Nurse-led clinics in the UK were first endorsed by the Government in the 1990s in a variety of documents including Making a Difference (Department of Health, 1999) and the Chief Nursing Officer's 10 key roles for nurses set out in The NHS Plan(2000), which also required hospital management to make changes and respond to the Government's strategy for nursing and midwifery by introducing new ways of working to improve service delivery by providing more quality care and treatment.
The field of ophthalmology has seen the development of several nurse-led services in recent years (Dunlop, 2010; Sandinha et al, 2012; Shum et al, 2017; Mohamed et al, 2018) including, for example, in the areas of oculoplastic surgery, cataract surgery, ocular oncology and intravitreal injections for medical retina disease. The authors' hospital, a tertiary ophthalmic centre within the subspecialty of oculoplastics, offers an outpatient lacrimal clinic service dealing specifically with the diagnosis and management of patients presenting with a watery eye, known as ‘epiphora’. The causes of watery eye are multifactorial, some of which require management with surgery, but others can be managed either conservatively or with the use of topical medications. The assessment of such patients requires a systematic approach, including the application of a few specialised clinical tests.
Until recently, patients in the lacrimal clinic have been assessed by an oculoplastic doctor—usually of surgical fellow or consultant grade. The ophthalmic nurses undertook lacrimal syringing as an assessment tool to report findings that the doctors explored further. However, it was proposed that, with the appropriate training and experience, a specialist nurse practitioner would be able to provide an equivalent safe and high-quality service to patients in a nurse-led setting, as opposed to the surgeon-led lacrimal clinic. Some of the proposed advantages of a nurse-led lacrimal clinic included an increase of patient flow through the oculoplastic service while maintaining a high level of patient satisfaction, improved cost-efficiency and an opportunity for nurses to develop new clinical skills. A period of training and a pilot study was therefore initiated. An audit was undertaken comparing the nurse-led diagnosis and management plans with that of an oculoplastic fellow or consultant. In addition, patient waiting times in the clinic and patient satisfaction were assessed, as important indicators of quality of care.
This article provides the reader with a rationale for managing watering of the eye and an outline of the anatomy and physiology of the lacrimal system. It illustrates how a variety of pathologies within this system can result in the development of a watery eye. Diagnostic and management decision-making will be explored, followed by the results of the pilot study and audit.
Rationale for managing watering of the eye
It is important to diagnose and treat patients with watery eyes, as this symptom has been shown to decrease patients' quality of life through impairment of their ability to perform activities of daily living (such as reading, watching TV and driving), cause embarrassment during social interactions, and reduce overall happiness (Shin et al, 2015). In addition, failure to treat a watery eye may impact the effectiveness of many ocular treatments, such as the administration of topical glaucoma medications, or may prevent an ophthalmologist from proceeding with cataract surgery owing to the potential risk of an infection. In cases of watery eye due to blockage of the tear drainage system, the patient may be predisposed to infection of the tear sac (dacryocystitis).
The lacrimal system
Tear secretion
Tears are made by the lacrimal gland, which is a tubular organ located in the superotemporal orbit. The primary purpose of tears is to protect and lubricate the ocular surface (Farmer et al, 2017). The tears form a thin film over the eye; the film is composed of three layers (Dartt and Wilcox, 2013):
Tear drainage
Drainage of tears away from the eye is mediated by the nasolacrimal tear drainage apparatus. This tear drainage system begins at the lacrimal puncta in the medial aspect of the upper and lower eyelids. In healthy subjects, the puncta should be open and in firm apposition to the globe (eyeball). The puncta are the openings of the superior and inferior canaliculi. These canaliculi pass approximately 2 mm vertically, then turn 90º and run 8-10 mm medially to join the lacrimal sac. The lacrimal sac lies in a bony fossa in the anterior medial orbit and extends inferiorly to form the nasolacrimal duct. This duct measures 12 mm in length and has a distal valve, the valve of Hasner, before it opens into the nose through an ostium at the inferior meatus (Kanski et al, 2007). See Figure 1.
The tears drain into the puncta from the tear meniscus along the lid margins by capillary action and also due to the negative pressure created by the sac along each canaliculus. As the sac is surrounded by the orbicularis muscle, normal blinking movements result in negative pressure in the sac when the lids are open and positive pressure when the lids are closed.
