Eye Assessment Fundamentals
Visual Acuity — Snellen Chart
| Result | Interpretation |
|---|
| 6/6 | Normal (20/20 ft equivalent) |
| 6/18 | Visual impairment (mild) |
| 6/60 | Legally visually impaired (WHO) |
| <3/60 | Blind — WHO definition |
| PL / NPL | Perceives / No light perception |
Technique: Test each eye separately, occlude other eye firmly. Standard 6 m (20 ft) distance. Use pinhole to differentiate refractive vs pathological.
Exam tip: The notation 6/X means patient reads at 6 m what a normal eye reads at X metres. Larger denominator = worse acuity.
Pupil Assessment — PEARL
- P — Pupils
- E — Equal
- A — And
- R — Reactive to
- L — Light (and accommodation)
Normal values: 2–6 mm, equal bilaterally
| Finding | Significance |
|---|
| Fixed dilated pupil | CN III palsy, herniation, atropine |
| Fixed mid-dilated (5–6 mm) | Acute angle closure glaucoma |
| Relative Afferent Pupillary Defect (RAPD) | Optic nerve or retinal disease |
| Miosis (small) | Horner syndrome, opioids, pilocarpine |
| Irregular pupil | Posterior synechiae (iritis), trauma |
Swinging flashlight test: detects RAPD — affected eye has paradoxical dilation when light swings to it.
Intraocular Pressure (IOP)
Normal range: 10–21 mmHg (Goldmann applanation tonometry — gold standard)
- Goldmann tonometry: anaesthetic drops + fluorescein required, slit-lamp mounted
- Non-contact tonometry (air puff): screening use, less accurate
- Icare rebound tonometer: no anaesthetic needed, suitable for children
IOP >21 mmHg = ocular hypertension. IOP >30 mmHg = high risk. In acute angle closure IOP may reach 50–70 mmHg.
Confrontation Visual Field Testing
Bedside screening test comparing patient's field to examiner's.
- Face patient at arm's length (1 m)
- Test each eye separately, cover the other
- Patient fixes on examiner's nose
- Examiner wiggles finger in 4 quadrants
- Ask: "Can you see my finger moving?"
Common defects
- Bitemporal hemianopia — pituitary adenoma
- Homonymous hemianopia — stroke/CVA
- Arcuate scotoma — glaucoma
- Central scotoma — macular disease
Colour Vision — Ishihara Plates
Tests red-green colour deficiency (most common hereditary colour vision defect).
- Standard set: 38 plates; screening set: 14 plates
- Each plate shown for ≤3 seconds per plate
- Illuminate with daylight or standard illuminant C
- Normal: reads all or most numbers correctly
- Colour deficient: misses or misreads numbers
GCC Relevance: Colour vision testing required for driver licences and many occupational health assessments in Saudi Arabia, UAE, Qatar.
Red Reflex Testing
Performed with direct ophthalmoscope at 30–50 cm in darkened room. Normal: bright orange-red symmetric glow from both eyes.
| Abnormal Finding | Possible Cause |
|---|
| Absent / white reflex (leukocoria) | Retinoblastoma, congenital cataract, vitreous haemorrhage |
| Asymmetric reflex | Unilateral cataract, refractive error, strabismus |
| Dark spot in reflex | Cataract, corneal opacity |
Leukocoria in a child = urgent ophthalmology referral to exclude retinoblastoma.
External Eye Examination
Structures to assess
- Eyelids: ptosis, entropion/ectropion, trichiasis, chalazion, hordeolum
- Conjunctiva: injection (redness), chemosis (oedema), discharge, follicles vs papillae, foreign body
- Cornea: clarity, ulcers, abrasions, keratoconus, Kayser-Fleischer rings
- Anterior chamber: depth (shallow = angle closure risk), hyphaema, hypopyon, flare
- Lens: clarity, position — requires slit-lamp or ophthalmoscope
Fluorescein Staining
Instill fluorescein dye — stains epithelial defects bright green under blue (cobalt) light.
