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Topical Anesthesia—A New Approach To Cataract Surgery
SEPTEMBER 2001, VOL 74, NO 3
Home Study Program TOPICAL ANESTHESIA-A NEW APPROACH TO CATARACT SURGERY
he article “Topical anesthesia: A new approach to cataract surgery” is the basis for this AORN Journul independent study. The behavioral objectives and examination for this program were prepared by the authors Bettyann Hutchisson, RN, BSN, MSOT, CNOR, and Carol Broman Nicoladis, RN, BSN, and by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, education program professional, Center for Perioperative Education. A minimum score of 70% on the multiple-choice examination is necessary to earn 2.5 contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Sept 30, 2004. Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to AORN Customer Service c/o Home Study Program 2 170 S Parker Rd, Suite 300 Denver, CO 8023 1-571 1 Or fax the information with a credit card number to (303) 750-3212
BEHAVIORAL OBJECTIVES
After reading and studying the article on a new approach to cataract surgery, the nurse will be able to ( 1) discuss the historical perspective of cataract treatment, ( 2 ) discuss the etiology of cataract formation, (3) describe the anesthetic options appropriate for cataract surgery, (4) describe the patient selection process and preoperative patient preparation, ( 5 ) discuss the steps of the surgical procedure for cataract extraction, and (6) describe perioperative nursing care of the patient undergoing cataract surgery under topical anesthesia. This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.
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Topical Anesthesia-A New Approach To Cataract Surgery
T
he earliest documented cataract procedures date from the fifth century BC. The Hindu surgeon Susruta performed a type of cataract surgery known as couching.‘ The procedure involved displacing the lens from the pupil into the vitreous cavity. Patients could see better, but vision was still blurry because no corrective lenses were available at that time. In 1747, Jacques Daviel, MD, after performing a failed couching procedure, completed the first cataract extraction by removing a patient’s lens from its normal position behind the iris.?Cataract surgery still is performed today using a similar form of this technique. Although cataract procedures continued to improve since that first procedure, patients having cataract surgery in the 18th and 19th centuries faced several obstacles. Patients with cataracts still were aphakic (ie, not having the crystalline lens in the eye), and although corrective lenses were available, they were cumbersome and often made activities of daily living more difficult for patients. Postoperative recovery was difficult as well. With these early attempts at cataract removal, patients were placed on complete bed rest. For the first 24 to 48 hours, patients had to lie flat in bed without even a small
pillow under the head. Sandbags were placed on either side of the head to prevent movement. Both of the patients’ eyes had to be patched, which completely obstructed vision. For the first four postoperative days, patients were not allowed to comb their hair, brush their teeth, or feed themselves. On the second postoperative day, the head of the bed could be elevated slightly. Dressings were removed from the nonsurgical eye, and patients were allowed to sit in a chair on the fifth postoperative day. The surgical eye remained patched for 10 to 14 days.’ Cataract surgery continued to improve during the 20th century. In 1949, Harold Ridley, MD, developed and implanted the first intraocular lens! This procedure has become the gold standard for cataract surgery today and is one of the most commonly performed surgical procedures for Medicare recipients. Today, cataract surgery has been refined significantly. Patients enter the health care facility the day of surgery and often return home within three to four hours. Implantable lenses have improved so much that additional vision correction no longer is necessary, and cataract surgery results are so favorable that patients undergo the procedure as soon as the cataract interferes with their activities of daily living. In the past, people suffered with worsening vision until the cataract was mature or “ripe.”
A B S T R A C T Patients undergoing cataract surgery with the use of topical anesthesia experience less pain, can return home faster, and avoid the need for an eye patch, which can cause depth perception problems. Patient education performed by the perioperative nurse significantly affects patients’ experience and recovery. This article discusses the history of cataract surgery, etiology of cataract formation, and traditional anesthetic choices. The patient selection process relative to topical anesthesia is defined, and the patient‘s experience throughout the perioperative phases of cataract extraction is described. AORN J 74 (Sept 2001) 340-350.
ANATOMY AND PHYSIOLOGY OF THE EYE
The eye is a soft tissue organ, which, when open, exposes the central nervous system to outside elements (Figure 1).5 The cornea is the transparent external surface that transmits and focuses the light as it enters the eye. The iris is the colored part that helps regulate the
BETTYANN HUTCHISSON, RN; CAROL BROMAN NICOLADIS, R N
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amount of light entering the eye. The pupil is the dark center in the middle of the eye that changes size to adjust for the amount of available light. The crystalline lens is a transparent structure situated behind the iris. The primary role of the lens is to refract (ie, bend) light rays so that they give a clear image to the retina.6Zonules are ligaments attached to the anterior portion of the ciliary body that help suspend the lens. The ciliary body is the wedge-shaped thickening in the middle layer of the eyeball, which secretes most of the aqueous humor. The lens cortex lies between the epithelium and nucleus on the anterior and posterior sides. The lens cortex also is known as secondary lens fibers. Accommodation is the process in which the ciliary muscles contract and relax tension on the zonules allowing the lens to change shape. Accommodation enables a sharp image to form on the retina and allows an individual to focus on objects that are at varying distances from the eye.' A cataract is when the crystalline lens becomes cloudy? Cataracts cause a decrease in visual acuity, blurred vision, glare, and a decrease in green-blue color vision. EllOLOGV OF CATARACT FORMATION
Age is the most common cause of cataract formation. As the lens ages, it increases in weight and thickness, and its proteins undergo a chemical
change. This causes an increase in pigmentation, which reduces transparency. The lens then becomes yellowish or brownish in color? Other causes of cataract formation are long-term use of certain medications, such as corticosteroids and psychotropics (eg, phenothiazine); metabolic disorders; congenital or infantile cataract disorders, and trauma. Metabolic disorders (eg, diabetes) can cause cataract formation because of an increase in ocular glucose content. The glucose enters the lens by d i f i sion and is converted into sorbitol, which is not metabolized and, therefore, remains in the lens. Congenital and infantile cataracts occur in one in every 2,000 live births. Cataracts that develop within the fust year of life are known as infantile cataracts. Most congenital and infantile cataracts are from undetermined causes.'O Traumatic causes of cataract formation can be clustered into four main categories: blunt injury, chemical injury, electrical shock, and radiation injury. Radiation injury can be further divided into ultraviolet radiation resulting from prolonged sun exposure and ionizing radiation resulting from exposure to x-rays. Both electrical shock and radiation cause ocular protein coagulation, which stimulates cataract formation. TREATMENT OPTIONS
Figure 1
Anatomy of the human eye. (///usfrationby Mark Kamik Denver) 342 AORN JOURNAL
Today, there are several options for cataract removal. It can be performed via an extracapsular approach or a clear corneal approach, which is discussed in this article. Patients can choose from several forms of anesthesia-general, retrobulbar, peribulbar, or topical. General anesthesia. General anesthesia may be used if the patient is young, hearing-impaired, or mentally impaired (eg, dementia, severe anxiety) or has language barriers or a known sensitivity to local anesthesia.
