Ординатура / Офтальмология / Английские материалы / The Ophthalmic Study Guide for Nurses and Health Professionals_Field_2009

The ophthalmic study guide

whether the eyelashes are crusted and clean them if necessary. Ask the patient to look up so that you do not accidentally abrade the cornea with the eye-dropper or ointment nozzle. Using the tissue to cover the thumb of one hand, gently pull the lower eyelid down and instil one drop into the lower fornix or squeeze about 1 cm of ointment into the lower fornix. The tissue will absorb any spilled eye-drops, particularly fluorescein.

Avoid touching the end of the dropper bottle or the nozzle of the tube with your own fingers or on the patient’s eyelids or eyelashes. If the tube or bottle is known to be contaminated, it should be discarded and a new bottle or tube brought into use (Qureshi et al., 2006).

Release the eyelid, then ask the patient to close their eye gently and carefully wipe away any surplus fluid. Complete the required documentation.

Teaching patients, parents and relatives to use eye-drops

Ensure that your education for independence includes information on the following:

●Storage of eye-drops at the correct temperature (and not to keep the used bottle for longer than a month).

●Storage of eye-drops safely (not within the reach of children, because like other medicines, their oral effects in overdose can be deadly).

●How to obtain repeat prescriptions (if required).

●What to do if adverse symptoms develop.

●The need for careful hand washing both before and after the procedure.

When teaching parents to instil eye-drops for their children, remember that some children are naturally fearful of having drops instilled into their eyes. It can help to ask the child to lie down with their eyes closed, and pretend to be asleep; they can be told that they are going have some ‘raindrops’ dropped on to their eyelids. A suitable reward for cooperation (e.g. a sticker on a special chart) may go a long way. Drop two eye-drops into the corner by the inner canthus of the eye to be treated. When the child is asked to open their eyes, a sufficient amount of the eye-drop will roll into the eye for treatment purposes. The excess should be dabbed away and the child cuddled and rewarded. (A similar method was used for a randomised controlled trial by Smith in 1991.)

The key principles of teaching self-instillation of eye-drops are:

●Patients must be knowledgeable about their own condition and treatment (within their personal capabilities).

●If indicated, patients should know how to obtain further supplies of their drops.

●Eye-drops must be stored safely. They are medicines, and some (e.g. atropine) can have fatal consequences if ingested by a small child. They should be stored in accordance with the manufacturer’s recommendations.

●Patients must be able to identify the correct eye-drop and the correct frequency of instillation. Help them to establish timings that are easy to remember within the prescription criteria (e.g. breakfast time, lunchtime, teatime, and bedtime). Some departments give patients tick charts to help them remember.

●Patients must wash their hands thoroughly before using eye-drops and should have a box of paper tissues to hand to wipe away excess drops.

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Suggest that they sit in a chair which offers good support to their head and neck, and advise them to use the forefinger of the non-dominant hand to gently pull the lower eyelid down to make a little pocket for the eye-drop to go into. Show them how to hold the dropper bottle in their dominant hand, pointing down, between finger and thumb. Show them how to rest the bottle on the forehead and gently squeeze the sides of the bottle until a drop comes out. Explain that if the drop does not land in the lower fornix, they should move the bottle up or down the forehead so that it does.

This is just one way of teaching patients eye-drop instillation. You may know others, but always follow the key principles above. Always try to educate patients for independence, in case their carer is unavailable. Give plenty of encouragement and issue a bottle of artificial teardrops if practice is needed prior to surgery.

For patients who have physical problems instilling their own eye-drops, because they are nervous or have limited arm mobility, there are two devices available on prescription in the UK that can help.

To do …

Find an up-to-date copy of the British National Formulary and find the section on eyedrops. Check your responsibilities for controlling microbial contamination of eye-drops in the ophthalmic operating theatre, ward and outpatient department.

Application of an eye pad

An eye pad may be applied for the following reasons:

●following an ophthalmic procedure where a retrobulbar, periorbital, subtenon’s or subconjunctival injection has been given and the eyelids are not closing satisfactorily

●to promote patient comfort following a deep corneal abrasion

●following eye surgery, either intraocular or to the eyelid.