- Indications: Corneal abrasion, ulcer, foreign body, dry eye, contact lens problems
- Dendrite pattern → Herpes simplex keratitis
- Geographic ulcer → HSV or bacterial
- Punctate staining → Dry eye disease
- Positive Seidel test → Aqueous leaking (penetrating injury)
Nursing: Remove contact lenses before instilling fluorescein. Warn patient dye temporarily discolours tears.
Acute Eye Emergencies
⚠ All acute eye emergencies require IMMEDIATE ophthalmology consultation. Time = vision.
Acute Angle Closure Glaucoma — EMERGENCY
Classic Presentation
- Sudden severe unilateral eye pain
- Red eye (circumcorneal injection)
- Blurred vision + haloes around lights
- Fixed mid-dilated pupil (~5–6 mm)
- Cloudy ("steamy") cornea
- Nausea and vomiting (vagal)
- IOP typically 40–70 mmHg
- Headache (can mimic migraine)
Risk Factors
- Hypermetropia (far-sighted)
- Female sex, Asian ethnicity
- Shallow anterior chamber
- Precipitated by: dim lighting, mydriatic drops, certain systemic medications (anticholinergics, antihistamines, TCAs)
- Family history
Management Sequence
- Call ophthalmologist IMMEDIATELY — this is a sight-threatening emergency
- Position: sit patient upright or supine (not face-down)
- IV Acetazolamide 500 mg (carbonic anhydrase inhibitor — reduces aqueous production)
- Topical Pilocarpine 2–4% drops (miotic — pulls iris away from angle) — every 15 min x4
- Topical Timolol 0.5% (beta-blocker — reduces aqueous production)
- Topical steroid (reduces inflammation)
- IV Mannitol 20% 1–2 g/kg if IOP not responding (osmotic agent)
- Analgesia and antiemetics as required
- Definitive treatment: Laser peripheral iridotomy (LPI) — creates hole in iris to equalise pressure
- Prophylactic LPI to fellow eye (bilateral risk)
Nursing note: Monitor IOP response every 30 min. Check electrolytes if IV mannitol used. Insert urinary catheter if large mannitol dose. Darkened room can worsen angle closure — keep lights on.
Central Retinal Artery Occlusion (CRAO)
Presentation
- Sudden painless monocular vision loss
- "Curtain coming down" or complete blackout
- Vision: typically hand movements or worse
- RAPD present
- Fundus: pale retina + cherry red spot at fovea
- Box-carring of vessels on fundoscopy
Emergency Management (within 24h — ideally <90 min)
- Ocular massage (5–15 sec firm pressure, release x10 cycles) — may dislodge embolus
- Reduce IOP: IV acetazolamide, topical beta-blocker, anterior chamber paracentesis
- Lie patient flat — increases retinal perfusion pressure
- Inhale carbogen (95% O2 + 5% CO2)
- Treat underlying cause: embolic work-up (carotid Doppler, ECG for AF, echo)
- Urgent stroke team involvement — may represent TIA equivalent
CRAO = ocular stroke. Involve neurology/stroke team urgently. Prognosis poor if ischaemia >4–6 hours.
Chemical Burns — IMMEDIATE IRRIGATION
Do NOT wait for assessment. Start irrigation immediately.
Irrigation Protocol
- Topical anaesthetic drops (proxymetacaine) for patient comfort
- Irrigate with 1–2 litres normal saline / Hartmann's / Morgan lens
- Evert eyelids — sweep fornices to remove particulate matter
- Check pH with litmus paper every 5 min — irrigate until pH 7.0–7.4
- Allow 5 min equilibration after irrigation, recheck pH
- Document time, substance, irrigation volume, pH before and after
Roper-Hall Classification
| Grade | Cornea | Limbus | Prognosis |
|---|
| I | Clear | No ischaemia | Excellent |
| II | Hazy | <1/3 ischaemia | Good |
| III | Stromal haze | 1/3–1/2 ischaemia | Guarded |
| IV | Opaque | >1/2 ischaemia | Poor |
Alkali burns (lime, cement, bleach) are worse than acid burns — alkaline liquefactive necrosis penetrates deeper. pH >12 = severe.
