PARS PLANA VITRECTOMY, RIGHT

A Case Study on the Operating Room

Presented to

The Faculty of School of Nursing

University of Baguio

In

Partial fulfillment of the

Requirement for the Subject

NCENL06

SUBMITTED TO:

Larry Michelle Pascual, RN

Clinical Instructor

SUBMITTED BY:

Arlene Esilen Carreon

September 2012

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ACKNOWLEDGMENT

I owe my deepest gratitude to the following for the making of this case possible:

First and foremost to our Creator, as source of our life and being, and for reasons too numerous to mention;

To the University of Baguio, for being true to its mission and vision of empowering its students, giving us the chance to develop our skills through experience;

To the Dean, Ms. Jocelyn Apalla, Department Head, Ms.

Helen Alalag, and BSN IV Coordinator, Ms. Minda Bahug for making hospital exposure feasible;

To my clinical instructor, Mr. Larry Michelle Pascual, who’s intellectual, clinical and practical insights and guidance made our hospital duty experience appreciated and valued in all dimensions;

To my parents, for their unending love and support, and for molding me to become the person that I am right now, for the encouragement and words of wisdom they have inculcated in my mind, and the lessons they have taught that help me go on in this part of my journey in life, my deepest gratitude.

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TABLE OF CONTENTS

Chapter Page

Title page...... i

Acknowledgement...... ii

Table of Content ...... iii

Chapter I

Patient’s Profile...... 1

a. Biographic Data

Chapter II

Anatomy and Physiology...... 2 a. Structure of the Chapter III

Pathophysiology...... 15

Chapter IV

Patient’s Preparation...... 26

a. Skin preparation b. Position c. Draping d. Anesthesia used

Chapter V

Discussion of the Procedure...... 28

Chapter VI

Instrumentation ...... 30

Chapter VII

Drug study...... 34

Bibliography

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CHAPTER I

PATIENT’S PROFILE

A. Bibliographical Data

NAME: Patient X

AGE: 66 years old

SEX: Female

CIVIL STATUS: Single

ADDRESS: 122 New Lucban Extension, Baguio City

NATIONALITY: Filipino

RELIGION: Roman Catholic

CHIEF COMPLAINT: Blurred Vision

ADMITTING DIAGNOSIS: Vitreous Hemorrhage, Right eye;

Cataract

FINAL DIAGNOSIS: Vitreous Hemorrhage, Cataract Right eye

secondary to branch retinal vein

occlusion

OPERATION PERFORMED: Vitrectomy, Right Eye

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CHAPTER II

ANATOMY AND PHYSIOLOGY

The anatomy and physiology of the human eye is an important part of body. Any eye problem should be considered an emergency.

Above: Schematic diagram of the Structure of the Human Eye.

1.

Located at the front of each eye in the human body. A

5 watery fluid that fills the chamber called the "anterior chamber of the eye" which is located immediately behind the and in front of the , and also the

"posterior chamber of the eye" which is a very narrow compartment located between the peripheral part of the , the suspensory ligament of the lens, and the .

The aqueous humour is very slightly alkaline salt solution that includes tiny quantities of sodium and chloride ions.

It is continually produced, mainly by the capillaries of the ciliary processes, and drains away into Schlemm's canal, located at the junction of the cornea and

2.

The layer of the eyeball located between the and the .

It is a thin, highly vascular (i.e. it contains blood vessels) membrane that is dark brown in colour and contains a pigment that absorbs excess light and so prevents blurred vision (due to too much light on the retina).

The choroid is loosely attached to the inner surface of the sclera by the lamina fusa. The side of the choroid closest to the centre of the

6 eyeball is attached to the retina.

This transparent innermost layer of the choroid is called Bruch's

Membrane.

The structure of the choroid itself consists mainly of a dense capillary plexus and of many arterioles and venules transporting blood to and from this plexus.

3.

Located in each eye in the human body. It is one of three zones of the (which connects the choroid with the iris).

Contraction and relaxation of the ciliary muscle alters the curvature of the lens. The correct term for the adjustment of the shape of the lens to change the focus of the eye is

"". This process may be described simply as the balance existing at any one time between between two states:

Ciliary Muscle relaxed: The suspensory ligaments attached to the ciliary body that hold the lens in place are stretched, causing the lens to be relatively flat. This enables the eye to focus on distant objects.

Ciliary Muscle contracted: The tension on the suspensory ligaments attached to the ciliary body is reduced allowing the lens to be relatively round. This enables the eye to focus on close objects (near to the eye).

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4. CORNEA

Transparent circular part of the front of the human eyeball. It has an important optical function as it refracts light entering the eye through the and onto the lens (which then focuses the light onto the retina).

The degree of curvature of the cornea varies between individuals and also throughout the life of an individual.

It is more prominent in youth than later in life, when it can become flatter in shape.

The cornea has a complex structure that specialist texts describe in terms of the following layers (from the outside inwards):

1. Several strata of epithelial cells, continuous with those of the ;

2. A thick central fibrous structure called the substantia propria;

3. A homogeneous elastic lamina;

4. A single layer of endothelial cells forming part of the lining membrane of the anterior chamber of the eyeball.

The cornea a non-vascular structure (which means that it does not contain any blood vessels) as the capillaries that supply it with nutrients terminate in loops at its circumerfence. It is supplied by many nerves derived from the ciliary nerves. These enter the laminated tissue of the cornea. It is therefore extemely sensitive.

