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Nursing Skills in Ophthalmic Surgery
NURSING SKILLS IN OPHTHALMIC SURGERY Caroline Rogers, R.N.
Our precious gift of sight oftimes is taken for granted. We give little thought to the truly wondrous gift that it is. A patient coming to the hospital, however, is acutely aware of this gift, and sight becomes a valued possession as he contemplates eye surgery. This patient temporarily entrusts in our care God’s great gift to him. Unfortunately, not all OR nurses enjoy assisting on eye surgery. There is a vast difference in the skills applied to opthalmic surgery and the needed skills in general surgery. Surgeons expect and are grateful for good nursing assistance. Since many ophthalmologists work without a doctor assistant, they depend on good nursing assistance to help them achieve the maximum beneficial operative result for their patient. The time and effort spent by a nurse to learn the proper approach to patient care during eye surgery can be rewarding.
ANATOMY A review of the basic anatomy of the eye and a brief definition of terms most frequently used in eye surgery will help to clear our perspective. akinesia: loss of or impaired motor function of the lids. anterior chamber: that area between the Caroline Rogers, R.N., is head nurse in charge of urological, eye, ear, nose and throat and orthopedic operating rooms at Mercy Hospital in Rockville Centre, N. Y. She has worked in the OR almost exclusively since graduation from Mary Immaculate Hospital in N. Y. Mrs. Rogers is a member of the AORN Editorial Committee.
August 1967
posterior surface of the cornea and the anterior surface of the iris. posterior chamber: that area between the posterior surface of the iris and the anterior surface of the lens. aphakiu: the condition of the eye without a lens. aqueous humor: fluid found in both anterior and posterior chambers. choroid: the middle coat of the eyeball between the sclera and the retina. conjunctiva : the mucous membrane covering the anterior portion of the globe reflected upon the lids and extending to their free edges. cornea: the transparent anterior portion of the eyeball. lens: a refractive organ of accommodation. limbus: the edge of the cornea at its junction with the sclera. 0.d.: oculus dexter (right eye) O.S. : oculus sinister (left eye) retrobulbar : behind the eyeball. synechia: adhesions of parts of the eye; iris to lens, iris to cornea. strabismus: an eye disorder due to lack of muscle coordination. May be convergent, divergent, alternating or vertical. scZera: the firm fibrous outer layer of the eyeball, continuous with the sheath of the optic nerve behind and with the cornea in front. Tenon’s capsule: the fascia of the eyeball which envelopes the whole eyeball except the cornea. zonule : the suspensory structure supporting the lens.
39
that the new nurse was there only to observe and learn. There is no doubt the patient was immediately overcome by a feeling somewhat less than confident.
THE CIRCULATING NURSE
PATIENT ARRIVES IN OR The circulating nurse, after greeting the patient on his arrival in the OR, checks his identification and places him on the operating table. The routine preoperative eye drops instilled in the eyes on the nursing unit may have blurred his vision, and it is important that he be assured there is someone looking out for his safety while his vision is temporarily impaired. When the patient is asked to move onto the operating table it helps to place his hand on the table so that he may feel the table and judge more accurately how far he must move. A short explanation, in a low calm voice, of everything the nurse is doing to the patient is important.
The role of the circulating nurse requires that she maintain an atmosphere of efficient, peaceful tranquility. There is a twofold need for this environment. First, it is essential to the surgeon so that he can perform a very delicate operation without interruption or sudden loud distracting noises. Secondly, the patient usually comes to the operating room heavily sedated but nevertheless awake, and remains in a state of semi-analgesia. Many eye operations are routinely done under local anesthesia and the patient is constantly aware of the activities around him. Even normal conversation which is totally unrelated to the patient may very well be misunderstood by him. Recently, a surgeon while donning his gown and gloves was introduced to a nurse in the room by the circulating nurse with this phrase, “Dr. Jones, this is Miss Brown, one of our new nurses. She has never scrubbed for a cataract before.” The patient of course did not know that there was another experienced scrub nurse also to assist the surgeon and
POSITIONING The patient’s proper position on the table will insure maximum comfort and ease of working for the surgeon. Some doctors prefer the patient’s head positioned to the top edge of the table. Whether the doctor sits or stands, he will not then experience back strain from leaning forward while operating. There are, of course, other surgeons who prefer to have the patient’s head about five or six inches from the top edge of the table. This position provides a place for the surgeon to rest his arms during surgery thus enabling him to better control his hand motion. The head of the patient should be hyperextended and where a general anesthesia is used it helps to place the head on a doughnut or between sandbags. The patient is told that his arms are being restrained to prevent him from bringing his hands to his face during the operation, because most patients fall asleep while the surgeon is working and forget that they are being operated upon. Two things will be accomplished: first, there is the psy-
A-Anterior chamber B-Cornea C-Iris D-Ciliary body E-Retina
40
F-Choroid GLens H-Sclera I-Vitreous body J-Optic Disc
AORN Journal
chological assurance to the patient that the operation will not be a dreadful painful experience if it is likely he will fall asleep; and secondly, and more importantly it will prevent contamination of the sterile field once the operation is in progress. Place the blood pressure apparatus on the arm leaving the stethoscope in place under the cuff. This will facilitate frequent checking of the blood pressure during the operation without disturbing the sterile drapes.