Penetrating Eye Injury
- Do NOT remove the embedded object
- Protect with rigid eye shield (not pressure pad)
- Do NOT instill drops if globe rupture suspected
- Keep patient nil by mouth — urgent theatre
- Tetanus prophylaxis if indicated
- IV antibiotics (broad spectrum)
- Seidel test to detect aqueous leak
- Urgent surgical repair by vitreoretinal team
NBM immediately — surgical repair often needed same day.
Hyphaema (Blood in Anterior Chamber)
Grading (Hyphema)
- Grade I: Fills <1/3 AC
- Grade II: 1/3–1/2 AC
- Grade III: >1/2 AC
- Grade IV: "Eight-ball" — fills entire AC
Management
- Semi-recumbent position (30–45°) — allows blood to settle inferiorly
- Eye shield (no pressure)
- Antifibrinolytics: aminocaproic acid or tranexamic acid (reduces re-bleed)
- Avoid aspirin/NSAIDs
- Monitor IOP daily
- Sickle cell screen — rebleed risk higher
Interactive Red Eye Triage Tool
Chronic Eye Conditions
Diabetic Retinopathy — GCC High Priority
GCC context: Diabetic retinopathy is the leading cause of preventable blindness in working-age adults in the GCC, driven by among the world's highest diabetes prevalence rates.
Classification
| Stage | Features |
|---|
| Mild NPDR | Microaneurysms only |
| Moderate NPDR | Dot/blot haemorrhages, hard exudates, cotton wool spots |
| Severe NPDR | 4-2-1 rule: haemorrhages in 4 quadrants OR venous beading in 2 quadrants OR IRMA in 1 quadrant |
| PDR | New vessels (NVD/NVE), vitreous haemorrhage, tractional detachment |
| Macular oedema | Any stage — central vision threatening |
Intravitreal Anti-VEGF Agents
| Drug | Target |
|---|
| Ranibizumab (Lucentis) | VEGF-A fragment |
| Bevacizumab (Avastin) | Full VEGF-A (off-label) |
| Aflibercept (Eylea) | VEGF-A, VEGF-B, PlGF |
| Faricimab (Vabysmo) | VEGF-A + Ang-2 (bispecific) |
Additional treatments
- Panretinal photocoagulation (PRP) laser — PDR
- Focal/grid laser — macular oedema (older approach)
- Pars plana vitrectomy (PPV) — vitreous haemorrhage, tractional retinal detachment
Screening: Annual dilated fundal examination for all diabetic patients. Type 1: start 5 years after diagnosis. Type 2: at diagnosis. Pregnant diabetics: each trimester.
Age-Related Macular Degeneration (AMD)
Dry AMD
- Drusen + retinal pigment epithelium changes
- Gradual central vision loss
- Geographic atrophy (advanced)
- No proven cure — AREDS2 supplements (zinc, vitamins C & E, lutein, zeaxanthin) slow progression
Wet AMD (Neovascular)
- Choroidal neovascularisation (CNV)
- Rapid central vision loss
- Metamorphopsia (distorted lines) — Amsler grid test
- Treatment: intravitreal anti-VEGF (ranibizumab / aflibercept)
- Loading dose: 3 monthly injections, then PRN or treat-and-extend
Amsler grid: Daily home monitoring tool. Distorted or missing lines = urgent ophthalmology review.
Primary Open Angle Glaucoma (POAG)
"The silent thief of sight" — asymptomatic until late. Irreversible damage.
