a&e emergency nurse practitioner protocols · 11.2 emergency nurse practitioner diagnosis and...

A&E Emergency Nurse Practitioner Protocols

Protocol Summary These Protocols are intended provide guidance for the practice of the A&E Emergency Nurse Practitioners

Version: 4.2

Status: FINAL Approved: 14th June 2016 Ratified: 14th June 2016

A&E ENP Protocols June 2016 2

Version History

Version Date Issued Brief Summary of Change Author

4.1 March 2014 Reformatted, addition new protocols all protocols incorporated in to one document

L.Langton

R. Apostol

4.2 April 2016 All protocols reviewed, updated. R.Apostol

R. Timbol

F.Dirir

T.Gwenhure

L.Langton

For more information on the status of this document, please contact:

A&E Matron

Protocol Author L. Langton, R. Apostol

Protocol Owner Accidents and Emergency Nursing

Department Accidents and Emergency Department

Date of issue 14th June 2016

Review due date 14th June 2018

Approved by A&E Service (27-04-16) Clinical Audit and effectiveness Committee

Intended audience A&E Nursing/Practitioners


1. Scope These protocols apply to those Nurses at Band 6 or above designated as Emergency Nurse Practitioners (ENPs) in the Accident& Emergency Service at Moorfields Eye Hospital NHS Foundation Trust. Each protocol has a matching competency that is an assessment tool to evaluate the competency of the nurse. Only when each nurse has successfully completed the matching competency can they independently assess and manage patients with the relevant condition.

2. Purpose These protocols are to provide guidance on the assessment and management of the clinical conditions that have been designated by the A&E service as suitable for ENPs to assess, manage, treat and discharge patients independently. These protocols are evidence based and intended to inform good practice, they are not a substitute for the practitioner’s own sound clinical judgement, which they should continue to exercise. 3. Training

3.1 Nursing staff must be at Band 6 or above with a suitable ophthalmic qualification or

course. They must have undertaken additional training in the A&E department supervised by the senior nursing staff and passed the designated competency for each condition before being allowed to independently assess and treat patients.

3.2 Competency will be reassessed on a two yearly basis by each nurse’s line manager or a

designated member of the A&E senior nursing team or the Clinical Education team. If there are indications that the competency process needs to be assessed more frequently such as questions over accuracy of diagnosis or management this will be carried out immediately. If the ENP does not pass the designated competencies at any time then they will not be permitted to practice independently until the relevant training and support has enabled them to reach the required level.

3.3 Medications will be:

Either supplied in the department by the ENP using a Patient Group Direction (PGD). Each ENP must have undergone the trust’s Medicines Awareness training and be competent in the use of the PGD as described in trust policy.

Prescribed by those ENPs who hold the non- medical prescriber qualification 3.5 For those ENPs who have completed and passed the non- medical prescribing course

medication can only be prescribed within their sphere of practice and they must adhere to the trust’s non- medical prescribing policy. 4. Stakeholder Engagement and Communication These protocols were drawn up by the A&E nursing team and clinical education team with the A&E Service Director and with support from the A&E medical staff. 5. Approval and Ratification These protocols will be agreed by the A&E Service Director and A&E Service, followed by approval and ratification by the Clinical Audit and Effectiveness Committee.


6. Dissemination and Implementation Each ENP will be required to keep a copy of the associated competency and hard copies of the protocol document will be held by the A&E Matron in the A&E Department. These protocols will also be placed on the Trust Intranet 7. Review and Revision Arrangements

These protocols will be reviewed every two years by the A&E Matron, the A&E Clinical Educator and the clinical education team in conjunction with the A&E Service Director and the A&E department ENPs. 8. Document Control and Archiving

8.1 The current and approved version of this document can be found on the Trust’s intranet site on the Clinical Guidelines page. Should this not be the case, please contact the Protocol owner / author.

8.2 Previously approved versions of this Protocol will be removed from the intranet by the Head of Clinical Governance and archived on the shared drive. Any requests for retrieval of archived documents must be directed to the Head of Clinical Governance or the relevant department. 9. Monitoring compliance with this Protocol

Monitoring method Monitoring frequency

Monitoring lead

Monitoring reported to…

A retrospective audit will be undertaken by the A&E Clinical Educator or a designated deputy. Twenty sets of notes belonging to patients seen by the ENPs will be reviewed for accuracy of documentation, management and treatment.

Two yearly or more frequently if issues around individual practice indicate that this is required

A&E Clinical Educator or designated deputy

A&E Service

10. Supporting References / Evidence Base Common references for all protocols:

Accident and Emergency Handbook

Moorfields Original A&E Nurse Practitioner Protocols – original version 1998

Moorfields Eye Hospital- The Medicines Management policy

Moorfields Eye Hospital -Patient Group Directions (PGD) Policy

Moorfields Eye Hospital – History Taking SOP

Specific references for each condition are listed at the end of the condition protocol

A&E ENP Protocols April 2016

Accident and Emergency ENP Protocols

11.1 Emergency Nurse Practitioner Diagnosis of Bacterial Conjunctivitis Protocol

Introduction This guideline is intended to inform good practice, it is not a substitute for the practitioner’s own sound clinical judgement, which they should continue to exercise. The format follows the structure of the knowledge and skills framework. It will help inform the process of assessment of competence. Preparation Assess patient in designated Red Room Clean slit lamp Introduce self to patient, establish rapport and sit the patient safely at the slit lamp Procedure History Taking: Question the patient about:

Any discomfort, usually described as burning or grittiness?

Any discharge (may cause temporary blurring of vision)?

Any crusting of the eye lids –are the eye lids stuck together on waking?

Any redness? The condition is usually bilateral – one eye may be affected before the other (by one or two days) Review visual acuity Ocular Examination: Examine both eyes systematically using the slit lamp. If unilateral, examine unaffected eye first (infection control)

Check the eye lids for crusting

Check lids for follicles and/or papillae and subtarsal foreign bodies and signs of blepharitis

Check and note any purulent or mucopurulent discharge

Check for conjunctival injection

Check the tarsal conjunctiva which may show mild papillary reaction


Check the cornea. In bacterial conjunctivitis there is usually no involvement apart from mild superficial punctate keratitis. If the cornea is significantly involved, consider possibility of gonococcal infection

Check for any palpable preauricular node – not usually present in bacterial conjunctivitis

Wash and dry hands Diagnosis: Review and analyse your findings to confirm the diagnosis. (If unsure of the diagnosis, refer patient to the doctor) Treatment and Management:

Select the appropriate medication as per PGD G. Chloramphenicol with two drops to be applied to the affected eye every three hours or more frequently if required. Treatment should be continued for at least 48 hours after eye appears normal.

A bacterial swab collection for bacteriology should be taken if indicated. Swabs for chlamydia and virus isolation should also be taken if indicated.