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5. FOVEA

A small depression forming a shallow pit in the retina at the back of each eye in the human body.

Because it contains a large number of the light-sensitive photo-detector cells called cones, the fovea is the area of greatest acuity of vision.

This means that when an eye is directed at an object, the part of the image of that object formed on the retina that falls onto the fovea is the part of the image that will be perceived in the greatest detail.

The fovea is slightly yellow in apperance and so was first called the "Yellow Spot" or "Macula Lutea" of Sömmerring.

The existance of such an area is only known to occur in humans, the quadrumana (a group of primates comprising apes and monkeys), and some saurian reptiles.

6. HYALOID MEMBRANE

A transparent membrane that encloses the vitreous humour, seperating it from the retina.

In front of the (the area in which the retina terminates as a jagged margin towards the front of the eyeball as it approaches the ciliary body) the hyaloid membrane is thickened by radial fibres and is called the or (another name for the same thing, the zonula ciliaris).

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7. IRIS

The coloured part of the human eye. That is, the anterior surface of the iris has different colours in different individuals and is also marked by lines that converge toward the pupil. However, the posterior (back) surface of this iris has a deep purple tint due to two layers of pigmented columnar epithelium. This pigmented epithelium is usually referred to as the "pars iridica retinae" but is sometimes called simply "" due to the similarity of its colour to that of a ripe purple grape.

It is a thin circular contractile curtain located in the aqueous humour - in front of the lens but behind the cornea. It contains a circular aperture (or "hole") called the pupil and located just to the nasal side of the centre of the iris.

A simple description of the iris is that it is a coloured diaphragm of variable size whose function is to adjust the size of the pupil to regulate the amount of light admitted into the eye. It does this via the pupillary reflex (which is also known as the "light reflex"). That is, when bright light reaches the retina, nerves of the parasympathetic nervous system are stimulated, a ring of muscle around the margin of the iris contracts, the size of the pupil is reduced, hence less light is able to enter the eye.

Conversely, in dim lighting conditions the pupil opens due to stimulation of the sympathetic nervous system that contracts of radiating muscles, hence increases the size of

10 the pupil.

The iris is composed of a series of layers, including:

(1.) Flattened endothelial cells on a hyaline basement- membrane;

(2.) Stroma - consisting of fibres and cells;

(3.) Muscular Fibre - consisting of circular and radiating fibres;

(4.) Pigment - the location of pigment cells differing in different irides;

(5.) Arteries of the iris, and

(6.) Nerves of the Choroid and Iris.

8. LENS

An important part of the structure of the eye. This lens is a transparent structure enclosed in a thin transparent capsule. It is located behind the pupil of the eye and encircled by the ciliary processes - that slightly overlap its edges.

The lens of the eye helps to refract light travelling through the eye (which first refracted by the cornea). The lens focuses light into an image on the retina. It is able to do this because the shape of the lens is changed according to the distance from the eye of the object(s) the person is looking at.

This adjustment of shape of the lens is called accomodation and is achieved by the contraction and relaxation of the ciliary muscle.

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The Structure of the Lens

The capsule of the lens is a transparent, brittle, yet highly elastic membrane.

This capsule is thicker in front of the lens than behind it

The lens itself is a transparent, biconvex body of approx.

9-10 mm diameter and approx. 4 mm from front to back.

The basic structure of the lens is composed of concentric layers.

9. OPTIC NERVE

The route by which information is sent from the eye for processing by the brain. An optic nerve leaves the posterior surface of each eye.

The optic nerve is the second cranial nerve (II), so called because this nerve transmits visual information. Each optic nerve contains approx. one million fibres carrying information from the rods and cones of the retina.

The optic nerves progress from the posterior of the eyeball, into the skull, through the optic chiasma (also known as the optic commissure), the non to the cortex of the occipital lobe on each side of the brain.

10. OPTIC PAPILLA

The Optic Papilla is also known as the . Located on the retina of the eye at which the optic nerve leaves the eye-transmitting signals from the eye to the brain.

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11. PUPIL

Located in the centre of each eye in the human body.

It generally appears to be the dark "centre" of the eye, but can be more accurately described as the circular aperture in the centre of the iris through which light passes into the eye.

The size of the pupil (and therefore the amount of light that is admitted into the eye) is regulated by the pupillary reflex (also known as the "light reflex").

That is, when bright light reaches the retina, nerves of the parasympathetic nervous system are stimulated, a ring of muscle around the margin of the iris contracts, the size of the pupil is reduced, hence less light is able to enter the eye. Conversely, in dim lighting conditions the pupil opens due to stimulation of the sympathetic nervous system that contracts of radiating muscles, hence increases the size of the pupil.

Note that although some animals' are basically structured in a similar way to human eyes, they may appear to be very different.

E.g. Differently shaped of cats compared

with people.

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12. RETINA

The retina is located at the back of the human eye.

