Discuss about the Clinical and Experimental Ophthalmology.
The patient presents with hypertension. The patient has a history of hyperacidity, hyperthyroidism, an elevated BMI above 40 and a 20-year loss of vision in the left eye. Mrs XXX has undergone a cataract removal surgery in her right eye. On admission, she presented with a heavily discharging left eye with poor vision, hypertension, an elevated left eye intraocular pressure, and anxiety. This case is significant because it covers the viral eye infections that occur in patients with diabetes mellitus. As such, there are three priority concerns about the case of Mrs XXX. The first one is the orbital viral infection that is exacerbated by type II DM. The elimination of this viral infection is the goal of my management. This goal will be achieved by administration of topical acyclovir. The patient will then have reduced discharges from the eye. Secondly, the elevated blood sugar levels are dangerous to the health of Mrs XXX and the management using antidiabetic agents is a priority. The blood sugar levels will be reduced to a normal of between 65 and 110 milligrammes per deciliter (Fogli, Mogavero, Egan, Del Re & Danesi, 2016). Lastly, the high blood pressure that Mrs XXX has is also a priority that I will manage using antihypertensive drugs. The goal is to normalise the pressure to a systolic of between 95 and 140 mmHg and a diastolic of between 60 and 90 mmHg (Fogli et al., 2016).
Mrs XXX presents with viral ocular infection, and therefore, the nursing intervention is to administer topical acyclovir and an anti-inflammatory agent such as prednisolone (Patrone, Eriksson, & Lindholm, 2014). The conservative treatment with topical acyclovir, which acts to relieve the viral infection and suppress its further multiplication in the eye, is the lead remedy against the eye problem (Patrone, Eriksson, & Lindholm, 2014). I will also use a low dose of a topical anti-inflammatory to relieve pressure that is exerted on the eye thereby restoring comfort especially in the case where visual ability is impaired. In this case, I administered prednisolone eye ointment (Patrone, Eriksson, & Lindholm, 2014). The inflammatory process is the primary cause of tearing and excessive discharge from her left eye. Takakura (2014) was very categorical when explaining the need to use prednisolone because precautions are necessary, but its effectiveness is satisfying (Takakura et al., 2014).
Also, I would irrigate the eye. Irrigation of the eye with an ophthalmic fluid prevents the spread of infections from the optic secretions by cleaning them out. The irrigation of Mrs XXX’s eye with an ophthalmic fluid that I would initiate is meant to eliminate the discharge from her left eye, which has been blind for the past 20 years. The discharges from the eyes harbour microorganisms that can further cause damage to the eyes through localised infections. It also prevents the spread of the condition to her right eye through the optic chiasma and even the physical factors such as rubbing which are not evident in Mr XXX’s history. In addition, I used timolol because Mrs XXX’s IOP was raised to greater than 40 (Kempen et al., 2014). Educating a patient on various aspects of eye care and management prevents complications that may cause blindness. Often, diabetic patients ought to be partakers in their own care as opposed to being passive receivers of interventions (Misra, Braatvedt, & Patel, 2016). Educating Mrs XXX on the complications of hyperglycemia and the actively taking part in making decisions helps in being vigilant and understanding the necessary steps to undertake when alone.
On the other hand, I administered glipizide together with metformin to manage the blood glucose levels. This drug is important because it enhances the pancreatic activity in the release of insulin (Patrone, Eriksson, & Lindholm, 2014). Thus, it ensures that enough insulin is supplied to the tissues to help reduce blood glucose thus managing type II DM. Importantly; glipizide is very effective when utilised together with exercise and nutritional considerations (Patrone, Eriksson, & Lindholm, 2014). Mrs XXX benefits a great deal from this drug since her body has a tendency of insulin resistance due to obesity as Scheen explains (Scheen, 2014). Again, precautions are necessary because the drug may lead to severe hypoglycemia due to increased effectiveness thus leading to shock and death (Scheen, 2014). The cataract in Mrs XXX’s right eye was removed through a surgical operation as a corrective measure, and I will review it because cataracts mostly resurface (Scheen, 2014).
To administer Metformin as prescribed. Metformin acts on the body by preventing the production of non-sugars into sugars, which occur in the liver thus maintaining a normal glycemic state (Herman, 2015). This nursing action that I initiated on Mrs XXX’s was meant to battle her elevated blood sugar levels, and it was timely and necessary because of the use of metformin. It also improves insulin sensitivity to tissues leading to glucose being transported into the cells thus helping in the reduction of blood sugar levels to normal ranges of 4mg/dl -6mg/dl. It also decreases the ability of the intestine to absorb sugars into the blood stream and in turn promotes the utilisation of available glucose by tissues and the peripheries (Herman, 2015). In Mrs XXX’s case, this drug is very effective because the major condition that she suffers from is type II DM. However, the effectiveness of this medication can be further improved when it is used in combination with insulin, a phenomenon that misses in the management of Mrs XXX. Furthermore, there is need to monitor acidotic levels in blood because metformin may cause lactic acidosis (Herman, 2015). Importantly, the side effects of this drug ought to be uncannily explained to Mrs XXX, for instance, numbness in the extremities, uneven heart rate, stomachache, nausea, vomiting among others (Herman, 2015). Moreover, the normalised blood glucose level, an effect of metformin, will reduce the retinal complications of diabetes thus alleviating ocular infections and their outcomes such as blindness (Kempen et al., 2014).
