ASORN_Insight_Q2_2017_WEB

Journal of the American Society of Ophthalmic Registered Nurses

Volume 42, Number 2
Spring 2017

&Zika Virus

the Eye

The Pediatric Ophthalmic Examination:
Challenges and Strategies, Part II
Nursing Considerations for Patients
Undergoing Retinal Prosthesis Implantation:
One Center’s Experiences

2017

COMBINED OPHTHALMIC SYMPOSIUM

ASORN NURSE

AND TECHNICIAN
PROGRAM AUGUST 11–12

AUSTIN, TEXAS

JW MARRIOTT

Early Bird Registration Now Open: March 14 – June 23
Preregistration: June 24 – August 1
Find more information at www.asorn.org/educational_programs

Volume 42, Number 2, Spring 2017. Insight—Journal of Journal of the American Society of Ophthalmic Registered Nurses
the American Society of Ophthalmic Registered Nurses
(ISSN 1060-135X) is published quarterly (four issues per volume,   continuing education (cover feature):
one volume per year) by the American Society of Ophthalmic
Registered Nurses, 655 Beach Street, San Francisco, CA, 94109. 05 T he Zika Virus and the Eye
Periodicals Postage Paid at San Francisco, CA and at additional Rolly Coronica, DNP, FNP-C, CRNO
mailing offices.
  FOCUS
POSTMASTER: Send address changes to Insight—Journal of the
American Society of Ophthalmic Registered Nurses, American 11 The Pediatric Ophthalmic
Society of Ophthalmic Registered Nurses, 655 Beach Street, Examination: Challenges and
San Francisco, CA 94109, phone 415.561.8513. Strategies, Part II
Orwa Nasser, MD, MPH; Alina Dumitrescu, MD; and Scott A.
SUBSCRIBER SERVICES: Domestic individual, $69; domestic Larson, MD
student/resident, $35; domestic institution, $109; international   EYE WONDER
individual, $79; international student/resident, $39; international
institution, $119. Prices subject to change without notice. 17 Nursing Considerations for
Printed in USA. Patients Undergoing Retinal
Prosthesis Implantation:
Copyright © 2017 by the American Society of Ophthalmic One Center’s Experiences
­Registered Nurses. Kari Magill, BSN, RN, CNOR

ASORN Board of Directors
Barbara Ann Harmer, MHA, BSN, RN, President
Deborah Anne Ehlers, MSN, BSN, RN, President-Elect
Nancy Haskell, RN, CNOR, CRNO, Secretary-Treasurer
Ann B. Kelly, RN, CRNO, Director-at-Large
Kari L. Magill, BSN, RN, CNOR, Director-at-Large
Gail Morrell, MSN, RN, CRNO, Provider Unit Director
Pam J. Opremcak, MPA, RN, Annual Meeting Director

Editorial Board
Susan B. Fowler, PhD, RN, CNRN, FAHA, Editor
Tulay Cakiner-Egilmez, PhD, ANP, CRNO, COA, COT
Lorrie Durbin, BSN, RN, COMT
Rolly Coronica, DNP, FNP-C, CRNO
Janet Marsden, PhD, RN

Publisher
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The Editorial Board welcomes manuscripts and ideas for articles
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Susan B. Fowler, PhD, RN, CNRN, FAHA
Editor
E: [email protected]

Statements and opinions expressed in the articles and communica-
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the editor, the American Society of Ophthalmic Registered Nurses,
or the publisher. The editor, Society, and publisher disclaim any
responsibility or liability for such material and do not guarantee,
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Contents

continued on next page

2
Journal of the American Society of Ophthalmic Registered Nurses

Contents (continued) Additional Services

  Columns professional directions Indexed or abstracted in the International Nursing Index,
22 Cumulative Index to Nursing & Allied Health Literature
(CINAHL), and MEDLINE.
  Departments
03 President’s Message Reprints in quantity must be purchased from ASORN.
04 Viewpoint To order reprints, contact ASORN at 415.561.8513;
fax 415.561.8531.
  Quick as a Wink
This Journal has been registered with Copyright Clearance
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  Resources Corporate Affiliates + that the copier pay directly to the center for copying beyond
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creating new collective works. All inquiries regarding copy-
righted material from this publication, other than those that
can be handled through the Center, should be directed,
in writing (include complete citation, number of copies,
and use), to ASORN, 655 Beach Street, San Francisco,
CA 94109; fax 415.561.8531.

All rights reserved. No part of this publication may be repro-
duced, stored, or transmitted in any form or by any means,
electronic or mechanical, including photoc­ opy, recording, or
any information storage and retrieval system, without permis-
sion in writing from the publisher.

Journal of the American Society of Ophthalmic Registered Nurses 2017 is flying by just like
the Zika mosquito.
Volume 42, Number 2
Spring 2017

&Zika Virus
the Eye

The Pediatric Ophthalmic Examination:
Challenges and Strategies, Part II
Using Processing Digital Imaging Techniques
in Uveitis Diagnosis and Management

ASORN INSIGHT Spring 2017

3

PRESIDENT’S MESSAGE

Women’s Eye Health

RESEARCH HAS SHOWN that the rate of eye A and Vitamin C, beta carotene, lutein, Protect your eyes at home and at work.
disease is increasing in the United States, zinc, omega-3 fatty acids and zeaxanthin. Research tells us that the majority of
mostly because people are living longer. Keep your diet low in sodium and caffeine. eye injuries occur at home. Wear safety
Women on average live longer than men, Exercise frequently. Stress, a bad diet and glasses when needed, but especially when
thus women are more susceptible to age- obesity can contribute to an unhealthy set using tools, dangerous chemicals, weld-
related eye diseases; macular degenera- of eyes. ing, and playing sports where an eye injury
tion, glaucoma, dry eyes and cataracts to could occur. Rest your eyes at work when
name a few. Two-thirds of blindness and Avoid smoking and second hand smoke. using a computer.
other visual problems occur in women. Smoke has been shown to increase the
development of cataracts and macular Vision is a precious gift, who is caring for
Prevent Blindness America has named degeneration. your eyes?
April as Women’s Eye Health and Safety
Month to educate women about the steps Wear good sunglasses (100% UV protec-
they should take to make eye health a pri- tion) and wide-brimmed hats. UV light has
ority. Taking care of the family’s health has also been shown to increase the risk of
been one of the jobs that a mother/wife cataracts and macular degeneration.
has assumed for a very long time. Women
often forget to take care of their own Know your family history. Be able to
health, including the health of their eyes. discuss with your eye care professional
During the month of April, the emphasis any disease or disorders that other family
is for women to remember to take care of members or ancestors may have or had
themselves and take the necessary steps in their past. Having this discussion may
to prevent blindness and preserve their assist your eye care professional in pre-
vision. venting or lessening the possibility of those
conditions occurring in you.

Here are some recommendations to Use cosmetics and contacts safely. Barbara Ann Harmer, MHA, BSN, RN
lessen or prevent vision problems: Always wash your hands before applying ASORN President
any make-up or putting contact lenses MedAssist Consultants, Inc.
Get routine eye care – receive an annual into your eyes. Do not use contacts Gainesville, FL
exam that includes dilation. It is suggested beyond the manufacturer’s directions. [email protected]
that a woman should have a comprehen- Throw old make-up away. Do not share
sive eye exam by age 40 and then annu- make-up with anyone else. By following
ally thereafter. these guidelines, an infection may be pre-
vented which may have led to permanent
Eat healthy and exercise. Eating a diet that vision loss.
includes a generous water intake, Vitamin

ASORN INSIGHT Spring 2017

4

VIEWPOINT

Guest Editorial:
Patient Care Is Not an Individual Sport

Smart health-care professionals “Coming together is a beginning.

learn early in their careers that when we Keeping together is progress.Working
work together, everything goes better and
the patient is the beneficiary. No matter together is success.” – Henry Ford
the patient setting or service line focus,
delivering quality care takes a team. Add repair retinal defects, remove cancer, or As in any good relationship, performing
to this today’s rapid pace of change – repair eye muscles. The ophthalmic sur- as an effective and efficient team requires
from new technologies and care advance- gery environment differs from many ORs, ongoing attention and effort. Successful
ment to increasing regulations and requiring highly delicate instrumentation outcomes for our patients cannot happen
reporting requirements – and collaboration and equipment and with surgeries often unless every team member practices
becomes more essential than ever for taking place in low light. these key fundamentals:
positive patient outcomes and our own job
satisfaction. Surgeons tell me that the best eye team is • H ave a surgical conscience. Know
one in which all members – techs, nurses, your role, value your colleagues’ roles,
Since 1988, I have worked in operating anesthesiologists – work together like a and recognize (out loud) that every per-
rooms (ORs) for nearly every service – well-oiled machine, with each being as son in the OR makes a difference in the
including cardiac, neurology, and ophthal- aware as the surgeon is about what is outcome of patients.
mology – first as a licensed practical nurse going on in the procedure, anticipating
and then as a registered nurse (RN), doing what will happen next, and recognizing • S tay current, train on advances.
scrub, surgical tech, circulation, manage- when something is not going as planned. Understand procedures and their
ment, education, and process improve- In other words, the surgeons say, if they sequences. Know how each piece of
ment coordination. I have found that given are looking under a microscope focused
the intricacies and increasing volumes on the patient and can’t look away, they continued on page 36
of today’s ophthalmic procedures, eye need to feel confident that the person
teams have developed some of the best handing over an instrument is correctly
approaches to effective teamwork. observing and anticipating what the
patient needs.
But increasing patient volumes, produc-
tivity demands, medical advances, and Building a Winning Team Nathalie Walker, MBA, RN, CNOR
health-care professional shortages are President of the Association of periOperative
putting pressure on our ability to keep OR If the eye team is a well-oiled machine, Registered Nurses (AORN).
teams in sync. To maintain or improve then the circulating RN is the oil. The RN
quality of care for our patients, healthy makes sure all the parts of the surgery
teamwork must be a priority. machine work toward the patient’s well-
being. The circulating RN is the patient
Ophthalmology’s Unique advocate, making sure that the patient
Challenges is the focus, that each team member is
doing what is expected, and that every-
Each year in the United States we perform thing is going well.
more than four million cataract surgeries,
refractive procedures, and surgeries to

ASORN INSIGHT Winter 2017

Rolly Coronica, DNP, ARNP, FNP-C, CRNO &Zika Virus

the Eye
continuing education
accreditation: learning objectives:
This continuing education activity is The intrauterine Zika virus (ZIKV) infection produces
provided by ASORN. 1. Describe the Zika virus human neurologic abnormalities and retinal lesions (De
2. Identify effects of the Zika virus Paula Freitas et al., 2016; Jampol & Goldstein, 2016;
ASORN is accredited as a provider Ventura, Maia, Dias, Ventura, & Belfort, 2016). It is important
of continuing nursing education by on the eye to understand the full impact of the effects of ZIKV infection on
the American Nurses Credentialing 3. D iscuss diagnosis and prevention pregnancy outcomes. Aside from the neurologic and retinal dis-
Center’s Commission on eases, there are other neurophysiologic effects, such as decreased
Accreditation. of Zika infection hearing and motor function abnormalities, that hinder neuro-
development and alter developmental milestones of affected
ASORN is provider-approved by successful completion children (Spong, 2016). Characterizing and understanding the
the Cali­fornia Board of Registered degree of the impact of the ZIKV infection on fetal development
Nursing CEP #16717. 1.00 Nursing contact hours may be can guide in the development of tools and algorithms to assess,
earned for this learner paced activity. diagnose, treat, and monitor affected children.
disclosure: Successful completion includes
The authors, planners and content reading the article, completing an The Zika Virus
reviewers have disc­ losed that they do evaluation, taking an online post- The Zika virus belongs to the Flaviviridae family and is related
not have a conf­licti­ng relationship of test, and achieving a passing score to the Japanese encephalitis, yellow fever, West Nile, and den-
a financial, profess­ ional, or personal of 80% or higher. gue viruses. The ZIKV is primarily transmitted by the female
nature related to this activity. Aedes aegypti mosquito in the mosquito–human–mosquito
An email will be sent when the test is cycle, but reports suggest that it can also spread through blood
There is no commercial or non- posted. To take the examination for transfusion or sexual contact (Ahmad & Ustianowski, 2016;
commercial company support for this continuing education credits, go to
CNE activity. www.EyeCareCE.org. The expiration
date for this activity is 3/31/2020
and will also be stated within the
course description posted on
EyeCareCE.

