medical nursing quiz opthalmology

Opthalmology

Ophthalmology is a branch of medicine dealing with the diagnosis, treatment and prevention of diseases
of the eye and visual system.

Definition of Terms
  • Ophthalmologist: It is a medical or osteopathic doctor who specializes in eye and vision care. An
    ophthalmologist diagnoses and treats all eye diseases, performs eye surgery and prescribes and fits
    eyeglasses and contact lenses to correct vision problems. Many ophthalmologists are also involved in
    scientific research on the causes and cures for eye diseases and vision disorders.
  • Optometrists: are healthcare professionals who provide primary vision care ranging from sight testing
    and correction to the diagnosis, treatment, and management of vision changes. An optometrist is not a
    medical doctor.
  • Opticians: are technicians trained to design, verify and fit eyeglass lenses and frames, contact lenses,
    and other devices to correct eyesight.
  • Ophthalmic Nurse: is a nursing professional that focuses on assessing and treating patients with a variety of eye diseases and injuries
Role of ophthalmic nurses
  1.  They can provide first aid treatment in cases of eye injuries and emergencies.
  2. They can perform preliminary physical examinations, such as a blood test, to detect possible
    underlying illness that could contribute to an eye problem (for example, hypertension).
  3. They can perform initial screenings on patients.
  4. They can collect medical histories.
  5. They can assist in eye examinations.
  6. They can offer tips and advice to help patients manage eye pain and other symptoms.
  7. They can show patients how to administer medication.
  8. They can educate patients on the treatment of ocular conditions.
  9. They prepare patients for surgery and assist during operations.
  10. They can provide after-surgery care for patients.
  11. They can carry out some eye tests and procedures.

Ophthalmic emergencies

Sudden loss of vision due to:

  1. Central retinal artery occlusion;
  2. Central retinal vein occlusion;
  3. Giant cell arteritis;
  4. Retinal detachment – particularly if the macula is still attached.
  5. Primary acute glaucoma;
  6. Trauma, particularly penetrating or perforating injuries;
  7. Chemical burns;
  8. Orbital cellulitis.

Urgent cases that the nurse may have to deal with, but which are not classed as emergencies, include:
>Corneal ulcer;
> Vitreous haemorrhage;
> Acute dacryocystitis;
> Optic nerve disorders;
> Ocular tumours;
> Acute uveitis.

Pre-operative care of an eye surgery

In addition to routine pre-operative care for surgery being performed under either local or general
anesthesia, the nurse may be required to carry out the following procedures, depending on the
personal preferences of the ophthalmic surgeon:

  •  Instilling mydriatic drops prior to cataract extraction or retinal detachment surgery as the pupil
    needs to be dilated for such surgery to be performed;
  •  Instilling miotic drops prior to trabeculectomy and keratoplasty;
  •  Instilling local anesthetic drops such as G. oxybuprocaine 0.4%, if the operation is to be
    performed under a local anesthetic.
  •  These drops are usually administered against a prescription or patient group direction.
Post-operative care of an eye surgery

In addition to the normal post-operative care required by any patient after surgery, the ophthalmic nurse
will need to follow a routine such as that described here, although this will vary to some extent according
to hospital practice.
Eye care:  Post-operative eye care involves dressings, cleaning the eye or skin wound, inspection of the eye,
instillation of drops and protection of the eye.
Dressings – eye pads are used but also cartella shields, with or without a pad, may be in place
following surgery. If indicated, as in some types of minor lid surgery, the pad is removed before
the patient leaves the unit.
 Cleaning the eye or skin wound – the eye or skin will usually only be cleaned on the day following
surgery; subsequent cleaning is usually performed once a day or more frequently if indicated. In
the case of some oculoplastic procedures, the pad and bandage will remain untouched for
between 5 and 7 days.
Inspection of the eye and surrounding structures will be undertaken post-operatively.
 Instillation of drops – if prescribed, given accordingly; ointment, if prescribed, may be applied at
night.
> It should be noted that ointment may be prescribed for structures other than the eye, for
example suture lines on the lids.
 Protection of the eye – eye pads or cartella shields may be worn on the first post-operative day;
cartella shields are usually worn only at night for 1 or 2 weeks following surgery.