Give patient a full explanation of the condition, expected course and outcome of condition and allow opportunity to ask questions.

Discuss levels of pain or discomfort and advise patient on pain relief.

Ensure patient understands when return visit to A&E may be required i.e. decrease in vision or sudden increase in pain/discomfort

Discuss preventative measures i.e. infection control and give patient information leaflet

If the patient is a contact lens wearer they should be advised not to wear contact lenses until the course of treatment has been completed and they are symptom free

Wash hands and slit lamp Record keeping Clearly document findings, sign and print name and designation in the patient health records Print letters: GP letter, letter for the patient, letter for the patient records and sign Appropriate action Consult doctor if there is corneal involvement, pseudo membrane or any AC activity References: Royal College of Optometrists -CLINICAL MANAGEMENT GUIDELINES Conjunctivitis (bacterial) 4-07-14 Marsden Janet (ED). An Evidence Base for Ophthalmic Nursing.(2007)John Wiley and Sons Ltd. Sussex https://www.medicinescomplete.com/mc/bnf/current/PHP3531-chloramphenicol.htm?q=Bacterial%20Conjunctivitis- Accessed April 2016

https://www.medicinescomplete.com/mc/bnf/current/PHP3531-chloramphenicol.htm?q=Bacterial%20Conjunctivitis-

https://www.medicinescomplete.com/mc/bnf/current/PHP3531-chloramphenicol.htm?q=Bacterial%20Conjunctivitis-


11.2 Emergency Nurse Practitioner Diagnosis and Treatment of Blepharitis Protocol Introduction This guideline is intended to inform good practice, it is not a substitute for the practitioner’s own sound clinical judgement, which they should continue to exercise. The format follows the structure of the knowledge and skills framework. It will help inform the process of assessment of competence. Preparation Introduce self to patient, establish rapport and sit the patient safely at the slit lamp Clean slit lamp Procedure History Taking: Question patient about:

Description of ocular discomfort

When symptoms are worse i.e. morning or evening

Any aggravating symptoms

Any discharge or crusting of lids

Duration of symptoms and any previous episodes

Any recent URTI or GU problems, general malaise?

Swollen preauricular glands?

Contact lens wear?

Recent contact with conjunctivitis sufferer?

History of hay fever or allergy? Review visual acuity Observe patient’s facial skin for signs of Rosacea Ocular Examination: Examine both eyes systematically using the slit lamp. If unilateral, examine unaffected eye first (infection control)

Check lids and lashes for collarettes, hyperaemia, hypertrophy, inflamed or blocked meibomian gland orifices and seborrhoea

Note tear film integrity

Check for signs of concurrent infection i.e. conjunctival injection, follicles, inflamed meibomian glands etc.

Check cornea for signs of marginal keratitis

Check AC for cells and flare

Stain cornea with G. Fluorescein for signs of dryness and tear break-up time

Wash and dry hands Diagnosis:


Review and analyse your findings to confirm the diagnosis. (If unsure of the diagnosis, refer patient to the doctor) Treatment: Select the appropriate treatment protocol as follows:-

Anterior Blepharitis Lid hygiene twice daily for 2 weeks and then as required Posterior Blepharitis Hot compresses and lid massage twice daily for 2 weeks

and then as required Mixed Blepharitis Both of the above until symptoms relieved and then as

required * There is evidence to suggest that mite infestation with Demodex folliculorum and Demodex brevis gives rise to Demodex blepharitis. Demodex folliculorum tends to be clustered to the root of the lashes, while Demodex brevis tends to present individually in meibomian glands. Weekly lid scrub with 50% tea tree oil showed dramatic improvements in symptoms, ocular surface inflammation, lipid tear film stability, corneal epithelium smoothness and visual acuity. Demodex count usually drops to zero in 4 weeks without recurrence in a majority of cases.

If conjunctival injection and discharge are present, supply Chloramphenicol ointment 1% 3 times daily for seven days to reduce bacterial commensal load and Carmellose 0.5% eye drops 1 to 2 drops 4 times daily or as needed for up to one month if any evidence of dry ocular surface as per PGD Give patient a full explanation of the condition, expected course and outcome of condition and allow opportunity to ask questions Wash hands and slit lamp Record keeping Clearly document findings, sign and print name and designation in the patient health records Print letters: GP letter, letter for the patient, letter for the patient records and sign Appropriate action Consult doctor if there is any sign of AC activity, marginal keratitis or Rosacea References Gao YY, Di Pascuale MA, Elizondo A, Tseng SC. Clinical treatment of ocular demodecosis by lid scrub with tea tree oil. Cornea 2007; 26: 136-143. Kheirkhan A, Casas V, Li W, Raju VK, Tseng SC. Corneal infestations of ocular demodex infestation. Am J Ophthalmol 2007: 143: 743-749. Liu J, Sheha H, Tseng SC. Pathogenic role of Demodex mites in blepharitis. Curr Opin Allergy Clin Immunol 2010: 10(5): 505-510


11.3 Emergency Nurse Practitioner Diagnosis and Treatment of a Corneal Foreign

Body (CFB) Protocol

Introduction This guideline is intended to inform good practice, it is not a substitute for the practitioner’s own sound clinical judgement, which they should continue to exercise. The format follows the structure of the knowledge and skills framework. It will help inform the process of assessment of competence. Preparation Clean slit lamp Introduce self to patient, establish rapport and sit the patient safely at the slit lamp Procedure History Taking: Question patient about the complaint including: -

Mechanism of injury: Was it a high velocity? i.e. more likely to be penetrating

Were they wearing eye protection

Were they wearing glasses or contact lenses at the time of the injury?

Happened at work or home?

Review visual acuity Ocular Examination:

Wash hands and slit lamp

Examine both eyes systematically using the slit lamp

Check both eyes for the presence of foreign bodies including subtarsal FBs

Identify location of the corneal foreign body.

Be suspicious of perforating injury until proved otherwise. Carry out Seidels test to ensure there is no perforating injury.

Retro illuminate to examine the iris for any irregularity suggesting IOFB compare with other eye.

Removal of Corneal Foreign Body:

Explain procedure for removal to patient in a reassuring manner and ensure they fully understand and the procedure.

Instil local anaesthetic eye drop to affected eye as per PGD

Use whichever hand is comfortable for you.

Use a sterile green needle with bevel facing you

Insure your hand is steady and that the patient is comfortable

Use other hand to hold their eyelids open as necessary

Remind patient to keep eyes still, open and if required give them a target to fixate on.

Remind the patient to keep their head still and their forehead pressed against the bar of the slit lamp.


Slowly guide the needle tip into field of view from below.

When nearly in position, change to viewing through the slit lamp making final adjustments.

Gently try to lift the foreign body edge with the edge of the needle in a scooping fashion.

Ensure the tip of the needle does not become contaminated by contact with anything other than the patient’s cornea, if contamination occurs change the needle.

