The Ophthalmic Study Guide

https://www.evidence.nhs.uk

Chapter 1

Information for students and mentors

This book is designed to guide your learning in the clinical environment. It encourages use of the internet so that you can watch animated models of how conditions develop and are treated, and see films of surgical procedures. This chapter explains how the book may be used in the clinical setting, and how a personal portfolio could be used by mentor, student and manager as evidence of personal development for the NHS Knowledge and Skills Framework (KSF 2013), and Ophthalmic nursing: An integrated career and competence framework (RCN 2012).

All NHS employees should be in possession of a KSF outline of their post and what is expected of them, together with a related job description. This is designed to guide both employee and employer when the time comes for an annual review. It gives the employer the opportunity to check the individual staff member’s learning and development and how they are applying their increased learning to their job. This will be related to a mutually agreed further plan for the next 12 months.

It is important that all professional groups working in ophthalmology build on their theoretical and practical knowledge year on year, using the KSF. This helps to progress competence and enjoyment of work within clinical practice. The knowledge and skills obtained will provide a useful foundation for subsequent academic study and development of specialist practice for all groups within ophthalmology.

Change, with the requirement to help more patients every year (using equipment that is continually evolving), demands new methods of learning and working and is acknowledged to be the greatest challenge of the 21st century. Knowledge used to double every century but the speed of growth is now exponential. For instance, in 2009, human knowledge was thought to be doubling every five years. David Russell Schilling, writing in April 2013, stated that human knowledge was doubling every 12 months, and predicted that it would soon be doubling every 12 hours (Russell Schilling 2013). Of course, these are only estimated averages. Nanotechnology is also doubling quickly, and clinical knowledge is now doubling every 18 months. These statistics do not refer to the knowledge stored in our human brains but to the knowledge that is mostly accessible on the internet, as the worldwide web continues to grow.

Lifelong learning

Whether you are a registered nurse, a healthcare assistant or a member of another healthcare profession, a lifelong approach to learning is increasingly necessary, due to the speed of change in knowledge and technical development. To work well, lifelong learning needs to exist primarily as part of your attitude or approach to life in general. Secondly, it needs to be adopted within working teams, where questions are welcomed and information and skills are readily shared. Finally, lifelong learning requires ‘top down’ support from the employer, including availability of textbooks and access to the internet in the clinical setting, a good annual appraisal system with six-monthly ‘follow-ups’ on progress towards objectives, and realistic training and educational plans for staff.

The NMC is clearly aiming to strengthen public confidence in the wake of healthcare scandals. Nurses will be required to record and submit:

•450 practice hours or 900 if revalidating as both a nurse and midwife

•35 hours continuous professional development (CPD), including 20 hours participatory learning

•Five pieces of practice-related feedback

•Five written reflective accounts

•Reflective discussion

•Health and character declaration

•Professional indemnity arrangements

•Confirmation.

Revalidation is expected to encourage a culture of sharing, reflection and improvement among nurses and midwives, and will be a continuous process to engage with throughout their careers. It will allow them to demonstrate safe effective practice, strengthening public confidence in the nursing and midwifery professions.

Developing and maintaining a personal portfolio, including robust reflection on and in practice, is now fundamental for all registered nurses’ revalidation. Engaging with this Ophthalmic Study Guide, by documenting reflections on your growing knowledge, skills and competence within ophthalmic care, will help you provide evidence for revalidation (NMC 2015).

Keeping up to date

Methods of keeping up to date suggested by the RCN include:

•Higher education

•Conferences

•Web seminars and online-learning modules

•Personal reading, being mentored and mentoring

•Use of their medical and nursing websites.

The National Health Service Knowledge and Skills Framework (KSF)

The NHS KSF is a generic approach used across all the healthcare disciplines to help employers to identify the core skills needed for specific jobs. This is helpful when advertising vacancies and identifying potentially useful candidates for interview. The six dimensions of the KSF are: communication; personal and people development; health, safety and security; service improvement; quality; and equality and diversity.

If each employee is given a ‘tailored’ KSF job description, identifying the core skills they need to do their job, then annual appraisals should be specific, fair and efficient. Staff will also be aware of the areas they need to work on in order to keep up to date with skills and new developments, both in their immediate sphere of practice and in wider areas within their profession.

Getting yourself organised to learn about the eye

You will need:

A mentor: This person should be an experienced professional, preferably with an ophthalmic qualification. Choose someone you like, who is respected for their excellent clinical practice. If you are a nurse, your mentor should have completed a recognised ophthalmic nursing course and be academically competent in ophthalmic theory and practice as applied to nursing.

Two folders: These folders can be on paper or online, but do keep back-up copies.

