PARS PLANA VITRECTOMY, RIGHT EYE
A Case Study on the Operating Room
Presented to
The Faculty of School of Nursing
University of Baguio
In
Partial fulfillment of the
Requirement for the Subject
NCENL06
SUBMITTED TO:
Larry Michelle Pascual, RN
Clinical Instructor
SUBMITTED BY:
Arlene Esilen Carreon
September 2012
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ACKNOWLEDGMENT
I owe my deepest gratitude to the following for the
making of this case possible:
First and foremost to our Creator, as source of our
life and being, and for reasons too numerous to mention;
To the University of Baguio, for being true to its
mission and vision of empowering its students, giving us the
chance to develop our skills through experience;
To the Dean, Ms. Jocelyn Apalla, Department Head, Ms.
Helen Alalag, and BSN IV Coordinator, Ms. Minda Bahug for
making hospital exposure feasible;
To my clinical instructor, Mr. Larry Michelle Pascual,
who’s intellectual, clinical and practical insights and
guidance made our hospital duty experience appreciated and
valued in all dimensions;
To my parents, for their unending love and support, and
for molding me to become the person that I am right now, for
the encouragement and words of wisdom they have inculcated
in my mind, and the lessons they have taught that help me go
on in this part of my journey in life, my deepest gratitude.
TABLE OF CONTENTS
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Chapter Page
Title page........................................... i
Acknowledgement...................................... ii
Table of Content .................................... iii
Chapter I
Patient’s Profile............................... 1
a. Biographic Data
Chapter II
Anatomy and Physiology.............................. 2
a. Structure of the Human Eye
Chapter III
Pathophysiology...................................... 15
Chapter IV
Patient’s Preparation................................ 26
a. Skin preparationb. Positionc. Drapingd. Anesthesia used
Chapter V
Discussion of the Procedure.......................... 28
Chapter VI
Instrumentation .................................... 30
Chapter VII
Drug study.......................................... 34
Bibliography
CHAPTER I
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PATIENT’S PROFILE
A. Bibliographical Data
NAME: Patient X
AGE: 66 years old
SEX: Female
CIVIL STATUS: Single
ADDRESS: 122 New Lucban Extension, Baguio City
NATIONALITY: Filipino
RELIGION: Roman Catholic
CHIEF COMPLAINT: Blurred Vision
ADMITTING DIAGNOSIS: Vitreous Hemorrhage, Right eye;
Cataract
FINAL DIAGNOSIS: Vitreous Hemorrhage, Cataract Right eye
secondary to branch retinal vein
occlusion
OPERATION PERFORMED: Pars Plana Vitrectomy, Right Eye
CHAPTER II
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ANATOMY AND PHYSIOLOGY
The anatomy and physiology of the human eye is an
important part of body. Any eye problem should be considered
an emergency.
Above: Schematic diagram of the Structure of the Human Eye.
1. AQUEOUS HUMOUR
Located at the front of each eye in the human body. A
watery fluid that fills the chamber called the "anterior
chamber of the eye" which is located immediately behind
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the cornea and in front of the lens, and also the
"posterior chamber of the eye" which is a very narrow
compartment located between the peripheral part of
the iris, the suspensory ligament of the lens, and the
ciliary processes.
The aqueous humour is very slightly alkaline salt solution
that includes tiny quantities of sodium and chloride ions.
It is continually produced, mainly by the capillaries of
the ciliary processes, and drains away into Schlemm's
canal, located at the junction of the cornea and
2. CHOROID
The layer of the eyeball located between the retina and
the sclera.
It is a thin, highly vascular (i.e.
it contains blood vessels) membrane
that is dark brown in colour and
contains a pigment that absorbs
excess light and so prevents blurred
vision (due to too much light on the
retina).
The choroid is loosely attached to
the inner surface of the sclera by
the lamina fusa. The side of the
choroid closest to the centre of the
eyeball is attached to the retina.
This transparent innermost layer of
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the choroid is called Bruch's
Membrane.
The structure of the choroid itself consists mainly of a
dense capillary plexus and of many arterioles and venules
transporting blood to and from this plexus.
3. CILIARY MUSCLE
Located in each eye in the human body. It is one of three
zones of the ciliary body (which connects the choroid with
the iris).
Contraction and relaxation of the ciliary muscle alters the
curvature of the lens. The correct term for the adjustment
of the shape of the lens to change the focus of the eye is
"accommodation". This process may be described simply as
the balance existing at any one time between between two
states:
Ciliary Muscle relaxed: The suspensory ligaments attached
to the ciliary body that hold the lens in place are
stretched, causing the lens to be relatively flat. This
enables the eye to focus on distant objects.
Ciliary Muscle contracted: The tension on the suspensory
ligaments attached to the ciliary body is reduced allowing
the lens to be relatively round. This enables the eye to
focus on close objects (near to the eye).
4. CORNEA
Transparent circular part of the front of the human
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eyeball. It has an important optical function as it
refracts light entering the eye through the pupil and onto
the lens (which then focuses the light onto the retina).
The degree of curvature of the cornea varies between
individuals and also throughout the life of an individual.
It is more prominent in youth than later in life, when it
can become flatter in shape.
The cornea has a complex structure that specialist texts
describe in terms of the following layers (from the outside
inwards):
1. Several strata of epithelial cells, continuous with
those of the conjunctiva;
2. A thick central fibrous structure called the substantia
propria;
3. A homogeneous elastic lamina;
4. A single layer of endothelial cells forming part of the
lining membrane of the anterior chamber of the eyeball.