continued on the next page
ASORN INSIGHT Winter 2017

6 CONTINUING EDUCATION (CE) ARTICLE

The Zika Virus and the Eye

Continued from page 5

Figure 1. Countries and Territories Where ZIKV Has Been Reported (CDC, 2016). short-lived signs and symptoms include fever, conjunctivitis,
headache, maculopapular rash, and joint pain (see Table 1) (De
Jampol & Goldstein, 2016). There are also reports of breast- Paula Freitas et al., 2016; Jampol & Goldstein, 2016). ZIKV
milk and perinatal transmission of ZIKV (De Paula Freitas et infection in adults has been linked to Guillain-Barré syndrome
al., 2016). The RNA of the Zika virus has now been detected (GBS). Infection during pregnancy increases the prevalence
in blood, urine, semen, saliva, female genital tract secretions, of microcephaly in newborns, and vision-threatening findings
cerebrospinal fluid, amniotic fluid, and breastmilk (Falcao et among these infants are likely associated with the ZIKV infec-
al., 2016). Two ZIKV strains, the African and the Asian, have tion (De Paula Freitas et al., 2016; Jampol & Goldstein, 2016).
been identified. Since the ZIKV outbreaks in French Polyne- Zika virus infection in pregnancy has been linked to adverse
sia, in Cape Verde, and then in Brazil and Colombia, a rapid complications, including miscarriage, stillbirth, fetal brain
geographical spread of ZIKV infection has been observed (see anomalies, and eye disorders (Spong, 2016).
Figure 1) (Falcao et al., 2016).
The ZIKV and Microcephaly
Signs and Symptoms of ZIKV Infection In April 2016, the Centers for Diseases Control and Preven-
About 80% of patients with ZIKV infection, also known as tion (2016) pointed out the causal relationship between prena-
Zika virus disease or ZIKV fever, are asymptomatic or oligo- tal ZIKV infection and fetal microcephaly and other cerebral
symptomatic (De Paula Freitas et al., 2016). The symptom- abnormalities. The head circumference criteria for microcephaly
atic patients manifest dengue fever-like symptoms. These were established to less than two standard deviations below the
average, or 33 centimeters or less. Table 2 describes the micro-
Table 1 cephaly criteria based on fetal ultrasonography (CDC, 2016;

Signs and Symptoms of Zika Viral Infection Table 2

Signs and symptoms Specifics Microcephaly Criteria
Fever No fever or low fever < 38.5°C (1–2 days) for Prenatal ZIKV Infection
Skin rash Frequent
Myalgia Moderately frequent Fetal Ultrasound Examination
Arthralgia Moderately frequent; in wrists and hands, At least one of the following criteria:
with complete regression 1. Cerebral calcifications and/or
Non-purulent conjunctivitis 50%–90% of cases 2. Ventricular abnormalities and/or
Headache Frequent; moderate intensity 3. At least two of the following:
Pruritus Moderate to severe
Lymphadenopathy Moderately frequent a. hypoplasia of the cerebellum
Neurological complications Guillain-Barré syndrome b. hypoplasia of the cerebellar vermis
among adults Encephalitis (rare) c. widening of the posterior fossa greater than 10 mm
Microcephaly d. agenesis/hypoplasia of the corpus callosum
Neurological complications Chorioretina and optic nerve abnormalities
among newborns Table 3

Ocular Findings in Infants with Presumed
Congenital Zika Virus Infection

(De Paula Freitas et al., 2016; Falcao et al., 2016) Ocular findings N = 17 Incidence (%)
Focal pigment mottling 11 64.7%
Chorioretinal atrophy 11 64.7%
Optic nerve abnormalities 8 47.1%
Iris coloboma 2 11.8%
Lens subluxation 1 5.9%
Signs of active uveitis 0 0
Vasculitis 0 0

ASORN INSIGHT Spring 2017

CONTINUING EDUCATION (CE) ARTICLE 7

Figure 2. Macular Pigmentary Mottling and Chorioretinal Atrophic Lesion. Left: De Paula Freitas et al., 2016; Falcao et al., 2016;Ventura, Maia,
Right eye shows granular and pigmentary mottling in the macula. Right: Left eye Bravo-Filho, Góis, & Belfort, 2016).
has chorioretinal lobulated atrophic lesion and pigmentary mottling.
These ultrasound findings can be detected as early as the 18th
Figure 3. Chorioretinal Atrophy and Hyperpigmented Mottling.Both eyes show week of pregnancy. Other ultrasound findings may include
round paramacular superotemporal chorioretinal atrophy surrounded by hyper- intrauterine growth retardation, arthrogryposis, oligohydramnios
pigmented halo and mottling. or anhydramnios, and cerebral or umbilical artery flow abnor-
malities (CDC, 2016; De Paula Freitas et al., 2016; Falcao et al.,
Figure 4. Optic Nerve Abnormalities, Pigment Mottling, and Chorioretinal 2016; Ventura, Maia, Bravo-Filho, Góis, & Belfort, 2016).
Atrophy. Left: Right eye has enlarged cup-to-disc ratio and macular pigmentary
mottling. Right: Left eye has macular chorioretinal atrophic lesion with hyperpig- De Paula 1. Freitas and colleagues (2016) conducted a descrip-
mented halo and pigmentary mottling and enlarged cup-to-disc ratio. tive study of infants born with microcephaly after a ZIKV
infection outbreak in Brazil. Investigators found that ophthalmic
defects were primarily located in the chorioretina and optic
nerve and developed during the first or second trimester of preg-
nancy. The study included infants with head circumference of
32 cm or less born to mothers who had presumed ZIKV infection
during pregnancy. Excluded from the study were microcephalic
infants whose mothers had drug or alcohol use during pregnancy
or familial history of microcephaly. Infants with congenital infec-
tions such as syphilis, cytomegalovirus, herpes simplex virus,
rubella, HIV, or toxoplasmosis were also excluded. Table 3 lists
ocular findings from infants with presumed congenital Zika virus
infection (De Paula Freitas et al., 2006; McCarthy, 2016).

The fundus photographs in Figures 2–6 show ocular findings in
infants with presumed intrauterine ZIKV infection (De Paula
Freitas et al., 2016).

Adults infected with ZIKV who present with conjunctivitis may
have uveitis. Some patients with the diagnosis of ZIKV-related
conjunctivitis can have intraocular inflammation, which may be
a potential manifestation of ZIKV infection (Furtado, Espósito,
Klein, Teixeira-Pinto, & Da Fonseca, 2016).

Figure 5. Chorioretinal Scar and Pigment Mottling. Both eyes have a superotem- ZIKV Infection Diagnosis
poral perimacular chorioretinal scar with perilesional pigmentary mottling. Positive real-time reverse transcription polymerase chain
reaction (rRT-PCR), immunoglobulin M (IgM) antibody, and
Figure 6. Optic Nerve Abnormalities, Pigment Mottling, and Chorioretinal Atro- neutralizing antibody are the molecular and serologic tests avail-
phy. Left: Right eye has optic disc hypoplasia, peripapillary nasal atrophy, and a able to confirm ZIKV infection (CDC, 2016; Rabe, Staples, &
round excavated nasal lesion with hyperpigmented halo and a colobomatous- Villanueva, 2016; Falcao et al., 2016). Each of these tests has its
like defect. Right: Left eye has optic disc hypoplasia, peripapillary nasal atrophy, strengths and limitations.
and a retinal nasal lesion with a similar pattern.
The rRT-PCR is useful for detecting the ZIKV on the first few
days of acute infection but is not helpful to confirm infection
in infants. A positive rRT-PCR confirms ZIKV infection, but a
negative rRT-PCR result does not exclude infection. Following
rRT-PCR, the next step in diagnosis is to utilize IgM and neu-
tralizing antibody testing, which can identify additional recent
ZIKV infections. However, ZIKV antibody test results can be

continued on the next page

ASORN INSIGHT Spring 2017

8 CONTINUING EDUCATION (CE) ARTICLE

The Zika Virus and the Eye

Continued from page 7

misleading because of cross-reactivity with other flaviviruses or in
individuals previously infected with or vaccinated against related
flaviviruses (CDC, 2016; Rabe, Staples, & Villanueva, 2016;
Falcao et al., 2016).

ZIKV RNA can be detected in blood samples within one to five Figure 7. Pamphlet on ZIKV Infection (CDC, 2016)
days after the start of symptoms. Keep in mind that a negative
result does not rule out ZIKV infection because the sensitivity
of rRT-PCR is estimated to be 40%. Because the virus persists
in the urine, rRT-PCR should be performed on a urine sample
between the fifth and the 15th day after the start of symptoms.
Serological tests can detect IgM from the fourth day; and IgG,
from the 12th day (CDC, 2016; Rabe, Staples, & Villanueva,
2016; Falcao et al., 2016).

ZIKV Infection Treatment no vaccine or medication that can prevent ZIKV infection. The
No specific antiviral treatment is available for ZIKV infections. best way to prevent ZIKV infection is to avoid mosquito bites
The management of acute ZIKV illness consists of oral hydration; by wearing appropriate clothing, using insect repellant, and
medications for symptomatic relief of pain, fever, and itching; staying indoors when traveling to known ZIKV transmission
and rest. Dengue fever is considered as the primary diagnosis areas. The CDC (2016) advises pregnant women not to travel
until ruled out because it has acute severe complications (CDC, to transmission countries. Men who have traveled to a ZIKV
2016; Falcao et al., 2016). Until dengue fever has been ruled out, area are advised to practice abstinence or use condoms. How
affected persons should avoid nonsteroidal anti-inflammatory long after infection the ZIKV can be sexually transmitted is still
drugs (NSAIDs). Pregnant women beyond the 32nd week of unknown. Non-pregnant women of childbearing age who have
gestation should also avoid NSAIDs because of the risk of early travelled in these areas are advised to delay pregnancy for at least
closure of the arterial duct. Additionally, avoid using aspirin in eight weeks (CDC, 2016; Scully & Robinson, 2016). The CDC
children under the age of 12 years because of the risk of Reye has printed materials including this information for education
syndrome (CDC, 2016; Falcao et al., 2016). purposes (see Figure 7.)

The following are recommendations for pregnant women (CDC, Pregnant ophthalmic patients should be encouraged to seek
2016; Falcao et al., 2016): medical attention for possible diagnosis and treatment, outlined
earlier in the article. Infants with ocular findings associated with
• I f the laboratory test is positive for ZIKV or inconclusive, serial presumed intrauterine ZIKV infection and their families will
ultrasound examinations are recommended. need support and follow-up from the ophthalmic team.

