ࡱ> 5@ 8bjbj22 rXX_0L(L(L(8(l(\l?X)()())),,,>>>>>>>$ARlC?l-?,@,l-l-?))&?F3F3F3l-))>F3l->F3:F33r<<>)L) `L(z/f=><C0DC>C>,",F3,,,,,??Dd $3"Glaucoma Description Ocular disorder characterized by increased intraocular pressure, optic nerve atrophy, and visual field loss People respond differently to the increase in pressure; some sustain no damage while others result in blindness Attacks peripheral vision first. Incidence of Glaucoma Over 80,000 persons blind b/c of glaucoma 2nd leading cause of blindness Leading cause of blindness in Afro-Am Occurs more frequently with advancing agebut is not a normal part of aging process Person may not be aware they are developing. May not have signs or symptoms until too late, silent thief of vision Risk Factors: hypertension, heart disease, diabetes, smoking, increased caffeine and alcohol intake, long term steroid use, obesity. 7. Can be unilateral or bilateral (one or both eyes) Pathophysiology Ciliary body secretes approximately 4-5ml of aqueous humor a day This bathes the lens then flows through pupil into anterior chamber Outflow of the aqueous humor is decreasedmany different reasons why this can happen Because the aqueous humor cannot leave the eye at the same rate it is being produced, it remains in the eye and pressure increases. Normal pressure of eye is 12-20mmHg. High pressure causes ischemia to optic nerve disc, loss of peripheral vision leading to blindness Pressure >23 mm Hg = developing glaucoma  SHAPE \* MERGEFORMAT  Types of Glaucoma (type of angle determined by the width of the angle between the cornea and the iris.) Primary Open-Angle: 90% of primary glaucoma cases; most common. May be genetic. Bilateral, no pain Gradual build-up of humor/IO pressure; insidious onset. Referred to as thief in the night regular eye exams can detect Unknown etiology but think that its associated with the trabecular meshwork. Aqueous humor usually flows in and out of the meshwork, but for some reason, the meshwork tightens and aqueous humor builds up and cannot flow through. No S&S Angle-Closure Anatomical angle is already narrow Sudden blockage and flow obstructed, usually unilaterally. S&S: Severe pain, blurred vision, vision loss Rainbow halos around lights, N&V Emergency situation Can be triggered by dark rooms, stress, antihistamines, anti-depressants, cold meds  SHAPE \* MERGEFORMAT  Secondary glaucoma Increased IOP occurs as postop complication from eye surgery, trauma, infection, inflammation, tumor, and chronic use of topical corticosteroids (eye drops). Something that somehow changes the anatomy of your eye and the angle closes. Clinical manifestations Increased intraocular pressure Cupping or indentation of the optic nerve head (disc) Visual field defects Treatment (may be on multiple medications) Pharmacological Goals for outcome management: Facilitate outflow of aqueous humor by removing obstruction Maintain intraocular pressure within a range that prevents further damage to the optic nerve. Chronic open-angle glaucoma Pharmaceuticals first: Requires accurate timing. Miotic drops open and drain and increase rate of fluid flow out of eye (Pilocarpine, Carbachol) by constricting the pupil. Reduce intraocular