Administer antihypertensive drugs. With the increased blood pressure that Mrs. XXX presents with, visual difficulties and blurred visions, the blood pressure has to be normalised by the use of an antihypertensive drugs like telmisartan and amlodipine (Ley, Hamdy, Mohan, & Hu, 2014). Telmisartan is an angiotensin II receptor antagonist. As such, it blocks the effects of the renin-angiotensin-aldosterone mechanism such as vasoconstriction and increased blood pressure. Ultimately, blood pressure shall be normalised thus preventing complications like a capillary rupture in the eyes and other vital tissues (Ley, Hamdy, Mohan, & Hu, 2014). On the other hand, amlodipine is a calcium channel blocker that prevents the flow of calcium ions into the cells of the heart and blood vessels thus lowering their contraction that subsequently causes vasoconstriction. Blood pressure is very critical in the management of diabetes type two as almost all diabetic patients present with increased and elevated blood pressure (Ley, Hamdy, Mohan, & Hu, 2014). This causes dizziness, confusion, reduced visual acuity and bloody vision. Active management of the blood pressure helps save the patient from injury, total loss of vision and kidney damages (Misra, Braatvedt, & Patel, 2016).
Teach the patient on exercising tips and good habits of daily living. For instance, regular and consistent body exercise can help prevent most complications. With a body mass index (BMI) of greater than 40, she should work tirelessly to reduce this to normal body mass index. In obesity; the body becomes resistant to insulin leading to glucose not being carried to cells and tissues for metabolism thus leading to persistently high blood sugar levels (Misra, Braatvedt, & Patel, 2016). When the body weight is reduced to manageable levels, the tissues become receptive to insulin leading to glucose being transported to tissues and cells thus normalisation of blood sugar levels (Nayak, Maharaj, & Fatt, 2012). Regular and vigorous exercises also result in the available glucose being metabolised to release energy and water as a by-product and in the long run reducing the blood sugar levels (Nayak, Maharaj, & Fatt, 2012). Exercise should be aimed at least 150 minutes weekly. The exercise should be vigorous and involve all parts of the body actively. In addition to exercising, nutrition is also a major component of the active management of type 2 diabetes. With proper nutrition, blood sugar levels will be reduced and maintained regularly and at normal levels. One is advised to take foods rich in high fibre to help loosen the stool and take the digested glucose away from being absorbed in the gastrointestinal tract into the colon thus reducing the amount of absorbed glucose hence reducing blood glucose levels (Nayak, Maharaj, & Fatt, 2012). Foods rich in carbohydrates are discouraged, and only a small amount is encouraged as a lot of carbohydrates in the diet will lead to a lot of glucose being produced and absorbed after its digestion thus leading to high blood sugars and increasing weight as the excess sugars are converted to glycogen which accumulates in the body causing an increase in weight (Patrone, Eriksson, & Lindholm, 2014).
The case of Mrs XXX is critical because it tackles viral eye infections, hyperglycemia and high blood pressure. Viral eye infections are as a result of increased blood sugar in type II DM (Szeto et al., 2016). Type II DM is an endocrine, metabolic disorder that is characterised by extremely high blood glucose levels due to the inability of insulin to transport the glucose from the blood to the tissues since they are not receptive (Szeto et al., 2016). Intriguingly, in Type II Diabetes, the pancreas secretes sufficient amount of insulin, but the tissues are non-receptive leading to it not being effective in the transport of glucose into cells. Diabetes Type II is a lifestyle disorder that arises due to poor and bad eating habits, which cause an abnormally, increase in body weight (Szeto et al., 2016). Thus it can be managed through lifestyle change. Diabetes comes with retinal complications, which includes reduced visual acuity, blood vision, glaucoma, increased intraocular pressure and poor vision. It also causes a number of systemic complications such as high blood pressure, kidney failure, nerve failure, non-healing wounds, peripheral neuropathy and permanent disability (Takakura et al., 2014). I managed Mrs XXX’s diabetes primarily with oral hypoglycemic agents like metformin and glipizide which help reduce the blood sugar levels by promoting uptake of glucose into the cells, preventing the absorption of more sugars and glucose in the gastrointestinal tract and preventing the production of glucose from non-sugar compounds (Takakura et al., 2014). I also managed the viral inflammation using topical acyclovir, and the inflammation lowered by prednisolone among other interventions. Again, I fostered diet adjustment, i.e. reducing carbohydrates in the diet, and increasing fibre in the diet, eliminating junks from the diet, taking more fruits and fluids. All these interventions, as I executed partly in Mrs XXX’s case, are assumed to be fruitful (Thomas G Chu, 2015).