The retina may be described as the "screen" on which an image is formed by light that has passed into the eye via the cornea, aqueous humour, pupil, lens, then the hyaloid and finally the vitreous humour before reaching the retina.

The function of the retina is not just to be the screen onto which an image may be formed (necessary but not sufficient), but also to collect the information contained in that image and transmit it to the brain in a suitable form for use by the body.

The retinal "screen" is therefore a light-sensitive structure lining the interior of the eye. It contains photosensitive cells (called rods and cones) and their associated nerve fibres that convert the light they detect into nerve impulses that are then sent onto the brain along the optic nerve.

The retina has a complex structure that specialist texts describe in terms of ten layers labelled (from contact with the vitreous humour, outwards) as:

1. Membrana limitans interna.

2. Layer of nerve-fibers (stratum opticum).

3. Ganglionic layer, consisting of nerve cells.

4. Inner molecular, or plexiform, layer.

5. , or layer of inner granules.

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6. Outer molecular, or plexiform, layer.

7. , or layer of outer granules.

8. Membrana limitans externa.

9. Jacob's membrane (layer of rods and cones).

10. Pigmentary layer (tapetum nigrum).

13. SCLERA

The sclera is the tough white sheath that forms the outer- layer of the ball.

It is also referred to by other terms, including the sclerotic and the sclerotic coat (both having exactly the same meaning as the sclera).

In all cases these names are due to the the extreme density and hardness of the sclera (sclerotic layer). It is a firm fibrous membrane that maintains the shape of the eye as an approximately shape. It is much thicker towards the back/posterior aspect of the eye than towards the front/anterior of the eye.

The white sclera continues around the eye; most of which is not visible while the eyeball is located in its socket within the face/skull. The main area of the eye that is not covered by the area is the front part of the eye that is protected by the transparent cornea instead.

The Structure of the Sclera

The sclera is composed of white fibrous tissue intermixed with fine elastic fibers and corpuscles of flattened

15 connective-tissue. These fibers are grouped together in bundles.

Blood supply to the sclera is via small (but not very numerous) interlinking capillaries.

The nerves connected to the sclera are from the ciliary nerves.

14. VISUAL AXIS

The Visual Axis is one of the axes through the eye that is a useful construct for optical equipment designers and those working with the physics / optics rather than the biology / physiology of human vision.

A simple definition of the visual axis is:

" A straight line that passes through both the centre of the pupil and the centre of the fovea".

15. VITREOUS HUMOUR

The Vitreous Humour (also known as the ) is located in the the large area that occupies approx. 80% of each eye in the human body.

The vitreous humour is a perfectly transparent thin-jelly- like substance that fills the chamber behind the lens of the eye - click for diagram. It is an albuminous fluid enclosed in a delicate transparent membrane called the hyaloid membrane.

There is a canal called the canal of Stilling running

16 through the centre of the vitreous humour from the entrance of the optic nerve to the posterior surface of the lens.

This is filled with fluid and lined by a prolongation of the hyaloid membrane.

16. ZONULA CILIARIS

The Zonula Ciliaris has many other similar names, including the Zonule of Zinn, and simplyZonules. In all cases these terms refer to the part of the of the human eye formed by the change of structure of the hyaloid membrane as it - and the vitreous humour that it contains - moves in front of

(anterior to) the ora serrata - which is the area in which the retina terminates as a jagged margin towards the front of the eyeball as it approaches the ciliary body.

N.B. The distance between the ora serrata and ciliary body is exaggerated on this diagram and the approx. position of the Hyaloid Membrane at the position at which it becomes the Zonules is shown as a

dotted line for emphasis.

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CHAPTER III

PATHOPHYSIOLOGY

Algorithm (assuming diagnosis has already been made).

Reference: RUBEN S T et al. Br J Ophthalmol 1997;81:163-167

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The pars plana is the section of the eye between the retina and the . The retina is the multi-layer of cells in the back of the eye that sends images to the brain; the pars plicata creates the fluid in the front of the eye (aqueous humor). The pars plana has no specific use and is a safe place to place the vitrectomy instruments where there won't be any damage to any tissue.

The vitreous is a normally clear, gel-like substance that fills the center of the eye. It makes up approximately 2/3 of the eye's volume, giving it form and shape before birth.

Certain problems affecting the back of the eye may require a vitrectomy, or surgical removal of the vitreous. After a vitrectomy, the vitreous is replaced as the eye secretes aqueous and nutritive fluids. The vitreous fluid is the clear jelly that fills the back of the eye and presses against the retina. The vitreous is composed mostly of water; however, the vitreous itself is unable to clear itself of any type of debris that might accumulate in the eye, such as blood or substances from inflammatory processes. If enough of these materials collect in the vitreous, vision can be decreased. During a pars plana vitrectomy--named after the part of the eye the instruments are placed in-- the vitreous is removed, along with any debris.

PARS PLANA VITRECTOMY

A vitrectomy may be performed to clear blood and debris from the eye, to remove scar tissue, or to relieve traction on the retina. Blood, inflammatory cells, debris, and scar

19 tissue obscure light as it passes through the eye to the retina, resulting in blurred vision. The vitreous is also removed if it is pulling or tugging the retina from its normal position.