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General anesthesia, however, has the potential risk for postoperative nausea and vomiting, which can increase intraocular pressure. Additionally, the most prevalent patient population for cataract extraction is older adult patients who often have concurrent disease processes that preclude the use of general anesthesia. Retrobulbar anesthesia. Retrobulbar anesthesia, a traditional method of anesthesia delivery, consists of injections of anesthetic medications behind the globe of the patient's eye to block the ciliary ganglion and nerve impulses. The patient also experiences temporary paralysis of his or her extraocular muscles. Retrobulbar injections, however, also present the following potential risks: hemorrhage, ptosis, conjunctival or eyelid bruising, globe penetration, optic nerve damage, central vein and artery occlusion, and brain stem anesthesia and death." Peribulbar anesthesia. Peribulbar anesthesia consists of injection of anesthetic medications around the soft tissue of the globe after directing the needle to the floor or roof of the orbit. This type of anesthesia can be used instead of the traditional method of retrobulbar anesthesia. Peribulbar anesthesia injection usually is performed 10 to 15 minutes before surgery. Topical anesthesia. Topical anesthesia is administered by instilling anesthetic drops into the eye. This may be supplemented with infiltration of additional anesthesia into the anterior chamber, thus avoiding the risks involved with other anesthetic options. Topical anesthesia, therefore, often is the anesthesia of choice, depending on appropriate patient evaluation during the patient selection process. PATIENT SELECTION
One of the most important aspects of a successful cataract procedure using topical anesthesia is patient selection. At this time, no standard criteria for patient selection is used consistently by all ophthalmologic surgeons. The surgeon assesses the patient's ability to tolerate topical anesthesia at the preoperative office visit, and surgical team members assess the patient again the morning of the procedure. A patient who suffers fkom severe claustrophobia or other severe anxiety disorders or mental incapacity is not a good candidate for topical anesthesia. These conditions might interfere with the patient's ability to lie
still, even for a short period of time, especially with drapes covering the face. The patient must be able to cooperate and follow directions.I2 The patient also cannot have communication problems (eg, language bamers, uncorrected hearing deficits). The surgeon also considers the difficulty of the surgical procedure when deciding to use topical anesthesia. Difficult procedures might take longer and could preclude the use of topical anesthesia. Some of these surgical difficulties include glaucoma, a hypermature cataract (ie. a lens that is densely opaque), or weak zonules." Concerns for older adult patients. Many patients having cataract surgery are older adults. A major concern in the older adult population is cardiac morbidity-the leading cause of death after anesthesia and surgery. Cardiac risks increase significantly with age. Diabetes, hypertension, arthritis, and chronic obstructive lung disease are other conditions that also should be evaluated preoperatively. Although intraoperative monitoring of blood pressure, electrocardiogram (ECG) and pulse oximetry readings, respiration, and level of consciousness is important for all patients, it is especially crucial in older adult patients. This monitoring is performed by a perioperative nurse other than the circulating nurse or the anesthesia care provider." PREOPERATIVE PHASE
The preoperative phase begins when the patient decides to have surgery. The nurse performs the preoperative nursing assessment, as well as the preoperative patient teaching, before the patient arrives for surgery. Table 1 outlines the nursing care plan for patients undergoing cataract removal. Preoperative nursing assessment, The nurse assesses the patient and identifies appropriate, patient-specific nursing diagnoses and a plan of care. Older adult patients who present for cataract surgery often have other preexisting medical conditions. Nursing diagnoses appropriate for this patient population include risk for ineffective coping related to surgical experience, risk for injury related to visual impairment, and knowledge deficit regarding home care related to unfamiliarity with information. Patient education. Several days before the scheduled surgery, the perioperative nurse calls the
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Table 1 NURSING CARE PLAN FOR PATIENTS UNDERGOING CATARACT REMOVAL
Nursing diagnosis Risk for ineffective coping related to surgical experience
Intervention Assesses coping mechanisms based on psychological status. Elicits patient's perceptions of surgery.
Outcome criteria The patient verbalizes an ability to cope throughout the perioperative period.
Develops individualizedplan of care.
Outcome statement The patient demonstrates knowledge of psychologicaI responses to surgical or other invasive procedures.
Identifies individual's values and wishes concerning care. Risk for injury related to visual impairment
* Notes the following sensory
The patient's function, sensation, and motion are maintained or improved.
impairments: asks what patient can see with each eye, implements protective measures to prevent injury (eg, assistance with walking), orients the patient to the environment, and removes potential hazards.
The patient is free from signs and symptoms of physical injury.
Evaluates environment for home care. Identifies potential hazards, such as throw rugs, extension cords, pets, and stairs. Knowledge deficit regarding home care related to unfamiliarity with informatinn ..-, ,
Determines knowledge level based on psychological status. Provides instruction about prescribed medications.
The patient communicates purpose, dosage, route, and possible side effects of medications; returns demonstration on proper medication administration; communicates proper medication storage.
Identifies expectations for home care: working is permitted; limited stair climbing is allowed; keep eye shield in place for 12 to 18 hours; put nothing in eye unless instructed by surgeon; have a companion stay with patient; and contact physician if pain, vision, or nausea worsens or if vomiting occurs.
The patient communicates concerns related to the surgical procedure, next planned visit with the health care provider, goals in realistic terms, sequence of postoperative events, and activities related to his or her care. The patient communicates sequence of wound healing related to surgical procedure; concerns about healing, dressing care, and wound management techniques; and goals of wound healing.
Evaluates response to instructions.
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The patient demonstrates knowledge of medication management, rehabilitation process, and eye wound care.
