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Ophthalmology Nursing Guide

GCC Clinical Reference — Evidence-based Practice

GCC Edition 2026

Eye Assessment

Visual Acuity

Snellen Chart

  • Tested at 6 metres (or 20 feet) in good illumination
  • Each eye tested separately; occlude non-tested eye
  • Record as fraction: 6/6 (normal), 6/12, 6/60
  • If <6/60: count fingers (CF), hand movements (HM), perception of light (PL), no PL
  • Pinhole VA: improves refractive but not pathological loss

LogMAR Scale

  • Used in research and low vision; logarithm of minimum angle of resolution
  • 6/6 = LogMAR 0.0 (best); 6/60 = LogMAR 1.0
  • Lower LogMAR = better vision
TipUse the Visual Acuity Converter tool in the GCC Context tab for instant conversions.
Pupil Assessment

PERRL

Pupils Equal, Round, Reactive to Light

  • Direct reflex: light → same pupil constricts
  • Consensual reflex: light → opposite pupil constricts
  • Accommodation reflex: near object → miosis + convergence
  • Document size in mm (normal 2–6 mm in light)

RAPD (Marcus Gunn Pupil)

  • Swinging flashlight test: light swings between eyes every 2 sec
  • Positive RAPD: affected pupil dilates when light swings to it
  • Indicates optic nerve or extensive retinal disease
  • Graded +1 to +4; any RAPD warrants urgent investigation
Red FlagUnequal pupils (anisocoria >1 mm) combined with ptosis and anhidrosis = Horner syndrome. Fixed dilated pupil = CN III palsy or acute glaucoma emergency.
Confrontation Visual Fields
  • Examiner and patient at same level, 1 metre apart
  • Patient covers one eye; examiner covers opposite eye
  • Wiggle fingers or use a hat pin in each quadrant
  • Identifies gross field defects: hemianopia, quadrantanopia, scotoma

Field Defect Patterns

DefectLikely Site
Central scotomaMacula / optic nerve
Bitemporal hemianopiaOptic chiasm (pituitary)
Homonymous hemianopiaOptic tract / occipital lobe
Inferior altitudinalSuperior retinal/CRAO branch
Arcuate scotomaGlaucoma (nerve fibre layer)
Extraocular Movements
  • Test 8 cardinal positions of gaze (H-pattern)
  • Ask patient to report diplopia; note if it worsens in any direction
  • Cover test: detects latent tropia/phoria
  • Hirschberg reflex: corneal light reflex centred = orthophoric

Cranial Nerve Palsies

  • CN III: eye down and out, ptosis, fixed dilated pupil
  • CN IV: vertical diplopia; head tilt away from affected side
  • CN VI: lateral rectus palsy → esotropia, failure to abduct
  • Internuclear ophthalmoplegia: failure of adduction (MS, brainstem)
EmergencySudden painful CN III palsy with dilated pupil = posterior communicating artery aneurysm until proven otherwise. Immediate neurosurgical referral.
Intraocular Pressure (IOP)
  • Normal range: 10–21 mmHg (mean ~15.5 mmHg)
  • Diurnal variation up to 4 mmHg; highest in early morning

Goldmann Applanation Tonometry

  • Gold standard; requires slit lamp, fluorescein, topical anaesthetic
  • Flatten 3.06 mm area; mire rings aligned for reading
  • Central corneal thickness affects reading (±3 mmHg per 50 µm)

iCare Rebound Tonometer

  • No anaesthetic required; portable; suitable for community screening
  • Probe bounces off cornea → measures deceleration
  • Nurse-led IOP checks in GCC diabetic retinopathy clinics
NoteIOP >21 mmHg = ocular hypertension. IOP >30 mmHg with symptoms = possible acute glaucoma → URGENT.
Slit Lamp & Fundoscopy

Slit Lamp Basics

  • Biomicroscope with adjustable beam width, height, angle and filter
  • Examine: lids/lashes, conjunctiva, cornea, anterior chamber, lens, vitreous
  • Fluorescein + blue filter: corneal epithelial defects fluoresce green
  • Flare and cells in anterior chamber → uveitis