The FB may ‘float’ off in the tear film in which case remove with a sterile dressed orange stick moistened by a drop of sterile saline.

If FB is embedded, try a scraping motion once or twice more

If rust ring remains either scrape with edge of needle or use an Alger brush with sterile burr

Check depth of excavation regularly

Repeat Seidel test after the FB has been removed Treatment:

Instigate treatment plan (doctor’s or NP PGD)

Instil G.Cyclopentolate 1% multi-dose or unit dose eye drop one drop only if eye(s) very painful or photophobic as per PGD

Give patient a full explanation of the condition, expected outcome and allow opportunity to ask questions.

Discuss pain relief, advise use of Paracetamol or similar analgesic unless contraindicated. Advise patient of the estimated duration of the period in which they will experience pain and discomfort.

Ensure patient understands when a return visit to A&E may be required i.e. no improvement or any increase in symptoms.

If the patient is a contact lens wearer, advise them to refrain from contact lens wear for the duration of the treatment and only to resume contact lens wear when the eye is completely symptom free and at least 24 hours after completion of treatment. If there a large epithelial defect, advise patient to see contact lens practitioner before resuming contact lens wear.

Discuss preventative measures including use of eye protection. Wash hands and slit lamp Record keeping Clearly document findings, sign and print name and designation in the patient health records Print letters: GP letter, letter for the patient, letter for the patient records and sign Appropriate action If FB is very deep or penetrating do not attempt removal. Consult doctor If there is difficulty in removing the FB a doctor must see the patient. If there is anterior activity or corneal infiltrates, refer the patient to the doctor References Denniston, A. K. O. and Murray, P. I. (2009) Oxford Handbook of Ophthalmology 2nd Ed. Oxford Medical Publications, Oxford.


Khaw, P.T.; Shah, P. and Elkington, A. R. (2004) ABC of Eyes: Injury to the eye. British Medical Journal (328) 7430 pp36-38 Jackson Timothy L Ed. 2007. Moorfields Manual of Ophthalmology 1st Edition. Mosby, London. Marsden J. Ed. 2007. An Evidence Base for Ophthalmic Nursing Practice. Edition. John Wiley & Sons, UK.

The College of Optometrists (2015) Clinical Management Guidelines: Corneal abrasion. The college of Optometrist publication. London. Turner, A and Rabiu, M. (2006) Patching for corneal abrasion. Cochrane Database of Systemic Reviews. John Wiley and Sons, Ltd. http://emedicine.medscape.com/article/1195581-treatment [Accessed 12.04.2016] http://cks.nice.org.uk/corneal-superficial-injury [Accessed 09.04.2016] http://www.evidence.nhs.uk/Search?om=[{%22toi%22:[%22Evidence%20Summaries%22]}]&ps=20&q=corneal+foreign+body [accessed 11.04.2016]

http://www.bestbets.org/bets/bet.php?id=892 [Accessed 11.04.2016]

http://patient.info/doctor/corneal-foreign-bodies-injuries-and-abrasions [Accessed 12.04.2016]

http://emedicine.medscape.com/article/1195581-treatment

http://cks.nice.org.uk/corneal-superficial-injury

http://www.evidence.nhs.uk/Search?om=%5b%7b%22toi%22:%5b%22Evidence%20Summaries%22%5d%7d%5d&ps=20&q=corneal+foreign+body

http://www.evidence.nhs.uk/Search?om=%5b%7b%22toi%22:%5b%22Evidence%20Summaries%22%5d%7d%5d&ps=20&q=corneal+foreign+body

http://www.bestbets.org/bets/bet.php?id=892

http://patient.info/doctor/corneal-foreign-bodies-injuries-and-abrasions


11.4 Emergency Nurse Practitioner Diagnosis and Treatment of Chalazia Protocol

Introduction This guideline is intended to inform good practice, it is not a substitute for the practitioner’s own sound clinical judgement, which they should continue to exercise. The format follows the structure of the knowledge and skills framework. It will help inform the process of assessment of competence. Preparation Introduce self to patient, establish rapport and sit the patient safely at the slit lamp Clean slit lamp Procedure History Taking: Question patient about:

Duration of lid lump and any changes since first appeared

Description of any associated ocular discomfort/pain

Any discharge or crusting of lids

Any previous episodes of lid lumps

Contact lens wear?

History of hay fever or allergy? Review visual acuity Observe patient’s facial skin for signs of Rosacea Ocular Examination: Examine both eyes systematically using the slit lamp

Check lids and lashes for collarettes, hyperaemia, hypertrophy, inflamed or blocked meibomian gland orifices and seborrhoea

Evert lid to visualise chalazion if patient can tolerate same

Note tear film integrity

Check for signs of concurrent infection i.e. conjunctival injection, follicles, inflamed meibomian glands etc.

Check cornea for signs of marginal keratitis

Check AC for cells and flare

Stain cornea with G. Fluorescein for signs of dryness and tear break-up time

Check patient’s temperature if there is extensive lid swelling and redness Wash and dry hands Diagnosis: Review and analyse your findings to confirm the diagnosis.


(If unsure of the diagnosis, refer patient to the doctor) Treatment: * Up to 80% of chalazia resolve spontaneously, although this may take weeks to months. People with various forms of blepharitis is at risk of developing chalazion and it is therefore important to manage this to reduce the potential for recurrence. Select the appropriate treatment protocol for associated blepharitis as follows:-

Anterior Blepharitis Lid hygiene twice daily for 2 weeks and then as required Posterior Blepharitis Hot compresses and lid massage twice daily for 2 weeks

and then as required Mixed Blepharitis Both of the above until symptoms relieved and then as

required

If conjunctival injection and discharge are present, Chloramphenicol ointment 1% 4 times daily for seven days can be supplied as per PGD. Give patient a full explanation of the condition, expected course and outcome of condition and allow opportunity to ask questions. Discuss suitable pain relief if the patient is experiencing pain or discomfort. * An onward referral to the appropriate clinic for incision and curettage is arranged If chalazion is large, persistent and does not respond to conservative treatment (hot compress and lid massage) or causing significant astigmatic refractive error due to mechanical effects on the cornea. Wash hands and slit lamp Record keeping Clearly document findings, sign and print name and designation in the patient health records Print letters: GP letter, letter for the patient, letter for the patient records and sign Appropriate action Refer patient to a doctor if there is excessive lid swelling or discharge, excessive pain or the patient is pyrexial * There is evidence to suggest that a number of different benign, premalignant and malignant conditions may clinically masquerade as a chalazion. Chalazion that recur in the same location or are atypical in appearance should be urgently referred to the doctor to rule out serious pathologies such as sebaceous gland carcinoma which is an extremely aggressive form of eyelid malignancy and accounts for majority of misdiagnosed recurrent chalazia.