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patient to review preoperative teaching. During this telephone call, the nurse instructs the patient to increase fluid intake the day before surgery; remain NPO after midnight the night before surgery; not take a dose of insulin the morning of surgery because blood will be drawn after being admitted, and insulin will be given based on the serum glucose test results-the patient should bring his or her insulin to the hospital so the correct type of insulin can be administered; arrange for a responsible adult to take the patient home and remain with him or her for 24 hours postoperatively; arrive at the hospital one hour before the scheduled procedure time; wear loose, comfortable clothing; and remove makeup, jewelry, and nail polish before arriving at the hospital. PreoDerative activities. After arriving at the hospital, the patient is asked to change into a hospital gown and give his or her belongings to the adult who accompanied the patient. The nurse assists the patient onto the ophthalmology stretcher and starts an IV line of lactated Ringer’s solution through which needed medications can be administered. To ensure that surgery is performed on the correct eye, the surgeon identifies the patient, asks the patient to confirm which eye is being operated on, and uses a marking pen to place an “X” above the brow of the surgical eye. The nurse places ECG patches on the patient’s chest to monitor cardiac rhythm and instills dilating eye drops in the surgical eye. The patient remains on the ophthalmology stretcher for the entire procedure and recovery. A chest x-ray, an ECG, or blood work is obtained at this time, if ordered, and insulin is administered if needed based on the patient’s serum glucose results. The perioperative nurse assigned to circulate during the procedure introduces herself or himself to the patient in the preoperative holding area and assesses the patient to verify NPO status, allergies, pertinent medical information, the surgical site, and any special patient care needs. At this time, the nurse tells the patient about the intraoperative phase of the procedure describing the OR environment (eg, lights, sounds, temperature), positioning during the procedure, surgical skin prep, topical anesthesia, the patient’s responsibilities (eg, looking up or v
down when instructed to by the surgeon), what the patient may experience during the surgery (eg, pressure fluctuations that should not be painful), how the patient can ask for pain medication if needed, and the importance of remaining very still. The nurse emphasizes that the patient should let the surgeon know first before moving (eg, needing to cough or sneeze). The patient is reassured that a member of the surgical team will assist him or her in satisfying any needs, such as scratching an itch or needing to urinate. INTRAOPERATIVE PHASE
The circulating nurse is responsible for ensuring that the OR and the specialized ophthalmic equipment and supplies are available and functioning correctly. The nurse turns on and checks the microscope and makes sure the surgeon’s lens of choice is on the scope. The nurse also checks the phacoemulsification machine and enters the surgeon’s specific information. After the nurse obtains and delivers the intraoperative instrumentation to the sterile field, the scrub person labels all medications. The scrub person and the nurse cooperatively prime the phacoemulsification unit and hand piece. The circulating nurse and anesthesia care provider transfer the patient into the OR. They position the stretcher so that the microscope can be used. Marks placed on the floor help correctly orient the position of the stretcher. The nurse places a pillow under the patient’s knees to help relieve pressure on the patient’s lower back while lying flat. The anesthesia care provider connects the monitoring equipment and secures a nasal oxygen cannula to the patient. The nurse detaches the headpiece of the stretcher to reveal a U-shaped headrest. This headrest allows the surgeon to sit closer to the patient’s head. The side rails are lowered, and the safety strap is checked to ensure it is securely in place across the patient’s thighs, avoiding bony prominences. The nurse secures the patient’s arms at his or her side with a draw sheet that then is taped across the chest.15Dilating eye drops of phenylephrine 2.5% (Neo-synephrine), cyclopentolate 1% (Cyclogyl), and flurbiprofen sodium 0.03% (Ocufen) are administered in the surgical eye.Ih Immediately before the surgical skin prep, the circulating nurse administers one drop of tetracaine 4% into both eyes. The drops are instilled to locally anesthetize the surgical eye and reduce the blink
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reflex in both eyes.” The circulating nurse preps the surgical eye only using 10% povodine-iodine scrub solution. With gauze sponges, the circulating nurse preps in a circumferential pattern around the surgical eye. One drop of 5% povodine-iodine (ie, 10% povodine-iodine diluted to one-half strength with 0.9% sodium chloride) is instilled into the surgical eye at the completion of the prep to remove surface microbes. Table 2 lists common medications used for cataract procedures and their actions. Draping. The circulating nurse places a metal eye shield over the nonsurgical eye to protect it from the drapes. The scrub person then drapes the patient by securing a towel with an adhesive strip on the patient’s forehead and placing a body drape down the entire length of the patient. A sterile draped Mayo stand is placed over the patient’s chest. A plastic incise drape with an adhesive edge and a pouch to collect fluids is placed on the patient’s eye and is draped over the Mayo stand. A tent is formed, which, combined with the supplemental oxygen provided through a nasal cannula, allows the patient to breathe comfortably during the procedure. Procedure. The surgeon cuts a hole in the incise drape, opens the surgical eyelid, and puts the lid retractor in place. The surgical microscope is positioned above the patient’s eye, and the surgeon sits temporally to the patient (eg, behind the patient’s head) during the procedure. The patient is reminded that the microscope light is very bright at the beginning of the procedure, but that his or her eye will adjust quickly. The phacoemulsification unit also is appropriately positioned behind the patient for use during the procedure. The surgeon uses a 20-g microvitrioretinal blade to make two stab incisions in the cornea at the 10 o’clock and 2 o’clock positions. This allows the surgeon to instill balanced salt solution (BSS) and insert surgical instruments. Lidocaine 1% without preservative is injected intracamerally with a blunt 27-g needle into the anterior chamber of the eye to provide additional anesthesia if needed during the procedure. The surgeon makes a 3-mm incision into the temporal portion of the cornea using a diamond keratome knife and uses a 27-g cannula to inject sodium hyaluronate (Healon). This medication protects the corneal endothelium, reduces cell loss during surgery, and maintains the chamber shape, ocular volume, and ocular pressure during the procedure.’*The surgeon uses a curved 27-g cystotome for the capsulorhexis (ie, rupture of the lens capsule). Hydrodissection is performed by the surgeon using a curved Binkhorst cannula to the right and a 20-g McIntyre needle attached to a syringe filled with BSS. The surgeon
performs the phacoemulsification using a 30-g microflow phacoemulsification tip. Phacoemulsification involves the use of ultrasound vibrations to break the lens into small pieces during extracapsular cataract extraction. The nucleus and cortex of the lens are broken into small pieces by rapid ultrasonic vibrations. The surgeon uses concurrent irrigation and aspiration to remove the fragments from the eye.I9 The incision seals around the microflow tip, which prevents the radical pressure fluctuations that some patients experienced in the past. After the lens is emulsified and removed, the surgeon removes the rest of the cortex using an imgation and aspiration system. This system has two handlesone that irrigates and one that aspirates. The surgeon now injects additional sodium hyaluronate. The incision is deepened enough to insert the foldable intraocular lens. The sodium hyaluronate is removed with the irrigation and aspiration system. The surgeon injects carbachol (Miostat) with a 27-g cannula and checks the incision for leaks. Balanced salt solution is injected immediately after the carbachol to prevent postoperative brow pain. The circulating nurse removes the microscope; applies neomycin, polymyxin B sulfates, and dexamethasone ointment (Maxitrol); and tapes the eye shield in place over the surgical eye. The shield has holes in it, and an eye patch under the shield is not needed so problems with depth perception are minimized, although not completely eliminated. The surgical procedure usually lasts approximately 20 minutes. POSTOPERATIVE PHASE
The patient remains in the postoperative unit for approximately one hour, during which the nurse monitors the patient’s vital signs. The nurse discontinues the IV line when the patient is able to tolerate oral fluids. The anesthesia care provider visits the patient and determines when the patient can be discharged based on preestablished discharge criteria and the patient’s current health status. Discharge criteria include stable vital signs, ability to tolerate oral fluids without vomiting, ability to ambulate without dizziness, and ability to urinate. The postanesthesia care unit nurse provides the patient with discharge instructions, which include directions to 9 have a responsible adult remain with the patient for 24 to 48 hours after surgery; continue presurgery diet and fluids; keep the eye shield in place for 12 to 18 hours to protect the eye; continue presurgery activities with caution due to the change in depth perception caused by having a
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Table 2 MEDICATIONS FOR TOPICAL ANESTHESIA
Medication
Action
Balanced salt solution (ie, sodium chloride, potassium chloride, calcium chloride, magnesium chloride, buffering agents, pH adjusters, preservatives, purified water) 500 mL mixed with Epinephrine (1 : 1,000) 0.5 mL Vancomycin 10 mg
An isotonic irrigation solution used to maintain pupil dilation and keep the eye moist.