pressure. Usually prescribed four times a day. Can cause blurred vision, burning, brow ache. Have to use these for the rest of your life. Topical Epinephrine lowers IOP by increasing flow rate out of eye Beta-blockers suppress the secretion of aqueous humor. Usually BID. Contraindicated in clients with asthma or COPD. Assess for bradycardia prior to administration. Carbonic anhydrase inhibitors reduce the production of aqueous humor. Available in oral doses. Osmoglyn may be prescribed for emergency situations. Laser Surgeryused when meds dont work Laser trabeculoplasty applied to damaged drain stretching and opening trabecular meshwork allowing fluid to flow. Laser makes holes in network. May have to be repeated over time because the meshwork may tighten again. Medical treatment is normally continued. Angle-Closure Surgery Laser iridotomy: creates a hole in the iris to allow passage of aqueous humor Filtering surgery: trabeculectomy creates a new drain in the meshwork and the sclera Screening Important! Over 45 years screened annuallyshould be screened before that, but yearly after 45. Family history African or Asian descent DM, myopia, HTN, steroid intake Morning headaches Recurrent blurry vision Rainbow halos around lights at night Pain around eyes after watching TV or leaving a dark room Nursing Management of the Surgical Client Preoperative Care Teach client the expected outcome of the procedure. Teach client that popping sounds and flashing lights may be experienced. There will be a waiting period following procedure to evaluate a possible rise in intraocular pressure. Should obtain alternative transportation. Postoperative care Instruct the client not to lie on the operative side to avoid pressure. Clients intraocular pressure should be assessed. Also assess unrelieved pain, nausea, and decreased vision. Cataract Description Development of an opacity within the lensinterferes with light transmission to the retina. Ability to perceive images in not clear. 3rd leading cause of preventable blindness Incidence increases with age By 85 years, 95% develop opacities (normal aging variance)Most people develop some opacities by 85 yrs of age, but not necessarily the whole lens Etiology The lens enlarges with age and cataracts develop as a result of alterations in the metabolism and transport of nutrients within the lens Risk factors: DM, Down syndrome, trauma, maternal rubella, UV light predispose to cataract formation. **Must use UV protectant sunglasses to help prevent cataracts! Smoking, alcohol intake also contribute to the development of cataracts. Signs and Symptoms Blurred vision Photophobia Glareespecially when driving at nightesp with oncoming headlights. See better in low-light when pupil is dilated Cloudy lens seen on examination with ophthalmoscope; red reflex distorted or absent. Surgical TreatmentThe only treatment for cataracts! Not a high risk surgery. Remove Opacified lens Intracapsular=entire capsule removed (rare)front and back lens removed and a permanent plastic lens is placed. Extracapsular (90%)= back lens left in place to hold implanttake off front lens and place plastic lens into place, leaving back lens in place.