INDICATIONS

Some diseases that can be treated with a pars plana vitrectomy are diabetic , retinal detachments, holes in the retina and vitreous hemorrhage. Diabetic eye disease and retinal detachments can both cause vitreous hemorrhages as well. The vitreous hemorrhage is often given a chance to settle and attempt to reabsorb before surgery is scheduled. The severity of the initial disease before the pars plana surgery gives an indication as to what the level of vision will be after the surgery.

COMPLICATIONS

Along with the usual complications of surgery, such as infections, vitrectomy can result in retinal detachment. A more common complication is high intraocular pressure, bleeding in the eye, and cataract, which is the most frequent complication of vitrectomy surgery. Many patients will develop a cataract within the first few years after surgery.

PROCEDURE

This procedure is usually done as an outpatient procedure.

Either local or general anesthesia can be used during this procedure. At least three instruments are placed in the eye through the pars plana: one to remove the vitreous; another

20 to inject fluid to help the eye maintain its shape while the vitreous is being removed; and one with a light source.

The surgeon uses a microscope to view inside of the eye during the procedure. The eye is filled with a saline solution after all of the vitreous is removed. In some cases, the openings where the instruments were inserted are stitched shut; in others, the incisions don't need stitches and will heal on their own.

RISKS

Some of the risks of pars plana vitrectomy include infection, retinal detachment, increased eye pressure, vitreous hemorrhage and development of a cataract. Cataract is the most common adverse effect after vitrectomy procedures. Less common adverse effects include swelling of the tissue below the retina, a significant change in eyeglasses prescriptions and swelling in the center of the macula. The surgeon takes great care to avoid these outcomes and will also follow the patient closely after the procedure to manage these problems if they do arise.

PARS PLANA VITRECTOMY - THE SURGERY

The retinal surgeon performs the procedure through a microscope and special lenses designed to provide a clear image of the back of the eye. Several tiny incisions just a few millimeters in length are made on the sclera. The retinal surgeon inserts microsurgical instruments through the incisions such as:

 Fiber optic light source to illuminate inside the eye;

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 Infusion line to maintain the eye's shape during

surgery;

 Instruments to cut and remove the vitreous.

Vitrectomy is often performed in conjunction with other procedures such as retinal detachment repair, macular hole surgery, and macular membrane peel. The length of the surgery depends on whether additional procedures are required and the overall health of the eye.

The retinal surgeon may use special techniques along with vitrectomy to treat the retina. Your surgeon will determine if any of these are appropriate for your eye:

Sealing blood vessels - Laser is sometimes used to stop tiny retinal vessels from bleeding inside the eye

Gas bubble - A small gas bubble may be placed inside the eye to help seal a macular hole.

Silicone oil - After reattachment surgery, the eye may be filled with silicone oil to keep the retina in position.

IMMEDIATE POST-OPERATIVE EXAMINATION

The eye is patched after the first postoperative checkup.

This can usually be removed the same evening at bedtime.

Since the anesthesia numbs the lids and temporarily prevents blinking, it is very important to keep the eye patch on until you are able to blink the eye normally.

Begin using drops after the patch has been removed.

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OCULAR DISCOMFORT

It is common to experience some discomfort immediately after the surgery and for several days afterward. This is primarily related to swelling on the outside of the eye and around the . A scratchy feeling or occasional sharp pain is normal.

Ice compresses gently placed on the swollen areas (ice placed inside a resealable plastic bag work well) reduce the aching and soreness. Tylenol is also helpful for minor aching.

If you have a deep ache or throbbing pain that does not respond to Tylenol or other over-the-counter pain medication, please call the office.

Redness is common and gradually diminishes over time. Some patients may notice a patch of blood on the outside of the eye. This is similar to bruising on the skin and slowly resolves on its own.

OTHER PROCEDURES

Because vitrectomy is performed for many different problems and often in conjunction with other eye surgeries, the recovery period varies with the individual. In some cases, such as macular hole surgery, the surgeon may place a gas bubble inside the eye that places gentle pressure on the macula. This may require special head positioning to keep the bubble positioned correctly.

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Dilating drops (red cap bottle) may be prescribed that keep the pupil of the operated eye large, causing be light sensitivity.

POSTOPERATIVE GUIDELINES

Since vitrectomy is often performed along with other procedures, postoperative instructions may vary. Some general guidelines are provided; however, please consult with your surgeon for specific instructions.

Begin using any anti-inflammatory and antibiotic drops prescribed by your physician immediately after your eye patch has been removed.

Wear the plastic eye shield when sleeping for the first 7 days following surgery. The shield should be worn for the first 3 days following surgery when showering.

Avoid bending, stooping, lifting objects over 5 pounds, or any strenuous activity for one week (unless directed otherwise by your physician).

Take Tylenol or gently apply ice compresses to the eye to relieve mild discomfort.

Follow any special instructions given by your physician for head positioning (this is not necessary in all cases).

MACULAR HOLE SURGERY

Macular hole surgery is unique because the outcome is not only dependent on the surgeon's skill, it requires the commitment of the patient afterward.