The cornea a non-vascular structure (which means that it
does not contain any blood vessels) as the capillaries that
supply it with nutrients terminate in loops at its
circumerfence. It is supplied by many nerves derived from
the ciliary nerves. These enter the laminated tissue of the
cornea. It is therefore extemely sensitive.
5. FOVEA
A small depression forming a shallow pit in the retina at
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the back of each eye in the human body.
Because it contains a large number of the light-sensitive
photo-detector cells called cones, the fovea is the area of
greatest acuity of vision.
This means that when an eye is directed at an object, the
part of the image of that object formed on the retina that
falls onto the fovea is the part of the image that will be
perceived in the greatest detail.
The fovea is slightly yellow in apperance and so was first
called the "Yellow Spot" or "Macula Lutea" of Sömmerring.
The existance of such an area is only known to occur in
humans, the quadrumana (a group of primates comprising apes
and monkeys), and some saurian reptiles.
6. HYALOID MEMBRANE
A transparent membrane that encloses the vitreous humour,
seperating it from the retina.
In front of the ora serrata (the area in which the retina
terminates as a jagged margin towards the front of the
eyeball as it approaches the ciliary body) the hyaloid
membrane is thickened by radial fibres and is called
the Zonule of Zinn or (another name for the same thing, the
zonula ciliaris).
7. IRIS
The coloured part of the human eye. That is, the anterior
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surface of the iris has different colours in different
individuals and is also marked by lines that converge
toward the pupil. However, the posterior (back) surface of
this iris has a deep purple tint due to two layers of
pigmented columnar epithelium. This pigmented epithelium is
usually referred to as the "pars iridica retinae" but is
sometimes called simply "uvea" due to the similarity of its
colour to that of a ripe purple grape.
It is a thin circular contractile curtain located in
the aqueous humour - in front of the lens but behind
the cornea. It contains a circular aperture (or "hole")
called the pupil and located just to the nasal side of the
centre of the iris.
A simple description of the iris is that it is a coloured
diaphragm of variable size whose function is to adjust the
size of the pupil to regulate the amount of light admitted
into the eye. It does this via the pupillary reflex (which
is also known as the "light reflex"). That is, when bright
light reaches the retina, nerves of the parasympathetic
nervous system are stimulated, a ring of muscle around the
margin of the iris contracts, the size of the pupil is
reduced, hence less light is able to enter the eye.
Conversely, in dim lighting conditions the pupil opens due
to stimulation of the sympathetic nervous system that
contracts of radiating muscles, hence increases the size of
the pupil.
The iris is composed of a series of layers, including:
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(1.) Flattened endothelial cells on a hyaline basement-
membrane;
(2.) Stroma - consisting of fibres and cells;
(3.) Muscular Fibre - consisting of circular and radiating
fibres;
8. LENS
An important part of the structure of the eye. This lens is
a transparent structure enclosed in a thin transparent
capsule. It is located behind the pupil of the eye and
encircled by the ciliary processes - that slightly overlap
its edges.
The lens of the eye helps to refract light travelling
through the eye (which first refracted by the cornea). The
lens focuses light into an image on the retina. It is able
to do this because the shape of the lens is changed
according to the distance from the eye of the object(s) the
person is looking at.
This adjustment of shape of the lens is
called accomodation and is achieved by the contraction and
relaxation of the ciliary muscle.
The Structure of the Lens
The capsule of the lens is a transparent, brittle, yet
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highly elastic membrane.
This capsule is thicker in front of the lens than behind it
The lens itself is a transparent, biconvex body of approx.
9-10 mm diameter and approx. 4 mm from front to back.
The basic structure of the lens is composed of concentric
layers.
9. OPTIC NERVE
The route by which information is sent from the eye for
processing by the brain. An optic nerve leaves the
posterior surface of each eye.
The optic nerve is the second cranial nerve (II), so called
because this nerve transmits visual information. Each optic
nerve contains approx. one million fibres carrying
information from the rods and cones of the retina.
The optic nerves progress from the posterior of the
eyeball, into the skull, through the optic chiasma (also
known as the optic commissure), the non to the cortex of
the occipital lobe on each side of the brain.
The Optic Papilla is also known as the Optic Disc. Located
on the retina of the eye at which the optic nerve leaves
the eye-transmitting signals from the eye to the brain.
10. OPTIC PAPILLA
11. PUPIL
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Located in the centre of each eye in the human body.
It generally appears to be the dark "centre" of the eye,
but can be more accurately described as the circular
aperture in the centre of the iris through which light
passes into the eye.
The size of the pupil (and therefore the amount of light
that is admitted into the eye) is regulated by
the pupillary reflex (also known as the "light reflex").
That is, when bright light reaches the retina, nerves of
the parasympathetic nervous system are stimulated, a ring
of muscle around the margin of the iris contracts, the size
of the pupil is reduced, hence less light is able to enter
the eye. Conversely, in dim lighting conditions the pupil
opens due to stimulation of the sympathetic nervous system
that contracts of radiating muscles, hence increases the
size of the pupil.
Note that although some
animals' eyes are
basically structured in a
similar way to human
eyes, they may appear to
be very different.
E.g. Differently shaped
pupils of cats compared
with people.
12. RETINA
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The retina is located at the back of the human eye.
The retina may be described as the "screen" on which an
image is formed by light that has passed into the eye via
the cornea, aqueous humour, pupil, lens, then
the hyaloid and finally the vitreous humour before reaching
the retina.
The function of the retina is not just to be the screen
onto which an image may be formed (necessary but not
sufficient), but also to collect the information contained
in that image and transmit it to the brain in a suitable
form for use by the body.
