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Clinical Practice Keywords Hygiene/Eye care/Eye cleansing/Swabbing Practical procedures This article has been Ophthalmology double-blind peer reviewed Principles and procedure for eye assessment and cleansing

he eyes have a vital role in helping l Antimicrobial protection against Authors Tendai Gwenhure is clinical us carry out our daily activities potential pathogens (McDermott, 2013). educator, Moorfields Eye Hospital NHS safely (Shaw, 2014). Light entering drain away from the eyes into the Foundation Trust; Eileen Shepherd is Tthe eye is converted into nerve via the lacrimal puncta (sin- clinical editor, Nursing Times. impulses that are transmitted to the occipital gular punctum) (part of the lacrimal appa- region of the brain, where they are converted ratus), which are found on the upper and Abstract Eyes should be assessed as into the images we see. Patients may present lower eye lids (Fig 1). part of a holistic patient assessment to hospital with pre-existing eye conditions and eye care is an essential part of daily or need help to care for their eyes during a Eye assessment personal care. This article outlines the period of illness. Nurses need to be able to: Eyes should be assessed as part of a holistic principles of eye assessment and the l Carry out a baseline assessment of the patient assessment and as part of personal procedure for eye cleansing. eye and vision; care. It is important to discuss any long- l Deliver essential care including eye term eye problems the patient has and docu- Citation Gwenhure T, Shepherd E cleansing; ment how these are managed; for example, (2019) Principles and procedure for eye l Administer topical therapies; glaucoma requires regular eye drops, or assessment and cleansing. Nursing l Know when to make a referral for blepharitis (inflammation of eye lid margin) Times [online]; 115: 12, 18-20. specialist support. may require a personalised plan of care. Falls are linked to poor eyesight so eye External structure of the eye assessment is an integral part of falls pre- Box 1. Indications for eye care The external structures of the eye (Fig 1) vention. Older people with impaired vision serve an important function in protecting fall 1.7 times more often, and sustain hip l To clean the eye of discharge the eye from injury. For example, the eye- fractures 1.3-1.9 times more frequently and crusts lashes provide a barrier to grit and debris than those with normal eyesight (College l After to prevent and prevent sweat from running of Optometrists, 2014; College of Optome- complications into the eyes. contain muscles that trists and British Geriatrics Society, 2011). l Prior to eye drop installation enable them to open and close (Dougherty In response to these concerns, the Royal l To soothe eye irritation, pain and and Lister, 2015) and the lacrimal appa- College of Physicians (2017) has produced a discomfort ratus is responsible for tear production bedside tool to help check older patients’ l To prevent corneal damage/abrasion and drainage. Tears provide: eyesight and reduce hospital falls risk. in unconscious/sedated patients l Lubrication that prevents drying of Patients should be asked whether they Sources: Dougherty and Lister (2015); the ocular surface; have any new problems with their vision. Shaw (2014) l A smooth surface that allows light to These should be reported immediately, as enter the eye; acute eye problems such as acute glau- coma, orbital cellulitis or retinal detach- Fig 1. External structure of the eye and the lacrimal glands ment may result in serious eye complica- tions if treatment is delayed. It is important to record any sight aids the Excretory ducts patient uses such as glasses, contact lenses of lacrimal gland and a prosthetic eye. If necessary, patients should be given support to use these aids, Iris such as ensuring that patient’s glasses are Pupil Upper clean; nurses should seek expert help if they lack skills to meet a patient’s needs.

Lacrimal Procedure for eye cleansing canal Lateral Lacrimal Eye cleansing is an essential aspect of daily punctum Nasolacrimal hygiene and patients in hospital or resi- Medial duct dential/care home, or those who are Lower eyelid canthus dependent on care at home may need sup- Palpebral covered by Interior meatus of port to maintain this aspect of their care. covers lids bulbar conjunctiva nasal cavity Those with reduced vision or blindness may struggle to maintain independence in