Fundoscopy Key Findings

StructureWhat to Note
Optic discCup:disc ratio (>0.6 suspicious), pallor, swelling, haemorrhage
VesselsAV nipping, silver wiring, flame haemorrhages, BRVO/CRVO
MaculaDrusen (AMD), macular oedema, cherry-red spot, CSME
PeripheryLattice degeneration, tears, detachment, neovascularisation

Common Ophthalmic Conditions

Diabetic Retinopathy — GCC Priority Condition
GCC EpidemicDiabetic retinopathy is the leading cause of blindness in working-age adults in the GCC. UAE, Saudi Arabia and Kuwait rank among the top 10 countries globally for diabetes prevalence.

Non-Proliferative DR (NPDR)

  • Mild: microaneurysms only
  • Moderate: dot/blot haemorrhages, hard exudates, cotton-wool spots
  • Severe (4-2-1 rule): haemorrhages in all 4 quadrants OR venous beading in 2+ quadrants OR IRMA in 1+ quadrant

Proliferative DR (PDR)

  • Neovascularisation on disc (NVD) or elsewhere (NVE)
  • Risk: vitreous haemorrhage, tractional retinal detachment
  • Treatment: panretinal photocoagulation (PRP), intravitreal anti-VEGF

Diabetic Macular Oedema (DME)

  • Can occur at any stage of DR
  • Clinically significant ME (CSME) within 500 µm of fovea
  • OCT is gold standard for diagnosis and monitoring
  • Treatment: intravitreal anti-VEGF (ranibizumab, aflibercept), focal laser

Screening Intervals (GCC Guidelines)

  • No DR: annual screening
  • Mild NPDR: 6–12 monthly
  • Moderate NPDR: 3–6 monthly
  • Severe NPDR / PDR: urgent referral <4 weeks
Glaucoma

Primary Open-Angle Glaucoma (POAG)

  • Chronic, painless; often asymptomatic until advanced
  • Elevated IOP damages optic nerve → progressive field loss
  • Risk factors: IOP >21, family history, myopia, Black ethnicity
  • Treatment: topical IOP-lowering drops, laser (SLT), trabeculectomy
  • Target IOP: typically 18 mmHg or 25–30% reduction

Acute Angle-Closure Glaucoma

Emergency — see Emergencies tabIOP often >40 mmHg; causes irreversible vision loss within hours if untreated.
  • Narrow angle → iris occludes trabecular meshwork
  • Risk factors: hyperopia, female, Asian ethnicity, age >50, dark room
  • Prevention: prophylactic Nd:YAG laser peripheral iridotomy
Age-Related Macular Degeneration (AMD)

Dry AMD

  • 90% of AMD cases; drusen + RPE atrophy
  • Geographic atrophy: severe form with central vision loss
  • AREDS2 supplements (vitamins C, E, zinc, lutein, zeaxanthin) slow progression
  • No specific treatment for geographic atrophy currently (emerging therapies 2024–25)

Wet AMD

  • Choroidal neovascularisation (CNV) → rapid severe vision loss
  • Amsler grid: metamorphopsia (wavy lines) early sign
  • Treatment: intravitreal anti-VEGF (ranibizumab, aflibercept, bevacizumab, faricimab)
  • Frequency: typically monthly loading then PRN or T&E
Nurse RoleEducate patients to use Amsler grid daily and report any distortion or new scotoma immediately.
Cataract
  • Opacification of crystalline lens; age-related most common
  • Other causes: congenital, traumatic, steroid-induced, diabetic
  • Symptoms: painless blurred vision, glare, haloes, myopic shift

Surgical Criteria

  • VA ≤6/12 with functional impact OR patient's visual demands
  • Phacoemulsification: ultrasonic fragmentation + aspiration, 2.4 mm incision
  • IOL implanted in capsular bag; biometry (AL + K readings) determines power
  • Day-case procedure; topical anaesthesia; 2–4 week recovery
Corneal Conditions & Retinal Detachment

