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Perioperative Patient Education for Retinal Surgery
APRIL 2002, VOL 75, NO 4 ShelsweN
Perioperative Patient Education for Retinal Surgery
P
atient education is a dynamic, ongoing process that occurs fiom admission to discharge. Intradepartmental communication, planning, and team coordination are essential factors in promoting successful surgical results. A knowledgeable, organized team of perioperative RNs in the ambulatory surgery department can play a dynamic role in properly educating surgical patients for eventual home care.
The transparent convex cornea contributes approximately 70% of the refractive power of the eye. The sclera is the white, tough outer protective layer of the eye that merges with the cornea to form the corneoscleraljunction or limbus. The iris controls the amount of light entering the pupil by coordinating its two opposing muscles (ie, the sphincter pupillae muscle, the dilator pupillae muscle). The sphincter pupillae muscle contracts to constrict the pupil, relaxes to dilate it, and is under the control of the parasymOCULARBNATONW pathetic nervous system, and the dilator pupillae musBefore perioperative nurses can serve as effec- cle dilates the pupil by direct stimulation of the symtive team members who provide patient education for pathetic nervous system. The crystalline lens, which retinal surgery, they need to understand ocular anato- provides approximately 30% of the refractive power, my, pathophysiology, and surgical interventions. A is biconvex and has the ability to change its shape to midsaggital view of the eye reveals the major corn- increase or decrease its focusing power.’ The cornea, ponents of the eye (Figure I), including the iris, and crystalline lens work together to focus light convex cornea, onto the retina.’ The choroid is the middle vascular sclera, layer that nourishes the eye, and the thin inner layer limbus, is the retina, which forms images and sends them to iris, the brain by way of the optic nerve? crystalline lens, The retina is composed of two layers, including the stratified inner sensory layer, which is closest to choroid, and the vitreous, and a single outer layer of retinal pig* retina. ment epithelium, which is attached to the choroid by Bmch’s membrane. The innermost layer of A B S T R A C T the sensory retina (ie, the nerve Anticipation of retinal surgery and fear of permanent vision loss fiber layer) forms the optic nerve. can be Stressful for patients. When patients first are diagnosed with The outermost layer, which is retinal problems and informed that ocular surgery is required, they adjacent to the retinal pigment may not be psychologically or emotionally ready to absorb the infor- epithelium, consists of photoremation needed to prepare them for the postoperative recovery phase. ceptors, rods, and cones. The Perioperative nurses have an opportunity to affect patient outcomes entire sensory retina extends from by providing information to patients before, during, and after Surgery. the optic nerve posteriorly to the Well-educated patients have the necessary knowledge to maximize ora serrata anteriorly. The periphCOmpllanCe and afford themselves an optlmal surgical outcome. eral portion of the sensory retina AORN J 75 (April 2002) 801-807. comprises rods that function in
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Figure 1
The anatomy of the eye.
dim light and are used to see gray scales? The macula is located in the center of the retina. It is approximately 6 mm in diameter, and it primarily consists of cones that function in bright illumination and are used to see color. In the center of the macula is the fovea, which is approximately 1 mm in diameter. The fovea creates the most finely detailed vision for such daily tasks as reading, threading a needle, or driving a car. To maintain its round shape, the eyeball is filled with approximately 5 mL. of a jelly-like substance called vitreous humor.' BASIC PATH0PHYsIou)Gy
Breaks in the continuity of the retina may be caused by degeneration, holes, or tearing.6As a person ages, the vitreous jelly liquifies and falls away from the retina. This is a normal event, occurring in people 40 to 70 years of age. This phenomenon is referred to as a posterior vitreous detachment. As the vitreous contracts and pulls away from the retina, patients may complain about seeing floaters, which often are depicted as dots, spots, bugs, or curly lines. The shrinking and pulling of the vitreous also may stimulate the retina to produce a flash of light known as photopsia. The tractional force created by the shrinking vitreous also may rupture blood vessels. The patient sees this as a shower of spots or a large dark blob if a hemorrhage occurs. Vitreous hemorrhage may be described as a large visual field loss or an overall decrease in a patient's vision. If the vitreous is exceptionally adherent to a weak point on the retina, a tear, hole, or
detachment may d e ~ e l o pOne . ~ proposed mechanism of macular hole formation suggests that the vitreous shrinks and pulls toward the front of the eye, while a portion of the vitreous remains firmly attached to the central part of the retina. Fluid may seep through the hole, causing a localized separation of the retina around the hole. The longer the macula is detached, the more likely there will be irreversible vision loss due to photoreceptor cell damage.' Patients may complain of visual distortion with reading or notice a decrease of central vision for both distance and near activities? "A retinal detachment is a progressive painless loss of peripheral vision or visual field that can present in any quadrant and can also be asymptomatic."'0 There are two major types of retinal detachmentsrhegmatogenous and nonrhegmatogenous." A rhegmatogenous retinal detachment, which is the most predominant type, usually is affiliated with a hole or tear in the sensory retina. Liquefied vitreous, serous fluid, or blood may collect in the subretinal space between the sensory retina and the underlying layer of retinal pigment epithelium.'2The potential for tears is related to degenerative changes in the retina or vitreous and increases with age. Other predisposing ocular conditions include myopia; aphakia, which is absence of the crystalline lens of the eye congenitally, from trauma, or from surgical extraction of a cataract; pseudophakia from intraocular lens implantation; and blunt or penetrating trauma, including sports injuries. Moderate trauma, such as stooping or lifting weights, may precipitate retinal detachments in a predisposed eye.I3Patients present with diminished vision and may complain of flashing lights, a shower of floaters, seeing cobwebs, or a dark shade or curtain folding over the eye.I4 A nonrhegmatogenous retinal detachment has two subtypes tie, tractional, exudative). Tractional retinal detachments occur when fibrous tissue in the vitreous remains f d y attached to the sensory retina. Shrinking of the vitreous pulls the retina from its normal attachment, but no hole or tear is produced. This type of detachment may manifest in patients with diabetes mellitus, retinopathy of prematurity, sickle cell disease, and various other conditions. This detachment also may be associated with a vitreous hemorrhage or abnormal retinal blood vessel growth. Exudative retinal detachments may be caused by the production of fluid under the retina in response to inflammatory disorders, connective tissue diseases, and macular degenerative condition^.^^ Conditions