Causes of a watery eye
The causes of a watery eye are multifactorial but can be broadly divided into two categories:
Some patients will have a combination of factors from both groups.
Overproduction of tears
Often referred to as ‘reflex tearing’ or ‘tear hypersecretion’, overproduction of tears is triggered by conditions that compromise the stability of the normal tear film or the health of the ocular surface. These include ocular surface inflammation or irritation (by smoke, dust, foreign bodies or injury), allergic eye disease, and blepharitis, which causes meibomian gland dysfunction that leads to evaporative dry eye. The superficial oily layer of the tear film is particularly implicated in tear overproduction; a deficiency in the oily layer results in evaporation of the aqueous layer, and this leads on to reflex tear hypersecretion. The most common cause of this is blepharitis, in which there is inflammation of the lid margin and dysfunction of the meibomian glands (Obata, 2002; Call et al, 2016).
Impaired tear drainage
Obstruction along the nasal lacrimal drainage system causes ‘true epiphora’, which is defined as overflow of tears on to the face. An obstruction can be congenital or acquired (Shen et al, 2016). In adults, obstructions are largely acquired and include the following causes:
Other non-obstructive causes of epiphora include malposition of the lacrimal puncta due to outward rolling of the lower lid (ectropion) or lacrimal pump failure in lower lid laxity or in cases of weakness of the orbicularis muscle such as facial nerve palsy (Damasceno et al, 2011).
Assessing the reason for watering of the eye
History-taking
To assess the reason for watering of the eye and its impact on the patient, the nurse will obtain a thorough history of the presenting complaint, duration, onset, and severity of symptoms. Symptoms that can suggest reflex tearing as the cause for a watery eye include itching, discharge, red eyes or a burning sensation of the lids, and often a worsening of symptoms in cold weather or during certain seasons. These symptoms reflect poor health of the ocular surface.
Symptoms that suggest poor tear drainage include whether tears drip down the cheek (true epiphora as seen in nasolacrimal duct obstruction), or down the lateral side of the face (indicative of eyelid laxity, which contributes to poor lacrimal pump function and punctal malpositions).
A past medical history, particularly a past ophthalmic and nasal history, including infections, injuries, surgical procedures and radiation exposure, is important to elicit as these can lead to alteration of the anatomy or scarring of the nasolacrimal system.
Other systemic conditions known to cause watering of the eye, and specifically nasal lacrimal obstruction, are sinusitis, sarcoidosis and granulomatosis with polyangiitis. In addition, conditions that can cause dry eyes and reflex tearing include rheumatoid arthritis, sarcoidosis and Sjögren's syndrome.
A drug history is the next step and should include specific questioning regarding the use of drugs known to potentially impact the tear drainage system. For example, previous use of cytotoxic drugs such as mitomycin C is known to cause punctal-canalicular stenosis in 14-43% of patients (Kopp et al, 2004; Khong and Muecke, 2006). Anti-glaucoma medication used to decrease the eye pressure, such as timolol and pilocarpine, are associated with nasal lacrimal duct obstruction (Kashkouli et al, 2008; Ortiz-Basso et al, 2018) and chronic use of adrenaline (epinephrine) may cause closure of the vascular plexus, which is responsible for the opening and closure of the lumen of the lacrimal passage (Paulsen et al, 2001).
The systemic neoplastic medication 5-fluorouracil blocks the enzyme thymidylate synthetase, and the drug docetaxel used in breast cancer treatment induces changes in the lacrimal sac and nasal mucosa (Esmaeli et al, 2003).
Examination
Facial inspection can reveal signs suggestive of inadequate tear drainage. For example, facial asymmetry may suggest a congenital malformation or acquired trauma to the nasolacrimal duct drainage system. Observation of the eyelids may show lid laxity or frank displacement of the lacrimal puncta away from the globe, as is the case in ectropion (Arabi et al, 2011). A facial palsy may be observed, which can contribute to impaired lacrimal pump function. Complications of chronic epiphora, such as dermatitis of the eyelid due to constant facial dabbing with a tissue, are also sought.