If you are required to apply an eye pad, there are two key principles to observe. First, if it follows a surgical procedure, it should not be applied so tightly that it causes undue pressure on the eye. Second, every effort should be made to ensure that the eye does not open under the pad, causing the patient to develop a corneal abrasion. An ophthalmologist and the scrub nurse normally apply postoperative eye pads. Usually a small piece of paraffin gauze is gently smoothed over the closed eyelids with gloved hands. This is to inhibit eye opening. A pad and cartella shield are then applied.

This approach can be carried out as a clean procedure if you are required to apply an eye pad in the ophthalmic emergency or outpatient department. Alternatively, instead of applying paraffin gauze, the eyelids can be lightly taped shut using a small strip of surgical tape, and the eye pad firmly applied on top.

A Cochrane Review carried out by Turner and Rabiou (2006) concluded that treating simple corneal abrasions with a patch does not improve healing rates on the first day post injury and does not reduce pain. They recommend that patches are not used for simple corneal abrasions. They do however recommend that further research should focus on the effects of patching large abrasions. As a junior person it will therefore be your responsibility to carry out the ophthalmologist’s directions, but when you become entrusted with a personal caseload, you will have to make your own decisions on whether to patch, based on the condition of the patient’s eye, the patient’s preference and the ophthalmic research available at the time.

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Insertion of a ‘bandage’ corneal lens

Bandage contact lenses are large, soft lenses that do not contain any optical prescription as their use is purely to protect the cornea from perforation, damage, leaking. The lens should be of a high quality, suitable for long term wear, with good oxygen permeability. A large silicone hydrogel lens is suitable, and is inserted on an ophthalmologist’s instructions. Reasons for using a ‘bandage lens’ include:

●treatment of small corneal lacerations

●corneal thinning and danger of perforation

●treatment of large, recalcitrant recurrent erosions

●pain relief of large corneal abrasions.

They may also be used for a pathological problem with the cornea (e.g. bullous keratopathy) or to protect the cornea in severe cases of in-growing eyelashes causing corneal scarring’

You will need:

●a sterile towel on a clean surface (plus a spare sterile towel to protect the patient from any drips)

●a sterile gallipot

●sterile normal saline

●small sterile swabs to dry the eyelids

●a bandage contact lens

●a comfortable treatment chair for the patient

●a good light.

Also have available just in case a minim of oxybuprocaine 0.4 % (Benoxinate ) and a minim of saline 0.9%.

Check the patient’s identity and notes to check which eye will require the lens and explain to the patient what you are going to do. Seat them in the chair comfortably, with their head well supported, and the chair adjusted to a good working height. Clean your hands and open the sterile towel (or eye dressing pack) and the minims onto the sterile field. Tip the sterile bandage lens into the gallipot. Wash your hands again (alcohol gel is not recommended at this stage because it could contaminate the bandage lens). Stand behind or facing the patient according to your preference, with your working materials easily accessible to your dominant hand. Put a sterile paper towel around the patient’s neck on the affected side.

Fig. 14.9

Bandage contact lens ready for insertion

Place the bandage lens on your index finger, then ask your patient to look down. With the first finger of your other hand, pull the upper eyelid fully open, holding it securely, close to the eyelid margin. Then ask the patient to look up, and secure the lower eyelid with your second finger. Being very careful not to drop the lens, gently insert it on to the exposed cornea.

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Fig. 14.10

Bandage contact lens applied.

Ensure that the edges are tucked under the eyelids. Ask your patient to blink, and then close their eyelid firmly to remove any air bubbles. When you are learning, you might need to make a second attempt, particularly if the patient has a small eye, or tight lids, or is a ‘squeezer’. This is when the oxybuprocaine 0.4% can be useful. If the eye is quite dry, use the saline minim. Make sure that the lens does not get turned ‘inside out’.

When instilling eye-drops into a patient’s eye where a bandage lens is present, preservativefree drops are normally used (Rubinstein and Evans, 1997).

Ryaz et al. (2007) have described a new method for inserting a bandage lens that involves picking up the exterior surface of the lens with the nozzle of a minim by suction, placing it on the cornea and releasing it by breaking the suction. They suggest that it can reduce the risk of infection in already compromised eyes. It is possible that this may prove easier in principle than practice.

Teaching eyelid taping

Lower eyelid taping for entropion relief

Entropion tends to occur in the older people, and is due to dysfunction of the muscle groups in the lower eyelid. Initially it may be unilateral, but it tends to affect both eyes. It is relieved surgically, but at the time of diagnosis the patient may be in considerable discomfort with a lower eyelid that is tending to roll inwards, causing the eyelashes to abrade the cornea. Applying surgical tape is a temporary means of helping the patient to cope while surgery is arranged.