1.The first folder is a professional portfolio in which you will store ‘summary’ information to show how you are meeting the main headings of your Knowledge and Skills (KSF) job description. The RCN Ophthalmic Competencies (2012) or AHPO Occupational Standards (undated) can help you to demonstrate that you are meeting your job description by developing your ophthalmic competency. You should show this folder to your assessor at your annual appraisal. The NMC website (Revalidation) offers Guidance sheets and Reflective Accounts/Discussion Forms, which may help to focus your efforts and provide evidence of your continued learning and performance.

2.The second is a personal folder for you to store your personal notes on the tasks you have been set as you work through this book. This will enable you to look over what you have achieved, and discuss your progress with your mentor. Bearing in mind that we all work in very busy, fast-paced, highly technology-dependent settings, we need to choose our moments for questioning and discussion. A small pocket notebook may therefore be useful to note key words and ideas for later study, discussion and reflective practice.

Access to the internet: If you do not have internet access at home, it may be possible to check some facts on a computer at work. Hospitals have good libraries, and you may be able to book an appointment with the librarian if you need specific help. Notes regarding particularly useful websites are provided throughout this study guide.

Access to NHS Evidence Health Information Resources: This can be accessed via the National Institute for Health and Care Excellence (NICE) website: https://www.evidence.nhs.uk

It enables you to search for evidence on any medical topic. It also gives you access to journals, databases, e-books and specialist evidence.

Competence

The aim of this study guide is professional competence. The UK vocational movement places emphasis on competence to do the job – not on the person – and on minimum standards to do the job, rather than superior performance. In terms of nursing competence, this approach also emphasises workplace performance more than underpinning knowledge. The approach taken by Roach (1992) seems preferable. This suggests that competence is the state of having the knowledge, judgement, skills, energy, experience and motivation required to respond adequately to the demands of one’s professional responsibilities. However, competence is the basic acceptable level of care. Ophthalmic professionals should reach higher skill levels that combine clinical skills with critical thinking.

Clearly, nursing practice requires an evidential base. Sackett et al. (1996) offer a medical definition of an evidence-based approach to practice, which is increasingly applicable to ophthalmic professionals. They see this approach as the conscientious, explicit and judicious use of current best evidence when making decisions about the care of individual patients. It involves integrating individual clinical expertise with the best available external clinical evidence from systematic research. They define clinical expertise as the professional judgements that individual clinicians acquire through clinical experience and clinical practice.

Bearing this in mind, together with your mentor, you must seek to achieve the higher levels of Bloom’s taxonomy (Bloom et al.) in terms of your cognitive, affective and psychomotor development within ophthalmology (a taxonomy is a technical term for a list that systematically classifies, ranks or prioritises concepts). Check this out on the internet. As you are beginning to see, learning begins at the basic level of just knowing about something and, in the committed individual, may progress as far as redesigning the manner in which an ophthalmic service is managed (for example, in terms of better patient outcomes, motivated staff, increased efficiency or better use of resources). This is all about developing the HOTS for ophthalmology – otherwise known as Higher Order Thinking Skills!

Staying up to date

When you have finished working through this study guide, keep your eyes open for other ophthalmic textbooks. You should aim to purchase one new book per year. Ophthalmic books are expensive, but you may be able to find used copies of relatively recent publications via the internet. This will help you build on your understanding of more complex conditions, and keep your knowledge up to date. After work, it is useful to spend 10 minutes at home looking up anything you did not understand. If you then decide to study a university ophthalmic unit, you will be well prepared, in terms of having good basic knowledge and some of your own study materials.

The National Health Service Knowledge and Skills Framework

The KSF is the key to the pay system of the NHS.

Prepare for your annual KSF appraisal by collecting material about your learning and clinical practice in your professional portfolio between one appraisal and the next.

•You can progress at your own rate.

•It can be specific to ophthalmology.

•It can help to meet the NMC’s revalidation requirements.

Suggestions for preparing your professional portfolio for revalidation

Your folder, whether digital (remember to back it up!) or written, will contain divisions. This portfolio will differ from previous portfolios because it must contain up-to-date evidence (which should never be more than 1–3 years old). Work on producing your evidence for assessment and place it in your professional portfolio in the following sections:

Section 1: Write a very short but current summary CV, about a page long. Date and sign it to show that it is current.

Section 2: Make a truthful self-appraisal of your personal strengths, weaknesses, opportunities and threats (SWOT). Then date it and sign it. This will probably give you some insight into areas of your nursing practice that you need to develop or modify. Include a copy of your most recent appraisal report here.