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such as advanced hypertension, pregnancy-induced ates scarring, which eventually seals the break. In a hypertension (ie, preeclampsia), or eclampsia, as pneumatic retinopexy procedure, two common gases well as intraocular tumors, predispose patients to (ie, perfluoropropane, sulfur hexafluoride) are used this type of retinal detachment.I6The exudate col- as a tamponade to hold the retina in place while it lects in the subretinal space, forcing the layers to heals (Figure 2). Perfluoropropane is a much longer separate. acting gas than sulfur hexafluoride. The surgeon selects which gas to use based on the desired length MEDICWSURGICAL-IONS of time the gas is to remain in the eye and whether the Various combinations of medical and surgical patient is phakic (ie, the natural crystalline lens is therapies can be used to repair retinal defects. The present) or aphakic. The surgeon also will determine extent and location of the damage will determine the if the gas is to be used full strength or mixed with technique used. The first step in any retinal surgery sterile air to a prescribed concentration. usually is a trans pars plana vitrectomy. Under direct The gas then is insufflated into the vitreous cavmicroscopic visualization, three tiny incisions (ie, ity by a technique called gadfluid exchange. The sclerotomies) are made through the sclera a few mil- inert gas displaces the fluid in the vitreous cavity and limeters behind the limbus. This area, known as the maintains pressure against a specific area of the retipars plana, provides access to the posterior segment na to promote reattachment. Maintenance of a preof the globe, where trans pars plana vitrectomy is scribed head position is essential for seven to 10 days performed. Entering the eye at this location avoids to achieve successful retinal apposition. The gas may damage to the retina and the crystalline lens. remain in the eye for up to two to three months. Instruments are introduced through the sclerotomies Gradually it is absorbed by the body and is replaced to aid in removing the vitreous and releasing the with the eye’s own fluid.’*If cryopexy or pneumatic traction on the retina that initially caused the hole or retinopexy fail to successfully reattach the retina, the detachment.l 7 surgeon most likely will take the patient to the OR for Through one sclerotomy port, a high intensity more extensive treatment. fiber-optic light source is used to illuminate the vitreLensectomy. Removal of the crystalline lens durous cavity as the surgeon works, and a continuous ing a trans par plana virectomy procedure may be necnear normal intmocular pressure is maintained by an essary if the presence of a cataract obliterates the surinfusion of balanced salt solution injected through geon’s view of the vitreous cavity. The lens is removed another port. Special contact lenses placed over the with ultrasound similar to how phacoemulsificationis cornea provide a clear magnified view of the vitreous used during cataract surgery. Phacoemulsificationuses cavity. Through the third sclerotomy, vitreous is removed with an instrument that allows for simultaneous cutting and aspiration. Various scissors, forceps, and picks are used to remove the tractional epiretinal membrane, which releases the retina and permits it to lie flat. After this preliminary work is complete, the repair of the actual detachment may begin. Rhegmatogenous retinal detachment repair. There are several options available to treat this type of retinal detachment. The surgeon may elect to use any or all of the following therapies to repair a rhegmatogenous retinal detachment based on the severity and location of the detachment. Ctyopexy and pneumatic retinopexy. Cryopexy and pneumatic retinopexy usually are performed in the OR, but they also may be performed in the surgeon’s office as an initial therapy to treat retinal detachment. In a cryopexy procedure, a probe with a Figure 2 When the potient is in the face-down poslfrozen tip is placed externally on the sclera over the tion with a gas bubble in place, the bubble presses area of a retinal hole or tear. A thermal response cre- against the retina as the detachment heals. 803 AORN JOURNAL
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high frequency ultrasound waves to fragment the lens inner retina to encourage its reattachment. This promaterial into tiny pieces that then can be aspirated cedure generally is reserved for recurrent resistant from the eye. An intraocular lens may be implanted retinal detachments when routine reattachment theraduring the ultrasound procedure. pies have failed. The human body does not absorb Diathermy. A diathermy procedure uses heat this medium, which makes it an excellent treatment generated by radio frequency. This heat is applied to option for long-term tamponade of the retina. the scleral surface. The thermal response and scar for- Postoperative prescribed positioning is necessary for mation can be used to control hemostasis or seal a proper retinal healing when silicone oil is used. Nonrhegmatogenous retinal detachment retinal break. Laser photocoagulation. Laser photocoagulation repair. Nonrhegmatogenous retinal detachments uses laser light to heat the intraocular tissue around a can be treated medically or surgically,depending on retinal hole or tear. This leads to scarring and brings the type and cause.” Types of nonrhegmatogenous about reattachment of the retina. retinal detachments include traction retinal detachLiquid perfluorocarbon. This procedure is used ments, which frequently are due to proliferative to flatten complicated retinal detachments. The pro- fibrous or fibrovascular tissue in the vitreous cavity cedure uses a highly stable, inert liquid with a high that pulls the retina away from the back of the eye. density, which is heavier than water or saline. It is Proliferative diabetic retinopathy is a common used to displace subretinal fluid and return the retina cause of traction retinal detachments?’ Trans par to its normal anatomical position. The liquid has a plana virectomy and membrane removal, with or high boiling point, making it an excellent medium without laser photocoagulation, with or without a through which to perform photocoagulation safely. It gaslfluid exchange, and with or without scleral also has a high vapor pressure, which allows it to be buckling, may be performed.22Another type of nonremoved easily at the end of the surgical pr~cedure.’~rhegmatogenous retinal detachment is exudative Scleral buckling. Scleral buckling involves retinal detachment. A serous exudative retinal placing an external encircling band or small explant detachment commonly is managed by determining locally to create an indentation on the sclera. the underlying cause of the condition and treating it Buckling pushes the outer layers of the eye against medi~ally.’