The lacrimal sac (near the medial canthus) is palpated for warmth, tenderness, and swelling. A soft mass may indicate a dacryocele or a collection of pus in the lacrimal sac. Digital massage with gentle pressure over the mass can produce mucopurulent discharge from the eyelid puncta. A hard mass and/or nasal bleeding along with watering may be suggestive of a more sinister problem. The nose is examined for congestion, purulence and bleeding by asking the patient to keep the head in a neutral position as the tip of the nose is carefully elevated with the thumb, so that the nasal cavity can be visualised with a pen torch or other light source.
Slit lamp examination is performed by the nurse to look for signs of ocular surface disease that would contribute to tear overproduction. Examples of signs that can point to the cause of tear hypersection include subtarsal papillae in allergic eye disease, or collarettes or crusting seen around the base of the lash in blepharitis and, in rare instances, demodex mite infection. Blepharitis can also appears on examination as thickened, hyperaemic lid margins, blocked meibomian openings, excessive abnormal meibomian secretions, and frothy discharge on the lid margins.
The eyelid should be everted and examined to detect hidden foreign bodies such as ingrowing eyelashes (trichiasis) and the puncta inspected closely for narrowing, indicating punctal stensosis.
Internal examination and in-depth visualisation of the tear film, cornea and conjunctiva is aided by the help of 2% fluorescein dye and the slit lamp cobalt blue filter, which illuminate disturbance in the integrity of the structures, such as conjunctival staining in Sjögren's syndrome and corneal ulcers. A reduced tear film or lowered tear meniscus, and increased debris in tear film indicates dry eyes, whereas a raised tear meniscus indicates impaired lacrimal outflow.
Investigations performed in the nurse-led lacrimal clinic
Specific tests are performed by the nurse in the lacrimal clinic, which further help to delineate the cause(s) of watery eye. These include:
If the patient tastes salty water after gently syringing, the lacrimal drainage system is patent. However, if high injection pressure was applied, a ‘functional’ duct obstruction could still be present despite the nasolacrimal system appearing normal under high pressure testing. If functional obstruction is suspected (persistent epiphora in the absence of other explanation) further tests are necessary to confirm this, such as the use of dacrocystograms or dacryoscintigraphy. A dacrocystogram is radiographic visualisation of the lacrimal sacs and associated structures after injection of a contrast medium. Dacryoscintigraphy is a form of nuclear medicine imaging that provides greater understanding of the outflow of tears under more physiological conditions and can be particularly useful in cases of functional nasolacrimal duct obstruction (Wearne et al, 1999).
If the patient cannot taste salty water, the lacrimal drainage system is blocked. The type of ‘stop’ experienced on inserting the cannula helps to determine the level of blockage:
In some instances mechanical or infectious processes can narrow the punctum, making lacrimal syringing impossible without punctal dilation. In such instances the nurse will insert a pointed double-ended steel rod 2 mm downwards, gently rotating it clockwise and anticlockwise to dilate the punctum before lacrimal syringing is performed.
Diagnostic and management decision making
As discussed above, in many cases, patients present with more than one cause for watering of the eye. The nurse's role in the lacrimal clinic is to carry out a systematic history taking and physical examination and use investigative skills and experience of similar cases to assist in decision-making, diagnosis and management planning (Balogh et al, 2015). The practitioner should also listen carefully to the patient's concerns in order to address symptoms that would provide the greatest relief.
The practitioner's decision-making skills are particularly important in the management of multifactorial disease, such as in many patients with watery eye, as it is often challenging to identify the more pertinent contributing factors, and to balance the benefits and risks of the treatment of the various aetiologies.
Watering of the eyes due to reflex tearing or lacrimation requires medical management to address the dry eye condition with topical lubricants or blepharitis with lid scrubs, oral tetracycline and topical steroids and/or lubricants. Ingrowing lashes or trichiasis would require epilation or electrolysis.
True watering or epiphora involves largely surgical correction. The nurse in the lacrimal clinic should have an understanding of the common surgical procedures involved and be able to outline the principles of surgery, and the benefits and risks to the patient to gain consent. If patient consent is gained, the patient is listed for surgery and sent for pre-operative assessment.
Examples of surgical treatments for lacrimal outflow obstruction include:
If, following discussion with the nurse, a patient chooses endonasal dacryocystorhinostomy (surgery performed up the nose) to access the tear duct rather than external dacryocystorhinostomy (through the medial skin overlying the nose) the nasal cavity is examined thoroughly by the surgeon with a rigid endoscope to help plan surgery.
