Age Related Macular Degeneration Essay
PATHOPHYSIOLOGY
Age- related macular degeneration (AMD), a chronic, progressive disorder of the retina, is the most common cause of blindness in individuals over the age of 60. The macula is the part of the retina which provides high resolution color vision (Redmond &While 2008). As the macula degenerates, individuals lose their central vision and color vision. There are two types of macular degeneration: wet, or choroidal neovascularization and dry, or nonneovascular . Dry AMD is the more common of the two types, occurring roughly 80-90% of the time. The hallmark sign of dry AMD is the appearance of drusen. These are whitish-yellow lipid deposits on the macula. These deposits can lift the retinal pigmented epithelium away from the choroidal circulation, causing it to deteriorate (Redmond &While 2008). Dry AMD can progress to the wet form, which occurs in 10-20% of …show more content…
cases, in which new vessel growth occurs suddenly in the macular region. This displaces the retinal pigmented epithelium, disrupting its blood supply, and causes scarring.
NURSING ASSESSMENT
There are several nursing diagnoses that are important considerations for the care of the patient with macular degeneration. Three of these are risk for falls related to disturbed visual sensory perception, anxiety related to threatened role change, and risk for impaired home maintenance. A patient at risk for falls related to visual changes would ideally be free of falls both in the hospital and at home. This could be achieved by the nurse educating the patient about using assistive ambulatory devices as needed. The use of assistive ambulatory devices will allow the patient to reduce the hazard of tripping by providing support for the patient while ambulating. Proper education on use of these devices is necessary to reap their benefit. The nurse could also educate the patient on keeping his environment as free of clutter as possible, including possible tripping hazards like throw rugs. The fewer obstacles a patient has to work around, the less likely he is to trip. The nurse should also be careful to orient the patient to his environment in the hospital, and make no unnecessary changes to the environment once the patient is oriented. The nurse should also encourage the patient to practice this at home. An environment that the patient is familiar with will be easier for the patient to navigate. If the nurse institutes these interventions, the patient should remain free of falls due to the changes in his vision.
A patient experiencing anxiety related to threat to role functions can be aided in several ways by the nurse. The nurse should encourage the patient to acknowledge and talk about the anxious feelings. Assisting the patient to identify his anxiety will help to keep his anxiety from escalating. The nurse can then discuss anxiety relieving techniques with patient such as deep breathing and relaxation. When the patient has tools to reduce his own anxiety, he may experience less anxiety and be able to alleviate his own symptoms when they occur. The nurse can work to educate the patient and family about macular degeneration and what types of lifestyle changes the patient is likely to need to undertake. When the patient and family are educated, there is less likelihood that the family will make demands that the patient is unable to fill, and the patient will have a better sense of their own boundaries. The patient would hopefully experience fewer episodes of anxiety and have greater capability to handle to episodes that do occur.
With declining visual acuity the macular degeneration patient may also be at risk for impaired home maintenance. The nurse can impact this risk by initiating discharge planning immediately after hospital admission, coordinating access to home health care services for patient. The expedient initiation of discharge planning will allow patient time to place services if necessary before returning home. The nurse should assess patient’s understanding of home care needs to determine if he needs help in crafting a home care plan. The nurse can work with the patient to ensure that he understands what changes will be necessary to his routines, and how to adapt to these. The nurse should also strive to provide access to Occupational Therapy for the patient, who can work with the patient and may be able to provide assistive devices for home maintenance. Once all interventions are in place, patient will have the tools to maintain their home to the standard to which they are accustomed.
DIAGNOSTIC TESTS
Three diagnostic tools are used by an ophthalmic specialist to diagnose AMD. The first, an Amsler gird, is a square grid made of evenly spaced horizontal and vertical lines. A small dot is located in the center of the grid for fixation. Each eye is tested individually by covering one eye at a time and looking at the dot in the center. The patient is instructed to report any wavy, bent, missing, discolored or blurry lines, or if any of the boxes are a different shape or size. The second tool, fluorescein angiography is performed by injecting a fluorescent compound into a peripheral vein. A special camera photographs the fluorescein as it circulates through blood vessels in the retina. The patterns can reveal circulation problems, edema, leaking or abnormal blood vessels. In optical coherence tomography, the third diagnostic test, images of tissue structure at the micron scale are provided in real time with fiberoptics.