Discharge
  1.  All patients should be given instructions about care and follow-up:
  2.  Eye drops or ointment – the patient or carer’s ability to instil drops or apply ointment should be
    determined. Ideally, this process will have commenced at pre-assessment. Names of drops or
    ointment and times of instillation/ application must be given verbally as well as written down.
  3.  Cleaning the eye – if the eye is sticky in the mornings, it should be cleaned using cooled, boiled
    water in a clean receptacle and using cotton wool or gauze. Advise patients to avoid using dry
    cotton wool near the eye, as fibres can get into the eye.
  4.  General instructions – patients should avoid stooping down too low in case they lose their
    balance. If appropriate, the patient should be advised to avoid anything causing increased
    exertion that will raise the intra-ocular pressure, such as lifting anything heavy. Patients should
    take care when they wash their hair to avoid getting soap or water into the eye as this would
    cause irritation that could result in rubbing behaviour. These restrictions should be heeded for 2
    weeks initially, but are becoming increasingly less necessary with small incision surgery. Patients
    must take particular care not to knock or rub the eye, which could cause haemorrhage or cause
    the iris to prolapse through the wound.
  5. Outpatient appointment – ensure that the patient has an appointment, usually at 1 or 2 weeks
    following discharge. Transport may need to be arranged for the day.
  6. Primary care – the nurse may need to arrange for a community nurse to assist with drop
    instillation, or may need to organize for the social worker to assess the need for home help or
    meals on wheels for the patient, prior to discharge.
  7. Convalescence – not used often, but in some areas recuperation in a convalescent, residential or
    nursing home can be arranged for patients before they return to their own homes.
  8. Specialist procedures such as vitrectomy may require a patient to ‘posture’ in certain positions
    to ensure a satisfactory surgical outcome. To ensure that the patient complies with the posturing instructions, especially if they live alone, it may be necessary to involve other agencies such as
    those provided by social services and primary care.
  9. It is helpful if all the above information and instructions are written down as well as given
    verbally, as there is often much detail to absorb in the excitement of going home.
Responsibility of nurse during ophthalmology
Recording visual acuity

Visual acuity is the measurement of acuteness of central vision only. An accurate assessment of visual
acuity is one of the most important parts of any ophthalmic examination. Visual acuity is a test of the
visual system from the occipital cortex to the cornea.

Accurate visual acuity testing requires:

  • Patient co-operation and comprehension of the test;
  • Ability to recognize the forms displayed;
  • Clear ocular media and correct focusing;
  • Ability of the eyes to converge simultaneously;
  • Good retinal function;
  • Intact visual pathways and occipital cortex
Common charts used in the measurement of distance visual acuity

The most common chart for measuring distance visual acuity in a literate adult is the Snellen chart.
Distance vision is tested at 6 m, as rays of light from this distance are nearly parallel. If the patient wears
glasses constantly, vision may be recorded with and without glasses, but this must be noted on the
record. Each eye is tested and recorded separately, the other being covered with a card held by the
examiner.

Snellen’s test type

Snellen Chart

Heavy block letters, numbers or symbols printed in black on a white background, are arranged on a chart
in nine rows of graded size, diminishing from the top downwards. The top letter can be read by the
normal eye at a distance of 60 m, and the following rows should be read at 36, 24, 18, 12, 9, 6, 5 and 4
m, respectively.

Using the pinhole in the measurement of visual acuity

Using the pinhole in the measurement of visual acuity
Occasionally, a patient’s visual acuity may be below average, which could be a result of a refractive error
not corrected by glasses, or due to the patient wearing an old pair of prescription glasses. One effective,
but very simple, way to see if distance visual acuity can be improved through spectacles or a change of
prescription is a pinhole. A pinhole disc only allows central rays of light to fall onto the macula and does
not need to be refracted by the cornea or lens. A ‘pinhole disc’ is used if the VA is less than 6/6 or 6/9,
which may improve VA. If considerable increase in vision is obtained, it may usually be assumed that
there is no gross abnormality, but a rather a refractive error.


