1. Chapter 26
Ophthalmic Surgery

2. Ophthalmic Surgery Important terms and definitions
Review terms and definitions listed at beginning of chapter
Use your medical dictionary if necessary
Familiarize yourself with the chapter terminology.
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3. Ophthalmic Surgery The orbital cavity.
The goal of ophthalmic surgery is to restore vision lost from disease, injury, or a congenital defect, and to produce a good cosmetic effect.
Eye procedures are delicate and precise.
Most eye procedures are performed under monitored anesthesia care (MAC), so the patient will be required to stay still during the procedure.
(From Thibodeau G, Patton K: Anatomy and physiology ed 6, St Louis, 2007, Mosby.)
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4. Ophthalmic Surgery External structures of the eye.
What structures make up the external anatomy of the eye?
Why is the bony orbit lined with fatty tissue?
(From Thibodeau G, Patton K: Anatomy and physiology, ed 6, St Louis, 2007, Mosby.)
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5. Ophthalmic Surgery Globe.
(From Thibodeau G, Patton K: Anatomy and physiology, ed 6, St Louis, 2007, Mosby.)
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6. Ophthalmic Surgery Eye muscles.
How many ocular muscles make up the bony orbit?
Reference Figure 24-2, Muscles of the eye, in the textbook.
(From Thibodeau GA, Patton KT: Anatomy and physiology, ed 5, St Louis, 2003, Mosby.)
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7. Ophthalmic Surgery Conjunctiva Cornea
The thin, transparent mucous membrane that lines each eyelid an covers the sclera
Divided into palpebral and bulbar regions
Cornea
Clear tissue layer overlying the front of the eyeball
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8. Ophthalmic Surgery Sclera
Thick, white fibrous tissue that encloses about three fourths of the eyeball
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9. Ophthalmic Surgery Choroid Ciliary body
Vascular pigmented choroid layer lies beneath the sclera
Prevents light reflection within the eyeball
Ciliary body
An extension of the choroid located at the periphery of the anterior choroid
Smooth muscle to which the suspensory ligaments are attached
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10. Ophthalmic Surgery Retina Lens Innermost layer of the posterior globe
Lies directly behind the iris; is a biconcave, clear structure encompassed by a transparent capsule
The lens is held in place by suspensory ligaments and focuses images projected onto the retina
What is the function of the lens?
The lens is naturally flexible. The lens bends light rays and focuses them on the iris, creating an image to be sent to the brain.
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11. Ophthalmic Surgery Anterior chamber Posterior chamber
Is divided into two chambers by the iris
Lies directly in front of the iris
Posterior chamber
Is directly posterior to the iris but anterior to the lens
What is aqueous humor? What purpose does it serve?
What is vitreous humor? What purpose does it serve?
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12. Ophthalmic Surgery The lacrimal apparatus.
(From Abrahams Marks, & Hutchings: McKinn’s color atlas of human anatomy, 5e, 2003, Elsevier..)
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13. Ophthalmic Surgery Refraction
Bending of light rays through a transparent medium
Focal point – Location where light converges
Accommodation – Process of focusing
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14. Ophthalmic Surgery Diagnostic testing Refraction
Fluorescein angiography
Ophthalmic ultrasonography
Magnetic resonance imaging (MRI) and computed tomography (CT)
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15. Ophthalmic Surgery Psychological considerations
Create relaxing environment
Blindness is possible complication
Procedures commonly done under conscious sedation
Patients must override normal reflex to pull away
Most patients with impaired vision are older adults, so they require individualized care that takes into consideration the environment, the room temperature, the choice of anesthetic, and special written postoperative instructions.
Since the majority of patients are placed under conscious sedation, keep the room as quiet and calm as possible. Patients will tend to pull away from the surgeon when startled or frightened. This reaction can lead to injury to the operative eye.