• If the fetus has a confirmed diagnosis of microcephaly, evaluate Conclusion
for amniocentesis from the 15th week of pregnancy onward. A better understanding of the full impact of the effects of ZIKV
infection on pregnancy outcomes is needed. The CDC has
• W omen who live in a transmission area, should undergo blood established clinical cases that may indicate the causal relation-
tests for ZIKV at the beginning of their prenatal visits. ship between prenatal ZIKV infection and fetal microcephaly
and other cerebral abnormalities. The presence of ocular find-
• Women who have history of travel to transmission areas should ings such as focal pigment mottling, chorioretinal atrophy, and
be offered serologic tests 2–12 weeks after traveling. optic disc abnormalities contribute to timely diagnosis of ZIKV
congenital infection in infants born with microcephaly. Experts
Implications for the Ophthalmic Team strongly recommend that infants with microcephaly undergo rou-
Any member of the ophthalmic team might interact with patients tine ophthalmologic evaluation to identify chorioretinal and optic
who may have plans to travel or have already travelled to areas disc lesions especially in transmission areas of South and Central
of reported active Zika transmission (see Figure 1). Education America and the Caribbean. However, it has been suggested that
on prevention is critical and should be provided by physicians,
nurses, and infection prevention specialists. Presently, there is

ASORN INSIGHT Spring 2017

CONTINUING EDUCATION (CE) ARTICLE 9

microcephaly should not be a required criterion for a congenital doi:10.1001/jamaophthalmol.2016.0267
ZIKV infection diagnosis because there could be infants without Falcao, M., Cimerman, S., Luz, K., Chebabo, A., Brigido, H., Lobo,
microcephaly who have been infected by ZIKV during the ges-
tational period. Fundus screening for all infants with suspected I., . . . & Bandeira, A. (2016). Management of infection by the Zika
congenital ZIKV infection should be conducted because ocular virus. Annals of Clinical Microbiology and Antimicrobials, 15, 57.
findings might be missed if microcephaly remains an inclusion doi:10.1186/s12941-016-0172-y
criterion in the screening process. There are no reported cases Furtado, J., Espósito, D., Klein, T., Teixeira-Pinto, T., & Da Fonseca,
of infants diagnosed with congenital ZIKV infection who did not B. (2016). Uveitis associated with Zika virus infection. New England
have microcephaly but did have ocular findings. Journal of Medicine, 375(4), 394–396. doi:10.1056/NEJMc1603618
Jampol, L., & Goldstein, D. (2016). Zika virus infection and the
Rolly Coronica, DNP, ARNP, FNP, CRNO, CCRN-A, is affiliated to Ophthalmology Depart- eye. JAMA Ophthalmology, 134(5), 535–536. doi:10.1001/
ment of VA Boston Medical Center and South University as Ophthalmic Supervising NP and jamaophthalmol.2016.0284
Assistant Professor respectively. McCarthy, M. (2016). Severe eye damage in infants with microcephaly is
presumed to be due to Zika virus. BMJ, 352.
References Rabe, L., Staples, J., & Villanueva, J. (2016). Interim guidance for
interpretation of Zika virus antibody test results. Morbidity and
Ahmad, S., & Ustianowski, A. (2016). Zika virus: Management of infection Mortality Weekly Report, 65. doi:10.15585/mmwr.mm6521e1
and risk. BMJ, 352, 1062. doi:10.1136/bmj.i1062 Scully, C., & Robinson, A. (2016). Check before you travel: Zika virus –
another emerging global health threat. British Dental Journal, 220,
Centers for Disease Control and Prevention (CDC). (2016). Preventing 265–267. doi:10.1038/sj.bdj.2016.182
Zika. Retrieved from https://www.cdc.gov/zika/ Spong, C. (2016). Understanding Zika virus pathogenesis: An interview
with Catherine Spong. BIOMed Central. 14, 84. doi:10.1186/s12916-
De Paula Freitas, B., De Oliveira Dias, J., Prazeres, J., Sacramento, G., 016-0628-0
Ko, A., Maia, M., & Belfort, R. (2016). Ocular findings in infants Ventura, C., Maia, M., Bravo-Filho, V., Góis, A., & Belfort, R. (2016).
with microcephaly associated with presumed Zika virus congenital Zika virus in Brazil and macular atrophy in a child with microcephaly.
infection in Salvador, Brazil. JAMA Ophthalmology, 134(5), 529–535. Lancet, 387(10015), 228. doi:10.1016/S0140-6736(16)00006-4
Ventura, C., Maia, M., Dias, N., Ventura, L., & Belfort, R. (2016). Zika:
Neurological and ocular findings in infant without microcephaly.
Lancet, 387(10037), 25055. doi:10.1016/S0140-6736(16)30776-0

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T e s t Y o u r K no w l e d g e !

Act Now with

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POST-TEST QUESTIONS

1. The Zika virus belongs to the Flaviviridae 3. Which parts of the eye of the fetus does 5. Ocular findings in infants with presumed 7. When educating patients on strategies to
family and is related to the following
viruses: the Zika virus primarily affect during the intrauterine ZIKV infection are varied and prevent Zika infection from the mosquito,

A. Yellow fever, West Nile, dengue, and first or second trimester of pregnancy? include the following: what directions should be provided by
malaria A. Cornea and retina members of the ophthalmic team?
B. Chorioretina and lens
B. Yellow fever, West Nile, chikungunya, A. Wear appropriate clothing, use insect
and dengue TC. Optic nerve and cornea repellent, and stay indoors
SD. Chorioretina and optic nerve
C. Japanese encephalitis, yellow fever, A. Enlarged cup-to-disc ratio B. Men who have travelled to Zika
West Nile, and dengue B. Macular pigmentary mottling transmission areas should practice
C. Chorioretinal atrophy and scarring abstinence or use condoms
D. Japanese encephalitis, yellow fever, D. All of the above
West Nile, and chikungunya TE IT 4. Infection during pregnancy increases the C. Pregnant women should not travel to
prevalence of microcephaly. What findings 6. How soon after the start of symptoms transmission countries
2. Although 80% of patients with ZIKV infec- on ultrasound may indicate microcephaly? can the ZIKV RNA be detected in blood
tion are asymptomatic, symptoms may E MA. Hyperplasia of the cerebellum samples? D. All of the above
include: L BB. Hypoplasia of the cerebellum
P UC. Narrowing of the posterior fossa A. Immediately
A. Weight loss, pruritus, arthralgia
SDAOMNOT SD. Hyperplasia of the corpus callosum B. After five days
B. Lymphadenopathy, myalgia, weight
loss C. Within one to five days

C. Non-purulent conjunctivitis, headache, D. Anytime during illness
skin rash

D. Skin rash, non-purulent conjunctivitis,
productive cough

ASORN members and other eye care professionals now have an online source for continuing education and training: EyeCareCE. The site is the collaborative effort of five organizations. Together,
the International Joint Commission on Allied Health Personnel in Ophthalmology (IJCAHPO), the American Society of Ophthalmic Registered Nurses (ASORN), the Association of Technical
Personnel in Ophthalmology (ATPO), the Canadian Society of Ophthalmic Medical Personnel (CSOMP), the American Academy of Ophthalmic Executives (AAOE), the Contact Lens Society of
America (CLSA), and the Ophthalmic Photographer’s Society (OPS), teamed to produce a comprehensive online training resource for eye care professionals. ASORN is proud to participate in
this online educational partnership.

ASORN INSIGHT Spring 2017

11

Orwa Nasser, MD, MPH; Alina Dumitrescu, MD; and Scott A. Larson, MD

focus

The Pediatric Ophthalmic Examination:
Challenges and Strategies, Part II

This article, which is Part II of a two-part series on pediatric oph- Common tests for fusion include the Worth four-dot test and the
thalmic examination, will focus on steps five through 10 of the four-prism diopter base-out (PDBO) test.
examination (see Table 1). For Part I, see 42(1) issue of Insight.
The Worth four-dot test can be used to test for central and
Table 1 peripheral fusion, with the lack of a fusion response indicating
suppression. The child wears spectacles with colored filters. The
Ten Steps of the Pediatric red filter is placed in front of the right eye, and the green filter
Ophthalmic Examination is placed in front of the left eye. A color-matched flashlight with
four dots (two green, one red, and one white) is held at 1/3 meter
History or Examination Element from the child to test for peripheral fusion and at six meters to
1 Gather medical and ocular information from previous charts. test for central fusion (Morale et al., 2002). The child should
2 Establish a friendship with the child during the first encounter. report how many dots they see, including the color and location.
3 Observe the child while talking to the child or the family. A child with normal binocularity will report four dots (two red,
4 Take medical and ocular history from the child and family. two green). The white dot may appear red or green, or it may
5 Examine ocular sensory status (fusion and stereopsis). flicker between red and green, depending on eye dominance.
6 Examine visual acuity, color vision, and confrontation visual fields.
7 Examine ocular alignment and motility. Preverbal children can be encouraged to “touch the dots” on
8 Examine face, orbit, and anterior segment. the flashlight. If they touch all four dots, it is assumed that they
9 Perform cycloplegic retinoscopy and posterior segment examination. have peripheral fusion. This assumption should be validated
10 Perform other ancillary tests: photos, visual evoked potentials, with follow-up testing when the child can verbalize. If there is
suppression of one of the eyes, the child will see only two red or
electroretinogram, eye movement recordings, formal visual field three green dots (Morale et al., 2002; Etezad Razavi, Najaran,
testing, corneal topography, corneal pachymetry, and optical Moravvej, Ansari Astaneh, & Azimi, 2012). A patient with stra-
coherence tomography (when possible and if necessary). bismus without suppression will complain about diplopia and see
five dots (two red and three green, or three red and two green).
Step 5. Examine Ocular Sensory Status If red circles are reported on the left side of the green dots, this
Fusion is the brain’s ability to sense a single object from both means crossed diplopia or exotropia. If red dots are reported on
eyes and create a single image. Fusion depends on good visual the right side of the green lights, uncrossed diplopia or esotropia
acuity from both eyes and good eye alignment between the eyes. is suspected. A child with normal results at near and suppression
Because the eyes are separate from each other, the images sent at distance may have normal peripheral fusion but abnormal cen-
to the brain are slightly dissimilar. When the visual system is tral fusion due to a central suppression scotoma. This typically
functioning correctly these image disparities are interpreted as occurs in a monofixation syndrome.
depth; this perception is referred to as “stereo vision.”
The four-PD BO test assesses motor fusion and detects the pres-
Fusion can be artificially categorized as “central” or “peripheral,” ence of a suppression scotoma, partial loss of vision, or a blind
as well as “sensory” or “motor.” Various tests of fusion attempt
to categorize these different aspects of the fusion response. The continued on the next page
absence of fusion, or suppression, is the brain’s adaptation to
dissimilar visual input, either from monocular blur or diplopia.

ASORN INSIGHT Spring 2017

12 focus

The Pediatric Ophthalmic Examination:
Challenges and Strategies, Part II

Continued from page 11

Table 2

Measuring VA in Children According to Age

Age/Cooperation Method Normal Result
0–3 months Popping eye reflex Opens the eyes widely when room lights are turned off
Preverbal and uncooperative Light blink reflex Blinks to light when light is shined over the eye
children Visual attention Follow faces or bright lights
3 months to 2 years
Preverbal and uncooperative Preferential looking Using Teller acuity cards or Cardiff cards, the child should be visually attentive to vertical
children Fixate & Follow or horizontal gratings. The finest grating detected correlates to visual acuity.
CSM: Central, Steady, Maintained
2–5 years The eye fixates and follows the presented target.
Optokinetic drum
Visual evoked potential (VEP) Corneal light reflex is central and the eye is steady when the other eye is covered. Either
Allen/Lea pictures chart eye keeps fixation maintained when the cover is removed through a blink. Use a 14-16
base-down prism for children without manifest strabismus.

The eyes follow the stripes in an involuntary pursuit movement and are brought back to
their initial point with a saccade.

Measures the functional integrity of the entire visual pathway. Sweep VEP can be used
to estimate visual acuity. VA is 20/20 by the age of six months.

Normal VA is 20/40 to 20/20.

Verbal, cooperative children HOTV chart For children who don’t know how to describe pictures or don’t know letters or games,
Snellen chart a matching chart should be introduced. Entire lines or single optotypes with crowding
bars are presented.

+5 years E-game chart Normal VA is 20/30 to 20/20.
Snellen chart

Verbal, cooperative children
Victor, 1972; Yates & Brown, 1981; Bowman, McCulloch, Law, Mostyn, & Dutton, 2010; Dobson & Teller, 1978; Jackson et al., 1990; Fulton, Hansen, & Manning, 1981; Gräf, Becker, &
Kaufmann, 2000; Hered, Murphy, & Clancy, 1997; Sokol, Hansen, Moskowitz, Greenfeld, & Towle, 1983; Wright, Edelman, Walonker, & Yiu, 1986.

spot in an otherwise normal visual field. It is performed by plac- Example of how to encourage the child to do stereo
ing a four-prism diopter prism base in front of either eye. acuity tests:
—“Hey, I have some magic glasses. When you put them on you
Example of how to encourage the child to do fusion can see different animals popping up from plate. Can you catch
tests: the fly’s wings? Which circle/animal is raised? Can you push it
—“I have some magical glasses. When you put them on you will back down?”
see red and green colors. Here, you can try it. How many colors
do you see?” Step 6. Examine Visual Acuity, Color Vision, and
Confrontation Visual Fields
Many ocular abnormalities can interfere with the development of Best-corrected visual acuity (VA) should be measured at both dis-
stereo acuity, such as strabismus, anisometropia, refractive error, tance and near viewing. A child’s VA can vary according to their
media opacities, and others (Ying et al., 2013; Odell, Hatt, Leske, attentive state (Mackie et al., 1998). A child who is sleepy or sick
Adams, & Holmes, 2009; Ponsonby et al., 2013). Stereo vision will be less visually attentive. VA in children should be measured
is tested by presenting two slightly different images to each eye. at the most advanced developmental level for each child (Hoyt
The brain, in turn, interprets the different images as a single & Taylor, 2013). Table 2 describes methods for measuring VA in
image with volume and depth. Stereo acuity tests need the coop- children according to age. All methods should be performed for
eration of the child but they can be performed in verbal children. each eye singly at both distance and near.