Sheridan Gardner test chart

Sheridan Gardner test chart
The Sheridan Gardner test chart can be used for children and patients who are illiterate. This test type
has a single reversible letter on each line. For example, A, V, N. The child holds the card with these letters
printed on and is asked to point to the letter on his card which corresponds to the letter on the test type.
This test can also be used for very young children as they do not have to name a letter.


Kay picture chart

Kay picture chart
The Kay picture chart is again used with patients who are illiterate or with children. Instead of letters,
the book contains pictures, which are also of varying sizes. The patient is asked what the picture
represents. In order to avoid any misunderstanding amongst patients with language difficulties, it is good
practice to ask the hospital’s official interpreter to translate for patients.


Tumbling E chart

Tumbling E chart
The tumbling E chart again is mainly used for patients who are illiterate. In the chart, the Es face in
different directions. The patient is asked to hold a wooden E in his hand and to turn it the same way as
the one the examiner is pointing to on the test chart.
It is important to remember to identify in the patient’s notes which chart system has been used to test
the patient’s visual acuity; for example, if the Kay picture chart is used, this must be indicated in the
notes.

CARE OF THE PATIENT’S EYES.
  • Involves:
    • Cleaning of the eye
    • Instillation of eye drops
    • Cold and warm compressions
    • Eye irrigation
Indications
  1.  Patients with eye discharge
  2.  Post operative care for patients following a cataract operation
  3.  Eye care for the unconscious patient
  4.  To be performed prior to instilling eye drops or ointment
    Aim
    To prevent and treat infections.

Requirements.
Tray:
• Gallipot of swabs/cotton balls
• Gallipot of solution of normal saline 0.9% or cool boiled water
• Receiver
• Gloves
• Mackintosh and towel.
At the bed side.
• Hand washing equipment

Procedure
  1.  Observe general rules
  2. Identify the patient and explain the procedure
  3.  Position the patient: s/he may be sitting or lying down
  4.  Place protective mackintosh and towel in place.
  5.  Wash and dry hands and put on gloves
  6.  Dip the swabs/cotton balls in the solution and bathe the eye. Swab from the nasal to the
    temporal aspect, using the swab once and then discard it. Repeat the swabbing until the eye is cleared
    of all discharge.
  7.  Dry excess fluid with dry swab
  8.  Thank and leave the patient comfortable.
  9.  Clear away.
INSTILLATION OF EYE DROPS/ OINTMENT.

This is the process of application of medication into the patients’ eyes.

Indications.

For eye drops:

  •  To treat infections e.g., use of antibiotic eye drops
  •  To keep eyes moist e.g., use of normal saline eye drops in post cataract operation.
  •  To anaesthetize the eye e.g., as for cataract operations.
  •  To dilate the pupil e.g., for further examination
    For eye ointment:
  •  To protect the vision of neonates.
  •  To treat infection e.g., as in use of antibiotic ointment.
Requirements

Patient’s medication chart.
Tray.
• Prescribed eye drops/eye ointment
• Gallipot of swabs/ cotton balls
• Receiver
• Gloves
• Eye pad in a receiver
• Strapping.
Bed side.
• Hand washing equipment