References Elsayed MA, Alkahtani SA. Chalazion Management: Evidence and Questions. Eyenet 2015 September: 37-39. National Institute for Clinical Excellence (2015) Meibomian cyst (chalazion). National Institute for Clinical Excellence. Available from: cks.nice.org.uk Ozdal PC, Codere F, Callejo S, Caissie AL, Burnier MN. Accuracy of the clinical diagnosis of chalazion. Eye 2004: 18: 135-138. Sabermoghaddam AA, Zarei-Ghanavati S, Arishami M. Effects of chalazion excision on ocular aberrations Cornea 2013: 32(6): 757-760. The College of Optometrists (2015) Chalazion (Meibomian cyst). The College of Optometrists. Available from: www.college-optometrists.org


11.5 Emergency Nurse Practitioner Diagnosis and Treatment of Corneal Abrasion Protocol

Introduction This guideline is intended to inform good practice, it is not a substitute for the practitioner’s own sound clinical judgement, which they should continue to exercise. The format follows the structure of the knowledge and skills framework. It will help inform the process of assessment of competence. Preparation Clean the slit lamp Introduce self to patient, establish a rapport and sit the patient safely at the slit lamp Procedure History taking: Question patient about presenting complaint including:-

Previous similar episodes

Any trauma

Contact lenses wearer?

Onset (classically on waking) and duration

Associated symptoms

Where patient was when symptoms started

Any safeguarding concerns? Wash and dry hands Review visual acuity Instil local anaesthetic eye drop to affected eye as per PGD if required for pain management Ocular Examination:

Examine both eyes systematically using the slit lamp.

Check for signs of abrasion, infiltrates and cells and flare in the AC

Check for subtarsal and corneal foreign bodies

Remove foreign body as per competency protocol if present

Instil G. Fluorescein 2% to both eyes and examine with blue filter light.

Note size, shape and position of abrasion and any loose epithelium, which indicates the need for debridement by medical colleague.

Carry out Seidels test at the same time – be suspicious of perforating injury until proved otherwise.

Retroilluminate to examine the iris for any irregularity suggesting IOFB compare with other eye.

Wash and dry hands


Diagnosis: Review and analyse your findings to confirm the diagnosis. (If unsure of the diagnosis, refer patient to the doctor) Treatment:

Supply medication in accordance with the PGD

Discuss pain relief and advise use of Paracetamol or other over the counter pain relief. Advise the patient on the likely duration of the pain or discomfort.

Instil G.Cyclopentolate 1% multi-dose or unit dose eye drop one drop only if eye(s) very painful or photophobic as per PGD

Give patient a full explanation of the condition, expected course and outcome of condition and allow opportunity to ask questions

Ensure patient understands when return visit to A&E may be required i.e. decrease in vision or sudden increase in pain/discomfort, symptoms do not resolve

If patient is a contact lens wearer, advise then to refrain from contact lens wear for the duration of the treatment then get checked by their contact lens practitioner before resuming contact lens wear.

Discuss preventative measures e.g. eye protection. Wash hands and slit lamp Record keeping Clearly document findings, sign and print name and designation in the patient health records Print letters: GP letter, letter for the patient, letter for the patient records and sign. Appropriate action Consult doctor also if the patient has corneal infiltrates, deep corneal laceration or penetrating eye injury References

Denniston, A. K. O. and Murray, P. I. (2009) Oxford Handbook of Ophthalmology 2nd Ed. Oxford Medical Publications, Oxford.

Jackson Timothy L Ed. 2007. Moorfields Manual of Ophthalmology,1st Edition. Mosby. London Khaw, P.T.; Shah, P. and Elkington, A. R. (2004) ABC of Eyes: Injury to the eye. British Medical Journal (328) 7430 pp36-38

Marsden J. Ed. 2007. An Evidence Base for Ophthalmic Nursing Practice. Edition. John Wiley & Sons, UK.


The College of Optometrists (2015) Clinical Management Guidelines, Corneal Abrasion. The college of Optometrist publication. London.

The Royal College of Ophthalmologists 2013, Ophthalmic Services Guidance: Emergency Eye care.

Turner, A and Rabiu, M. (2006) Patching for corneal abrasion. Cochrane Database of Systemic Reviews. John Wiley and Sons, Ltd. Wipperman, J. L. and Dorsh, J. N. (2013) American Family Physician 87 (2) pp114-120. Evaluation and management of corneal abrasions.

http://emedicine.medscape.com/article/1195402-overview [Accessed 12.04.2016]

http://cks.nice.org.uk/corneal-superficial-injury [Accessed 09.04.2016]

https://www.evidence.nhs.uk/Search?om=[{%22toi%22:[%22Evidence%20Summaries%22]}]&ps=20&q=Corneal+abrasion [Accessed 21.04.2016]

http://emedicine.medscape.com/article/1195402-overview


https://www.evidence.nhs.uk/Search?om=%5b%7b%22toi%22:%5b%22Evidence%20Summaries%22%5d%7d%5d&ps=20&q=Corneal+abrasion

https://www.evidence.nhs.uk/Search?om=%5b%7b%22toi%22:%5b%22Evidence%20Summaries%22%5d%7d%5d&ps=20&q=Corneal+abrasion


11.6 Nurse Practitioner (Advanced) Diagnosis and Treatment of Recurrent Erosion

Introduction This guideline is intended to inform good practice, it is not a substitute for the practitioner’s own sound clinical judgement, which they should continue to exercise. The format follows the structure of the knowledge and skills framework. It will help inform the process of assessment of competence.

Preparation Clean the slit lamp Introduce self to patient, establish a rapport and sit the patient safely at the slitlamp

Procedure History taking: Question patient about presenting complaint including:-

1. Previous similar episodes? 2. Any corneal trauma current or past? 3. Contact lenses wearer? 4. Onset (classically on waking) and duration 5. Associated symptoms 6. Where patient was when symptoms started

Wash and dry hands Review visual acuity Instill G. Amethocaine to affected eye as per PGD if required for pain management Ocular Examination: Examine both eyes systematically using the slit lamp.