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16. Ophthalmic Surgery Verification of the operative site
Is responsibility of entire surgical team to verify the operative eye
The Joint Commission recommends surgeon mark skin near operative site
Check with patient for correct procedure and correct site
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17. Ophthalmic Surgery Positioning the patient
Supine, with head stabilized in a doughnut
Safe, comfortable, pillow under the knees
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18. Ophthalmic Surgery Routine eye prep Draping
The canthus of the eye is considered contaminated
Draping
Will include isolation of hairline and nonoperative side
If Betadine is used as a prep, it must be diluted to 10% strength.
How is the hairline isolated for draping?
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19. Ophthalmic Surgery Anesthesia
Many procedures done with regional anesthetic with monitored sedation
Pediatric patients given general anesthetic
Retrobulbar block
Why are pediatric patients given general anesthesia for ophthalmic surgery?
The patient is anesthetized just before the retrobulbar block is administered. The placement of the block can be very uncomfortable.
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20. Ophthalmic Surgery Medications
Instilled or injected into eye before, during, and after surgery
Uses vary according to type of surgery
Labeled as soon as they are on the field
Identified and acknowledged with the surgeon
Recorded on the operative report
Neosynephrine is an example of a mydriatic medication.
Pilocarpine is an example of a miotic medication.
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21. Ophthalmic Surgery Cutting Instruments
The surgical technologist should examine each instrument for damage before and after use. Eye instruments are very delicate.
The majority of the surgery will take place in the dark. The surgical technologist must keep a neat table and know exactly where each instrument is located.
A, Diamond knife. B, Diamond step knife. C, Barraquer iris scissors. D, Stevens scissors.
(Courtesy Katena Eye Instruments, Denville, NJ.)
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22. Ophthalmic Surgery Forceps, Calipers, and Needle Holders
A, Bipolar forceps. B, Bishop-Harmon forceps. C, Bonn forceps. D, Castroviejo needle holder.
(Courtesy Katena Eye Instruments, Denville, NJ.)
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23. Ophthalmic Surgery Electrosurgical unit (ESU) Eye sponges Sutures
Ophthalmic dressings
Sutures, blades, and needle tips are counted for an ophthalmic procedure.
What sizes of syringes must the surgical technologist have available?
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24. Ophthalmic Surgery Techniques (microsurgery)
Surgeon’s field of vision magnified
Scope (area of vision) very limited
Surgeon cannot look away from field
Scrub must prepare ahead for each step of procedure
Scrub must prevent movement of microscope
Limit your caffeine intake before scrubbing for an ophthalmic procedure, to keep your hands steady.
The surgical technologist must pay close attention to the case and view the surgical site through the microscope during the procedure, taking care to not move or bump the microscope during the procedure.
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25. (Courtesy Carl Zeiss, Dublin, Calif.)
Ophthalmic Surgery
The operating microscope.
The microscope should be adjusted for height and placement over the patient by the surgeon just before scrubbing.
The microscope will require draping. This is performed after the patient has been prepped and draped.
(Courtesy Carl Zeiss, Dublin, Calif.)
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26. Ophthalmic Surgery Excision of chalazion
Nodal tissue arising from a sebaceous gland is excised from the tarsal plate
A chalazion is an inflammatory, benign growth that originates in a sebaceous gland of the eyelid
A curette will be used to remove the chalazion contents.
Suturing is usually not required; however, a pressure dressing will be applied.
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27. Ophthalmic Surgery Repair of entropion
Entropion is the abnormal inversion of the lower eyelid. The goal of surgery is to correct the anatomical position by resection
What is an entropion? What is the most common cause of an entropion?
The surgical technologist must have chalazion clamps, a dye marking pen, calipers, and a metal ruler available for the surgery.
A, A marginal strip of lid is overlapped to estimate the amount of lid shortening. B, A tarsal incision is made, and 4-0 traction sutures are placed in the conjunctiva and the lower lid. The redundant tissue is removed.
(From Tyers AG, Collin JRO: Colour atlas of ophthalmic plastic surgery, ed 2, Oxford, 2001, Butterworth-Heinemann.)