~ Evaluating an exudative detachment the inner retinal tissue, which has separated from its requires a comprehensive ophthalmoiogic examinaattachment (Figure 3). tion, including angiography, ultrasonogaphy, and a Silicone oil instillation. Silicone oil is a clear vis- complete medical w o r k ~ p . ~ ~ cous medium used to maintain pressure against the Macular hole repair. After removal of vitreous and restricting membranes, the retina is allowed to lie flat. Additional intraocular tamponade is required to hold the retina in place while it heals. To accomplish this, a long-lasting gas bubble or silicone oil is instilled into the vitreous cavity. The surgical procedure is only part of treatment, however. A patient’s ability to position himself or herself properly after surgery is crucial to provide the best chance for longterm hole closure. The patient must maintain his or her face-down position for the first two to four weeks postoperatively. The chin should be positioned slightly higher than the forehead to permit the oil or gas bubble to remain pressed against the macula. The gas or oil will float to the highest level within the eye, holding the retina in place during healing. Both gas and oil “act much like a hand holding wallpaper against the wall permitting it to stick and remain in position as the ‘wallpaper glue’ dries.’)2sThis keeps Figure 3 Scleral buckling requires piacing an encirthe hole closed and encourages new tissue growth cling band or explant. This pushes the outer layers of across the hole, permanently sealing the eye against the inner retinal tissue. 804 AORN JOURNAL
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PERIOPERATM MTIENT EDUCATION
Although the physician ultimately is responsible for providing patients with information regarding diagnosis, treatment, prognosis, risks, and altematives to surgery, the perioperative nurse plays an integral role in helping the patient understand this information. The principal goal of patient education is to facilitate a change in behavior. “When nurses value patient education and are able to implement it into practice, patients will be better prepared for assuming their own health care responsibilitie~.”~~ A list of lifestyle modifications should be shared with patients to help make their recovery phase tolerable and as normal as possible. The surgical process begins with the preadmission nursing telephone assessment. During the initial contact, patient knowledge and comprehension of expected behaviors is assessed. Appropriate head positioning for patients having gas or silicone oil placed in the eye is reiterated, and suggestions for modifying daily activities without interrupting the prescribed head positioning are offered. A list of tips and informational pamphlets for obtaining optional positioning devices for home use should be mailed to the patient well in advance of surgery. This time interval allows the patient and his or her family members ample time to make accommodations for home head positioning requirements. Adequate patient preparation and involvement before retinal detachment or macular hole surgery increases patient awareness and understanding of the essential need for specific positioning, thereby increasing the likelihood of complyingwith the prescribed regimen. The followingteaching strategiesmay be used to affect patient behavior to promote desirable lifestyle modifications for home care of the surgical On the day of surgery, preoperative nurses evaluate the patient’s understanding of the surgical procedure and postoperative home care requirements. Each successive phase of the patient’s surgical experience is an opportunity for perioperative nurses to emphasize the importance of required head positioning to achieve a positive surgical outcome. In general, the patient should try to maintain a positive attitude. That and a sense of humor will help make the recovery phase less arduous. In addition, healing is enhanced when the body is well rested. The patient needs to get plenty of rest several days before surgery. A family member or friend should stay with the patient after surgery to provide assistance. Inform patients that routine household duties, such as bill paying, laundry, and housecleaning,
During the initial contact, patient knowledge and comprehension of expected behaviors is assessed.
should be taken care of a few days before surgery. In addition, furniture should be arranged to ease navigation through the house while the patient’s head is in the face-down or other prescribed position. The patient also should be informed that grocery shopping and meal preparation should be planned ahead of time. Stockmg up on nutritious, ready-to-cook fkozen foods and cooking multiple meals in advance and fieezingthem is a great convenienceduring the recovery phase. The patient may find it helpful to have access to a microwave oven, and placing food items on the bottom shelf of the refi-igerator provides easy access. If the patient needs to eat with his or her head in the face-down position, he or she may find that placing the meal on a lower table or tray next to the dining table helps. This allows the patient to rest his or her forehead on the higher table and see the meal on the lower table. In addition, soft foods are easier to swallow while in the prescribed or face-down position, and leaning forward and bending at the waist will help the patient swallow foods and liquids. Flexible straws are key to making drinking easier. Nurses also should educate patients about the following factors. 8 Face-down or other prescribed positioning. The face-down position is specific for healing macular holes. The patient’s eyes should be looking perpendicular to the floor. This may be accomplished by telling the patient to look straight down at his or her shoelaces and tipping the head so that the chin is slightly higher than the forehead. This position aligns the macula perpendicular to the floor and ensures proper contact of the gas or oil over the macula. Prescribed positioning will begin immediately after surgery and must be maintained 24 hours per day. The surgeon may require that this position be sustained for a few days up to a
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Taking eye drops or oral medications. The patient should turn his or her head to the side to place eye drops in from the side. Oral medications may be crushed and put in applesauce if they are too difficult to swallow in the face-down position. Medications with sustained release action, however, should never be broken or crushed. The patient always should check with a physician, pharmacist, or nurse regarding whether a particular medication may be crushed. Clothing. Nurses should advise the patient to wear loose, comfortable clothing (eg, pajamas, sweat clothes, bathrobes) without buttons, especially down the front of the garment. Buttons can cause irritation to the chest if the patient must maintain a face-down position. Approved patient activities while keeping the head in the prescribed position. The patient should be advised to limit the time he or she spends in bed. He or she should try to maintain normal sleeping and waking patterns. Staying active promotes recovery. The patient should check with his or her physician about doing 20 to 30 minutes of moderate exercise a day (eg, stretching, walking on a treadmill, going outside with a companion). Bathing and shampooing the hair is permitted, as long as the prescribed head position is maintained and soap and water do not get in the eye. Other surgery. The patient should be informed that if general anesthesia is required for additional surgery while the gas bubble is in his or her eye, it is extremely important that the surgeon and anesthesia care provider are made aware of the presence of the gas bubble. Nitrous oxide, which is an anesthetic gas, will cause the gas bubble to expand and increase the pressure inside the eye to a level that can interfere with blood circulation in the eye. Things the patient should avoid. Nurses should inform the patient that driving a motor vehicle is prohibited. In addition, reading should be avoided during the healing period, as it leads to undesirable jerking movement of the eyes. Swimming is not allowed for at least two weeks or until the physician says it is all right to do so. The patient should stay away from sandy or dusty environments, which may cause irritation or infection in the eye. Air travel above 3,000 ft is not permitted. Reduced cabin pressure inside the airplane will allow the gas bubble to expand and cause increased pressure inside the eye, which could