You will need:

●scissors (thoroughly cleaned with a medical wipe prior to use)

●paper surgical tape (e.g. Micropore which sticks well and is slightly softer than some other tapes, so if it accidentally detaches it may cause less corneal trauma)

●a mirror for teaching the patient.

Cut a length of paper surgical tape measuring about 26 mm wide. With the entropion of the lower eyelid pulled back into its correct anatomical position, carefully seal the tape on to the skin as close to the lower eyelashes as you can, and gently pull it down, securing the bulk of the tape on the patient’s upper cheek. Make sure that your patient (and possibly their carer) knows how to do this. Give the patient a new roll of surgical tape to take home, and ask them to renew the taping as often as required. This is a difficult problem to manage effectively this way, but is worth trying while the patient is waiting for surgery.

Other eyelid problems

You may occasionally be asked to advise a patient who has a condition such as exophthalmos, proptosis or a paralysis of the facial nerve (e.g. Bell’s palsy). This might include advice on instilling

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lubricating eye-drops frequently to prevent corneal exposure. You can also show them how to manually ‘blink’ their paralysed eyelids by placing a finger on the upper eyelid and moving it up and down.

Sometimes patients are issued with transparent occlusive eye shields to act as ‘moisture chambers’ and to help prevent dry areas developing on the cornea. A good tip for patients is that if the chamber is ‘steaming up’, making a tiny pinhole on the periphery of the transparent chamber will alleviate this problem.

Patients also need to be taught how to tape their eyelids closed at night. Cut a length of paper surgical tape (preferably Micropore ) about 13 mm wide. Draw the bottom eyelid up and gently secure paper surgical tape to it. Then, while continuing the gentle traction on the tape holding the lower lid, bring the top eyelid down to meet it using a finger from the other hand. Secure both eyelids shut using the remainder of the tape, leaving a folded over area at the end to facilitate removal of the tape in the morning.

4. MINOR TREATMENTS

Before commencing any treatment, record the history and check and record the central visual acuity. Emergency eye irrigation is the only exception to this rule, and is the procedure that all ophthalmic nurses should be able to carry out without delay. There is a range of ophthalmic procedures undertaken by ophthalmic nurses, and this section is offered as an introduction to some of these.

Eyelid eversion

Reasons for doing this are when:

●you believe there may be something under the top eyelid

●you need to examine the conjunctiva of the upper eyelid

●the person has a chemical injury and you need to thoroughly wash round the eye.

You will need:

●cotton buds moistened with sterile saline

●reading spectacles if you have them

●a good light.

N.B. There are several ways to do this, but this is probably the easiest method when you are learning this skill for the first time.

Wash your hands. Seat your patient in a comfortable chair, with their head well supported. Explain that you are going to look under their top eyelid. Reassure them that what you are about to do will not hurt but may feel rather strange. Ask them to help you by concentrating on looking down. Do not start until you are certain that you feel calm and ready, and your patient feels calm and confident in you. Stand behind the patient, and tilt their head back until it is resting on your chest. Ask them to open both eyes and concentrate on looking down all the time with both eyes. Take a firm hold of the eyelashes of their upper eyelid. Using your other hand, place one end of your cotton bud behind the cartilage plate of the upper eyelid. Push down gently on the cotton bud at the same time as pulling gently the upper eyelashes down and out, away from the eye. Using these movements, gently evert the eyelid, continuously reminding your patient to keep on looking down. Keep holding the eyelid everted with your first three fingers until you have finished your procedure.

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Examine the conjunctiva lining the upper eyelid. If you suspect that there may be a foreign body under the top eyelid, use a moist cotton bud to gently remove it. If you cannot see anything, it is wise to gently wipe the inside of the eyelid anyway. Let go of the eyelid and ask your patient to look up. The eyelid will return to its natural position. If you were right, and there was a foreign body under the eyelid, the condition will be immediately improved.

When examining a patient at the slit lamp, you will need to develop the technique of everting the eyelid while the patient is facing you within the restraining frame of the slit lamp. Experienced nurses are able to do this very gently, using just their fingers.

Eye irrigation

Reasons for doing this are:

●to treat acid or alkali burns

●to wash out dust and dirt particles.