**Most common tx. of cataracts! c. Implants are not done with DM patients because of their decreased ability to heal and because their microvasculature and circulation for such fine surgery can be inadequate. Intraocular implants Permanent plastic lens Contraindicated in diabetic retinopathy Surgery without Implant Aphakia corrected by use of eyeglasses or contact lensesA person without lenses (because of removal and no implant placed) may need to use extremely thick glasses to correct vision. Eyeglasses very thick and may also magnify objects. Difficult to judge distances, spatial relationships. Reduces and distorts peripheral vision. Important safety consideration: Cannot judge distances even with glasses/contact lens corrections. Should NOT be driving!! Contacts do not magnify or distort. Manual dexterity of elders causes problems. Expensive. Post-Op Teaching with Implants Outpatient Surgery=need transportation Wear eye patch for 24 hours. Glasses during the day and sunglasses outdoors. Do not bend head down; squat or kneel to pick up something up Sleep on back or opposite of operative side (1 week) For one week, avoid: rubbing eyes, squeezing eyes shut, straining with BM, lifting over 5 lbs., driving, coughing, sneezing, vomiting, sexual relations. No bending, stooping, coughing, etc. NO pressure either externally or internally on the eye post surgery! Very important to inform pts about this! Post-Op Meds Like glaucoma meds May also include antibiotic and/or corticosteroid eye drops Itching sensation normal after cataract surgery Report s/s increase IOP (intraocular pressure) immediately (pain, h/a, brow pain, blurred vision, halos, double vision Chronic Hearing Impairment Description: Number 1 disability in USA 1 in 15 Americans affected By year 2050, 1 in 5 Americans affected because of the graying of our population. Many people afraid/ashamed to admit to hearing loss Etiology Heredity Toxic substances Trauma age-related (presbycusis) noise exposureThis is the big one! Head sets, telephones that sit around/in ears, too loud! infections, or history of infections: esp. measles, mumps, meningitis Arteriosclerosis ototoxic drugs (Gentamicin, Vancomycin, Lasix, salicylates) neuromas of the 8th cranial nerve Other Hearing Disorders Tinnitus: head noises; ringing, NOT a disease but a distressing symptom and warning of hearing loss; subjective Balance disorders: problems of vestibular system and righting reflexes; vertigo; subjective Presbyastasis: balance disorder of aging; degenerative aging changes; high risk for falling. Menieres disease: vertigo, hearing loss, and tinnitus. Vertigo is often the most troublesome manifestation in the early stages. Notes from Handouts in Class Regarding Nursing Implications for Pharmacology: The Client With Glaucoma: Mioticsare all cholinergic drugs. The ocular effect of these drugs is to block the sympathetic nervous system input, which causes the pupil to dilate in low light. In addition, they contract the ciliary muscle, allowing the lens to accommodate for near vision. The effect of miosis and ciliary muscle contraction is to stretch or open the trabecular meshwork. Nursing responsibilities: After administering drops, have the client gently squeeze the