SURGICAL OPHTHALMOLOGY

FOR OPHTHALMIC NURSES

OCTOBER 2010
 Surgery is increasingly needed to treat the
major causes of preventable blindness.

For surgery we need to follow basic surgical

principles.
1.Knowledge of basic science
2.Surgical technique
3.Practical surgical skill
 SURGICAL TECHNIQUES
1.Sterility and prevention of infection
2.Correct handling of instruments
3.Basic surgical method
4.Haemostasis
5.Wound closure and sutures
 There are 2 Suture types
1.Absorbable-eg Cat gut, collagen and vicryl
For deep structures.
2.Non absorbable-eg Silk, Nylon
To close skin.
‘’Follow tight knot not tight suture principle’’.
NB ,For extra ocular surgery 4-0 & 6-0 are used.
 EYE SURGERY HAS 2 DIVISIONS
A.Extraocular Surgery- On eye lid ,conjunctiva.
B.Intraocular Surgery-on the eye ball.
Has limited recovery and poor tolerance for
second surgery.
 OR PROCEDURES & EOUIPMENT
Infection sources in OR are,
1.From the patient
2.Staff-poor scrubbing , no touch technique
forgotten.
3.OR equipment- poor sterilization ,flies etc.
 SAFE SURGERY NEEDS
1, Correct patient preparation.
2, Sterilization.
3, Correct handling of instruments & dressings
‘No touch technique’
 Methods of sterilization and disinfection

1. Autoclave /sterilizes/ -safest most reliable.

- 134-138 degrees at 3 min
- 126-129 degrees at 10 min
-121-123 degrees at 15 min
- 115-116 degrees at 30 min
2. Dry heat oven /sterilizes/
-Preserves sharps better.
- for 1 hr at 180 degrees/for 2 hr at 170 degrees
3. Boiling /disinfects/-cheap ,quick and simple
Disadvantage- corrosion.
4. Immersion in chemicals/disinfects/,-
eg Chlorehexidine& Cetrimide/SAVLON/,
Povidone Iodine 10%,
Formalin vapor
-Preserves sharps.
-Disadvantage-Toxic, can lose potency.
 Surgery of the Eye Lids
• Know the anatomy
NB-Important features of lid,
-Thin mobile elastic skin.
-Edema in subcutaneous tissue as there is no fat.
-Good blood supply.
-Good for graft.
 Rules to follow in eye lid surgery
• Make horizontal incision along skin crease.
• Lower lid vertical incision to prevent contraction.
• The Gray line-less bleeding.
• Use Adrenalin 1:100,000 in local anesthesia.
• Local infiltration just under the skin/+/- topical in the
conjunctiva.
• Avoid post op bleeding by firm pad and bandage.
• Use lid guard.
• Close skin and conjunctiva & no knot on conjunctiva side.
 Anesthesia of the eye
1.GA
2.LOCAL
Local anesthesia achieved in 3 ways
1.Topical drops-Amethocaine 1 %,Cocaine 4 %.
2.Local infiltration-Lignocaine 1% & 2%.
3.Nerve block-for intraocular surgery.
-Blocks sensory and motor function.
 AIM OF NERVE BLOCK
1.Anaesthesia of the eye.
2.Paralysis of Eom.
3.Paralysis of orbicularis occuli.
4.Blocking vision
Thus we need to combine 2 nerve blocks,
a.Facial &
b.Retrobulbar/ Sub- tenon
We use LIGNOCAINE 2 %/ BUPIVACAINE 0.5 % with
Adrenalin & Hayaluronidase.
 FACIAL BLOCK
• A) O’ Brien  division of the nerve around the
neck of mandible.It is not used nowadays.
• B) Van lint method  paralysis of orbicularis
occuli by local infiltration around orbit.
• Given close to the bone under orbicularis as
motor nerves enter the muscle on its deep
side.
 RETROBULBAR BLOCK
- With in muscle cone.
- 2nd, 3rd, 6th & branches of 5th cranial nerve.
- 4th nerve not involved.
AIM
1) No sensation
2) No movement
3) No vision
 METHOD
a) 3-5ml of 2% lignocaine with 26 G ,50mm
needle.
b) Given 30 mm deep to skin.
c) 1/3 away from lateral end of eyelid.
d) Push your needle 15 mm straight back.
e) Then push15 mm upward to opposite occiput.
f) Check for blood.
g) Stick to the rule of no movement!
g) Apply 5-10 minute hand pressure!

