Key learning points
- The interplay between vision and long-term conditions
- Types of eye conditions that may affect sight
- How primary care nurses can help patients with their vision
You will have seen many patients like Eileen before. She is older, lives on her own and has recently had a fall. She is frail and has to live with several long-term conditions. Her fracture is being cared for and she is getting help with her pain and breathing. But she is not looking you in the eye and seems confused. It seems obvious, but would you think to ask her if she’s supposed to be wearing glasses?
The role nurses can play
Checking if people have the right glasses with them is the simplest and most obvious way nurses can consider the impact eye health has on a patient’s care. If you are visiting a patient in their home and they are supposed to be wearing glasses or contact lenses then it is worth checking that they are actually using them, particularly if they are elderly. Vision problems increase greatly with age and 74% of people in the UK either wear corrective glasses or contact lenses or have had laser eye surgery to help them see better.1 If they cannot see clearly, they might find it hard to read, eat, take their medicine or see people’s faces. Putting on glasses can make a huge and instant difference to their experience of care.
Checking that patients are using their eye drops (if they need them) is another quick way nurses can improve their patients’ care. Glaucoma is a major cause of blindness in the UK but people may prevent sight loss by using eye drops every day. If someone has not used their eye drops for an extended period of time, this may cause irreversible damage to their vision. There are approximately 480,000 people affected by glaucoma in the UK, most of who are over 40 years of age.2 People who need eye drops to reduce the pressure in their eye will not notice a short-term benefit to their sight, so it is important to make sure they understand that they must keep using the drops even if their sight is not getting any better.
The link between falls and vision
Falls like the one Eileen suffered are the biggest cause of hospital admissions among older people and many of those who have suffered a fall require care from community nurses at home once they have left hospital. There are many reasons why older people injure themselves so frequently from falls, but poor vision is recognised as a major factor. The National Institute for Health and Care Excellence (NICE) recommends that a falls risk assessment includes a vision assessment. Cataract surgery and the right glasses both reduce the risk of falls but vision is often overlooked. At Queen’s Medical Centre in Nottingham everyone who is admitted with a falls related fracture has their sight tested by an optometrist and around half have vision problems but this doesn’t happen in all hospitals. If you are visiting a patient in their home who has had a fall, just asking them when they last had their eyes tested can make a real difference. Older people should have a sight test at least every two years and some more often than that. The College of Optometrists will shortly publish a report recommending how best to integrate vision into falls pathways.
Common eye conditions
Sight tests do not just prevent falls. Most of the eye diseases that cause visual impairment are detected by optometrists through routine eye examinations. Cataracts (when the lens of the eye becomes cloudy, resulting in blurred or misty vision) are extremely common and surgery to remove them is the most performed operation in the NHS. It takes around half an hour and the benefits are almost immediate.
Glaucoma is a group of eye conditions where the optic nerve is affected by the pressure in the eye. This slowly damages peripheral vision (starting in one eye first) and so patients are often unaware that their sight is being affected. This means they can be suffering from it for a long time unless they go for regular sight tests where it would be picked up by an optometrist.
Age-related macular degeneration (AMD) is less well known yet it is the biggest cause of sight loss in the UK. The macula is the small area at the centre of the retina which helps people see straight ahead and focus. When the macula is damaged, which can happen as people get older, it can result in blurred vision and difficulty with reading, writing and recognising faces. There are two types of AMD - ‘wet’ which can progress rapidly over a few months and ‘dry’ which is more common and develops much more slowly. Dry AMD cannot be treated, but wet AMD can be treated with injections given into the affected eye. Like glaucoma, it is a long-term condition, but
early treatment of the ‘wet’ type may save people’s sight.
Diabetic retinopathy, which occurs when blood sugar levels damage the cells at the back of the eye is another chronic condition. This may cause blurred vision and sometimes even blindness. With timely treatment, its impact on vision can be mitigated but it remains one of the biggest causes of blindness among working age people. Encouraging patients to have regular screening for diabetic retinopathy and regular sight tests are the two best things nurses can do to prevent blindness from some of these major eye diseases.
At-risk patient groups to look out for
There are certain groups of people, that nurses should be particularly aware of, who are more likely to have problems with their eyes. These include those over 60, people with dementia, people with learning difficulties and those of Afro-Caribbean descent.
We have already highlighted the link to falls, but older people with dementia may be at particular risk. We suspect they are more likely to have vision problems but less likely to have them diagnosed and treated effectively. The College of Optometrists is leading pioneering new research to explore this link.
People of all ages with learning difficulties are 10 times more likely to have poor eye health, but the problems are less likely to be picked up. Afro-Caribbean people are more likely to suffer from glaucoma and from an earlier age than their Caucasian counterparts. As with so many other conditions people from more deprived areas are also at higher risk. People who smoke are also more at risk of developing age-related macular degeneration (AMD).
The answers for nurses are however the same regardless of the person you are looking after. Remember people’s eyes, help them get regular sight tests and make sure they have got the right glasses and eye medicine to hand. You might find Eileen is a lot chattier and happier once she gets her specs back on.
1. Britain’s Eye Health in Focus, The College of Optometrists, 2013
2. NICE. Clinical Guideline 85 - Glaucoma: Diagnosis and management of chronic open angle glaucoma and ocular hypertension. London; NICE; 2009.
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