Eye-opening Careers
Advances in ophthalmologic technology create new opportunities for nurses

By Melissa Gaskill
May 14, 2003

When Penny Gold, RN, was working in the operating room years ago, she traded off with other nurses to avoid ophthalmologic cases. Then, an eye surgeon approached her and offered to teach her the field if she would work for him. She's now been in ophthalmology for more than 20 years.

"This is a field where you won't be bored; there is a lot to learn. It is very rewarding," said Gold, now OR supervisor at Southwestern Eye Center in Mesa, Ariz., a multispecialty, statewide practice performing all kinds of eye surgeries.

Students have little exposure to ophthalmology in nursing school or even after, and nurses who work in the field say those outside of it may know little about it or think it uninteresting. But those who do enter the field tend to stay.

"This is an incredibly exciting field to work in," said Jane Katzen, RN, director of refractive surgical services at Katzen Eye Care & Laser Center in Florida. "It gives you a tremendous degree of satisfaction to improve or return the miracle of sight."

Vision is precious to patients, for one thing. Gold has seen patients with more fear about a procedure on their eyes than they had about heart surgery. For another, doctors of ophthalmology can identify many health problems, and many diseases have complications that involve the eyes. Patients come from all walks of life and all age groups. No two days are ever the same.

"Leonardo da Vinci said about the eye, 'Who would believe that so small a space could contain the images of all the universe?' " said Victoria Navarro, MSN, RN, director of nursing at The Wilmer Eye Institute at Johns Hopkins. "The eye is a complex organ and there are many subspecialties within ophthalmology."

Many nurses enjoy that new technologies are continually being developed, so there is always something new to learn and improvements to be made. Cataract surgery, for example, used to be an inpatient procedure involving a stay in the hospital, sandbags to immobilize a patient's head postsurgery and eye patches. Today, patients walk out after a quick outpatient laser surgery, already with better vision. That kind of immediate result can be gratifying for a nurse, Gold said.

Degree of influence

Laser technology means ophthalmic procedures are quicker and less invasive. Outcomes are generally improved. Most procedures are done on an outpatient basis. Yet nurses are needed more than ever-to assess patients, provide pre- and postoperative instructions, perform diagnostic tests, give medications and counsel patients. They save physicians time and improve continuity of care. In freestanding surgery centers, nurses are often largely responsible for the safeguards that ensure that everything is being done correctly.

"Even though laser surgery is a safe and effective procedure, I want patients to understand there are still risks associated with it," said Jean Hill, MSN, RN, CRNO, nurse supervisor at the University of Iowa Hospitals and Clinics' Department of Opthalmology & Visual Sciences. "I don't think any of our doctors want a patient to be taken lightly."

Rapid growth in the number of freestanding clinics, many of them devoted primarily to Lasik (laser in-situ keratomileusis) vision correction, creates some concern among ophthalmology nurses. Because this procedure is an elective one, paid for out of the patient's pocket, centers are competing in ways that seem more suitable to consumer products than medical procedures. That makes many nurses uncomfortable.

"People need to ask appropriate questions and make an informed decision," Hill said.

"Advertising misleads people," said Kate Wilson, RN, a staff nurse at the ophthalmology clinic at Kaiser Permanente Redwood City in California, and selecting a surgeon on the basis of price is a bad idea. Patients should have extensive prescreening to determine if they are good candidates for the procedure-and surgery should not be performed on those who aren't.

Sharon Sjulstad, RN, CRNO, CNOR, director of operations at Barnet Dulaney Perkins Eye Center in Arizona, is comfortable with advertising, as long as patients know what they are getting. "But the patient has to dig deep to make sure they know."

Standardized vision

Concerned about the lack of standards in the field, a group of nurses helped develop a recommended-practices manual under the aegis of the American Society of Ophthalmic Registered Nurses. Katzen, Navarro and Sjulstad were members of the work group that wrote the standards.

"Lasik is not totally sterile like the OR," Hill said. "It is a combination of clean and sterile. We felt the situation needed to be researched to find the best practice of how to manage that, to ensure patients would not have adverse results from the surgery." The group expects the guidelines to be somewhat controversial, as well as to evolve in time.

"The idea was to have unified practices," Katzen said. "We made the first statement that anything that touches the eye must be sterile." As data are compiled on the effectiveness of the guidelines, evidence-based practices can ultimately be developed.

Part of the problem, though, is finding trained nurses or even nurses who are interested in the field, Sjulstad said. "Typically, technicians work up the patients in the clinic without nurses to help them through it." By providing guidance for those technicians, the standards, the authors hope, will improve patient care.

To Katzen, the ideal situation would be for nurses in ophthalmologic centers to be cross-trained, able to handle the technical aspects as well as the patient care. "Nurses have been trained in sterile procedures, where for the most part technicians have not," she said. For that to happen, the medical community must be educated about the value of a nurse in this setting.

"There's no question that it is a cost-containment issue," Navarro said. "But I think we will transcend it. Because there is a nursing shortage, we need to make sure nurses are taking care of patients and not doing routine tasks that someone else can do."

"If you have a crisis in the center-and we've had full cardiac and respiratory arrests-you need a nurse," Katzen said. "Nurses have been fully trained in CPR skills."

She encourages nurses to look into the field. "Not only is it exciting and fulfilling, but from a lifestyle standpoint, you are able to have fairly regular hours. It is mostly 9 to 5, five days a week."

Besides, as baby boomers age, the population needing eye care will grow tremendously. That means even more nurses will be needed.

Contact Melissa Gaskill at gaskill@dbcity.com