METHODS OF TREATMENT:
To date, there are very few treatments available for macular degeneration. At this time, there are no treatments for dry macular degeneration, only for wet. Conventional FDA approved therapies include anti-vascular endothelial growth factor, referred to as anti-VEGF, photodynamic therapies, thermal laser treatment and macular translocation therapy. Anti-VEGF therapy is the most commonly sought treatment for macular degeneration. Macugen and Lucentis are two anti-VEGF commonly used. The drugs pegaptanib (Macugen) and ranibizumab (Lucentis) are anti-vascular endothelial growth factors (anti-VEGFs) that target the eye proteins contributing to the disease with the goal of stopping neovascularization. They are administered intravitreally every 4 to 6 weeks. Pain, retinal detachment and endophthalmitis are the most common adverse reactions to these drugs (Young, 2008). Photodynamic therapy (PDT) combines an I.V. injection of a photosensitizing drug, such as verteporfin (Visudyne), and a non thermal laser application that destroys new blood vessels without damaging normal surrounding tissue. This procedure, which doesn’t damage the overlying neurosensory retina, is generally painless except for the insertion of the I.V. catheter (Covell, Graziano, Rich & Tobin 2007). This therapy has reduced the risk of moderate visual loss for some patients at 12 and 24 months after treatment (Feret, Steinweg, Griffin, & Glover, 2007). Thermal laser treatment is a third treatment sought after. The advanced form of age related macular degeneration can be helped by a laser surgery called thermal laser photocoagulation, Sealing the leaking blood vessels in the advanced type of macular degeneration can slow down the damage to the eye. The disadvantages of thermal laser treatment may include permanent and immediate loss of vision (Feret, Steinweg, Griffin, & Glover, 2007). The last conventional therapy sought for macular degeneration treatments is macular translocation. In this therapy, the retina is detached and shifted from the neovascular complex to normal retinal pigment epithelial cells. This approach permits the CNV to be treated with various therapies. Results of macular translocation are good in selected cases but the risks include retinal detachment, macular pucker, increased lens opacity and tilted image (Feret, Steinweg, Griffin, & Glover, 2007). At this time, the only holistic treatment of macular degeneration is the use of dietary interventions. Dietary interventions that stress the use of antioxidants and include the use of zinc, vitamin C, vitamin E, copper and beta-carotene seem to be of help to individuals with age related macular degeneration. The dietary interventions seem to slow the progression to the severe stages of the condition. Leutin and zeaxnthin are carotenoid plant pigments naturally found in the macula, which help to protect the retina and retinal pigment epithelium (RPE) from light initiated damage. Johnson reported the leutin and zeaxanthin function as antioxidants and provide blue light filters. Foods known to have the highest amount of lutein and zeanxanthin are kale, spinach, broccoli, peas and Brussels sprouts (Feret, Steinweg, Griffin, & Glover, 2007). Alternative therapies include acupuncture and microcurrent stimulation. Acupuncture refers broadly to a group of procedures that stimulate the skin. ("Alternative therapies," 2007) This is a very low risk procedure, and has no conclusive evidence to help with macular degeneration. Microcurrent stimulation is a technique to apply electrical stimulation to nerve fibers using cutaneous electrodes ("Alternative therapies," 2007)
PATIENT TEACHING:
A patient with a new diagnosis of macular degeneration should be aware of struggles they may face with their new disease. First and foremost, their home should be clear of clutter to prevent falls and ensure their safety. Use of assistive ambulation equipment may be required. They should be taught the proper administration of eye drops or ointments, with repeat demonstration shown to the nurse to ensure understanding of their ongoing care at home. To make certain the patient maintains the level of independence they enjoyed prior to diagnosis, including their family or support group would be essential in forming realistic expectations of their homecare. They can be set up with homecare contacts, such as visiting nurses, community transportation, local Red Cross, social services and any local agencies that may provide support to the visually deficient. One wants to be sure the patient also understands that this is a degenerative disease, so even if their vision is not impacted greatly initially, over time it could potentially degenerate. There are also several assistive aids for low visionary needs such as magnified televisions, fluorescent lamps, glare protectors and hand magnifiers.