EYE DROPS An instillation of two or three drops of sterile ophthalmic anesthetic solution in each eye about three to four minutes apart for four or more times will provide enough topical anesthesia to the conjunctival sac to prevent the discomfort of burning when the face is prepped. Anesthetic drops are placed in both eyes because both are prepped. Mydriatic drops are placed only in the eye to be operated on. (This routine is eliminated when the surgery is to be done under general anesthesia. ) Extreme care must be taken in regard to the instillation of eye drops. The RIGHT drug in the RIGHT strength in the CORRECT eye is of paramount importance. The exact number of drops at the correct interval and number of times designated by the surgeon must be carefully carried out. The proper method of instilling eye drops to get the maximum benefit of the drug is to retract the lower lid gently with the forefinger and retract the upper lid with the thumb making sure the drops fall directly onto the conjunctival sac. To prevent crossinfection between patients, the edge of the medicine dropper or squeeze bottle should never be allowed to touch the lid. Individual sterile dropper bottles are available for ophthalmic drugs and are commonly used. Many surgeons order a routine instillation of antibiotic eye drops preoperatively for five to seven days. This is done to sterilize the
August 1967
conjunctival sac as much as possible. If the edge of the dropper or bottle touches the lid, it contaminates the dropper and the solution and in addition it is very likely that a twitch of the eyelids at the moment of contact would cause the solution to run off the lid onto the face and thus the desired beneficial effect of the drug is lost. Ophthalmic solutions have various effects on the eye. Tetracaine 0.5 per cent is used for topical anesthesia. Cyclogyl one per cent, Cyclomydril 0.5 per cent, Atropine one per cent, and Neo-Synepherine 10 per cent are used to dilate the pupil. Pilocarpine two per cent contracts the pupil. If the nurse is requested to cut the eyelashes, it helps to put a small amount of ophthalmic ointment or vaseline on the scissor’s blade so that the lashes will adhere to the blades and not fall free into the operative area. PREP After placing the OR table in the room, it is advisable to adjust the lights before draping is done so that only a minute adjustment will be needed after the draping has been completed. Usually it is the circulating nurse who washes or preps the face preoperatively, explaining the procedure to the patient. A soft gentle wiping motion is employed. The vigorous scrub used on skin in other types of surgery cannot be used in eye surgery. Although anesthetic drops are used to prevent conjunctival irritation, care should be taken to keep the cleansing agents out of the eye. Ask the patient to close his lids gently and not to squeeze them tightly together while the forehead, eyes, nose and cheeks are wiped. The solution used for the skin preparation will depend upon the surgeon’s choice of agents. With a sponge that has been immersed in the skin disinfectant in each hand start the prep at the bridge of the nose. Wipe to cover both lids and the area to the hair-
41
line. Discard these two sponges and with two fresh sponges start the next stroke at the midline of the forehead, covering the brows and continuing outward and downward well beyond the ears. After each wipe discard the sponge and take fresh ones so that no one sponge will be re-used on an area already prepped. Complete the prep by using a wiping motion in ever increasing circles around the eyes. Some surgeons prefer that the prep cover the entire face down to and including the chin. In this case, care must be taken not to have an excess of solution on the gauze. Excess of solution could conceivably run into and up the patient’s nostrils. This may cause an irritation of the mucous membrane causing the patient to sneeze or cough after the surgeon has started the operation. This could be disastrous. Care must also be taken that an excess of solution does not run into the ear and remain in a pool in the outer ear. A large splash basin with sterile water should be supplied so that the personnel gowned and gloved for the operation may rinse their gloves before touching the drapes and the instruments. This will free the gloves of any small particles of powder that could cause irritation in the eye. After making sure that the scrub nurse has all the needed instruments, sutures and solutions, the circulating nurse is then free to write the operative record forms and organize materials for the next case. She should remain alert to any arising needs of the patient, surgeon or scrub nurse. INSTRUMENTS After completing the prescribed scrubbing routine, the scrub nurse sets up her table. A good ophthalmic nurse gives herself ample time to set up. As the instruments are removed one by one from the sterilizing tray it is helpful to place them on the back table in the same order in which they will be placed on the Mayo. This relates to the order
42