lacrimal sac (right at the bridge of the nose) for 1-2 minutes to increase the local effect and decrease systemic absorption. Assess client for contraindications to therapy with miotic agents: including bronchial asthma, peptic ulcer disease, intestinal obstruction, urinary retention, hypotension, bradycardia. Assess client for possible side effects including: Increased lacrimation Brow pain Headache These drops are usually administered/prescribed 3-4 X/day for life. Mydriaticsympathommetic drug acting to dilate the pupil, reduce the production of aqueous humor and increase its absorption, effectively reducing the intraocular pressure in open-angle glaucoma. Nursing Responsibilities Assess client for contraindications and adverse reactions to epinephrine, including acute angle-closure glaucoma, HTN, CAD. Monitor bp, hr and respirations Teach client to report any change in visual acuity or eye paineye pain may indicate an attack of angle-closure glaucoma and should be reported immediately to the physician! **Often, the mydriatic and miotics are used together in combinationone opens the meshwork, and one reduces the production of aqueous humor! Beta-Adrenergic Receptor Blockers--Used to reduce intraocular pressure by reducing the production of aqueous humor in the ciliary body. Because beta-blockers do not affect pupil size and lens accommodation, they do not have the adverse effects on visual acuity that miotics and mydriatics do. An additional advantage is a longer duration of actionallowing 2X/day dosing! Nursing Responsibilities: Assess client for allergies or contraindications to beta-blocker therapy: asthma, COPD, heart block and heart failure. Maintain pressure over the lacrimal sac after administration to prevent systemic absorption. Assess for side effects: bradycardia, hypotension, wheezing and difficulty breathing. Carbonic Anhydrase Inhibitorsreduce the production of aqueous humor and lower intraocular pressure. Some are used as eyedrops in adjunctive therapy for clients who cannot use beta-blockers, and others are used orally or IV as adjunctive therapy to reduce intraocular pressure preoperatively for the client with angle-closure glaucoma. Nursing Responsibilities: Assess for contraindications including known allergies to sulfa, severe renal or hepatic disease, and electrolyte or acid-base imbalances. Assess daily weight, I&O for potential volume depletion. Assess skin for reactions: pruritis, purpura, pallor and bleeding. Monitor serum electrolytes Administer in a.m. to prevent sleep disruption b/c of diuretic effect. Teach client: To maintain 2-3L/day intake; rise slowly from sitting position (orthostatic hypotension); notify physician if febrile, sore throat, easily bleed, numbness or tingling, skin rash. Chronic Vision Problems Lecture Nov 18Page  PAGE 8 of  NUMPAGES 9Chronic Final 6 QuestionsBlack: 1809-17, 1831-40    B R r y   a p    x ﰞqmfT#hjh~5CJOJQJ^JaJ hchchch~6CJOJQJ^JaJhj6CJOJQJ^JaJhc6CJOJQJ^JaJ#hch~6CJOJQJ^JaJ#hchj6CJOJQJ^JaJhcCJOJQJ^JaJ hiOhjCJOJQJ^JaJhjCJOJQJ^JaJ hiOh~CJOJQJ^JaJ   ) S r b   . o   gdc^gdc $ & Fdhgdj  & Fdhgdj  & Fdhgdj  & Fdhgdj  & Fdhgdj_88   = A B Y Z [ ] _ ` q s ",3QScdl¾ЏraaЏaYhchc6 hiOh\ CJOJQJ^JaJhjCJOJQJ^JaJh\ 