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Keywords Hygiene/Eye care/Eye cleansing/Swabbing This article has been double-blind peer reviewed

The eyes have a vital role in helping us carry out our daily activities safely (Shaw, 2014). Light entering the eye is converted into nerve

impulses that are transmitted to the occipital region of the brain, where they are converted into the images we see. Patients may present to hospital with pre-existing eye conditions or need help to care for their eyes during a period of illness. Nurses need to be able to:l Carry out a baseline assessment of the

eye and vision;l Deliver essential care including eye

cleansing;l Administer topical therapies;l Know when to make a referral for

specialist support.

External structure of the eyeThe external structures of the eye (Fig 1) serve an important function in protecting the eye from injury. For example, the eye-lashes provide a barrier to grit and debris and eyebrows prevent sweat from running into the eyes. Eyelids contain muscles that enable them to open and close (Dougherty and Lister, 2015) and the lacrimal appa-ratus is responsible for tear production and drainage. Tears provide:l Lubrication that prevents drying of

the ocular surface; l A smooth surface that allows light to

enter the eye;

l Antimicrobial protection against potential pathogens (McDermott, 2013). Tears drain away from the eyes into the

nasal cavity via the lacrimal puncta (sin-gular punctum) (part of the lacrimal appa-ratus), which are found on the upper and lower eye lids (Fig 1).

Eye assessmentEyes should be assessed as part of a holistic patient assessment and as part of personal care. It is important to discuss any long-term eye problems the patient has and docu-ment how these are managed; for example, glaucoma requires regular eye drops, or blepharitis (inflammation of eye lid margin) may require a personalised plan of care.

Falls are linked to poor eyesight so eye assessment is an integral part of falls pre-vention. Older people with impaired vision fall 1.7 times more often, and sustain hip fractures 1.3-1.9 times more frequently than those with normal eyesight (College of Optometrists, 2014; College of Optome-trists and British Geriatrics Society, 2011). In response to these concerns, the Royal College of Physicians (2017) has produced a bedside tool to help check older patients’ eyesight and reduce hospital falls risk.

Patients should be asked whether they have any new problems with their vision. These should be reported immediately, as acute eye problems such as acute glau-coma, orbital cellulitis or retinal detach-ment may result in serious eye complica-tions if treatment is delayed.

It is important to record any sight aids the patient uses such as glasses, contact lenses and a prosthetic eye. If necessary, patients should be given support to use these aids, such as ensuring that patient’s glasses are clean; nurses should seek expert help if they lack skills to meet a patient’s needs.

Procedure for eye cleansingEye cleansing is an essential aspect of daily hygiene and patients in hospital or resi-dential/care home, or those who are dependent on care at home may need sup-port to maintain this aspect of their care. Those with reduced vision or blindness may struggle to maintain independence in an unfamiliar environment, such as

Clinical PracticePractical procedures Ophthalmology

Authors Tendai Gwenhure is clinical educator, Moorfields Eye Hospital NHS Foundation Trust; Eileen Shepherd is clinical editor, Nursing Times.

Abstract Eyes should be assessed as part of a holistic patient assessment and eye care is an essential part of daily personal care. This article outlines the principles of eye assessment and the procedure for eye cleansing.

Citation Gwenhure T, Shepherd E (2019) Principles and procedure for eye assessment and cleansing. Nursing Times [online]; 115: 12, 18-20.

Fig 1. External structure of the eye and the lacrimal glands

Principles and procedure for eye assessment and cleansing

Box 1. Indications for eye care lTo clean the eye of discharge

and crustslAfter eye surgery to prevent

complications lPrior to eye drop installation lTo soothe eye irritation, pain and

discomfortlTo prevent corneal damage/abrasion

in unconscious/sedated patients

Sources: Dougherty and Lister (2015); Shaw (2014)

Eyebrow

IrisPupil

Lateralcanthus

Lower eyelid

Palpebral conjunctivacovers lids

Sclera covered bybulbar conjunctiva

Medialcanthus

Lacrimalpunctum

Eyelash

Upper eyelid

Lacrimal gland Excretory ductsof lacrimal gland

Lacrimalcanal

Nasolacrimalduct

Interior meatus ofnasal cavity

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3. Discuss the procedure with the patient, ask about their usual eye care routine and any problems they have with their eyes.

4. Obtain informed consent to carry out the procedure.

5. Ensure the patient’s privacy by screening the bed or ensuring their room door is closed.

6. Assemble your equipment and ensure the bed is at the correct working height.

7. Position the patient sitting comfortably with the head tilted back (Fig 2).

8. Decontaminate hands and put on an apron. Gloves should be applied if assess-ment indicates they are required.

9. Assess the external appearance of the eye.

10. Ask the patient to close their eyes.

11. Check for any discharge, bruising or inflammation (Fig 3). If the eyelids fail to close completely, report this to medical staff as it may be a sign that a lump or cyst is present (Dougherty and Lister, 2015), or there may be problems with eyelid muscles.