Diagnosis
- Elevated IOP (>21 mmHg) — though 1/3 have normal IOP
- Optic disc cupping: cup:disc ratio >0.6, vertical elongation, notching, disc haemorrhage
- Visual field defects: arcuate scotoma, nasal step, tunnel vision (late)
- Open anterior chamber angle on gonioscopy
Medical Treatment (step-up)
- Prostaglandin analogues (first-line): Latanoprost, bimatoprost, travoprost — once daily nocte — increases uveoscleral outflow
- Beta-blockers: Timolol (avoid in asthma/COPD, bradycardia, heart block)
- Carbonic anhydrase inhibitors: Dorzolamide, brinzolamide
- Alpha-2 agonists: Brimonidine (avoid in children)
- Combination drops, selective laser trabeculoplasty (SLT), trabeculectomy
Patient education: Glaucoma drops must be used lifelong. Missed doses cause IOP spikes. Punctal occlusion after instillation reduces systemic absorption.
Cataracts
Types & Causes
- Nuclear sclerosis — most common age-related (myopic shift early)
- Posterior subcapsular — steroids, diabetes (visual glare, near vision worse)
- Cortical — spoke-like opacities
- Congenital — urgent surgery
- Traumatic — after blunt/penetrating injury
Phacoemulsification Procedure
- Topical/local anaesthesia (peribulbar block)
- Small incision (2.4–2.8 mm) — self-sealing
- Capsulorrhexis — circular tear of anterior capsule
- Phaco probe: ultrasonic emulsification of lens
- IOL insertion into capsular bag
- IOL power calculated by biometry (A-scan)
Post-Cataract Surgery Instructions
Eye shield at night x4 weeks
No rubbing or pressing
No swimming x4 weeks
No driving until reviewed
Avoid dusty environments
OK to shower (avoid direct water)
Urgent return if: Increasing pain, redness, sudden vision loss, photophobia, floaters — may indicate endophthalmitis.
Ophthalmic Surgery Nursing
Pre-operative Assessment
Cataract Surgery Pre-op Checklist
- Informed consent — risks: endophthalmitis, posterior capsule tear, IOL dislocation, corneal oedema, retinal detachment, vitreous haemorrhage
- Biometry completed (IOL power calculation)
- Anticoagulation: check INR if warfarin — target INR <3.0 for topical anaesthesia; liaise with surgical team re: bridging for antiplatelet agents
- Dilating drops: Tropicamide 1% + phenylephrine 2.5% — instilled 30–60 min pre-op (3 cycles 5 min apart)
- Mark correct eye on consent AND on patient's forehead
- Baseline IOP, visual acuity documented
- Nil by mouth per anaesthetic requirements
Anaesthesia Options
| Type | Description |
|---|
| Topical | Proxymetacaine drops — awake, cooperative patient, surgeon preference |
| Sub-Tenon | Local anaesthetic under Tenon capsule — akinesia + analgesia |
| Peribulbar block | Injection into orbit — complete akinesia |
| General anaesthesia | Children, uncooperative patients, complex surgery |
| MAC (monitored) | IV sedation with topical — day surgery |
Vitreoretinal Surgery
Pars Plana Vitrectomy (PPV)
- Indications: vitreous haemorrhage, tractional retinal detachment, macular hole, epiretinal membrane, endophthalmitis
- 3 ports at pars plana (3.5 mm from limbus)
- Infusion, illumination, vitrector
- Tamponade agents used to keep retina in place:
| Agent | Duration | Special |
|---|
| Air | 1–2 weeks | Minimal positioning |
| SF6 gas 20% | 2–3 weeks | Face-down |
| C3F8 gas 14% | 6–8 weeks | Face-down |
| Silicone oil | Months | Requires removal later |
Gas Tamponade Nursing
STRICT POSTURING REQUIRED: Face-down positioning for gas tamponade (macular hole/superior detachment) to keep gas bubble against retina.
- Face-down 45–50 min per hour, waking hours
- Use rental posturing equipment (face-down pillow, massage table)
- Sleep face-down or on side as directed
- Duration per surgeon instruction (usually 5–14 days)
- Risk: pressure sores on forehead/chin — skin care
AIR TRAVEL PROHIBITED while intraocular gas present — expansion at altitude → acute angle closure/vision loss. Carry alert card. Duration: until gas absorbed (confirm with surgeon).