in which they will be used. The eye is a delicate organ and everything related to the operation should be delicate and precise. Sharp points and cutting edges must be carefully handled. Perfect approximation of teeth on closing edges of the instruments is absolutely necessary. All eye instruments are precision manufactured and one has to develop a light touch in regard to their handling. Such instruments should never be tossed on top of one another, thrown together in a basin during or after the operation or in any way be allowed to become entangled with one another. It is best to place instruments for sterilization in a carrier or tray that is large enough to accommodate all the instruments side by side without any overlapping. Keratomes, cataract knives and all other knives or blades should be left in their protective rack throughout sterilization until such time as the surgeon is ready to use them. A knife edge must be protected at all times from the slightest contact with other articles. Dulling of the knife edge will occur from simply having the edge touch cloth, gauze or metal. The nurse should not remove the knife from the protective rack until she is ready to hand it to the surgeon. She remains alert to receive it and replace it in the rack after he has used it. Generally speaking, the surgeon uses the knife for no more than 10 seconds during an entire cataract extraction or other operation that requires the use of a keratome or cataract knife. Before the nurse hands the knife to the surgeon, the tip of the knife should be dipped in saline to remove any microscopic lint. Care must be taken so that the blade does not hit the bottom or sides of the solution bowl. There are some surgeons who require that every instrument, used intraocularly, be dipped in saline immediately prior to his using it. Nothing should ever be handed to the surgeon by passing it directly over the eye. The eye is held open by a speculum and is
AORN Journal
very vulnerable to damage because it now lacks the normal protection it receives from the lids. Any accidental dropping of instruments or trailing of suture ends or suture needles may cause corneal abrasions or damage to the globe. An exaggerated arc motion of passing items around the eye should become a habit. At the same time the nurse must keep her hands out of the surgeon’s way. This does indeed sound paradoxical and is the reason why it is so important for the scrub nurse to observe closely and learn the best method of manipulating the instruments and maneuvering her hands so that she is an able assistant. OPERATING MICROSCOPE There is at present a tremendous increase in the use of the operating microscope. This presents technical difficulties for the nurse in ophthalmic surgery. With the use of the microscope there remains a sterile field of approximately five inches in which to maneuver her hands and the instruments between the patient and the scope. Careful draping of the scope is very important. DEVELOP A STEADY HAND
If the surgeon asks the nurse to rotate the eyeball with a muscle hook or fixation forcep the eye should not be pulled in that direction but should conform gently to the normal rotation of the eye. The delicateness of the eye calls for the employment of slow, deliberate, steady motions rather than quick, jerky movements. A very gentle but firm hand is used to sponge blood from the operative site. Gentle pressure with a cotton wick or pledget is acceptable provided this pressure is applied only to the conjunctiva, sclera or lid. However, never apply pressure on the cornea or on the globe when the chamber is open. The size of the wick is important for good sponging. The cotton wick or pledget dipped in saline or water and squeezed almost dry is
August 1967
then rolled between the palms of the hand. This presses out all the excess fluid and forces the wick into shape with both ends becoming tapered. Observe the surgeon’s perfect coordination between his eyes and fingers. Notice how the surgeon finds a resting place for his hand either on the patient’s face or head when cutting sutures or executing a very delicate move. Observe and learn to develop a steady hand. When cutting sutures, grasp the scissor firmly with the blades resting on top of the forefinger. In this way the point of the scissor cannot accidently touch the cornea. The epithelial tissue of the cornea is very easily scratched and this can cause discomfort for the patient. When the scrub nurse is the only assistant to the surgeon, she should see to it that a few drops of saline are placed on the cornea from time to time to prevent a dry cornea. The eye is normally bathed in lachrimal fluid each time we blink. During surgery this bathing process is halted because the eye is kept open with a speculum and the resulting drying out of the epithelium of the cornea can cause considerable irritation postoperatively since erosion of the corneal epithelium can occur. INSTRUMENTS As in all types of surgery, it is extremely important to know how the instruments are used. There are many variations of the same kind of strument. The most accurate way of becoming acquainted with the names of the instruments and their utility is to read the manufacturer’s catalogue. There are whole groups of forceps for example, designed for use on the iris only. Remembering the correct name of an instrument can be made easy by word association. A very bizarre word association oftimes will make a lasting impression. The shape of the Hess iris forcep has always reminded me of the bayonet weapon used by the Hessian troops in battle. The
