Chapter 1
The Ophthalmic Patient
Introduction
The ophthalmic patient may be of any age, from a few days to over 100 years old. Ophthalmic conditions affect all age groups, though most of the ophthalmic patients seen are elderly.
Most infants and children will have parents who wish to be involved in their child’s care. The child whose parents are either unable or unwilling to become involved will need the extra care and attention of a nurse to reassure him in unfamiliar and possibly frightening surroundings.
The ophthalmic patient may have other diseases such as diabetes, ankylosing spondylitis and arthritis, as these have ocular manifestations. He may also suffer from unrelated diseases. Co-morbidity can be challenging for the ophthalmic nurse who will have to make decisions about care and management based on need.
The ophthalmic patient will arrive at the eye hospital or unit either as a referral to the outpatient department or as a casualty, where many are selfreferred and may not be ‘emergencies’ as such. They will present with a variety of conditions, from a lump on the lid to sudden visual loss or severe ocular trauma.
Most people will be anxious on a first visit to a hospital. Even for the elderly but otherwise fit person, it might be his first experience of a hospital. Those arriving following trauma will be in varying degrees of shock depending on the nature and type of accident. They and their relatives may be very anxious. Something that seems fairly minor to the nurse with ophthalmic knowledge may, to the layman, appear serious and be thought to threaten sight.
Many people have a fear of their eyes being touched, making examination difficult. Some feel faint – or do faint – while certain procedures, such as removal of a foreign body, are being performed.
There are some old wives’ tales about the eye. One of the most common is that the eye can be removed from the socket for examination and treatment, and be replaced afterwards. This kind of false information does not help the patient’s frame of mind.
Each person will arrive at the hospital with his own individual personality and past experience to influence any attitude towards the eye condition.
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Some will be stoical, others extremely agitated. Those with chronic or recurrent eye conditions may become more used to visiting the eye hospital. Most patients having ophthalmic surgery are outpatients, day cases or overnight-stay patients. This means they have a very short time to adjust to the hospital setting and have little time to ask the questions that may be initially forgotten in the midst of all the activity. They may feel reluctant to express minor concerns when there appears to be little contact time with nurses.
The actual visual impairment experienced by the patient will vary with the eye condition. With many conditions there is no, or only slight, visual impairment and this may be temporary. Others cause gross visual loss that may have occurred suddenly or gradually over the years. This visual loss may be untreatable and permanent, may be progressive, or sight may be restored. Some patients will have only one eye affected and others both eyes, probably to different degrees. Some will have blurred vision; some will only be able to make out movements. Others will be able to differentiate only between light and dark, or will see nothing at all. Some will have lost their central vision, others their peripheral vision. Some patients will see better in bright light than dim light, and vice versa. Some degrees of visual loss can be very upsetting to the patient and prove to be a severe impairment to daily living. All patients experiencing severe visual loss will require practical and emotional help in coming to terms with it, regardless of the cause and the course it has taken.
Registration for the blind and partially sighted
Research carried out by the Royal National Institute for the Blind (RNIB) (Bruce et al., 1991) suggested that three-quarters of people eligible for registration are not in fact registered. There is no reason to suppose that this situation has changed. People are reluctant to take the final step as it can appear to be the giving up of any hope that treatment will help. But this need not be the case. Blind or partial sight registration can be a much more liberating experience for many as they realise, with help and support, that they can maximise their quality of life.
Blind register
The statutory definition for the purpose of registration as a blind person under the National Assistance Act 1948 is that the person ‘is so blind as to be unable to perform any work for which eyesight is essential’. This refers to any form of employment, not only that which the patient formerly followed. It also only takes into account visual impairment, disregarding other bodily or mental infirmities. People with a visual acuity of less than 3/60 on the Snellen chart (see p. 21) or with a visual acuity of 6/60 but with a marked peripheral field defect will be eligible for registration.
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Partially sighted register
There is no statutory definition of partial sight although a person who does not qualify to be registered as blind but nevertheless is substantially visually impaired can be registered as partially sighted. Those people with 3/60 to 6/60 vision and full peripheral field, those with vision up to 3/60 with moderate visual field contraction, opacities in the media, aphakia and those with 6/18 or better visual acuity but marked field loss can be included on this register. In England and Wales a Letter of Vision Impairment (LVI 2003) is obtainable from high street optometrists. In outpatient settings staff complete the Referral of Vision Impaired Patient (RVI 2003). Patients can obtain one if eligible and take this to their social services department.
Assistance and rehabilitation
The National Assistance Act 1948 directs all local authorities to compile a register of blind and partially sighted people residing in their area and to provide advice, guidance and services to enable them and their families to maintain their independence and live as full a life as possible.
Registration is voluntary. People can choose to register but if they do register they can have their names removed from the register at any time should they wish. The local authority has the responsibility of reviewing the register regularly and updating the circumstances of the people on it. Local authorities must offer services to all those identified as visually impaired, whether they choose to register or not. However, registration is necessary to qualify for financial benefits and for help from the many voluntary organisations. Registration is a good guide as to whether a person is coming to terms with their sight loss.
The process of registration starts with the ophthalmologist certifying on a form. A new system for registering as blind was introduced in England and Wales in November 2003. The Certificate of Visual Impairment (CVI 2003) replaces the old BD8. It is argued that the new system is easier to use and will speed up the process. The BP1 in Scotland and A655 in Northern Ireland are still in place that a person is eligible for either blind or partially sighted registration. The person signs this form agreeing for information on the form to be shared with their local social services, general practitioner and the Department of Population Census which maintains records of all those opting to share this information.
The Social Services Department has the responsibility of registering people. Some social services departments have delegated this task to their local voluntary organisation which deals with the blind and partially sighted people within their area. The role of the social worker is that of counsellor. They provide support and information about the services available. This includes entitlement to benefits and referral to other statutory bodies involved with retraining, special needs education for those of school and college age, rehabilitation, employment, social, leisure and recreational activities, and introduction to self-help groups.
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Voluntary organisations
There are a number of voluntary organisations that work with the visually impaired. Most local areas or counties have their own organisations. These are established to provide aids and social contact for the visually impaired. Many local authorities have an arrangement with voluntary organisations to provide services to facilitate independent living such as talking or tactile watches and clocks, to alarms that sound when rained upon so that the washing can be brought in. The increase in technology has resulted in equipment being available, for example, to enlarge print onto a TV screen, to convert the written word into Braille or to use voice synthesisers.
Local voluntary organisations are often centres of social contact for the visually impaired and their carers. Some voluntary organisations maintain contact through radio stations; Glasgow for example has a radio station dedicated entirely to people with visual impairment.
The needs of people from ethnic minority groups should not be overlooked. Ethnic Enable (www.ethnicenable.com) is an organisation set up to assist people with visual impairment who are from specific ethnic groups.