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33: Care of the Ophthalmic Surgical Patient
Carolyn G. Baddeley
Caring for the ophthalmic surgical patient offers unique challenges and requires a thorough understanding of not only ocular anatomy and physiology but also other important aspects of an ophthalmic patient’s care. Today’s perianesthesia nurse will need to have a detailed knowledge base of ocular terminology and ocular procedures, along with a comprehensive understanding of ophthalmic pharmacology and anesthetic considerations used. Due to the vast array of age groups that may undergo ophthalmic surgery, the nurse must understand that the patient’s comorbidities can significantly influence the pre-, intra-, and postoperative outcomes for the patient. Educating patients and their caregivers before surgery concerning the course of events that is to come will alleviate anxiety, provide realistic expectations, and reduce the overall postoperative workload of the perianesthesia nurse. It is imperative that the perianesthesia nurse knows the signs, symptoms, and treatment of untoward side effects of medications along with complications secondary to the surgical anesthetic and/or procedures that are performed. Prompt recognition and treatment will reduce unintended sequelae. Postoperative instructions and the adherence to these is very important to convey to the patient and can be a determinate factor on the overall success of the procedure as well.
oculocardiac reflex; ophthalmic anesthetic considerations; ophthalmic care; ophthalmic medications; postoperative nausea and vomiting; preoperative evaluation; preoperative ophthalmic care; postoperative
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 well. 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 requires the perianesthesia nurse to have a fundamental knowledge base about the variety of outpatient ophthalmic procedures so that he or she can anticipate an array of patients’ pre- and postoperative needs. Recognition and treatment of a complexity of symptoms and/or complications and providing sufficient patient education as well as specific discharge planning are just a few of the many needs with which the perianesthesia nurse will have to contend.
Even though ophthalmic surgical procedures are considered to be low risk, some patients are considered to be at higher risk due to their extremes in age.2 Any age-appropriate special needs and/or medical concerns should be identified by the perianesthesia nurse during the preadmission evaluation. Knowledge of comorbidities in elderly patients becomes even more important when the amount of time with each patient is limited. Hypertension, diabetes mellitus, and coronary artery, cerebrovascular, and/or renal disease are just a few examples. These comorbidities and other factors may predispose patients to sudden and potentially life-threatening postoperative complications. Therefore, preoperative patient optimization is essential. 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 noted. These comorbidities and other factors may predispose patients to sudden and potentially life-threatening postoperative complications. 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.
Blepharoplasty Removal of excess tissue, fatty deposits, or tightening of the skeletal muscle from the upper or lower eyelids to reduce sagging of excess skin and/or muscle. Performed for cosmetic or reconstructive purposes to increase the field of vision.
Cataract An opacity, or “clouding,” located in the crystalline lens of the eye.
Chalazion An eyelid mass that is a result of chronic inflammation of a meibomian gland.
Dacryocystorhinostomy A procedure in which a new pathway is created from the lacrimal sac to the nasal passageway.
Deep Lamellar Endothelial Keratoplasty (DLEK) Transplantation of the cornea in which the epithelium of the cornea is replaced without an incision in the anterior corneal surface.
Descemet’s Stripping Endothelial Keratoplasty Transplantation of the corneal inner endothelium and the underlying membrane via two small incisions.
Entropion Inversion of the eyelid (typically the lower lid) that 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 the removal of a small section of the skin, muscle, and tendon.
Enucleation Complete removal of the eye globe.
Evisceration of the Eye Removal of the entire contents of the eye globe, leaving the sclera and extraocular muscles intact.
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 due to its resemblance of human bone in its chemical and porous properties. The orbital tissues are attached directly and the 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 a 1.4-mm or smaller incision.
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.
LASIK (Laser-Assisted In Situ Keratomileusis) A surgical procedure used to correct nearsightedness (myopia), farsightedness (hyperopia), and astigmatism in which an excimer laser is used to remove the inner layers of cornea tissue, thereby reshaping it.
Phacoemulsification Fragmentation and removal of the lens, with ultrasonic vibrations simultaneously irrigating and aspirating during cataract surgery. This allows for the usage of very small incisions.
Plaque Therapy A highly concentrated radiation implant most commonly used in the treatment of cancer of the eye.
Retinoblastoma A malignant tumor of the retina that occurs predominantly in early childhood.
Retinopexy Surgical procedure to correct retinal tears. This is done by causing scar formation to occur with the use of laser photocoagulation, electric current, cryotherapy, and/or injection of a gas bubble into the vitreous humor.
Scleral Buckle A piece of silicone plastic or sponge material surgically sewn onto the sclera to correct a retinal detachment via compression of the sclera against the retina. This procedure is often used in conjunction with a retinopexy and very 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. Occasionally treated with glasses and/or drops. However, this can lead to amblyopia if not treated in a timely manner.
