One of the delights of ophthalmology is to witness the joy on the face of a patient with cataract when the dressing is taken off and sight has been restored. Unfortunately, for some patients, the result does not live up to their expectations. Despite cataract surgery being one of the most successful surgical interventions available, there is evidence that the visual outcome of cataract surgery in sub-Saharan Africa is not always good (defined as a VA of 6/18 or better). The proportion of good outcomes range from only 23% up to 70%, failing to reach the WHO target of 85% or better

Adekhera, Ebby

Astbury, Nick

Nyamai, Lily A

PubMed

LSHTM Research Online

  COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 94 | 2016 23One of the delights of ophthalmology is to witness the joy on the face of a patient with cataract when the dressing is taken off and sight has been restored. Unfortunately, for some patients, the result does not live up to their expecta-tions. Despite cataract surgery being one of the most successful surgical interven-tions available, there is evidence that the visual outcome of cataract surgery in sub-Saharan Africa is not always good (defined as a VA of 6/18 or better). The proportion of good outcomes range from only 23% up to 70%, failing to reach the WHO target of 85% or better.1A good outcome is crucial for the individual patient, but will also have a wider impact on the community. In sub-Saharan Africa, for example, uneasiness about surgery can mean that patients stay away – more so if they hear about an operation that was not successful. Good outcomes in cataract surgery, in those brave enough to undergo the procedure, are therefore essential to encourage other people with poor vision from the community to come forward for examination and treatment.In order to optimise good outcomes, patients need to have relevant infor-mation. They must have confidence in the eye service and in the people providing it, so that they will be willing to attend follow-up visits and to come back immedi-ately if they notice anything wrong after the operation. It is helpful to have a team member who speaks the language of patients as this can help to increase people’s under-standing of any information being shared and boost their trust in the eye service. Before surgeryPatients and their families must be given advice and counselling about the operation, including what happens before, during and after. They should then sign an informed consent form. It is our responsibility to ensure that the patient understands – in straight-forward terms – what is going to happen and what this means for them and their eye health. We must also take time to address any fears, doubts and myths about cataract surgery.It is important to ensure that patients and their families have realistic expecta-tions about their vision after surgery. They must understand the risks and benefits, including the potential effect of different complications on their eyesight. A disappointed patient is not a good advertisement for our service. Our patients also have a role to play in alerting the eye team to potential compli-cations at an early stage. Before surgery, explain to patients how their eyes will look and feel after a successful operation, including what level of discomfort is normal at the different stages of recovery. Encourage them to speak with an eye team member if they experience anything that concerns them.After surgeryAfter the operation, patients should be given clear instructions about how to look after their operated eye when they are back at home (see panel on page 24). Give specific information about follow-up visits (where to go, when, and at what time) and ensure patients know how to get in touch with the eye clinic or their surgeon if they have any signs or symptoms that can indicate a compli-cation (worsening sight, increasing pain, redness, swelling or discharge). Discussion groups for patients, based on their gender and initial visual outcome, offer an opportunity to talk about coping with the challenges of self-care and follow-up appointments, which may be different for each individual. Giving patients an opportunity to attend such groups may help to allay fears and can give them an opportunity to ask questions if they are uncertain about anything. DischargeBefore discharging a patient, check that they have all of the following: • Instruction sheet to take home• Clinic contact details• Eye shield (if available)• Eye drops and instructions for storage and use• Painkillers to use at home• A follow-up appointment date and time.Follow-upWe recommend that cataract patients are followed up and examined as follows:• The day after surgery (day 1), in the hospital.• 4–8 weeks after surgery. This visit is important, as it is also the time to conduct postoperative refraction. Actively encourage patients to attend, for example by including the visit in the price of the cataract operation. Transport may be a barrier for some INVOLVING PATIENTSWorking with patients to optimise cataract outcomesNick Astbury Clinical Senior Lecturer: International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK.Ebby AdekheraNursing Officer: Sabatia Eye Hospital, Wodanga, Kenya.Lily A Nyamai Tutorial Fellow: Department of Ophthalmology, University of Nairobi, Nairobi, Kenya. lilynyamai@gmail.comContinues overleaf ➤Lindsay HamptonA woman tells new patients about her cataract operation. KENYACEHJ94_OA.indd   3 16/09/2016   15:0324   COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 94 | 2016INVOLVING PATIENTS Continuedpatients and it may be helpful