AVOIDABLE COMPLICATIONS OF
RETROBULBAR ANAESTHESIA
a) Inaequate anaesthesia & akinesia.
b) Retrobulbar hemorrhage.
c) Injection into vessel & CSF.
d) Injection into the eyeball .
e) Neurologic damage.
f) Toxic reaction.
OTHER NERVE BLOCKS
There are two nerve blocks other than retro bulbar.
1) Sub- Tenon block – extremely safe, uses blunt
cannula, injected directly to retro bulbar space.
METHOD-
Apply local anesthetic drop to conjunctiva.
- Speculum inserted.
- Patient looks upward & outward.
- Incision made in the conjuctiva & tenon capsule
in the inferomedial quadrant 5-6 mm from the
limbus.
- Blunt cannula is pushed backward round the eye
with the tip touching the globe all the way.
- Injection given after checking for blood & CSF.
 2) Peribulbar block
- Extremely low complications compared to retro
bulbar block.
- Injection is in the periorbital region.
- There is no need for facial nerve block as anesthesia
diffuses out of the orbit to orbicularis occuli muscle.
- Less risk of injection to CSF or causing neurologic
damage.
- Same risk of retro bulbar hemorrhage, injection to
eyeball or blood vessel.
- Needs 2 injections.
- Needs longer time to work.
- Brings proptosis.
- Given via conjunctiva outside the muscle
cone.
- Works by slow spreading in to the retro bulbar
space.
 METHOD
1) Use 10 ml, 23 G fine needle
2) Lower fornix, lateral to midline.
3) 25mm back to equator, 5ml injection given
after checking for blood,
4) 2nd injection 4ml via caruncle medially to the
nose . Check for eye movement not to pass
muscle cone.
5) Apply pressure for 5 minutes.
 Methods of sterilization and disinfection

1. Autoclave /sterilizes/ -safest most reliable.

- 134-138 degrees at 3 min
- 126-129 degrees at 10 min
-121-123 degrees at 15 min
- 115-116 degrees at 30 min
2. Dry heat oven /sterilizes/
-Preserves sharps better.
- for 1 hr at 180 degrees/for 2 hr at 170 degrees
PRINCIPLES OF INTRAOCULAR SURGERY
1) Magnification & illumination
2) Prevention of tremor
3) Prevention of infection
4) Surgical access
5) Haemostasis
6) Protecting corneal endothelium
7) Avoiding damage to the lens
8) Handling iris
9) Management of vitreous
10) Wound closure
11) Reducing post operative inflammation

CATARACT SURGERY
a) History of cataract surgery
b) Restoring focus after surgery / spectacles
c) Indication for surgery
4) Choice of operation
5) ECCE & ICCE / SICS, phakoemulsification
6) IOL types, ACIOL/ PCIOL.
7) Routine post op care.
8) Post op complications & how to manage
them.
 SIDE EFFECT OF + 10 SPECTACLES USED FOR
APHAKICS
1) Distortion
2) Magnification ( 1/3 x)
3) Prismatic effect
4) Discomfort
5) Aniseikonia
 INDICATIONS FOR CATARACT SURGERY
1) Is IOL planned / After biometry.eg for myopes small
power lens or sometimes aphakia may be chosen.
2) How bad is the cataract.
3) What kind of vision does the patient need. E.g
Glare of PSC cataract
4) Is there evidence of other disease in the same eye?
5ps’ pressure/pupil/projection/posterior part of the
eye/pinhole.
5) What is the condition of the other eye.
6) What facilities are available.