PROGNOSIS
The prognosis for macular degeneration is not generally positive, since it is a degenerative disease. The predicted outcome for this disease is the decline in visual acuity, generally leading to blindness. While there are new treatments emerging, there is no cure for macular degeneration, and few treatments to prevent the decline in vision. With the help of ongoing clinical trials of surgical and medical interventions, hopefully there will one day be a treatment that can all together prevent macular degeneration, or stop the progression. Bibliography
1.
Feret, A, Steinweg, S, Griffin, H.C>, & Glover, S. (2007). Macular degeneration: types, causes, and possible interventions. Geriatric Nursing, 28(6), 387-392. (Feret, Steinweg, Griffin, & Glover, 2007)
2. Young, J.S. (2008). Age related eye diseases: a review of current treatment and recommendations for low-vision aids. Home Healthcare Nurse, 26(8), 454-473. (Young, 2008)
3. Moore, L.W., & Miller, M. (2005). Driving strategies used by older adults with macular degeneration: assessing the risks. Applied Nursing Research, 18, 110-116.
4. Redmond, N., & While, A. (2008). Age related macular degeneration: visual impairment with advancing age. British Journal of Community Nursing, 13(2), 68-75.
5. Covell, C.A., Graziano, J., Rich, D., & Tobin, K.A. (2007). New outlook for age-related macular degeneration. Nursing2007, 37(3), 22-24.
6. Christensen, B.L., & Kockrow, E.O. (Ed.). (2006). Adult health nursing, fifth edition. St. Louis, Missouri: Mosby Elsevier.
(2007). Alternative therapies. Retrieved from
http://www.aao.org/eyecare/treatment/alternative-therapies/index.cfm
Age- related macular degeneration (AMD), a chronic, progressive disorder of the retina, is the most common cause of blindness in individuals over the age of 60. The macula is the part of the retina which provides high resolution color vision (Redmond &While 2008). As the macula degenerates, individuals lose their central vision and color vision. There are two types of macular degeneration: wet, or choroidal neovascularization and dry, or nonneovascular . Dry AMD is the more common of the two types, occurring roughly 80-90% of the time. The hallmark sign of dry AMD is the appearance of drusen. These are whitish-yellow lipid deposits on the macula. These deposits can lift the retinal pigmented epithelium away from the choroidal circulation, causing it to deteriorate (Redmond &While 2008). Dry AMD can progress to the wet form, which occurs in 10-20% of …show more content…
cases, in which new vessel growth occurs suddenly in the macular region. This displaces the retinal pigmented epithelium, disrupting its blood supply, and causes scarring.
NURSING ASSESSMENT
There are several nursing diagnoses that are important considerations for the care of the patient with macular degeneration. Three of these are risk for falls related to disturbed visual sensory perception, anxiety related to threatened role change, and risk for impaired home maintenance. A patient at risk for falls related to visual changes would ideally be free of falls both in the hospital and at home. This could be achieved by the nurse educating the patient about using assistive ambulatory devices as needed. The use of assistive ambulatory devices will allow the patient to reduce the hazard of tripping by providing support for the patient while ambulating. Proper education on use of these devices is necessary to reap their benefit. The nurse could also educate the patient on keeping his environment as free of clutter as possible, including possible tripping hazards like throw rugs. The fewer obstacles a patient has to work around, the less likely he is to trip. The nurse should also be careful to orient the patient to his environment in the hospital, and make no unnecessary changes to the environment once the patient is oriented. The nurse should also encourage the patient to practice this at home. An environment that the patient is familiar with will be easier for the patient to navigate. If the nurse institutes these interventions, the patient should remain free of falls due to the changes in his vision.
