Factsheets Planning the Operation

Introduction

This factsheet will examine some factors that need to be considered when planning a person's stay in hospital, and how successful surgery can be achieved.

Planning

• The success of surgery for people with learning disabilities is often totally dependent on having a clearly identified and recorded plan of support that has been prepared before the actual admission and treatment.
• Staff working with people with learning disabilities may need to be able to reassure ophthalmic consultants that an appropriate level of support will be available to individuals during their hospitalisation and after their operation.  
• A staff support package (covering both pre-operative and post-operative care) is crucial - despite the fact that most operations are straightforward. Nurses are seldom available to offer special individual care.

Our Eye Surgery Support plan has been written to help family carers and staff plan eye operations.

Anaesthetic

Many eye surgical procedures these days can be performed under local anaesthetic. These include:

• Cataract surgery
• Laser treatments for diabetes and glaucoma
• Some interventions for Keratoconus (Intacs and Collagen Cross Linking)  

It is usually considered too risky for people with learning disabilities to have a local anaesthetic.  A general anaesthetic is usually given because of the problems people may have co-operating during a local anaesthetic.

Local anaesthetic involves considerable co-operation from the patient, who may need to keep their head still for up to twenty minutes, while the operation is performed.  A small minority of people do have local anaesthetics often because their other medical problems would place them at too great a risk for general anaesthetic. 

The Benefits of Surgery

Decisions involving surgery must not be prejudiced by the fact that someone has a learning disability.  There needs to be discussion, weighing up the benefits and potential risks.  Before surgery is offered or denied, time should be taken to discuss: 

• individual needs
• social implications of sight loss on their life
• medical issues - e.g. other existing eye problems, general health
• possible alternatives to surgery
• likely outcomes
• what support the person will need.

It is vital that an informed choice is made.

Support staff should have high levels of awareness of visual impairment and its effects on individual lives before they are involved in decisions about surgery.  Parents, carers and advocates also need this information, and everyone involved may possibly require advice and support if the damage to the eye is severe.

Promoting individual need

• The patient’s understanding of the procedure may be limited so it is vitally important to have the same member of staff or family carers supporting them at appointments - to explain and give confidence.  Ophthalmologists often deal with staff who barely know the individual or his/her background. 
• Supporters need to make doctors and nurses aware
  • of the person’s strengths and abilities
  • hospital staff need to know what type of support family carers or staff can provide during their stay in hospital and when they return home
  • how the individual is affected by his/her visual impairment
  • should remember that their opinion is valued - particularly by medical staff who may have limited experience of people with learning disabilities.  
• Parents and staff members who know the individual well can influence the way that procedures are undertaken to gain the maximum co-operation from the person.  They need to be consistent and positive in approach.
• Parents and staff can reduce stress for people with learning disabilities by finding out about the techniques involved in eye examination, as well as the surgical process.

Talking to the individual

• Many people (of all levels of ability) are fearful of going into hospital for an operation.
• It is important that the person knows that someone they trust will be there with them throughout their time in hospital. 
• Before the operation there must be careful preparation.  People need to know as much as possible about what is going to happen to them. 
• People may need to accept eye drops after surgery.  They may be an important part of the healing process.  Ways to insert drops and familiarise people with the procedure are described in our factsheet, ‘Eye drops for people with learning disabilities’.
• People need to be shown the eye pad and the shield which are worn after the operation.
• People may want written information or audio versions which they can read by themselves.  

Consent

Please look at our Consent for Medical Treatments booklet

Planning admission to hospital

It is crucial to explain to the consultant, registrar or any junior doctors involved and the hospital admissions' officer, that a person's date of admission must not be cancelled or postponed unless the person is unwell.  Being emotionally prepared for an operation and then coping with a change of date, is distressing for all of us. 

Medication, allergies and eye patches

It is important to find out if any medication (such as pain relief) and eye drops will be given and the possible side effects or contra-indications. 

Visiting the ward before admission

It is usually possible for supporters and carers to contact the hospital staff and arrange for people to make several visits to the ward if they are to be admitted.  This will be an opportunity to discuss the person’s special needs and to anticipate any problems.

Staffing issues

Adequate staff cover may be the most important consideration if the person is being offered surgery.  If there is not enough support it may be impossible to convince medical staff that an operation is the best course of action.  This must form part of pre-operative planning. 

Risk assessment

Before some medical procedures it may be appropriate to carry out a thorough risk assessment on all aspects of the person’s lifestyle.  Some of the factors that need to be considered are:

• Safe activities that need to be found to keep the individual stimulated after surgery.
• Sports that involve contact or bending may need to be avoided.  Swimming may cause irritation or infection.
• Boredom or under-stimulation that may increase the likelihood of self-injurious behaviour.
• What might be appropriate for the person to withdraw from  (such as day centres, college and so on) during the ‘risk period’ in case another service user causes injury to the individual.  During the risk period, it is safer to provide a more tailored 1:1 service away from busy environments.
• Hygiene issues - hair washing, bathing and face washing all need to be done with care to prevent the risk of injury.
• Eye make-up that should be avoided.  There is a possibility that some products could irritate the eye or cause problems.
• What information should be sought before people insert contact lenses following operations.

Follow-up treatment

• An operation is not the end of the story!  It is obviously important that all follow-up appointments are kept and supporters continue to monitor people closely for signs of eye problems.
• People who have had surgery to improve their sight usually need regular eye examinations and new prescriptions for glasses or contact lenses. 
• Registered blind/severely sight impaired and partially sighted/sight impaired people are entitled to free NHS sight tests - but we hope that eye surgery will be successful in preventing more people losing their sight.

June 2009  

For further information on this topic please read:

Eye Conditions that Require Surgery

Eye Drops for People with Learning Disabilities

Eye Lid Hygiene

Eye Surgery for People with Learning Disabilities

Preoperative Procedures

Day of the Operation

What to Expect at Hospital

Related Information:

Cataracts and Eye Surgery 

Consent for Medical Treatment

Eye Poking and Touching in People with Learning Disabilities

Eye Poking and Touching - Strategies for Supporting People

Glaucoma

Keratoconus

Low Vision Services for People with Learning Disabilities