ASORN INSIGHT Spring 2017



14 focus

The Pediatric Ophthalmic Examination:
Challenges and Strategies, Part II

Continued from page 13

A “vergence” is the simultaneous movement of both eyes. This The practitioner should assess the color, shape, diameter, and
movement occurs to obtain or maintain single binocular vision response of the pupils. The pupil size should be assessed in both
(Hoyt & Taylor, 2013; Nelson & Olitsky, 2015). Convergence dim and bright light. Direct and consensual responses should
occurs when both eyes move toward the nose. Divergence occurs also be assessed with the swinging flashlight test. By comparing
when both eyes move horizontally away from each other in the the rate and amount of constriction of each pupil in quick succes-
temporal direction. Vergence testing is only possible in coopera- sion, one can check for a relative afferent pupillary defect.
tive older children who can recognize and verbalize when they
see diplopia. Vergence movements are tested binocularly with a The external and anterior segment exam in children can be
prism bar. To perform this test the child focuses on a picture or performed with a penlight, indirect ophthalmoscope, slit lamp,
toy at near distance and the examiner slowly moves the target or handheld slit lamp. The practitioner should determine the
toward the child’s nose. best way to examine the anterior segment according to the age
and cooperative state of the child. In infants and young children,
Examples of how to make the ocular alignment and a penlight exam, indirect ophthalmoscopy using the lens 20D or
motility exam interesting: 28D as a magnifier, or a portable slit lamp may be enough to rule
—“Hey, look – I am putting the sticker on my big nose. Can you out important pathology.
tell me who is in the picture? How many ears does he have? How
many noses?” A fixed slit lamp can cause fear in some children, and smaller
children may have difficulty positioning correctly for an adequate
—“Hey, look at my funny stick. There are animals there that keep period of time. In older and cooperative children, a fixed slit
turning around. Can you tell me which one of them you can see lamp can be used with minor adjustment of the seat and position.
now?” To lessen the child’s fear, the light on the slit lamp should be dim
as possible. One way to make the slit lamp exam a fun game is
—“I have a new cartoon on that screen. Can you tell me who you to have the child grab the handlebars, like the handlebars of a
see? What is his hair color? What is he wearing?” bicycle or motorcycle. Also, try to engage the child in conversa-
tion. A worried three-year-old with juvenile idiopathic arthritis
—“Let’s play with my funny toy. Keep looking at it when I might not volunteer for a slit-lamp examination, but when he is
move my hand. Don’t let it go away; keep looking, You are very given the chance to talk about a cherished new pair of sneak-
smart …” ers, or when a sibling or parent shows him how to do it first, he
may eagerly allow a good view of the anterior segment (Hoyt &
Step 8. Examine Face, Orbit, and Anterior Taylor, 2013).
Segment
The ocular eye exam of the child begins the moment the prac- During the anterior segment examination the practitioner should
titioner meets the child. While talking to the child or the family examine the eyelids, conjunctiva, sclera, cornea, anterior cham-
during the first minutes of the encounter, the practitioner can ber, iris, lens, and anterior vitreous. The practitioner should look
gather information about the child’s ocular condition (Swartz, for common pathologies of the anterior segment in the pediatric
2014). The external physical exam should not be limited to the population. These include ptosis, eyelid coloboma, distichiasis,
eyelids and eyes; the practitioner should also inspect the head, trichiasis, conjunctival nevus or mass, corneal dystrophy, corneal
face, and body (Swartz, 2014). Is the child alert? Is the child edema, dry eye syndrome, anterior segment dysgenesis, cataract,
aware of you and of the surroundings? Are there any signs of and persistent fetal vasculature.
distress? Are there any gross bodily abnormalities? Are there
any facial abnormalities? Are there any neuromuscular abnor- Examples of how to make the anterior segment exam
malities? Does the patient maintain eye contact? Is there any interesting:
abnormal head position? Are there facial, orbital, eyelid, or —“Hey, look – do you want to take a look at my penlight? When
ocular surface abnormalities? The information gained from this I shine it into your eyes it makes rainbow colors.”
inspection is important and can help direct the examiner.
—“Hey, look – I have special camera in my hand (handheld slit
lamp)… Let me take some pictures of your eyes.”

ASORN INSIGHT Spring 2017

focus 15

—“Did you see my special toy (Icare)? I can put it in front of Implications for Ophthalmic Team Members
your face. It will not hurt at all but it may feel a little funny.” A complete and thorough eye exam is a collaborative effort
between all clinic members and does not rely solely on the physi-
Step 9. Cycloplegic Retinoscopy and Posterior cian. Technicians and nurses should understand the pediatric
Segment Examination eye exam so they can intervene appropriately and provide age-
After finishing the anterior segment exam, dilating drops should appropriate care. Cooperation, communication, consistency, and
be administered. It is most helpful to have someone other than coordination between technicians, nurses, physicians, and all
the primary examiner administer the drops. The hope is that the other eye clinic members are essential for a successful eye exam.
child will not equate the uncomfortable sensation of the drops
with the examiner. The drops should dilate the pupil but can also Conclusion
cause cycloplegia. The eye drops most commonly used in the The pediatric ophthalmic examination requires a different inter-
pediatric examination are tropicamide 1%, cyclopentolate 1%, personal skill set than the adult examination. Foremost among
phenylephrine 2.5%, and atropine 1%. Weaker drops, such as the examiner’s priorities should be gaining the trust of the child
cyclopentolate 0.5% or 0.2% and phenylephrine 1%, are used for and building a friendship with him or her in order to perform a
younger children and infants. thorough and detailed examination. The examiner should create
a welcoming, friendly environment and have the right equipment
Retinoscopy is easier if it precedes ophthalmoscopy. After finish- and facilities to ease the process. We recommend a step-wise
ing retinoscopy, indirect ophthalmoscopy should be performed approach to the pediatric eye examination that minimizes the
to examine the lens, vitreous, optic nerve, macula, posterior chances of obtaining incorrect information. The practitioner
pole, and retinal periphery. Indirect ophthalmoscopy is the best should remember that with the proper experience, knowledge,
way to examine the posterior segment in children since they and patience, the pediatric ophthalmic examination can be a pro-
may not be cooperative for slit lamp or fundus photography. An ductive and rewarding experience for both examiner and child.
examination under anesthesia may be indicated if the risk of
missing an important problem is high. During ophthalmoscopy, Orwa Nasser, MD, MPH, can be reached at the Department of Ophthalmology and Visual
the practitioner looks for lens, vitreous, retinal, and optic nerve Sciences, University of Iowa Hospitals and Clinics, Iowa City, Iowa, [email protected].
abnormalities. Alina Dumitrescu, MD, is an assistant professor of ophthalmology and works at the
University of Iowa.
Examples of how to make the retinoscopy and Scott A. Larson, MD, is the William E. Scott Professor of Pediatric Ophthalmology
posterior segment exam easy: Education and director of Fellowship Programs for the University of Iowa, and a full-time
—“Hey, let’s play a game: you look into the movie, and I look into academic pediatric ophthalmologist.
your eye. You tell me what you see, and I tell you what I see.”
References
—“Look at my funny hat. It shines like rainbows. I will put my
lens in front of your face so you can see the rainbows, too.” American Academy of Ophthalmology. (2015a). Basic and clinical science
course: Neuro ophthalmology. Section 6. Chapter 7: Diagnostic
—“If I look closely into your eyes, I may be able to see if you techniques for strabismus and amblyopia. San Francisco: AAO.
have super powers/princess powers!”
American Academy of Ophthalmology. (2015b). Basic and clinical science
—“Hey, let’s play a game. I will put my hat on and you look at course: Neuro ophthalmology. Section 5. Chapter 3: The patient with
my toy.” decreased vision: Evaluation. San Francisco: AAO.

Step 10. Perform Other Ancillary Tests Bowman, R., McCulloch, D. L., Law, E., Mostyn, K., & Dutton, G. N. (2010).
After finishing the clinical exam and depending on the patient’s The ‘mirror test’ for estimating visual acuity in infants. British Journal of
suspected diagnosis, the practitioner can add imaging and/or Ophthalmology, 94(7), 882–885. doi:10.1136/bjo.2009.162750
electrophysiology exams, including magnetic resonance imaging
and computerized tomography scans, visual evoked potentials, Choi, R. Y., & Kushner, B. J. (1998). The accuracy of experienced
electroretinography, eye movements recording, formal visual strabismologists using the Hirschberg and Krimsky tests. Ophthalmology,
field testing, corneal topography, optical coherence tomography, 105(7), 1301–1306.
and A and B scan ocular ultrasonography.
Dobson, V., & Teller, Y. (1978). Visual acuity in human infants: A review
and comparison of behavioral and electrophysiological studies. Vision
Research, 18(11), 1469–1483.

Eskridge, J. B., Wick, B., & Perrigin, D. (1988). The Hirschberg test: A
double-masked clinical evaluation. American Journal of Optometry and
Physiological Optics, 65(9), 745–750.

Etezad Razavi, M., Najaran, M., Moravvej, R., Ansari Astaneh, M. R., &
Azimi, A. (2012). Correlation between worth four dot test results and
fusional control in intermittent exotropia. Journal of Ophthalmic and
Vision Research, 7(2), 134–138.

Fulton, A. B., Hansen, R. M., & Manning, K. A. (1981). Measuring visual
acuity in infants. Survey of Ophthalmology, 25(5), 325–332.

Gräf, M. H., Becker, R., & Kaufmann, H. (2000). Lea symbols: Visual acuity
assessment and detection of amblyopia. Graefe’s Archive for Clinical and

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The Pediatric Ophthalmic Examination:
Challenges and Strategies, Part II

Continued from page 15

Experimental Ophthalmology, 238(1), 53–58. Ponsonby, A. L., Smith, K., Williamson, E., Bridge, D., Carmichael, A.,
Griffin, J. R., & Cotter, S. A. (1986). The Brückner test: evaluation of clinical Dwyer, T., . . . & Swartz, M. H. (2013). History and examination. In
Textbook of physical diagnosis: (7th ed., pp. 671–742). New York: Elsevier
usefulness. Am J Optom Physiol Opt, 63(12), 957-61. Saunders.
Hered, R. W., Murphy, S., & Clancy, M. (1997). Comparison of the HOTV
Simunovic, M. P. (2010). Colour vision deficiency. Eye (London), 24(5),
and Lea Symbols charts for preschool vision screening. Journal of 747–755. doi:10.1038/eye.2009.251
Ophthalmic Nursing and Technology, 16(2), 68–73.
Hoyt, C. S., & Taylor, D. (2013). Examination, history and special tests in Sokol, S., Hansen, V. C., Moskowitz, A., Greenfield, P., & Towle, V. L. (1983).
pediatric ophthalmology. In Pediatric Ophthalmology and Strabismus (4th Evoked potential and preferential looking estimates of visual acuity in
ed., pp. 45–54). New York: Elsevier Saunders. pediatric patients. Ophthalmology, 90(5), 552–562.
Jackson, G. R., Jessup, N.S., Kavanaugh, B. L., Moats, V. L., Daum, K. M.,
Marsh Tootle, W. L., & Rutstein, R. P. (1990). Measuring visual acuity in Swartz, M. H. (2014). Textbook of physical diagnosis: History and examination
children using preferential looking and sine wave cards. Optometry and (7th ed.). Philadelphia: Elsevier Saunders.
Vision Science, 67(8), 590–594.
Mackie, R. T., McCulloch, D. L., Saunders, K. J., Day, R. E., Phillips, S., & Tongue, A. C., & Cibis, G. W. (1981). Brückner test. Ophthalmology, 88(10),
Dutton, G. N. (1998). Relation between neurological status, refractive 1041-4.
error, and visual acuity in children: A clinical study. Developmental
Medicine and Child Neurology, 40(1), 31–37. Victor, D. (1972). Eye-popping reflex in infants. Journal of Pediatrics, 81(6),
Morale, S. E., Jeffrey, B. G., Fawcett, S. L., Stager, D. R., Salomão, S. R., 1223.
Berezovsky, A., . . . & Birch, E. E. (2002). Preschool Worth 4-shape test:
Testability, reliability, and validity. Journal of AAPOS, 6(4), 247–251. Wright, K. W., Edelman, P. M., Walonker, F., & Yiu, S. (1986). Reliability
Nelson, L. B., & Olitsky, S. E. (2015). Pediatric eye examination. In Harley’s of fixation preference testing in diagnosing amblyopia. Archives of
Pediatric Ophthalmology (6th ed., pp. 93–104). New York: Lippincott Ophthalmology, 104(4), 549–553.
Williams & Wilkins.
Odell, N. V., Hatt, S. R., Leske, D. A., Adams, W. E., & Holmes, J. M. (2009). Yates, S. K., & Brown, W. F. (1981). Light-stimulus-evoked blink reflex:
The effect of induced monocular blur on measures of stereoacuity. Journal Methods, normal values, relation to other blink reflexes, and observations
of AAPOS, 13(2), 136–141. doi:10.1016/j.jaapos.2008.09.005 in multiple sclerosis. Neurology, 31(3), 272–281.