The retinal "screen" is therefore a light-sensitive
structure lining the interior of the eye. It contains
photosensitive cells (called rods and cones) and their
associated nerve fibres that convert the light they detect
into nerve impulses that are then sent onto the brain along
the optic nerve.
The retina has a complex structure that specialist texts
describe in terms of ten layers labelled (from contact with
the vitreous humour, outwards) as:
1. Membrana limitans interna.
2. Layer of nerve-fibers (stratum opticum).
3. Ganglionic layer, consisting of nerve cells.
4. Inner molecular, or plexiform, layer.
5. Inner nuclear layer, or layer of inner granules.
6. Outer molecular, or plexiform, layer.
7. Outer nuclear layer, or layer of outer granules.
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8. Membrana limitans externa.
9. Jacob's membrane (layer of rods and cones).
13. SCLERA
The sclera is the tough white sheath that forms the outer-
layer of the ball.
It is also referred to by other terms, including
the sclerotic and the sclerotic coat (both having exactly
the same meaning as the sclera).
In all cases these names are due to the the extreme density
and hardness of the sclera (sclerotic layer). It is a firm
fibrous membrane that maintains the shape of the eye as an
approximately globe shape. It is much thicker towards the
back/posterior aspect of the eye than towards the
front/anterior of the eye.
The white sclera continues around the eye; most of which is
not visible while the eyeball is located in its socket
within the face/skull. The main area of the eye that is not
covered by the area is the front part of the eye that is
protected by the transparent cornea instead.
The Structure of the Sclera
The sclera is composed of white fibrous tissue intermixed
with fine elastic fibers and corpuscles of flattened
connective-tissue. These fibers are grouped together in
bundles.
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Blood supply to the sclera is via small (but not very
numerous) interlinking capillaries.
The nerves connected to the sclera are from
the ciliary nerves.
14. VISUAL AXIS
The Visual Axis is one of the axes through the eye that is
a useful construct for optical equipment designers and
those working with the physics / optics rather than the
biology / physiology of human vision.
A simple definition of the visual axis is:
" A straight line that passes through both the centre of
the pupil and the centre of the fovea".
15. VITREOUS HUMOUR
The Vitreous Humour (also known as the Vitreous Body) is
located in the the large area that occupies approx. 80% of
each eye in the human body.
The vitreous humour is a perfectly transparent thin-jelly-
like substance that fills the chamber behind the lens of
the eye - click for diagram. It is an albuminous fluid
enclosed in a delicate transparent membrane called
the hyaloid membrane.
There is a canal called the canal of Stilling running
through the centre of the vitreous humour from the entrance
of the optic nerve to the posterior surface of the lens.
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This is filled with fluid and lined by a prolongation of
the hyaloid membrane.
16. ZONULA CILIARIS
The Zonula Ciliaris has many other similar names, including
the Zonule of Zinn, and simplyZonules. In all cases these
terms refer to the part of the of the human eye formed by
the change of structure of the hyaloid membrane as it - and
the vitreous humour that it contains - moves in front of
(anterior to) the ora serrata - which is the area in which
the retina terminates as a jagged margin towards the front
of the eyeball as it approaches the ciliary body.
N.B. The
distance
between the ora
serrata and
ciliary body is
exaggerated on
this diagram
and the approx.
position of the
Hyaloid
Membrane at the
position at
which it
becomes the
Zonules is
shown as a
dotted line for
emphasis.
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CHAPTER III
PATHOPHYSIOLOGY
Algorithm (assuming diagnosis has already been made).
Reference: RUBEN S T et al. Br J Ophthalmol 1997;81:163-167
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The pars plana is the section of the eye between the retina
and the pars plicata. The retina is the multi-layer of cells
in the back of the eye that sends images to the brain; the
pars plicata creates the fluid in the front of the eye
(aqueous humor). The pars plana has no specific use and is a
safe place to place the vitrectomy instruments where there
won't be any damage to any tissue.
The vitreous is a normally clear, gel-like substance that
fills the center of the eye. It makes up approximately 2/3
of the eye's volume, giving it form and shape before birth.
Certain problems affecting the back of the eye may require a
vitrectomy, or surgical removal of the vitreous. After a
vitrectomy, the vitreous is replaced as the eye secretes
aqueous and nutritive fluids. The vitreous fluid is the
clear jelly that fills the back of the eye and presses
against the retina. The vitreous is composed mostly of
water; however, the vitreous itself is unable to clear
itself of any type of debris that might accumulate in the
eye, such as blood or substances from inflammatory
processes. If enough of these materials collect in the
vitreous, vision can be decreased. During a pars plana
vitrectomy--named after the part of the eye the instruments
are placed in-- the vitreous is removed, along with any
debris.
PARS PLANA VITRECTOMY
A vitrectomy may be performed to clear blood and debris from
the eye, to remove scar tissue, or to relieve traction on
the retina. Blood, inflammatory cells, debris, and scar
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tissue obscure light as it passes through the eye to the
retina, resulting in blurred vision. The vitreous is also
removed if it is pulling or tugging the retina from its
normal position.
INDICATIONS
Some diseases that can be treated with a pars plana
vitrectomy are diabetic eye disease, retinal detachments,
holes in the retina and vitreous hemorrhage. Diabetic eye
disease and retinal detachments can both cause vitreous
hemorrhages as well. The vitreous hemorrhage is often given
a chance to settle and attempt to reabsorb before surgery is
scheduled. The severity of the initial disease before the
pars plana surgery gives an indication as to what the level
of vision will be after the surgery.