1. Check for signs of abrasion, infiltrates and cells and flare in the AC 2. Check for subtarsal and corneal foreign bodies 3. Remove foreign body as per competency protocol if present 4. Instill G. Fluorescein 2% to both eyes and examine with blue filter light. 5. Note size, shape and position of abrasion and any loose epithelium, which indicates

the need for debridement by medical colleague. 6. Carryout Seidel at the same time – be suspicious of perforating injury until proved

otherwise. 7. Retroilluminate to examine the iris for any irregularity suggesting IOFB (compare

with other eye). Wash and dry hands Diagnosis Review and analyse your findings to confirm the diagnosis. (If unsure of the diagnosis, refer patient to the doctor) Treatment Supply medication in accordance with the PGD


Give patient a full explanation of the condition, expected course and outcome of condition and allow opportunity to ask questions Ensure patient understands when return visit to A&E may be required i.e. decrease in vision or sudden increase in pain/discomfort, symptoms do not resolve. If the patient is a contact lens wearer, advise them to refrain from contact lens wear and see optician to discuss best options refractive error correction. Discuss preventative measures e.g. regular eye lubrication. Wash hands and slit lamp Record keeping Clearly document, sign and print name and designation in patient’s notes and on PAS. Appropriate action Consult doctor also if loose epithelium requires debriding. Refer patient to External Disease Service if this is the second or more episode of recurrence. References

Das S. and Seitz, B. (2008) Recurrent Erosion Syndrome. Survey Ophthalmology 53 (1) 3-15 Ramamurthi, S.; Rahman, M. Q.; Dutton, G. N. and Ramesh, K (2006) pathogenesis, clinical features and management of recurrent corneal erosion. Eye 20 pp 635-644 The College of Optometrists (2015) Clinical Management Guidelines: Recurrent

corneal epithelia erosion syndrome. The college of Optometrist publication. London.

Watson, S. L. and Baker N. H. (2007) Interventions ofr recurrent corneal erosions. Cochrane Database of Systemic Reviews. John Wiley and Sons, Ltd. http://emedicine.medscape.com/article/1195183-overview . https://www.reviewofoptometry.com/article/peeling-back-the-layers-of-rce

http://www.aao.org/eyenet/article/treatment-of-recurrent-corneal-erosions




https://www.reviewofoptometry.com/article/peeling-back-the-layers-of-rce

http://www.aao.org/eyenet/article/treatment-of-recurrent-corneal-erosions



11.7 Emergency Nurse Practitioner Diagnosis and Treatment of Photokeratitis Protocol

Introduction This guideline is intended to inform good practice, it is not a substitute for the practitioner’s own sound clinical judgement, which they should continue to exercise. The format follows the structure of the knowledge and skills framework. It will help inform the process of assessment of competence. Preparation Clean the slit lamp Introduce self to patient, establish a rapport and sit the patient safely at the slit lamp Procedure History taking: Question patient about presenting complaint including: -

Bilateral redness?

Nature of pain?

Any photophobia?

Lacrimation?

Visual disturbance?

Recent welding or sun lamp usage without eye protection?

Onset of symptoms following this exposure? (usually approx. 12hrs)

Any other potential cause i.e. chemical injury? Contact lens wear? Wash and dry hands Review visual acuity Instil one drop of local anaesthetic to affected eye as per PGD if required for pain management Ocular Examination: Examine both eyes systematically using the slit lamp.

Check for signs of corneal abrasion and/or oedema, infiltrates and cells and flare in the AC


Remove foreign body as per competency protocol if present


Note extent of any punctate epitheliopathy. Wash and dry hands Diagnosis: Review and analyse your findings to confirm the diagnosis. (If unsure of the diagnosis, refer patient to the doctor) Treatment:


Supply medication in accordance with the PGD G.Chloramphenicol to the affected eye/s QDS for 5 days.

Discuss pain relief and advise use of Paracetamol or other suitable analgesic.

Instill G. Cyclopentolate 1% multi-dose or unit dose eye drop one drop only if eye(s) very painful or photophobic as per PGD

Give patient a full explanation of the condition, expected course and outcome of condition and allow opportunity to ask questions


If patient is a contact lens wearer, advise them to refrain from contact lens wear for the duration of the treatment and until the eye is completely symptom free 24 hours after completing the treatment regime.

Discuss preventative measures and advise use of suitable eye protection. Wash hands and slit lamp Record keeping Clearly document findings, sign and print name and designation in the patient health records Print letters: GP letter, letter for the patient, letter for the patient records and sign Appropriate action Consult doctor also if the patient has corneal infiltrates or oedema References

The College of Optometrists (2015) Clinical Management Guidelines: Photokeratitis

(Ultraviolet [UV] burn, Arc eye, Snow Blindness. The college of Optometrist

publication. London.


http://emedicine.medscape.com/article/799025-overview [Accessed 21.04.2016]




11.8 Emergency Nurse Practitioner Diagnosis and Treatment for a Retained Contact Lens Protocol


What type of contact lens used?

When lens was inserted?

What happened when patient tried to remove lens?

What is the patient’s normal regime of contact lens wear

Have they recently worn lenses for longer that the recommended periods.

Have they experienced previous problems in removing their contact lenses Review visual acuity

Ocular Examination:



Evert upper and lower lids

Locate retained contact lens

Instil G. Fluorescein 2% to locate lens if unable to visualise without. Inform patient lens will be stained if ‘soft’ lens and obtain consent.

Observe cornea for abrasion and infiltrates any other irregularities Treatment:

Explain procedure for removal to patient in a reassuring manner


Instil local anaesthetic drop as per PGD to facilitate contact lens removal.

Remove contact lens using moistened sterile dressed orange stick.

Sweep upper and lower fornices with dressed orange stick if unable to visualise or all contact lens not removed.

If conjunctival injection and discharge are present instigate treatment as per PGD.

Ensure patient understands when a return visit to A&E may be required

i.e. FB sensation persists or any new symptoms develop.

Discuss preventative measures i.e. safe insertion and removal techniques.

Advise patient when it is safe to insert contact lens again. Wash hands and slit lamp


Record keeping Clearly document findings, sign and print name and designation in the patient health records Print letters: GP letter, letter for the patient, letter for the patient records and sign. Appropriate action If the eye shows signs of discharge supply medication as documented in PGD for retained contact lens. Refer to protocol and PGD for corneal abrasion if an abrasion is present Consult doctor if all pieces of contact lens are not accounted for or patient has signs of corneal infiltrates. If the patient has experienced this problem before or if there are indications that the contact lenses do not fit properly i.e. too tight, then the patient should be advised to see their contact lens practitioner to consider a change in the type of contact lens worn.

Reference:

Agarwal, P.K; Ahmed, T; Diaper, C. J (2010) Retained soft contact lens masquerading as a chalazion: a case report Indian Journal of Ophthalmology. 61(2): 80-81 Thatam, J. (2016) Contact Lens Removal emedicineWebMD. www.emedicine.com


11.9 Emergency Nurse Practitioner Diagnosis and Treatment of Subtarsal Foreign Body (STFB) Protocol


Mechanism of injury: Was it a high velocity? I.e. more likely to be CFB or penetrating

Any eye protection worn?

Glasses/contact lenses in situ?

Happened at work or home?

Review visual acuity Ocular Examination: Wash hands and slit lamp Carryout full anterior segment examination using the slit lamp including lid eversion Treatment:



Use a sterile dressed orange stick moistened with a few drops of sodium chloride 0.9% to remove STFB

Instil G. Fluorescein 2 % as per PGD for staining and examine cornea for signs of abrasion

Instigate treatment plan including treatment for a corneal abrasion if corneal abrasion noted.