Ying, G. S., Huang, J., Maguire, M. G., Quinn, G., Kulp, M. T., Ciner,
E., . . . & Orel-Bixler, D. (2013). Vision in Preschoolers Study Group.
Associations of anisometropia with unilateral amblyopia, interocular acuity
difference, and stereoacuity in preschoolers. Ophthalmology, 120(3),
495–503. doi:10.1016/j.ophtha.2012.08.014

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ASORN INSIGHT Spring 2017





eye wonder 19

planned surgery at our eye center. The game plan identified all
personnel involved in the surgery. The list included surgeons, OR
nursing staff, anesthesia staff, company specialists, and a visiting
surgeon with prior experience implanting retinal prostheses. The
game plan included an itemized list of events detailing each step
of the surgical procedure (see Figure 6). The list included every
step, including patient positioning, drugs given, surgical steps,
instrumentation and supplies, nursing care, and device testing.

A rehearsal with the nursing and surgeon team was conducted Figure 5. Reviewing the Intraoperative Checklist. A device company representa-
in the OR the night before the surgery to physically map out the tive reviews the intraoperative checklist with the OR nurse prior to the start of the
steps to be taken the next day. Team collaboration among the procedure in Germany.
surgeons and nursing staff was vital in ensuring the smooth transi-
tion from planning to implementation, and as a result, our first
and subsequent surgeries were completed with confidence and
calm assurance, creating an atmosphere of reassurance for our
patients and their families.

Preoperative Process Figure 6. Game Plan
After the selection process, retinal prosthesis patients at our eye
center are given additional preoperative clinical visits that include It is important to remember that these patients are completely
a history and physical, anesthetic evaluation, review and sign- blind. Nurses and ancillary personnel should lead the patient by allow-
ing of consent forms, introduction to postoperative rehabilitation ing them to grasp the health-care provider’s elbow and describing the
services, and counseling to manage expectations. The clinic team area as they guide the patient. They should also take care to describe
includes a retinal surgeon, an electrophysiologist, ophthalmic what they are doing before and during the action, so the patient is not
technicians, a genetic counselor, and an occupational therapist. surprised. For example, they should tell the patient that they are about
Once the decision is made to schedule surgery, the OR team is to give an eye drop, and that they will be touching the lower eyelid as
contacted and the OR purchaser places an order for the device. they do so.
The triage nurses, who are part of our pre-anesthesia clinic,
phone the patient to conduct a preoperative risk assessment operative eye. A certified RN anesthetist does an anesthetic
and identify factors that may put the patient at increased risk for assessment and explains the anesthetic plan to the patient and
complications. They coordinate surgical, anesthesia, nursing, and family. The surgeon visits the patient
laboratory care. The triage nurses are also a key element in creat-
ing a rapport with the patients and their families, which helps to
allay anxiety related to the upcoming procedure.

The OR nurse reviews the scheduled patient information and
makes sure that the correct device is ordered (retinal prostheses
are laterality specific) and that instruments and supplies are avail-
able. These items include microscope, vitrectomy machine, and
ophthalmic instrumentation, special retinal tack-holding forceps,
silicone-tipped forceps for handling the implant, silicone sleeve
implants, medications, and pericardial tissue implants.

Surgery: Preoperative, Operative, and and family in the preoperative area to answer last-minute ques-
Postoperative Steps tions and confirm and mark the surgical site. The OR nurse visits
On the morning of surgery, the patient arrives in the preoperative the patient and family to check on the patient’s readiness for
holding area. The preoperative area RN then does an assessment, the OR. Items assessed include patient NPO status, completed
discusses the pre- and post-surgical care plan with the patient
and family, and administers the dilating drops to the patient’s continued on the next page

ASORN INSIGHT Spring 2017

20 eye wonder

Retinal Prosthesis Implantation

Continued from page 19

consent, history and physical completed within 30 days, and other end is connected to a computer, which measures the impe-
surgical site marked by the surgeon. dence of the electrodes in the array.

Retinal prosthesis patients may have heightened anxiety related The patient is given subconjunctival antibiotics and steroid injec-
to high expectations. The day of surgery is the culmination of an tions, followed by atropine drops and antibiotic/steroid ointment.
extended period of preparation and can evoke great emotion An eye patch and shield are placed over the eye. To prevent
for both patients and their support people. It is important for the discomfort from catheter removal, the OR nurse removes the
nurse to acknowledge the importance of this day and encourage catheter before the patient emerges from anesthesia. After the
the patient and family or friends to express their hopes, fears, and patient is awake, they are transported to the post-anesthesia
questions. care unit, where nurses assess, monitor, and care for the patient,
addressing needs for comfort, orientation, safety, and pain control.
Because the implantation surgery usually takes three to four hours Nursing staff educate the patient and family about post-procedure
and is conducted under general anesthesia, it is important for care, including monitoring for pain and infection and follow-up
the nurse to discuss the anticipated use of an indwelling urinary appointments. Because early detection of postoperative compli-
catheter for the duration of surgery. Patients may not anticipate cations is critical to maintaining successful outcomes, patients
the use of a catheter and may need information about that aspect need to be educated about the early signs of endopthalmitis and
of their care and what they can expect. At our surgery center, we conjunctival erosion, such as increased pain and swelling, and
remove the catheter prior to sending the patient to the recovery instructed to immediately report them to their physician.
area so patients are spared the discomfort of being awake when
the catheter is inserted or removed. Recovery and Follow-up
After recovery from surgery, the patient can visit the clinic to have
When the patient is brought to the OR, the surgical team does the device fitted and programmed. This process involves connect-
a preoperative verification and positions the patient appropri- ing the device to a computer and electrically stimulating the elec-
ately. Anesthesia is induced, and the OR nurse places a urinary trodes to determine the patient’s response. A custom program is
catheter. The patient is prepped and draped as for a posterior then downloaded to the VPU for the patient to use in conjunction
vitrectomy. A 360-degree conjunctival peritomy is performed, and with the video camera glasses. Once the patient begins to per-
the four rectus muscles are isolated. The encircling band of the ceive phosphenes (spots of light), they begin training to interpret
extraocular portion of the device is put in place behind the mus- and use this vision (Second Sight Medical Products, 2016).
cles in the manner of a scleral buckle. The electronic case and
implant coil are positioned in the supero-temporal quadrant and After programming, the patient begins intensive training with an
sutured to the sclera. Exacting measurements ensure the precise occupational therapist to develop the new skills needed to local-
placement of the coil, which is vital to ensuring optimal placement ize, track, and recognize objects. The patient is asked to wear
of the electrode array on the macula. A three-port vitrectomy is the device at home and to practice using it between clinic visits to
then performed. A 5.2-mm sclerotomy is made, through which the incorporate its use into activities of daily living. Each of our newly
cable with the array is inserted. The array is attached to the retina implanted patients is partnered with one of our “veteran” patients,
with a custom titanium retinal tack (included in device packag- who acts as a support person before and after device implanta-
ing). The sclerotomies are closed and a pericardial patch graft is tion. These more experienced partners are able to give valuable
placed over the area of suture tabs and cable insertion (Ghodasra, first-hand experience, offer advice and support, and serve as
2016). It is important that no cautery of any kind be used after valuable guides.
the implant is placed in the eye, as it may damage the delicate
electronics of the implant. Careful and complete closure of the Patient Challenges
conjunctiva is then performed. There are significant challenges to using the retinal prosthesis.
Patients must be motivated, sufficiently mobile, and able to
Periodic testing of the device is done during the procedure to understand and use technology. They need to have access to the
ensure that it is functioning: upon opening the device, after place- surgical center and rehabilitation services. It is important to have
ment of the external portion, after insertion, and at the end of the family members or friends available for emotional support, trans-
procedure. To test the device, a wireless transmitter is covered portation, and help with rehabilitation exercises. Well-developed
with a sterile probe cover and placed next to the implant. The

ASORN INSIGHT Spring 2017

eye wonder 21

interpersonal relationships with the rehabilitation team can 2017 EyeQ Webinar Series
facilitate the process by identifying potential barriers to successful
device usage and managing expectations. Sterilization

Outcomes Barbara Ann Harmer, MHA, BSN, RN
While outcomes vary, our patients commonly report visual experi- Tuesday, May 16
ences including being able to visualize children and pets, “seeing”
fireworks, and recognizing things like kitchen counters, door han- 4:30pm PT/7:30pm ET
dles, and dinnerware. Ultimately, many patients find that the most
rewarding use of the retinal prosthesis is not related to mobility. Zika Virus
Many report that recognizing the movements of family members
or pets is most emotionally significant. Perhaps the impact is best William May, MD
explained by one of our patients: “I can tell when people move. I Tuesday, July 11
can tell when my grandson runs through the house [breaks into a 4:30pm PT/7:30pm ET
chuckle]. He’s only two, and he’s fast! It’s a big, big improvement”
(Kellogg Eye Center, 2014). Age Related Wet and
Dry Macular Degeneration
Kari Magill, BSN, RN, CNOR, is Retina Service Lead in the OR at Kellogg Eye Center, Uni-
versity of Michigan, Ann Arbor, Michigan. She can be reached at [email protected]. Andrew N. Antoszyk, MD
Tuesday, October 3
The author would like to thank Drs. K. Thiran Jayasundera and David Zacks and the rest of
the Retinal Prosthesis Team at the Kellogg Eye Center for sharing their experiences, exper- 5:00pm PT/8:00pm ET
tise, and support and for their permission to use the photos reprinted in this article. Can't make the live webinar?
Register and watch the recording!
References Free for ASORN members!

Ahuja, A. K., Yeoh, J., Dorn, J. D., Caspi, A., Wuyyuru, V., McMahon, M. J., Nonmembers $45
. . . Dacruz, L. (2013). Factors affecting perceptual threshold in Argus II Visit the ASORN website for detailed
Retinal Prosthesis subjects. Visual Science Technology, 2(4),1. descriptions, course objectives and to register.

American Society of Ophthalmic Registered Nurses. (2015). Essentials www.asorn.org/educational_programs/webinars
of ophthalmic nursing, Book 3. San Francisco: American Society of
Ophthalmic Registered Nurses.

Food and Drug Aministration. (2013). FDA approves first retinal implant for
adults with rare genetic eye disease. FDA News Release. Retrieved from:
http://fda.gov/Newsroom/PressAnnouncements/ucm339824.htm

Ghodasra, D. H., Chen, A., Arevalo, J. F., Birch, D. G., Branham, K., Coley,
B., . . . Jayasundera, K. T. (2016). Worldwide Argus II implantation:
Recommendations to optimize patient outcomes. BMC Ophthalmology,
16, 52. doi:10.1186/s12886-016-0225-1

Hahm, B. J. (2008). Depression and the vision-related quality of life in
patients with retinitis pigmentosa. British Journal of Ophthalmology, 92,
650–654.

Hartong, D., Berson, E. L., Dryja, T. P. (2006). Retinitis pigmentosa. Lancet,
368(9549), 1795–1809.