A vasoconstrictor used to decrease bleeding. An antibiotic added to help prevent postoperative infection.
Carbachol 0.01o/o intraocular solution (Miostat)
A potent cholinergic (ie, parasympathomimetic) agent used for miosis during surgery.'
Cyclopentolate 1 9'0 ophthalmic solution (Cyclogyl)
A cycloplegic medication that dilates the pupil and inhibits focusing of the eye; aids in refraction procedures.*
Flurbiprofen sodium 0.03% ophthalmic solution (Ocufen)
A topical, nonsteroidal, anti-inflammatoryagent that inhibits intraoperative m i ~ s i s . ~
Lidocaine 1 Yo (without preservative)
A local anesthetic medication with a duration of approximately 45 to 60 minute^.^
Neomycin, polymyxin B sulfates, and dexamethasone ophthalmic ointment (Maxitrol)
An anti-infective ~teroid.~
Phenylephrine 2.5% (Neo-synephrine)
A mydriatic medication that dilates the pupil but permits the patient to focus.6
Tetracaine 4% ophthalmic solution
A topical anesthesia that has a rapid onset (ie, 5 to 20 seconds) and a moderate duration of action (ie, 10 to 20 minutes).'
Sodium hyaluronate (Healon)
A surgical aid in anterior segment procedures that protects the corneal endothelium, reduces cell loss during surgery, and maintains the chamber shape, ocular volume, and ocular pressure during the procedure.*
NOTES .1. T F Mauger, E L Craig,
ed, Huvener's Oculur Phumucolugy, sixth ed (St Louis: Mosby, 1994). 2. Physician's Desk Reference for Ophthalmology, 22nd ed (Montvale, NJ: Medical Economics Data, 2001). 3. Ibid. 4. Mauger, Craig, Huvenefs Oculur Phumucology. 5. Physician's Desk Reference for Ophthulmology. 6 . M H Meeker, J C Rothrock, Alexander's Cure of the Patient in Surgery 1 lth ed (St Louis: Mosby, 1999) 7. Ibid. 8. Physician's Desk Reference for Ophthulmology.
shield on one eye; limit the number of trips up and down stairs for the first few days; use a laxative if the patient has not had a bowel movement by the third day after surgery; and not put anything (eg, eye drops) into the eye unless instructed to by the surgeon.'" Patients also are instructed to return to the physician's office the next day for an appointmen; ?he patient is instructed to call his or her physician if
pain is not relieved with over-the-counter medicine, he or she experiences nausea or vomiting, or vision suddenly becomes worse." RISKS AND BENEFITS
The benefits of using topical anesthesia outweigh the risks associated with general, retrobulbar, and peribulbar anesthesia. The risks associated with topical anesthesia primarily involve the possibility of destroying the eye if the patient moves suddenly
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during the procedure. Careful evaluation of the patient’s ability to tolerate topical anesthesia and educating the patient preoperatively about the need to remain motionless during the procedure can minimize this risk. Other risks associated with cataract procedures include posterior capsule tears with loss of vitreous fluid, increased intraocular pressure, macular edema, capsule opacification, and intraocular hemorrhage.*2
Nicoladis
immediately postoperatively and have less pain because of the small incision. Additionally, patients do not need sutures, have no bruising, and maintain depth perception because there is no need to patch the eye. A Bettyann Hutchisson, RN,BSN, MSO7: CNOR, is a clinical education consultant in the advanced sterilization products department of Johnson & Johnson, Houston. She was a nurse clinician, perioperative education, at Methodist Hospital at the time this article was written.
CONCLUSION
Cataract surgery has proven to be a successful and reliable solution to cataract formation. With the use of topical anesthesia, patients have better acuity NOTES 1. N S Jaffe, “History of cataract surgery,” Ophthalmology 103 suppl (August 1996) S5-16. 2. “Cataract surgery in the modem era,” American Academy of
Ophthalmology, http://www.aao.org/ aaowebI/Foundation/311-32208.cfm (accessed 17 May 2001). 3. R H Parkinson, Eye, Ear; Nose, and Throat Manualfor Nurses, fitth ed (St Louis: Mosby, 1994) 101-102. 4. Jaffe, “History of cataract surgery,” S5-16. 5. M Anthony, M McBrayer “Ophthalmic surgery,” in Patient Care During Operative and lnvasive Procedures, ed M L Phippen, M P
Wells (Philadelphia, W B Saunders CO,2000) 629-631. 6. J D Fischel, J R Lipton, “Cataract surgery and recent advances: A review,” Nursing Standard 10 (July 3, 1996) 39-43. 7. S Goldberg, Ophthalmology
Carol Broman Nicoladis, RN,BSN, is a nurse clinician and the ORpostanesthesia care unit nurse educator at Methodist Healthcare System, Missouri City, Tex.
Made Ridiculously Simple (Miami: MedMasters, Inc, 1991) 4. 8. K E Rose, “Caring for patients with cataracts,” Nursing Standard 1 1 (Sept 17, 1997) 49-53. 9. Ibid, 49-53. 10. Fischel, “Cataract surgery and recent advances: A review,” 39-43. 1 1. S F Brint, “Refractive cataract surgery,’’ International Ophthalmology Clinics 34 (Fall 1994) 1- 11.
12. D D Garbee, “Phacoemulsification procedures performed with topical anesthesia,” AORN Journal 66 (August 1997) 253-265. 13. J Belardo, D Hoyt, D Dupree, “Making the transition to topical anesthesia,” Journal of Ophthalmic Nursing and Technologv 17 (2) 7276. 14. B P Gallagher, “Anesthesia for the older ophthalmic patient,” Today’s Surgical Nurse 19 (September/ October 1997) 23-27. 15. D D Garbee, “Phacoemulsification procedures performed
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with topical anesthesia,” 253-265. 16. R J Noecker, S F Golightly, “Pharmacology of ocular surgery,” Ophthalmic Nursing and Technology 18 (May/June 1999) 101-108. 17. M H Meeker, J C Rothrock, Alexander’s Care of the Patient in Surgery, 1 Ith ed (St Louis: Mosby, 1999) 645. 18. Noecker, Golightly, “Pharmacology of ocular surgery,” 101-108. 19. Meeker, Rothrock, Alexander k Care of the Patient in Surgety 1 1th ed, 676 20. N Burden, Ambulatory Surgical Nursing (Philadelphia: W B Saunders Co, 1993) 465-467. 2 I . Belardo, Hoyt, Dupree,
“Making the transition to topical anesthesia,” 72-76. 22. S Roman, F Auclin, M Ullem, “Topical versus peribulbar anesthesia in cataract surgery,” Journal of Cataract Refiactive Surgery 22 (October 1996) 1121-1124.