COMPLICATIONS
Along with the usual complications of surgery, such as
infections, vitrectomy can result in retinal detachment. A
more common complication is high intraocular pressure,
bleeding in the eye, and cataract, which is the most
frequent complication of vitrectomy surgery. Many patients
will develop a cataract within the first few years after
surgery.
PROCEDURE
This procedure is usually done as an outpatient procedure.
Either local or general anesthesia can be used during this
procedure. At least three instruments are placed in the eye
through the pars plana: one to remove the vitreous; another
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to inject fluid to help the eye maintain its shape while the
vitreous is being removed; and one with a light source. The
surgeon uses a microscope to view inside of the eye during
the procedure. The eye is filled with a saline solution
after all of the vitreous is removed. In some cases, the
openings where the instruments were inserted are stitched
shut; in others, the incisions don't need stitches and will
heal on their own.
RISKS
Some of the risks of pars plana vitrectomy include
infection, retinal detachment, increased eye pressure,
vitreous hemorrhage and development of a cataract. Cataract
is the most common adverse effect after vitrectomy
procedures. Less common adverse effects include swelling of
the tissue below the retina, a significant change in
eyeglasses prescriptions and swelling in the center of the
macula. The surgeon takes great care to avoid these outcomes
and will also follow the patient closely after the procedure
to manage these problems if they do arise.
PARS PLANA VITRECTOMY - THE SURGERY
The retinal surgeon performs the procedure through a
microscope and special lenses designed to provide a clear
image of the back of the eye. Several tiny incisions just a
few millimeters in length are made on the sclera. The
retinal surgeon inserts microsurgical instruments through
the incisions such as:
Fiber optic light source to illuminate inside the eye;
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Infusion line to maintain the eye's shape during
surgery;
Instruments to cut and remove the vitreous.
Vitrectomy is often performed in conjunction with other
procedures such as retinal detachment repair, macular hole
surgery, and macular membrane peel. The length of the
surgery depends on whether additional procedures are
required and the overall health of the eye.
The retinal surgeon may use special techniques along with
vitrectomy to treat the retina. Your surgeon will determine
if any of these are appropriate for your eye:
Sealing blood vessels - Laser is sometimes used to stop tiny
retinal vessels from bleeding inside the eye
Gas bubble - A small gas bubble may be placed inside the eye
to help seal a macular hole.
Silicone oil - After reattachment surgery, the eye may be
filled with silicone oil to keep the retina in position.
IMMEDIATE POST-OPERATIVE EXAMINATION
The eye is patched after the first postoperative checkup.
This can usually be removed the same evening at bedtime.
Since the anesthesia numbs the lids and temporarily prevents
blinking, it is very important to keep the eye patch on
until you are able to blink the eye normally. Begin using
drops after the patch has been removed.
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OCULAR DISCOMFORT
It is common to experience some discomfort immediately after
the surgery and for several days afterward. This is
primarily related to swelling on the outside of the eye and
around the eyelids. A scratchy feeling or occasional sharp
pain is normal.
Ice compresses gently placed on the swollen areas (ice
placed inside a resealable plastic bag work well) reduce the
aching and soreness. Tylenol is also helpful for minor
aching.
If you have a deep ache or throbbing pain that does not
respond to Tylenol or other over-the-counter pain
medication, please call the office.
Redness is common and gradually diminishes over time. Some
patients may notice a patch of blood on the outside of the
eye. This is similar to bruising on the skin and slowly
resolves on its own.
OTHER PROCEDURES
Because vitrectomy is performed for many different problems
and often in conjunction with other eye surgeries, the
recovery period varies with the individual. In some cases,
such as macular hole surgery, the surgeon may place a gas
bubble inside the eye that places gentle pressure on the
macula. This may require special head positioning to keep
the bubble positioned correctly.
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Dilating drops (red cap bottle) may be prescribed that keep
the pupil of the operated eye large, causing be light
sensitivity.
POSTOPERATIVE GUIDELINES
Since vitrectomy is often performed along with other
procedures, postoperative instructions may vary. Some
general guidelines are provided; however, please consult
with your surgeon for specific instructions.
Begin using any anti-inflammatory and antibiotic drops
prescribed by your physician immediately after your eye
patch has been removed.
Wear the plastic eye shield when sleeping for the first 7
days following surgery. The shield should be worn for the
first 3 days following surgery when showering.
Avoid bending, stooping, lifting objects over 5 pounds, or
any strenuous activity for one week (unless directed
otherwise by your physician).
Take Tylenol or gently apply ice compresses to the eye to
relieve mild discomfort.
Follow any special instructions given by your physician for
head positioning (this is not necessary in all cases).
MACULAR HOLE SURGERY
Macular hole surgery is unique because the outcome is not
only dependent on the surgeon's skill, it requires the
commitment of the patient afterward.
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During surgery, a gas bubble is placed inside the eye. The
bubble puts gentle pressure on the macula and helps the hole
to seal. In order to enjoy the benefit of the surgery, it is
imperative that the bubble floats against the macula during
the critical healing phase. Since the gas rises, this is
only possible when the head is in a face-down position.
Obviously, it is impossible to remain face-down 100% of the
time; however, each moment spent in this position increases
the likelihood of successful surgery.
When the bubble is first injected, it nearly fills the eye.
This obstructs vision for the first few weeks following
surgery. Over time, the bubble gradually dissolves, and
vision improves. As the bubble gets smaller, it sometimes
breaks up into several smaller bubbles. This is common and
does not pose a problem. The outcome of the surgery cannot
be determined until the bubble begins to disappear.