Give patient a full explanation of the condition, expected outcome and allow opportunity to ask questions

Ensure patient understands when a return visit to A&E may be required i.e. no improvement or any increase in symptoms

Discuss preventative measures i.e. use of eye protection Wash hands and slit lamp


Record keeping Clearly document findings, sign and print name and designation in the patient health records Print letters: GP letter, letter for the patient, letter for the patient records and sign. Appropriate action Consult a doctor if there are signs of corneal infiltrates or AC activity If the patient is a contact lens wearer advise the patient to stop wearing contact lenses for the duration of treatment and until they are symptom free

References Lynn Ring & Miriam Okoro. (2012). A Handbook of Ophthalmic Nursing Standards & Procedures. M&K Publishing. Cumbria.

College of optometrist. (2016). Sub-tarsal foreign body. Clinical Management Guidelines. McGavin M. (2005).How to evert the upper eyelid and remove a sub-tarsal foreign body. Community Eye Health Journal; Vol 18 No.55 pg 110.


11.10 Emergency Nurse Practitioner Diagnosis and Treatment of a Subconjunctival Haemorrhage (SCH) Protocol

Introduction This guideline is intended to inform good practice, it is not a substitute for the practitioner’s own sound clinical judgement, which they should continue to exercise. The format follows the structure of the knowledge and skills framework. It will help inform the process of assessment of competence. Preparation Clean slit lamp Introduce self to patient, establish rapport and sit the patient safely at the slit lamp History Taking: Ask the patient if they have had any of the following

Any trauma sustained?

Any pain or tenderness to touch?

Any visual disturbance?

Recent Valsalva-type activity e.g. vomiting?

History of hypertension or/ and diabetes?

Are they on any anticoagulants?

Review Visual acuity Ocular Examination: Examine the lids- remember to evert them, lashes, conjunctiva, anterior chamber, pupil, and lens.

Examine the conjunctiva and note if the posterior margin of the subconjunctival haemorrhage is visible. If it is not refer the patient to the A&E doctor. Perform tonometry if patient has a history of glaucoma or over 40yrs of age. Check the patient’s blood pressure (BP) and if they are diabetic check their blood glucose. Treatment:

If the patient’s BP and blood glucose is within normal parameters reassure the patient by giving a full explanation of their condition. Explain that the haemorrhage can take anywhere from 7 days to 3 weeks to clear.

Give patient SCH information leaflet.Ensure patient understands when a return visit to A&E may be required i.e pain or visual changes.

Lubricants may help to alleviate foreign body sensation. Record Keeping

Record an accurate and systematic account of the examination and outcome.

Appropriate actions: Consult the A&E Dr if the BP or blood glucose is raised or the patient complains of visual disturbance and/or pain.


If the Subconjunctival haemorrhage is recurrent the patient should be referred to their GP for blood test. Similarly if they are on anticoagulants and are having recurrent SCH they should be referred for INR check. References Harold A. Stein, Raymond M. Stein, Melvin I. Freeman.(2013). The ophthalmic assistant. 9th Ed. A text for allied and associated ophthalmic personnel. Elsevier Saunders. London.

The physicians guide to eye care.(2012). 4th Ed. American Academy of Ophthalmology. Italy

Bercin tarlan., Hayyam Kiratli (2013). Subconjunctival Haemorrhage: risk factors and potential indicators. Clinical Ophthalmology.

Tatsuya mimura., Tomohiko Usui., Hideharu Funatsu., Hidetake Noma., Norihiko Honda., Shiro Amano. (2009). Recent causes of subconjunctival haemorrhage Ophthalmologia.

Sundaram, V., Barsam, A., Alwitry, A., Khaw, P.T. (2009).Training In Ophthalmology: The essential clinical curriculum. Oxford University Press. Oxford.

Field. D., Tillotson. J. (2008). Eye Emergencies: The practitioner’s guide. M&K Publishing. Cumbria. College of optometrist.(2015). Subconjunctival Haemorrhage Clinical Management Guidelines. Stein, H.A., Stein, R.M & Freeman, M.I. (2013). The Ophthalmic Assistant: A Text For Allied And Associated Ophthalmic Personnel. Elsevier Saunders. London.


11.11 Emergency Nurse Practitioner Diagnosis and Treatment of Trichiasis Protocol Introduction This guideline is intended to inform good practice, it is not a substitute for the practitioner’s own sound clinical judgement, which they should continue to exercise. The format follows the structure of the knowledge and skills framework. It will help inform the process of assessment of competence. Preparation Clean the slit lamp Introduce self to patient, establish a rapport and sit the patient safely at the slit lamp Procedure History taking: Question patient about presenting complaint including:-

History of trichiasis?

Any redness?

Any discharge and nature of same?

Any visual changes? Wash and dry hands Review visual acuity Ocular Examination: Examine both eyes systematically using the slit lamp.

Check for signs of abrasion, infiltrates and cells and flare in the AC


Examine lid margin to identify aberrant lashes; number or and position


Check for any obvious lid pathology contributing to condition i.e. entropion, symblephron.

* It is important to recognise the mechanism by which trichiasis has occurred as the treatment of choice depends on the pathological process underlying this disorder. Trichiasis may be classified as: Acquired metaplastic eyelashes - this usually follows chronic eyelid inflammation such as meibomitis or surgical trauma, where meibomian gland epithelium undergoes metaplastic change into hair follicles. The result of this process is the growth of eyelashes from positions posterior to the normal lash line, which are often vertically or posteriorly directed


Congenital metaplastic eyelashes (distichiasis) – this is a congenital anomaly where multipotential meibomian gland cells develop into hair follicle cells and a second row of lashes arises from the meibomian gland orifices Misdirected eyelash – this is a normal lash which, as a result of minor scarring of the lid margin and lash orifice, changes direction and abrades the cornea Marginal entropion – this is a subtle in-turning of the lid margin resulting from mild scarring of the posterior lamella of the eyelid. There is posterior migration or conjunctivalization of the meibomian glands and rounding of the lid margin. This requires lid surgery to correct the entropic component of the eyelid * Trachomatous trichiasis is caused by an infection due to Chlamydia trachomatis. There is characteristic chronic follicular/papillary or intense conjunctival inflammation causing tarsal conjunctival scarring and distortion of the tarsal plate which then leads to entropion, trichiasis and corneal opacification. Although epidemiologically rare in the UK, trachoma is the leading infectious cause of blindness worldwide. Wash and dry hands Diagnosis: Review and analyse your findings to confirm the diagnosis. (If unsure of the diagnosis, refer patient to the doctor) Treatment:



Epilate all ingrowing lashes (within patient’s tolerance level) using forceps. Remind patient that lashes will re-grow within 4-6 weeks and epilation may need to be repeated

● Consider ocular lubricants for symptomatic relief


Discuss treatment alternatives if persistent and extensive problem (i.e. electrolysis) Wash hands and slit lamp Record keeping Clearly document findings, sign and print name and designation in the patient health records Print letters: GP letter, letter for the patient, letter for the patient records and sign. Appropriate action Consult doctor if it is felt that the patient needs onward referral for alternative treatment or if any other lid pathology found.