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contour of the green fixation forcep brings to my mind the portable seats that spectators will stick in the ground to rest on during a golf tournament. The word green is an integral part of golf. Try word association yourself and you’ll find it is fun and makes remembering so much easier. There are toothed forceps that should be used only on conjunctiva or skin. There are other toothed forceps designed specifically for the sclera and still others for the cornea. Corneal scissors are used only on the cornea and never for any other purpose. Sutures should not be cut with a scissor designed to be used on the conjunctiva or cornea. While all eye instruments are delicate there are many that are exquisitely delicate. A fine needle holder made for microsurgery is perfect for needles on a 7-0 or 8-0 suture but would go on the repair list quickly if they were used for the heavier needle on the traction suture. In a situation where the ophthalmic instruments are owned by the hospital, the nurse has the responsibility of selecting the proper instruments for the scheduled cases. This task can be made easy and accurate by having a file card for each surgeon, listing the specific instruments the surgeon prefers for the various types of operations and a brief explanation of procedure. Ophthalmologists may vary in their preference for instruments and operations may differ in the surgical approach, but the same basic set of instruments will be required. Listed below are some of the more frequently performed operations in an average hospital and the basic set of instruments needed : Capsulotomy: an incision into the lens capsule. (cataract set-up) Cataract extraction: removal of the crystalline lens combined with iridectomy, peripheral iridectomy or iridotomy. (cataract set-up) Chalazion: small cyst formation of the lid
44
due to chronic inflammation of Meibomian glands. (chalazion set-up) Cyclodiaysis : operation forming a communication between the anterior chamber of the eye and the space between the sclera and the choroid. (This is done in cases of glaucoma.) (cataract set-up) Discission or Needling: making an opening into the capsule of the lens to break down membranous particles remaining after extra-capsular extraction. (cataract set-up plus special knives and condensing lens) Ectropion: eversion or outward turning of the eyelid. (lid plasty set-up) Entropion: iversion or inward turning of the eyelid. (lid plasty set-up) Excision of Xanthelasma: removal of small yellowish tumors of the eyelid. (lid plasty set-up) Iridectomy: removal of part of the iris. (iridectomy set-up) Iridencleisis: iris tissues left in the wound as a wick to provide filtration from the anterior chamber. This is done in cases of glaucoma. (iridectomy set-up) Keratoplasty : plastic surgery on the cornea. (corneal transplant set-up) Lachrimal probing: exploration of the opening and passageway of the tear duct. (probing set-up) Pterygium : triangular shaped ticketing of the bulbar conjunctiva extending from the sclera onto the cornea. (pterygium set-upj Strabismus: resection or recession of recti or oblique muscles. (strabismus set-up)
BASIC SET OF INSTRUMENTS FOR OPHTHALMOLOGICAL SURGERY Cataract Extraction Air injection cannula #30 gauge Alpha-Chymotrypsin cannula Anterior chamber irrigators ( 2 ) Blade breaker and razor blade Capsule extracting forceps Corneal section scissors (right and left) Corneal suture forcep
RORN Journal:
Cyclodialysis cannula Cystotomes Eresiphakes Fixation forceps 1x2 teeth Fixation forceps 2 x 3 teeth Iris forceps Iris spatula Keratome and/or cataract knife Loop Needle holder Plain fine forcep Serrefines Speculum Spoon Strabismus hooks (muscle) Straight and curved iris scissors Straight and curved tenotomy scissors Suture scissor Utility forceps
Chalazion Anterior chamber irrigator Blade handle #3 with #ll and #15 blades Chalazion forceps Curettes Fixation forceps 1x2 teeth Fixation forceps 2 x 3 teeth Needle holder Plain fine forceps Serrefines Straight and curved tenotomy scissors Suture scissors 1ridectomy Same as cataract set but delete capsule forceps Spoon and loop
Lachrimal Probing Anterior chamber irrigator Lacrimal probes Punctum dilator Nasal Sueculum (small)
Au,gust 1967
Straight and curved gold lacrimal needles
T pins Lid Plasty Anterior chamber irrigator Blade handle #3 with #I1 and $15 blade Caliper Chalazion forceps Curettes Fixation forcep 1x2 teeth Fixation forcep 2~ 3 teeth Lid clamp Lid plate Lid retractors Lid skin hooks Mosquito clamps Needle holder Plain fine forcep Ptosis clamp Serrefines Straight and curved tenotomy scissors Suture scissor
Pterygium Same as Chalazion but replace Chalazion forceps with a speculum Strabismus Anterior chamber irrigator Caliper Fixation forceps 1x2 teeth Fixation forceps 2x3 teeth Mosquito clamps Muscle clamps Needle holder Plain fine forcep Ruler Serrefines Speculum Strabismus hooks (Muscle) Straight and curved tenotomy scissors Suture scissor Utility forcep
45
Our precious gift of sight oftimes is taken for granted. We give little thought to the truly wondrous gift that it is. A patient coming to the hospital, however, is acutely aware of this gift, and sight becomes a valued possession as he contemplates eye surgery. This patient temporarily entrusts in our care God’s great gift to him. Unfortunately, not all OR nurses enjoy assisting on eye surgery. There is a vast difference in the skills applied to opthalmic surgery and the needed skills in general surgery. Surgeons expect and are grateful for good nursing assistance. Since many ophthalmologists work without a doctor assistant, they depend on good nursing assistance to help them achieve the maximum beneficial operative result for their patient. The time and effort spent by a nurse to learn the proper approach to patient care during eye surgery can be rewarding.