It is important to remain face-down as much as possible for
9-10 days after surgery. While this may seem a bit awkward,
there are several things activities that can be done in this
position. Many patients read a book or magazine while
looking down. The non-operated eye will not suffer from
overuse or strain.
Some patients watch television by placing it face-up on the
floor. An alternative is to place a mirror in order to see a
reflection of the television screen when looking down. Other
activities that can be done while sitting and looking down
are perfectly acceptable.
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At times, the positioning may be uncomfortable; but a
successfully closed hole and improved vision is well worth
the temporary aggravation.
The eye is patched after the first postoperative checkup.
This can usually be removed the same evening at bedtime.
Since the anesthesia numbs the lids and temporarily prevents
blinking, it is very important to keep the eye patch on
until you are able to blink the eye normally. Begin using
drops after the patch has been removed.
HOW SHOULD THE EYE FEEL?
It is common to experience some discomfort immediately after
the surgery and for several days afterward. This is
primarily related to swelling on the outside of the eye and
around the eye lids. A scratchy feeling or occasional sharp
pain is normal.
Ice compresses gently placed on the swollen areas (ice
placed inside a resealable plastic bag work well) reduce the
aching and soreness.
If you have a deep ache or throbbing pain that does not
respond to Tylenol or other over-the-counter pain
medication, please call your doctor.
Redness is common and gradually diminishes over time. Some
patients may notice a patch of blood on the outside of the
eye. This is similar to bruising on the skin and slowly
resolves on its own.
Until the gas bubble has cleared, your vision will be very
poor. In some cases, it may take several weeks for the
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bubble to clear completely. You will notice your vision
slowly returning as the bubble clears.
While taking the dilating drop (red cap) the pupil of the
operated eye will be quite large and you may be light
sensitive. This drop makes more room for the gas bubble by
keeping the pupil dilated. It also keeps the eye more
comfortable.
POST-OPERATIVE INSTRUCTIONS
Following surgery, patients are examined the same day or the
following morning.
Keep the eye patched until later in the day when you are
able to blink the eye lids normally.
Begin taking medications as directed after the eye patch has
been removed.
If you experience aching or soreness immediately after
surgery, gently place ice compresses on the eye. Tylenol is
also helpful for minor aching and soreness.
Wear the plastic eye shield when sleeping for the first 7
days after surgery. It should also be worn when showering
for the first 3 days after surgery.
The eye is most susceptible to infection for the first 7
days after surgery. To minimize the risk, avoid touching,
rubbing, or bumping the eye.
Avoid air travel until the gas bubble has completely
dissipated from the eye. This is important because the gas
expands at high altitudes and could elevate the eye pressure
27
to a dangerous level. Please check with your surgeon to be
sure that the bubble is gone before flying.
Most importantly: Keep your head in a face-down position for
9-10 days following surgery. This can be done while sitting
or lying down.
Most patients take three different eye drops after surgery.
The eye drops serve several purposes such as: preventing
infection, reducing swelling inside the eye, reducing
redness, and keeping the eye comfortable. The dilating drop
with the red cap keeps the pupil very large and causes light
sensitivity. Consult your written instructions for a list of
medications and appropriate dosage.
During your follow-up visits, you will receive instructions
how to gradually reduce the frequency of the drops and
eventually stop them all together.
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CHAPTER IV
PATIENT’S PREPARATION
Signed Consent for surgery was obtained. A physical
examination was performed along with laboratory tests. The
patient was asked and ordered to fast (not to eat or drink
anything) for eight hours before the procedure. This was to
ensure that she’ll have an empty stomach. Having an empty
stomach helps but does not guarantee that vomiting will be
prevented. Vomiting can lead to possible aspiration
(breathing in) of stomach contents into lungs. Irritation of
the lung and possible pneumonia could result from such an
aspiration event. Prescription for pain medication by the
attending physician was also given prior to surgery.
Dentures, nail polish, jewelleries were removed from the
patient. Moreover, bowel and bladder content evacuation was
maintained. Pre- operative orders and preparations were
carried out systematically.
A. SKIN PREPARATION
Skin preparation was done aseptically using a gauze with
BETADINE® which contains 7.5% povidone-iodine for
microbicidal sudsing cleanser that promptly kills a broad
spectrum of pathogens all over the patient’s right eye.
B. POSITION
The patient was positioned in a supine position which is
lying on the back; having the face upward and having the
palm of the hand or sole of the foot upward.
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C. Draping
The patient was draped aseptically using four towel sheets
and a wide lap sheet that covers the entire body of the
patient.
D. Anesthesia used
Laryngeal Mask Airway (LMA) was used to sedate the patient.
It is a device for maintaining a patent airway without
tracheal intubation, consisting of a tube connected to an
oval inflatable cuff that seals the larynx. The LMA was
proven to be very effective in the management of airway
crisis. Laryngeal mask airway is used in eye surgery to
evaluate: 1) the limits of safe handling; 2) the feasibility
of its use in long operative procedures, and 3) whether
patients with higher anaesthetic risk (hypertension, asthma,
and children) may profit from the LM. Side-Effects of the
LMA include:
• Throat soreness
• Dryness of the throat and/or mucosa
• Side effects due to improper placement vary based on the
nature of the placement
30
CHAPTER V
DISCUSSION OF THE PROCEDURE
Insertion of light pipe, vitreous cutter and infusion
line in the right sclera creating 3.5mm from limbus
using 19 gauge needle.
31
Catheterization of sclerotic vessel in the superior
hall of the retina.
32
Lens 20 degrees and 30 degrees placed in cornea for
magnification.
Vitrectomy done at 750 continuous passive motion and 20
millimeter per mercury ampule.