A patient experiencing anxiety related to threat to role functions can be aided in several ways by the nurse. The nurse should encourage the patient to acknowledge and talk about the anxious feelings. Assisting the patient to identify his anxiety will help to keep his anxiety from escalating. The nurse can then discuss anxiety relieving techniques with patient such as deep breathing and relaxation. When the patient has tools to reduce his own anxiety, he may experience less anxiety and be able to alleviate his own symptoms when they occur. The nurse can work to educate the patient and family about macular degeneration and what types of lifestyle changes the patient is likely to need to undertake. When the patient and family are educated, there is less likelihood that the family will make demands that the patient is unable to fill, and the patient will have a better sense of their own boundaries. The patient would hopefully experience fewer episodes of anxiety and have greater capability to handle to episodes that do occur.
With declining visual acuity the macular degeneration patient may also be at risk for impaired home maintenance. The nurse can impact this risk by initiating discharge planning immediately after hospital admission, coordinating access to home health care services for patient. The expedient initiation of discharge planning will allow patient time to place services if necessary before returning home. The nurse should assess patient’s understanding of home care needs to determine if he needs help in crafting a home care plan. The nurse can work with the patient to ensure that he understands what changes will be necessary to his routines, and how to adapt to these. The nurse should also strive to provide access to Occupational Therapy for the patient, who can work with the patient and may be able to provide assistive devices for home maintenance. Once all interventions are in place, patient will have the tools to maintain their home to the standard to which they are accustomed.
DIAGNOSTIC TESTS
Three diagnostic tools are used by an ophthalmic specialist to diagnose AMD. The first, an Amsler gird, is a square grid made of evenly spaced horizontal and vertical lines. A small dot is located in the center of the grid for fixation. Each eye is tested individually by covering one eye at a time and looking at the dot in the center. The patient is instructed to report any wavy, bent, missing, discolored or blurry lines, or if any of the boxes are a different shape or size. The second tool, fluorescein angiography is performed by injecting a fluorescent compound into a peripheral vein. A special camera photographs the fluorescein as it circulates through blood vessels in the retina. The patterns can reveal circulation problems, edema, leaking or abnormal blood vessels. In optical coherence tomography, the third diagnostic test, images of tissue structure at the micron scale are provided in real time with fiberoptics.
METHODS OF TREATMENT:
To date, there are very few treatments available for macular degeneration. At this time, there are no treatments for dry macular degeneration, only for wet. Conventional FDA approved therapies include anti-vascular endothelial growth factor, referred to as anti-VEGF, photodynamic therapies, thermal laser treatment and macular translocation therapy. Anti-VEGF therapy is the most commonly sought treatment for macular degeneration. Macugen and Lucentis are two anti-VEGF commonly used. The drugs pegaptanib (Macugen) and ranibizumab (Lucentis) are anti-vascular endothelial growth factors (anti-VEGFs) that target the eye proteins contributing to the disease with the goal of stopping neovascularization. They are administered intravitreally every 4 to 6 weeks. Pain, retinal detachment and endophthalmitis are the most common adverse reactions to these drugs (Young, 2008). Photodynamic therapy (PDT) combines an I.V. injection of a photosensitizing drug, such as verteporfin (Visudyne), and a non thermal laser application that destroys new blood vessels without damaging normal surrounding tissue. This procedure, which doesn’t damage the overlying neurosensory retina, is generally painless except for the insertion of the I.V. catheter (Covell, Graziano, Rich & Tobin 2007). This therapy has reduced the risk of moderate visual loss for some patients at 12 and 24 months after treatment (Feret, Steinweg, Griffin, & Glover, 2007). Thermal laser treatment is a third treatment sought after. The advanced form of age related macular degeneration can be helped by a laser surgery called thermal laser photocoagulation, Sealing the leaking blood vessels in the advanced type of macular degeneration can slow down the damage to the eye. The disadvantages of