CHOICE OF OPERATION
a) ECCE- The anterior capsule opened and cortex and
nucleus removed and posterior capsule remains intact.
ADVANTAGE
1) Better fixation for IOL
2) Less cystoid macular edema
3) SICS 4) Less risk of disturbing vitreous
 DISADVANTAGE
1) Needs coaxial illumination & operating microscope
2) Posterior capsular thickening
3) More post op uveitis
b) ICCE /Removal of the entire lens.
ADVANTAGE
4) No microscope needed
5) No posterior capsular thickening
VISION BY ACIOL / OR +10 LENS
 DISADVANTAGE
1) High risk of cystoid macular edema
2) Larger incision with astigmatism
3) IOL related complication esp. ACIOL ,UGH uveitis,
glaucoma, hyphaema.
4) Vitreous loss with its complications
STEPS OF ECCE
5) Starting the incision after peritomy and cautery.
6) Capsulotomy after A/C entry.
7) Hydro dissection of the lens.
4) Completing the incision.
5) Expressing the nucleus.
6) Irrigation / aspiration of the remaining cortex.
7) Inserting the IOL.
8) Wound closure & final irrigation/ aspiration
 THE FOUR MAIN COMPLICATIOS OF
VITROUS LOSS
1) Retinal detachment
2) Cystoid macular edema
3) Poor wound healing
4) An up drawn pupil
POST OP COMPLICATIONS
5) EARLY
- Poor wound closure
- Aqueous leakage
- Iris prolapse
- Striate keratopathy
- Hyphaema
- Infection
- Iridocyclitis
- Pupil block and malignant glaucoma
2) LATE
- Retinal detachment
- Cystoid macular edema
- Corneal edema & bulous keratopathy
- Thickening of the posterior lens capsule
- Glaucoma
- Chronic uveitis
- infection
 ENDOPHTHALMITIS
TYPES
1/ Early-in the first 48 hours-2 weeks.
2/ Late- > 2 weeks.
 Features of post op Endophthalmitis
1.Pain & photophobia.
2.Reduced vision.
3.Swollen eye lids.
4.Chemosis and circum corneal injection.
5.Mucopurulent conjunctival secretion.
6.Hazy cornea.
7.Turbid anterior chamber with protein and cells
forming hypopyon.
8.RAPD. 9 . Soft eye.
 Treatment
Antibiotic covering G+ ,G-
1.Injection in to the vitreous is the best.
Vancomycine,Amikacin or ceftazidime +/- Gentamycine.
Only 0.1 ml given.
2.Systemically ,Ciprofloxacin and cephalosporin or
Ampcillin and Flucloxacillin.
3.Topically,Chloramphenicol/Gentamycin/Cephalospori
ns.
4.By subconjunctival injection.
 For Endophthalmitis
-Steroids are used but wisely.
-Mydriatics.

POST OP INFECTION IS AN EMERGENCY !!