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28. Ophthalmic Surgery Repair of Entropion (cont.)
The most common and successful surgical procedure for entropion repair is the excision of a base-down tarsoconjunctival triangle. See Figure 26-15, Repair of entropion, in the textbook.
During the repair, the surgical technologist must irrigate the cornea with balanced salt solution (BSS) to keep it moist. The surgical technologist must also dry the site with a cotton-tipped applicator to help the surgeon visualize the surgical field.
C, Double-arm sutures are passed anterior to the tarsal plate and through the skin inferior to the lashes. D, The lid margin is closed.
(From Tyers AG, Collin JRO: Colour atlas of ophthalmic plastic surgery, ed 2, Oxford, 2001, Butterworth-Heinemann.)
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29. Ophthalmic Surgery Repair of Ectropion
Restoration of a drooping eyelid to its normal position
A, Before surgery. B, A skin flap is raised, and redundant tarsal tissue is removed. C, The area of resection is measured. D, Completed closure.
(From Tyers AG, Collin JRO: Colour atlas of ophthalmic plastic surgery, ed 2, Oxford, 2001, Butterworth-Heinemann.)
What is an ectropion?
To keep the ectropion from reforming, the surgeon will place one or more sutures of 4-0 absorbable suture on a spatula needle through the tarsal plate and the canthal ligament.
See repair of ectropion in Figure 26-16, in the textbook.
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30. Ophthalmic Surgery Excision of pterygium
The pterygium membrane is surgically removed to prevent loss of vision
A pterygium is a benign growth of conjunctival tissue over the corneal surface. It usually grows slowly, except in patients who live in southern climates, where it grows aggressively.
To prevent the pterygium from reoccurring, treatment with mitomycin or an excimer laser may be required.
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31. Ophthalmic Surgery Dacryocystorhinostomy
What are the symptoms of dacryocystitis?
The lacrimal duct may be stented with silicone tubing, which is passed into the nose. The tube is passed down the nasolacrimal duct and retrieved under the inferior turbinate.
A, The medial canthal tendon is exposed. The angular vein (a) lies anteriorly on the orbicularis muscle. The orbicularis muscle is separated at the point of insertion of the canthal tendon (dotted line). B, The periosteum is incised and reflected anteriorly.
(Modified from McNab AA: Manual of orbital and lacrimal surgery, ed 2, Oxford, 1998, Butterworth-Heinemann.)
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32. Ophthalmic Surgery Lacrimal duct probing
Lacrimal duct is opened; obstruction is removed
During development of lacrimal system, three anomalies possible:
Passage may not develop
Punctum of lower eyelid is absent
Congenital dacryocystocele or mucocele may occur, causing obstruction
What is the most common symptom of a lacrimal gland abnormality?
A series of probes, increasing in size, are introduced into the duct system to increase the drainage of tears.
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33. Ophthalmic Surgery Muscle resection and recession
Performed to correct deviation of the eye caused by strabismus
A, The sclera is incised. B, A muscle hook is inserted to expose the insertion of the muscle. C, With the muscle hook in place, the attachment is divided with Westcott scissors. D, Sutures are placed across the muscle attachment in its new location.
(From Jaffe N: Atlas of ophthalmic surgery, ed 2, St Louis, 1995, Mosby.)
Muscle surgery is performed to treat what condition?
What is the difference between a resection of the lateral muscle and the recession of the medial muscle?
At the conclusion of surgery, antibiotic ointment is placed in the eye, and then an eye pad and Fox shield.
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34. A running suture is placed.
Ophthalmic Surgery
Penetrating Keratoplasty (Corneal Transplant)
Penetrating keratoplasty is the transplantation of a donor cornea to restore vision.
Why is the cornea an excellent recipient of donor tissue?
A running suture is placed.
(From Jaffe N: Atlas of ophthalmic surgery, ed 2, St Louis, 1995, Mosby.)