ANATOMY A review of the basic anatomy of the eye and a brief definition of terms most frequently used in eye surgery will help to clear our perspective. akinesia: loss of or impaired motor function of the lids. anterior chamber: that area between the Caroline Rogers, R.N., is head nurse in charge of urological, eye, ear, nose and throat and orthopedic operating rooms at Mercy Hospital in Rockville Centre, N. Y. She has worked in the OR almost exclusively since graduation from Mary Immaculate Hospital in N. Y. Mrs. Rogers is a member of the AORN Editorial Committee.
August 1967
posterior surface of the cornea and the anterior surface of the iris. posterior chamber: that area between the posterior surface of the iris and the anterior surface of the lens. aphakiu: the condition of the eye without a lens. aqueous humor: fluid found in both anterior and posterior chambers. choroid: the middle coat of the eyeball between the sclera and the retina. conjunctiva : the mucous membrane covering the anterior portion of the globe reflected upon the lids and extending to their free edges. cornea: the transparent anterior portion of the eyeball. lens: a refractive organ of accommodation. limbus: the edge of the cornea at its junction with the sclera. 0.d.: oculus dexter (right eye) O.S. : oculus sinister (left eye) retrobulbar : behind the eyeball. synechia: adhesions of parts of the eye; iris to lens, iris to cornea. strabismus: an eye disorder due to lack of muscle coordination. May be convergent, divergent, alternating or vertical. scZera: the firm fibrous outer layer of the eyeball, continuous with the sheath of the optic nerve behind and with the cornea in front. Tenon’s capsule: the fascia of the eyeball which envelopes the whole eyeball except the cornea. zonule : the suspensory structure supporting the lens.
39
that the new nurse was there only to observe and learn. There is no doubt the patient was immediately overcome by a feeling somewhat less than confident.
THE CIRCULATING NURSE
PATIENT ARRIVES IN OR The circulating nurse, after greeting the patient on his arrival in the OR, checks his identification and places him on the operating table. The routine preoperative eye drops instilled in the eyes on the nursing unit may have blurred his vision, and it is important that he be assured there is someone looking out for his safety while his vision is temporarily impaired. When the patient is asked to move onto the operating table it helps to place his hand on the table so that he may feel the table and judge more accurately how far he must move. A short explanation, in a low calm voice, of everything the nurse is doing to the patient is important.
The role of the circulating nurse requires that she maintain an atmosphere of efficient, peaceful tranquility. There is a twofold need for this environment. First, it is essential to the surgeon so that he can perform a very delicate operation without interruption or sudden loud distracting noises. Secondly, the patient usually comes to the operating room heavily sedated but nevertheless awake, and remains in a state of semi-analgesia. Many eye operations are routinely done under local anesthesia and the patient is constantly aware of the activities around him. Even normal conversation which is totally unrelated to the patient may very well be misunderstood by him. Recently, a surgeon while donning his gown and gloves was introduced to a nurse in the room by the circulating nurse with this phrase, “Dr. Jones, this is Miss Brown, one of our new nurses. She has never scrubbed for a cataract before.” The patient of course did not know that there was another experienced scrub nurse also to assist the surgeon and
POSITIONING The patient’s proper position on the table will insure maximum comfort and ease of working for the surgeon. Some doctors prefer the patient’s head positioned to the top edge of the table. Whether the doctor sits or stands, he will not then experience back strain from leaning forward while operating. There are, of course, other surgeons who prefer to have the patient’s head about five or six inches from the top edge of the table. This position provides a place for the surgeon to rest his arms during surgery thus enabling him to better control his hand motion. The head of the patient should be hyperextended and where a general anesthesia is used it helps to place the head on a doughnut or between sandbags. The patient is told that his arms are being restrained to prevent him from bringing his hands to his face during the operation, because most patients fall asleep while the surgeon is working and forget that they are being operated upon. Two things will be accomplished: first, there is the psy-
A-Anterior chamber B-Cornea C-Iris D-Ciliary body E-Retina
40
F-Choroid GLens H-Sclera I-Vitreous body J-Optic Disc
AORN Journal
chological assurance to the patient that the operation will not be a dreadful painful experience if it is likely he will fall asleep; and secondly, and more importantly it will prevent contamination of the sterile field once the operation is in progress. Place the blood pressure apparatus on the arm leaving the stethoscope in place under the cuff. This will facilitate frequent checking of the blood pressure during the operation without disturbing the sterile drapes.