6CJOJQJ^JaJh\ CJOJQJ^JaJ hchcjhCUmHnHujhCUhChch~CJOJQJ^JaJ hiOh~CJOJQJ^JaJhc6CJOJQJ^JaJhj6CJOJQJ^JaJ" = > ? @ A ^ _ ` ,d & Fdhgdc  & Fdhgdc  & Fdhgdj  & Fdhgdj  & Fdhgdj^gdcgdC & Fgdc /6<JPYdg޾ޝykYG9h~CJOJQJ^JaJ# *hCh~CJOJQJ^JaJ# *hChjCJOJQJ^JaJhCCJOJQJ^JaJ#hCh~6CJOJQJ^JaJ#hChj6CJOJQJ^JaJ#hChC6CJOJQJ^JaJhj6CJOJQJ^JaJhjCJOJQJ^JaJ#hjhj5CJOJQJ^JaJ hiOh~CJOJQJ^JaJ hiOhjCJOJQJ^JaJ/Pd BWJf  & Fdhgd$r  & Fdhgd$r  & Fdhgd$r  & Fdhgdj  & Fdhgd2>  & Fdhgd2>  & FdhgdjgdC  & Fdhgdj89xzW`bŷũũ|k]N]h$r6CJOJQJ^JaJh$rCJOJQJ^JaJ h2>h2>CJOJQJ^JaJh~6CJOJQJ^JaJhC6CJOJQJ^JaJhj6CJOJQJ^JaJhjCJOJQJ^JaJhCCJOJQJ^JaJ hiOh~CJOJQJ^JaJ hChCjhCUjhCUmHnHuhCjhCU IJ}.T]յզզ䕆xxixi[J[ hiOhnWCJOJQJ^JaJhnWCJOJQJ^JaJh}6CJOJQJ^JaJh}CJOJQJ^JaJhnd%6CJOJQJ^JaJ hiOh~CJOJQJ^JaJh2>6CJOJQJ^JaJ h$rh$rCJOJQJ^JaJhC6CJOJQJ^JaJh$r6CJOJQJ^JaJh$rCJOJQJ^JaJh2>CJOJQJ^JaJ'5+189Rĵu㵗fTuFh$rCJOJQJ^JaJ#h}h}6CJOJQJ^JaJh~6CJOJQJ^JaJ hiOhCCJOJQJ^JaJ h}h}CJOJQJ^JaJhnW6CJOJQJ^JaJhnd%6CJOJQJ^JaJh}6CJOJQJ^JaJh}CJOJQJ^JaJ hiOh~CJOJQJ^JaJhC6CJOJQJ^JaJhCCJOJQJ^JaJ+SXn&{L  & Fdhgd +  & Fdhgd +  & Fdhgd +  & Fdhgd$r  & Fdhgd$r  & Fdhgd$r  & Fdhgd},-Wn}~EFzKõߤtcTCCCC hiOhnWCJOJQJ^JaJhC6CJOJQJ^JaJ hiOh +CJOJQJ^JaJh +CJOJQJ^JaJ h +h +CJOJQJ^JaJ h +h$rCJOJQJ^JaJ h +h~CJOJQJ^JaJhnWCJOJQJ^JaJh$rCJOJQJ^JaJhCCJOJQJ^JaJ hiOh~CJOJQJ^JaJh$r6CJOJQJ^JaJKLvclx)2Fl{\13´¥”‚se´WsWsWht:CJOJQJ^JaJhBCJOJQJ^JaJht:6CJOJQJ^JaJ# *hCh~CJOJQJ^JaJ hiOhBCJOJQJ^JaJhC6CJOJQJ^JaJh +CJOJQJ^JaJ hiOh~CJOJQJ^JaJ hnWhnWCJOJQJ^JaJhnWCJOJQJ^JaJh~CJOJQJ^JaJLvpclx)Fl]  & Fdhgd +  & Fdhgd +  & Fdhgd +  & Fdhgdj  & FdhgdnW  & FdhgdnW  & FdhgdnW  & FdhgdnW  & FdhgdnW]pT) !!!!!"#$7$^$$  & Fdhgd +  & Fdhgd + 8dh^8gdt:  & Fdhgd +  & Fdhgd +  & Fdhgd +3QSfg( ) * e f !!!!!!""."/"">#A##($6$;$A$$Ϳ͢͢Ϳ͢ͿqqͿͿͿ͢ hiOh +CJOJQJ^JaJht:ht:6 ht:6ht:h~6CJOJQJ^JaJh +CJOJQJ^JaJht:6CJOJQJ^JaJht:CJOJQJ^JaJ hiOh~CJOJQJ^JaJhB5CJOJQJ^JaJ#hBh~5CJOJQJ^JaJ&$$%%%%M&&'k'x'''(?(G(H(M(Y(_(z((((;ܦܘܦ܇vvdVGh6F6CJOJQJ^JaJh6FCJOJQJ^JaJ# *h6Fh~CJOJQJ^JaJ hiOh;TCJOJQJ^JaJ hiOh +CJOJQJ^JaJh +CJOJQJ^JaJht:CJOJQJ^JaJ *ht:ht:5h~6CJOJQJ^JaJht:6CJOJQJ^JaJ hiOh~CJOJQJ^JaJ#ht:h~6CJOJQJ^JaJ$$%%M&Z&m&&&P'k'x'''(6(?(H(Y(`(  & Fdhgd;T  & Fdhgd +  & Fdhgd +  & Fdhgd +  & Fdhgdj  & Fdhgd + & Fdhgdt:  & Fdhgd +`(z(()/)k)))*q**R+S++'-A--../ & Fdhgd6F & Fdhgd6F & Fdhgd6F & Fdhgd6Fdhgdj  & Fdhgd;T  & Fdhgdj  & Fdhgd;T(((())**++Q+R+S+++++, ---%-&-'-@-A---....// / ///X/Y/b///0000³ޯ||w| h6F6h6Fh6F6>*h6Fh6F6h6Fhjh6F5 hj5hJUh\ 5hJUh6F5h[{hj6CJOJQJ^JaJhjCJOJQJ^JaJh6FCJOJQJ^JaJ hiOh~CJOJQJ^JaJ h6Fh~CJOJQJ^JaJ./ //Y/060001 2334r446266697 & Fdhgdj & Fdhgdj & Fdhgdjdhgdj & Fdhgd6F & Fdhgd6F & Fdhgd6F & Fdhgd6F05060000011 2 2.2022k3333344q4r4444,566162666668797S7T777]8^8_888888888888888۽ζhcjhU*hJ !mHnHu*jhUh h6Fh6F hjhjhjhj6>*hjhj6 hj6 hj5h6Fhj6hjhjh6F6h6Fh6F6h6F997T77^8_888888Qkd $$Ifl0H$ t644 la $$Ifa$gdU$=$Ifdhgdj & Fdhgdj 888888dhgdjQkdl$$Ifl0H$ t644 la8888 h6Fh6FhJ !h&1h:p e/ =!"#$%nk. ?+ƞk_w!PNG  IHDRSzsBITOPLTEsތc9ƥB!k!1))s9JR!!J!cJ!kcJJ{J{kcνΥJB{έcZs{sBƄcRJR1B1cs19kΔ)ck{19Jskk[bKGDH IDATx[vHH ;R3>b ݋տ Z$ gM =E5lGgz|yvZ\,0Jn mavMYx/ZRw¢6K:N8~7 >TN.|!|8ynt@)>{s654XFo+;;;5)uv (#-L&IRetV&+I`<,} ߥ;ypds(w"AwM ӨfxnCP&JZ[‹,n"&Z*n露dmV q%7]G+me $a G'a3c/@ 7I`sXz)UlA>Oˠfj7"d˒!