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35. Ophthalmic Surgery LASIK or laser in situ keratomileusis
LASIK is performed to shape the curvature of the cornea and correct a refractory problem
Lasik surgery is performed to reduce the curvature of the cornea and correct a refractory problem.
What laser is used to perform Lasik surgery?
What are the advantages of Lasik surgery?
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36. Ophthalmic Surgery Cataract extraction
Removal of opaque lens (cataract)
Result of aging process, trauma, glaucoma, or medications
May occur as congenital anomaly
Linked to radiation exposure
Sunlight
X-ray radiation
Cataract removal involves removal of what tissue?
Intracapsular extraction requires a large incision through which the entire lens is removed.
Extracapsular extraction requires a small incision, and the lens is extracted using phacoemulsification.
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37. Ophthalmic Surgery Cataract extraction (cont.) Phacoemulsification
Fragmentation of tissue through ultrasonic vibration
Phacoemulsification destroys only the targeted tissue.
What are the advantages of phacoemulsification?
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38. Ophthalmic Surgery Extracapsular Cataract Extraction
How is extracapsular cataract extraction different from intracapsular extraction?
What is a bridle suture?
What viscoelastic material is placed into the anterior chamber?
The nucleus is displaced toward 6 o'clock with the bent-tipped needle; the maneuver is performed inside the capsular bag.
(From Jaffe N: Atlas of ophthalmic surgery, ed 2, St Louis, 1995, Mosby.)
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39. Ophthalmic Surgery Anterior vitrectomy
Removal of vitreous fluid from the anterior chamber
For what indications is an anterior vitrectomy performed?
The vitrectomy probe, the infusion line, and the vacuum are attached to the phacoemulsification machine.
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40. Ophthalmic Surgery Anterior vitrectomy
Performed to remove the vitreous from the anterior chamber
Vitrectomy equipment and setup (see text for details). A, Wide-angle viewing system. B, Internal illumination system. C, Cutting suction infusion system. D, Position of instruments.
(From Rothrock JC: Alexander’s care of the patient in surgery, ed 17, St Louis, 2007, Mosby.)
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41. Ophthalmic Surgery Scleral buckling procedure for detached retina
Scleral buckling is preformed when the sensory layer of the retina becomes separated from the pigment epithelial layer
What are the symptoms of a detached retina?
What is diathermy?
Intraocular gas injection is performed to create pressure on the retina while subretinal fluid is reabsorbed and scars form. The gas must be drawn into syringe using a filter.
A sponge is sutured in place over the treated site of the retinal tear.
(From Ryan S et al: Retina, ed 2, St Louis, 1994, Mosby.)
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42. Ophthalmic Surgery Trabeculectomy
A, A sponge with an antimetabolite is placed on the sclera. B, The sclera is drawn over the sponge. C, Irrigation. D, Scleral flaps are created. E, An incision is made into the anterior chamber. F, G, A fistula is created by the removal of a flap from the limbus.
(From Rothrock JC: Alexander’s care of the patient in surgery, ed 17,St Louis, 2007, Mosby.)
Why is a trabeculectomy done?
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43. Ophthalmic Surgery Filtering procedures and trabeculectomy
Types of glaucoma
Primary angle-closure glaucoma
Open-angle or chronic glaucoma
Secondary glaucoma
Congenital glaucoma
What is the broad definition of glaucoma?
The incidence of primary-angle closure glaucoma is higher in women.
What causes secondary glaucoma to occur?
The classic sign of congenital glaucoma is called an “ox eye.”
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44. Ophthalmic Surgery Argon laser trabeculoplasty
Use of the laser shrinks the collagen and stretches the canal of Schlemm, which expands the canal and increases drainage, thus reducing pressure
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45. Ophthalmic Surgery Orbital decompression
One or more bony sections of the orbital cavity are removed to reduce pressure on the optic nerve
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46. Ophthalmic Surgery Enucleation Complete removal of eyeball
For what conditions is an enucleation performed?
A prosthesis called a sphere is implanted to preserve the shape of the socket until the sphere can be replaced by an artificial eye.
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