Macular Degeneration

Macular Degeneration Nursing Diagnosis Interventions and Care Plans

Macular Degeneration NCLEX Review Care Plans

Nursing Study Guide on Macular Degeneration

Macular degeneration (MD) is a condition in which the macula of the eye deteriorates and loses its light-sensing capabilities.

This is often brought about by old age and is the cause of severe, permanent vision loss for people 60 years old and above.

Due to the nature of onset, it is oftentimes coined as Age-related Macular Degeneration (AMD).

Likewise, macular degeneration is not limited in the elderly. It is known as Stargardt Disease or Juvenile Macular Degeneration (JMD) if it affects a young individual.

Types of Macular Degeneration

There are two main types of AMD: the exudative (wet) and non-exudative (dry) type.

Between the two, the most common AMD is the dry type, though this can progress to the wet form.

Only 10% of patients initially develop the wet form of AMD. Non-exudative type can develop much slower (over decades) compared to exudative type which may take a matter of months to progress.

  1. Non-exudative AMD. In the dry or atrophic type of AMD, the patient develops yellow deposits in the retina called, Drusen. Drusen, in small numbers, may not usually give vision problems. However, as it progresses in amount and in size, will dim and distort ones’ vision. Eventually, the cones thin out and degenerate, producing blind spots in the field of vision. Consequently, this results in the lost of central vision.
  2. Exudative AMD. In the wet-type of AMD, blood vessels grow underneath the retina (subretinal neovascularization), allowing for the sipping of blood and fluid in the retina. This accumulation of liquid distorts visual capabilities. This distortion, together with blood clot formation, contributes to irreversible loss of central vision. ‘

Signs and Symptoms of Macular Degeneration

The signs and symptoms of MD for both forms may show up suddenly, or develop gradually, and they include:

  • Difficulty with night vision
  • Visual fluctuation
  • Difficulty with reading
  • Metamorphopsia – distortion of visual images
  • Retinal bleeding

Causes and Risk Factors of Macular Degeneration

The retina is a membrane covering the back and inner lining of the eye.

It primarily receives the light from the lens, converts it to neural signals, then transmits these signals to the brain via the optical nerve for interpretation.

Within this structure is the macula, a pigmented and oval-shaped area in the middle part of the retina.

The macula contains a high concentration of light-sensitive cells called cones that are often associated with the best color recognition and 20/20 vision.

When the macula becomes damaged and loses its light-sensing capabilities, macular degeneration occurs.

The risk factors for developing macular degeneration include:

  • Age – AMD is more common in older patients
  • Oxidative stress – the exposure of the retina to light and oxygen is believed to play in the development of age-related macular degeneration
  • Family History – AMD is widely accepted to have genetic roots, starting later in life; genetic factors such as chromosomes 1, 6, and 10 attribute to 50% of developing AMD
  • Lifestyle – Other lifestyle factors, such as smoking history and diet habits and higher body mass index may have direct and indirect effects to the structures of the eye and can affect vision
  • Certain conditions such as hypertension and diabetes – may interfere with normal eye health and cause vision problems
  •  Blue light emitted from devices such as smartphones and computers – the blue light interacts with the retina, creating toxic molecules within the photoreceptor and non-photoreceptor cells, thereby contributing to the development of macular degeneration

Complications of Macular Degeneration

  1. Irreversible loss of vision. The major complication of dry age-related macular degeneration is the progression towards the exudative form of AMD, which can lead to permanent loss of central vision.
  2. Mental health problems. Secondary complications brought about by MD is the risk for the development of depression and social isolation. Due to changes in visual ability, the patient is compelled by feelings of hopelessness and dependence, making them prone to develop psychological imbalances.
  3. Charles Bonnet Syndrome. With the extreme loss of vision, patients may also experience visual hallucinations.