12. Ask the patient to open their eyes and check for signs of redness in the conjunc-tiva and for evidence of discharge (Fig 4) (Dougherty and Lister, 2015). These signs may indicate the presence of infection or inflammation.

13. Take a sterile swab in your hand and moisten it slightly with sterile water or saline. A very wet swab can be uncomfort-able for the patient and increase the risk of contamination of the opposite eye.

(Royal College of Nursing, 2018) and be aware of local policies for glove use for this procedure. When gloves are required they must be single-use and should be disposed of according to local infection prevention and control policy (Loveday et al, 2014).

The procedure1. Confirm the patient’s identity.

2. Decontaminate hands following the five moments for hand hygiene (World Health Organization, 2009).

hospital, and may need help to manage their eye care (Dougherty and Lister, 2015).

Indications for eye cleansing are outlined in Box 1. The procedure aims to maintain healthy eyes and it is important that infec-tion from one eye is not transferred into the other. General principles underpinning the procedure are outlined in Box 2.

Equipmentl Sterile dressing pack;l Sterile low-lint swabs;l Sterile water or saline (cool boiled

water can be used in the home);l Disposable apron.

Glove useNurses need to assess individual patients for risk of exposure to blood and body fluids

For more articles on practical procedures, go to nursingtimes.net/clinical-archive/#pracproc

Clinical PracticePractical procedures

Box 2. The underpinning principles of eye cleansing lThe eye should be carefully assessed

before eye care is providedlPatients should be encouraged to

carry out their own eye care if they are assessed and found able to do so

lEach eye should be treated as a separate procedure and a separate dressing pack should be used for each eye to prevent cross contamination

lInfected eyes should be treated last to reduce the risk of cross infection (Dougherty and Lister, 2015)

lA clean technique can be used for eye cleansing unless there are specific concerns about infection risk such as in post-operative patients – in which case an aseptic procedure should be used (Dougherty and Lister, 2015)

lLow-lint or lint-free swabs should be used to cleanse eyes as lint fibres can scratch the cornea. Cotton wool should be avoided as the cotton wool threads can catch on the eyelashes

lDougherty and Lister (2015) recommend sterile water for eye cleansing and suggest sterile sodium chloride 0.9% may cause stinging and irritation. However, other authors suggest using sodium chloride 0.9% (Shaw and Lee 2016; Ring and Okoro, 2012)

lA light source should be positioned behind the nurse so it illuminates the eye, but it should not shine directly into the eye as this will be uncomfortable for the patient

Fig 2. Ask the patient to sit with their head tilted back

Fig 3. Check for discharge, bruising or inflammation

Fig 4. Check for signs of redness in the conjunctiva and for evidence of discharge

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14. Ask the patient to close their eyes again and swab the lower eye lid from the medial canthus outwards (Fig 5). Swabbing in this direction reduces the risk of introducing infection into the lacrimal punctum (Dougherty and Lister, 2015). Do not allow the swab to go above the lid, to ensure that contact between the swab and cornea is avoided – this is uncomfortable and may cause damage to the cornea.

15. Repeat, using a clean swab each time to reduce the risk of infection, until the eyelid is clean.

16. Ask the patient to look down and slightly evert (turn inside out) the upper lid (Fig 6a).

17. Moisten a swab and gently clean the upper eyelid from the medial canthus out-wards (Fig 6b).

18. Repeat with a new moistened swab until the lid is clean. Dab off any excess water/saline around the eye to ensure patient is dry and comfortable.

19. Make the patient comfortable.

20. Remove your apron (and gloves if worn).

21. Decontaminate hands.

22. Repeat the procedure on the second eye if required.

23. Record the care in the patient’s records. Record and report any abnormal findings.

ReferencesCollege of Optometrists (2014) Focus on Falls. London: College of Optometrists. College of Optometrists, British Geriatrics Society (2011) The Importance of Vision in Preventing Falls. Bit.ly/BGSVisionFallsDougherty L, Lister S (2015) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Oxford: Wiley-Blackwell.Loveday HP et al (2014) epic3: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection; 86: S1, 1-70.McDermott AM (2013) Antimicrobial Compounds in Tears. Experimental Eye Research; 117: 53-61.Ring L, Okoro M (2016) A Handbook of Ophthalmic Standards and Procedures. Oxford: M&K Publications. Royal College of Nursing (2018) Tools of the Trade: Guidance for Health Care Staff on Glove Use and the Prevention of Contact Dermatitis. Bit.ly/RCNGlovesRoyal College of Physicians (2017) Look Out! Bedside Vision Check for Falls Prevention. Bit.ly/RCPLookOut2017Shaw M (2014) How to administer eye drops and ointments. Nursing Times; 110: 40, 16-18.World Health Organization (2009) WHO Guidelines for Hand Hygiene in Health Care. Bit.ly/WHOHandHygiene

Fig 5. Swab the lower eye lid from the nasal corner outwards

Fig 6a and b. Ask the patient to look down and slightly evert the upper lid