Effect of Post Cataract Surgery Discharge Instructions on Reducing Eye Infection among Elderly Patients

Introduction

Cataract is a common serious eye disease, considered the major cause of blindness globally.  It is called a “disease of aging” and considered the leading cause of reversible visual impairment worldwide, affecting 95 million people globally.  (Jin, et al., 2018). In Egypt there were about 1 million cases of blindness and about 3 million cases visually impaired as a result of cataract. Nearly 60% of the visually impaired in Egypt have cataract. (WHO, 2018)

Cataract disease can lead to major negative effects on the quality of older people’s lives as it closely associated with increased risk for falling, fair or poor health status, restricted activity, impaired driving ability, and significant emotional distress for the patient as well as family members. When cataract affects the older adult’s safety or quality of life, cataract surgery is usually recommended. (Boyd, 2018).

The rate and risk of cataract surgery complications has significantly decreased with better technique, but it is greater among elderly  as a result of diminished immunity response, poor nutrition as well as normal age related changes and presence of comorbidities. Endophthalmitis considered the most feared and serious complication of intraocular surgery that result in irreversible blindness. (Deborah, 2018)

Several studies highlighted that, the implementation of   post-operative discharge instructions is the primary concern of the postoperative nursing care that gives positive results in decreasing the incidence of complications, and help patients to return to their activities of daily living (ADLs) within a shorter period of time^.  (Taha and Abd Elaziz, 2015).

Significance of the study:

Endophthalmitis is a nightmare for surgeons, hospitals, and undoubtedly for the patients. Postoperative endophthalmitis is the most common form of endophthalmitis ,it represents approximately 70% of all cases , about 90% of postoperative endophthalmitis occurs after cataract surgery as the most common intraocular surgery specially among elderly people , it^'s occurrence can lead to irreversible blindness in the infected eye within hours or days of symptom onset as well as increase in health care cost. (Durand, 2017)

Several studies revealed that endophthalmitis considered the most common complication after cataract surgery. One of these studies was conducted in Ophthalmology Department at Assiut University hospital. In this study, the investigator found that thirty one cases of endophthalmitis were clinically diagnosed after cataract surgery and recommended that patient education and self-care management postoperatively   is very important in order to reduce the incidence of eye infection and to improve patient outcome.  (Gharamah, et al., 2012)

In addition to, another study which conducted by (Khattab and Abdel Fattah, 2014) in Cairo University, who founded a fifty patients were clinically diagnosed as post-operative endophthalmitis, mainly after cataract surgery, who attended the Research Institute of Ophthalmology. The results revealed that, the most common isolated microorganism was Pseudomonas aeruginosa (57%) followed by Staphylococcus aureus (43%).

Aim of the study

The aim of the current study was to evaluate the effect of post cataract surgery discharge instructions on reducing eye infection among elderly patients.

Research hypothesis

Implementations of post cataract surgery discharge instructions will be reduce eye infection among elderly patients.

Research Design:

The quasi-experimental research design was utilized in the current study.

Subjects:

A purposive sample of one hundred elderly patients was involved in the current study according to the inclusion criteria, they classified into two equal groups (n= 50) for a control group and (n= 50) for study group according to the determination of the sample size based upon the following sample calculation formula.

N = 100 elderly patients

Inclusion criteria:

1)       Patients 60 years and older of both sex.

2)  Patients who are undergoing cataract surgery for first time in preoperative period.

Exclusion criteria: 

1)       Patients who have unstable and uncontrollable chronic disease.

2)       Unable to communicate.

3)       Refuse to participate.

4)       Patients missed during follow up period.

Setting:

The current study was carried out at ophthalmology department and follow up was done at the ophthalmology outpatient clinics at Minia University Hospital.

Study Duration:

Data collection for this study was carried out through six months,   from the beginning of January 2018 till the end of June 2018.

Tools of data collection

The data of this study was collected by using three tools. 