Home Study Program TOPICAL ANESTHESIA-A NEW APPROACH TO CATARACT SURGERY
he article “Topical anesthesia: A new approach to cataract surgery” is the basis for this AORN Journul independent study. The behavioral objectives and examination for this program were prepared by the authors Bettyann Hutchisson, RN, BSN, MSOT, CNOR, and Carol Broman Nicoladis, RN, BSN, and by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, education program professional, Center for Perioperative Education. A minimum score of 70% on the multiple-choice examination is necessary to earn 2.5 contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Sept 30, 2004. Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to AORN Customer Service c/o Home Study Program 2 170 S Parker Rd, Suite 300 Denver, CO 8023 1-571 1 Or fax the information with a credit card number to (303) 750-3212
BEHAVIORAL OBJECTIVES
After reading and studying the article on a new approach to cataract surgery, the nurse will be able to ( 1) discuss the historical perspective of cataract treatment, ( 2 ) discuss the etiology of cataract formation, (3) describe the anesthetic options appropriate for cataract surgery, (4) describe the patient selection process and preoperative patient preparation, ( 5 ) discuss the steps of the surgical procedure for cataract extraction, and (6) describe perioperative nursing care of the patient undergoing cataract surgery under topical anesthesia. This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.
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Topical Anesthesia-A New Approach To Cataract Surgery
T
he earliest documented cataract procedures date from the fifth century BC. The Hindu surgeon Susruta performed a type of cataract surgery known as couching.‘ The procedure involved displacing the lens from the pupil into the vitreous cavity. Patients could see better, but vision was still blurry because no corrective lenses were available at that time. In 1747, Jacques Daviel, MD, after performing a failed couching procedure, completed the first cataract extraction by removing a patient’s lens from its normal position behind the iris.?Cataract surgery still is performed today using a similar form of this technique. Although cataract procedures continued to improve since that first procedure, patients having cataract surgery in the 18th and 19th centuries faced several obstacles. Patients with cataracts still were aphakic (ie, not having the crystalline lens in the eye), and although corrective lenses were available, they were cumbersome and often made activities of daily living more difficult for patients. Postoperative recovery was difficult as well. With these early attempts at cataract removal, patients were placed on complete bed rest. For the first 24 to 48 hours, patients had to lie flat in bed without even a small
pillow under the head. Sandbags were placed on either side of the head to prevent movement. Both of the patients’ eyes had to be patched, which completely obstructed vision. For the first four postoperative days, patients were not allowed to comb their hair, brush their teeth, or feed themselves. On the second postoperative day, the head of the bed could be elevated slightly. Dressings were removed from the nonsurgical eye, and patients were allowed to sit in a chair on the fifth postoperative day. The surgical eye remained patched for 10 to 14 days.’ Cataract surgery continued to improve during the 20th century. In 1949, Harold Ridley, MD, developed and implanted the first intraocular lens! This procedure has become the gold standard for cataract surgery today and is one of the most commonly performed surgical procedures for Medicare recipients. Today, cataract surgery has been refined significantly. Patients enter the health care facility the day of surgery and often return home within three to four hours. Implantable lenses have improved so much that additional vision correction no longer is necessary, and cataract surgery results are so favorable that patients undergo the procedure as soon as the cataract interferes with their activities of daily living. In the past, people suffered with worsening vision until the cataract was mature or “ripe.”
A B S T R A C T Patients undergoing cataract surgery with the use of topical anesthesia experience less pain, can return home faster, and avoid the need for an eye patch, which can cause depth perception problems. Patient education performed by the perioperative nurse significantly affects patients’ experience and recovery. This article discusses the history of cataract surgery, etiology of cataract formation, and traditional anesthetic choices. The patient selection process relative to topical anesthesia is defined, and the patient‘s experience throughout the perioperative phases of cataract extraction is described. AORN J 74 (Sept 2001) 340-350.
ANATOMY AND PHYSIOLOGY OF THE EYE
The eye is a soft tissue organ, which, when open, exposes the central nervous system to outside elements (Figure 1).5 The cornea is the transparent external surface that transmits and focuses the light as it enters the eye. The iris is the colored part that helps regulate the
BETTYANN HUTCHISSON, RN; CAROL BROMAN NICOLADIS, R N
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amount of light entering the eye. The pupil is the dark center in the middle of the eye that changes size to adjust for the amount of available light. The crystalline lens is a transparent structure situated behind the iris. The primary role of the lens is to refract (ie, bend) light rays so that they give a clear image to the retina.6Zonules are ligaments attached to the anterior portion of the ciliary body that help suspend the lens. The ciliary body is the wedge-shaped thickening in the middle layer of the eyeball, which secretes most of the aqueous humor. The lens cortex lies between the epithelium and nucleus on the anterior and posterior sides. The lens cortex also is known as secondary lens fibers. Accommodation is the process in which the ciliary muscles contract and relax tension on the zonules allowing the lens to change shape. Accommodation enables a sharp image to form on the retina and allows an individual to focus on objects that are at varying distances from the eye.' A cataract is when the crystalline lens becomes cloudy? Cataracts cause a decrease in visual acuity, blurred vision, glare, and a decrease in green-blue color vision. EllOLOGV OF CATARACT FORMATION
Age is the most common cause of cataract formation. As the lens ages, it increases in weight and thickness, and its proteins undergo a chemical
change. This causes an increase in pigmentation, which reduces transparency. The lens then becomes yellowish or brownish in color? Other causes of cataract formation are long-term use of certain medications, such as corticosteroids and psychotropics (eg, phenothiazine); metabolic disorders; congenital or infantile cataract disorders, and trauma. Metabolic disorders (eg, diabetes) can cause cataract formation because of an increase in ocular glucose content. The glucose enters the lens by d i f i sion and is converted into sorbitol, which is not metabolized and, therefore, remains in the lens. Congenital and infantile cataracts occur in one in every 2,000 live births. Cataracts that develop within the fust year of life are known as infantile cataracts. Most congenital and infantile cataracts are from undetermined causes.'O Traumatic causes of cataract formation can be clustered into four main categories: blunt injury, chemical injury, electrical shock, and radiation injury. Radiation injury can be further divided into ultraviolet radiation resulting from prolonged sun exposure and ionizing radiation resulting from exposure to x-rays. Both electrical shock and radiation cause ocular protein coagulation, which stimulates cataract formation. TREATMENT OPTIONS
Figure 1
Anatomy of the human eye. (///usfrationby Mark Kamik Denver) 342 AORN JOURNAL
Today, there are several options for cataract removal. It can be performed via an extracapsular approach or a clear corneal approach, which is discussed in this article. Patients can choose from several forms of anesthesia-general, retrobulbar, peribulbar, or topical. General anesthesia. General anesthesia may be used if the patient is young, hearing-impaired, or mentally impaired (eg, dementia, severe anxiety) or has language barriers or a known sensitivity to local anesthesia.
