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Understanding the role of the glaucoma specialist nurse

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VOL: 101, ISSUE: 38, PAGE NO: 32

Elizabeth Gray, MSc, RN, is nurse adviser, Innovex UK Ltd

Glaucoma is a condition characterised by increased tension or pressure in the eye causing progressive structural or functional damage (Brunner and Suddarth, 1992). It is a chronic disease that requires life-long treatment and could ultimately lead to blindness (Odberg et al, 2001).

Glaucoma is a condition characterised by increased tension or pressure in the eye causing progressive structural or functional damage (Brunner and Suddarth, 1992). It is a chronic disease that requires life-long treatment and could ultimately lead to blindness (Odberg et al, 2001).

In 2000 the prevalence of glaucoma in the UK was estimated at around 3.3 per cent in those over 40 years and at more than 5 per cent in those over 80 years of age (Traverso, 2005). In industrialised countries, glaucoma is the second most frequent cause of blindness after age-related macular degeneration (Traverso, 2005).

Glaucoma is often asymptomatic until serious functional alterations, which are irreversible, have occurred. The fundamental factor in the prevention of damage caused by glaucoma is being able to identify it in its early stages (Traverso, 2005). This is often problematic as the majority of people do not routinely consult an eye specialist during their lifetime, and may never do so unless a problem becomes evident (Traverso, 2005).

Quality of life
Everyday functional disability depends on the visual demands imposed by a patient's daily activities (Altangerel et al, 2003), including demands from both work and leisure. Patients may lose quality of life for several reasons:

- Psychological impact of the diagnosis;

- Damage to the visual field;

- Side-effects of treatment;

- Cost of treatment.

There is no universally accepted measure of the impact of glaucoma on quality of life (Altangerel et al, 2003). This makes it difficult to establish the effect glaucoma has on quality of life, and can make it hard to gather evidence to demonstrate the beneficial effects of service improvement for patients.

Some authors have investigated possible links between measurable visual acuity and visual field and reported quality of life. Sumi et al (2003) found a significant correlation between visual disability and both the visual field and visual acuity measurements. Nelson et al (2003) noted a significant relationship between perceived visual disability and the severity of binocular field loss in groups of patients with early and moderate glaucomatous visual field loss.

Mills et al (2001) found patterns of significant, although weak, correlations between visual field measures and patient-reported visual functioning and glaucoma-related symptoms. They stated that conventional wisdom suggested that only visual field defects close to fixation are symptomatic. However, they found that field loss outside central points, although not specifically symptomatic, may affect patients' perceptions of visual well-being.

However, Jampel et al (2002) and Parrish et al (1997) both suggested that an objective measurement of visual acuity or visual field may not accurately reflect the actual or perceived ability of the patient to function.

Altangerel et al (2003) stated that it appears that an individual's perception of her or his quality of life is strongly affected by monocular visual damage, even when such damage has had little or no impact on actual ability to function. They suggested that the reason for this was that monocular impairment of visual acuity caused anxiety, which was responsible for a subjective deterioration in a person's quality of life preceding the experience of functional difficulties.

Nelson et al (1999) observed a loss of confidence in performing certain tasks by the glaucoma patients before real problems with visual disability were apparent. These findings serve to demonstrate how difficult it is to predict how glaucoma is affecting quality of life for an individual.

A number of studies have aimed to discover the actual indicators for assessing quality of life for people with glaucoma. Nelson et al (2003) identified five factors as the main groups of difficulties encountered by glaucoma patients:

- Near vision;

- Peripheral vision;

- Dark adaptation and glare;

- Carrying out personal care and household tasks;

- Outdoor mobility.

Their findings challenge the belief that glaucoma is an insidious process in which symptoms do not appear until the later stages of the disease.

Impact of diagnosis
There is convincing evidence that suggests the diagnosis of glaucoma can negatively influence a person's quality of life through increased anxiety, even though they may have good vision and few subjective visual problems (Altangerel et al, 2003). Giving patients the opportunity to discuss their concerns with a health professional may help them understand and adhere to advice. Nurses possess the necessary skills to develop this role.

In a study designed to explore the impact a diagnosis of glaucoma may have on patients, Odberg et al (2001) found that more than 80 per cent reported negative emotions and as many as 31 per cent were afraid of going blind, with 70 per cent believing they would go blind if their glaucoma was not treated. It is also interesting to note that 48 per cent of the study participants had not noticed any visual problem at all when the diagnosis was made.

Therefore it seems logical that part of the developing role for nurses in managing glaucoma is to ensure that the patient has the relevant information at diagnosis and has access to ongoing support.

Treatment goals
The treatment goal in glaucoma is to forestall deterioration of the traditional clinical end points of visual acuity and visual field (Lee et al, 1998). There is also an awareness among ophthalmologists and patients with glaucoma that both disease progression and glaucoma treatment carry a burden of both non-visual and visual symptoms that are of considerable concern to patients (Lee et al, 1998).

A brief education programme could improve levels of knowledge of glaucoma, but patient education must be repeated to maintain a useful effect (Odberg et al, 2001). Having easy access to advice from a nurse may help with compliance and concordance issues. If the patient chooses to talk to a nurse, this allows the nurse the opportunity to discuss specific problems and to arrange an early review if necessary.