few weeks. Foam supports, rolled towels, blankets, or pillows may be used to maintain the head in a specifically prescribed position that allows the gas or oil to remain in contact with the repaired portion of the retina to promote proper healing. The face and eyes must never be turned upwards or sideways to view visitors, a television, or books. Placing a small television on the floor directly under the face for viewing provides a distraction, and having access to a telephone with a speaker makes talking to friends and family members much easier. In addition, a cassette or compact disc player may be placed within reach for listening to music or audio books. Positioning for the ride home. If the patient is required to maintain face-down positioning, there are a variety of positions he or she can assume for the ride home. These include sitting in the back seat of the car and resting the forehead on the seat in front while looking down at the floor. Another position is lying down in the back seat of the car on the side the physician has prescribed. The use of foam supports, rolled towels, blankets, or pillows may be used to support this position. If the patient is traveling in a truck, he or she can rest the hands on the dashboard and look down at the floor. Alternatively, the patient can assume a sidelying position. This is more difficult, but it is achievable. Tilt the patient’s head into the prescribed position and maintain it with the use of positioning aids. Sleeping. The patient should avoid trying to fall asleep. Watching television or listening to music or a book on audiotape until becoming drowsy promotes falling asleep naturally. The patient may find that taking a warm bath or getting a gentle massage, while maintaining the prescribed head position, helps relieve back tension. The patient should use pillows, rolled towels, blankets, or large pieces of foam to prop his or her body into the prescribed head position for sleeping. For side-lying positions, the patient can place props behind his or her back. Hugging a pillow and placing a pillow between the knees make sleeping on the side more comfortable. Face-down sleeping requires a little more ingenuity. The patient may consider the acquisition of face-down positioning support aids, such as pillows, chairs, or bed attachment devices specially designed for sleeping in the face-down position. Some suppliers offer insurance reimbursement. 806
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cause circulation problems within the eye. Ground travel by car or train is permitted, unless the vehicle moves rapidly from low to high altitudes, such as going from sea level to elevations of more than 5,000 ft. Inform patients that the gas bubble gradually will be absorbed during the two to three months after surgery. If silicone oil is used, it will only be removed surgically if it is causing a problem. CONCLUSlON
A successful patient outcome after retinal surgery is optimized by an educated interdisciplinary team approach that provides continuity in patient education. Initial patient education begins in the surgeon’s ofice. Perioperative nurses further reinforce this education throughout the patient’s surgical NOTES 1. T Britton, “Anatomy and physiology,” in Core Cuwiculumfor Ophthalmic Nursing, ed K Goldblum (Dubuque, Iowa: KendalMunt Publishing Co, 1997) 4,743. 2. F W Newell, Ophthalmology: Principles and Concepts, eighth ed, L Craven, K Cox, D A Circirello, eds (St Louis: Mosby-Year Book, 1996) 23-26, 322-325,334-336. 3. Ibid. 4. Ibid. 5. Ibid. 6. “Retinal tears and detachment,” Texas Retina Associates, http:llwww.dallas.net/-tra/leafletslret - _t d.htm (accessed 13 Feb 2002). 7. J A Sorenson, “Retinal detachment,” Vitreous-Retina-Macda Consultants of New York, http: /lwww.vnnny.comlretinal_detachment.htm (accessed 13 Feb 2002). 8. Ibid. 9. J S Slakter, “Macular hole,” Vitreous-Retina-Macula Consultants of New York, http:llwww.vrmny .com/MH.htm (accessed 13 Feb 2002); “Macular hole surgery,”
experience. The preadmission telephone call is an opportunity to assess patient understanding of expected home care behaviors and address any unmet needs before discharge. Instructions are reinforced firther during the patient’s admission, intraoperative surgical procedures, and finally with postoperative discharge instructions. A
Nancy L. Shelswell, RN, BSN, is an ophthalmic specialty nurse in the outpatient surgery center at Covenant Healthcare-Mackinaw Campus, Saginm, Mich. The author acknowledges the support and help of Paul Raphealian, AD, of Associated Retinal Consultants, Muskegon, Mich, and Sundhar Ramasamy, AD,of Anderson Eye Associates, Saginaw, Mich.
Texas Retina Associates, http:/lwww .dallas.net/-traileafletslmac~hole. htm (accessed 13 Feb 2002). 10. L S Elfervig, J L Elfervig, “Retinal detachment,” Insight 23 (June 1998) 66. 11. Newell, Ophthalmology: Principles and Concepts, eighth ed, 23-26,322-325, 334-336. 12. K M Kearney, “Emergency! Retinal detachment,” American Journal of Nursing 97 (August 1997) 50. 13. Ibid; Elfervig, Elfervig, “Retinal detachment,” 66-68. 14. Ibid. 15. Sorenson, “Retinal detachment.” 16. Elfervig, Elfervig, “Retinal detachment,” 66-68; Keamey, “Emergency! Retinal detachment,” 50. 17. Slakter, “Macular hole.” 18. K B Freund, “Vitrectomy,” Vitreous-Retina-Macula Consultants of New York, http:llwww.vrmny .codvitrectomy.htm (accessed 13 Feb 2002). 19. M D Lomeo, R Dim-Rohena,
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H M Lambert, “Use of peffluorocarbon liquid in the repair of retinoschisis retinal detachments,” Ophthalmic Suvgevy and Lasers 27 (September 1996) 778-781. 20. Elfervig, Elfervig, “Retinal detachment,” 66-68. 2 1. Sorenson, “Retinal detachment.” 22. Elfervig, Elfervig, “Retinal detachment,” 66-68. 23. Ibid. 24. Sorenson, “Retinal detachment.” 25. Slakter, “Macular hole,” 3. 26. “Macular hole surgery.” 27. P A Potter, A G Perry, “Teaching-learningprocess” in Fundamentals of Nursing: Concepts, Process, and Practice (St Louis: Mosby-Year Book, 1985) 351-377. 28. R Cullen, “Macular hole surgery: Helpful tips for preoperative planning and postoperative facedown positioning,” Journal of Ophthalmic Nursing and Technology 17 (SeptembedOctober 1998) 179181.