Corneal Abrasion

  • Pain, photophobia, lacrimation, FB sensation
  • Fluorescein staining under cobalt blue light
  • Treatment: topical antibiotic, lubricant, analgesia; no patch for contact lens-related
  • Healing: 24–72 hours for most abrasions

Retinal Detachment

Emergency"Curtain coming down", sudden shower of floaters + photopsia (flashes) = rhegmatogenous RD until proven otherwise. Same-day surgical referral.
  • Risk factors: myopia, trauma, previous RD, lattice degeneration
  • Macula-off RD: poorer prognosis; VA may not recover fully
  • Treatment: scleral buckle, vitrectomy, pneumatic retinopexy

Ophthalmic Medications

Eye Drop Instillation Technique
  1. Wash hands thoroughly for 20 seconds
  2. Tilt head back or lie supine; look upward
  3. Gently pull lower lid down to expose lower fornix (conjunctival sac)
  4. Instil ONE drop into lower fornix — do NOT touch eye or lashes with bottle tip
  5. Gently close eye; do NOT blink vigorously
  6. Apply punctal occlusion — press inner corner of eye with fingertip for 1 full minute
  7. If multiple drops needed: wait at least 5 minutes between drops
  8. Ointment after drops (if prescribed)
  9. Store drops as directed; discard 28 days after opening (most preparations)
Why Punctal Occlusion?Reduces systemic absorption via nasolacrimal duct. Particularly important for beta-blockers (timolol) to avoid bradycardia/bronchospasm, and for brimonidine to avoid CNS depression in children.
5-Minute RuleEach drop displaces up to 90% of the previous drop if instilled too soon. Always wait 5 minutes. Suspensions/gels go last.

Glaucoma Medications

ClassExampleMechanismKey Side Effects / Nursing Points
Prostaglandin analogues Latanoprost 0.005%
1st line		 ↑ uveoscleral outflow Iris pigmentation (irreversible), lash growth, periorbital fat atrophy. Once daily at night. Do not refrigerate after opening.
Beta-blockers Timolol 0.25 / 0.5%
Betaxolol		 ↓ aqueous production Systemic effects: bradycardia, bronchospasm, depression, masking hypoglycaemia. Contraindicated in asthma, COPD, heart block. Punctal occlusion essential.
Carbonic anhydrase inhibitors (CAI) Dorzolamide (topical)
Acetazolamide (oral/IV)		 ↓ aqueous production Topical: stinging, metallic taste. Oral: metabolic acidosis, renal stones, Stevens-Johnson (rare). Avoid in sulfa allergy.
Alpha-2 agonists Brimonidine 0.1–0.2% ↓ aqueous production, ↑ outflow Allergy/follicular conjunctivitis (up to 15%). AVOID in children <2: CNS depression, apnoea. Drowsiness in elderly.
Rho kinase inhibitor Netarsudil 0.02% ↑ trabecular outflow Conjunctival hyperaemia, cornea verticillata. Once daily. Newer class.

Mydriatics, Antibiotics & Steroids

DrugUseDurationKey Nursing Points
Tropicamide 1% Mydriasis for fundoscopy 4–6 hours Driving warning: patient must NOT drive for duration. Can precipitate angle-closure in predisposed eyes. Document pre-dilation VA and IOP if indicated.
Cyclopentolate 1% Cycloplegia (refraction in children) 12–24 hours Systemic toxicity in children (flushing, tachycardia, behavioural). Use 0.5% in neonates.
Phenylephrine 2.5 / 10% Mydriasis (sympathomimetic) 3–5 hours 10% contraindicated in CVD, hypertension. Use 2.5% in elderly, neonates, cardiac patients.
Chloramphenicol 0.5% Bacterial conjunctivitis, minor infections 5–7 days Rare aplastic anaemia (1:400,000). First-line OTC in many countries. Avoid in neonates (grey baby syndrome risk with systemic absorption).
Ciprofloxacin 0.3% Corneal ulcer, severe infections 2–3 weeks for ulcer Broad-spectrum fluoroquinolone. Intense initial regimen: q1h day 1, then taper. White corneal precipitates may form (resolves).
Prednisolone 0.5–1% Uveitis, post-operative inflammation Weeks–months IOP monitoring essential: steroid-responder IOP rise in ~35% (usually within 4–6 weeks). Also risk of posterior subcapsular cataract with prolonged use. Never use in active herpetic keratitis.