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During surgery, a gas bubble is placed inside the eye. The bubble puts gentle pressure on the macula and helps the hole to seal. In order to enjoy the benefit of the surgery, it is imperative that the bubble floats against the macula during the critical healing phase. Since the gas rises, this is only possible when the head is in a face-down position. Obviously, it is impossible to remain face-down

100% of the time; however, each moment spent in this position increases the likelihood of successful surgery.

When the bubble is first injected, it nearly fills the eye.

This obstructs vision for the first few weeks following surgery. Over time, the bubble gradually dissolves, and vision improves. As the bubble gets smaller, it sometimes breaks up into several smaller bubbles. This is common and does not pose a problem. The outcome of the surgery cannot be determined until the bubble begins to disappear.

It is important to remain face-down as much as possible for

9-10 days after surgery. While this may seem a bit awkward, there are several things activities that can be done in this position. Many patients read a book or magazine while looking down. The non-operated eye will not suffer from overuse or strain.

Some patients watch television by placing it face-up on the floor. An alternative is to place a mirror in order to see a reflection of the television screen when looking down.

Other activities that can be done while sitting and looking down are perfectly acceptable.

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At times, the positioning may be uncomfortable; but a successfully closed hole and improved vision is well worth the temporary aggravation.

The eye is patched after the first postoperative checkup.

This can usually be removed the same evening at bedtime.

Since the anesthesia numbs the lids and temporarily prevents blinking, it is very important to keep the eye patch on until you are able to blink the eye normally.

Begin using drops after the patch has been removed.

HOW SHOULD THE EYE FEEL?

It is common to experience some discomfort immediately after the surgery and for several days afterward. This is primarily related to swelling on the outside of the eye and around the eye lids. A scratchy feeling or occasional sharp pain is normal.

Ice compresses gently placed on the swollen areas (ice placed inside a resealable plastic bag work well) reduce the aching and soreness.

If you have a deep ache or throbbing pain that does not respond to Tylenol or other over-the-counter pain medication, please call your doctor.

Redness is common and gradually diminishes over time. Some patients may notice a patch of blood on the outside of the eye. This is similar to bruising on the skin and slowly resolves on its own.

Until the gas bubble has cleared, your vision will be very poor. In some cases, it may take several weeks for the

26 bubble to clear completely. You will notice your vision slowly returning as the bubble clears.

While taking the dilating drop (red cap) the pupil of the operated eye will be quite large and you may be light sensitive. This drop makes more room for the gas bubble by keeping the pupil dilated. It also keeps the eye more comfortable.

POST-OPERATIVE INSTRUCTIONS

Following surgery, patients are examined the same day or the following morning.

Keep the eye patched until later in the day when you are able to blink the eye lids normally.

Begin taking medications as directed after the eye patch has been removed.

If you experience aching or soreness immediately after surgery, gently place ice compresses on the eye. Tylenol is also helpful for minor aching and soreness.

Wear the plastic eye shield when sleeping for the first 7 days after surgery. It should also be worn when showering for the first 3 days after surgery.

The eye is most susceptible to infection for the first 7 days after surgery. To minimize the risk, avoid touching, rubbing, or bumping the eye.

Avoid air travel until the gas bubble has completely dissipated from the eye. This is important because the gas expands at high altitudes and could elevate the eye

27 pressure to a dangerous level. Please check with your surgeon to be sure that the bubble is gone before flying.

Most importantly: Keep your head in a face-down position for 9-10 days following surgery. This can be done while sitting or lying down.

Most patients take three different eye drops after surgery.

The eye drops serve several purposes such as: preventing infection, reducing swelling inside the eye, reducing redness, and keeping the eye comfortable. The dilating drop with the red cap keeps the pupil very large and causes light sensitivity. Consult your written instructions for a list of medications and appropriate dosage.

During your follow-up visits, you will receive instructions how to gradually reduce the frequency of the drops and eventually stop them all together.

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CHAPTER IV PATIENT’S PREPARATION

Signed Consent for surgery was obtained. A physical examination was performed along with laboratory tests. The patient was asked and ordered to fast (not to eat or drink anything) for eight hours before the procedure. This was to ensure that she’ll have an empty stomach. Having an empty stomach helps but does not guarantee that vomiting will be prevented. Vomiting can lead to possible aspiration

(breathing in) of stomach contents into lungs. Irritation of the lung and possible pneumonia could result from such an aspiration event. Prescription for pain medication by the attending physician was also given prior to surgery.

Dentures, nail polish, jewelleries were removed from the patient. Moreover, bowel and bladder content evacuation was maintained. Pre- operative orders and preparations were carried out systematically.

A. SKIN PREPARATION

Skin preparation was done aseptically using a gauze with

BETADINE® which contains 7.5% povidone-iodine for microbicidal sudsing cleanser that promptly kills a broad spectrum of pathogens all over the patient’s right eye.

B. POSITION

The patient was positioned in a supine position which is lying on the back; having the face upward and having the palm of the hand or sole of the foot upward.

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C. Draping

The patient was draped aseptically using four towel sheets and a wide lap sheet that covers the entire body of the patient.

D. Anesthesia used

Laryngeal Mask Airway (LMA) was used to sedate the patient.