Kellogg Eye Center. (2014). Medicine needs victors: Roger Pontz and the
Bionic Eye Team. Ann Arbor: University of Michigan. Retrieved from:
https://www.youtube.com/user/KelloggEyeCenter

Second Sight Medical Products. (2016). Argus II Retinal Prosthesis System
patient manual. Sylmar, CA: Second Sight Medical Products.

Schechtman, D. (2012) Nutritional one-two punch may slow retinitis
pigmentosa. Optometry Times, April 1 2012. Retreived from http://
optometrytimes.modernmedicine.com/optometrytimes/news/
modernmedicine/modern-medicine-now/nutritional-one-two-punch-may-
slow-retinitis-?

ASORN INSIGHT Spring 2017





24 Professional directions

An Integrative Literature Review of the Effectiveness
of Nurse-led Clinics in Ophthalmology

Continued from page 23

Figure 1. employing organization to work in an autono-
mous advanced role. The NP in each case
PRISMA Flow Diagram was described as holding a master’s degree
with postgraduate studies in pharmacology
Potentially relevant papers identified Duplicate papers excluded and extensive anterior segment training.
through database searching n = 10
n = 37 Scope of Practice
Papers excluded after examination of Our analysis made it clear that defining
Abstracts examined abstracts the scope of practice is central to defining
n = 27 n=7 the nurse’s role.. All the studies described
meticulous processes for developing the
Papers retrieved for full text examination Papers excluded after review of scope of practice, as well as protocols
n = 20 full paper and clinical pathways to underpin practice
n = 11 (Buchan et al., 2009; Johnson et al., 2003;
Papers included in the review Kirkwood, Coster, et al., 2006; Kirkwood,
n=9 Pesudovs, et al., 2006; Kirkwood et al.,
2005; Pedwell, 2005; Sandinha et al.,
The PRISMA flow diagram can be found in “Preferred Reporting Items for Systematic Reviews and Meta-analyses: The 2012; Slight et al., 2009; Varma et al.,
PRISMA Statement,” by Moher, D., Liberati, A., Tetzlaff, J., & Altman, D. G; the PRISMA Group, 2009, Annals of Internal 2013). These were developed with input
Medicine, 151(4), figure 1. from senior ophthalmologists and nurses.
Protocols for practice, once decided on,
than a nurse-led clinic (Burlew-Quartey, Additional education and training was were agreed to by all the consultants, thus
2008). described in six studies (Johnson, Griffiths, garnering support for the nurse-led clinics.
& Birch, 2003; Kirkwood et al., 2005; In two studies, protocols included written
Data Analysis Pedwell, 2005; Sandinha et al., 2012; protocols for administering and prescribing
Data analysis in an integrative review Slight et al., 2009; Varma, Lunt, Johnson, & specific ophthalmic medications for nurse-
involves coding, categorizing, and sum- Stanley, 2013). The type of training and the initiated treatments (Johnson et al., 2003;
marizing the data into an integrated educational content differed according to Kirkwood et al., 2005). In three studies with
conclusion (Whittemore & Knafl, 2005 cite the type of skills required and the nature of the same primary author (Kirkwood, Coster,
Cooper 1998). A thematic synthesis of the the clinic; however, some common exam- et al., 2006; Kirkwood, Pesudovs, et al.,
literature based on the process described ples were slit lamp examination, fundus 2006; Kirkwood et al., 2005), the nurse’s
by Thomas and Harden (2008) was fol- examination using the direct ophthalmo- scope of practice was further defined by
lowed in our review. This process involved scope, optic disc assessment, and anterior accreditation as an NP with the Nursing and
line-by-line coding of the findings, organiz- segment assessment. One study described Midwifery Board of Australia Thus the nurse
ing these findings into descriptive themes, the need for ongoing professional devel- in these studies was a registered nurse with
and developing analytical themes. opment and support and stated that this an advanced degree, authorized to practice
element had been largely forgotten during as an NP. In Australia, NPs are authorized to
Results the development of nurse-led programs provide high levels of clinically focused care
Four themes were identified: (1) education (Buchan et al., 2009). The remaining two in diverse contexts for people and commu-
and training, (2) scope of practice, (3) clini- studies (Kirkwood, Coster, & Essex, 2006; nities with varying levels of complex need.
cal supervision and competence, and (4) Kirkwood, Pesudos, Latimer, & Coster, The nurses running the nurse-led clinics in
evaluation of outcomes. 2006) were the only ones describing a the remaining studies (Buchan et al., 2009;
nurse-led clinic where the nurse was an NP. Johnson et al., 2003; Pedwell, 2005; Sand-
Education and Training In the context of these studies, an NP was inha et al., 2012; Slight et al., 2009; Varma
All nurses involved in the nurse-led clin- an ophthalmic-trained registered nurse with et al., 2013) were experienced ophthalmic
ics were ophthalmic-trained registered advanced clinical skills who was autho-
nurses with extensive clinical experience. rized by the national nursing board and the

ASORN INSIGHT Spring 2017

Professional directions 25

Table 2

Studies Included in the Review

Citation Setting/participants Research design/ Method Analysis
level of evidence

Johnson, Z. K., Griffiths, P. G., & Birch, Major hospital Retrospective Audit of diagnostic Experienced, trained ophthalmic nurses
M. K. (2003). Nurse prescribing in outpatient department study / Level 3 accuracy and treatment possess the skills and knowledge to
glaucoma. Eye, 17(1), 47–52. in the UK; 169 patients protocol prescribe first-line treatments for new
glaucoma patients.

Slight, C., Marsden, J., & Raynel, S. Large hospital in New Retrospective Audit of waiting list, Sharp decrease in waiting list numbers
(2009). The impact of a glaucoma Zealand; 300 patients study / Level 3 waiting times between and length of time waiting for specialist
nurse specialist role on glaucoma referral and first specialist assessment
waiting lists. Nursing Praxis in New over 10 months assessment
Zealand, 25(1), 38–47.

Kirkwood, B. J., Coster, D. J., & Outpatient clinic at a Prospective Audit of diagnostic 92% concordance between ONP and
Essex, R. W. (2006). Ophthalmic nurse major teaching hospital comparative accuracy and treatment ophthalmologist
practitioner led diabetic retinopathy in Australia; 95 patients study / Level 2 protocol
screening: Results of a 3-month trial. (189 eyes)
Eye, 20(2), 173–177.

Sandinha, T., Hebbar, G., Kenawy, N., Major hospital Patient related Descriptive statistics Nurse-led ocular oncology is feasible,
Hope-Stone, L., & Damato, B. (2012). outpatient department outcome measure with patients expressing high levels of
A nurse-led ocular oncology clinic in in the UK; 65 patients (PROM) and patient satisfaction.
Liverpool: Results of a 6-month trial. over a six-month period satisfaction survey
Eye, 26(7), 937–943.

Buchan, J. C., Ashiq, A., Kitson, N., Major hospital Retrospective audit Identification of No evidence of reattendance due to
Dixon, J., Cassels-Brown, A., & outpatient depart- reattendances misdiagnosis or suboptimal treatment
Bradbury, J. A. (2009). Nurse specialist ment in the UK; 1,831
treatment of eye emergencies: Five patients seen by eye
year follow up study of quality and service; 311 seen by
effectiveness. International Emergency the specialist
Nursing, 17(3), 149–154. ophthalmic nurses

Kirkwood, B. J., Pesudovs, K., Loh, Emergency eye clinic Prospective study Comparison of diagnosis ONP found to be effective and safe when
R. S., & Coster, D. J. (2005). in a major teaching and treatment plans operating within clearly defined scope
Implementation and evaluation of an hospital in Australia; between ONP and of practice.
ophthalmic nurse practitioner 259 patients ophthalmologist. Patients
emergency eye clinic. Clinical & first assessed by ONP and An ONP-led emergency clinic is feasible.
Experimental Ophthalmology, 33(6), then by the
593–597. ophthalmologist. Diagnosis
and treatment by the ONP
was masked.

Kirkwood, B. J., Pesudovs, K., Latimer, Outpatient clinic at a Descriptive study Concordance between NP Nurse-led cataract clinic can function
P., & Coster, D. J. (2006). The efficacy major teaching hospital and ophthalmologist safely and efficiently and lead to good
of a nurse-led preoperative cataract in Australia; 185 assessments; waiting visual and patient satisfaction outcomes;
assessment and postoperative care patients (221 eyes) over times for first clinic improves access for public patients.
clinic. American Journal of 18 months appointment and surgery;
Ophthalmology, 142(2), 368–369. visual acuity and degree
of visual disability; patient
satisfaction

Pedwell, K. An evaluation of the Major hospital Retrospective Evaluation of health care Nurse consultation found to be as
ophthalmic nurse practitioner in eye outpatient review of the case interventions model accurate as that of the doctors; was
examination of post-operative cataract department in the UK; notes comparing cost-effective and provided a high
patients 200 postoperative patient standard of documentation.
patients seen by three consultations of
ONPs and doctors ONPs with those of
doctors

Varma, D., Lunt, D., Johnson, P., & Major eye hospital Prospective audit Audit of all the Tasking specialist ophthalmic nurses
Stanley, S. (2013). A novel approach to in the UK; 1,400 intravitreal injection to administer intravitreal ranibizumab
expanding the role of nurses to deliver intravitreal ranibizumab procedures performed by injections provides a way of decreasing
intravitreal injections for patients with injections performed by specialist macular nurses. the increasing load on ophthalmologists
age-related macular degeneration. four specialist macular and facilitates advance practice roles.
International Journal of Ophthalmic nurses over five Quality, Innovation, Complications are comparable to those
Practice, 4(2), 68–74. consecutive months Productivity and Prevention of ophthalmologists.
program.

UK = United Kingdom; NP = nurse practitioner; ONP = ophthalmic nurse practitioner.

continued on the next page

ASORN INSIGHT Spring 2017

26 Professional directions

An Integrative Literature Review of the Effectiveness
of Nurse-led Clinics in Ophthalmology