 Methods of sterilization and disinfection

1. Autoclave /sterilizes/ -safest most reliable.

- 134-138 degrees at 3 min
- 126-129 degrees at 10 min
-121-123 degrees at 15 min
- 115-116 degrees at 30 min
2. Dry heat oven /sterilizes/
-Preserves sharps better.
- for 1 hr at 180 degrees/for 2 hr at 170 degrees
NB, In OR resuscitation devises should be available for
GA and nerve block.
In retro bulbar block ,anaesthesia comes before
akinesia.
If there is retro bulbar hemorrhage the eye may undergo
proptoses and be stony hard. Thus we should
1.Give Diamox.
2.Do Lateral canthotomy.
3.Use lubricant 4.Postpone surgery and follow .
 SICS
• Doesn't use stitches.
• Water tight scleral wound constructed.
• KERATOM & CRESCENT used.
• Refer to instruments for each step.
• NB, The surgery for children is lens aspiration and anterior
vitrectomy to prevent posterior capsular and anterior
vitreous opacification.
• Use of systemic steroid and short acting midriatics is vital.
• Eight week antibiotic Chloramphenicol 0.5 %, and steroid
Maxidex 0.1 % with +/- short acting Midriatics.
 TRABECULECTOMY
• Surgery to lower intraocular pressure.
• Excision of trabecular meshwork after half thickness scleral
dissection.
• Peripheral iredectomy done.
• Fluid drains to sub-conjunctival space.
Post op complications
• 1.Flat A/C due to button-holing of scleral flap or loose suturing.
Common after use of antimetabolites/cytotoxics i.e 5-FU or
MMC.
• 2.Hyphaema
• 3.Endophthalmitis 4.cataract formation
 DACRYOCYSTORHINOSTOMY/DCR
• Lacrimal sac is anastomosed to the nasal
mucus membrane .
• Done by removing part of the lacrimal crest
and all the thin bone separating the lacrimal
sac from the middle nasal miatus.
• Success rate of 90 %.
 STRABOTOMY
• Surgery on the muscles of the eye to correct
strabismus.
• Resection/ to strengthen.
• Recession / to weaken.
 The destructive surgeries
• 1/Enucleation-removal of the intact globe by
cutting the optic nerve and extra ocular muscles.
• 2/Eviceration-removal of the content of the
globe leaving the sclera and optic nerve intact.
Indications
• a/ Malignant tumor b/ Blind painful eye
c/ Ugly eyes/staphyloma d/ Endophthalmitis e/
Following a penetrating injury.
• Either can be used but-
• ENUCLEATE FOR SUSPECTED TUMOR AND FOR TRAUMATISED
EYE TO PREVENT TUMOR SPREAD AND SYMPATHETIC
OPHTHALMITIS !!
• Best if enucleation is done within 2 weeks.
• EVISCERATE FOR ENDOPTHALMITIS.
• Sympathetic ophthalmitis-is rare bilateral eye inflamation
after penetrating injury involving uvea. Traumatic eye excites
with redness and irritability and sympatising eye has
photophobia and blurred vision.
• Treated with topical,subconjunctival and systemic steroids.
RETROBULBAR ALCOHOL FOR PAINFULL EYE

• Given after 1ml of retro bulbar injection of

2 % lidocaine.
• 50 % ALCHOL 1-2 ML given.
 EXENTRATION
• The entire orbital contents down to the bone
are removed.
• For malignant tumors only.
• Modified Exentration-preserves one or both
eyelids or part of lid.
 Eye lid Surgery
Anterior Lamella/Skin and Orbicularis muscle.
Posterior Lamella/ Tarsal plate and conjunctiva.
Marginal artery 3mm above eyelid margin.
What is the difference between entropion and trichiasis.
If only trichiasis with few lashes and no corneal
consequence treatment options are
1.Epilation 2.Cutting the lashes
3.Electrolysis 4.Cryotherapy
5. Excision of lash follicles
 Operations for Entropion and Trichiasis
• 1.Anterior lamellar shortening
• 2.Posterior lamellar lengthening
• 3.Splitting the gray line to rotate the lashes forward.
• 4.Tarsal groving.
• 5.Tarsal rotation-
- Popular better than the others. Two type.
- a/ Ballen / Bilamelar rotation. With reliable good out
come b/ Trabut operation/ From the conjunctiva surface.
. 6. Tarsal slide
 Surgery for lower lid ENTROPION
• 1.THE WIES procedure.
• 2.PENTAGONAL WEDGE EXCISION
• FOR SEMINAR PRESENTATION AND GROUP
DISCUSSION.
 SURGERY FOR ECTROPION
• The Z-plasty
• Skin graft.
• For seminar discussion
TARSORRHAPHY
• Is closing the eyelids with sutures
• For facial palsy of different causes.eg Leprosy
• For long standing corneal ulcer to heal.
• a/ Permanent lateral 1/3rd eye lid length. For permanent Facial palsy.
• b/ Temporary to heal corneal ulcer near the center of the lids or
laterally.
• MATTRESS SUTURE USED FOR BOTH. Can be lateral and medial.
 Incision and curettage of a MEIBOMIAN
CYST
• Local infiltration
• Meibomian clamp
• Vertical inscision from the conjunctival side into the tarsal
plate.
TREATMENT OF EYE LID TUMOURS
• 1.type tumor
• 2.site
• 3. size
• Excision with lateral cantholysis.
• For seminar discussion
 EYE LID INJURY
• Cleaning debridement.
• Primary repair / with in 48 hours/in 2 layers
against deformity.
• Secondary reconstruction/ after 3 months.
• NB , CANALICULAR INJURY NEEDS REFERAL.