to  conduct follow-up appointments in primary health care centres in the community.Postoperative refractionPostoperative refraction and provision of spectacles (if needed) are essential to ensure the best possible visual outcome for a patient. This is important because satisfied patients will encourage others in the community to undergo cataract surgery. During the 4–8-week follow-up appoint-ment, refract both eyes and accurately check the visual acuity. Make sure you understand the patient’s refractive needs (e.g. their ideal working distance). If there is no intraocular lens, carefully check the back vertex distance and centring of the spectacles.Reference1 Blindness and visual impairment due to age-related cataract in sub-Saharan Africa: a systematic review of recent population-based studies. Andrew Bastawrous, William H Dean and Justin C Sherwin. Br J Ophthalmol 2013 97: 1237-1243. Originally published online in May 21, 2013.The nursing process is a systematic, scientific approach to managing a range of patients. This article explains how the nursing process can be applied when caring for cataract patients who have been admitted.The nursing process consists of five phases of management: • Assessment• Diagnosis• Planning• Implementation• Evaluation. AssessmentAssessment is done by using effective communication and observational skills to carry out a complete and holistic nursing assessment of every patient’s needs. An actual or potential problem with the patient (i.e. pain, or an infection following cataract surgery) may be discovered. Before surgery, take a history of the patient and obtain their baseline blood pressure and pulse (Figure 1). After surgery, look at the patient’s facial expression to determine if she or he is in pain and ask the patient how she or he is feeling. Measure vital signs (pulse and blood pressure). From the first day after surgery (day 1), carry out an eye examination to look at visual acuity, the state of the wound, the conjunctiva, the cornea, the anterior chamber, the pupil and the position of the intraocular lens. Observe the patient for any signs of infection (redness, swelling or discharge), ask about pain and treat or refer the patient as appropriate. At later follow-up visits, measure visual acuity to assess the need for refraction and spectacle correction, in collaboration with the patient.DiagnosisAfter the assessment phase, determine and prioritise the patient’s nursing needs, from their basic health needs to their eye care. Most importantly, be on the lookout for signs of complications: most commonly worsening sight, increasing pain, redness, swelling or discharge. PlanningWith the patient’s agreement, consider each of the problems identified, plan to manage them according to priority and set a measurable goal. For example, for pain, plan to give analgesics and reassure the patient. If there are signs of a postoperative complication, plan to either treat the complication or make a referral, depending on the suspected complication. ImplementationNext, record the methods by which the goals will be achieved in a clear format that all can understand. For example, record the time and dose when analgesics are administered. It is important to know the appropriate dose and be able to identify any side effects. EvaluationThis is a continuous process in which we look at the initial and the present situation, compare the two and evaluate progress towards the goals identified in the previous stages. If progress towards the goal is slow or if regression has occurred, change the plan of care accord-ingly. If the goal has been achieved, then the care can cease. For example, if a patient is relieved of pain, stop the analgesics. If not, adjust the plan and change to another form of management, depending on the cause of the pain.Ebby Adekhera Nursing officer: Sabatia Eye Hospital, Wodanga, Kenya.Ebby AdekheraFigure 1. Measuring vital signs before surgery.Even though you may feel well after surgery, you have had a big operation. You should take care of yourself and allow your eye to heal properly. Dos• Clean eyelids morning and evening with a moist, clean face cloth, avoiding pressure on the eyeball.• If possible, protect the operated eye for the first week by wearing an eye shield when sleeping and sunglasses or prescription spectacles during the day. • Instil eye drops as prescribed.• Follow a normal diet after surgery with enough water and fibre/roughage (from fruit, vegetables and whole grains) to avoid constipation.• Resume your regular medications, including any prescribed eye drops, immediately.• Contact the eye clinic in case of worsening sight, increasing pain, redness, swelling or discharge. • Keep your follow-up appointments without fail.• You can wash your hair a day after surgery but avoid soap, water or shampoo entering the eye. • You may resume sexual activity once you feel comfortable.Don’ts• Don’t wear eye makeup for at least a week, and don’t use shop-bought cotton wool balls on your eyelids. These may leave behind particles of cotton, which may attract germs, leading to infection.• Avoid sleeping on the operated side. • Do not lift heavy weights above 5 kg for 2 weeks.• Avoid swimming for 2 weeks.Instructions for patientsRoutine postoperative nursing management© The author/s and Community Eye Health Journal 2016. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License.CEHJ94_OA.indd   4 16/09/2016   15:03

Working with patients to optimise cataract outcomes.

Abstract

Similar works

Full text

Available Versions

LSHTM Research Online

Directory of Open Access Journals