Perioperative Patient Education for Retinal Surgery
P
atient education is a dynamic, ongoing process that occurs fiom admission to discharge. Intradepartmental communication, planning, and team coordination are essential factors in promoting successful surgical results. A knowledgeable, organized team of perioperative RNs in the ambulatory surgery department can play a dynamic role in properly educating surgical patients for eventual home care.
The transparent convex cornea contributes approximately 70% of the refractive power of the eye. The sclera is the white, tough outer protective layer of the eye that merges with the cornea to form the corneoscleraljunction or limbus. The iris controls the amount of light entering the pupil by coordinating its two opposing muscles (ie, the sphincter pupillae muscle, the dilator pupillae muscle). The sphincter pupillae muscle contracts to constrict the pupil, relaxes to dilate it, and is under the control of the parasymOCULARBNATONW pathetic nervous system, and the dilator pupillae musBefore perioperative nurses can serve as effec- cle dilates the pupil by direct stimulation of the symtive team members who provide patient education for pathetic nervous system. The crystalline lens, which retinal surgery, they need to understand ocular anato- provides approximately 30% of the refractive power, my, pathophysiology, and surgical interventions. A is biconvex and has the ability to change its shape to midsaggital view of the eye reveals the major corn- increase or decrease its focusing power.’ The cornea, ponents of the eye (Figure I), including the iris, and crystalline lens work together to focus light convex cornea, onto the retina.’ The choroid is the middle vascular sclera, layer that nourishes the eye, and the thin inner layer limbus, is the retina, which forms images and sends them to iris, the brain by way of the optic nerve? crystalline lens, The retina is composed of two layers, including the stratified inner sensory layer, which is closest to choroid, and the vitreous, and a single outer layer of retinal pig* retina. ment epithelium, which is attached to the choroid by Bmch’s membrane. The innermost layer of A B S T R A C T the sensory retina (ie, the nerve Anticipation of retinal surgery and fear of permanent vision loss fiber layer) forms the optic nerve. can be Stressful for patients. When patients first are diagnosed with The outermost layer, which is retinal problems and informed that ocular surgery is required, they adjacent to the retinal pigment may not be psychologically or emotionally ready to absorb the infor- epithelium, consists of photoremation needed to prepare them for the postoperative recovery phase. ceptors, rods, and cones. The Perioperative nurses have an opportunity to affect patient outcomes entire sensory retina extends from by providing information to patients before, during, and after Surgery. the optic nerve posteriorly to the Well-educated patients have the necessary knowledge to maximize ora serrata anteriorly. The periphCOmpllanCe and afford themselves an optlmal surgical outcome. eral portion of the sensory retina AORN J 75 (April 2002) 801-807. comprises rods that function in
.
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Figure 1
The anatomy of the eye.
dim light and are used to see gray scales? The macula is located in the center of the retina. It is approximately 6 mm in diameter, and it primarily consists of cones that function in bright illumination and are used to see color. In the center of the macula is the fovea, which is approximately 1 mm in diameter. The fovea creates the most finely detailed vision for such daily tasks as reading, threading a needle, or driving a car. To maintain its round shape, the eyeball is filled with approximately 5 mL. of a jelly-like substance called vitreous humor.' BASIC PATH0PHYsIou)Gy
Breaks in the continuity of the retina may be caused by degeneration, holes, or tearing.6As a person ages, the vitreous jelly liquifies and falls away from the retina. This is a normal event, occurring in people 40 to 70 years of age. This phenomenon is referred to as a posterior vitreous detachment. As the vitreous contracts and pulls away from the retina, patients may complain about seeing floaters, which often are depicted as dots, spots, bugs, or curly lines. The shrinking and pulling of the vitreous also may stimulate the retina to produce a flash of light known as photopsia. The tractional force created by the shrinking vitreous also may rupture blood vessels. The patient sees this as a shower of spots or a large dark blob if a hemorrhage occurs. Vitreous hemorrhage may be described as a large visual field loss or an overall decrease in a patient's vision. If the vitreous is exceptionally adherent to a weak point on the retina, a tear, hole, or
detachment may d e ~ e l o pOne . ~ proposed mechanism of macular hole formation suggests that the vitreous shrinks and pulls toward the front of the eye, while a portion of the vitreous remains firmly attached to the central part of the retina. Fluid may seep through the hole, causing a localized separation of the retina around the hole. The longer the macula is detached, the more likely there will be irreversible vision loss due to photoreceptor cell damage.' Patients may complain of visual distortion with reading or notice a decrease of central vision for both distance and near activities? "A retinal detachment is a progressive painless loss of peripheral vision or visual field that can present in any quadrant and can also be asymptomatic."'0 There are two major types of retinal detachmentsrhegmatogenous and nonrhegmatogenous." A rhegmatogenous retinal detachment, which is the most predominant type, usually is affiliated with a hole or tear in the sensory retina. Liquefied vitreous, serous fluid, or blood may collect in the subretinal space between the sensory retina and the underlying layer of retinal pigment epithelium.'2The potential for tears is related to degenerative changes in the retina or vitreous and increases with age. Other predisposing ocular conditions include myopia; aphakia, which is absence of the crystalline lens of the eye congenitally, from trauma, or from surgical extraction of a cataract; pseudophakia from intraocular lens implantation; and blunt or penetrating trauma, including sports injuries. Moderate trauma, such as stooping or lifting weights, may precipitate retinal detachments in a predisposed eye.I3Patients present with diminished vision and may complain of flashing lights, a shower of floaters, seeing cobwebs, or a dark shade or curtain folding over the eye.I4 A nonrhegmatogenous retinal detachment has two subtypes tie, tractional, exudative). Tractional retinal detachments occur when fibrous tissue in the vitreous remains f d y attached to the sensory retina. Shrinking of the vitreous pulls the retina from its normal attachment, but no hole or tear is produced. This type of detachment may manifest in patients with diabetes mellitus, retinopathy of prematurity, sickle cell disease, and various other conditions. This detachment also may be associated with a vitreous hemorrhage or abnormal retinal blood vessel growth. Exudative retinal detachments may be caused by the production of fluid under the retina in response to inflammatory disorders, connective tissue diseases, and macular degenerative condition^.^^ Conditions