&K"S^g>%OWYfi2le5^Vd_@e$ J_'ZB4H``"ǏQ'qp4ⶌ0{Z%Z\q,[4Y^`%-K : `vN5t:SX^R6^$ 75)%|dgKycl3e.k̴k%&E 6JkiQL+88]uc &Xzr(9m^:S''@GRKfn\"$R5.Cy&XK\g8xkJgſ` Mlc.Q6QN)6 tnK`F=4=`6qj %ˣBo%J,Dɗ_1wė7XOfH[&8^ 0IP+md=k/(ٶ-I ,SĜ!Vw{MS3u3M,J ;t/áG뇏? uҸ, p*,{‰ c,A 6xq!.?-rJ)CZ@ ~b^dVؕy AA 1 n.N/ A8޺ w?N')g"~J֊OhޏR;NR$^ }{o%$m]C V4#?N "|L+./U[af $#lp-: BKZ5ôMÃd(hNhFQtʤ/?L>plUgɪI_ch'Ӗ+ז%8x0-ISڕ@ j\XdqLe6xlgѝ'P=3Jv2/_SX Bٖ-<W6YV  `h0AX?G]ޮ,"ACO8͸ewh+_Ip}J<;.˜9Yd#.P>Ϥ;caIm\0o ZqN{n hߢoھ4,Fp}26I $ǨTאIA;a3|pIfYn|ʕqx"mW8Wm iZČ $ݐ[ h158pEII߸ c|e͗_AZ͋U1u]Q&J:Ռf@ڢ9mӀ)ڔ61ctR%tԨ*[ ?w[\-yWG5µk EuzN"2<$B 7@mz=I3?҆47PD99[$#L.k*iM(/N ZKy aCJQ!y3pKWp`pV* {ǑX"B[#T'`\"DObSB4d>aXdp9"-wm̤7 %Gև@6Rt6^=co- 25S#BHd|]J3[Վ ڡN\˦d\^Q*,~L3E<򷞋>zbY&e0uBNd a> 5xؐVIԼNaq{f.=0W컸p9D=QQGK@"C w,83yg}99W[6Lp&W` ӏ۹Umz:Ŧ[.@ 8,tU]ʧT#c%$tfPB8xuz&MelXG#ost”QlʻuB0>'rUSdBٲqsL؄˂bOJqb„&%t.]|.@ރծӹEWڻD &tN#|pȲ#Dd#b~`5X 3lH!DLw-*>`].{Xt]u̬AjlH0H(gsRxg Jtϔd{]xX8@K=2O1C,  kAY誀-,'Nk_CzKl@K[Hpe԰և$'qwv[ZhIP~K!Kbhyjm$قO|y;N@38VNoG" y0 q01ς]G#F+IgO,ޔ'lq}-+@eMW<&^Do?Yq c;$ GΑ-~mt">ᡉiӷ 3◐K W}^:*D" y)L>i/vf`Z }M`HxfqwFh:<<뵩<BCGHfWLubKѝ8Z(?&(F3ޚ@B ;i_C_A*rkǜ& Ek,d\ )c^C2蟁v1X-=籣 6$Y ;8Gyy-ο⎖;+Ὲ]/L̙+ I;`/~:\vɘ!'Gn>Xuְ%D\&>ifj1yWow3ArRa ~< 4Ҍ'!z|y+]ܪ-E"R?揨gg{q[[LEWdZ(3(L&.?MCksOwy,>O8A?~(Q6myoCՏTN$ zUaw}!gC}\z.[,Q`cHl3 永 ^cC_ pdk֬z!Pv@\5yu\}=:d~8&f"OK3c/w4l^Z2w"LܫgLfנ;;aqN%o?SaY1NQrM꨼v+V2rhg\s{<ְU(o 7Z9orf7R$gؐ5Ќw191KyK۰+>pa?|ZߜKvk$Fqo˹PBWC4~K_K,}!ZN.uHK8kU\ö8wz\.,*㬋Ue/%O ҀҽBw.5 | ,dkM/zIq~QORSR@b{Իl*[Ӯ׺3sBA kۏ𿬣}P`lI-ҚFm iKI]̔kk\PotA꽆un}$}3`Wɦ5!Uw]#(l?9!rvjeXvLd@S~?Px]by m>% hr/aqa wq[iwqARo4Rmf3<- ԿR=ȺG4'ɤظ<:@;eЏcxY؛9*v ',~ֲy*75t?wKIH_&'yprmشMnqԦ0z(4&u'8\5:o13ZakΫwDKDh˥s]p2M33,ӧOwww7%Jֈd%~PN6=Y̯ƒ//Oiv8/%j? V _\x/{KЇÕCHurh>-nKwVg!3j U;b_D݆% LLH4ys,b>_ͯRiݤ\wG0h|fwEl a.VB>JBٖ{̲NyZDAZ% [it(#9-rwf Tj<"Kuᑱz`,>YY4aZO0o!IG\s bN+G>1gL. "X7['ؖcgtF!zzU=.w3޸ Qhn8Ahl“׷^[;Yc*o;cm)p{kRVe3~<ECo-#m n1z5~txƇO#JIkaLS )cbMs{ bb49wҊX=A^,uE#2)#rQ\ݻoz2 >ͫ~o-в0x>+Wd&&~E &5(Fzlz<&3Dcًǻw.ःNh#U.({rp{A?x#4x+D6 M)ڤ񃰳1x!@xԸChg޳CB =P1Cjr\m"o3>d3,,xB-ᜆA.)Ďi, Jo8i@X-+nAGf-*Q@vFdXeXih?P Qפ.cI!w?!ׁ% wWvq{;Nſ<;cz/\yloߨ\ޞa?+"uD̫(K9L H6' x >DZ#}@VQ8fT5REpLyCǺ3wL 5h9K|dH_c7sDkpԫc6t1`O̔*#o.BZ$xIMC^l| B ]Ig n4~# CV/u %CA,R8'7#k@e\[XʹZZzÎ3M⩉vw*fѼ s 嘙w򝡲誀AI94wsUUk@{Gc/pn'TiE'ƑPNSw0P\ ,Gfu/',שu+ciNqV׌BwUz:TfCR?܍iTxRht}0u߾/۪t ?~3^| b34O&P~!wxJz8, Lj k gv )x?_<Tή&f/jiޱL7td )ӥh<370JJwhexG9 E?(|0+p~7CRAգ!z^jgAzvĺ,QvR޶?!#~;YHOw"IR;4`>%iڵfB2# -IDAT )<[ ޴`KG&`6Eߠi7TROqZ\/faAfwz~H mϬg,Y.5c,e)xM %8)[4`k課m;_m$Mu9- "Vk/n}^sG2r;GZ 9[.}"Ɠ7i%z-_D|.?D4W\o| @L;jtYfY$]ȭ^MՆi74V StkX/:y(,Y"鲓Uǁd̻nJ:@~c;eFM*(keTN44e;% / $vZ~,,~xR!j*M/4kg|l£2M yD|R|!8-ܦ)D)˜GHfdFIĔ~U@l!9jkK:hRq(h8i㩌Lkv*20-'Re'aU|[l5bo~͞bjo.E[ ~2bT;B +!栝JҪN&)*^l|;wN|V)3/ 4l6LY,$oEɝ gaըoxñ=Gt\z5 '$Tq><# ޠTp\lobo҈]pb{SOQ #|e ь^AM@Wn_hvҒɚ\[p|Џ=G{-tw< ^[ML~N37G/a(M&mW,^v's:7{ְ*֣QF]F7@u9z}յ@2|8q*U aϸ ~~mx/ zq蛫5~Kнc0Q9GC0XL_Tz$@]'>A|Lpn![/10&+~`r8Ի_߯FO˯a!?FM!ZɄ ?˨I|WFa!DH>~x['x@@~.ΈM(UV1SB|TILfE񕀨@Cofp`_Vh_XW/LYjo" qdwja0 ̴-XN5slVa<**S;WH[L7i :uR!6za۝خobm@2{ڶ|Z.^mLz ϟCF Vo`0ӿz7> 4.|@[J< [$AdĿ[mVgE}w4@(8'w9$FK#uE25>m dʘ&kQڅg ~-Zw4GW/xv d|5{ʺ LV0vFghqVtf!!@ܽ?Ay#|8}`|3:M [eo!ˮ|_,z2 `6릸DBzHڙ_S~ɵYgSrő}ڿ`?!_)nl5En8wֳ }nArŌ3SMe>_XQofG|xo-X1.29Qvf*~_!Ė9=[Ni>?P%WP/o}\~E'D`3GsT@4C*=򩪸k"I4k')%[r^᳂5(d,޺tq~ݡ G ǎ.o9CBN=¥L#4{*HOa#b@xv5!acV)]M+BRT6i"-ZE9g:l񿡌?