Section 3: Make a personal action plan for the year to come, taking into account what you found out about yourself by doing the SWOT self-appraisal. Date it and sign it. If you are a nurse, your action plan must include working through the NMC’s (2015) revalidation requirements. Look at the NMC resources first.

Use the RCN’s Ophthalmic Competencies to help you with the revalidation evidence (and possibly RCNi) and work online.

Section 4: This is where you will keep your Agenda for Change job description so that it is readily available for reference.

Section 5: Keep a copy of NMC’s (2015) revalidation requirements handy.

Section 6: Print out an overview of the NHS Knowledge and Skills Framework for reference.

You can use other numbered sections of your professional portfolio to demonstrate that you are meeting the core requirements of the NHS Knowledge and Skills Framework (KSF). Your job description will show you what other sub-dimensions you need to meet. You will probably find that they will all fit in with the ‘six dimensions’ of the KSF listed below:

•Communication

•Personal and people development

•Health, safety and security

•Service improvement

•Quality

•Equality and diversity.

If you are a nurse, you will need to work primarily on your NMC requirements and link the evidence to the KSF requirements. Your evidence of personal development will be a mixture of short reflective studies, witness statements and signed evidence of skills development.

References and further reading

Bloom, B. Taxonomy of Learning

Businessballs website. http://www.businessballs.com/bloomstaxonomyoflearningdomains.htm

(accessed 14 February 2016).

NHS Evidence Health Information Resources http://www.evidence.nhs.uk/ (accessed 14 February 2016).

NHS Knowledge and Skills Framework www.nhsemployers.org/simplifiedKSF (accessed 14 February 2016).

Nursing and Midwifery Council Revalidation 2015

http://www.nmc.org.uk/standards/revalidation/ (accessed 14 February 2016).

Nursing and Midwifery Council (2011). Standards to support learning and assessment in practice. 2nd edn.

https://www.nmc.org.uk/standards/additional-standards/standards-to-support-learning-and-assessment-in-practice/ (accessed 14 February 2016).

Roach, M. (1992). The Human Act of Caring: A Blueprint for the Health Professions. Ottawa: Canadian Hospitals Association Press.

Royal College of Nursing (RCN) (2012). Ophthalmic nursing: An integrated career and competence framework.

http://www.rcn.org (Use the keyword search to find the competencies) (accessed 14 February 2016).

Royal College of Nursing (RCN) (2013). Knowledge and Skills Framework (KSF). (Reviewed 2013).

http://www.rcn.org (Use the keyword search)

RCNi.com. RCNi Portfolio: Revalidation made simple.

http://rcni.com (Subscription site.) (accessed 1 August 2015).

Russell Schilling, D. (2013). Knowledge doubling every 12 months, soon to be every 12 hours. Industry tap into news.

http://www.industrytap.com/knowledge-doubling-every-12-months-soon-to-be-every-12-hours/3950 (accessed 14 February 2016).

Sackett, D. Rosenberg, W. Muir Gray, J. Haynes, R. & Richardson, W. (1996). Evidence based medicine: What it is and what it isn’t. British Medical Journal. 312, 71–72.

Useful web resources

Academy of Healthcare Science (AHCS)

http://www.ahcs.ac.uk/ (accessed 14 February 2016).

Association of Health Professions in Ophthalmology (AHPO)

http://www.ahpo.net/careers.html (accessed 14 February 2016).

Association for Perioperative Practice (formerly NATN)

http://www.afpp.org.uk (accessed 14 February 2016).

British and Irish Orthoptic Society (BIOS)

http://www.orthoptics.org.uk/ (accessed 14 February 2016).

International Ophthalmic Nurses Association (IONA)

http://www.iona-online.org/ (accessed 14 February 2016).

Nursing and Midwifery Council

http://www.nmc.org.uk (accessed 14 February 2016).

Chapter 2

Basic anatomy and physiology of the eye

Basic knowledge of anatomy and physiology of the eye is essential if we are to identify and use the correct names for the various structures and understand eye disorders. Ophthalmic professionals need to have a grasp of the correct vocabulary to create accurate documentation and make precise verbal communications. Always look up everything that crops up in practice. Learning will become a habit that makes clinical work interesting – not a chore.

The eye as a whole

Figure 2.1 The eye

You need to memorise all the basic diagrams in this chapter. Some people find that drawing the diagram on a page of their personal folder helps them learn its main features and remember the position and name of each structure. When examining the eye, it is normal to start from the outside and work inwards, so this is the most logical way to study the anatomy (see Figure 2.1).

