Opthalmic_Surgery.pptx_3_by_SALIH_NOOR.pptx

Ophthalmic Surgery
Prepared by: SALIH NOOR
Lecturer : PIMMS
noorsalih44@gmail.com
1/19/2023
SALIH NOOR
PIMMS
1

SPECIAL FEATURES OF OPHTHALMIC
SURGERY
• The patient undergoing ophthalmic surgery faces
impairment or loss of vision if the outcome of the
surgical intervention is unfavorable.
• Special features of ophthalmic surgery aim to prevent
such a loss.
• Surgical procedures on the eye are extremely delicate
and require precision instrumentation, a steady hand,
and quiet surroundings.
• The operating microscope, all accessory equipment, and
microinstruments should be set up and checked before
the surgical procedure.
• The outcome of the procedure depends on the condition
of the instruments.
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Ophthalmic Instrumentation
• The tips of these expensive, fragile
microinstruments should be protected and handled
with extreme care before, during, and after use.
• Eye instrumentation is unique to the specialty.
• With rare exception are any of the following used in
any other type of surgery:
• • Self-retaining lid retractors and scissors
• • Graspers and manual retractors
• • Enucleation and measuring devices
• • Punctum plug and forceps
• • Corneal trephine
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Enucleation and measuring devices
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Punctum plug
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Corneal trephine
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Operating Microscope
• Ophthalmic surgeons use the operating microscope
for intraocular procedures.
• When the operating microscope is used, the
operating bed should be mechanically secure, and
the patient’s head should be stabilized.
• Inadvertent movement is not tolerated because of
the minute surgical field.
• The headrest should be narrow so that it does not
obstruct the surgeon’s approach to the surgical site
from the sides of the vertical column of the
microscope.
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Ophthalmic Microscope
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Continued…
• The patient is instructed about the importance
of remaining still during the surgical procedure.
• Otherwise, the patient could easily move out of
the field of vision under the microscope or
precipitate a complication.
• The assistant observes the surgical procedure
through an assistant’s ocular and irrigates the
cornea with BSS to prevent drying (Fig. 39-13).
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Continued…
• The assistant should bring to the surgeon’s
attention any potentially unsatisfactory situation
that the surgeon cannot observe from his or her
position.
• Some scrub persons are trained to first-assist.
• The surgeon and the assistants should limit their
caffeine intake before the procedure to promote
steady hands when using microinstrumentation
under the microscope.
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Ophthalmic Drugs
• Many drugs are critical to the preparation of the eye for
the surgical procedure.
• Orders for patient preparation often contain common
abbreviations that identify the eye(s) to receive drops:
OD (right eye), OS (left eye), and OU (both eyes);
however, the Joint Commission (TJC) has advised that
the use of abbreviations can lead to human error and
recommends not using them in the interest of patient
safety.
• Before skin preparation, the circulating nurse instills the
medications and anesthetic drops as ordered.
• The following procedures should be observed when
instilling eye drops:
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Continued…
• 1. Wash your hands.
• 2. Identify the correct medication, eye, and patient.
• 3. Check for allergy or sensitivity.
• 4. Explain the procedure to the patient.
• 5. Tilt back the patient’s head, and tell the patient to
look up.
• While gently pulling down on the lower lid, instill
the medication in the middle third of the inner
aspect of the lower lid.
• Release the lid while the patient slowly closes the
eye to retain the drop; let the patient close the eye
between repeated drops.
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Continued…
• In a struggling child, have a parent tilt the child’s
head back and close both eyes.
• Instill the medication at the inner canthus.
• The drop will roll into the eye as the child opens
it.
• Some medications, such as atropine, may have a
systemic
• effect. To prevent drainage into the tear duct,
nose,
• and stomach, gently blot excess fluid.
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Continued…
• In small infants or young children, systemic
absorption is avoided by applying finger pressure
over the lacrimal sac region (inner canthus) of both
eyes simultaneously for 1 minute.
• 6. Administer only the specified number of drops.
• 7. Read the label on the vial before each instillation.
• 8. Each patient should receive a fresh, single-use,
disposable vial of medication that is discarded after
use.
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Mydriatic and Miotic Drugs
• Medications may be given to alter the size of the pupil
• (Fig. 39-14), including the following:
