • Teach the patient to avoid vigorous activities and heavy lifting for the immediate postoperative period.
  • Teach the patient the symptoms of retinal detachment and the action to take if it occurs again.
  • Instruct the patient about the importance of follow-up appointments,which may be every few days for the first several weeks after surgery.

Sources:
Marilyn Sawyer Sommers, RN, PhD, FAAN , Susan A. Johnson, RN, PhD, Theresa A. Beery, PhD, RN , DISEASES AND DISORDERS A Nursing Therapeutics Manual, 2007 3rd ed
UDAN, Mastering Medical-Surgical Nursing

Announcement!! Our hottest nursing game is out now in the App Store. Many nurses are playing now!LEARN MORE
+