Continued from page 25

nurses, although the papers did not ophthalmologists; rather, they provide The exception to this scarcity is the body of
specify whether they had completed an adjunct services that aim to shorten wait- evidence supporting the administration by
ophthalmic nursing program. ing lists and enable specialists to spend nurses of intravitreal injections (Li et al., 2015;
more time caring for patients with complex Michelotti et al., 2014). he nurses’ effective-
Clinical Supervision and needs. Consistent with the findings in this ness in this context may be due to the nature
Competence review, there is a wealth of evidence that of the task or the fact that while the nurses
Ophthalmologists provided clinical supervi- clearly demonstrates that nursing experts perform the injections, they do not diagnose
sion in all the nurse-led clinics. In addition, can provide essential care, leading to posi- or determine the treatment. Therefore, rather
nurses were supervised by ophthalmolo- tive health outcomes for patients (Moore et than a leading the clinic in the true sense (i.e.,
gists when they undertook the new role al., 2006; Schadewaldt & Schultz, 2011; assessment, diagnosis, and treatment), the
facilitating the nurse-led clinics. This Taylor et al., 2005). nurses work with the ophthalmologists as
supervision continued until the nurses was nurse injectors.
deemed competent by the ophthalmolo- Globally the number of nurse-led clinics is
gist and therefore, was able to run the increasing as health-care systems grapple Duffin et al. (2012) assert that establishing a
clinics independently (Buchan et al., 2009; with the growing demands of ageing popu- nurse-led clinic demands careful planning,
Johnson et al., 2003; Kirkwood, Coster, lations, increases in chronic disease, more ensuring the staff are adequately trained and
et al., 2006; Kirkwood, Pesudovs, et al., accessible health care, and new develop- determining how patient outcomes will be
2006; Kirkwood et al., 2005; Pedwell, ments in treatment and management (Ayre monitored. Hatchett (2005) concurs, adding
2005; Sandinha et al., 2012; Slight et al., & Bee, 2014; Chew & Yee, 2013; Loftus & that clear aims and objectives, strategies to
2009; Varma et al., 2013). Different strate- Weston, 2001; Mason, Freemantle, Gibson, overcome collegial resistance, and rigorous
gies were used to determine competence, & New, 2005; Wilson, Whitaker, & Whit- methods of audit and evaluation should be
including masked diagnosis and compari- ford, 2012). Similar challenges confront the incorporated into the plan. Likewise, several
son between nurse and ophthalmologist ophthalmic workforce (Ansah et al., 2015; papers in this review described the education
(Kirkwood, Pesudovs, et al., 2006), seeing Drury, 2014; Du Toit, Palagyi, & Brian, and training provided to the nurses, the strat-
patients in parallel with an ophthalmolo- 2010), and while it is known that nurse-led egies used to ensure competence, and the
gist (Johnson et al., 2003; Sandinha et clinics in ophthalmology are becoming patient outcomes that were measured (John-
al., 2012), and direct supervision by an more common, but only a few studies have son et al., 2003; Sandinha et al., 2012; Slight
ophthalmologist (Varma et al., 2013). evaluated them. Among these there are et al., 2009; Varma et al., 2013). Although
some encouraging conclusions. the planning process was not described
Evaluating Outcomes in the papers in this review, it was evident
Quality checks were built into the models For example, nurse-led preoperative cata- that sound planning was crucial to success.
and included retrospective audits of diag- ract clinics were first found to be effective This involved training the nurses, developing
nostic accuracy after three months (Buchan more than a decade ago (Rose, Water- protocols, and ensuring that quality control
et al., 2009; Johnson et al., 2003; Pedwell, man, Toon, McLeod, & Tullo, 1999). More systems were in place.
2005), alternating patients between the recently, Kirkwood, Pesudovs, Latimer,
nurse-led clinic and the ophthalmologist and Coster (2006) reported that a nurse- It is essential that ongoing, rigorous evalu-
(Sandinha et al., 2012), quality assurance led preoperative cataract clinic improved ation is included in the development of
evaluations (Kirkwood, Coster, et al., 2006; access for public patients and provided a nurse-led clinic, ensuring that services
Kirkwood, Pesudovs, et al., 2006; Kirk- safe and effective care with favorable are efficient and result in optimal patient
wood et al., 2005), and a prospective audit patient outcomes. Results from these two outcomes (Heale & Pilon, 2011; Strömberg
on identified outcomes (Varma et al., 2013). studies demonstrated a reduction in waiting et al., 2003). Consistent with the literature, all
time for clinic appointments and increased the papers included in this review described
Discussion patient satisfaction. Despite this, there is rigorous evaluation processes that focused
Nurse-led clinics are not meant to replace a paucity of evidence demonstrating the on patient outcomes.
the care and management provided by implementation of pre- and postoperative
cataract clinics globally.
ASORN INSIGHT Spring 2017





29

Samantha C. Ayoub, BA, and Meleha Ahmad, BS Quick as a Wink

Presbyopia: Clinical Update did you know?

Presbyopia, or “old vision,” is a condition still many unknowns regarding its mecha- (Nirmalan, Krishnaiah, Shamanna, Rao,
that occurs in most aging eyes and has nism. A better understanding of presby- & Thomas, 2006; Patel & West, 2007).
been described since ancient times. The opia is an important area of scientific and Undercorrection of presbyopia in the devel-
earliest experiment known to contribute clinical attention, as the condition is highly oping world is likely to account for its higher
to our understanding of presbyopia took prevalent and impacts quality of life and recorded prevalence in these regions.
place in 1619, when scientist Christo- productivity in the aging population. This
pher Scheiner designed the double pupil review aims to provide an overview of the Risk Factors
apparatus (a card with two pinholes) to state of knowledge about presbyopia, Age is the greatest risk factor for presby-
describe the process of accommoda- including epidemiology, pathophysiology, opia, with the highest incidence in people
tion, or change in the refractive power standards of clinical diagnosis and treat- aged 42 to 44 years. The age of onset
of the eye (Grosvenor, 2007). Subjects ment, new treatments in development, relies heavily on three factors: focusing abil-
monocularly looked at an object through and the role of the clinical team. ity, habitual reading distance, and depth of
the two pinholes. When the object was focus (Hickenbotham, Roorda, Steinmaus,
moved closer to or further from the eye, Epidemiology & Glasser, 2012). Other major factors
it appeared as a double image; the eye affecting age of onset include occupation,
then refocused and the object appeared Global Prevalence baseline refractive error and other ocular
again as a single image. This provided Presbyopia is an age-related condition refractive aberrations, pupil size, and opti-
evidence that the eye’s accommodative that results in diminished near vision and cal lens density. Minor factors affecting age
mechanism allows a change in refractive can cause significant decrease in quality of onset in presbyopia include sex, extent
power, thereby allowing us to view objects of life when left untreated. Nearly 1.272 of solar radiation, complexity of near tasks,
at different distances (Grosvenor, 2007). billion people are estimated to have the indoor light levels, and rural residence
In 1801, Thomas Young designed his own disease worldwide, and by 2050, 1.782 (Hickenbotham et al., 2012). Women have
optometer, similar in design to Scheiner’s, billion people are expected to be diag- been found to have higher prevalence and
and provided evidence that accommoda- nosed with presbyopia (Frick, Joy, Wilson, more severe presbyopia than men, for
tion is due to a change in the crystalline Naidoo, & Holden, 2015). According to the unknown reasons.
lens (Atchison & Charman, 2010). He and U.S. Department of Commerce, Bureau
his scientific predecessors tied together of the Census (2010), an estimated Economic Impact and Quality
evidence that the loss of accommodation 122 million Americans had presbyopia of Life
was associated with changes in the aging in 2010, using age over 45 as a sur- Untreated and undertreated presbyopia
lens. Young wrote, “It has been observed rogate. Although presbyopia seems to has an impact at both the macro and micro
that the central part of the crystalline [lens] be a widespread problem, less is known levels. In Europe, approximately 96% of
becomes rigid by age, and this is sufficient about the prevalence of the disease in less presbyopia is corrected, in contrast to
to account for presbyopia” (Atchison & developed countries. A study in Tanzania approximately 6% in Africa (Frick et al.,
Charman, 2010). found 62% prevalence of presbyopia in 2015). A recent study estimated a potential
people over 40 years of age (Patel & West, 0.016% loss of world gross domestic
Since these foundational experiments, 2007). Another study, focusing on rural product (GDP) due to uncorrected and
advancements have been made in our India, found 55% prevalence of presby-
understanding of presbyopia, but there are opia in people 30 years of age and older continued on the next page

ASORN INSIGHT Spring 2017

30 quick as a wink

Presbyopia: Clinical Update

Continued from page 29

An efficient replacement for the undercorrected presbyopia among people eye, accommodation allows for near vision
traditional syringe method of less than 50 years of age. by increasing the power of the lens. The
rinsing Phaco and I/A hand pieces, maximum change in lens power between a
cannulas, vit cutters, and tubing. In addition to GDP loss, quality of life is distant and a near object is termed “accom-
• Provides consistent rinsing also significantly affected in patients with modative amplitude.” Human lens amplitude
presbyopia. A study completed in seven of accommodation decreases with age,
pressure and volume European countries found that 80% of with the greatest changes in amplitude of
regardless of the operator. people over 40 years old had difficulty accommodation occurring between the
• Eliminates ergonomic issues reading important text on medical and ages of 20 and 50 years (Hamasaki, Ong, &
associated with repetitive food labels, and 60% of patients struggled Marg, 1956) (see Figure 1). Although it was
syringe use. in using a mobile phone. Interestingly, only once thought that declining ciliary muscle
• Frees up your hands to perform one-third of people surveyed had heard function leads to decreases in amplitude
other tasks, greatly improving of the term “presbyopia,” and only 59% of of accommodation, there is mounting evi-
the speed and efficiency of the patients were familiar with symptoms dence that ciliary muscle contraction is rela-
your reprocessing department. of the condition (Morgan, n.d.). tively maintained as humans age (Tabernero,
Chirre, Hervella, Prieto, & Artal, 2016).
Call AOI for Information Another study used the National Eye
800.576.1266 or Institute Refractive Error Quality of Life Theories
949.580.1266 Instrument to investigate visual quality of Two main theories, from Schachar and
life in patients with presbyopia. The survey Hemholtz, provide alternative models for
9 Orchard, Suite 111 measured many categories of visual presbyopia in the absence of ciliary muscle
Lake Forest, CA 92630 quality of life and compared four groups: dysfunction.
www.optisurgical.com subjects 45 years old or older with mono-
[email protected] vision correction; subjects 45 years old Schachar’s theory. Schachar proposed
or older with symmetrical correction with that it is a change in lens geometry, rather
ASORN INSIGHT Spring 2017 eye glasses, contact lenses, or surgery; than lens stiffening, that drives presbyopia.
subjects younger than 45 years old with The theory suggests that anterior and pos-
emmetropia; and subjects over 45 years terior zonule fibers attach to different regions
old with emmetropia. Visual quality of life of the ciliary muscle than do the equatorial
was significantly worse in patients over
45 years old than in patients less than 45 a. Distance vision in a
years old for nearly all categories, and this normal eye
difference was present even with visual
correction (McDonnell, Lee, Spritzer, Lind- b. Near vision with
blad, & Hays, 2003). This finding indicates accommodation of the
that presbyopia significantly affects quality lens in a normal eye
of life and that there is room for improve-
ment in currently available treatment
options.

Pathophysiology

Accommodation c. Near vision in presbiop-
Presbyopia is caused primarily by loss of ic eye – lens is unable
the accommodative power of the lens. For to accommodate and
this reason, a thorough understanding of image is not focused
the process of accommodation is essential on the retina
in understanding presbyopia. In a healthy
Figure 1. Accommodation in a normal and presbi-

opic eye

quick as a wink 31

zonule fibers (AAO, 2016). The process of by a factor of 20 (Heys, Cram, & Truscott, REPAIRPHACO HANDPIECE
accommodation causes the ciliary body to 2004).
contract and increases tension on equato- • Most Major Brands
rial zonule fibers while decreasing tension Researchers have yet to elucidate the cel- • Fast Turnaround
on anterior and posterior zonular fibers. lular processes that cause lens stiffening • Warranty Options
The resulting force distribution causes an proposed by Helmholtz, but a number of • Free Evaluation
increase in the equatorial diameter of the mechanisms have been suggested. The
lens, with a decrease in peripheral volume lens nucleus may stiffen as the mass of Advanced Optisurgical Inc. has over
and an increase in central lens volume the lens is pushed into the nuclear region 20 years of combined experience
(Schachar et al., 1996). The increase in with age (Petrash, 2013). Alternatively, repairing Phaco handpieces.
central volume increases the overall power metabolic changes in the aging lens
of the lens in the healthy eye. could contribute to its stiffening. Recent All repairs are performed
evidence suggests that the aging lens may at our facility in Lake Forest,
In presbyopia, Schachar proposed, there develop a diffusion barrier that decreases California USA.
is an increase in the equatorial diameter accessibility to glutathione, which normally
and volume of the aging lens, causing maintains a low level of disulfide linkages COMPLETE HANDPIECE REBUILD
zonule fibers to slacken. However, experi- between proteins and structural elements INCLUDES:
ments since this theory was proposed of the lens. A decrease in glutathione • New Ultrasonic Motor
have shown that the equatorial diameter of may increase the number of disulfide • New Connector
the lens is consistently decreased during bridges, resulting in decreased diffusion • New Cable and Strain Reliefs
accommodation and increased during of cytoplasmic protein complexes in lens WE BUY USED PHACO HANDPIECES
non-accommodation, providing evidence cells and loss of cellular pliability (Petrash, (working or not)
against Schachar’s theory (Wilson, 1997). 2013). WE SELL REFURBISHED PHACO
HANDPIECES (call for current
Hemholtz’s theory. The other major Standards of Clinical Diagnosis inventory)
theory of accommodation, suggested by and Treatment
Hemholtz in 1855, proposes that con- Call AOI for Information
traction of the ciliary muscles leads to Diagnosis 800.576.1266 or
relaxation of the zonular fibers surrounding Patients with presbyopia may report blurry 949.580.1266
the lens, which results in rounding of the vision, difficulties switching focus from
lens in accommodation (Fisher, 1973). The near to distance tasks, eye fatigue, prob- 9 Orchard, Suite 111
resulting increased curvature of the lens lems with reading, and headaches when Lake Forest, CA 92630
increases its optical power and allows the doing work close to their eyes. In general, www.optisurgical.com
eye to focus on near objects. a comprehensive eye exam is recom- [email protected]
mended in patients who present with
Helmholtz’s theory, currently the lead- suspected presbyopia to rule out other ASORN INSIGHT Spring 2017
ing theory on presbyopia, suggests that causes for symptoms (Mancil et al., 2010).
the lens itself stiffens with age, resulting Thus, diagnosis of presbyopia begins with
in decreased amplitude of accommoda- a thorough patient history, including the
tion (Fisher, 1973). Lenticular factors patient’s vocational and avocational visual
that decrease the amplitude of accom- requirements and any recent changes in
modation are a decrease in the elasticity visual demands that may have brought
modulus of the capsule, an increase in the a change in near vision to the patient’s
elasticity modulus of the lens substance, attention (Mancil et al., 2010). General
and a flattening of the lens (Fisher, 1973). health and ocular history should be
It has been shown that stiffening occurs collected. Patients with systemic condi-
most dramatically in the nucleus of the tions, notably diabetes mellitus, have
lens, with a research team showing that been shown to have lower amplitudes
the nucleus stiffened by a factor of 450 in of accommodation at earlier ages and
participants between the ages of 20 and
60, while the cortex of the lens stiffened continued on the next page

32 quick as a wink

Presbyopia: Clinical Update

Continued from page 31

therefore may present with presbyopia a. Correction of presbyopia with a convex lens. The
earlier than nondiabetic patients (Kawa- near image light rays are now focused on the retina
saki, 2005). It is also important to note that
myopic patients often have different expe-
riences with presbyopia than hyperopic
and emmetropic patients. Myopic patients
tend to experience presbyopia at a later
age, while hyperopic patients have an
earlier onset with more marked presbyopia
symptoms (Mancil et al., 2010).