You will need:

●a clean, dry work surface

●paper towels and paper tissues

●plastic protection or an apron over the patient’s clothing

●a small jug or plastic feeding beaker with lid

●a kidney dish

●a 500 mL sterile normal saline solution at room temperature (an intravenous giving set and normal saline may be used if the irrigation is to be prolonged)

●pH paper

●cotton buds

●local anaesthetic eye-drops

●a Morgan lens (optional).

Waste no time. Check the pH if you are able to do so. Reassure the patient, instil local anaesthetic drops if available, and briefly explain to them what you are going to do, as you get the equipment ready. Protect the patient’s clothing with a plastic apron and paper towels. Position them comfortably on their back, on a couch or on a treatment chair, with their head well supported.

Fill the beaker or jug with sterile sodium chloride. Ask them to turn their head slightly towards the affected side. They should hold the kidney dish close to their cheek to catch the irrigation fluid. Hold the lower eyelid down gently and direct the fluid first against the cheek, then inside the bottom eyelid. Ask them to look up, then down, then sideways while the irrigation is continued. Evert the upper eyelid while irrigating underneath it. Dry their eyelids and face prior to the removal of the kidney dish. Remove the plastic apron.

Remember:

Do not record visual acuity first when treating a chemical injury – speed is essential.

Instil local anaesthetic drops throughout the procedure as necessary, as these are being constantly leeched out by the irrigation process. Use a Desmarres retractor to double evert the upper eyelid if necessary. If you do not have one, improvise with moistened cotton buds.

Remove any solid material with a wet cotton bud. You may require a fine pair of forceps (such as Mathelone’s) to remove material that is wedged in the conjunctival surface. Fluid should not be directed

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on to the eye from a distance of greater than about 4 cm. Irrigation must be continued until the pH is back to normal. Expect that severe chemical burns may require slow irrigation for up to an hour, using an intravenous giving set, with possibly a Morgan lens if you have one available. It may be possible to move the patient’s couch up to the sink, and support their head over the sink for this treatment.

Check and record visual acuity before a doctor sees the patient. Continue irrigating as necessary.

Concretion removal

‘Concretions’ are creamy white inclusion cysts filled with keratin and epithelial debris that are found in the palpaebral conjunctiva of the upper and lower eyelids. They are completely benign. However, occasionally a patient complains of a scratchy sensation and on examination it may be seen that one of these deposits is sticking through the conjunctiva and scratching the front of the eye. Any troublesome concretion can be easily and painlessly removed, but you should only do this under the guidance of an experienced ophthalmic nurse or doctor until your competency has been officially recognised within your department.

You can read more about this condition in Austen (1999) and the Handbook of Ocular Disease Management online.

You will need:

●local anaesthetic eye-drops

●a slit lamp or magnifying loupe headband

●an injection needle of an appropriate size

●a syringe (1mL) to mount the injection needle on

●cotton swabs

●cotton-wool buds, moistened at the tip with a drop from the local anaesthetic minim.

Explain to your patient what you are going to do and why. Instil a local anaesthetic eye-drop in the area of the concretion and wait for 3 minutes for it to work. Prepare your equipment out of the patient’s direct line of sight. Mention the use of ‘a small instrument’ and the importance of the patient keeping very still for a few moments. Use the side of the injection needle like a sharp-sided spoon to scoop and lift out the concretion. Sometimes you may need the moistened swab to ‘capture’ crumbs from the concretion. There is sometimes a little bleeding following removal, particularly if the patient is taking aspirin or warfarin. A little gentle pressure can be applied to the bleeding area with a moistened cotton bud. No routine after care is required for this small procedure.

You will need to have undergone supervised practice and demonstrate sufficient knowledge and consistently satisfactory practice before you are accredited to carry out this procedure unsupervised.

Epilation of an eyelash

Eyelashes that are abrading the cornea need to be carefully evaluated. If the eyelash can readily be brushed back into the normal position, and if the patient following advice can maintain it in the normal position, it should not be removed. Removal could cause it to grow back at a slightly different, less advantageous angle.

These days epilation of eyelashes normally takes place with the patient positioned at the slit lamp. Pull the eyelid slightly away from the eye with a finger. A good pair of forceps such as Mathelone’s or jeweller’s forceps is necessary to grasp the eyelash securely, as close to its base as possible. With a tight grip around the lash, ensure that the patient’s cornea is tilted away from your forceps, and maintaining a steady pressure, pull the eyelash out in the direction of its growth.