It is a device for maintaining a patent airway without tracheal intubation, consisting of a tube connected to an oval inflatable cuff that seals the larynx. The LMA was proven to be very effective in the management of airway crisis. Laryngeal mask airway is used in eye surgery to evaluate: 1) the limits of safe handling; 2) the feasibility of its use in long operative procedures, and 3) whether patients with higher anaesthetic risk

(hypertension, asthma, and children) may profit from the

LM. Side-Effects of the LMA include:

• Throat soreness

• Dryness of the throat and/or mucosa

• Side effects due to improper placement vary based on the nature of the placement

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CHAPTER V

DISCUSSION OF THE PROCEDURE

 Insertion of light pipe, vitreous cutter and infusion

line in the right sclera creating 3.5mm from limbus

using 19 gauge needle.

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 Catheterization of sclerotic vessel in the superior

hall of the retina.

 Lens 20 degrees and 30 degrees placed in cornea for

magnification.

 Vitrectomy done at 750 continuous passive motion and

20 millimeter per mercury ampule.

 Parts of conjunctiva and sclera were closed using

vincryl 7-0.

 Corneal slot was opened.

 Intraocular lens 21.5 power with diameter of 5

millimeter inserted and dilated into the bags.

 Note of posterior capsular placement.

 Corneal slot was sutured with nylon 10-0 #2.

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CHAPTER VI

INSTRUMENTATION

 Mayo table- It drapes and carries the instrument for the operation.

 Sterile tow e l - linens placed on the patient or around the field to delineate sterile areas

 Several sterile gauze- used for absorbing fluids as well as dressing and protecting wounds

 Pair o f g l o v e - u s e d d u r i n g a l l p a t i e n t - care a c t i v i t i e s t h a t may i n v o l v e e x p o s u r e to blood and a l l o t h e r b o d y fluid

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 V i t r e c t o m y L e n s S e t - t h e s e c o m p r o m i s e a set of c o n t a c t l e n s e s w i t h c o n c a v e c o n t a c t s u r f a c e a n d c o m e s w i t h a r i n g to hold the c o n t a c t l e n s e s in p o s i t i o n

 Irrigating Vitrectomy Lens Set- it has refractive power of 90 degrees and a field of view of 24 degrees

 Backflush Flute Neeedle with Silicon tip- helps in safe back flushing of the incarcerated tissue during passive aspiration of intra ocular fluids

 Silicon Tip Cannula- with a needle of 20G with a soft automatic removal of intraocular fluids; used in the reposition of retinal folds or breaks.

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 Infusion Cannula- used for infusion during the surgery

 Silicon Oil Injector- used to control injection of the silicon oil into the eye with minimal efforts

 20D Aspheric Lens- provides ultra resolution retinal image with the binocular indirect ophthalmoscope.

 Lens Holder- to the lens in place for easier visualization of the cornea

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 Intraocular lens 21.5 power with diameter of 5 millimeter- it is implanted in the eye used to treat cataracts or myopia

 Surgical Sutures (vincryl 7-0 and nylon 10-0 #2- used

to closed/heal the wound on some parts of conjunctiva

and sclera during the surgery

 Eye Protection/goggles- protective eyewear that is used after surgery to enclose or protect the eye area in order to prevent particulates, infectious fluids, or chemicals from striking the eyes

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CHAPTER VII

DRUG STUDY

DRUG NAME MODE OF ACTION INDICATION/ SIDE EFFECTS/ NURSING CONTAINDICATION ADVERSE EFFECTS CONSIDERATION GENERIC NAME: Irreversibly binds with INDICATION: SIDE EFFECTS: 1.Best when taken glucocorticoid receptors >Reducing >mild stinging with food. Prednisone (GR) alpha and beta for inflammation in the >irritation 2.Never stop taking which they have a high eye. >fluid suddenly. Too much BRAND NAME: affinity. AlphaGR and >To reduce swelling, retention of the or too little may Deltasone BetaGR are found in redness, itching, face (moon be dangerous and virtually all tissues with and allergic face, Cushing's even life CLASSIFICATION: variable numbers between reactions affecting syndrome) threatening. Adrenocortical 3000 and 10000 per cell, the eye. >acne 3.Never skip doses. Steroid depending on the tissue >constipation, 4.Your child should involved. Prednisolone can CONTRAINDICATION: >mood swings see his/her eye DOSAGE: activate and influence >Hypersensitivity to doctor yearly if 2x a day on altered biochemical behaviour of any of the ADVERSE EFFECT: s/he is taking eye 1 drops most cells. The components of the >associated prednisone. steroid/receptor complexes preparation. with cataract 5.If the child is ROUTE: dimerise and interact with >Presence of viral, development ill and has a Topical Ophthalmic cellular DNA in the fungal, tuberculous temperature, (eye drops) nucleus, binding to or other bacterial vomiting and unable steroid-response elements infection. to keep down his or FORM: and modifying gene >Glaucoma her prednisone, Ophthalmic Solution transcription. They induce call child's doctor Or Suspension (eye synthesis of some immediately. drop) proteins, and inhibit synthesis of others.