Scleral Buckle
Silicone band/sponge sutured around sclera — indents wall to relieve traction and close retinal breaks. Often combined with cryotherapy. Post-op: diplopia common (temporary), sore eye, swelling — reassure patient.
Procedure Checklists (Accordion)
Pre-procedure
- Confirm patient identity (two identifiers), consent signed
- Confirm correct eye (surgical site verification)
- Check drug name, dose, expiry — 4-eyes principle
- Topical anaesthetic: proxymetacaine 0.5% drops x2
- Povidone-iodine 5% to conjunctiva — wait 60 seconds minimum
- Sterile drape, lid speculum insertion
- Measure 3.5–4 mm from limbus (pseudophakic 3.5 mm, phakic 4 mm)
Procedure & Post-injection
- 30-gauge needle, drug injected into vitreous cavity
- Apply sterile cotton swab to injection site
- Check for light perception immediately post-injection
- Check IOP (if facilities available)
- Remove speculum, check patient comfort
- Instruct: antibiotic drops x3 days (if protocol requires)
- Monitor 30 min post-injection for acute complications
ENDOPHTHALMITIS WARNING: Return SAME DAY if: increasing pain, redness, floaters, vision loss after injection. This is a sight-threatening emergency.
| Time | Action | Rationale |
|---|
| 0 min | Recognise: severe pain + red eye + fixed mid-dilated pupil + haloes + nausea | Early recognition saves sight |
| 5 min | Call ophthalmologist; record IOP, VA, pupil | IOP often 40–70 mmHg |
| 10 min | IV acetazolamide 500 mg slow push (check sulfa allergy) | Reduces aqueous production |
| 15 min | Topical pilocarpine 2% drops (affected + fellow eye) | Miosis — opens angle |
| 20 min | Topical timolol 0.5% (if no contraindication) | Reduces aqueous production |
| 30 min | Topical steroid (prednisolone 1%) | Reduces inflammatory mediators |
| Ongoing | Analgesia IV/oral; antiemetics | Pain and nausea management |
| If no response | IV mannitol 20% 1–2 g/kg over 45 min; catheterise, electrolytes | Osmotic IOP reduction |
| Definitive | Laser peripheral iridotomy once cornea clear | Creates alternate aqueous pathway |
| Fellow eye | Prophylactic LPI scheduled | ~50% bilateral risk over lifetime |
Standard Post-op Drop Regimen (4 weeks)
| Drop | Type | Frequency |
|---|
| Dexamethasone 0.1% or Prednisolone 1% | Steroid (anti-inflammatory) | 4x/day → taper |
| Chloramphenicol 0.5% or Ofloxacin 0.3% | Antibiotic | 4x/day x2 weeks |
| Ketorolac 0.5% (if prescribed) | NSAID | 4x/day |
Space drops 5 minutes apart. Steroid first, antibiotic second.
Instillation Technique (Teach-Back)
- Wash hands thoroughly with soap and water
- Tilt head back or lie down
- Gently pull lower lid down to form a pocket
- Hold bottle 1–2 cm from eye — do NOT touch eye or lashes
- Instill ONE drop into the lower fornix
- Close eye gently — do NOT blink rapidly or squeeze
- Apply gentle pressure to inner corner (punctal occlusion) for 2 min — reduces systemic absorption
- Wait 5 minutes before next drop
Patient education points: Never stop steroid drops abruptly. Shake bottle before use. Store as per instructions (some refrigerated). Replace bottle cap. If dose missed — instill as soon as remembered (do not double up).
Paediatric Ophthalmology
Retinoblastoma — Life-Threatening Ocular Tumour
Leukocoria (white pupil) + strabismus in a child = retinoblastoma until proven otherwise.
