Care of the Pre-Operative Opthalmic Surgical Patient

Care of the Pre-Operative Opthalmic Surgical Patient

•Advances in opthalmic surgical techniques and improved anesthetics have lessened the duration of the Peri-op and Post-op period.
•Most surgeries are completed within an hour.
•The goal of management is to maximize patient’s level of comfort using the least amount of sedation.

Discharge planning is coordinated in the Surgeon’s office pre-operatively. Patients must have a responsible adult drive them home and stay with them for the first 24 hours.

•Communication between the Circulating RN, the Block RN and Anesthesia is essential due to the quick turnover of cases.
•Efficient and effective time management while maintaining patient focused care is vital

Common Opthalmic Surgeries
Cataract Surgery
Normal Eye: A healthy, clear lens allows a sharp image to fall on every part of the retina allowing a crisp, clear image to be seen.
Cataract Eye: A cloudy lens scatters light, causing a hazy image to be seen.

•Usually less than 45 minutes
•Outpatient procedure
•Almost painless
•Usually only topical anesthetics (eye gtts) and lidocaine gel

VITRECTOMY
•a surgical procedure in which instruments are introduced into the eye to treat or repair various diseases and conditions of the retina and vitreous.
•performed under local anesthesia and in an ambulatory or outpatient operating room.
•30 minutes to 2 hours depending on the nature of the condition and the complexity of the operation.
•Some of the diseases that can be treated with a vitrectomy include retinal detachment, diabetic retinopathy, macular hole.

TRABECULECTOMY
•Patients with dangerously high IOP (glaucoma) that can not be treated with eye gtts, may require a trabeculectomy.
•a "flap valve" is made on the top of the eye, the white part of the eye hidden under the upper eyelid. This becomes a bypass for the blocked natural drain relieving the eye pressure



PRE-OP EYE DROPS
•Orders checked by Surgeon on the Department of Opthalmology Surgical Record
•Started 1 hour pre-op in SDS, continued in Block area
•Located on the SDS drug cart and pre-bagged.

MYDRIATICS AND CYCLOPLEGICS
Mydriatics dilate the pupil - tropicamide
- phenylephrine
Cylcoplegics dilate the pupil and cause paralysis of accommodation (inability to focus) -tropicamide
-cyclopentolate
-homatropine
NSAID
•Flubiprofen gtts
- Inhibition of intra-operative miosis (constriction) and inflammation of the eye.
TOPICAL AGENTS
•Tetracaine 0.5% gtts routinely used and given as prescribed by Anesthesia.
–Currently no standing order, but anesthesia will give a verbal
–Onset of action 5-10 seconds
–Gtts go in both eyes
–Located in blue bin on shelf in Block area
–Lidocaine gel is sometimes instilled by anesthesia to complete block
BLOCK MEDS
•Rovicaine/ Lidocaine
•Hyaluronidase: an enzyme that inactivates the Collagen Tissue
1. Less quantity of the anaesthetic solution required when the enzyme is used.2. Greater diffusion of the anaesthetic solution 3. Prolonged effect of the injected solution.

NURSING CONSIDERATIONS
•Instillation of gtts improve with tilting pts head upward
•place first gtt inside the lower lid
•Other drops may be instilled from above with pt looking downward.
•Avoid placing gtts on cornea
•The natural blinking of the eye distributes the drug
•Avoid touching the tip of the applicators to any part of the eye

ROLE OF THE BLOCK NURSE
•Admit pt to block area, receive report from SDS RN – when is next gtt due?
–TIP: at bottom of SDS nursing record the schedule will be noted ie:
•#1 0900 KL #2 0915 #3 0930 #4 on call

•Identify correct pt: check armband, check allergies
•Confirm laterality of operative site. SDS RN usually marks operative side with surgical marker, if it is not done, Block RN can do it.

•In order to increase efficiency, the Block RN will do the check on the OR side of the pre-operative checklist. This is necessary also, because as the Block Nurse, you also want to ensure that everything is complete and accurate before the anesthetist gives the block
–Anesthetic record
–H&P
–Consent
–Etc.
–NOTE: pt’s on anticoagulant therapy need a recent InR

•Ensure pt has voided
•Ask pt to move up on stretcher so head fits comfortably in the head support. TIP: place a rolled blanket under pt’s neck
•Place a blanket under pt’s knees
•Apply ECG lead and BP cuff. These will remain on for the entire surgical procedure (the leads will be returned with the next patient)

•NP can be applied and O2 turned on once versed is given by anesthesia
•Continue with the application of gtts. Communicate with anesthesia when you have given the 3rd dose
•Tetracaine gtts: 3 gtts OU intervals of 1 gtt per eye
•Topical Betadine solution to operative eyelid
•Anesthesia then ready to inject local anesthetic and the BLOCK
•After block, eye is taped shut to prevent corneal abrasions
•Monitor VS q5min until transfer to OR 18

HONAN BALLOON
•A Honan Balloon is sometimes used, especially with Dr. Dixon’s patients.






GUIDELINES FOR USING THE HONAN BALLOON
•All patients should be monitored for signs of bradycardia (Oculocardiac reflex) while pressure is being applied to the eye.
•The optimum pressure to be used should be well below pressure in the central retinal artery. Using the 20 to 30 mm Hg of monitored pressure for 30 to 60 minutes before surgery, clinically results in very soft, safe, surgical eyes. With a soft eye excess vitreous pressure is typically absent.
•Also encourages the block anesthetic agent to be absorbed posteriorly
•Some surgeons believe that when using the balloon, Intraocular lens implantation is much easier and safer. From the surgeon’s viewpoint, there is much less stress and strain.


RETROBULBAR BLOCKS
•Most anesthetists prefer to do Peri-bulbar Blocks, however some (Dr. O) likes the Retrobulbar as that is what he was trained to do. It used to be the ‘Gold Standard’
•Retro-bulbar is a longer needle, but uses less anesthetic. Drug is placed intraconally (between the rectus muscles and the optic nerve)
•slightly higher chance of Brainstem anesthesia

PERIBULBAR BLOCKS
•Local anesthetic agents are placed within the orbit, but do not enter the area of the cone of the rectus muscles.
•It was introduced as a safer method, but complications have also been reported.

Medial Canthus Peribulbar Block

Infero-temporal Peribulbar Block

•The signs of a succesful block are:
•Ptosis (drooping of the upper lid with inability to open the eyes)
•Either no eye movement or minimal movement in any direction (akinesia)
•Inability to fully close the eye once opened.
•Since the local anaesthetic is placed outside the muscle cone the concentration around the optic nerve may not be sufficient to abolish vision completely. Some light perception will therefore remain; however the patient is not able to see the operation.

COMPLICATIONS OF BLOCKS
Potential for:
•Seizures: treat like any other seizure: ABCD’s
•Vasovagal: from muscle tugging—vagal stimulant—bradycardia: treat with atropine
•Brain stem paralysis: observe change in LOC, RR, HR—will need critical care support: EMERGENCY!
•Hemorrhage: arterial/venous
•Perforation of the globe: Treatment is Vitrectomy
Notice how anesthetist asks pt to try to keep eye open during block. They are looking for tugging and twitching. If suspected will withdraw needle and reinsert