33 Care of the ophthalmic surgical patient
Amblyopia: Condition in which there is a lack of development of central vision in one eye because of a failure in using both eyes simultaneously (“lazy eye”). It primarily develops before 6 years of age and can have complete recovery with early diagnosis and treatment. Treatment is a combination therapy approach with prescriptive lenses, eye patching, prisms, and vision therapy.
Anterior Segment: The anterior one-third segment of the globe, extending from the anterior hyaloid face filled with aqueous fluid.
Blepharophimosis: Abnormal narrowing of the palpebral fissures or eye lids.
Blepharoplasty: Removal of excess tissue, fatty deposits, or tightening of the skeletal muscle from the upper or lower eyelids to increase range of vision by reduced sagging of excess skin.
Cataract: An opacity clouding that is found most commonly in the lens and the cortex of the eye.
Chalazion: A small eyelid cyst that is a result of chronic inflammation of a meibomian gland.
Choroid: The spongelike vascular membrane in the globe between the sclera and the retina, supplying nutrients to the retina.
Choroidal Melanoma: A rare form of cancer found in the spongelike vascular membrane of the eye. It is the most common form of cancer of the eye in the adult population.
Ciliary Body: A ring of tissue that encircles the lens of the eye, containing smooth muscle fibers and capillaries.
Ciliary Muscle: Smooth muscle fibers located in the ciliary body that control the shape of the lens.
Ciliary Process: Pigmented ridges located in the smooth muscle fibers surrounding the lens that contain capillaries that secrete aqueous humor into the anterior segment of the eye.
Dacryocystitis: Infection of the lacrimal sac.
Dacryocystorhinostomy: A procedure in which a new pathway is created from the lacrimal sac to the nasal passageway.
Deep Lamellar Endothelial Keratoplasty: Transplantation of the cornea in which the epithelium of the cornea is replaced without an incision in the anterior corneal surface.
Dermatochalasis: Excess tissue, fatty deposits, or excess relaxation of the skeletal muscle of the upper or lower eyelids.
Descemet’s Stripping Endothelial Keratoplasty: Transplantation of the corneal inner endothelium and its underlying membrane via two small incisions.
Ectropian: Eversion of the eyelid (typically the lower lid). Surgical correction is performed by horizontally shortening the lid.
Entropian: Inversion of the eyelid (typically the lower lid), which causes the eyelashes to continually rub against the surface of the eye. Surgical treatment is performed by one of two ways, both of which anastomose the lid after removing a small section of the skin, muscle, and tendon.
Enucleation: Complete removal of the eye globe.
Epiphora: Excessive tear production. Can be caused by secondary lacrimal duct obstruction.
Evisceration of the Eye: Removal of the entire contents of the eye globe, leaving the sclera and extraocular muscles intact.
Glaucoma: A family of eye diseases characterized by increased intraocular pressure resulting in permanent optic nerve damage and visual loss. Surgical treatment is aimed at reestablishing the outflow of aqueous fluid. Nearly all procedures are so-called filtration operations (e.g., trabeculectomy or tube shunt procedures).
Goniotomy: A surgical procedure for congenital glaucoma in which a 90- to 120-degree arc incision is made within the anterior trabecular meshwork of the eye.
Hydroxyapatite Implant: An implant that is a complex calcium phosphate salt made from coral. Placed after an enucleation, the implant is less likely to be rejected because of its resemblance of human bone in its chemical and porous properties. The orbital tissues are attached directly and a prosthesis placed over it. The implant becomes integrated over time with blood vessels and tissue, thus allowing for a more realistic appearance and movement.
Intraocular Lens Implant (IOL): An artificial lens implanted to replace the crystalline lens after removal in cataract surgery. IOLs are made in a variety of styles and from a variety of materials. One of the newest and smallest multifocal IOLs is a pliable, foldable lens that can be inserted through an incision of 1.4 mm or smaller.
Keratoplasty: Replacement of the diseased, central portion of the cornea with donor tissue. A cookie-cutter–like trephine is used on both the donor and recipient cornea.
Lacrimal Punctum: The opening of the lacrimal duct at either the upper or lower eyelid at the inner canthus of the eye.
Laser-Assisted In Situ Keratomileusis (LASIK): A surgical procedure used to correct nearsightedness (myopia), farsightedness (hyperopia), and astigmatism in which an excimer laser is used to remove inner layers of cornea tissue, thereby reshaping it.
Miosis: Contraction of the pupil induced by light or eye drops.
Mydriasis: Dilation of the pupils usually induced by eye drops, but also induced by lack of light.
Oculocardiac Reflex (OCR): A sudden onset bradycardia elicited by traction on the extraocular muscles, especially the medial rectus, or by direct pressure on the eye globe. This reflex is a trigeminovagal reflex arc. It can also cause cardiac dysrhythmias such as ventricular ectopy, sinus arrest, and ventricular fibrillation. The pediatric population is especially sensitive to OCR.
Phacoemulsification: Fragmentation and removal of the lens with ultrasonic vibrations while aspirating during cataract surgery.
Plaque Therapy: A highly concentrated radiation implant most commonly used in the treatment of choroidal melanoma.
Presbyopia: A condition associated with aging whereby the lens loses its flexibility and the ability to focus on objects up close.
Proliferative Diabetic Retinopathy: The latter stages of diabetic retinopathy in which a proliferative growth of abnormal new blood vessels develop from the retina. These vessels can lead to vitreous hemorrhages and detachment of the retina.