EYE DROPS An instillation of two or three drops of sterile ophthalmic anesthetic solution in each eye about three to four minutes apart for four or more times will provide enough topical anesthesia to the conjunctival sac to prevent the discomfort of burning when the face is prepped. Anesthetic drops are placed in both eyes because both are prepped. Mydriatic drops are placed only in the eye to be operated on. (This routine is eliminated when the surgery is to be done under general anesthesia. ) Extreme care must be taken in regard to the instillation of eye drops. The RIGHT drug in the RIGHT strength in the CORRECT eye is of paramount importance. The exact number of drops at the correct interval and number of times designated by the surgeon must be carefully carried out. The proper method of instilling eye drops to get the maximum benefit of the drug is to retract the lower lid gently with the forefinger and retract the upper lid with the thumb making sure the drops fall directly onto the conjunctival sac. To prevent crossinfection between patients, the edge of the medicine dropper or squeeze bottle should never be allowed to touch the lid. Individual sterile dropper bottles are available for ophthalmic drugs and are commonly used. Many surgeons order a routine instillation of antibiotic eye drops preoperatively for five to seven days. This is done to sterilize the
August 1967
conjunctival sac as much as possible. If the edge of the dropper or bottle touches the lid, it contaminates the dropper and the solution and in addition it is very likely that a twitch of the eyelids at the moment of contact would cause the solution to run off the lid onto the face and thus the desired beneficial effect of the drug is lost. Ophthalmic solutions have various effects on the eye. Tetracaine 0.5 per cent is used for topical anesthesia. Cyclogyl one per cent, Cyclomydril 0.5 per cent, Atropine one per cent, and Neo-Synepherine 10 per cent are used to dilate the pupil. Pilocarpine two per cent contracts the pupil. If the nurse is requested to cut the eyelashes, it helps to put a small amount of ophthalmic ointment or vaseline on the scissor’s blade so that the lashes will adhere to the blades and not fall free into the operative area. PREP After placing the OR table in the room, it is advisable to adjust the lights before draping is done so that only a minute adjustment will be needed after the draping has been completed. Usually it is the circulating nurse who washes or preps the face preoperatively, explaining the procedure to the patient. A soft gentle wiping motion is employed. The vigorous scrub used on skin in other types of surgery cannot be used in eye surgery. Although anesthetic drops are used to prevent conjunctival irritation, care should be taken to keep the cleansing agents out of the eye. Ask the patient to close his lids gently and not to squeeze them tightly together while the forehead, eyes, nose and cheeks are wiped. The solution used for the skin preparation will depend upon the surgeon’s choice of agents. With a sponge that has been immersed in the skin disinfectant in each hand start the prep at the bridge of the nose. Wipe to cover both lids and the area to the hair-
41
line. Discard these two sponges and with two fresh sponges start the next stroke at the midline of the forehead, covering the brows and continuing outward and downward well beyond the ears. After each wipe discard the sponge and take fresh ones so that no one sponge will be re-used on an area already prepped. Complete the prep by using a wiping motion in ever increasing circles around the eyes. Some surgeons prefer that the prep cover the entire face down to and including the chin. In this case, care must be taken not to have an excess of solution on the gauze. Excess of solution could conceivably run into and up the patient’s nostrils. This may cause an irritation of the mucous membrane causing the patient to sneeze or cough after the surgeon has started the operation. This could be disastrous. Care must also be taken that an excess of solution does not run into the ear and remain in a pool in the outer ear. A large splash basin with sterile water should be supplied so that the personnel gowned and gloved for the operation may rinse their gloves before touching the drapes and the instruments. This will free the gloves of any small particles of powder that could cause irritation in the eye. After making sure that the scrub nurse has all the needed instruments, sutures and solutions, the circulating nurse is then free to write the operative record forms and organize materials for the next case. She should remain alert to any arising needs of the patient, surgeon or scrub nurse. INSTRUMENTS After completing the prescribed scrubbing routine, the scrub nurse sets up her table. A good ophthalmic nurse gives herself ample time to set up. As the instruments are removed one by one from the sterilizing tray it is helpful to place them on the back table in the same order in which they will be placed on the Mayo. This relates to the order
42