Ophthalmic Procedures

Intravitreal Injection — Nursing Role

Pre-Injection

  • Verify informed consent signed; confirm indication, eye, and drug
  • Check allergy status — specifically iodine (povidone-iodine prep)
  • VA and IOP recorded pre-injection
  • Instil topical anaesthetic (oxybuprocaine 0.4% or proxymetacaine)
  • Dilate pupil if fundal assessment needed post-injection
  • Prepare betadine (povidone-iodine 5%) for conjunctival prep — most critical infection-prevention step

Injection Site (Physician/ANP)

  • 3.5 mm from limbus (phakic) or 3.0 mm (pseudophakic) in inferotemporal quadrant
  • Speculum inserted; 30-gauge needle perpendicular to sclera into vitreous

Post-Injection Monitoring (Nurse-led)

  • Check VA and optic disc perfusion at 30 min (light perception minimum)
  • IOP check if symptomatic (transient spike expected)
  • Observe for: subconjunctival haemorrhage (benign), vitreous floaters
  • Provide written discharge advice

Patient Instructions

  • No swimming, eye rubbing, or dusty environments for 1 week
  • Antibiotic drops: 3 days post-injection (if local protocol)
  • Return immediately for: severe pain, floaters increasing, vision worsening, purulent discharge (endophthalmitis)
EndophthalmitisIncidence ~0.02–0.05% per injection. Onset 2–7 days post-injection. Presents with severe pain, hypopyon, vision loss. Same-day vitreous tap and intravitreal antibiotics.
Laser Procedures

Panretinal Photocoagulation (PRP)

  • Indication: PDR, severe NPDR
  • 1200–1600 burns applied to peripheral retina over 2–3 sessions
  • Nurse prep: dilate fully (tropicamide + phenylephrine), topical anaesthetic, driving warning
  • Post-laser: dim vision for hours; may have field restriction long-term

Selective Laser Trabeculoplasty (SLT)

  • Indication: POAG, ocular hypertension — can replace or add to drops
  • 532 nm Nd:YAG; targets trabecular meshwork pigmented cells
  • Post-SLT: IOP spike risk in first 4 hours; check IOP at 1 hour post-laser
  • Effect: IOP reduction of 20–30%; repeatable

YAG Capsulotomy

  • Indication: posterior capsule opacification (PCO) after cataract surgery — "secondary cataract"
  • 1064 nm Nd:YAG creates opening in opacified posterior capsule
  • Post-procedure: IOP check at 1 hour; risk of IOL damage (rare), RD long-term
  • Safety: protective goggles for operator. Patient should not drive immediately after dilation.
Cataract Surgery Day-Case Pathway

Pre-operative

  • Biometry: A-scan/IOL-Master for axial length + keratometry → IOL power calculation
  • Consent: risks (posterior capsule rupture 2%, endophthalmitis 0.03–0.1%, RD 0.1%)
  • Dilate with tropicamide 1% + phenylephrine 2.5%; NSAID drops 3 days pre-op (some centres)
  • Mark correct eye; WHO surgical safety checklist

Post-operative Care

  • Eye shield overnight then for naps/sleep for 1–2 weeks
  • Post-op drops regimen (4-week course, typical):
DropFrequencyDuration
Antibiotic (e.g. levofloxacin)QDS2 weeks
Steroid (prednisolone 1%)QDS → taper4 weeks
NSAID (ketorolac 0.5%)QDS4 weeks
  • Avoid: rubbing, swimming, dusty environments, heavy lifting (>5 kg) for 4 weeks
  • Urgent return if: severe pain, increasing redness, sudden vision loss, photophobia

Eye Emergencies

Chemical Eye Burn — HIGHEST PRIORITY EMERGENCY
Act Within Seconds — Do Not Wait for AssessmentBegin copious irrigation IMMEDIATELY. This is the most time-critical action in all of ophthalmology.