Procedure.
  1. Refer to general rules.
  2.  Check the prescription.
  3.  The patient may be seated or lying down for this procedure
  4.  Wash hands and put on gloves.
  5.  Clean the eyes as before.
  6.  Place a folded swab on the lower lid up to lash margin.
  7.  Instilling eye drops:
  8.  Gently pull down the eye lid of the affected eye.
  9.  Request the patient to look up: hold the dropper
  10.  Close to the eye and drop the medicine according to the dose into the lower conjunctiva sac.
  11.  Release the lower eye lid after the eye drops are installed.
  12.  Request the patient to gently close the eye.
  13.  Apply gentle pressure over the inner Canthus.
  14.  Administering eye ointment:
  15.  Gently pull down the lid.
  16.  Squeeze a small amount (1.25cm) of ointment along the exposed sac from in outwards.
  17.  Instruct the patient to close the eyes.
  18.  Instruct the patient to roll the eyeball
  19.  Patient should keep the eye closed for few minutes.
  20.  Thank and leave the patient comfortable.
  21.  Clear away.
  22.  Record treatment given on the chart.
General principles – application of eye ointment
  1.  Ointment may be prescribed in addition to drops.
  2.  Ointment should be applied after any prescribed drops have been instilled, leaving approximately
    a 3-minute interval between medications.
  3.  Ointment may be prescribed for structures other than the eye.
  4.  Ointment may be prescribed for use after first dressing, and this may not happen for up to 1 week
    in the case of some oculoplastic surgery.
  5.  If requested, visual acuity should be recorded before ointment is applied as ointment clouds
    vision. Any existing ointment excess is normally removed prior to taking visual acuity
    measurement.
  6.  A 5-mm strip of ointment should be applied to the inner edge of the lower fornix of the
    appropriate eye.
  7.  The patient should close his eye and remove excess ointment with a swab.
  8.  The patient should be advised that the ointment is likely to cause blurring of vision because of its
    viscous nature.
  9.  In the case of wounds on the lids, face or eye socket, ointment should be squeezed directly onto
    the wound. It may be dispersed using a moistened swab. If requested to do so by the ophthalmic
    surgeon, the wound or scar should be massaged using the ointment
Procedure of instillation of eye ointment
  1.  Wash hands and prepare trolley and equipment in accordance with ANTT( Aseptic Non Touch Technique) principles.
  2.  Check patient identification band against eye-drop medication chart.
  3.  Prepare patient for the procedure and obtain consent, giving an explanation of procedure
    including any side-effects of the medication.
  4.  Assess the patient as before, including ensuring that the drops are not contra-indicated.
  5.  The patient should be seated.
  6.  Wash hands or use alcogel.
  7.  Prepare equipment and place in tray, identifying key parts to be protected during the procedure;
    in this case, the tips of bottles.
  8.  Check drops/ointment against the prescription.
  9.  Check the correct strength (%) of the drops against prescription.
  10.  Check drops/ointment have not expired. Check clarity of drops, i.e. the fluid in the bottle/minim
    must be clear and not discoloured.
  11.  Check packaging/bottle seal is intact when first used.
  12.  Identify any current allergy to the topical medications.
  13.  Ensure that the drops are instilled into the correct eye.
  14.  Examine the eye to be treated for the following: Redness not attributed to surgery or other
    known causes; Not sticky or painful; No deterioration of vision; Allergies to the prescribed eye
    drops.
  15.  Check no contact lens in situ unless advised to the contrary by doctor.
  16.  Remove gloves, clean hands with alcohol gel and reapply non-sterile gloves.
  17.  Open packaging, ensuring key parts remain protected. NB: You may need to open additional
    packaging if the eye needs cleaning prior to drop instillation, in which case you should proceed
    to eye cleaning first.
  18.  Instruct patient to slightly tilt the head back and ask the patient to look up. NB: Before using any
    bottle of eye drops, shake the bottle first.
  19.  Instill only one drop into the lower fornix towards the outer cantus or squeeze 5 mm of ointment
    along the lower fornix towards the outer cantus. NB: Ointment must only be applied after
    prescribed eye drops.
  20.  Ask the patient to gently close his eyes, counting slowly to 60. This helps to minimise systemic
    absorption.
  21.  Wipe away any excess drops/ointment, taking care not to wick away drops from the eye
  22.  If further drops are prescribed, wait an interval of 3 minutes before carrying out the procedure.
    Apply alcogel to hands before instilling the next eye drop.
  23.  Make the patient comfortable; patients usually appreciate being given a tissue to dab their
    cheeks.
  24.  Dispose of clinical waste, cleanse hands and then clean the tray.
  25.  Cleanse hands and document the procedure in the case notes and/or drop chart.
WARM EYE COMPRESS.

Aim.
To reduce signs of inflammation.

Indications.
• To relieve discomfort
• To decrease inflammation
• To enhance absorption of drugs
• To promote drainage of superficial infections.