in which they will be used. The eye is a delicate organ and everything related to the operation should be delicate and precise. Sharp points and cutting edges must be carefully handled. Perfect approximation of teeth on closing edges of the instruments is absolutely necessary. All eye instruments are precision manufactured and one has to develop a light touch in regard to their handling. Such instruments should never be tossed on top of one another, thrown together in a basin during or after the operation or in any way be allowed to become entangled with one another. It is best to place instruments for sterilization in a carrier or tray that is large enough to accommodate all the instruments side by side without any overlapping. Keratomes, cataract knives and all other knives or blades should be left in their protective rack throughout sterilization until such time as the surgeon is ready to use them. A knife edge must be protected at all times from the slightest contact with other articles. Dulling of the knife edge will occur from simply having the edge touch cloth, gauze or metal. The nurse should not remove the knife from the protective rack until she is ready to hand it to the surgeon. She remains alert to receive it and replace it in the rack after he has used it. Generally speaking, the surgeon uses the knife for no more than 10 seconds during an entire cataract extraction or other operation that requires the use of a keratome or cataract knife. Before the nurse hands the knife to the surgeon, the tip of the knife should be dipped in saline to remove any microscopic lint. Care must be taken so that the blade does not hit the bottom or sides of the solution bowl. There are some surgeons who require that every instrument, used intraocularly, be dipped in saline immediately prior to his using it. Nothing should ever be handed to the surgeon by passing it directly over the eye. The eye is held open by a speculum and is
AORN Journal
very vulnerable to damage because it now lacks the normal protection it receives from the lids. Any accidental dropping of instruments or trailing of suture ends or suture needles may cause corneal abrasions or damage to the globe. An exaggerated arc motion of passing items around the eye should become a habit. At the same time the nurse must keep her hands out of the surgeon’s way. This does indeed sound paradoxical and is the reason why it is so important for the scrub nurse to observe closely and learn the best method of manipulating the instruments and maneuvering her hands so that she is an able assistant. OPERATING MICROSCOPE There is at present a tremendous increase in the use of the operating microscope. This presents technical difficulties for the nurse in ophthalmic surgery. With the use of the microscope there remains a sterile field of approximately five inches in which to maneuver her hands and the instruments between the patient and the scope. Careful draping of the scope is very important. DEVELOP A STEADY HAND
If the surgeon asks the nurse to rotate the eyeball with a muscle hook or fixation forcep the eye should not be pulled in that direction but should conform gently to the normal rotation of the eye. The delicateness of the eye calls for the employment of slow, deliberate, steady motions rather than quick, jerky movements. A very gentle but firm hand is used to sponge blood from the operative site. Gentle pressure with a cotton wick or pledget is acceptable provided this pressure is applied only to the conjunctiva, sclera or lid. However, never apply pressure on the cornea or on the globe when the chamber is open. The size of the wick is important for good sponging. The cotton wick or pledget dipped in saline or water and squeezed almost dry is
August 1967
then rolled between the palms of the hand. This presses out all the excess fluid and forces the wick into shape with both ends becoming tapered. Observe the surgeon’s perfect coordination between his eyes and fingers. Notice how the surgeon finds a resting place for his hand either on the patient’s face or head when cutting sutures or executing a very delicate move. Observe and learn to develop a steady hand. When cutting sutures, grasp the scissor firmly with the blades resting on top of the forefinger. In this way the point of the scissor cannot accidently touch the cornea. The epithelial tissue of the cornea is very easily scratched and this can cause discomfort for the patient. When the scrub nurse is the only assistant to the surgeon, she should see to it that a few drops of saline are placed on the cornea from time to time to prevent a dry cornea. The eye is normally bathed in lachrimal fluid each time we blink. During surgery this bathing process is halted because the eye is kept open with a speculum and the resulting drying out of the epithelium of the cornea can cause considerable irritation postoperatively since erosion of the corneal epithelium can occur. INSTRUMENTS As in all types of surgery, it is extremely important to know how the instruments are used. There are many variations of the same kind of strument. The most accurate way of becoming acquainted with the names of the instruments and their utility is to read the manufacturer’s catalogue. There are whole groups of forceps for example, designed for use on the iris only. Remembering the correct name of an instrument can be made easy by word association. A very bizarre word association oftimes will make a lasting impression. The shape of the Hess iris forcep has always reminded me of the bayonet weapon used by the Hessian troops in battle. The