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General anesthesia, however, has the potential risk for postoperative nausea and vomiting, which can increase intraocular pressure. Additionally, the most prevalent patient population for cataract extraction is older adult patients who often have concurrent disease processes that preclude the use of general anesthesia. Retrobulbar anesthesia. Retrobulbar anesthesia, a traditional method of anesthesia delivery, consists of injections of anesthetic medications behind the globe of the patient's eye to block the ciliary ganglion and nerve impulses. The patient also experiences temporary paralysis of his or her extraocular muscles. Retrobulbar injections, however, also present the following potential risks: hemorrhage, ptosis, conjunctival or eyelid bruising, globe penetration, optic nerve damage, central vein and artery occlusion, and brain stem anesthesia and death." Peribulbar anesthesia. Peribulbar anesthesia consists of injection of anesthetic medications around the soft tissue of the globe after directing the needle to the floor or roof of the orbit. This type of anesthesia can be used instead of the traditional method of retrobulbar anesthesia. Peribulbar anesthesia injection usually is performed 10 to 15 minutes before surgery. Topical anesthesia. Topical anesthesia is administered by instilling anesthetic drops into the eye. This may be supplemented with infiltration of additional anesthesia into the anterior chamber, thus avoiding the risks involved with other anesthetic options. Topical anesthesia, therefore, often is the anesthesia of choice, depending on appropriate patient evaluation during the patient selection process. PATIENT SELECTION
One of the most important aspects of a successful cataract procedure using topical anesthesia is patient selection. At this time, no standard criteria for patient selection is used consistently by all ophthalmologic surgeons. The surgeon assesses the patient's ability to tolerate topical anesthesia at the preoperative office visit, and surgical team members assess the patient again the morning of the procedure. A patient who suffers fkom severe claustrophobia or other severe anxiety disorders or mental incapacity is not a good candidate for topical anesthesia. These conditions might interfere with the patient's ability to lie
still, even for a short period of time, especially with drapes covering the face. The patient must be able to cooperate and follow directions.I2 The patient also cannot have communication problems (eg, language bamers, uncorrected hearing deficits). The surgeon also considers the difficulty of the surgical procedure when deciding to use topical anesthesia. Difficult procedures might take longer and could preclude the use of topical anesthesia. Some of these surgical difficulties include glaucoma, a hypermature cataract (ie. a lens that is densely opaque), or weak zonules." Concerns for older adult patients. Many patients having cataract surgery are older adults. A major concern in the older adult population is cardiac morbidity-the leading cause of death after anesthesia and surgery. Cardiac risks increase significantly with age. Diabetes, hypertension, arthritis, and chronic obstructive lung disease are other conditions that also should be evaluated preoperatively. Although intraoperative monitoring of blood pressure, electrocardiogram (ECG) and pulse oximetry readings, respiration, and level of consciousness is important for all patients, it is especially crucial in older adult patients. This monitoring is performed by a perioperative nurse other than the circulating nurse or the anesthesia care provider." PREOPERATIVE PHASE
The preoperative phase begins when the patient decides to have surgery. The nurse performs the preoperative nursing assessment, as well as the preoperative patient teaching, before the patient arrives for surgery. Table 1 outlines the nursing care plan for patients undergoing cataract removal. Preoperative nursing assessment, The nurse assesses the patient and identifies appropriate, patient-specific nursing diagnoses and a plan of care. Older adult patients who present for cataract surgery often have other preexisting medical conditions. Nursing diagnoses appropriate for this patient population include risk for ineffective coping related to surgical experience, risk for injury related to visual impairment, and knowledge deficit regarding home care related to unfamiliarity with information. Patient education. Several days before the scheduled surgery, the perioperative nurse calls the
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Table 1 NURSING CARE PLAN FOR PATIENTS UNDERGOING CATARACT REMOVAL
Nursing diagnosis Risk for ineffective coping related to surgical experience
Intervention Assesses coping mechanisms based on psychological status. Elicits patient's perceptions of surgery.
Outcome criteria The patient verbalizes an ability to cope throughout the perioperative period.
Develops individualizedplan of care.
Outcome statement The patient demonstrates knowledge of psychologicaI responses to surgical or other invasive procedures.
Identifies individual's values and wishes concerning care. Risk for injury related to visual impairment
* Notes the following sensory
The patient's function, sensation, and motion are maintained or improved.
impairments: asks what patient can see with each eye, implements protective measures to prevent injury (eg, assistance with walking), orients the patient to the environment, and removes potential hazards.
The patient is free from signs and symptoms of physical injury.
Evaluates environment for home care. Identifies potential hazards, such as throw rugs, extension cords, pets, and stairs. Knowledge deficit regarding home care related to unfamiliarity with informatinn ..-, ,
Determines knowledge level based on psychological status. Provides instruction about prescribed medications.
The patient communicates purpose, dosage, route, and possible side effects of medications; returns demonstration on proper medication administration; communicates proper medication storage.
Identifies expectations for home care: working is permitted; limited stair climbing is allowed; keep eye shield in place for 12 to 18 hours; put nothing in eye unless instructed by surgeon; have a companion stay with patient; and contact physician if pain, vision, or nausea worsens or if vomiting occurs.
The patient communicates concerns related to the surgical procedure, next planned visit with the health care provider, goals in realistic terms, sequence of postoperative events, and activities related to his or her care. The patient communicates sequence of wound healing related to surgical procedure; concerns about healing, dressing care, and wound management techniques; and goals of wound healing.
Evaluates response to instructions.
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The patient demonstrates knowledge of medication management, rehabilitation process, and eye wound care.