Check the cornea for any abrasions caused by the lash rubbing, and treat accordingly. As the eyelash follicles stay intact, there will be re-growth, and the patient needs advice regarding re-treatment.

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To do …

Find out about trichiasis and distichiasis.

Removal of a superficial corneal foreign body

If a foreign body is lying on the cornea, it is likely to cause damage to the delicate endothelial surface of the cornea. Poking at it may cause damage, so in the first instance it is a good plan to see if the debris can be floated off the cornea by flushing it with a minim of normal saline. If it is displaced into the lower fornix, it can be very safely removed by asking the patient to look up, to tilt the cornea out of the way, and then removing it with a slightly moist cotton bud.

If flushing the corneal foreign body with sterile normal saline fails to remove it, but it is not embedded, it may be possible to remove it by instilling a local anaesthetic eye-drop. When the drop has had time to take effect, try gently brushing the foreign body with a moist cotton bud to remove it. Do not use any force, as no matter how gentle you are, you will still cause a slight corneal abrasion. Trained, experienced ophthalmic staff carry out the procedure below.

You will need:

●anaesthetic drops (e.g. proxyametacaine hydrochloride 0.5% (Ophthaine ), oxybuprocaine hydrochloride 0.4% (Benoxinate )

●a No. 1 disposable injection needle

●cotton-wool buds

●the patient’s notes.

Wash your hands. Examine both eyes. Explain to the patient what you are going to do, ensure they are positioned comfortably at the slit lamp. Anaesthetise the affected eye with the local anaesthetic eyedrops. Ask the patient to keep both eyes open and to focus on a distant object. Ensure that the patient’s forehead is firmly pressed against the top headband of the slit lamp throughout the procedure. This is for two good reasons – if they move back, they go out of slit lamp focus, and with the head kept firmly on the band they cannot move forwards on to your needle, they can only move away. Holding the injection needle horizontally and tangentially to the cornea, gently lift the foreign body off the cornea.

It may be necessary, depending on the location of the foreign body and whether the patient is able to keep his eye open, to hold the upper and lower lids of the affected eye open with your ‘spare’ hand. This of course, can make it difficult to keep the slit lamp in focus.

Record all your findings and treatment. If required, antibiotic eye-drops may be supplied according to local protocols. The patient should be asked to return to the eye department for further examination or treatment if required.

This procedure should only be carried under supervision until your competence and experience has been assessed.

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Conclusion

The nurse or professional allied to medicine (PAM) should always aim to give care that is of the highest quality. Ophthalmic nurses and optometrists have developed a wide range of published specialised knowledge and research. The ophthalmic patient needs to remain the focus of our care, beyond our own needs for experience and knowledge acquisition, and must be treated with respect as regards their personal fears, frailty and needs. With this in mind, the Ophthalmic Nursing Forum (2009) has re-issued their publication The Nature, Scope and Value of Ophthalmic Nursing to remind us of our therapeutic relationship with patients, as well as the importance of two-way communication between the patient and professional and the significance of patient education. This document identifies nine key standards of care, together with the means to audit these, and is essential reading for all who work within the field of ophthalmic care.

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References and further reading

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Cagle, G. and Abshire, R. (1981). Quantitative ocular bacteriology for the enumeration and identification of bacteria from the skin lash margin and conjunctiva. Investigative Ophthalmology and Visual Science, 20, 753–58.

Casser, C., Fingeret, M. and Woodcombe, H. (1997). Atlas of Primary Eye Care Procedures, 2nd edn. New York: McGraw Hill. Chern, K., Foley, E., Koo, J., Reddy, A. and Sandoval, B. (2004). Ophthalmic Office Procedures. New York: McGraw Hill.

Crossland, M. and Rubin, G. (2007). The Amsler chart: Absence of evidence is not evidence of absence. British Journal of Ophthalmology, 91(3), 391–93.

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Lim, R., Dhillon, B., Kurian, K., Aspinall, P., Fernie, K. and Ironside, J. (2003). Retention of corneal epithelial cells following Goldman applanation tonometry: implications for CJD risk. British Journal of Ophthalmology, 87(5), 583–6.

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Qureshi, M., Wong, S., Robbie, K., Qureshi. C. and Rowe, J. (2006). Contamination of single use minims eye-drops by multiple use in clinics. Journal of Hospital Infection, 62(2), 245–47.

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