References:

Burton M, Habtamu E, Ho D, Gower EW. Interventions for trachoma trichiasis. Cochrane Database of Systematic Reviews 2015 November: 11: 1-52.

Daniel C. Moorfields Eye Hospital Adnexal Service Induction Manual 2009.

Khooshabeh R. The Unwanted Eyelash. The Ophthalmic Research Network 2008. Available from: moorfieldsresearch.org.uk

Resnikoff S, Pascolini D, Etya’ale D, Kocur I, Pararajasegaram R, Pokharel GP, Mariotti SP. Global data on visual impairment in the year 2002. Bulletin of the World Health Organization 2004 November; 82(11): 844-851.


11.12 Emergency Nurse Practitioner- Diagnosis and Management of Viral Conjunctivitis Protocol

Introduction This guideline is intended to inform good practice, it is not a substitute for the practitioner’s own sound clinical judgement, which they should continue to exercise. The format follows the structure of the knowledge and skills framework. It will help inform the process of assessment of competence. Preparation Assess patient in designated Isolation room (Red Room) Clean slit lamp Introduce self to patient, establish rapport and sit the patient safely at the slit lamp Procedure History Taking: Question patient about

Any recent URTI or GU problems, general malaise?

Swollen preauricular glands?

Contact lens wear?

Recent contact with conjunctivitis sufferer?

History of hay fever or allergy?

Recent foreign travel and/or swimming?

Any discharge? If present, description of discharge

Nature of ocular discomfort if present i.e. itchy, achy or gritty? Review visual acuity Ocular Examination:

Examine both eyes systematically using the slit lamp. If unilateral, examine unaffected eye first (infection control)

Check lids for follicles and/or papillae

Note conjunctival injection i.e. diffuse or ciliary and presence of pseudomembrane Check cornea for sub epithelial infiltrates, stain cornea with G. Fluorescein and note any other corneal involvement

Wash and dry hands Diagnosis: Review and analyse your findings to confirm the diagnosis. (If unsure of the diagnosis, refer patient to the doctor) Treatment:

Advise patient on cold compresses and rest.


Supply G Carmellose 0.5% eye drops e.g. Optive (multi-dose) or Celluvisc 0.5% (single unit dose) to provide lubrication to relieve the discomfort from the symptoms of viral conjunctivitis.

Refer to Accident and Emergency medical staff if visual acuity is reduced

Give patient a full explanation of the condition, expected course and outcome of condition and allow opportunity to ask questions.

Advise the patient on the most appropriate form of pain relief i.e. Paracetamol or other over the counter analgesic.

Ensure patient understands when return visit to A&E may be required i.e. decrease in vision or sudden increase in pain/discomfort

Discuss preventative measures i.e. infection control and give patient information leaflet


Wash hands and slit lamp Record keeping Clearly document findings, sign and print name and designation in the patient health records Print letters: GP letter, letter for the patient, letter for the patient records and sign. Appropriate action Consult A&E doctor if:

There is corneal involvement, pseudomembrane or any AC activity.

If the conjunctivitis is thought to be due to chlamydia References: Yanoff, M. and Duker, J.S. (Eds.) (2009) Ophthalmology.3rd edn. Edinburgh: Mosby Elsevier Marsden Janet (ED). An Evidence Base for Ophthalmic Nursing.(2007)John Wiley and Sons Ltd. Sussex http://www.college-optometrists.org/en/utilities/document-summary.cfm/docid/841FDA5F-C2F0-436F-A780A6AAAC7DC3A7- Accessed April 2016

http://www.college-optometrists.org/en/utilities/document-summary.cfm/docid/841FDA5F-C2F0-436F-A780A6AAAC7DC3A7-

http://www.college-optometrists.org/en/utilities/document-summary.cfm/docid/841FDA5F-C2F0-436F-A780A6AAAC7DC3A7-


11.13 Emergency Nurse Practitioner- Diagnosis and Management of Contact Related Keratitis (Non- medical Prescribers only)

Introduction This guideline is intended to inform good practice, it is not a substitute for the practitioner’s own sound clinical judgement, which they should continue to exercise. The format follows the structure of the knowledge and skills framework. It will help inform the process of assessment of competence.

Preparation Clean slit lamp Introduce self to patient, establish rapport and sit the patient safely at the slit lamp

Procedure (Consultation):

History Taking: Question patient about the complaint including: -

Onset

Associated symptoms

What type of contact lenses worn?

Ask if the patient wears extended wear contact lenses (24) hours.

What is the patient’s normal regime of contact lens wear

Have they recently worn lenses for longer that the recommended periods.

Have they slept with contact lenses in?

Do they bathe or swim with contact lenses in?

Have they experienced previous problems related to their contact lens wear

Have they experienced any trauma Review visual acuity

Ocular Examination:

Wash hands and clean slit lamp


Evert upper and lower lids to ensure no corneal FB or retained contact lens

Instil G. Fluorescein 2% -observe cornea for abrasion and infiltrates and any other irregularities

If a corneal infiltrate is present note the size and location Treatment:

Prescribe medication as per A&E/External Disease service guidelines.

Discuss pain relief with the patient i.e. use of Paracetamol or similar over the counter pain relief.

Ensure the patient fully understands the need to comply with the prescribed regime of medication i.e. Hourly G. Levofloxacin day and night for 48 hours to the affected


eye. Explain to the patient that after review it will be reduced depending the outcome of the treatment.

Ensure patient understands they need to return to A&E in 48 hours for review and ensure they have an appointment for the review clinic with time and date

Advise patient they must return to A&E immediately if they experience an increase in pain, drop in VA, if they note exudate or discharge from the eye.

Ensure the patient understands that they must not insert their contact lens again until advised at their follow up appointment that it is safe to do so.

Discuss preventative measures i.e. correct safe contact lens wear for acceptable periods of time.

Emphasise the need for adherence to hygiene measures when inserting, removing and storing lenses.

Explain the need to discard the contact lens that had been worn in affected eye

Wash hands and clean slit lamp Record keeping Clearly document findings, sign and print name and designation in the notes and on e-patient Print GP letter , letter for the patient and a letter for filing in the patient’s health records. Appropriate action Consult doctor if patient has a corneal infiltrate that exceeds 1mm in size or has more than one infiltrate. Consult the doctor if the patient is a contact lens wearer and has herpes like corneal ulcer. Consult the doctor if the patient is experiencing a severe painful eye that should not be expected. Consult doctor if assessment of the patient indicates they will be unable to comply with the prescribed medication regime i.e. Hourly G. Levofloxacin day and night for 48 hours to the affected eye Consult doctor if the patient requires pain relief that needs to be obtained via a prescription. If the patient has experienced this problem before or if there are indications that the contact lenses do not fit properly i.e. too tight, then the patient should be advised to see their contact lens practitioner to consider a change in the type of contact lens worn.