On a personal reflection, I tackled the case of Mrs XXX professionally considering the interventions that I initiated as far as nursing is concerned. I considered that the management of Mrs XXX’s condition required both the conservative and the nursing interventions. As a result, all the interventions that I executed are presumed to be successful. Again, Mrs XXX was not refuting any of the interventions as prescribed in the rights of patients. She could be willingly ready to have them executed on her. Furthermore, the case of Mrs XXX has been a good example of infections of the eyes that arise from type II DM, hypertension and high blood pressure.
Therefore, the management was supposed to be strictly linked to these priority concerns (Threatt, Williamson, Huynh, Davis, & Hermayer, 2013). It was presumed that all the prescribed medications do not attract any form of hypersensitivity from Mrs XXX’s system. Additionally, she could not also exhibit their side effects, a reason many of them are prescribed at the same time or in combination with one another.
There are no infections that would arise from the interventions that I initiated on Mrs XXX. Her family would be readily available to help, especially her husband because he lives with her at the moment. Mrs XXX would need to see a nutritionist and a physiotherapist during her next visit (Yang, 2016).
In conclusion, health is vital in the life of any individual, and thus, the management of complications that arise from chronic diseases such, as diabetes mellitus must be implemented. A typical case study of Mrs XXX is an eye opener on the difficulties that most patients endure when ocular complications, hypertension and high blood sugars affect them.
References:
Fogli, S., Mogavero, S., Egan, C., Del Re, M., & Danesi, R. (2016). Pathophysiology and pharmacological targets of VEGF in diabetic macular oedema. Pharmacological Research, 103, 149-157.
Gummesson, A., Nyman, E., Knutsson, M., & Karpefors, M. (2017). Effect of Weight Reduction on Hemoglobin A1c in weight loss trials of Type 2 Diabetes Patients. Diabetes, Obesity, And Metabolism.
Heath, G., Airody, A., & Gale, R. (2017). The Ocular Manifestations of Drugs Used to Treat Multiple Sclerosis. Drugs, 77(3), 303-311.
Herman, W. (2015). Response to Comment on Inzucchi et al. Management of Hyperglycemia in Type 2 Diabetes, 2015: A Patient-Centered Approach. Update to a Position Statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2015;38:140–149. Diabetes Care, 38(9), e143-e143.
Kempen, J., Sugar, E., Varma, R., Dunn, J., Heinemann, M., & Jabs, D. et al. (2014). The risk of Cataract among Subjects with Acquired Immune Deficiency Syndrome Free of Ocular Opportunistic Infections. Ophthalmology, 121(12), 2317-2324.
Ley, S., Hamdy, O., Mohan, V., & Hu, F. (2014). Prevention and management of type 2 diabetes: dietary components and nutritional strategies. The Lancet, 383(9933), 1999-2007.
Misra, S., Braatvedt, G., & Patel, D. (2016). The impact of diabetes mellitus on the ocular surface: a review. Clinical & Experimental Ophthalmology, 44(4), 278-288.
Nayak, S., Maharaj, N., & Fatt, L. (2012). Association between altered lipid profile, body mass index, low plasma adiponectin and varied blood pressure in Trinidadian type 2 diabetic and non-diabetic subjects. Indian Journal Of Medical Sciences, 66(9), 214.
Patrone, C., Eriksson, O., & Lindholm, D. (2014). Diabetes drugs and neurological disorders: new views and therapeutic possibilities. The Lancet Diabetes & Endocrinology, 2(3), 256-262.
Scheen, A. (2014). Pharmacodynamics, Efficacy, and Safety of Sodium–Glucose Co-Transporter Type 2 (SGLT2) Inhibitors for the Treatment of Type 2 Diabetes Mellitus. Drugs, 75(1), 33-59.
Szeto, S., Chan, T., Wong, R., Ng, A., Li, E., & Jhanji, V. (2016). Prevalence of Ocular Manifestations and Visual Outcomes in Patients With Herpes Zoster Ophthalmicus. Cornea, 1.
Takakura, A., Tessler, H., Goldstein, D., Guex-Crosier, Y., Chan, C., & Brown, D. et al. (2014). Viral Retinitis following Intraocular or Periocular Corticosteroid Administration: A Case Series and Comprehensive Review of the Literature. Ocular Immunology And Inflammation, 22(3), 175-182.
Thomas G Chu, M. (2015). Patients with Advanced Diabetic Retinopathy’s Understanding of Diabetes Mellitus and Their Diabetic Eye Disease: A survey of 100 patients currently undergoing treatment for Diabetic Retinopathy in a Large Retinal Practice. Journal Of Clinical & Experimental Ophthalmology, 06(01).
Threatt, J., Williamson, J., Huynh, K., Davis, R., & Hermayer, K. (2013). Ocular Disease, Knowledge and Technology Applications in Patients With Diabetes. The American Journal Of The Medical Sciences, 345(4), 266-270.
Yang, C. (2016). Diabetic eye diseases. Diabetes Research And Clinical Practice, 120, S14.
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