Presentation
- Leukocoria (white/cat's eye reflex) — most common sign
- Strabismus (squint)
- Reduced vision
- Orbital inflammation (advanced disease)
- Heterochromia, hyphaema
Genetics
- RB1 gene mutation (tumour suppressor)
- Heritable form: bilateral, earlier onset — genetic counselling essential
- Non-heritable: unilateral, sporadic
Diagnosis & Treatment
- Fundal examination under anaesthesia (EUA)
- MRI orbits and brain (extent of disease, optic nerve involvement)
- Oncology MDT involvement
| Treatment | Indication |
|---|
| Intra-arterial chemotherapy (IAC) | Unilateral, advanced intraocular |
| Systemic chemotherapy | Bilateral, metastatic |
| Enucleation (eye removal) | Advanced unilateral, no visual potential |
| External beam radiotherapy | Less favoured — second malignancy risk |
| Focal treatments (laser, cryotherapy) | Small tumours |
Nursing role: Family support, genetic counselling referral, chemotherapy side effect education, prosthetic eye care if enucleated, psychological support.
Amblyopia (Lazy Eye)
Reduced visual acuity in one eye due to abnormal visual development — not correctable by glasses alone. Affects ~2–4% of children.
Causes
- Strabismic — squint causes cortex to suppress one eye
- Refractive — significant anisometropia (unequal refractive error)
- Deprivation — cataract, ptosis blocking visual axis
Treatment
- Correct refractive error first (glasses)
- Patching therapy: occlusion of the dominant (good) eye for 2–6 hours/day
- Atropine penalisation: 1% atropine drops to good eye
- Treatment most effective <7 years; possible up to ~12 years
Nursing education: Compliance is the biggest challenge. Encourage parents — reward charts, fun activities during patching. Skin care under patch.
Strabismus (Squint)
Misalignment of visual axes. Can cause amblyopia, diplopia, psychosocial impact.
Types
- Esotropia — eye turns inward (most common in children)
- Exotropia — eye turns outward
- Hypertropia/Hypotropia — vertical deviation
Management
- Glasses (refractive correction)
- Prism glasses (diplopia management)
- Botulinum toxin injection to extraocular muscle
- Surgical correction: recession/resection of extraocular muscles
Post-op Nursing Care
- Orbital oedema and redness — reassure, cold compresses
- Antibiotic drops as prescribed
- Conjunctival sutures dissolve (absorbable)
- Diplopia may be present initially — usually resolves
Congenital Cataracts
Urgency: Surgery required within weeks of birth to prevent irreversible deprivation amblyopia — critical visual development period.
- Causes: idiopathic, genetic, TORCH infections (toxoplasma, rubella, CMV, herpes), metabolic (galactosaemia)
- Dense unilateral cataract: surgery within 4–6 weeks
- Dense bilateral: within 6–10 weeks
- Post-op: contact lens/glasses correction required (young infant — IOL controversial in neonates)
- Intensive patching therapy for amblyopia prevention
- Long-term visual rehabilitation and follow-up
Retinopathy of Prematurity (ROP)
Screening Criteria (WHO/RCOPHTH)
- Birth weight <1500 g (or <2000 g if clinically unstable)
- Gestational age <31 weeks
- First screening: 4–6 weeks postnatal age or 31 weeks postmenstrual age (whichever later)
ROP Zones & Staging
- Zones I–III (posterior → peripheral)
- Stages 1–5 (1=demarcation line → 5=total detachment)
- Plus disease: vascular dilation and tortuosity — indicates aggressive disease
- Type 1 ROP / Threshold: Treatment required
Treatment
- Laser photocoagulation to avascular retina
- Intravitreal bevacizumab (off-label) — particularly Zone I disease
- Scleral buckle / vitrectomy for Stage 4–5
Nursing role: Ensure screening schedule followed. Parental education. Support developmental needs of premature infant. Document findings clearly.
GCC Context — Ophthalmology Nursing
Diabetic Eye Disease Epidemic in GCC
The GCC countries (Saudi Arabia, UAE, Qatar, Kuwait, Bahrain, Oman) have among the highest global diabetes mellitus prevalence rates — estimated 15–25% in adult populations. This drives epidemic levels of diabetic retinopathy.