References: Dart, J.; Stapleton, F.; Minassian, D. (1991) Contact lenses and other risk factors in microbial keratitis. The Lancet. 338:650-653


Kanski, J.J (2011) Clinical Ophthalmology. Butterworth and Company Limited: London Moriyama, A; Hongling-Lima, A (2008) Contact lens- associated microbial keratitis Arg. Brasil Oftalmol. 71 (6): 32-36 Tuft, S; Burton, M; (2013) Microbial Keratitis Focus: The Royal College of Ophthalmologist: Autumn 2013: 5-6


11.14 Emergency Nurse Practitioner- Diagnosis of Allergic Conjunctivitis Practice Protocol ( Non- Medical Prescribers only)

Introduction

This guideline is intended to inform good practice, it is not a substitute for the practitioner’s own sound clinical judgement, which they should continue to exercise. The format follows the structure of the knowledge and skills framework. It will help inform the process of assessment of competence. Seasonal allergic conjunctivitis (Associated with hay fever) Caused by seasonal allergens, including grass pollen, tree pollen: weeds and fungal spores: The onset of symptoms are associated with the seasonal production of allergens

Perennial allergic conjunctivitis Caused by non-seasonal allergens such as house dust mite or animal hair symptoms can occur throughout the year although there may be seasonal exacerbations. This condition is less common and usually less severe than seasonal allergic conjunctivitis. History Taking

Ask about onset of symptoms

Any previous episodes of this problem- if yes when they occurred

History of hay fever or allergy

Is occurrence of symptoms seasonal

Is the patient experiencing extreme irritation, redness and watering.

Has the patient experienced any discharge from the eye?

Are there any other associated symptoms i.e. sneezing, nasal congestion

Review visual acuity Ocular Examination:

Examine both eyes systematically using the slit lamp. If unilateral, examine unaffected

eye first (infection control)

Examine eye lids for redness and swelling

Check the conjunctiva for injection and chemosis note if it has a milky appearance.

Check the lower tarsal conjunctiva look for multiple fine papillae

Check the upper palpebral conjunctiva for giant papillae.


A stringy conjunctival discharge may be noted.

Check the cornea for any irregularities such as epithelial erosions or limbal or corneal

infiltrates

Wash and dry hands Diagnosis: Review and analyse your findings to confirm the diagnosis. (If unsure of the diagnosis, refer patient to the doctor) Treatment:

Instigate treatment plan G. Olopatadine 1mg/1ml eye drops twice daily for a

maximum period of 4 months

Give patient a full explanation of the condition, expected course and outcome of

condition and allow opportunity to ask questions.

Discuss levels of pain or discomfort and advise patient on pain relief.

Ensure patient understands when return visit to A&E may be required i.e. decrease

in vision or sudden increase in pain/discomfort.



Record keeping

Clearly document findings, sign and print name and designation in the patient health records Print letters: GP letter, letter for the patient, letter for the patient records and sign Appropriate action Consult doctor: If there is corneal infiltrate or any AC activity If giant papillae are present. If chronic conjuctival scarring is present. If limbal changes are noted

References:


Ophthalmology at a Glance, Jane Olver, Lorraine Cassidy, Gurjeet Jutley, Laura Crawley · Wiley-31 March 2014

Royal College of Optometrists: CLINICAL MANAGEMENT GUIDELINES Conjunctivitis (Acute Allergic). 16-02-15.

http://www.bnf.org/products/bnf-online/ accessed April 2016

http://www.bnf.org/products/bnf-online/


11.15 Nurse Practitioner Diagnosis and Treatment of Dry Eyes (Non- medical Prescribers only)

Preparation Introduce self to patient, establish rapport and sit the patient safely at the slit lamp Clean slit lamp

Procedure

History Taking: Question patient about:

1. Description of ocular discomfort-e.g. is there a FB sensation. 2. Are the symptoms in one eye or both eyes 3. Are symptoms exacerbated by environmental conditions i.e. smoky atmosphere,

wind, heat, cold? 4. How long have the symptoms been present and have there been any previous

episodes 5. Any discharge or crusting of lids 6. Any abnormalities noted with the eye lids- can they close the eye properly, do they

know if they close their eyes fully when sleeping 7. Does the patient wear contact lenses 8. History of hay fever or allergy? 9. Note for ocular proptosis and history of lid trauma 10. History of Sjogren’s or non Sjogren’s syndrome

Review visual acuity Before examining the patient on the slit lamp observe their eye lids and face checking for any signs of facial weakness or paralysis and lid abnormalities such as ectropion. Assess lid closure and Bell’s phenomenon. Ocular Examination: Examine both eyes systematically using the slit lamp. If unilateral, examine unaffected eye first (infection control)

1. Check lids and lashes for collarettes, hyperaemia, hypertrophy, inflamed or blocked meibomian gland orifices and seborrhoea

2. Check eye lids for abnormalities such as ectropion, check eye lid closure.

3. Note tear film integrity by:

Noting the tear meniscus at the lower lid margin- is this at least 1mm in height with a convex shape.

Check the tear film break up time after instillation of fluorescein- this should be more than 10 seconds

4. Check the tear film for excess mucous or debris 5. Check cornea for signs of punctate erosions, filaments.


6. Check for signs of concurrent infection i.e. conjunctival injection, follicles. 7. Check AC for cells and flare

Wash and dry hands Diagnosis: Review and analyse your findings to confirm the diagnosis. (If unsure of the diagnosis, refer patient to the doctor) Treatment: Instigate treatment plan of Carmellose Sodium 0.5% as required. If blepharits is present ensure the patient is informed and comprehends the required treatment and management of this disorder to ensure effective management of the dry eye problem. Give patient a full explanation of the condition, expected course and outcome of condition and allow opportunity to ask questions. Discuss levels of pain or discomfort and advise patient on pain relief. Ensure patient understands when return visit to A&E may be required i.e. decrease in vision or sudden increase in pain/discomfort. Wash hands and slit lamp Record keeping Clearly document findings, sign and print name and designation in the patient health records Print letters: GP letter, letter for the patient, letter for the patient records and sign Appropriate action Consult doctor if there is any sign of lid abnormalities, seventh nerve palsy or if there are signs of filamentary keratitis indicating severe dry eye syndrome. Consult doctor for cells, flares or any AC activity. Consult the doctor for dry eye related to Sjogren’s and non Sjogren’s tear deficiency dry eye. References: Foster, S. (2015) Dry Eye Syndrome emedicineWebMD. www.emedicine.com Yanoff, M. and Duker, J.S. (2009)


Ophthalmology. 3rd ed. Edinburgh: Mosby Elsevier

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