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DRUG NAME MODE OF ACTION INDICATION/ SIDE EFFECTS/ NURSING CONTAINDICATION ADVERSE EFFECTS CONSIDERATION GENERIC NAME: Contains the 4th generation INDICATION: SIDE EFFECTS: 1.Contact lenses fluoroquinolon >Used for the >Blurred vision, should not be worn Moxifloxacin Moxifloxacin has in vitro treatment of watery eyes, eye while using drug. activity against a wide range bacterial pain/dryness/redn 2.Stop and call the of Gram-(+) and Gram-(-) MO. conjunctivitis (a ess/itchiness Sym doctor if BRAND NAME: It inhibits the topoisomerase bacterial infection ptoms of an hypersensitivity Vigamox II (DNA gyrase) and on the surface of allergic reaction are experienced topoisomerase IV required for the eye)and include: rash, it (rash, itching, CLASSIFICATION: bacterial DNA replication, anterior segment of ching/swelling swelling of the Quinolone transcription repair, and the eye (especially of face/throat, or Antibiotic recombination. The C8-methoxy the difficulty moiety of these also lessens CONTRAINDICATION: face/tongue/throa breathing DOSAGE: the selection of resistant >Hypersensitivity t), dizziness, 3.Avoid 2x a day on mutants of Gram-(+) bacteria or drug allergy to trouble contamination by altered eye 1 compared to the C8-H moiety fluoroquinolones breathing. avoiding contact of drop found in older >Caution should be the tip of the eye fluoroquinolones. used in female ADVERSE EFFECT: dropper with ROUTE: Moxifloxacin’s bulky C-7 patients who are >Ocular anything and by Topical substituent group interferes pregnant or who are discomfort washing hands prior Ophthalmic (eye with the quinolone nursing. (burning or to use. drops) efflux pump mechanism of >For viral or stinging upon 4.Vigamox is a bacteria. Moxifloxacin is fungal infections instillation) solution so it FORM: often bactericidal at of the eye. >Ocular pruritus is not necessary to Ophthalmic concentrations equal shake the bottle Solution(eye to or slightly greater than before instilling drops) inhibitory concentrations. drops.

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DRUG NAME MODE OF ACTION INDICATION/ SIDE EFFECTS/ NURSING CONSIDERATION CONTAINDICATION ADVERSE EFFECTS GENERIC NAME: Mefenamic acid INDICATION: CV: CHF; hypertension; 1.Assess patients who inhibits the > For relief of mild to syncope; tachycardia. develop severe diarrhea Mefenamic Acid enzymes moderate pain in CNS: Dizziness, and vomiting for cyclooxygenase patients 14 y and older headache (up to 10%). dehydration and (COX)-1 and >Inflammation Derma: Pruritus, electrolyte imbalance. BRAND NAME: COX-2 and rashes (up to 10%). 2.Obtain periodic CBC, Ponstan reduces the CONTRAINDICATION: GI: Abdominal pain, Hct and Hgb, and kidney formation of >Hypersensitivity to constipation, function tests. CLASSIFICATION: prostaglandins mefenamic acid; diarrhea, dyspepsia, 3.Discontinue drug CNS Agent; and patients who have flatulence, GI ulcers promptly if diarrhea, Analgesic; leukotrienes. experienced asthma, (gastric/duodenal), dark stools, NSAID; It also acts as urticaria, or allergic- gross hematemesis, ecchymoses, Antipyretic an antagonist type reactions after bleeding/perforation, epistaxis, or rash occur at taking aspirin or other heartburn, nausea, and do not use again. Dosage: prostaglandin NSAIDs; treatment of vomiting (up to 10%). 4.Notify physician if 500 mg/capsule 3x receptor sites. perioperative pain in Hemat: Anemia, persistent GI a day (PRN for It has the setting of coronary increased bleeding discomfort, sore throat, pain); after analgesic and artery bypass graft time (up to 10%). fever, or malaise occur. meals antipyretic (CABG) surgery; active Hepatic: Elevated 5.Do not drive or engage properties with ulceration or chronic liver enzymes (up to in potentially hazardous ROUTE: minor anti- inflammation of either 10%). activities until oral inflammatory the upper or lower GI Miscellaneous: response to drug is activity. tract; preexisting Abnormal renal known. FORM: renal disease function, edema, 6.Monitor blood glucose Ophthalmic tinnitus (up to 10%). for loss of glycemic Solution(eye control if diabetic. drops)