PETER LAMB PETER an unfamiliar environment, such as

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Box 2. The underpinning (Royal College of Nursing, 2018) and be 3. Discuss the procedure with the patient, principles of eye cleansing aware of local policies for glove use for this ask about their usual eye care routine and procedure. When gloves are required they any problems they have with their eyes. l The eye should be carefully assessed must be single-use and should be disposed before eye care is provided of according to local infection prevention 4. Obtain informed consent to carry out l Patients should be encouraged to and control policy (Loveday et al, 2014). the procedure. carry out their own eye care if they are assessed and found able to do so The procedure 5. Ensure the patient’s privacy by l Each eye should be treated as a 1. Confirm the patient’s identity. screening the bed or ensuring their room separate procedure and a separate door is closed. dressing pack should be used for 2. Decontaminate hands following the five each eye to prevent cross moments for hand hygiene (World Health 6. Assemble your equipment and ensure contamination Organization, 2009). the bed is at the correct working height. l Infected eyes should be treated last to reduce the risk of cross infection 7. Position the patient sitting comfortably (Dougherty and Lister, 2015) Fig 2. Ask the patient to sit with the head tilted back (Fig 2). l A clean technique can be used for with their head tilted back eye cleansing unless there are 8. Decontaminate hands and put on an specific concerns about infection risk apron. Gloves should be applied if assess- such as in post-operative patients – in ment indicates they are required. which case an aseptic procedure should be used (Dougherty and 9. Assess the external appearance of the eye. Lister, 2015) l Low-lint or lint-free swabs should 10. Ask the patient to close their eyes. be used to cleanse eyes as lint fibres can scratch the cornea. Cotton wool 11. Check for any discharge, bruising or should be avoided as the cotton wool inflammation (Fig 3). If the eyelids fail to threads can catch on the close completely, report this to medical l Dougherty and Lister (2015) staff as it may be a sign that a lump or recommend sterile water for eye cyst is present (Dougherty and Lister, cleansing and suggest sterile sodium 2015), or there may be problems with chloride 0.9% may cause stinging Fig 3. eyelid muscles. and irritation. However, other authors Check for discharge, bruising or inflammation suggest using sodium chloride 12. Ask the patient to open their eyes and 0.9% (Shaw and Lee 2016; Ring and check for signs of redness in the conjunc- Okoro, 2012) tiva and for evidence of discharge (Fig 4) l A light source should be positioned (Dougherty and Lister, 2015). These signs behind the nurse so it illuminates may indicate the presence of infection or the eye, but it should not shine inflammation. directly into the eye as this will be uncomfortable for the patient 13. Take a sterile swab in your hand and moisten it slightly with sterile water or saline. A very wet swab can be uncomfort- hospital, and may need help to manage able for the patient and increase the risk of their eye care (Dougherty and Lister, 2015). contamination of the opposite eye. Indications for eye cleansing are outlined in Box 1. The procedure aims to maintain Fig 4. Check for signs of redness in the conjunctiva and for healthy eyes and it is important that infec- evidence of discharge tion from one eye is not transferred into the other. General principles underpinning the procedure are outlined in Box 2.

Equipment l Sterile dressing pack; l Sterile low-lint swabs; l Sterile water or saline (cool boiled water can be used in the home); l Disposable apron.

Glove use Nurses need to assess individual patients for risk of exposure to blood and body fluids

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Fig 5. Swab the lower eye lid from the nasal corner outwards 14. Ask the patient to close their eyes again and swab the lower eye lid from the medial canthus outwards (Fig 5). Swabbing in this direction reduces the risk of introducing infection into the lacrimal punctum (Dougherty and Lister, 2015). Do not allow the swab to go above the lid, to ensure that contact between the swab and cornea is avoided – this is uncomfortable and may cause damage to the cornea.

15. Repeat, using a clean swab each time to reduce the risk of infection, until the eyelid is clean.

16. Ask the patient to look down and slightly evert (turn inside out) the upper lid (Fig 6).

17. Moisten a swab and gently clean the upper eyelid from the medial canthus out- wards (Fig 7).

Fig 6a and b. Ask the patient to look down and slightly evert 18. Repeat with a new moistened swab the upper lid until the lid is clean. Dab off any excess water/saline around the eye to ensure patient is dry and comfortable.

19. Make the patient comfortable.

20. Remove your apron (and gloves if worn).

21. Decontaminate hands.

22. Repeat the procedure on the second eye if required.

23. Record the care in the patient’s records. Record and report any abnormal findings.

References College of Optometrists (2014) Focus on Falls. London: College of Optometrists. College of Optometrists, British Geriatrics Society (2011) The Importance of Vision in Preventing Falls. Bit.ly/BGSVisionFalls Dougherty L, Lister S (2015) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Oxford: Wiley-Blackwell. Loveday HP et al (2014) epic3: National evidence- based guidelines for preventing healthcare- associated infections in NHS hospitals in England. Journal of Hospital Infection; 86: S1, 1-70. McDermott AM (2013) Antimicrobial Compounds in Tears. Experimental Eye Research; 117: 53-61. Ring L, Okoro M (2016) A Handbook of Ophthalmic Standards and Procedures. Oxford: M&K Publications. Royal College of Nursing (2018) Tools of the Trade: Guidance for Health Care Staff on Glove Use and the Prevention of Contact Dermatitis. Bit.ly/RCNGloves Royal College of Physicians (2017) Look Out! Bedside Vision Check for Falls Prevention. Bit.ly/RCPLookOut2017 Shaw M (2014) How to administer eye drops and ointments. Nursing Times; 110: 40, 16-18. World Health Organization (2009) WHO Guidelines for Hand Hygiene in Health Care. Bit.ly/WHOHandHygiene

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