thermal laser treatment may include permanent and immediate loss of vision (Feret, Steinweg, Griffin, & Glover, 2007). The last conventional therapy sought for macular degeneration treatments is macular translocation. In this therapy, the retina is detached and shifted from the neovascular complex to normal retinal pigment epithelial cells. This approach permits the CNV to be treated with various therapies. Results of macular translocation are good in selected cases but the risks include retinal detachment, macular pucker, increased lens opacity and tilted image (Feret, Steinweg, Griffin, & Glover, 2007). At this time, the only holistic treatment of macular degeneration is the use of dietary interventions. Dietary interventions that stress the use of antioxidants and include the use of zinc, vitamin C, vitamin E, copper and beta-carotene seem to be of help to individuals with age related macular degeneration. The dietary interventions seem to slow the progression to the severe stages of the condition. Leutin and zeaxnthin are carotenoid plant pigments naturally found in the macula, which help to protect the retina and retinal pigment epithelium (RPE) from light initiated damage. Johnson reported the leutin and zeaxanthin function as antioxidants and provide blue light filters. Foods known to have the highest amount of lutein and zeanxanthin are kale, spinach, broccoli, peas and Brussels sprouts (Feret, Steinweg, Griffin, & Glover, 2007). Alternative therapies include acupuncture and microcurrent stimulation. Acupuncture refers broadly to a group of procedures that stimulate the skin. ("Alternative therapies," 2007) This is a very low risk procedure, and has no conclusive evidence to help with macular degeneration. Microcurrent stimulation is a technique to apply electrical stimulation to nerve fibers using cutaneous electrodes ("Alternative therapies," 2007)
PATIENT TEACHING:
A patient with a new diagnosis of macular degeneration should be aware of struggles they may face with their new disease. First and foremost, their home should be clear of clutter to prevent falls and ensure their safety. Use of assistive ambulation equipment may be required. They should be taught the proper administration of eye drops or ointments, with repeat demonstration shown to the nurse to ensure understanding of their ongoing care at home. To make certain the patient maintains the level of independence they enjoyed prior to diagnosis, including their family or support group would be essential in forming realistic expectations of their homecare. They can be set up with homecare contacts, such as visiting nurses, community transportation, local Red Cross, social services and any local agencies that may provide support to the visually deficient. One wants to be sure the patient also understands that this is a degenerative disease, so even if their vision is not impacted greatly initially, over time it could potentially degenerate. There are also several assistive aids for low visionary needs such as magnified televisions, fluorescent lamps, glare protectors and hand magnifiers.
PROGNOSIS
The prognosis for macular degeneration is not generally positive, since it is a degenerative disease. The predicted outcome for this disease is the decline in visual acuity, generally leading to blindness. While there are new treatments emerging, there is no cure for macular degeneration, and few treatments to prevent the decline in vision. With the help of ongoing clinical trials of surgical and medical interventions, hopefully there will one day be a treatment that can all together prevent macular degeneration, or stop the progression. Bibliography
1.
Feret, A, Steinweg, S, Griffin, H.C>, & Glover, S. (2007). Macular degeneration: types, causes, and possible interventions. Geriatric Nursing, 28(6), 387-392. (Feret, Steinweg, Griffin, & Glover, 2007)
2. Young, J.S. (2008). Age related eye diseases: a review of current treatment and recommendations for low-vision aids. Home Healthcare Nurse, 26(8), 454-473. (Young, 2008)
3. Moore, L.W., & Miller, M. (2005). Driving strategies used by older adults with macular degeneration: assessing the risks. Applied Nursing Research, 18, 110-116.
4. Redmond, N., & While, A. (2008). Age related macular degeneration: visual impairment with advancing age. British Journal of Community Nursing, 13(2), 68-75.
5. Covell, C.A., Graziano, J., Rich, D., & Tobin, K.A. (2007). New outlook for age-related macular degeneration. Nursing2007, 37(3), 22-24.
6. Christensen, B.L., & Kockrow, E.O. (Ed.). (2006). Adult health nursing, fifth edition. St. Louis, Missouri: Mosby Elsevier.
(2007). Alternative therapies. Retrieved from
http://www.aao.org/eyecare/treatment/alternative-therapies/index.cfm