All decisions require careful consideration of extenuating factors such as age, comorbidity, personal choice and convenience before a management plan is formulated. In many cases a decision may be made by the patient not to proceed with surgery and this should be respected. The nurse creates the management plan, which entails documentation of findings, diagnosis and how the condition should be managed. Where a medical management plan is not made, the nurse provides advice and/or prescribes medication, arranges a follow-up visit or discharges the patient. A surgical management plan involves the nurse recording the specific surgery required and the patient decision on whether or not to proceed. The nurse completes her consultation by listing the patient for surgery as required, obtains informed consent, writes to both the patient and the GP and refers the patient to pre-assessment.
Nurse lacrimal training programme
Owing to her expert knowledge and previous experience in the field of oculoplastics, the nurse consultant was chosen to be trained over a 6-month period in the assessment and management of patients with a watery eye. Training was delivered by a single oculoplastic consultant (DE) and included a review of the anatomy and physiology of the lacrimal system, its relationship to watery eye symptomatology, and the specific and systematic history and examination skills required to assess and diagnose patients with a watery eye. Once a foundation of knowledge had been established, further training took place through hands-on clinical assessment on a case-by-case basis in the surgeon-led lacrimal clinic. To aid in nurse-led patient assessment, a clinic proforma was designed (Figure 2) and used to record patient findings, and the derived diagnosis and management plan.
All decisions made by the nurse were recorded on the clinic proforma and were reviewed and discussed with the consultant to aid learning. The training and pilot study lasted 10 months (30 August to 25 May 2019).
Nurse-led lacrimal clinic audit
Audit aim
The aim of the audit was to assess the accuracy of diagnosis and management in the nurse-led lacrimal clinic. The nurse diagnosis and management plan was compared with the diagnosis and management plan made by the oculoplastic doctor for each patient. Since there is no known previous national standard in the diagnosis and management accuracy of lacrimal conditions, this study had no other alternative but to set its own standard to examine practice comparisons between the practitioners in the audit. Given that the lacrimal clinic was previously staffed by oculoplastic doctors, the achievement of the same decision or agreement between the nurse and an oculoplastic doctor was considered to have indicated the achievement of a ‘gold standard’. In addition, an assessment of patient satisfaction, waiting time and throughput was carried out.
Methods
The audit began in January 2019. The first 100 consecutive patients seen were audited. The nurse consultant independently assessed each patient and completed the clinic proforma. Following the nurse assessment, the satisfaction questionnaire was given to the patient by the clerk. This included the questions shown in Table 1.
| Question | Possible responses |
|---|---|
| How long did you wait to be seen by the nurse practitioner today? |
|
| How would you rate the consultation you had today with the nurse? |
|
After completion of the nurse-led appointment and the satisfaction questionnaire, the same patient was then assessed separately by the oculoplastic doctor. Although not blinded to the nurse's assessment and management decision, the doctor was able to either agree with the decision or override it. A level of agreement between the diagnosis and management plan between the nurse and the doctor was made, recorded as either A (agreement) or D (disagreement). In some cases, the patient was deemed unsuitable to have been booked into the nurse-led lacrimal clinic (U=unsuitable) due to previous complex lacrimal disease. In other cases, pathology unrelated to watery eye symptoms was incidentally picked up by the nurse, which required further input from the doctor (DR=requiring doctor input).
Audit results
The demographics of participants included 73 females and 27 males. The presenting symptoms of patients were multifactorial with complains of epiphora (74), discharge (12), redness (8), pain (12), itching, (32) and grittiness (30). Symptom duration ranged between 5 months and 20 years. A total of 61 patients had been seen and referred by a GP, 21 patients attended Moorfields Eye Hospital accident and emergency department and 18 were referred from other internal services such as primary care or external disease.
Patient satisfaction and waiting times
All 100 patients completed the patient satisfaction questionnaire. Eighty-nine patients rated the consultation as excellent. Nine patients considered the nurse consultation very good and two patients rated it as good (Figure 3).
A total of 72 patients were seen within 15–30 minutes, 28 patients seen within 30–60 minutes. No patients waited for over 1 hour to be seen (Figure 4).
Clinical throughput
During the audit period the nurse saw 100 patients in the nurse-led clinic, which was comparable to the number of new patients usually seen by a doctor. Therefore the nurse-led clinic throughput was considered efficient.