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patient to review preoperative teaching. During this telephone call, the nurse instructs the patient to increase fluid intake the day before surgery; remain NPO after midnight the night before surgery; not take a dose of insulin the morning of surgery because blood will be drawn after being admitted, and insulin will be given based on the serum glucose test results-the patient should bring his or her insulin to the hospital so the correct type of insulin can be administered; arrange for a responsible adult to take the patient home and remain with him or her for 24 hours postoperatively; arrive at the hospital one hour before the scheduled procedure time; wear loose, comfortable clothing; and remove makeup, jewelry, and nail polish before arriving at the hospital. PreoDerative activities. After arriving at the hospital, the patient is asked to change into a hospital gown and give his or her belongings to the adult who accompanied the patient. The nurse assists the patient onto the ophthalmology stretcher and starts an IV line of lactated Ringer’s solution through which needed medications can be administered. To ensure that surgery is performed on the correct eye, the surgeon identifies the patient, asks the patient to confirm which eye is being operated on, and uses a marking pen to place an “X” above the brow of the surgical eye. The nurse places ECG patches on the patient’s chest to monitor cardiac rhythm and instills dilating eye drops in the surgical eye. The patient remains on the ophthalmology stretcher for the entire procedure and recovery. A chest x-ray, an ECG, or blood work is obtained at this time, if ordered, and insulin is administered if needed based on the patient’s serum glucose results. The perioperative nurse assigned to circulate during the procedure introduces herself or himself to the patient in the preoperative holding area and assesses the patient to verify NPO status, allergies, pertinent medical information, the surgical site, and any special patient care needs. At this time, the nurse tells the patient about the intraoperative phase of the procedure describing the OR environment (eg, lights, sounds, temperature), positioning during the procedure, surgical skin prep, topical anesthesia, the patient’s responsibilities (eg, looking up or v
down when instructed to by the surgeon), what the patient may experience during the surgery (eg, pressure fluctuations that should not be painful), how the patient can ask for pain medication if needed, and the importance of remaining very still. The nurse emphasizes that the patient should let the surgeon know first before moving (eg, needing to cough or sneeze). The patient is reassured that a member of the surgical team will assist him or her in satisfying any needs, such as scratching an itch or needing to urinate. INTRAOPERATIVE PHASE
The circulating nurse is responsible for ensuring that the OR and the specialized ophthalmic equipment and supplies are available and functioning correctly. The nurse turns on and checks the microscope and makes sure the surgeon’s lens of choice is on the scope. The nurse also checks the phacoemulsification machine and enters the surgeon’s specific information. After the nurse obtains and delivers the intraoperative instrumentation to the sterile field, the scrub person labels all medications. The scrub person and the nurse cooperatively prime the phacoemulsification unit and hand piece. The circulating nurse and anesthesia care provider transfer the patient into the OR. They position the stretcher so that the microscope can be used. Marks placed on the floor help correctly orient the position of the stretcher. The nurse places a pillow under the patient’s knees to help relieve pressure on the patient’s lower back while lying flat. The anesthesia care provider connects the monitoring equipment and secures a nasal oxygen cannula to the patient. The nurse detaches the headpiece of the stretcher to reveal a U-shaped headrest. This headrest allows the surgeon to sit closer to the patient’s head. The side rails are lowered, and the safety strap is checked to ensure it is securely in place across the patient’s thighs, avoiding bony prominences. The nurse secures the patient’s arms at his or her side with a draw sheet that then is taped across the chest.15Dilating eye drops of phenylephrine 2.5% (Neo-synephrine), cyclopentolate 1% (Cyclogyl), and flurbiprofen sodium 0.03% (Ocufen) are administered in the surgical eye.Ih Immediately before the surgical skin prep, the circulating nurse administers one drop of tetracaine 4% into both eyes. The drops are instilled to locally anesthetize the surgical eye and reduce the blink
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reflex in both eyes.” The circulating nurse preps the surgical eye only using 10% povodine-iodine scrub solution. With gauze sponges, the circulating nurse preps in a circumferential pattern around the surgical eye. One drop of 5% povodine-iodine (ie, 10% povodine-iodine diluted to one-half strength with 0.9% sodium chloride) is instilled into the surgical eye at the completion of the prep to remove surface microbes. Table 2 lists common medications used for cataract procedures and their actions. Draping. The circulating nurse places a metal eye shield over the nonsurgical eye to protect it from the drapes. The scrub person then drapes the patient by securing a towel with an adhesive strip on the patient’s forehead and placing a body drape down the entire length of the patient. A sterile draped Mayo stand is placed over the patient’s chest. A plastic incise drape with an adhesive edge and a pouch to collect fluids is placed on the patient’s eye and is draped over the Mayo stand. A tent is formed, which, combined with the supplemental oxygen provided through a nasal cannula, allows the patient to breathe comfortably during the procedure. Procedure. The surgeon cuts a hole in the incise drape, opens the surgical eyelid, and puts the lid retractor in place. The surgical microscope is positioned above the patient’s eye, and the surgeon sits temporally to the patient (eg, behind the patient’s head) during the procedure. The patient is reminded that the microscope light is very bright at the beginning of the procedure, but that his or her eye will adjust quickly. The phacoemulsification unit also is appropriately positioned behind the patient for use during the procedure. The surgeon uses a 20-g microvitrioretinal blade to make two stab incisions in the cornea at the 10 o’clock and 2 o’clock positions. This allows the surgeon to instill balanced salt solution (BSS) and insert surgical instruments. Lidocaine 1% without preservative is injected intracamerally with a blunt 27-g needle into the anterior chamber of the eye to provide additional anesthesia if needed during the procedure. The surgeon makes a 3-mm incision into the temporal portion of the cornea using a diamond keratome knife and uses a 27-g cannula to inject sodium hyaluronate (Healon). This medication protects the corneal endothelium, reduces cell loss during surgery, and maintains the chamber shape, ocular volume, and ocular pressure during the procedure.’*The surgeon uses a curved 27-g cystotome for the capsulorhexis (ie, rupture of the lens capsule). Hydrodissection is performed by the surgeon using a curved Binkhorst cannula to the right and a 20-g McIntyre needle attached to a syringe filled with BSS. The surgeon
performs the phacoemulsification using a 30-g microflow phacoemulsification tip. Phacoemulsification involves the use of ultrasound vibrations to break the lens into small pieces during extracapsular cataract extraction. The nucleus and cortex of the lens are broken into small pieces by rapid ultrasonic vibrations. The surgeon uses concurrent irrigation and aspiration to remove the fragments from the eye.I9 The incision seals around the microflow tip, which prevents the radical pressure fluctuations that some patients experienced in the past. After the lens is emulsified and removed, the surgeon removes the rest of the cortex using an imgation and aspiration system. This system has two handlesone that irrigates and one that aspirates. The surgeon now injects additional sodium hyaluronate. The incision is deepened enough to insert the foldable intraocular lens. The sodium hyaluronate is removed with the irrigation and aspiration system. The surgeon injects carbachol (Miostat) with a 27-g cannula and checks the incision for leaks. Balanced salt solution is injected immediately after the carbachol to prevent postoperative brow pain. The circulating nurse removes the microscope; applies neomycin, polymyxin B sulfates, and dexamethasone ointment (Maxitrol); and tapes the eye shield in place over the surgical eye. The shield has holes in it, and an eye patch under the shield is not needed so problems with depth perception are minimized, although not completely eliminated. The surgical procedure usually lasts approximately 20 minutes. POSTOPERATIVE PHASE
The patient remains in the postoperative unit for approximately one hour, during which the nurse monitors the patient’s vital signs. The nurse discontinues the IV line when the patient is able to tolerate oral fluids. The anesthesia care provider visits the patient and determines when the patient can be discharged based on preestablished discharge criteria and the patient’s current health status. Discharge criteria include stable vital signs, ability to tolerate oral fluids without vomiting, ability to ambulate without dizziness, and ability to urinate. The postanesthesia care unit nurse provides the patient with discharge instructions, which include directions to 9 have a responsible adult remain with the patient for 24 to 48 hours after surgery; continue presurgery diet and fluids; keep the eye shield in place for 12 to 18 hours to protect the eye; continue presurgery activities with caution due to the change in depth perception caused by having a
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Table 2 MEDICATIONS FOR TOPICAL ANESTHESIA
Medication
Action
Balanced salt solution (ie, sodium chloride, potassium chloride, calcium chloride, magnesium chloride, buffering agents, pH adjusters, preservatives, purified water) 500 mL mixed with Epinephrine (1 : 1,000) 0.5 mL Vancomycin 10 mg
An isotonic irrigation solution used to maintain pupil dilation and keep the eye moist.