Immediate Management (Nurse-led)

  1. IMMEDIATE irrigation with normal saline (or any available clean water)
  2. Morgan lens preferred for continuous irrigation — delivers 500 mL+ over 20–30 min
  3. Evert lids; irrigate fornices and remove particulate material
  4. Check pH with indicator paper — target pH 7.0–7.4 before stopping irrigation
  5. Minimum 1–2 litres irrigation; repeat pH 5 minutes after stopping
  6. Instil topical anaesthetic for comfort and cooperation
  7. Document chemical agent, time of exposure, and irrigation volume
  8. Urgent ophthalmology referral regardless of apparent severity

Alkali vs Acid Burns

Alkali (worse)Acid
ExamplesLime, cement, bleach, ammoniaBattery acid, pool chemicals
MechanismSaponification → deep penetrationProtein coagulation → self-limiting
SeverityHigher; may perforate globeGenerally less severe

Roper-Hall Classification

  • Grade I: corneal epithelial damage only; full recovery expected
  • Grade II: corneal haze, <1/3 limbal ischaemia; good prognosis
  • Grade III: total corneal opacity, 1/3–1/2 limbal ischaemia; guarded
  • Grade IV: opaque cornea, >1/2 limbal ischaemia; very poor prognosis
Acute Angle-Closure Glaucoma

Presentation

  • Severe unilateral eye pain, headache, nausea and vomiting
  • Blurred vision with coloured haloes around lights
  • Fixed, mid-dilated, oval pupil — non-reactive to light
  • Conjunctival injection (circumcorneal flush)
  • Corneal oedema: hazy, "steamy" cornea
  • IOP typically >40 mmHg (may be 60–80 mmHg)

Emergency Management

  1. Urgent ophthalmology review — do NOT delay
  2. IV acetazolamide 500 mg stat (reduces aqueous production)
  3. Topical pilocarpine 2% (qid — constricts pupil, opens angle)
  4. IV mannitol 20% 1–2 g/kg over 45 minutes (hyperosmotic)
  5. Topical beta-blocker + alpha-agonist + steroid drops
  6. Antiemetic for nausea/vomiting
  7. Definitive: Nd:YAG laser peripheral iridotomy once IOP controlled
  8. Prophylactic iridotomy to fellow eye
Central Retinal Artery Occlusion (CRAO)

Presentation

  • Sudden, painless, profound monocular vision loss (counts fingers or worse)
  • RAPD present on affected side
  • Fundoscopy: diffuse retinal whitening + cherry-red spot at fovea (thin retina here shows underlying choroid)
  • Attenuated arterioles; "cattle-trucking" of blood column

