Examining the eye - Ophthalmic Nursing

Although the main focus in this section is on examining the eye, it is good nursing practice to take a holistic approach to patient care. Ensure that the patient you are going to examine is made comfortable and pain free. For any patients with a traumatic eye injury, ensure that the patient is not suffering from shock and has not sustained any other injuries. Always consider the patient’s age and psychological state.

Patients attending with an acute eye problem should always have their ophthalmic history taken ﬁrst to ascertain the nature and acuteness of the problem. For example, for patients attending with a chemical injury treatment should always be instigated prior to examining the eye.

When examining a patient’s eye, ﬁrst look at the patient’s face as a whole to determine facial symmetry and note any obvious palsy, ptosis, proptosis, obvious trauma, ocular movement or allergic reactions.

The eye is always examined from the outside inwards. If only one eye is affected, inspect the ‘good’ eye ﬁrst for comparison.

Ask the patient to open both eyes as this is easier than opening one. Use a slit lamp or a good pen torch. Ensure that the patient’s head is well supported.

If the patient is experiencing ocular pain, topical anaesthetic drops may be necessary. However, the patient’s pain must be assessed before administering any topical anaesthetic. The patient’s pain can be assessed using a pain-rating tool such as the verbal pain scale. Care should be taken not to ‘misuse’ the topical anaesthetic in controlling a patient’s corneal pain since this can actually delay corneal epithelial healing.On no account must these drops be given to the patient to take home. If the patient is in a great deal of pain, more effective oral analgesia or a non-steroidal anti-inﬂammatory such as Voltarol can be prescribed.

If there is a history of glass or ﬁbreglass in the eye or the history indicates possible penetrating injury or perforation, local anaesthetic should not be instilled. The reason for the former is to more easily identify if the glass/

ﬁbreglass has been removed; the latter to avoid the drug entering the eye.

Eyelids

Look for:

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Ptosis;

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Swelling;

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Discoloration;

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Discharge/crusting;

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Ingrowing lashes (see Figure 4.1);

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Entropion;

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Ectropion;

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Laceration.

Figure 4.1 Trichiasis with cicatricial pemphigoid.

Conjunctiva

The upper palpebral conjunctiva must also be examined by everting the upper lid. Look for:

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Injection (redness);

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Degree of injection;

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Position of injection:

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Limbal/ciliary;

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Localised – with or without dilated episcleral vessels;

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Generalised.

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Subconjunctival haemorrhage;

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Chemosis (swelling);

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Foreign body (see Figure 4.2);

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Laceration;

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Cysts;

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Pinguecula;

Figure 4.2 Penetrating injury.

Figure 4.3 Cobblestone papillae.

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Pterygium;

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Follicles;

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Papillae (see Figure 4.3).

Cornea

Look for:

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Clarity;

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Corneal curvature, e.g. keratoconus;

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Pannus (superﬁcial vascularisation of the cornea);

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Foreign body;

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Abrasion;

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Laceration;

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Ulcers.

Using a slit lamp, examine the layers of the cornea and note any abnormalities such as sub-epithelial opacities, corneal oedema, descemets folds or breaks, fresh or old keratatic precipitate or pigment on the endothelium.

Anterior chamber

Assess depth (should be deep but compare with other eye). Look for:

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Hyphaema (see Figure 4.4);

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Hypopyon;

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Flare and cells (using slit lamp).

Iris

Assess:

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Colour – compare with other eye;

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Clarity and pattern.

Figure 4.4 Hyphaema.

Look for:

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Iridodialysis;

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Iris prolapse.

Pupil

Assess:

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Shape (should be round – an irregular pupil could indicate synaechiae; an oval pupil could indicate acute glaucoma);

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Size;

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^Reaction;

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RAPD (relative afferent pupil defect);

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Position (should be central);

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Colour – usually black: the red reﬂex may be noted (a white or grey pupil suggests the presence of a cataract; a white pupil in a baby/child indicates a cataract or retinoblastoma or imperforate pupil membrane).

PROCEDURE GUIDELINE

Everting the upper lid

The upper lid is everted to inspect the palpebral conjunctiva over the sub- tarsal area. Foreign bodies, conjunctival follicles, papillae or concretions may be present.

Equipment

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Cotton bud;

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Slit lamp or illuminated magniﬁcation unit.

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Nursing Action

1 Wash hands and prepare trolley and gather equipment in accordance with Aseptic Non Touch Technique (ANTT) principles.

2 Prepare equipment, identifying key parts and key sites to be pro- tected during the procedure.

3 Check patient identiﬁcation against request card/notes with patient.

4 Obtain patient’s consent and co-operation. Explain procedure, in- cluding any side-effects. Warn patient that there will be a peculiar sensation during the examination.

5 Ask the patient to look downwards.

6 Take hold of the lashes of the upper lid with one hand and gently pull forwards and downwards.

7 With the other hand, place cotton bud vertically over tarsal plate (mid lid area) Do not apply any pressure on the globe.

8 Push gently into the tarsal plate, at the same time the hand holding the lashes everts the lid, discard the cotton bud.

9 Remind the patient to keep looking down.

10 Inspect the sub-tarsal conjunctiva.

11 Repeat for other eye if required.

12 Release the lid and ask the patient to rest back.

13 Dispose of waste appropriately, cleaning hands, tray/trolley as before.

14 Document the procedure in the patient’s notes, adding time, date and signature.