The bony orbit is commonly described as being pyramid shaped, with the highest point at the optic foramen (a passage through a bone generally for nerves and blood vessels to pass through) in the sphenoid bone, which provides the entrance to the optic canal. The optic canal carries the optic nerve, the ophthalmic artery and sympathetic nerve fibres from the carotid plexus. A fracture at or near the optic canal may cause damage to the optic nerve, resulting in visual loss.

The superior orbital fissure lies between the lesser and greater wings of the sphenoid bone. Through this foramen pass the oculomotor, trochlear and abducens nerves and the ophthalmic division of the trigeminal nerve. The superior ophthalmic vein leaves the orbit through the upper part of the superior orbital fissure.

The greater wing of the sphenoid bone and the orbital plate of the maxillary bone form the inferior orbital fissure. This transmits the maxillary division of the orbital branch of the trigeminal nerve and the inferior ophthalmic vein.

The bony margins of the orbit provide general protection to the eye against impact from larger objects, such as footballs. Smaller objects, like stones and squash balls, are likely to cause more damage. Fractures of the orbital margin generally cause no lasting problems with the eye. The orbital floor is very thin and may ‘blow out’ into the maxillary sinus with a blunt eye injury such as that sustained by impact with a fist or tennis ball. The orbital contents, including the inferior rectus and inferior oblique muscles, may get trapped in the fracture site, causing restriction of eye movements and double vision (diplopia) in some positions of gaze. A fracture into the thin ethmoid bone medially may be associated with subcutaneous emphysema of the eyelids when the patient blows his or her nose.

Blood supply to the eye and orbit

Both the arterial blood supply to and the venous drainage from the orbit are located within the cavernous sinus. The ocular nerve, trochlear nerve, ophthalmic nerve, abducent nerve and maxillary nerve also pass through this sinus. This is of particular significance if a patient develops orbital cellulitis, because without prompt antibiotic treatment there is a danger of infection passing back into the cavernous sinus and into the brain.

The eyelids

The edge of each eyelid is called the eyelid margin. The space between the two eyelids when the eyes are open is called the palpaebral fissure. The tiny openings to the tear drainage system in the nasal corners of each eye are called the lacrimal puncta (plural) or punctum (one). The corners of the eyelids are called the medial canthus (nearest the nose) and the lateral canthus (at the temple). The powerful muscle that closes the eyelids is called the orbicularis oculi, which encircles each eye. This is very significant when a person has a painful eye injury such as a chemical burn to the eye – it is very hard to get the eye open to wash out the chemical, due to the reflex spasm of this muscle.

Figure 2.2 The eyelid

The muscles responsible for keeping the upper eyelids open are the levator muscle, Muller’s muscle and the frontalis muscle of the brow. Each eyelid is lined by thin cartilage, called tarsal plates, which give shape and strength to the lids and provide protection for the eye. The eyelids are lined with conjunctiva (see Figure 2.2). The eyelid is key to understanding many external eye disorders, so it is important to learn about its structure.

To do…

Think about the eyelids carefully and list their main functions in your folder.

There are many potential problems with malfunctioning eyelids. With the help of colleagues, start to make a list of all the eyelid problems you can find under the following headings:

•Problems with eyelid closure

•Problems with eyelid opening

•Infections and inflammations

•Eyelash problems.

The lacrimal apparatus

The lacrimal gland is a small, almond-shaped gland situated beneath the conjunctiva, in the lacrimal fossa of the orbital bones on the upper, outer side of each orbit. Its outline can be seen under the skin of emaciated people. The lacrimal gland has several short ducts that open into the upper conjunctival fornix, and its sensory nerve supply comes from the lacrimal nerve, a branch of the ophthalmic division of the trigeminal nerve.

Figure 2.3 The tear film

As you can see from Figure 2.3, the tear film is composed of three layers. The inner mucin layer is secreted by goblet cells in the conjunctiva, and lies over the endothelial surface of the cornea. Its complex structure is critical for holding the aqueous (watery) layer of the tears on the front of the eye. The aqueous layer is the thickest, and keeps the surface of the eye healthily moist and clean. The oily layer, produced by the meibomian glands (see Figure 2.2), further assists in holding the aqueous layer of the tears on the front of the eye and inhibits evaporation of the tear film. A healthy tear film is essential to the surface of the eye, particularly the cornea, and blocked meibomian glands cause significant problems with the tear film.

To do

Make notes in your folder on the causes of dry eyes.

Diagnosis of dry eyes

Make notes on Schirmer’s test. This is described in Chapter 13 but your notes should be based on one you have carried out yourself!

•What is the normal result for this test?

•How reliable is it in practice?

•Fluorescein break-up time is a frequently used test for dry eye. How reliable is it?

Have a look at Moore et al. (2009) who discuss the accuracy of these and other dry eye tests in detail and Versura et al.