Management

90-Minute WindowRetinal ischaemia causes irreversible damage. Thrombolytic therapy (IV t-PA) may be considered within 4.5 hours at specialist centres — treat as stroke equivalent.
  • Ocular massage: lower IOP to dislodge embolus
  • Carbogen inhalation or re-breathing into bag (CO2 vasodilation)
  • Anterior chamber paracentesis (lowers IOP acutely)
  • Full stroke workup: carotid Doppler, echo, ECG (AF?), lipids, BP
  • Same-day neurovascular referral
Orbital vs Preseptal Cellulitis
FeaturePreseptal (periorbital)Orbital (post-septal)
ProptosisAbsentPresent Red Flag
EOM restriction/painAbsentPresent
Visual lossAbsentPossible — optic nerve compression
ChemosisAbsentOften present
SystemicMild feverHigh fever, unwell
ImagingClinical diagnosisCT orbit with contrast urgently
TreatmentOral co-amoxiclavIV antibiotics + surgical drainage if abscess
Complications of Orbital CellulitisCavernous sinus thrombosis, meningitis, brain abscess, optic nerve infarction. Requires immediate IV antibiotics (co-amoxiclav + metronidazole) and ENT/neurosurgery co-management.
Other Ophthalmic Emergencies — Quick Reference
ConditionKey SignImmediate Action
Open globe injuryTeardrop pupil, uveal prolapse, positive Seidel testMetal shield (NO pressure); NPO; IV antibiotics; surgical repair
HyphaemaBlood in anterior chamberBed rest at 30–45°; avoid aspirin/NSAIDs; IOP monitoring
Retinal detachmentCurtain/floaters/flashesSame-day referral; keep macula-on if possible
Giant cell arteritisAge >50, ESR/CRP↑, jaw claudication, scalp tendernessIV methylprednisolone 1 g immediately; temporal artery biopsy within 2 weeks
EndophthalmitisPost-op pain, hypopyon, vision lossSame-day vitreous tap + intravitreal vancomycin/ceftazidime

GCC Context

#1–5
GCC countries in global diabetes prevalence rankings
~20%
Adult diabetes prevalence in UAE & Saudi Arabia
30–40%
Diabetics with some degree of retinopathy in GCC
1 in 3
Eye injuries in GCC are occupational (construction sector)
Ophthalmic Public Health in the GCC

Diabetic Retinopathy Epidemic

  • GCC has among the highest T2DM rates globally (IDF 2023)
  • Urban lifestyle, high-carbohydrate diet, low physical activity drive prevalence
  • Late presentation common — many patients unaware of DR until advanced
  • National DR screening programmes: Saudi Arabia (VISION 2030), UAE Diabetic Retinopathy Program
  • Nurse-led telemedicine fundus photography expanding rapidly across the Gulf

Occupational Eye Injuries

  • High construction workforce (expat labour) → foreign body injuries, chemical exposures
  • Sand and dust: pterygium, dry eye, allergic conjunctivitis endemic in GCC
  • PPE compliance and site first aid training is a nursing education priority
  • Labour camp clinics often staffed by nurses as primary eye care providers

Trachoma — Historical Context

  • Chlamydia trachomatis — leading infectious cause of blindness globally
  • Previously endemic in Gulf region; now largely eliminated through WHO SAFE strategy
  • Still relevant in humanitarian/refugee settings in the wider MENA region
Leading Eye Hospitals & Nurse Specialist Role

Key Regional Centres

  • King Khaled Eye Specialist Hospital (KKESH) — Riyadh, Saudi Arabia; largest dedicated eye hospital in the world
  • Magrabi Eye Hospitals — Multi-site across GCC (Saudi, UAE, Egypt); high-volume cataract and refractive surgery
  • Moorfields Eye Hospital Abu Dhabi & Dubai — UK partnership; tertiary ophthalmology, research, nurse specialist training
  • Al-Amal Hospital for Eye, ENT & Neurology — Kuwait
  • Hamad Medical Corporation Eye Department — Qatar; leading retinal surgery centre

Ophthalmology Nurse Specialist (ONS) in GCC

  • Expanding role: intravitreal injection clinics, laser procedure support, DR screening
  • Nurse-led pre-assessment: biometry, VA testing, IOP measurement, consent
  • Community outreach: mobile screening units to labour camps and remote areas
  • Continuing education: Royal College of Ophthalmologists (RCOphth) and ICO-recognised courses available in region
  • Cultural competency: eye contact, gender preferences, fasting patients (Ramadan medication compliance)
Interactive Tool: Visual Acuity Converter

Convert Visual Acuity Between Scales

Interactive Tool: Diabetic Retinopathy Screening Interval Calculator

Recommended Screening Interval

Practice MCQs — Ophthalmology Nursing

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