Parts of conjunctiva and sclera were closed using
vincryl 7-0.
Corneal slot was opened.
Intraocular lens 21.5 power with diameter of 5
millimeter inserted and dilated into the bags.
Note of posterior capsular placement.
Corneal slot was sutured with nylon 10-0 #2.
CHAPTER VI
INSTRUMENTATION
Mayo table- It drapes and carries the instrument for
the operation.
33
S t e r i l e t o w e l - linens placed on the patient or
around the field to delineate sterile areas
Several sterile gauze- used for absorbing fluids
as well as dressing and protecting wounds
P a i r o f g l o v e - u s e d d u r i n g a l l p a t i e n t -
c a r e a c t i v i t i e s t h a t m a y i n v o l v e
e x p o s u r e t o b l o o d a n d a l l o t h e r b o d y
f l u i d
V i t r e c t o m y L e n s S e t - t h e s e c o m p r o m i s e a
s e t o f c o n t a c t l e n s e s w i t h c o n c a v e
c o n t a c t s u r f a c e a n d c o m e s w i t h a r i n g t o
h o l d t h e c o n t a c t l e n s e s i n p o s i t i o n
34
Irrigating Vitrectomy Lens Set- it has refractive power
of 90 degrees and a field of view of 24 degrees
Backflush Flute Neeedle with Silicon tip- helps in safe
back flushing of the incarcerated tissue during passive
aspiration of intra ocular fluids
Silicon Tip Cannula- with a needle of 20G with a soft
automatic removal of intraocular fluids; used in the
reposition of retinal folds or breaks.
Infusion Cannula- used for infusion during the surgery
35
Silicon Oil Injector- used to control injection of the
silicon oil into the eye with minimal efforts
20D Aspheric Lens- provides ultra resolution retinal
image with the binocular indirect ophthalmoscope.
Lens Holder- to the lens in place for easier
visualization of the cornea
36
Intraocular lens 21.5 power with diameter of 5
millimeter- it is implanted in the eye used to
treat cataracts or myopia
Surgical Sutures (vincryl 7-0 and nylon 10-0 #2- used
to closed/heal the wound on some parts of conjunctiva
and sclera during the surgery
Eye Protection/goggles- protective eyewear that is used
after surgery to enclose or protect the eye area in
order to prevent particulates, infectious fluids, or
chemicals from striking the eyes
37
CHAPTER VII
DRUG STUDY
DRUG NAME MODE OF ACTION INDICATION/CONTAINDICATION
SIDE EFFECTS/ADVERSE EFFECTS
NURSING CONSIDERATION
GENERIC NAME:
Prednisone
BRAND NAME:Deltasone
CLASSIFICATION:Adrenocortical Steroid
DOSAGE:2x a day on altered eye 1 drops
ROUTE:Topical Ophthalmic (eye drops)
FORM:Ophthalmic Solution Or Suspension (eye drop)
Irreversibly binds with glucocorticoid receptors (GR) alpha and beta for which they have a high affinity. AlphaGR and BetaGR are found in virtually all tissues with variable numbers between 3000 and 10000 per cell, depending on the tissue involved. Prednisolone can activate and influence biochemical behaviour of most cells. The steroid/receptor complexes dimerise and interact with cellular DNA in the nucleus, binding to steroid-response elements and modifying gene transcription. They induce synthesis of some proteins, and inhibit synthesis of others.
INDICATION:>Reducing inflammation in the eye.>To reduce swelling, redness, itching, and allergic reactions affecting the eye.
CONTRAINDICATION:>Hypersensitivity to any of the components of the preparation. >Presence of viral, fungal, tuberculous or other bacterial infection. >Glaucoma
SIDE EFFECTS:>mild stinging>irritation
>fluid retention of the face (moon face, Cushing's syndrome)>acne>constipation, >mood swings
ADVERSE EFFECT:>associated with cataract development
1.Best when taken with food.2.Never stop taking suddenly. Too much or too little may be dangerous and even life threatening.3.Never skip doses.4.Your child should see his/her eye doctor yearly if s/he is taking prednisone.5.If the child is ill and has a temperature, vomiting and unable to keep down his or her prednisone, call child's doctor immediately.
34
DRUG NAME MODE OF ACTION INDICATION/CONTAINDICATION
SIDE EFFECTS/ADVERSE EFFECTS
NURSING CONSIDERATION
GENERIC NAME:
Moxifloxacin
BRAND NAME:Vigamox
CLASSIFICATION:Quinolone Antibiotic
DOSAGE:2x a day on altered eye 1 drop
ROUTE:Topical Ophthalmic (eye drops)
FORM:Ophthalmic Solution(eye drops)
Contains the 4th generation fluoroquinolonMoxifloxacin has in vitro activity against a wide range of Gram-(+) and Gram-(-) MO. It inhibits the topoisomerase II (DNA gyrase) and topoisomerase IV required for bacterial DNA replication, transcription repair, and recombination. The C8-methoxy moiety of these also lessens the selection of resistant mutants of Gram-(+) bacteria compared to the C8-H moiety found in older fluoroquinolones. Moxifloxacin’s bulky C-7 substituent group interferes with the quinolone efflux pump mechanism of bacteria. Moxifloxacin is often bactericidal at concentrations equal to or slightly greater than inhibitory concentrations.
INDICATION:>Used for the treatment of bacterial conjunctivitis (a bacterial infection on the surface of the eye)and anterior segment of the eye
CONTRAINDICATION:>Hypersensitivity or drug allergy to fluoroquinolones >Caution should be used in female patients who are pregnant or who are nursing.>For viral or fungal infections of the eye.
