/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/delegationpractice-protocols/,/clinical/cckm-tools/content/delegationpractice-protocols/ambulatory-delegation-protocols/,

/clinical/cckm-tools/content/delegationpractice-protocols/ambulatory-delegation-protocols/name-97373-en.cckm

201711331

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Delegation/Practice Protocols,Ambulatory Delegation Protocols

Premedication Procedures in Ophthalmology - Adult - Ambulatory [64]

Premedication Procedures in Ophthalmology - Adult - Ambulatory [64] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols



Delegation Protocol Number: 64

Delegation Protocol Title:
Premedication Procedures in Ophthalmology - Adult - Ambulatory

Delegation Protocol Applies To:
UW Health Ophthalmology Clinics

Target Patient Population:
Adult patients undergoing eye examinations requiring or procedures requiring dilated pupils or
intraocular pressure exams

Delegation Protocol Champion:
Neal Barney, MD – Department of Ophthalmology

Delegation Protocol Reviewers:
Gary Lukes, Clinic Coordinator - Ophthalmology
Mary Sue Reilly, Clinic Manager - Ophthalmology

Responsible Department:
Department of Ophthalmology

Purpose Statement:
To delegate authority from Ophthalmology Providers to Registered Nurses (RNs) and Ophthalmic Technicians
(COTs) in UW Health Ophthalmology Clinics to order dilating eye drops to adult patients who require a dilated
fundus exam or who are undergoing testing or photography which requires a dilated pupil, and to administer
anesthetic drops to adult patients who require an intraocular pressure (IOP) exam.

Who May Carry Out This Delegation Protocol:
Registered Nurses (RNs) and Certified Ophthalmic Technicians (COTs) trained in the use of this protocol

Guidelines for Implementation:
1. This protocol is initiated when a patient presents for a dilated fundus exam, testing or photography requiring
a dilated pupil, or an intraocular pressure (IOP) exam.
2. The RN/COT will review the medical record including problem list, allergies and medications, paying
particular attention to any issues with eye medications or drops.
3. If the patient has any of the following contraindications to the protocol, the staff will consult the provider
prior to ordering and administering any drops.
3.1. Allergy to dilating or numbing drops specified in this protocol
3.2. Pregnant
3.3. Narrow anterior angle chamber or history of acute angle closure
3.4. Blood pressure exceeds 180 mmHg systolic or 100 mmHg diastolic. (The RN/COT will consult the
provider for direction on where to send patient for appropriate medical follow-up.)
3.5. Abnormal or questionable results for pupil symmetry, reaction to light, or Marcus Gunn reflex
4. If the patient has none of the listed contraindications the RN/COT will order and administer the following:
4.1. Dilation Required
• Phenylephrine 2.5% one drop and tropicamide 1%, one drop to each eye requiring dilation.
These medications may be repeated once in 5-7 minutes with retinal disease patients if pupils
show little response to initial drops or as requested by the provider. RN/COT technician will
review history or interview patient to determine presence of retinal disease.
4.2. Intraocular Pressure (IOP) Exam
• TonoPen IOP Method – one drop to each eye of of proparacaine 0.5%
• Goldmann Tonometer IOP Method – one drop to each eye of flourescein sodium
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


0.25%/benoxinate hydrochloride 0.4%
5. The RN/COT will instruct the patient that blurred vision and photophobia may occur for 4-6 hours and
will provide disposable sunglasses if patient did not bring their own.
6. The RN/COT will document the following for each patient:
6.1. The medications administered
6.2. Medication concentration
6.3. Number of drops given
6.4. Specify eye(s) to which medications administered
6.5. Evidence of teaching


References:
1. Ophthalmic Medical Assisting by the American Academy of Ophthalmology 4th edition, copyright 2006
2. Nurses Guide to Clinical Procedures, Jean Smith Temple and Joyce Young Johnson 6th edition copyright
2010

Collateral Documents/Tools: NA

Approved By:
UW Health Ambulatory Protocol Committee: January 2012, *July 2014, *March 2017
UWHC Pharmacy and Therapeutics Committee: January 2012, *August 2014, *March 2017
UWHC Medical Board: February 2012, *August 2014, *March 2017
UW Health Chief Clinical Officer: *August 2014; *March 2017

Effective Date: March 2017

Scheduled for Review: March 2020
*Expedited Review Process
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org