1.  First Tool:

A Structured interviewing questionnaire sheetwas developed by the researcher in order to collect the necessary data from the patients based on relevant literature. (Tahaand Abd Elaziz, 2015). It was collected by the researcher at the first interview and it covered two main parts:

Part (I): Sociodemographic data: that included (age, sex, marital status, income, education, residence, job, and smoking habit).

Part (II): Medical profile: that included (previous eye disease and past medical history).

2. Second Tool: (self-care compliance scale):    

This scale was used to evaluate patient’s self-care compliance post cataract surgery. Adopted from (Cho and Rho, 2012). It included 4 domains as the following: 1^st one was eye dropsincluded4 items: -( washing   hands before the eye drops, not let the tip of bottle touch the eye or eyelid,instilling eye drops as indicated frequency, instilling different eye drops at 5-minute intervals). 2^nd one washygiene included 3 items: - (washing hair but did not wet operated eye, washing face but did not wet operated eye,having shower but did not wet operated eye). 3^rd one was protection of operation siteincluded6 items: (applying eye shields during the bedtimes, avoid rubbing or compressing the eye, avoid sleeping on the side of operation or lying on face, avoid facing flame, avoid watching T.V for 7 days after surgery, avoid exposure the eye to sun rays,   dirt and dust).4^th domain was daily lifeincluded 2 items : (visiting the clinic on the reservation date of follow up, restricting outdoor activities and   strenuous exercise like soccer and swimming).

The score for each item ranged from (1to 3),not done take score (1) ,done sometimes take score (2) ,done always take score (3).Scoring system for this scale calculated by the sum of patient's response, it ranges from 15 to 45. When patient's assessments range from (15 to 23) this mean low self- compliance but when he/ she have scored (24 to 32) this means has moderate self-compliance, finally if it equal (33 and more) indicate higher self-compliance. This scale was applied three times on patients (study group) through three observations (1^st day, 7^th days and 30^th days) post operatively. 

3-Third Tool:  Post-operative assessment tool

Third tool was used to assess incidence of eye infection post cataract surgery adopted from (Tahaand Abd Elaziz, 2015). It was applied three times on both study and control groups through the three observations (1^st day, 7^th days and 30^th days) post operatively through 10 closed-end questions, it included sudden/severe pain, persistent headache, redness, discharge, blurring, photophobia, floaters, difficulty to see TV, bruising of the eye or eyelids and difficulty recognizing faces.

Tools validity

The tools and scale content validity was done to identify the degree to which the used tools measure what was supposed to be measured? Developed tools and scales were examined by a panel of five expert's opinion in the field of medical-surgical nursing specialty and ophthalmology.

Reliability of tools

Tools reliability was done to identify the extent of tools items were measurable with the study concept and its correlation with each other. The reliability of self-care compliance scale was Cronbach's   ⍺= 0.8.

Pilot Study

A pilot study was carried out on 10% (10 patients) of the total sample to test feasibility, objectivity, and applicability of the data collection tool& scale. The pilot study sample was excluded from the study sample.

Ethical Consideration

An official permission to conduct the study was obtained from the ethical committee of the faculty of nursing, dean of nursing faculty, Minia University Hospital director, research center afflicted to Egypt Ministry of Health and agreement from Egypt academic for research center and technology. Subject's participation in this study was voluntary who was informed about the purpose, procedure, benefits, nature of the study, follow up and his/her had the right to withdraw from the study at any time without any rationale. Oral consent was obtained from subjects, informed them that obtained data will not be included at any further researches without a second consent. Confidentiality and anonymity of each subject were ensured through coding of all data and protecting the obtained data.

Procedure (Techniques for Data Collection):

The current study was conducted by preparing of different data collection tools, collection of study data was done through daily basis (3days per week) during morning or evening shift. Selected sample was admitted to ophthalmology department in preoperative period (day before surgery) patient who was scheduled for cataract surgery was informed by the investigator individually about purpose and nature of the study, then investigator obtained oral consent from those who accepted to participate in this study.

The investigator has started a collection of socio demographic data from control group firstly in three months by using the first toolpreoperatively and follow up done by using the third tool three times post-operatively. While data collection from study group was started after finishing control group by using the first tool preoperatively, providing educational information and training practices for elderly patients undergoing cataract surgery, second tool, and third tool were used three times post-operatively.