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contour of the green fixation forcep brings to my mind the portable seats that spectators will stick in the ground to rest on during a golf tournament. The word green is an integral part of golf. Try word association yourself and you’ll find it is fun and makes remembering so much easier. There are toothed forceps that should be used only on conjunctiva or skin. There are other toothed forceps designed specifically for the sclera and still others for the cornea. Corneal scissors are used only on the cornea and never for any other purpose. Sutures should not be cut with a scissor designed to be used on the conjunctiva or cornea. While all eye instruments are delicate there are many that are exquisitely delicate. A fine needle holder made for microsurgery is perfect for needles on a 7-0 or 8-0 suture but would go on the repair list quickly if they were used for the heavier needle on the traction suture. In a situation where the ophthalmic instruments are owned by the hospital, the nurse has the responsibility of selecting the proper instruments for the scheduled cases. This task can be made easy and accurate by having a file card for each surgeon, listing the specific instruments the surgeon prefers for the various types of operations and a brief explanation of procedure. Ophthalmologists may vary in their preference for instruments and operations may differ in the surgical approach, but the same basic set of instruments will be required. Listed below are some of the more frequently performed operations in an average hospital and the basic set of instruments needed : Capsulotomy: an incision into the lens capsule. (cataract set-up) Cataract extraction: removal of the crystalline lens combined with iridectomy, peripheral iridectomy or iridotomy. (cataract set-up) Chalazion: small cyst formation of the lid
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due to chronic inflammation of Meibomian glands. (chalazion set-up) Cyclodiaysis : operation forming a communication between the anterior chamber of the eye and the space between the sclera and the choroid. (This is done in cases of glaucoma.) (cataract set-up) Discission or Needling: making an opening into the capsule of the lens to break down membranous particles remaining after extra-capsular extraction. (cataract set-up plus special knives and condensing lens) Ectropion: eversion or outward turning of the eyelid. (lid plasty set-up) Entropion: iversion or inward turning of the eyelid. (lid plasty set-up) Excision of Xanthelasma: removal of small yellowish tumors of the eyelid. (lid plasty set-up) Iridectomy: removal of part of the iris. (iridectomy set-up) Iridencleisis: iris tissues left in the wound as a wick to provide filtration from the anterior chamber. This is done in cases of glaucoma. (iridectomy set-up) Keratoplasty : plastic surgery on the cornea. (corneal transplant set-up) Lachrimal probing: exploration of the opening and passageway of the tear duct. (probing set-up) Pterygium : triangular shaped ticketing of the bulbar conjunctiva extending from the sclera onto the cornea. (pterygium set-upj Strabismus: resection or recession of recti or oblique muscles. (strabismus set-up)
BASIC SET OF INSTRUMENTS FOR OPHTHALMOLOGICAL SURGERY Cataract Extraction Air injection cannula #30 gauge Alpha-Chymotrypsin cannula Anterior chamber irrigators ( 2 ) Blade breaker and razor blade Capsule extracting forceps Corneal section scissors (right and left) Corneal suture forcep
RORN Journal:
Cyclodialysis cannula Cystotomes Eresiphakes Fixation forceps 1x2 teeth Fixation forceps 2 x 3 teeth Iris forceps Iris spatula Keratome and/or cataract knife Loop Needle holder Plain fine forcep Serrefines Speculum Spoon Strabismus hooks (muscle) Straight and curved iris scissors Straight and curved tenotomy scissors Suture scissor Utility forceps
Chalazion Anterior chamber irrigator Blade handle #3 with #ll and #15 blades Chalazion forceps Curettes Fixation forceps 1x2 teeth Fixation forceps 2 x 3 teeth Needle holder Plain fine forceps Serrefines Straight and curved tenotomy scissors Suture scissors 1ridectomy Same as cataract set but delete capsule forceps Spoon and loop
Lachrimal Probing Anterior chamber irrigator Lacrimal probes Punctum dilator Nasal Sueculum (small)
Au,gust 1967
Straight and curved gold lacrimal needles
T pins Lid Plasty Anterior chamber irrigator Blade handle #3 with #I1 and $15 blade Caliper Chalazion forceps Curettes Fixation forcep 1x2 teeth Fixation forcep 2~ 3 teeth Lid clamp Lid plate Lid retractors Lid skin hooks Mosquito clamps Needle holder Plain fine forcep Ptosis clamp Serrefines Straight and curved tenotomy scissors Suture scissor
Pterygium Same as Chalazion but replace Chalazion forceps with a speculum Strabismus Anterior chamber irrigator Caliper Fixation forceps 1x2 teeth Fixation forceps 2x3 teeth Mosquito clamps Muscle clamps Needle holder Plain fine forcep Ruler Serrefines Speculum Strabismus hooks (Muscle) Straight and curved tenotomy scissors Suture scissor Utility forcep
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