|ϴZQ)E)PrR7vN◼#R;Tw'ak3Ͱ]Gߟ'h;D8N'،Lx4iY iEͶgS^rx̧q-` (}0Q؈\K㕁 RC9NQߧH`!]SdBX2M_3̲ F.Ifk9Dbx@@H]+~ټP`͍C( } + Mq,2? %bg`ggu7ybۣ,+|ߵ bě1p-P>rL#F#W>i_5ECYkbxh=gm؄v0nYd~ط%YAgD wpp'hf'5v2`XNwc'y|SFDŠ 8IKȇvUCP2D j9&w2'?Bѹ2w.Fh,L,h_uǫۄO# O@a3\ڍ9J81 ">D{ݡ{zrn{`RX_%]l* >* BD?Ʀ},rڮ.4hEy= 6WWי~ GK$釕Q:GEgA?DRٌR>es,e/yyn&7\*L[dkMu_z#4* J4OLY|a$>`{#?i,[mvڵm[Slf[쎋%[TuuHSuopv tmgFԆ= ՁiIENDB`n-0lMAIPNG  IHDRSsBITOPLTEތs{kB!JssRJskޥ֔Jc{1ZccZJ){111BJJJc9skέsssJ){ƜZJ1RksB1BRJvJbKGDH IDATx[m{8, $p9m nKC O-w>G6d]7f̙*>|?cp~{;{ҵ~,.]] E^M?lW";^oԿlIo_(Um#&>4o;.c#dhmJ3uzmɺ߶RidםۏIzF 'Y+-)'\Km l46p-yJ Q>cU! .: ($ػ:xyכPqKQ~0ya1"EKY aWs46L2{zt CϳAsa 3z齚o-f Uw?6˫;;-O]ό:\`/H `":H#`H۶*'P" !.{is^5=Go Nt o9"m0#bMf.$0ZC0V)_T!N*kʏo9:wŻ #| uͧ)dca%#- Ir:$:*PY'p3&ٗA@ ,?2y~8=<%cNc)a1(yvgU^4ЄO=AZoX|8JYC3_9ں8KVIXuqb;O٩ !l,(pff*(z<0z!%u=ꉟVׇ$7ToWqMUzδjUS7zZ,4|YP#0L(+LJ+h%oeu 5rwj+qqo7ؼi`a(AtڲLq9N ϧ~+N{vxSԩX!t WP%r8/w'zZc͇*ői:w RIuK69):NkjIJ4dhiRluQΪO&ʐ~yt0.u#"MT[h.⠹4 ي3]'h~.XY{:ov3:oÀ)e?ڬ,W|.5!K7ðk3Sh %cnRЄ|bI&!3Ƒ)hm|A8>U5P|*\tTJ@*IaXR9e.&)&Bz{x̅8`އK #1-z1)U䜥Y*[X1 ~#q~.0D¨'1:% Aܘ$I5HT}Z{=(&׳aJB,oNÔG4.qd„_{2~E?(Dž*\1lrd%)qrbX4nEGJЫ>9Ӏ -^yӻ?eju[ݽ|~yr2Ru 'K\PʡrP¥,%{݉^&Qa6&v=w4see7O_n=]m|)~Φ"܀WuݴK`1d4Er\aKҿe6ukGcy#^R0EztZd_>w1xOx;ݹXiYB$iyf5+IQSTT%)ܱ|>m7`Oɼ|Dg|:Ms"ʧ-m|6ڥ;>]e*Ū ~k :dEgRv@;E)=uo&abj] q|<4v<Qu ¦^71&=[8)ǒ\2bJV]`Þioyv}:[e#HMK Yrvtq.1/9h>mw2HL'KGp0@bKPcS# .\mܴSC݂&SD.ϝ% qc됵 (#8LKJu3v鐭 W2ֻ/J`\ܛJLn~o<==?s&5™kgӃui/ ɕ"pOJEJ** hcux%'1zzP#4泳) 5^spg<Ӕ[JSLG29ay9J[,d|Dd7OT٠t;[ewSh6킵1 BmD7 %6M)M& :==;<ߙ?7ԖQ6SbL>#P+|ʨ)c!9}QdsN1Ug i~=;}SBml8g%A9Q 'JoY/SdArZD;k%/"g5sFrZ꙯z~?鏏MC[`*)3*(mAGFEfQR z,[Dpʣw;ކl25V }X(d ic;.NV'rO[ur>bt2A+Ydė}hMS)D>\MuѻUڃԘ 'm<6l\MǏIziY>=Vs1an3A3XV(6$@2و"zaD0&DVטSo2uӻI n10=1@3E̗)ͬMײ,"MB!q1[m 8el&R޶ =Cbq!4U OKhS7vyO9'#0#%I IpRy,eG~@D{6ۈ\RV+ф{ B)[-S]1(g FC ~~+@bա-j`A SyXJNnh~fQ  -,U^vn)@T-"LSah0$=exփ [a!bu~M|ETOe}IBYש_D82듗aPR%V@cD Q逵m* +0lHN-$joDb@m Ěu3.:{|{;ssMU]ɻk:@mDJ2X bPsHvz#Z>Qˡ6' }a2$MUeLd6QmkC2X4LF^GPlBu V~#mdna0b-LفuPIHUcil3x&+;|{>;NzU8n.F$\)~S$ؔQTaG*8c1=`gh+q|t5UE[+x&D,wάuJ"$E{W96AGXVWLWȻ*F̤|Qވ*Wop}mwhǀ($mP HF"bMm  GT8 Ғ}1VUd&.HڎXSEvK,008ZVm)%5ӜU%e.yf1jBHRtaƛG%%AK2%"BԧIive+8Di חp8$f^dtd `<" gJ`~ŝ锤{%b0pͪ K@#jcwl[7SH[rB?/ hEr(o|Ҭdtw5#Nκ Ȅ JX`rmd˝r9+|Oa#sb667JņE_^,`<*?b׵ja׾3[WP5%ժ<_,φ$ק$?FX:{(}'HsFQ#鎫"_ ,`6:%Ow!؟6J."<SoQ|pr22ؤy]+vД5h RPZVܜ'IhLIW^1 Aз$Ϡ#nj5=.I:,t#ш9(Qt½ѾExK&EDDG¬"sCs>~s o P #t; v}ӎpNQNj!zl PgD䌥f](N$"I>,D&RKp5m ^—EY..!oN(Xg0"Y1\) IDATE(c+DrEyq!lBGD.NVQ'iv!#+%$d^1FXEJ1yb vCBfZXʂ/7~%xWNX )وr%_#^ 2d(FVs #&w{\SKr^4=<-P/T/GEѸv7se2}Gĉy@ Y 8~ j4qLOQrkDzXX} &X00MD%qJ<қUېNaf%[g{aXXDyφX]!4Ie13QL vi*E߁V{|^JÞvE?ጙOȆrۉ؝x WQzlLY{% %ױDSVF`FDAha,j:ό՟S52~7=C"*[=)h'o9Sa`xZsb뤊b2c$PȿIN8ZFȢPjOrOMe2ɧ $MIO:1+߇2q__}g1!2<7HZ~S<I:jnm"`zR5ߋtQͣ#mJH 8,U>1*.*Z6 >N_"*^njk:ٲȆ"WMz n=ǻ?ZV"(}5 %@ _t _]]p3˟1n@}ڝhiwgF$ZQrY|΀7oa z ,?.[e0|,dEMTHyJD>vЛܔ^%29ǸOc:|b'/ W˸m|ߐxPBx7_N;_͖6[JK/脌S`h [$-ΐrxEn (F_+`vxHf'6ÁL)^8q[1W4(m(1Y#"w 9xa{!tDXl?GQSLgBiz9/;Wœؼ*?`~#uZSw<*TB@ܽCrJOM|L1^q\&4$fdX\syN}ux<[<&P)I~9Si{})KXT~uEe[#~ *Պ8b8v|'>S+A_,UR^\|5z/Q g`p{424Á?E!;te/{amoh4o7)OO&1?ׁ<*W%v@Q-[9mJf3 HuF_ lmiqflnZ,畁-툟dc9KI:CEuMSteQ =JL-i=ia sb#5v"G> DAQC*:a1t1O[ɅHX=\#NPb?E 2نIq LQB&0%tfPb6ual \}i9=oH5;c($mfbGtEAy͡~![hbɼ t:bx$_eL*vp|?K-@DTtRtQ?*_uf $QwTjqLBv؝ݵ?s c[Ot ; qeqg9=+jO X(EuZ&;Иvme+}q)Z_Ǹe%ڻ翺ۨ 9k0dO2֛E'M9),s",u@$luCou(a[3NT.h*z,p HUmf!3@JI VhƐv&8z5   dLVcʠ" ʣ iD7nJ`N̐OQ ]dL ,՚.