Data collection for study sample was done in ophthalmology department first during their hospitalization (ranged from 1to 2days) then in outpatient clinic for follow-up. The total number of sessions for data collection & instruction session for the study group was 1-2 sessions. Session plane designed according span of attention and level of education of the elderly patients.

Educational brochure was prepared in Arabic language; it wasformulated by investigator after reviewing related literature. (Community Eye Health Journal, 2016), (Beth, et al., 2015). It included:

• Knowledge about meaning, causes, risk factors, prevention, signs & symptoms, treatment, complication of eye cataract as well as home self-care after cataract surgery.
• Practice included: technique of eye drops administration and eye care.

Post cataract discharge instructions explained by investigator for patient and patient's family regarding use of eye drops, wearing eye shield, protection of the eye, precautions to prevent infection, unusual symptoms, follow–up   as well as the investigator explained the steps and demonstrate application of instillation of eye drops technique and eye care, at the end of the session, a handout (photo brochure) was given to   the patients or relatives including postoperative instructions.

Follow-up for all patients (study &control) started at 1^st day 7^th day and 30^th   day postoperatively through face to face interview to evaluate patients compliance with the given instructions (for the study group) and to assess signs and symptoms of eye infection (for both groups).Also, the investigator was encouraged patients for follow up visits through calling them at different time to ensure that, they are compline with the given instructions; patients not come at pre appointment follow up were excluded from the sample.

Statistical analysis of data:

Statistical analysis was done by using Statistical Package for the Social Science (SPSS 20.0). Quality control was done at the stages of coding and data entry. Data were presented by using descriptive statistics in the form of frequencies and percentage for qualitative variables, and mean & standard deviation (SD) for quantitative variable. Chi square was used to test the association between two qualitative variables and the sample size large. Fisher's exact test used to test the association between two qualitative variables   and the sample size is small. Graphs were done for data visualization using Microsoft Excel. Correlation coefficient test was also used between two variables and statistical significance was considered at p ≤ 0.05.

Results

Table (1):  Distribution of the study and control group according to their socio-demographic data (n = 100)

        NS= not significant           

Table (1) Showed that, females had the highest percentage 64% and 54% for the study and control group respectively. As regards marital status 50% and 64% were married for the study and control group respectively.  In respect to the age, the mean age among study and control group was (63.8 ± 4.2years and 64.3 ± 4.2years) respectively. Concerning to residence; it was founded that 98 % and 92 %of study and control groups were lived in rural area respectively. As regarding to educational level; it was founded that, 70% and 82% of study and control group were illiterate respectively, while 76% of the study and control group not work.

As regarding to smoking habit, 82% weren’t smoke for both groups. Related to income level, it sufficient, more than 70% for both study and control group. Lastly, there were no significant differences between study and control groups regarding socio demographic characteristics

Table (2): Distribution of the study and control group regarding to their medical profile (n = 100)

NS= No Significant difference                                

Table (2) illustrated that 50% of the study and control groups had chronic diseases .Percentage of hypertension (HTN) was 40% and 77.8% for the study and control groups respectively, followed by diabetes mellitus (DM). Respect to presence of eye disease, it was founded that 16% and30% of the study and control group had previous eye disease.  Lastly, there were no significant differences between study and control groups regarding medical profile.

Table (3): Percentage distribution of the study group regarding to self- care compliance scale (n= 50)

Table (3) displayed that; more than 90% the study group were compline with the self-care instruction post operatively.

Figure (1) Percentage distribution of the study and control groups according to presence of eye infection manifestation after cataract surgery

Figure (1) Displayed that 32%   of the study group had no signs of infection compared to 6% of the control group didn’t had any signs of infection in 1^st day after operation. Also 66% of the study group had no signs of infection in 7^th day after operation compared to 24% of the control group. While 88 % of the study group had no signs of infection compared to 60% of the control group didn’t had signs of infection in 4^th week post operatively with statistical significance difference.