Requirements
  • Bowl with warm water
  • Sterile water or normal saline
  • Mackintosh cape and towel/dressing
    mackintosh
  • Sterile bowl
  • Cotton swabs
  • Receiver
  • Bedside  Hand washing equipment
    Screen
    An adjustable light/ a torch,
Procedure
  1. Identify the eye to be treated.
  2.  Follow the general rules.
  3.  The patient may be seated or lying down for this procedure.
  4.  Place the bowl with solution in a bowl of warm water.
  5.  Wash dry hands and put on gloves.
  6.  Place the swab in the warm solution (37 -41 degrees centigrade).
  7. Squeeze out the excess solution.
  8.  Instruct the patient to close the eye. Gently apply the swab on top of the affected eye.
  9.  Change the compress every 2 minutes for the prescribed length of time.
  10.  Use a dry swab to clean and dry the eyes.
  11.  If required apply eye drops/ ointment.
  12.  Thank and leave the patient comfortable.
COLD EYE COMPRESS

Is placing of a cold compress/pack over the affected area or eye
to relieve discomfort.

Indication
  • To reduce swelling or bleeding
  • To ease peri-orbital discomfort
  • To relieve itching
    Requirement
    Tray
  • Small plastic bag or glove
  • Ice cubes/chips
  • Strapping
  • Sterile solution (water or normal saline)
  • Swabs
  • Mackintosh and towel
  • Clean gloves
Procedure
  1. Follow the general rules of nursing procedure.
  2.  Identify the eye to be treated.
  3.  The patient should lie down for this procedure.
  4.  Position the mackintosh and towel to protect the patient’s clothes.
  5.  Place the swab in the bowl of ice chips (18_27° C).
  6.  Wash dry hands and put on gloves.
  7.  Place the moist swab over the affected closed eye.
  8.  After 15-20 minutes, remove the cold compress
  9.  Use a dry swab to clean and dry the patient’s face
  10.  If required apply eye drops /ointment.
  11.  Thank and leave the patient comfortable.
  12.  Clear away and document procedure.
Eye Irrigation

Washing of the conjunctiva sack with a stream of fluid(water).
Purpose
1. To remove foreign body from the eye
2. To remove chemicals which have been accidentally splashed into the eye(s)
3. To washout discharge
4. Before administration of medication
5. In preparation for eye operations

Requirements
Tray-sterile

  • Irrigating solution-Normal saline at 370C or plain boiled
    cooled water(sterile).
  • Sterile gloves, patient’s towel
  • Lid retractor
  • Litmus paper
  • Undine or any small container with a pouring spout
    e.g. feeding cup, bulb syringe
    or Sterile irrigation set
  • Eye pad/water proof pad
  • Gallipot of cotton balls or facial tissues
  • 2 receivers, mackintosh cape and towel/dressing
    mackintosh
  • Boric acid 2 to 4 %
  • Gallipot of cotton
Procedure
  1.  Follow the general rules for all nursing procedures.
  2.  Have the patient sit or lie down with the head tilted toward the side of the affected eye. Protect
    the patient and the bed with a dressing mackintosh or water proof pad and a towel.
  3.  Put on gloves. Clean the eye as before.
  4.  Place the curved part of the receiver at the cheek on the side of the affected eye to receive the
    irrigating solution. If the patient is sitting up request the patient to hold the receiver.
  5.  Expose the lower conjunctival sac and hold the upper lid open with the non-dominant hand.
  6.  Hold the irrigator about 2.5 cm from the eye. Direct the flow of the solution from the inner to the
    outer canthus along the conjunctival sac.
  7.  Irrigate until the solution is clear or all the solution has been used. Use only sufficient force gently
    to remove secretion from the conjunctiva without touching any part of the irrigating equipment.
  8.  Tell the patient to close the eye and move the eye periodically.
  9.  Dry the area after irrigation with cotton balls. Offer the towel to the patient if the face and neck
    are wet.
  10.  Remove gloves and wash your hands.
  11.  Make the patient comfortable.
  12.  Document the procedure or findings.
  13.  Clear away.
Points to remember
  •  For chemical burns irrigate each eye for at least 15 minutes with normal saline solution to dilute
    and wash out the harsh chemicals.
  •  If the patient cannot identify the specific chemical, use litmus paper to determine if the chemical
    is acidic or alkaline or to be sure the eye has been irrigated adequately.
  • When irrigating both eyes, ask the patient to tilt his head
    towards the side being irrigated to avoid contamination.
  • An irrigation fluid  may be pre-packed in a disposable set for
    use or a sterile 50ml syringe may be used.

 

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