Diagnosis of Macular Degeneration

  • Routine eye exam – to test for visual acuity using:
    • Fundus photography to assess for the presence of drusen
    • Use of Amsler grid, a pattern of straight lines mimicking a checkerboard; a wavy pattern visualized by the patient would mean the presence of MD
  • Optical coherence tomography – to gain a 3-dimensional image of the thickness of retinal walls; any deviations from the set level of thickness would be highly suggestive of macular degeneration
  • Fluorescein angiography – involves intravenous injection of contrast dye that reaches the blood vessels of the eye, thereby allowing for the visualization and assessment of any deviations of its internal structures
  • Staging – Dry AMD has multiple features such as drusen formation, alterations in retinal pigment epithelium, and retinal epithelium thinness. The most common staging system used for dry AMD was described in the Age-related Eye Disease Study (AREDS) and includes the following:
    • Category 1 – No AMD characterized by absence or few insignificant drusen
    • Category 2 – Early AMD characterized by various small drusen, a few intermediate drusen or mild RPE malformations
    • Category 3 – Intermediate AMD characterized by various intermediate drusen, at least one large drusen or retinal degenerate not located centrally
    • Category 4 – Advanced AMD characterized by retinal degenerate located centrally

Treatment for Macular Degeneration

Currently there is no cure for macular degeneration, but there are treatment options utilized to limit or delay the onset of severe vision loss brought about by AMD.

  1. Medications. Anti-angiogenic drugs stop the body from forming new blood vessels in the eye and the leaking of fluids in the retina, thereby preventing wet macular degeneration.
  2. Laser therapy. This involves the use of high intensity light to burn off abnormally growing blood vessels in the eye causing AMD.
  3. Photodynamic laser therapy. This involves intravenous administration of a photosensitive drug that gets absorbed by the blood vessels in the eye. Afterwards, a laser is applied over the eye, thereby activating the drug that consequently destroys the abnormal blood vessels that caused AMD.
  4. Vitamins. A study by AREDS shows benefits if foods rich in vitamins C, E, beta-carotene, zinc, and copper are introduced to the patient’s diet.
  5. Low vision aides. Lenses or devices that enlarge images are helpful in addressing difficulties such as visual distortions.

Nursing Care Plans for Macular Degeneration

Nursing Care Plan 1

Nursing Diagnosis: Disturbed Sensory Perception (Visual) related to the deterioration of macula as evidenced by verbal complaint of vision problems such as blurry or distorted vision and inability to see properly at night

Desired Outcome: The patient will regain optimal vision while being able to cope with and accept permanent vision changes.

InterventionRationale
Assess the vision ability of the patient using an eye chart, and I.V. fluorescein angiography.To establish a baseline assessment of macular degeneration in terms of vision capacity.
Encourage the patient to have regular checkups with an ophthalmologist at least once a year.To monitor worsening of vision loss and treat accordingly.
Encourage the patient to promote sufficient lighting at home.The patient may not be able to perform activities of daily living as normal if he/she cannot see properly. Sufficient lighting also reduces the risk for injury.
Administer medications as prescribed.Anti-angiogenic drugs stop the body from forming new blood vessels in the eye and the leaking of fluids in the retina, thereby preventing wet macular degeneration.  
Encourage the patient to use low vision aides.Lenses or devices that enlarge images are helpful in addressing difficulties such as visual distortions.
Prepare the patient for laser therapy if indicated.  Laser therapy involves the use of high intensity light to burn off abnormally growing blood vessels in the eye causing AMD.
Encourage the patient to add foods containing vitamins C, E, beta-carotene, zinc, and copper in his/her diet in accordance to daily recommended intake.A study by AREDS shows benefits if foods containing vitamins C, E, beta-carotene, zinc, and copper are introduced to the patient’s diet.
Encourage the patient to inform the ophthalmologist if there is any worsening of symptoms.To monitor if MD is worsening and if there is a need for further investigation and treatment.

Nursing Care Plan 2

Nursing Diagnosis: Risk for Trauma/Injury related to loss of vision and/or reduced visual acuity

Desired Outcome: The patient will be able to prevent trauma or injury by means doing activities that can be done within the parameters of visual limitation and by modifying environment to adapt to current vision capacity.

InterventionRationale
Assess the patient’s degree of visual impairment.To establish a baseline of visual acuity and gain useful information before modifying the patient’s environment.  
Place the bed in the lowest position. Place the call bell within reach (if there’s any), and keep the visual aides and patient’s phone and other devices within reach.To prevent or minimize injury of the patient.
Promote adequate lighting in the patient’s room.To promote safety measures and support to the patient in doing ADLs optimally.
Ensure that the floor is free of objects that can cause the patient to slip or fall.To promote safety measures and support to the patient in doing ADLs optimally.
Advise the patient to wear sunglasses especially when going outdoors.To reduce glare and help protect the eyes.

Other possible nursing diagnoses:

  • Depression
  • Deficient Knowledge
  • Powerlessness

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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