A full visual assessment is beneficial when b. Bifocal, trifocal and progressive lens designs (left to right)
a patient presents at the appropriate age Figure 2. Correction of presbyopia with spectacles
with symptoms of presbyopia. Clinical
visual acuity is a measurement of the correction. Bifocal lenses incorporate “Monovision” is a term used to describe
ability to recognize black, high-contrast distance and near vision prescriptions into correction of one eye for near vision and the
optotypes on a white background. Visual a single lens: the largest part of the lens, other eye for distance vision (if required); it
acuity for both near and distance is use- at the top, is typically used for distance can be achieved using contact lenses or
ful in evaluating the patient’s ability to vision, and near vision correction is gener- intraocular lens (IOLs) replacement surgery,
complete near tasks (Mancil et al., 2010). ally confined to a smaller portion at the which will be described below. Complica-
Refraction, assessed with a phoropter, is bottom of the lens. Trifocal lenses take into tions of this approach include decreased
another essential component of presby- account distance, intermediate, and near contrast sensitivity and stereopsis. The
opia diagnosis and management. Optical lens prescriptions. These spectacles can reported success rates for monovision con-
correction for presbyopia is the sum of mostly assist patients with advanced pres- tact lenses range from 60% to 80% (Mancil
correction for distance plus the power of byopia, as they correct for vision needed et al., 2010). Bifocal contact lenses come in
the near addition (Mancil et al., 2010). for both intermediate-range and near tasks alternating and simultaneous designs. Alter-
(Mancil et al., 2010). Progressive addition nating bifocal contact lenses are similar to
Treatment lenses (PALs), another treatment option for bifocal spectacles, with near and far lenses
Treatment of presbyopia ranges from non- patients requiring both near and distance placed on top of each other. Simultaneous
surgical approaches, such as spectacle vision correction, are preferred by many contact lenses allow the patient to look both
correction and contact lens use, to surgi- patients over bifocal or multifocal lenses, near and far at the same time, and they can
cal procedures of varying invasiveness. primarily for cosmetic reasons. PALs be either concentric or aspheric (Mancil et
Treatment must be made on a patient- connect the distance and near portions of al., 2010).
by-patient basis, with risks and benefits the lens through a corridor of progressive
explained to the patient prior to decision changing power (see Figure 2). New Treatments in Development
making.
Contact lenses. Patients may pre- Pharmacological Treatment
Spectacles. Single vision lenses may be fer contact lenses over spectacles for Pharmacological treatments for presbyopia
prescribed when the patient only needs management of presbyopia. Thorough slit- are currently under investigation. One pilot
near vision correction. These spectacles lamp evaluation of ocular pathology can study tested ophthalmic eye drops, called
are typically effective for patients with help determine whether contact lenses are Verajano drops, in 14 patients (28 eyes).
emmetropia or a low degree of ametropia. suitable for the patient. In many cases, the The drops contain a parasympathetic
Although single vision spectacles provide extent of the patient’s refractive error can agent, a nonsteroidal anti-inflammatory
a whole field of view for near vision, they limit the options for contact lenses. drug (NSAID), two alpha agonists, and an
can blur distance vision. Multifocal lenses anticholinesterase agent (Renna, Vejarano,
can be prescribed for patients who desire
simultaneous near and distance vision

ASORN INSIGHT Spring 2017



34 quick as a wink

Presbyopia: Clinical Update

Continued from page 33

Extraocular approaches: Corneal. typically in the nondominant eye (Waring & thus restoring accommodative amplitude.
Klyce, 2011). CIs act by various mecha- However, scleral relaxing incisions are no
See Table 1 for a description of each nisms to achieve pseudo-accommodation, longer being used due to their risk of ante-
approach. including changing the cornea’s index of rior segment ischemia and scleral perfora-
refraction, changing the curvature, and tions, and a gradual return of scleral shape
Laser in situ keratomileusis (LASIK)-based through small-aperture optics. All CIs are during healing (Torricelli et al., 2012).
monovison can be particularly useful surgically removable and can be repo-
for patients who have presbyopia and sitioned and easily combined with other Newer scleral approaches are undergo-
myopia, as they commonly complain of refractive procedures. Many are performed ing testing via clinical trials. The first such
difficulties with near vision following LASIK in the nondominant eye only, in a monovi- technology to be developed is Presview
(Torricelli et al., 2012). Success rates sion fashion (see Figure 3). In contrast to Scleral Implants (Refocus), which consists
for LASIK-based monovison have been monovision LASIK, there is no significant of clear plastic polymethyl methacrylate
reported as approximately 80%–98% (Gil- decrease in distance vision in eyes with a band implants, placed underneath the
Cazorla et al., 2016). Negatives include corneal inlay, allowing for good binocular surface of the sclera in all four quadrants.
the risks of LASIK, such as flap complica- function, including depth perception. These bands lift the sclera and ciliary mus-
tions, diffuse lamellar keratitis, corneal cle away from the lens, serving to increase
ectasia, and dry eye, as well as loss of Extraocular approaches: Scleral. the space between the lens and the ciliary
contrast sensitivity and difficulty with activi- muscle and increase zonular tension. This
ties including extreme depth perception Schachar hypothesized that the primary procedure has been done in over 300
and stereopsis (Torricelli et al., 2012). A cause for presbyopia is a gradual increase patients, and of those who have been fol-
trial with monovision CLs prior to perform- in the diameter of the lens, decreasing lowed for 24 months, 89% rated their near
ing LASIK is typically recommended to the effective force that the ciliary muscle vision as better to significantly better than
ensure the patient tolerates monovision can apply to the lens equator through the preoperative vision. However, there is no
sufficiently prior to surgery. slackened zonule fibers. This theory is evidence of increased / improved ampli-
the basis for the concept of using scleral tude postoperatively, precluding objective
Presbyond Laser Blended Vision (also expansion surgery to treat presbyopia evidence of improvement. Distance vision
known as mini-monovision) is an alterna- (Greenwood et al., 2016). Research has does not appear to be affected (Davidson
tive approach to monovison LASIK that shown that although the ciliary muscle et al., 2016).
involves aiming for plane 0 in the distance can still contract with age, it may not
eye and −1.00 to −1.25 in the near eye to be able to move forward and backward Intraocular approaches: Lens-based.
achieve a slightly myopic refractive error. as efficiently (Croft et al., 2013). Scleral
This technique has the advantages of bet- approaches to presbyopia correction See Table 2 for a description of each
ter preservation of stereopsis and distance attempt to alter the scleral and ciliary approach.
vision in the “near” eye (Davidson et al., body anatomy to correct these age-
2016). related changes. Past attempts involved Role of the Clinical Team
scleral relaxing incisions. It was theorized The impact of presbyopia can alter a
Corneal inlays (CIs) consist of synthetic that this allowed for increased tension to patient’s quality of life, productivity, and
intrastromal implants placed either develop during ciliary muscle contraction, self-image. The ophthalmologic team
underneath a LASIK flap or into a corneal plays a key role in collecting pertinent
pocket produced by femtosecond laser, information for diagnosis and gauging
individual patient visual needs. In addition,
A. B. proper education about the condition and
treatment options can help patients feel
Figure 3. A. Corneal inlay design: a neutral central aperature surrounded by positive refractive material or ma- empowered in managing and treating this
terial with thousands of microperforations. B. Corneal inlays focus light from near objects through increasing natural part of the aging process. Through
the refractive power of the paracentral corneal or filtering out unfocused light. education, the nursing staff plays a vital
role in managing patient expectations of
ASORN INSIGHT Spring 2017 different treatment options. Distribution of

quick as a wink 35

written educational materials or directing Surgical Table 2
patients to reputable websites can further approach
enhance knowledge and understanding. Pseudophakic Intraocular Surgical Treatment
The ophthalmologic team can also have a multifocal
significant impact on the care of pres- intraocular Description
byopic patients by showing empathy, as lenses (MIOLs)
patients can struggle with accepting the • Operate similarly to multifocal contact lenses but have the advantage of increased
aging process and may resist treatment. Lens softening mechanical stability and different plane correction as compared to contact lenses

Conclusion • Operate by the principle of diffraction by using steps across the surface of the lens
Presbyopia is a natural part of the aging to allow for diffraction of light for multiple focal planes
process that has yet to be thoroughly
understood by the medical and scientific • Bifocal MIOLs are designed with concentric zones that focus light at two different
community. Routine screening, diagnosis, distances for near and far, whereas trifocal MIOLs add an additional intermediate
and treatment of presbyopia in patients zone (Braga-Mele et al., 2014).
over 40 years old can lead to improved
quality of life and productivity. There are • S creen for irregular astigmatism, corneal dystrophies, and macular and optic nerve
advantages and disadvantages to each abnormalities due to the high risk of decreased contrast sensitivity.
of the treatment options in presbyopia.
Patients and the ophthalmic team can • Preoperative planning should include accurate measurement of both anterior cor-
work together to choose the best option. neal curvature by traditional manual keratometry and posterior corneal curvature
The ophthalmic team plays an essential using modern techniques.
role in managing patient expectations
regarding treatment and supporting • Patients should be properly educated on the risks, including vision limitations at
patients who struggle with aging and certain distances or in certain lightings, glares, and halos.
presbyopia.
• Research showed that multifocal lenses accounted for approximately 23% of
Samantha Ayoub, BA, is a medical student at New York all explanted IOLs, with the leading reason being glare and optical aberrations
University School of Medicine and can be reached at (Mamalis, Brubaker, Davis, Espandar, & Werner, 2008).
[email protected].
Meleha Ahmad, BS, is a medical student at New York Uni- • Anterior chamber “phakic” MIOLs provide good effectiveness but carry many
versity School of Medicine and can be reached at meleha. risks, including endophthalmitis and corneal endothelial cell loss (Baikoff, Matach,
[email protected]. Fontaine, Ferraz, & Spera, 2004).

References • A ttempts to soften the lens using pharmaceutical agents that have been largely
unsuccessful
Ackermann, R., Kunert, K. S., Kammel, R.,
Bischoff, S., Buhren, S. C., Schubert, H., . . . • Mechanical alterations carried out using femtosecond laser, which allows the lens
Nolte, S. (2011). Femtosecond laser treatment to be cut without breaking the capsule, have shown promising results, but this
of the crystalline lens: A 1-year study of technique has yet to be studied on humans in the United States (Ackermann et al.,
possible cataractogenesis in minipigs. Graefe’s 2011; Schumacher et al., 2009).
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Frick, K. D., Joy, S. M., Wilson, D. A., Naidoo, K.
S., & Holden, B. A. (2015). The global burden ASORN INSIGHT Spring 2017