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. Baerveldt and Ahmed shunt devices can also be implanted to shunt aqueous fluid out of the eye.
Vitrectomy Surgical removal of the vitreous gel within the eye. Performed to clear blood occluding vision, to sever vitreous traction bands 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.
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 in order to optimize any preexisting conditions and reduce patient and caregiver anxiety. Upon evaluation, if the need for further medical testing arises, the patient can then be referred to his or her primary care physician or to a subspecialty to obtain medical clearance.12 A preadmission evaluation can decrease cancellations, provide ample time to establish rapport, and assess for any psychological and/or psychosocial needs that can be addressed before the actual day of surgery. In a 2-year retrospective review of 269 patients at a Veterans Affairs (VA) Medical Center, Dawson et al.3 concluded that preventable causes of ophthalmology surgical case cancellations could be dramatically reduced by 23% by simply using preoperative templates and technological updating of preoperative measurements. With the improved preadmission evaluations, cancellations can be reduced, thereby increasing operating room utilization along with decreasing the anxiety and frustration level of patients, caregivers, and health care team members on the day of surgery.
Most ophthalmic medications are administered topically in very concentrated solutions (Table 33.1). Due to the highly vascular nature of the conjunctival sac and the nasolacrimal duct leading to the vascular mucosa of the nasopharynx, undesirable systemic effects can be caused by the rapid systemic absorption of topical solutions that are administered. These medications can also significantly alter a patient’s reaction to anesthetic drugs and thus cause changes in the intraocular dynamics.2 It is essential that the perianesthesia nurse learn to identify these medications and their potential systemic effects. The elderly patient is at higher risk for these severe systemic effects. This age group takes a higher number of prescription medications and undergoes a higher percentage of eye surgeries than any other age group.1
|Name of Medication|
|Oral dryness, hypertension, bradycardia, dysrhythmias, tachycardia, hypotension, nausea, visual disturbance, dizziness|
|Central anticholinergic syndrome|
Tachycardia, flushing, dry skin, thirst
Elderly may display agitation or CNS excitation
Increases aqueous drainage
Reduction in plasma cholinesterase for up to 3 to 7 weeks after discontinued
Prolongation of procaine, chloroprocaine, and succinylcholine’s duration of action
|Decreases postoperative inflammation and pain|
|Burning sensation, headache, rhinitis, facial edema, abdominal pain, nausea, delayed wound healing|
|Increased IOP, delayed wound healing|
|Lightheadedness, headache, fatigue, disorientation, general CNS depression, bradycardia, bronchospasm, palpitations, syncope, increased blood pressure, worsening of heart block, and CHF|
|Carbonic anhydrase inhibitor|
|Decreases IOP pressure via decreased production of aqueous humor|
|Confusion, tinnitus, flushing, headache, polyuria, electrolyte imbalance, dyspepsia with long-term use|
IV administration can cause acute hypotension
|Headache, bradycardia, hypotension, flushing, and bronchospasm|
May inhibit focusing
|Decreases IOP via increasing outflow of aqueous humor|
|Ocular dryness, visual disturbances|
Headache, increased risk of infections
|Intravascular dye for evaluation of retinal vasculature|
|Urticaria, rhinorrhea, dizziness, pharyngoedema, nausea and vomiting|
CHF, Congestive heart failure; CNS, central nervous system; IOP, intraocular pressure; IV, intravenous.
From Physician’s Desk Reference. Available at: www.pdr.net. Accessed September 7, 2021.
To easily identify the specific classifications of topical ocular medications, the American Academy of Ophthalmology (AAO), with input from pharmaceutical companies and the Food and Drug Administration (FDA), developed a universal color-coding system to distinguish among all topical ophthalmic medications. The color-coded system identifies every pharmaceutical class with its own unique cap and label color scheme (Table 33.2). With the introduction and implementation of the voluntary color-coding system, the AAO expects to “decrease the amount of serious adverse events resulting from patients’ (and medical personnel’s) difficulty in distinguishing between various ocular medications.”4 The threefold partnership of voluntary cooperation among the FDA, pharmaceutical industry, and AAO has proven to be very effective in and advantageous to the primary interest of patient safety since its inception.
Ophthalmic Medication Color-Coding System
|Adrenergic agonist combinations|
|Beta blocker combinations|
|Carbonic anhydrase inhibitors|
|Mydriatics and cycloplegics|
Adapted from American Academy of Ophthalmology. Color codes for topical ocular medications (website). www.aao.org/about/policies/color-codes-topical-ocular-medications. Accessed March 26, 2021.
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