Level of agreement between nurse and doctor
The level of diagnostic agreement between the nurse and doctors was 98.67% regarding diagnosis and 98.33% for the management plan (Figure 5 and Figure 6).
One patient was deemed unsuitable (U) for the nurse-led lacrimal clinic as his history included two previous dacryocystorhinostomy surgeries at another hospital and required a dacrocystogram and to be reviewed in the doctors' clinic.
In the case of another patient, the nurse recommended medical management of lid hygiene for blepharitis. The patient also had a mild entropion (rolling in of the eyelid) on lid closure so the nurse recommended lid-tightening surgery. Although the doctor agreed with the lid hygiene management plan (A), there was disagreement (D) with regard to the current need for surgery. However, the doctor recommended that surgery may be needed in future.
In one patient the nurse diagnosed a mucocele requiring dacryocystorhinostomy surgery, and there was agreement in the diagnosis and management plan with the doctor (A). However, additional incidental findings of bilateral significant lacrimal gland swelling were picked up by the nurse unrelated to the patient's diagnosis of mucocele and confirmed by a doctor (A). This condition required additional input from the doctor (DR) to investigate and manage the lacrimal gland swelling.
The various conditions diagnosed are shown in Figure 7.
Nurse consultant's perspective on setting up a nurse-led clinic
From a personal perspective I believe there must be an organisational need for the nurse-led service and it must be clearly communicated to all stakeholders. This pilot study was established on the basis that a trained nurse would be able to reduce the huge number of lacrimal patients waiting to be seen in the outpatient clinic. As an autonomous nurse consultant I was suited to the role since I currently manage and have previously set up other nurse-led clinics. In addition, I am in possession of the prerequisite skills to deliver excellent care, namely, competence in undertaking ophthalmic examination of the eye, good rapport during consultations with patients, ability to perform lacrimal syringing, ability to gain consent, leading in decision making, prescribing medication with the relevant supportive information and technological infrastructure and independently managing my own caseload. Therefore with the provision of a mentor and further training in the specific area of lacrimal assessment and management I could extend the delivery of excellent care to patients without it being a time-consuming detriment to the service.
Nonetheless, time was the main challenge faced as I patiently awaited formulation of the protocol to ensure the training was systematic and encompassed every area of lacrimal assessment to be undertaken. Time away from the clinic, be it annual leave or study leave, acted as a barrier to completing the training sooner. On completion of training it was important to discuss with the service manager:
This would help establish a timely functional clinic and ensure the appointment letters to be generated included all the information necessary. A protocol was established for governance and to ensure my indemnity insurance was covered by the Trust. Before the pilot went live it was also important to inform all supportive services such as the X-ray department and pre-assessment that they were likely to see an increase in their activities.
Conclusion
The introduction of the nurse-led lacrimal clinic has established new ways of working and has improved the overall service delivery. Specifically, the audit has demonstrated that there was a high level of agreement between nurse and doctor diagnosis and management plans as well as a high level of patient satisfaction. This demonstrates that high-quality care is being maintained as the service moves from surgeon-led only to include nurse-led care. Furthermore, in an increasingly burdened and under-resourced healthcare system, the addition of a nurse-led clinic has enabled patients to be seen in the clinic in a more timely manner from the point of referral, and also frees up the senior surgical team (the oculoplastic fellow and consultant) to see patients with more complex disease such as those who have undergone multiple previous operations. Additionally, it has provided an excellent opportunity for the nurse consultant to develop clinical skills, experience and expertise.
Financially, the clinic was initially considered cost neutral within the audit period. However, following the pilot a nurse specialist joined the team, and the throughput per clinic has doubled, which has enabled the nurse-led lacrimal clinic to become a positive income generator for the Trust. The introduction of a second nurse practitioner has also improved the sustainability of the service.
Overwhelmingly, the pilot study audit results point to the establishment of a nurse-led lacrimal clinic as a safe, effective, efficient and profitable service that can provide excellent care for the benefit of many patients. However, referrals to the nurse-led clinic are carefully scrutinised to exclude patients with complex conditions, such as those who have previously undergone lacrimal surgery. Additionally, an oculoplastic doctor should be contactable for a second opinion should one be required in the case of unexpected findings or complexity. The audit will be repeated on a 2-yearly basis.