• • Mydriatic drops: 2.5% or 10% phenylephrine to dilate
the pupil.
• • Mydriatic-cycloplegic drops: 1% cyclopentolate
hydrochloride, 1% atropine, and 0.25% scopolamine to
dilate the pupil, paralyze the ciliary body, diminish the
reaction to trauma, and prevent anterior synechiae (e.g.,
adherence of iris to the lens).
• These drugs are longer acting than phenylephrine.
• • Miotic drops: 2% pilocarpine to constrict the pupil.
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Mydriatic & Miotic, synechiae
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Local and Topical Anesthesia
• Except in children and select patients, local and
topical anesthetics are commonly used for
ophthalmic surgical procedures.
• Most surgical procedures are scheduled as
monitored anesthesia care or attended local.
• An anesthesia provider monitors the patient and
administers oxygen and/or supplements the local
anesthetic if necessary.
• Intravenous midazolam and/or fentanyl
(Sublimaze) or propofol (Diprivan) is often given to
relax the patient.
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Continued...
• The sedative effects of these agents increase the
patient’s tolerance to procedures.
• If a general anesthetic is used, the usual general
anesthesia routines are followed.
• Local anesthesia consists of the following:
• 1. Topical instillation of anesthetic drops.
• The drug used may be 0.5% proparacaine , 0.5%
tetracaine , or 2% lidocaine.
• Most surgeons prefer to use this method in
combination with moderate sedation.
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Continued…
• 2. Local infiltration by injection of the lids and tissue
around the eyes with anesthetic medication.
• 3. Retrobulbar block.
• An absolutely quiet eye is necessary, especially at
high magnifications of the microscope.
• When general anesthesia is used, some surgeons
administer a retrobulbar block for immobility and to
lower IOP.
• A popular solution for this block consists of a
mixture of equal parts of 2% or 4% lidocaine and
0.75% bupivacaine, 3.75 units/mL, for penetration.
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Continued…
• A 25-gauge 3 11⁄2-inch (3.8-cm) needle with a sharp,
rounded point (e.g., Atkinson needle) and a 5-mL
syringe are used.
• The surgeon inserts the needle behind the eyeball to
anesthetize the globe and paralyze the muscles.
• The patient is asked to look up and away from the
injection site and is told that a slight burning
sensation may accompany the injection.
• Up to 5 mL of solution may be slowly and carefully
injected.
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Atkinson needle
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Continued…
• Retrobulbar block may be followed by intermittent
massage of the eye to soften it, lower IOP, and
facilitate surgical manipulation during cataract
extraction, especially when insertion of an IOL is
being contemplated.
• Massage is continued until the IOP is lowered to a
satisfactory level (e.g., 10 to 12 scale reading on
sterile Schiotz tonometer).
• Some surgeons apply the Honan balloon pressure
device to soften the eyeball after a retrobulbar block
(Fig. 39-15).
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Tonometer
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Continued…
• In using this device, a small inflatable balloon is
placed directly over the closed eyelid and is
secured with a strap around the head.
• The balloon is inflated to 30 to 40 mm Hg for 5
to 10 minutes to lower intravitreal pressure.
• 4. Peribulbar anesthesia.
• This is an alternative to retrobulbar injection.
• With this method, injections are made in the soft
tissue superior and inferior to the globe rather
than behind it.
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Continued…
• A greater amount of the same anesthetic
solution used for retrobulbar injection is
• used for peribulbar anesthesia. With this
procedure,
• adequate anesthesia is obtained without the risk
for retrobulbar hemorrhage.
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Ophthalmic Solutions
• Extreme and constant care must be used with
ophthalmic
• solutions. Nearly all of these solutions are colorless and
• may be stored in similar receptacles. These solutions are
• immediately and individually labeled by the scrub
person;
• the solution is discarded if the identification is missing.
• Solutions for intraocular use must be separated from all
• other solutions. Ideally, these solutions should be
filtered
• with micropore filters before injection.
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Continued…
• Epinephrine or other sympathomimetics may have side
• effects when used with some anesthetic agents.
Therefore,
• the surgeon should check with the anesthesia provider
• before using medications intraoperatively. Medications
• that may induce vomiting are also avoided. Any straining
• or gross movement may cause intraocular hemorrhage, a
• sudden rise in IOP that results in a loss of vitreous, or
the
• expulsion of ocular contents through the wound; all of
• these conditions can cause blindness.
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Opthalmic_Surgery.pptx_3_by_SALIH_NOOR.pptx

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