Key Statistics
- Diabetic retinopathy: leading cause of preventable blindness in working-age adults in the GCC
- Saudi Arabia: ~18% adult DM prevalence (IDF estimates)
- UAE: ~16–19% adult DM prevalence
- Qatar: ~16% adult DM prevalence
- GCC DR screening programmes expanding rapidly
Diabetic Retinopathy Screening Programmes
- Saudi Arabia: Vision 2030 health initiatives; MOH-led diabetic retinopathy screening integrated into primary care; SCHS-certified ophthalmology nurses coordinate grading programmes
- UAE: DHA (Dubai) and DOH (Abu Dhabi) mandated annual eye screening for all registered diabetic patients; telemedicine retinal photography expanding
- Qatar: PHCC-led community screening; QCHP licensed nurses participate in screening clinics
Nursing implication: Ophthalmology nurses are integral to DR screening — operating retinal cameras, grading images, coordinating referrals, providing patient education in Arabic.
Trachoma — Historical to Eliminated
Trachoma: bacterial (Chlamydia trachomatis) — leading infectious cause of blindness globally.
- Was historically highly prevalent in GCC and Middle East due to poverty, water scarcity, poor hygiene
- WHO SAFE strategy: Surgery, Antibiotics (azithromycin), Facial cleanliness, Environmental improvement
- Most GCC countries have now achieved WHO elimination target (<1 case/1000 population)
- Saudi Arabia, UAE, Qatar declared trachoma-free
- Ongoing vigilance in migrant worker populations
GCC achievement: WHO certified elimination in most GCC states — a public health nursing success story.
Dry Eye Disease — GCC Climate
GCC climate factors create unique dry eye burden:
- Extreme heat and aridity — low ambient humidity
- Ubiquitous air conditioning (indoor dehumidification)
- Desert dust and sandstorms (khamsin/shamal)
- High screen/device usage
- High prevalence of Sjogren's syndrome (autoimmune)
Management
- Lubricating artificial tears (preservative-free preferred for frequent use)
- Omega-3 fatty acid supplementation — systemic anti-inflammatory
- Warm compresses + lid hygiene (meibomian gland dysfunction)
- IPL (intense pulsed light) therapy — for MGD
- Cyclosporin 0.05% (Restasis) / lifitegrast (Xiidra) — prescription
- Punctal plugs
Vernal Keratoconjunctivitis (VKC)
GCC highly prevalent — hot climate, young males (children/adolescents), allergic/atopic background.
- Symptoms: Intense itching (hallmark), photophobia, thick mucous discharge, blepharospasm
- Signs: Giant papillae ("cobblestones") on upper tarsal conjunctiva, Trantas dots (limbal), Shield ulcers (corneal, central — vision-threatening)
- Seasonal pattern: Worse in spring/summer in temperate climates; year-round in GCC
Treatment
- Mast cell stabilisers: sodium cromoglicate 2%, nedocromil
- Antihistamine drops: olopatadine, ketotifen
- Topical steroids: short course only (cataract/glaucoma risk with long-term)
- Ciclosporin 1–2% drops (preservative-free)
- Cold compresses, cool environment, avoid rubbing
- Shield ulcer: debridement, therapeutic contact lens, intensive lubricants
Nursing education: Avoid eye rubbing — worsens symptoms and can cause keratoconus. Regular follow-up essential during flares.
GCC Nursing Regulatory Bodies — Ophthalmology
| Body | Jurisdiction | Relevance |
|---|
| DHA | Dubai, UAE | Ophthalmic nursing licensing; annual CPD requirements; retinal screening competencies |
| DOH | Abu Dhabi, UAE | Scope of practice for ophthalmic nurses; intravitreal injection support competencies |
| MOH UAE | Northern Emirates | Northern UAE licensing; competency frameworks aligned with DHA/DOH |
| SCFHS | Saudi Arabia | Classification of ophthalmic nursing as specialty; Saudi nursing board exams include ophthalmology content; Prometric exam |
| QCHP | Qatar | Qatar Council for Healthcare Practitioners; ophthalmology nursing licensure; Prometric CBT exam |
| NHRA | Bahrain | National Health Regulatory Authority; nursing competency standards |
Exam tip: GCC ophthalmology nursing exams commonly test: glaucoma drug mechanisms, DR classification, acute angle closure management, post-op cataract care, intravitreal injection complications.