SIDE EFFECTS:>Blurred vision, watery eyes, eye pain/dryness/redness/itchiness Symptoms of an allergic reaction include: rash, itching/swelling (especially of the face/tongue/throat), dizziness, trouble breathing.
ADVERSE EFFECT:>Ocular discomfort (burning or stinging upon instillation) >Ocular pruritus
1.Contact lenses should not be worn while using drug.2.Stop and call the doctor if hypersensitivity are experienced (rash, itching, swelling of the face/throat, or difficulty breathing3.Avoid contamination by avoiding contact of the tip of the eye dropper with anything and by washing hands prior to use. 4.Vigamox is a solution so it is not necessary to shake the bottle before instilling drops.
35
DRUG NAME MODE OF ACTION INDICATION/CONTAINDICATION
SIDE EFFECTS/ADVERSE EFFECTS
NURSING CONSIDERATION
GENERIC NAME:
Mefenamic Acid
BRAND NAME:Ponstan
CLASSIFICATION:CNS Agent;Analgesic;NSAID;Antipyretic
Dosage:500 mg/capsule 3x a day (PRN for pain); after meals
ROUTE:oral
FORM:Ophthalmic Solution(eye drops)
Mefenamic acid inhibits the enzymes cyclooxygenase (COX)-1 and COX-2 and reduces the formation of prostaglandins and leukotrienes. It also acts as an antagonist at prostaglandin receptor sites. It has analgesic and antipyretic properties with minor anti-inflammatory activity.
INDICATION:> For relief of mild to moderate pain in patients 14 y and older>Inflammation
CONTRAINDICATION:>Hypersensitivity to mefenamic acid; patients who have experienced asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs; treatment of perioperative pain in the setting of coronary artery bypass graft (CABG) surgery; active ulceration or chronic inflammation of either the upper or lower GI tract; preexisting renal disease
CV: CHF; hypertension; syncope; tachycardia.CNS: Dizziness, headache (up to 10%).Derma: Pruritus, rashes (up to 10%).GI: Abdominal pain, constipation, diarrhea, dyspepsia, flatulence, GI ulcers (gastric/duodenal), gross bleeding/perforation, heartburn, nausea, vomiting (up to 10%).Hemat: Anemia, increased bleeding time (up to 10%).Hepatic: Elevated liver enzymes (up to 10%).Miscellaneous: Abnormal renal function, edema, tinnitus (up to 10%).
1.Assess patients who develop severe diarrhea and vomiting for dehydration and electrolyte imbalance.2.Obtain periodic CBC, Hct and Hgb, and kidney function tests.3.Discontinue drug promptly if diarrhea, dark stools, hematemesis, ecchymoses, epistaxis, or rash occur and do not use again.4.Notify physician if persistent GI discomfort, sore throat, fever, or malaise occur.5.Do not drive or engage in potentially hazardous activities until response to drug is known. 6.Monitor blood glucose for loss of glycemic control if diabetic.
36
DRUG NAME MODE OF ACTION
INDICATION/CONTAINDICATION
SIDE EFFECTS/ADVERSE EFFECTS
NURSING CONSIDERATION
GENERIC NAME:Pilocarpine
BRAND NAME:Isopto Carpin
CLASSIFICATION:Cholinergic Agents
Dosage:Eye Drops- Instill 1 or 2 drops per eye, 3 to 4 times per day
ROUTE:Topical Ophthalmic (eye drops)
FORM:Ophthalmic Solution(eye drops)
Pilocarpine is a tertiary parasympathomimetic that directly stimulates cholinergic receptors in the eyes causing pupillary constriction, spasm of accommodation and a transient rise in IOP followed by a fall.
INDICATION:>To treat high pressure inside the eye due to glaucoma or other eye diseases (e.g., ocular hypertension). Lowering high pressure inside the eye helps to prevent blindness, vision loss, and nerve damage. Used during certain eye surgeries and to reverse the effects of drugs used to enlarge the pupil (e.g., during an eye exam). Works by causing the pupil of the eye to shrink and decreasing the amount of fluid within the eye.
CONTRAINDICATION:>To patients with uncontrolled asthma, and allergic to pilocarpine.
Most Common- Sweating, nausea, runny nose, diarrhea, chills, flushing, frequent urination, dizziness, weakness. Miscellaneous- Headache, indigestion, vomiting, heartburn, increased tears, stomach pain, swelling of arms, hands, feet, ankles, or lower legs, changes in vision, fast or slow heart beat.
ADVERSE EFFECT:Ocular: Pain and irritation, blurred vision, lachrymation, browache, conjunctival vascular congestion, superficial keratitis, vitreous haemorrhage, increased pupillary block.
1.It may lead to dehydration to the body, so drink plenty of water while taking this medication. 2.It may cause change in vision in night, so be careful while driving a car or other dangerous performance.3.During acute phases, the miotic must be instilled into the unaffected eye to prevent an attack of angle-closure glaucoma.4.Not for internal use. To prevent contaminating the dropper tip and solution, care should be taken not to touch the eyelids or surrounding areas with the dropper tip of the bottle.
37
DRUG NAME MODE OF ACTION INDICATION/CONTAINDICATION
SIDE EFFECTS/ADVERSE EFFECTS
NURSING CONSIDERATION
GENERIC NAME:Proparacaine Hydrochloride 0.5%
BRAND NAME:ALCAINE®
CLASSIFICATION:Topical Local Anesthetic For Ophthalmic Use
Dosage:Instill 1 drop to the eye every 5 to 10 minutes for 5 to 7 doses
ROUTE:Topical Ophthalmic (eye drops)
FORM:Sterile Ophthalmic Solution
With a single drop, the onset of anesthesia begins within 30 seconds and persists for 15 minutes or longer.The main site of anesthetic action is the nerve cell membrane where proparacaine interferes with the large transient increase in the membrane permeability to sodium ions that is normally produced by a slight depolarization of the membrane. As the anesthetic action progressively develops in a nerve, the threshold for electrical stimulation gradually increases and the safety factor for conduction decreases; when this action is sufficiently well developed, block of conduction is produced.
