Aretinal detachment occurs when the retina is pulled away from or out of its normal position. Approximately 5% of the U.S. population has retinal breaks, but most do not lead to retinal detachment, which has a prevalence of 0.3%. Estimates are that 15% of people with retinal detachments in one eye develop detachment in the other eye, and the risk of bilateral detachment increases to 30% in people who have had bilateral cataract surgery.
The retina is the innermost lining of the eye and contains millions of photoreceptors, lightsensitive nerve fibers, and cells that are responsible for converting light energy into nerve impulses. The retina functions as film does in a camera: the light enters through the lens to the retina, and an image is transmitted to the brain via the optic nerve. The retina is attached to the choroid (vascular coat of the eye between the sclera and the retina) at two locations: at the optic nerve and at the ciliary body. The remaining retina relies on the vitreous ( jelly-like mass that fills the cavity of the eyeball) to apply pressure against the lining to maintain its position. The detachment can occur spontaneously as a result of a change in the retina or vitreous; this detachment is referred to as a primary detachment. Secondary detachment occurs as a result of another problem, such as trauma, diabetes, or pregnancy-induced hypertension. Complications from retinal detachment include visual impairment and blindness.
The most common cause of retinal detachment is the formation of a hole or tear, which can occur as part of the normal aging process or during cataract surgery or trauma. The hole allows the vitreous fluid to leak out between the layers, thus separating the sensory retinal layer from its blood supply in the choroid. Patients who have had previous cataract surgery, severe injury, or a family history of detachment, glaucoma, and nearsightedness are more likely to experience a retinal detachment.
Nursing care plan assessment and physical examination
Patients with suspected retinal detachment complain of a painless change in vision. Ask the patient if he or she has experienced “floaters” or black spots, flashing lights, or the sensation of a curtain being pulled over the field of vision. Some patients report feeling as if they are looking through a veil or through cobwebs. Ask the patient if he or she recently experienced any eye trauma.
A thorough visual examination is done to detect changes in vision. Inspect the retina with an ophthalmoscope to determine the extent of the tear. Assess the patient’s ability to ambulate safely and to perform the normal activities of daily living.
If the patient is still employed rather than retired, determine the effect of visual impairment on the patient’s ability to perform the job. Determine the effects of visual changes on leisure activities. Assess the patient’s support system, access to healthcare, and financial resources.
Nursing care plan primary nursing diagnosis: Sensory-perceptual alterations (visual) related to decreased sensory reception.
Nursing care plan intervention and treatment plan
The main objective in treating a tear or hole is to prevent a retinal detachment. Photocoagulation, cryotherapy, and diathermy are used to produce an inflammatory response that creates an adhesion or scar, which seals the edges of the tear. These therapies differ in the mechanism used to cause the scarring effect. Photocoagulation uses light beams; cryotherapy uses cold to freeze the tissues; diathermy uses energy from a high-frequency current. All three result in sealing of the hole to prevent the vitreous from spilling between the layers.
If the retina is detached, surgical repair is required. The objective of the surgical procedure is to force the retina into contact with the choroid. The scleral buckling procedure places the retina back into position. Preoperatively, the patient is on bedrest and has activity restrictions, depending on the size and location of detachment. Total eye rest may be needed. The patient may not read, watch television, or participate in any activity that causes rapid eye movements. An eye patch may be prescribed. It is important to position the patient either to keep the retinal tear lowermost within the eye or in the dependent position to allow the retina to fall back against the epithelium, which prevents further detachment. When gas or oil is used, the physician asks the patient to remain in a position that keeps the gas or oil bubble against the repaired area of the retina. The head is usually kept parallel to the floor and turned to the side with the unaffected eye down. It may take 4 to 8 days for the bubble to absorb. The patient cannot fly or travel to high altitudes until the gas bubble is gone because a rapid increase in altitude can increase the intraocular pressure and result in a redetachment of the retina. Reading, writing, close work, watching television, shampooing, shaving, and combing the hair may be restricted.
Assure the patient that it is normal for vision to continue to be distorted after surgery because of postoperative inflammation and cycloplegic eye drops. Inform the patient that vision will return to normal over several weeks. During hospitalization, keep the side rails raised, the bed in a low position, and the call light within the patient’s reach. Provide a safe environment and identify potential safety hazards. The patient needs to assume the position that was ordered by the physician for postoperative management. Assist the patient to use an over-the-bed table if necessary, or place pillows to support the arms and lower back. Place a sign at the head of the bed, giving each practitioner instructions on the position to be maintained. Observe the eye patch for drainage and notify the physician for drainage other then serous. Once the initial eye patch has been removed, place cool compresses over the closed eyelid for relief of discomfort. The eye may be swollen, reddened, and ecchymotic for several days, and the conjunctiva may persist for weeks. If the patient experiences postoperative nausea and vomiting, maintain an odor-free environment and apply cool compresses to the forehead.
Nursing care plan discharge and home health care 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.