GCC Exam Prep — MCQ Practice (DHA / MOH / SCFHS / QCHP Style)
Q1. A patient presents with sudden unilateral severe eye pain, nausea, blurred vision, and a fixed mid-dilated pupil with a hazy cornea. IOP is 52 mmHg. What is the MOST appropriate IMMEDIATE nursing action?
- A. Apply an eye patch and refer routinely
- B. Instil artificial tears and observe for 2 hours
- C. Call ophthalmologist immediately and prepare IV acetazolamide, pilocarpine drops
- D. Perform fluorescein staining to rule out corneal ulcer
Correct: C. This is acute angle closure glaucoma — an ophthalmic emergency. IOP of 52 mmHg requires immediate reduction. IV acetazolamide 500 mg, topical pilocarpine and timolol are first-line. Urgent ophthalmology is mandatory. Routine referral or observation is inappropriate.
Q2. According to WHO definitions, a patient with best-corrected visual acuity of 3/60 in both eyes is classified as:
- A. Mildly visually impaired
- B. Moderately visually impaired
- C. Severely visually impaired
- D. Blind (profound visual impairment)
Correct: D. WHO defines blindness as best-corrected visual acuity worse than 3/60 (or visual field <10° in better eye). 3/60 is the threshold — at or below 3/60 = blind category. 6/60 = severely visually impaired (legal blindness threshold in many countries).
Q3. A diabetic patient undergoes intravitreal anti-VEGF injection. The FOLLOWING DAY they call reporting increasing eye pain, severe redness and blurred vision. The nurse should:
- A. Reassure that this is a normal post-injection reaction and to continue antibiotic drops
- B. Advise ibuprofen and review at next scheduled appointment
- C. Advise the patient to attend the eye unit IMMEDIATELY — possible endophthalmitis
- D. Advise warm compresses and rest for 48 hours
Correct: C. Increasing pain, redness and vision loss after intravitreal injection is endophthalmitis until proven otherwise. This is a sight-threatening emergency requiring same-day assessment. Vitreous tap and intravitreal antibiotics may be needed within hours. Reassurance is dangerous in this context.
Q4. A premature infant born at 28 weeks gestation weighing 1,100 g. When should FIRST retinopathy of prematurity (ROP) screening be performed?
- A. At 2 weeks postnatal age
- B. At discharge from NICU, regardless of age
- C. At 4–6 weeks postnatal age or 31 weeks postmenstrual age, whichever is LATER
- D. At 3 months corrected gestational age
Correct: C. ROP screening timing follows the "later" rule: 4–6 weeks postnatal OR 31 weeks postmenstrual age, whichever comes later. This infant at 28 weeks GA: 31 weeks PMA would be 3 weeks postnatal — so first screen at 4–6 weeks postnatal age applies. Screening too early misses treatable disease; too late risks missing the treatment window.
Q5. A patient with a gas bubble (C3F8) in the eye after vitreoretinal surgery is planning to fly internationally for urgent family reasons. What is the CORRECT nursing advice?
- A. Flying is safe if the patient uses oxygen during the flight
- B. The patient may fly after 2 weeks post-operatively
- C. Advise to sit in a pressurised first class cabin only
- D. Air travel is ABSOLUTELY CONTRAINDICATED until the gas is completely absorbed — risk of acute vision loss from gas expansion
Correct: D. Intraocular gas (SF6, C3F8, air) expands at altitude as cabin pressure drops. This can cause acute IOP elevation → central retinal artery occlusion and permanent blindness. C3F8 lasts 6–8 weeks. The patient must NOT fly until the ophthalmologist confirms gas has been absorbed. They should carry an alert card. Urgency of travel does not override this risk.
Ophthalmology Nursing Guide — GCC Exam Prep | DHA · DOH · MOH · SCFHS · QCHP | Updated April 2026