Proptosis or Exophthalmos: Protrusion of the eyeball.
Pterygium: A benign growth of the conjunctiva that extends to the cornea at approximately a 3 o’clock or a 9 o’clock position. It is caused by excessive exposure to ultraviolet light (sunlight) or wind. Excision becomes necessary when visual disturbances become present.
Ptosis: Drooping of the upper eyelid. Surgery involves various procedures on the upper eyelid and/or the levator muscle.
Retinoblastoma: A malignant tumor of the retina that occurs predominantly in early childhood.
Retinopexy: Surgical procedure to correct a retinal tear. This is done by causing scar formation to occur with the use of laser photocoagulation, electric current, or cryotherapy.
Scleral Buckle: A piece of silicone plastic or sponge material that is surgically sewn onto the sclera in order to correct a retinal detachment via compression of the sclera against the retina. This procedure is often used in conjunction with a retinopexy, often with a pars plana vitrectomy.
Strabismus: A condition in which the eyes are not properly aligned and the extraocular muscles lack coordinated muscle movements. Inward deviation is called esotropia, and outward deviation is called exotropia. Surgical correction is performed by either shortening and removal of part of the tendon or lengthening a muscle via transfer of the muscle insertion site posterior to the original attachment point on the eye. It is occasionally treated with glasses or drops; however, it can lead to amblyopia if not treated in a timely manner.
Tonometer: An instrument used for the measurement of intraocular pressure. Can be hand-held or mounted to a slit lamp microscope. Requires topical anesthesia via eye drops, unless a noncontact “air pull” instrument is used.
Trabecular Meshwork: A ring of spongelike tissue through which aqueous humor drains to control the intraocular pressure.
Trabeculectomy: A surgical procedure to create a drainage channel from the anterior chamber to the subconjunctival space to lower intraocular pressure, for treatment of uncontrolled glaucoma.
Vitrectomy: Surgical removal of the vitreous gel within the eye. Performed to clear blood that is occluding vision, to sever vitreous traction bands that are pulling on the retina, or to help with the repair of a retinal detachment. The removed vitreous is replaced with fluid, specialized gas, or silicone oil.
Vitreous Fluid: A clear, jellylike substance that fills the posterior chamber of the eye.
Vitreous Hemorrhage: Bleeding within the vitreous fluid that is usually the result of proliferative diabetic retinopathy, a retinal tear, detachment, or trauma.
Zonule of Zinn: A ring of fibrous strands that connects the ciliary processes with the crystalline lens of the eye. The eye focuses (accommodates) by the ciliary muscle exerting traction on the zonules, thereby changing the shape of the lens.
Caring for the ophthalmic surgical patient offers unique challenges to the perianesthesia nurse. It requires a thorough understanding of not only the surgical aspect of the patient’s care, but also the pharmacologic, physiologic, and emotional concerns. As the need for maintaining quality patient care and controlling overall medical costs continues to grow, many surgical advances have taken the most complex of ophthalmic procedures from hospital-based operating rooms to free-standing ambulatory surgery centers, thus enabling more patients to return home within 24 hours of surgery.1 This trend alone necessitates that the perianesthesia nurse have a fundamental knowledge base to anticipate an array of patients’ preoperative and postoperative needs. Recognizing and treating a variety of complex symptoms and complications, providing sufficient patient education, and planning discharge are just a few of the many needs with which the perianesthesia nurse will have to contend on a daily basis. Ophthalmic surgical patients vary widely in age. Any age-appropriate special needs or medical concerns should be identified by the perianesthesia nurse during the preadmission evaluation time. Knowledge of comorbidities in elderly patients becomes even more important when the amount of time with each patient is limited. Hypertension, diabetes mellitus, coronary artery, cerebral vascular, and renal disease are just a few examples. Despite the fact that ophthalmic surgery is most common in the elderly, advances in anesthesia, surgical techniques, and surgical instrumentation have allowed the most sophisticated procedures to be performed on the most fragile of the pediatric population (i.e., premature infants and neonates).2 Normal growth and development in the pediatric patient should be assessed and any variances should be noted. These comorbidities and other factors may predispose patients to sudden and potentially life-threatening postoperative complications.3 Close attention to the preoperative assessment is of utmost importance. Working with this wide range in patient population, certifications in advanced cardiac life support (ACLS) and pediatric advanced life support (PALS) are essential in the educational foundation for the perianesthesia nurse.
Preoperative evaluation
Preadmission evaluations are a critical tool for the perianesthesia nurse. Many hospitals and free-standing ambulatory surgery facilities have established preadmission testing clinics with guidelines designed for this purpose. The goals of the preoperative evaluation in the surgical patient is to obtain informed consent, perform physical assessments, arrange for laboratory tests and any necessary consultations, prescreen for any diseases, and provide patient education to reduce patient and caregiver anxiety. Upon evaluation, if the need for further medical testing arises, the patient can then be referred to their primary care physician or to a subspecialty to obtain medical clearance.4 A preadmission evaluation can decrease cancellations, provide ample time to establish rapport, and assess for any psychological or psychosocial needs that can be addressed before the actual day of surgery. In a 10-year observational study, Jiménez and colleagues5 concluded that 57.1% of surgical cases that were cancelled had a preventable or possibly preventable cause. With preadmission evaluations, this percentage can be greatly reduced, thereby decreasing the anxiety and frustration level of patients, caregivers, and health care team members on the day of surgery.
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