\b'oqM9t/#cm>IԏDž9=J̩t"2SX䖉@ 䘷đû4IW obw}C"2>tg*oڜ)?xU0)J'`tqd#+y'/y-*$N2)ņՊ2r0V:q`y  ް7$lp7 䴺a8~/rPʫ׳5z7®:l?;ȣ sIENDB`DdD  3 @@"?Dd D  3 @@"?J$$If!vh55#v:Vl t65J$$If!vh55#v:Vl t65@@@ NormalCJ_HaJmH sH tH N@N ~ Heading 17$8$@&H$CJ(OJQJ^JaJ(^@^ ~ Heading 27$8$@&H$^`CJ OJQJ^JaJ ^@^ ~ Heading 3I7$8$@&H$^I`CJOJQJ^JaJDAD Default Paragraph FontRi@R  Table Normal4 l4a (k(No ListzOz mCTable no gridlines7:V0j@j mC Table Grid7:V04@4 uHeader  !4 @"4 uFooter  !0l )Srb.o=>?@A^_`,d/Pd B W J f +SXn&{Lvpclx)Fl]pT)7^MZmPkx 6 ? H Y ` z !/!k!!!"q""R#S##'%A%%&&' ''Y'(6((() *++,r,,.2...9/T//^0_0000000000 0 0 0  0  0  0 0 0 0 0 0 00b0b 0 0 0 0 0 0 00000000 0 0``( 0( 0( 0( 0( 0 0 0p 0``( 0( 0( 0( 0( 0( 00d 0``( 0( 0`( 0 ( 0 ( 0  0 0W W  0 W  0 W  0 W  0 W ( 0J J ( 0f J ( 0f J ( 0f J ( 0f J ( 0f J  0W  0++ 0+ 0XX 0XX 0 0 0 0 0 0 0 0 0 0 0L 0v 0v 0v 0v 0L 0 0 0 0cc 0lc 0lc 0lc 0lc 0c 0 0 0c 0]] 0]] 0]] 0]] 0]] 0c 0TT( 0( 00) 0TT( 0( 0p 0Tp 0 0 0p 0T 0 0p 0p 0p 0 0 0T 0MM 0MM 0MMp 0MM 0p 0PPp 0kPp 0kPp 0kP 0kPp 0Pp 06 6 p 06 6 p 06 6 p 06 6  06 6  06 6  06 6 p 06 6 p 06 6 p 0 0!! 0!!p 0"! 0"!p0"0" 0  0#"  0?%" 0?%"  0?%"  0&"p 0&" 0&" 0?%"  0"  0q'" 05("( 05(" 05("0" 0" 0%*"( 0+" 0+"p 0+" 0"( 0," 00." 00." 00." 00."( 0 0(0p@0 @0 @0 @0p @0p @0t @0My0008 )Sr.o`,d/PdW f +SXn&{l)Fl]pT)7^MZmPk 6 ? H Y ` z !/!k!!!"q""R#0 0 0S 0S 0 0X 0X 0X 0X 0 0$ 0 $ 0 $ 0 $ 0 $ 0 0 *@ 0*@ 0*@ 0(@ 0My00*@ 0 0* 0* 0* 0* 0* 0* 0 0* 0 0 0* 0* 0* 0  0 0" 0* 0$n 0%X 0 0'  0(  0)  0*  0+  0,  0-  0.  0 0/  00  01  02  0 03  04  0 05  06  07  08  09  0 0:f * 0;y * 0<y  0=f * 0> * 0?  0 0@L  0AL  0BL  0 0C 0D 0E 0F 0G 0 0H 0I 0J 0K 0 0L 0M 0N 0O 0 0P 0Q 0R 0S 0T 0U 0V 0W 0X 0 0Y 0Z 0[z 0\z@0bVb K3$(088 "$%&(),-025 L]$`(/9788!#'*+./1348AY\0__.57<GI!/Xb$ ?+ƞk_w!s.(lb$0lMAI-@(    RAf angle_closureS"`?  NAf normal_flowS"`?B S  ?Z0t ttt00B*urn:schemas-microsoft-com:office:smarttagscountry-region9*urn:schemas-microsoft-com:office:smarttagsplace   q | Yht})6m x /!7!?!I!K!U!W!\!^!i!k!s!q"~"""$ $$$%%%%3&9&&&&'c'q'((0,8,,,,,>-F-///"/_000 ,c/ S w { 6 e -%;gj/0 {` k z  /!7!k!s!###b$&&_000333333333333333333333333333)Sr.< ,Pd B W J f f Xn&{vpcx] ^$MP6 z !!#`$'%A%&'(6(((++.2.9/T/_000000000$ $_000Theresa L LyonsLaurieJO2rl;Zw rl;T*i*hh^h`OJQJo(hH^`OJQJo(hH88^8`OJQJo(hH^`OJQJo(hH^`OJQJo(hHpp^p`OJQJo(hH  ^ `OJQJo(hH@ @ ^@ `OJQJo(hH  ^ `OJQJo(hHhh^h`OJQJo(hH^`OJQJo(hH88^8`OJQJo(hH^`OJQJo(hH^`OJQJo(hHpp^p`OJQJo(hH  ^ `OJQJo(hH@ @ ^@ `OJQJo(hH  ^ `OJQJo(hH#hh^h`56CJOJQJaJo(hH.#^`56CJOJQJaJo(hH. 88^8`o(hH. ^`o(hH. ^`o(hH.pp^p`B*OJQJo(phhH H^`o(hH() ^`o(hH() ^`o(hH()؞,ԟ(T*Zw 䞄 @CJ OJQJo(z8 @CJOJQJo(z @CJOJQJo(y @CJOJQJo(y4> @CJOJQJo(z"!;T$r2>W*3iOJ !nd% +{4t:U$=mCnW jDXo[{}6Fj/JU ecCjB\ ~ju\_00000000@$$$$0P@UnknownGz Times New Roman5Symbol3& z Arial?& Arial Black5& z!Tahoma;WingdingsEMonotype Sorts"qh93l*lf3-l58')W8')Wq$x24dG0G03QH ?mCChronic Vision Problems:Theresa L LyonsLaurieJ    Oh+'0 , H T ` lxChronic Vision Problems:hroTheresa L LyonsherherNormal LaurieJ4urMicrosoft Word 10.0@~mg@NҜ@AY@`8')՜.+,0 hp|  iWG0A Chronic Vision Problems: Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdfghijklnopqrstuvwxyz{|}~Root Entry FPϩaData e1TablemDWordDocumentrSummaryInformation(DocumentSummaryInformation8CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q