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such as advanced hypertension, pregnancy-induced ates scarring, which eventually seals the break. In a hypertension (ie, preeclampsia), or eclampsia, as pneumatic retinopexy procedure, two common gases well as intraocular tumors, predispose patients to (ie, perfluoropropane, sulfur hexafluoride) are used this type of retinal detachment.I6The exudate col- as a tamponade to hold the retina in place while it lects in the subretinal space, forcing the layers to heals (Figure 2). Perfluoropropane is a much longer separate. acting gas than sulfur hexafluoride. The surgeon selects which gas to use based on the desired length MEDICWSURGICAL-IONS of time the gas is to remain in the eye and whether the Various combinations of medical and surgical patient is phakic (ie, the natural crystalline lens is therapies can be used to repair retinal defects. The present) or aphakic. The surgeon also will determine extent and location of the damage will determine the if the gas is to be used full strength or mixed with technique used. The first step in any retinal surgery sterile air to a prescribed concentration. usually is a trans pars plana vitrectomy. Under direct The gas then is insufflated into the vitreous cavmicroscopic visualization, three tiny incisions (ie, ity by a technique called gadfluid exchange. The sclerotomies) are made through the sclera a few mil- inert gas displaces the fluid in the vitreous cavity and limeters behind the limbus. This area, known as the maintains pressure against a specific area of the retipars plana, provides access to the posterior segment na to promote reattachment. Maintenance of a preof the globe, where trans pars plana vitrectomy is scribed head position is essential for seven to 10 days performed. Entering the eye at this location avoids to achieve successful retinal apposition. The gas may damage to the retina and the crystalline lens. remain in the eye for up to two to three months. Instruments are introduced through the sclerotomies Gradually it is absorbed by the body and is replaced to aid in removing the vitreous and releasing the with the eye’s own fluid.’*If cryopexy or pneumatic traction on the retina that initially caused the hole or retinopexy fail to successfully reattach the retina, the detachment.l 7 surgeon most likely will take the patient to the OR for Through one sclerotomy port, a high intensity more extensive treatment. fiber-optic light source is used to illuminate the vitreLensectomy. Removal of the crystalline lens durous cavity as the surgeon works, and a continuous ing a trans par plana virectomy procedure may be necnear normal intmocular pressure is maintained by an essary if the presence of a cataract obliterates the surinfusion of balanced salt solution injected through geon’s view of the vitreous cavity. The lens is removed another port. Special contact lenses placed over the with ultrasound similar to how phacoemulsificationis cornea provide a clear magnified view of the vitreous used during cataract surgery. Phacoemulsificationuses cavity. Through the third sclerotomy, vitreous is removed with an instrument that allows for simultaneous cutting and aspiration. Various scissors, forceps, and picks are used to remove the tractional epiretinal membrane, which releases the retina and permits it to lie flat. After this preliminary work is complete, the repair of the actual detachment may begin. Rhegmatogenous retinal detachment repair. There are several options available to treat this type of retinal detachment. The surgeon may elect to use any or all of the following therapies to repair a rhegmatogenous retinal detachment based on the severity and location of the detachment. Ctyopexy and pneumatic retinopexy. Cryopexy and pneumatic retinopexy usually are performed in the OR, but they also may be performed in the surgeon’s office as an initial therapy to treat retinal detachment. In a cryopexy procedure, a probe with a Figure 2 When the potient is in the face-down poslfrozen tip is placed externally on the sclera over the tion with a gas bubble in place, the bubble presses area of a retinal hole or tear. A thermal response cre- against the retina as the detachment heals. 803 AORN JOURNAL
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high frequency ultrasound waves to fragment the lens inner retina to encourage its reattachment. This promaterial into tiny pieces that then can be aspirated cedure generally is reserved for recurrent resistant from the eye. An intraocular lens may be implanted retinal detachments when routine reattachment theraduring the ultrasound procedure. pies have failed. The human body does not absorb Diathermy. A diathermy procedure uses heat this medium, which makes it an excellent treatment generated by radio frequency. This heat is applied to option for long-term tamponade of the retina. the scleral surface. The thermal response and scar for- Postoperative prescribed positioning is necessary for mation can be used to control hemostasis or seal a proper retinal healing when silicone oil is used. Nonrhegmatogenous retinal detachment retinal break. Laser photocoagulation. Laser photocoagulation repair. Nonrhegmatogenous retinal detachments uses laser light to heat the intraocular tissue around a can be treated medically or surgically,depending on retinal hole or tear. This leads to scarring and brings the type and cause.” Types of nonrhegmatogenous about reattachment of the retina. retinal detachments include traction retinal detachLiquid perfluorocarbon. This procedure is used ments, which frequently are due to proliferative to flatten complicated retinal detachments. The pro- fibrous or fibrovascular tissue in the vitreous cavity cedure uses a highly stable, inert liquid with a high that pulls the retina away from the back of the eye. density, which is heavier than water or saline. It is Proliferative diabetic retinopathy is a common used to displace subretinal fluid and return the retina cause of traction retinal detachments?’ Trans par to its normal anatomical position. The liquid has a plana virectomy and membrane removal, with or high boiling point, making it an excellent medium without laser photocoagulation, with or without a through which to perform photocoagulation safely. It gaslfluid exchange, and with or without scleral also has a high vapor pressure, which allows it to be buckling, may be performed.22Another type of nonremoved easily at the end of the surgical pr~cedure.’~rhegmatogenous retinal detachment is exudative Scleral buckling. Scleral buckling involves retinal detachment. A serous exudative retinal placing an external encircling band or small explant detachment commonly is managed by determining locally to create an indentation on the sclera. the underlying cause of the condition and treating it Buckling pushes the outer layers of the eye against medi~ally.’