A vasoconstrictor used to decrease bleeding. An antibiotic added to help prevent postoperative infection.
Carbachol 0.01o/o intraocular solution (Miostat)
A potent cholinergic (ie, parasympathomimetic) agent used for miosis during surgery.'
Cyclopentolate 1 9'0 ophthalmic solution (Cyclogyl)
A cycloplegic medication that dilates the pupil and inhibits focusing of the eye; aids in refraction procedures.*
Flurbiprofen sodium 0.03% ophthalmic solution (Ocufen)
A topical, nonsteroidal, anti-inflammatoryagent that inhibits intraoperative m i ~ s i s . ~
Lidocaine 1 Yo (without preservative)
A local anesthetic medication with a duration of approximately 45 to 60 minute^.^
Neomycin, polymyxin B sulfates, and dexamethasone ophthalmic ointment (Maxitrol)
An anti-infective ~teroid.~
Phenylephrine 2.5% (Neo-synephrine)
A mydriatic medication that dilates the pupil but permits the patient to focus.6
Tetracaine 4% ophthalmic solution
A topical anesthesia that has a rapid onset (ie, 5 to 20 seconds) and a moderate duration of action (ie, 10 to 20 minutes).'
Sodium hyaluronate (Healon)
A surgical aid in anterior segment procedures that protects the corneal endothelium, reduces cell loss during surgery, and maintains the chamber shape, ocular volume, and ocular pressure during the procedure.*
NOTES .1. T F Mauger, E L Craig,
ed, Huvener's Oculur Phumucolugy, sixth ed (St Louis: Mosby, 1994). 2. Physician's Desk Reference for Ophthalmology, 22nd ed (Montvale, NJ: Medical Economics Data, 2001). 3. Ibid. 4. Mauger, Craig, Huvenefs Oculur Phumucology. 5. Physician's Desk Reference for Ophthulmology. 6 . M H Meeker, J C Rothrock, Alexander's Cure of the Patient in Surgery 1 lth ed (St Louis: Mosby, 1999) 7. Ibid. 8. Physician's Desk Reference for Ophthulmology.
shield on one eye; limit the number of trips up and down stairs for the first few days; use a laxative if the patient has not had a bowel movement by the third day after surgery; and not put anything (eg, eye drops) into the eye unless instructed to by the surgeon.'" Patients also are instructed to return to the physician's office the next day for an appointmen; ?he patient is instructed to call his or her physician if
pain is not relieved with over-the-counter medicine, he or she experiences nausea or vomiting, or vision suddenly becomes worse." RISKS AND BENEFITS
The benefits of using topical anesthesia outweigh the risks associated with general, retrobulbar, and peribulbar anesthesia. The risks associated with topical anesthesia primarily involve the possibility of destroying the eye if the patient moves suddenly
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during the procedure. Careful evaluation of the patient’s ability to tolerate topical anesthesia and educating the patient preoperatively about the need to remain motionless during the procedure can minimize this risk. Other risks associated with cataract procedures include posterior capsule tears with loss of vitreous fluid, increased intraocular pressure, macular edema, capsule opacification, and intraocular hemorrhage.*2
Nicoladis
immediately postoperatively and have less pain because of the small incision. Additionally, patients do not need sutures, have no bruising, and maintain depth perception because there is no need to patch the eye. A Bettyann Hutchisson, RN,BSN, MSO7: CNOR, is a clinical education consultant in the advanced sterilization products department of Johnson & Johnson, Houston. She was a nurse clinician, perioperative education, at Methodist Hospital at the time this article was written.
CONCLUSION
Cataract surgery has proven to be a successful and reliable solution to cataract formation. With the use of topical anesthesia, patients have better acuity NOTES 1. N S Jaffe, “History of cataract surgery,” Ophthalmology 103 suppl (August 1996) S5-16. 2. “Cataract surgery in the modem era,” American Academy of
Ophthalmology, http://www.aao.org/ aaowebI/Foundation/311-32208.cfm (accessed 17 May 2001). 3. R H Parkinson, Eye, Ear; Nose, and Throat Manualfor Nurses, fitth ed (St Louis: Mosby, 1994) 101-102. 4. Jaffe, “History of cataract surgery,” S5-16. 5. M Anthony, M McBrayer “Ophthalmic surgery,” in Patient Care During Operative and lnvasive Procedures, ed M L Phippen, M P
Wells (Philadelphia, W B Saunders CO,2000) 629-631. 6. J D Fischel, J R Lipton, “Cataract surgery and recent advances: A review,” Nursing Standard 10 (July 3, 1996) 39-43. 7. S Goldberg, Ophthalmology
Carol Broman Nicoladis, RN,BSN, is a nurse clinician and the ORpostanesthesia care unit nurse educator at Methodist Healthcare System, Missouri City, Tex.
Made Ridiculously Simple (Miami: MedMasters, Inc, 1991) 4. 8. K E Rose, “Caring for patients with cataracts,” Nursing Standard 1 1 (Sept 17, 1997) 49-53. 9. Ibid, 49-53. 10. Fischel, “Cataract surgery and recent advances: A review,” 39-43. 1 1. S F Brint, “Refractive cataract surgery,’’ International Ophthalmology Clinics 34 (Fall 1994) 1- 11.
12. D D Garbee, “Phacoemulsification procedures performed with topical anesthesia,” AORN Journal 66 (August 1997) 253-265. 13. J Belardo, D Hoyt, D Dupree, “Making the transition to topical anesthesia,” Journal of Ophthalmic Nursing and Technologv 17 (2) 7276. 14. B P Gallagher, “Anesthesia for the older ophthalmic patient,” Today’s Surgical Nurse 19 (September/ October 1997) 23-27. 15. D D Garbee, “Phacoemulsification procedures performed
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with topical anesthesia,” 253-265. 16. R J Noecker, S F Golightly, “Pharmacology of ocular surgery,” Ophthalmic Nursing and Technology 18 (May/June 1999) 101-108. 17. M H Meeker, J C Rothrock, Alexander’s Care of the Patient in Surgery, 1 Ith ed (St Louis: Mosby, 1999) 645. 18. Noecker, Golightly, “Pharmacology of ocular surgery,” 101-108. 19. Meeker, Rothrock, Alexander k Care of the Patient in Surgety 1 1th ed, 676 20. N Burden, Ambulatory Surgical Nursing (Philadelphia: W B Saunders Co, 1993) 465-467. 2 I . Belardo, Hoyt, Dupree,
“Making the transition to topical anesthesia,” 72-76. 22. S Roman, F Auclin, M Ullem, “Topical versus peribulbar anesthesia in cataract surgery,” Journal of Cataract Refiactive Surgery 22 (October 1996) 1121-1124.