INDICATION:>For topical anesthesia in ophthalmic practice. > A topical anesthetic prior to surgical operations such as cataract extraction.
CONTRAINDICATION:>Patients with known hypersensitivity to any component of the solution.
Occasional temporary stinging, burning and conjunctival redness A rare, severe, immediate-type, apparently hyperallergic corneal reaction characterized by acute, intense and diffuse epithelial keratitis, a gray, ground glass appearance, sloughing of large areas of necrotic epithelium, corneal filaments and, sometimes, iritis with descemetitis has been reported.Allergic contact dermatitis from proparacaine with drying and fissuring of the fingertips has also been reported.
1.Patients should be advised to avoid touching the eye until the anesthesia has worn off. 2.Do not touch dropper tip to any surface as this may contaminate the solution.3.Store in carton until empty to protect from light. If solution shows more than a faint yellow color, it should not be used.4.A protective eye patch is recommended after surgery.
38
DRUG NAME MODE OF ACTION INDICATION/ CONTAINDICATION
SIDE EFFECTS/ADVERSE EFFECTS
NURSING CONSIDERATION
GENERIC NAME:Tobramycin+Dexamethasone
BRAND NAME:TobraDex ST
CLASSIFICATION:Eye Antiseptics with Corticosteroids
Dosage:1or2 drops instilled into the conjunctival sac(s) every 4-6 hours
ROUTE:Topical Ophthalmic (eye drops)
FORM:Ophthalmic Solution
An aminoglycoside antibiotic, has actions similar to that of gentamicin and is active against Staphylococci, Streptococci, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, Enterobacter aerogenes, Proteus mirabilis, Morganella morganii, most Proteus vulgaris strains, Haemophilus influenzae andH. aegyptius, Moraxella lacunata, Acinetobacter calcoaceticus and some Neisseria species. Dexamethasone, a synthetic fluorinated corticosteroid, has mainly glucocorticoid activity and suppresses inflammatory response.
INDICATION:>The use of a combination drug with an anti-infective component is indicated where the risk of superficial ocular infection is high or where there is an expectation that potentially dangerous numbers of bacteria will be present in the eye.
CONTRAINDICATION:Epithelial herpes simplex keratitis (dendritic keratitis), vaccinia, varicella, and many other viral diseases of the cornea and conjunctiva. Mycobacterial infection of the eye. Fungal diseases of ocular structures. Hypersensitivity to a component of the medication.
Hypersensitivity reactions, lid itching and swelling, conjunctival erythema, increase in intraocular pressure, glaucoma, optic nerve damage, posterior subcapsular cataract formation and delayed wound healing.
1.Do not touch the dropper or tube opening to any surface, including your eyes or hands. The dropper or tube opening is sterile. 2.If it becomes contaminated, it could cause an infection in the eye.3.Do not use any eye drop that is discolored or has particles in it.4.Store at room temperature away from moisture and heat. Keep the bottle or tube properly capped.
39
DRUG NAME MODE OF ACTION INDICATION/ CONTAINDICATION
SIDE EFFECTS/ADVERSE EFFECTS
NURSING CONSIDERATION
GENERIC NAME:Tropicamide + phenylephrine hydrochloride
BRAND NAME:Tropicacyl
CLASSIFICATION:Mydriatic and Cycloplegic Agents
Dosage:5 drops every 5 minutes for 5 doses
ROUTE:Topical Ophthalmic
FORM:Ophthalmic Solution
Tropicamide binds to and blocks the receptors in the muscles of the eye (muscarinic receptor M4). Tropicamide acts by blocking the responses of the iris sphincter muscle to the iris and ciliary muscles to cholinergic stimulation, producing dilation of the pupil and paralysis of the ciliary muscle.
INDICATION:To induce mydriasis (dilation of the pupil) and cycloplegia (paralysis of the ciliary muscle of the eye) in diagnostic procedures, such as measurement of refractive errors and examination of the fundus of the eye.
CONTRAINDICATION:Hypersensitivity to any component of the products, potassium guaiacolsulfonate, or to sympathomimetic amines; severe hypertension; ventricular tachycardia; pheochromocytoma;
CV: Angina; arrhythmias; bradycardia; CV collapse with hypotension; fatal subarachnoid hemorrhage; hypertension; MI; syncope; tachycardia.CNS: Anxiety; CNS depression; convulsions; dizziness; excitability; fear; hallucinations; headache; insomnia; nervousness; pallor; restlessness; tremor; weakness.EENT: With ophthalmic and intranasal forms: blurring of vision; rebound congestion; transitory stinging on initial instillation.GI: Nausea.GenitourinaryDysuria; urinary retention.RespiratoryRespiratory difficulty.
1.To instill ophthalmic solution, tilt patient's head back, hold dropper over eye, drop medication inside lower lid, and apply pressure to inside corner of eye for 2 to 3 min. 2.Take care not to touch dropper to eye.3.Prolonged exposure of ophthalmic solution to air or strong light may cause oxidation and discoloration.4.Do not use if solution is discolored or cloudy or contains precipitate.5.Heavily pigmented irides may require larger doses.
40
41
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