~ Evaluating an exudative detachment the inner retinal tissue, which has separated from its requires a comprehensive ophthalmoiogic examinaattachment (Figure 3). tion, including angiography, ultrasonogaphy, and a Silicone oil instillation. Silicone oil is a clear vis- complete medical w o r k ~ p . ~ ~ cous medium used to maintain pressure against the Macular hole repair. After removal of vitreous and restricting membranes, the retina is allowed to lie flat. Additional intraocular tamponade is required to hold the retina in place while it heals. To accomplish this, a long-lasting gas bubble or silicone oil is instilled into the vitreous cavity. The surgical procedure is only part of treatment, however. A patient’s ability to position himself or herself properly after surgery is crucial to provide the best chance for longterm hole closure. The patient must maintain his or her face-down position for the first two to four weeks postoperatively. The chin should be positioned slightly higher than the forehead to permit the oil or gas bubble to remain pressed against the macula. The gas or oil will float to the highest level within the eye, holding the retina in place during healing. Both gas and oil “act much like a hand holding wallpaper against the wall permitting it to stick and remain in position as the ‘wallpaper glue’ dries.’)2sThis keeps Figure 3 Scleral buckling requires piacing an encirthe hole closed and encourages new tissue growth cling band or explant. This pushes the outer layers of across the hole, permanently sealing the eye against the inner retinal tissue. 804 AORN JOURNAL
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PERIOPERATM MTIENT EDUCATION
Although the physician ultimately is responsible for providing patients with information regarding diagnosis, treatment, prognosis, risks, and altematives to surgery, the perioperative nurse plays an integral role in helping the patient understand this information. The principal goal of patient education is to facilitate a change in behavior. “When nurses value patient education and are able to implement it into practice, patients will be better prepared for assuming their own health care responsibilitie~.”~~ A list of lifestyle modifications should be shared with patients to help make their recovery phase tolerable and as normal as possible. The surgical process begins with the preadmission nursing telephone assessment. During the initial contact, patient knowledge and comprehension of expected behaviors is assessed. Appropriate head positioning for patients having gas or silicone oil placed in the eye is reiterated, and suggestions for modifying daily activities without interrupting the prescribed head positioning are offered. A list of tips and informational pamphlets for obtaining optional positioning devices for home use should be mailed to the patient well in advance of surgery. This time interval allows the patient and his or her family members ample time to make accommodations for home head positioning requirements. Adequate patient preparation and involvement before retinal detachment or macular hole surgery increases patient awareness and understanding of the essential need for specific positioning, thereby increasing the likelihood of complyingwith the prescribed regimen. The followingteaching strategiesmay be used to affect patient behavior to promote desirable lifestyle modifications for home care of the surgical On the day of surgery, preoperative nurses evaluate the patient’s understanding of the surgical procedure and postoperative home care requirements. Each successive phase of the patient’s surgical experience is an opportunity for perioperative nurses to emphasize the importance of required head positioning to achieve a positive surgical outcome. In general, the patient should try to maintain a positive attitude. That and a sense of humor will help make the recovery phase less arduous. In addition, healing is enhanced when the body is well rested. The patient needs to get plenty of rest several days before surgery. A family member or friend should stay with the patient after surgery to provide assistance. Inform patients that routine household duties, such as bill paying, laundry, and housecleaning,
During the initial contact, patient knowledge and comprehension of expected behaviors is assessed.
should be taken care of a few days before surgery. In addition, furniture should be arranged to ease navigation through the house while the patient’s head is in the face-down or other prescribed position. The patient also should be informed that grocery shopping and meal preparation should be planned ahead of time. Stockmg up on nutritious, ready-to-cook fkozen foods and cooking multiple meals in advance and fieezingthem is a great convenienceduring the recovery phase. The patient may find it helpful to have access to a microwave oven, and placing food items on the bottom shelf of the refi-igerator provides easy access. If the patient needs to eat with his or her head in the face-down position, he or she may find that placing the meal on a lower table or tray next to the dining table helps. This allows the patient to rest his or her forehead on the higher table and see the meal on the lower table. In addition, soft foods are easier to swallow while in the prescribed or face-down position, and leaning forward and bending at the waist will help the patient swallow foods and liquids. Flexible straws are key to making drinking easier. Nurses also should educate patients about the following factors. 8 Face-down or other prescribed positioning. The face-down position is specific for healing macular holes. The patient’s eyes should be looking perpendicular to the floor. This may be accomplished by telling the patient to look straight down at his or her shoelaces and tipping the head so that the chin is slightly higher than the forehead. This position aligns the macula perpendicular to the floor and ensures proper contact of the gas or oil over the macula. Prescribed positioning will begin immediately after surgery and must be maintained 24 hours per day. The surgeon may require that this position be sustained for a few days up to a
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Taking eye drops or oral medications. The patient should turn his or her head to the side to place eye drops in from the side. Oral medications may be crushed and put in applesauce if they are too difficult to swallow in the face-down position. Medications with sustained release action, however, should never be broken or crushed. The patient always should check with a physician, pharmacist, or nurse regarding whether a particular medication may be crushed. Clothing. Nurses should advise the patient to wear loose, comfortable clothing (eg, pajamas, sweat clothes, bathrobes) without buttons, especially down the front of the garment. Buttons can cause irritation to the chest if the patient must maintain a face-down position. Approved patient activities while keeping the head in the prescribed position. The patient should be advised to limit the time he or she spends in bed. He or she should try to maintain normal sleeping and waking patterns. Staying active promotes recovery. The patient should check with his or her physician about doing 20 to 30 minutes of moderate exercise a day (eg, stretching, walking on a treadmill, going outside with a companion). Bathing and shampooing the hair is permitted, as long as the prescribed head position is maintained and soap and water do not get in the eye. Other surgery. The patient should be informed that if general anesthesia is required for additional surgery while the gas bubble is in his or her eye, it is extremely important that the surgeon and anesthesia care provider are made aware of the presence of the gas bubble. Nitrous oxide, which is an anesthetic gas, will cause the gas bubble to expand and increase the pressure inside the eye to a level that can interfere with blood circulation in the eye. Things the patient should avoid. Nurses should inform the patient that driving a motor vehicle is prohibited. In addition, reading should be avoided during the healing period, as it leads to undesirable jerking movement of the eyes. Swimming is not allowed for at least two weeks or until the physician says it is all right to do so. The patient should stay away from sandy or dusty environments, which may cause irritation or infection in the eye. Air travel above 3,000 ft is not permitted. Reduced cabin pressure inside the airplane will allow the gas bubble to expand and cause increased pressure inside the eye, which could