In the study by Odberg et al (2001), older patients felt their vision to be poorer and had more visual problems than younger patients. On the other hand, they seemed less concerned. The younger patients were more anxious and inquiring.

Glaucoma patients tend towards anxiety related to gradual visual disturbance, and it is necessary to evaluate their quality of life in addition to traditional visual measurements of visual acuity and visual field (Uenishi et al, 2003).

Nelson et al (1999) used a questionnaire to identify the most commonly perceived disabilities in the daily life of patients with glaucoma. A loss of confidence in performing certain tasks was described by the patients before any real problems with visual disability were apparent.

From the beginning of their glaucoma, patients experienced difficulties in recognising steps on a staircase or pavement and had problems when trying to recognise familiar faces or reading timetables at railway stations.

Another study found that patients with advanced glaucoma had difficulty in outdoor activities, driving, recognising traffic signs and using ATM bank machines (Uenishi et al, 2003). Loss of hope for the future was an important problem in all groups of glaucoma patients. For this reason, psychological support of patients appears to be important (Uenishi et al, 2003).

Sinclair et al (2004) carried out a retrospective study to determine the characteristics of those patients who developed blindness as a result of glaucoma. They found that approximately 25 per cent showed definite evidence of poor compliance with the management of their condition in terms of failing to take medication, non-attendance at appointments and refusing to have glaucoma surgery when recommended by their ophthalmologist (Sinclair et al, 2004).

Early surgery should be considered if it is felt that the patients may have problems in complying with treatment. It is important that ophthalmologists are aware of support services that are available to their patients, so that rehabilitation and social workers can be given the opportunity to work with people who need their expertise (Sinclair et al, 2004).

Several studies in recent years have highlighted the fact that many people who are eligible to be registered as blind or partially sighted are not registered and are therefore denied access to support services (Sinclair et al, 2004).

Physicians should not rely on traditional methods such as visual fields to assess the impact of glaucoma on a patient, especially in its early stages. Careful discussions with the patient about her or his concerns, symptoms and feelings can bring a closer understanding of how glaucoma is affecting the patient's health-related quality of life. This in turn may help to guide rational choice of therapy, estimate the likelihood of concordance, and suggest avenues of appropriate counselling for the patient (Mills et al, 2001).

It is likely that visual functioning as reported by patients and visual function as measured by their physicians will correlate more closely as glaucoma damage increases with time (Mills et al, 2001).

National Service Framework
One of the priorities of the National Service Framework for Older People (Department of Health, 2001) is to provide evidence-based specialist care to improve eye health screening and low vision services (Watkinson, 2005).

The NHS and local authorities spend almost £20bn annually on long-term and residential care and nursing homes to support older people with visual impairment (Department of Health, 2001). Helping these people to maintain independence in their own homes would be much more cost-effective and would also help reduce the burden of failing sight on health services in the future (Watkinson, 2005).

Primary open angle glaucoma has a non-dramatic onset and generally occurs after the age of 40 (Watkinson, 2005). Most older people with glaucoma are based in the community and are not admitted to ophthalmic wards. Therefore the nurse's role is focused on patient education for self-management and control of the condition (Watkinson, 2005).

Concordance with treatment is vital to gain good control of the condition as there is no cure at present. The nurse should stress the importance of maintaining the intraocular pressure within normal limits in order to preserve existing sight and prevent any further visual field loss (Watkinson, 2005). Nurses should also stress to patients the need to attend regular clinic appointments in order to monitor further deterioration in the condition (Watkinson, 2005).

Although the recent National Service Framework for Long Term Conditions (Department of Health, 2005) focuses on neurological conditions, much of the guidance can apply to anyone living with a long-term condition. In terms of glaucoma, 'quality requirement 2: early recognition, prompt diagnosis and treatment' is particularly pertinent, as are the quality requirements surrounding ongoing care and support.

The majority of glaucoma services are currently located within acute care and many of the departments are overstretched. This means that the nurses involved in these services have limited time to spend with patients who have been diagnosed with glaucoma.

Changes in funding within the NHS, with the increased emphasis on primary care, may provide an opportunity to re-examine the management of glaucoma. Although shared care schemes between optometrists and ophthalmologists have been investigated and tried in some parts of the country (Gray et al, 1997; Jones, 2005; Urquhart and Rughani, 2005), lack of training and standardisation of equipment have been raised as possible obstacles to establishing such schemes nationwide.

Learning objectives
Each week Nursing Times publishes a guided learning article with reflection points to help you with your CPD. After reading the article you should be able to:

- Identify factors that may influence the quality of life for patients with primary open angle glaucoma;

- Have an understanding of the potential role of a glaucoma specialist nurse;

- Have an awareness of how National Service Frameworks may be used to develop services for patients with primary open angle glaucoma;

- Outline the purpose of treatment for patients with primary open angle glaucoma.

Guided reflection
Use the following points to write a reflection for your PREP portfolio:

- Outline your place of work and why this article is relevant for you;

- List the main points the article makes about primary open angle glaucoma;

- Explain any new information this article has taught you about primary open angle glaucoma;

- Outline how you intend to use this new information in your practice;

- Explain how you are going to disseminate what you have learnt from this article.

This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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