few weeks. Foam supports, rolled towels, blankets, or pillows may be used to maintain the head in a specifically prescribed position that allows the gas or oil to remain in contact with the repaired portion of the retina to promote proper healing. The face and eyes must never be turned upwards or sideways to view visitors, a television, or books. Placing a small television on the floor directly under the face for viewing provides a distraction, and having access to a telephone with a speaker makes talking to friends and family members much easier. In addition, a cassette or compact disc player may be placed within reach for listening to music or audio books. Positioning for the ride home. If the patient is required to maintain face-down positioning, there are a variety of positions he or she can assume for the ride home. These include sitting in the back seat of the car and resting the forehead on the seat in front while looking down at the floor. Another position is lying down in the back seat of the car on the side the physician has prescribed. The use of foam supports, rolled towels, blankets, or pillows may be used to support this position. If the patient is traveling in a truck, he or she can rest the hands on the dashboard and look down at the floor. Alternatively, the patient can assume a sidelying position. This is more difficult, but it is achievable. Tilt the patient’s head into the prescribed position and maintain it with the use of positioning aids. Sleeping. The patient should avoid trying to fall asleep. Watching television or listening to music or a book on audiotape until becoming drowsy promotes falling asleep naturally. The patient may find that taking a warm bath or getting a gentle massage, while maintaining the prescribed head position, helps relieve back tension. The patient should use pillows, rolled towels, blankets, or large pieces of foam to prop his or her body into the prescribed head position for sleeping. For side-lying positions, the patient can place props behind his or her back. Hugging a pillow and placing a pillow between the knees make sleeping on the side more comfortable. Face-down sleeping requires a little more ingenuity. The patient may consider the acquisition of face-down positioning support aids, such as pillows, chairs, or bed attachment devices specially designed for sleeping in the face-down position. Some suppliers offer insurance reimbursement. 806
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cause circulation problems within the eye. Ground travel by car or train is permitted, unless the vehicle moves rapidly from low to high altitudes, such as going from sea level to elevations of more than 5,000 ft. Inform patients that the gas bubble gradually will be absorbed during the two to three months after surgery. If silicone oil is used, it will only be removed surgically if it is causing a problem. CONCLUSlON
A successful patient outcome after retinal surgery is optimized by an educated interdisciplinary team approach that provides continuity in patient education. Initial patient education begins in the surgeon’s ofice. Perioperative nurses further reinforce this education throughout the patient’s surgical NOTES 1. T Britton, “Anatomy and physiology,” in Core Cuwiculumfor Ophthalmic Nursing, ed K Goldblum (Dubuque, Iowa: KendalMunt Publishing Co, 1997) 4,743. 2. F W Newell, Ophthalmology: Principles and Concepts, eighth ed, L Craven, K Cox, D A Circirello, eds (St Louis: Mosby-Year Book, 1996) 23-26, 322-325,334-336. 3. Ibid. 4. Ibid. 5. Ibid. 6. “Retinal tears and detachment,” Texas Retina Associates, http:llwww.dallas.net/-tra/leafletslret - _t d.htm (accessed 13 Feb 2002). 7. J A Sorenson, “Retinal detachment,” Vitreous-Retina-Macda Consultants of New York, http: /lwww.vnnny.comlretinal_detachment.htm (accessed 13 Feb 2002). 8. Ibid. 9. J S Slakter, “Macular hole,” Vitreous-Retina-Macula Consultants of New York, http:llwww.vrmny .com/MH.htm (accessed 13 Feb 2002); “Macular hole surgery,”
experience. The preadmission telephone call is an opportunity to assess patient understanding of expected home care behaviors and address any unmet needs before discharge. Instructions are reinforced firther during the patient’s admission, intraoperative surgical procedures, and finally with postoperative discharge instructions. A
Nancy L. Shelswell, RN, BSN, is an ophthalmic specialty nurse in the outpatient surgery center at Covenant Healthcare-Mackinaw Campus, Saginm, Mich. The author acknowledges the support and help of Paul Raphealian, AD, of Associated Retinal Consultants, Muskegon, Mich, and Sundhar Ramasamy, AD,of Anderson Eye Associates, Saginaw, Mich.
Texas Retina Associates, http:/lwww .dallas.net/-traileafletslmac~hole. htm (accessed 13 Feb 2002). 10. L S Elfervig, J L Elfervig, “Retinal detachment,” Insight 23 (June 1998) 66. 11. Newell, Ophthalmology: Principles and Concepts, eighth ed, 23-26,322-325, 334-336. 12. K M Kearney, “Emergency! Retinal detachment,” American Journal of Nursing 97 (August 1997) 50. 13. Ibid; Elfervig, Elfervig, “Retinal detachment,” 66-68. 14. Ibid. 15. Sorenson, “Retinal detachment.” 16. Elfervig, Elfervig, “Retinal detachment,” 66-68; Keamey, “Emergency! Retinal detachment,” 50. 17. Slakter, “Macular hole.” 18. K B Freund, “Vitrectomy,” Vitreous-Retina-Macula Consultants of New York, http:llwww.vrmny .codvitrectomy.htm (accessed 13 Feb 2002). 19. M D Lomeo, R Dim-Rohena,
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H M Lambert, “Use of peffluorocarbon liquid in the repair of retinoschisis retinal detachments,” Ophthalmic Suvgevy and Lasers 27 (September 1996) 778-781. 20. Elfervig, Elfervig, “Retinal detachment,” 66-68. 2 1. Sorenson, “Retinal detachment.” 22. Elfervig, Elfervig, “Retinal detachment,” 66-68. 23. Ibid. 24. Sorenson, “Retinal detachment.” 25. Slakter, “Macular hole,” 3. 26. “Macular hole surgery.” 27. P A Potter, A G Perry, “Teaching-learningprocess” in Fundamentals of Nursing: Concepts, Process, and Practice (St Louis: Mosby-Year Book, 1985) 351-377. 28. R Cullen, “Macular hole surgery: Helpful tips for preoperative planning and postoperative facedown positioning,” Journal of Ophthalmic Nursing and Technology 17 (SeptembedOctober 1998) 179181.