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DRUG NAME MODE OF INDICATION/ SIDE EFFECTS/ NURSING CONSIDERATION ACTION CONTAINDICATION ADVERSE EFFECTS GENERIC NAME: Pilocarpine INDICATION: Most Common- Sweating, 1.It may lead to Pilocarpine is a >To treat high pressure nausea, runny nose, dehydration to the body, tertiary inside the eye due diarrhea, chills, so drink plenty of water BRAND NAME: parasympath to glaucoma or other eye flushing, frequent while taking this Isopto Carpin omimetic diseases (e.g., ocular urination, dizziness, medication. that hypertension). Lowering weakness. 2.It may cause change in CLASSIFICATION: directly high pressure inside the Miscellaneous- Headache, vision in night, so be Cholinergic stimulates eye helps to prevent indigestion, vomiting, careful while driving a Agents cholinergic blindness, vision loss, heartburn, increased car or other dangerous receptors and nerve damage. Used tears, stomach pain, performance. Dosage: in the eyes during certain eye swelling of arms, hands, 3.During acute phases, Eye Drops- causing surgeries and to reverse feet, ankles, or lower the miotic must be Instill 1 or 2 pupillary the effects of drugs used legs, changes in vision, instilled into the drops per eye, 3 constrictio to enlarge the pupil fast or slow heart unaffected eye to to 4 times per n, spasm of (e.g., during an eye beat. prevent an attack of day accommodati exam). Works by causing angle-closure glaucoma. on and a the pupil of the eye to ADVERSE EFFECT: 4.Not for internal use. ROUTE: transient shrink and decreasing the Ocular: Pain and To prevent contaminating Topical rise in IOP amount of fluid within irritation, blurred the dropper tip and Ophthalmic (eye followed by the eye. vision, lachrymation, solution, care should be drops) a fall. browache, conjunctival taken not to touch the CONTRAINDICATION: vascular congestion, eyelids or surrounding FORM: >To patients with superficial keratitis, areas with the dropper Ophthalmic uncontrolled asthma, and vitreous haemorrhage, tip of the bottle. Solution(eye allergic to pilocarpine. increased pupillary drops) block.

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DRUG NAME MODE OF ACTION INDICATION/ SIDE EFFECTS/ NURSING CONTAINDICATION ADVERSE EFFECTS CONSIDERATION GENERIC NAME: With a single drop, the INDICATION: Occasional temporary 1.Patients should Proparacaine onset of anesthesia begins >For topical stinging, burning and be advised to Hydrochloride 0.5% within 30 seconds and anesthesia in conjunctival redness A avoid touching persists for 15 minutes or ophthalmic rare, severe, the eye until the BRAND NAME: longer. practice. > A immediate-type, anesthesia has ALCAINE® The main site of anesthetic topical apparently worn off. action is the nerve cell anesthetic prior hyperallergic corneal 2.Do not touch CLASSIFICATION: membrane where proparacaine to surgical reaction characterized dropper tip to Topical Local interferes with the large operations such by acute, intense and any surface as Anesthetic For transient increase in the as cataract diffuse epithelial this may Ophthalmic Use membrane permeability to extraction. keratitis, a gray, contaminate the sodium ions that is normally ground glass solution. Dosage: produced by a slight CONTRAINDICATION: appearance, sloughing 3.Store in carton Instill 1 drop to depolarization of the >Patients with of large areas of until empty to the eye every 5 to membrane. As the anesthetic known necrotic epithelium, protect from 10 minutes for 5 action progressively hypersensitivity corneal filaments and, light. If to 7 doses develops in a nerve, the to any component sometimes, iritis with solution shows threshold for electrical of the solution. descemetitis has been more than a faint ROUTE: stimulation gradually reported. yellow color, it Topical Ophthalmic increases and the safety Allergic contact should not be (eye drops) factor for conduction dermatitis from used. decreases; when this action proparacaine with 4.A protective FORM: is sufficiently well drying and fissuring eye patch is Sterile Ophthalmic developed, block of of the fingertips has recommended after Solution conduction is produced. also been reported. surgery.

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DRUG NAME MODE OF ACTION INDICATION/ SIDE NURSING CONTAINDICATION EFFECTS/ CONSIDERATION ADVERSE EFFECTS GENERIC NAME: An aminoglycoside INDICATION: Hypersensiti 1.Do not touch Tobramycin+ antibiotic, has actions >The use of a combination vity the dropper or Dexamethasone similar to that of drug with an anti-infective reactions, tube opening to gentamicin and is active component is indicated where lid itching any surface, BRAND NAME: against Staphylococci, the risk of superficial and including your TobraDex ST Streptococci, Pseudomonas ocular infection is high or swelling, eyes or hands. aeruginosa, Escherichia where there is an conjunctival The dropper or CLASSIFICATION: coli, Klebsiella expectation that potentially erythema, tube opening is Eye Antiseptics pneumoniae, Enterobacter dangerous numbers of increase in sterile. with aerogenes, Proteus bacteria will be present in intraocular 2.If it becomes Corticosteroids mirabilis, Morganella the eye. pressure, contaminated, it morganii, most Proteus glaucoma, could cause an Dosage: vulgaris strains, Haemoph CONTRAINDICATION: optic nerve infection in the 1or2 drops ilus influenzae andH. Epithelial herpes simplex damage, eye. instilled into the aegyptius, Moraxella keratitis (dendritic posterior 3.Do not use any conjunctival sac(s) lacunata, Acinetobacter keratitis), vaccinia, subcapsular eye drop that is every 4-6 hours calcoaceticus and varicella, and many other cataract discolored or has some Neisseria species. viral diseases of the cornea formation particles in it. ROUTE: Dexamethasone, a and conjunctiva. and delayed 4.Store at room Topical Ophthalmic synthetic fluorinated Mycobacterial infection of wound temperature away (eye drops) corticosteroid, has the eye. Fungal diseases of healing. from moisture and mainly glucocorticoid ocular structures. heat. Keep the FORM: activity and suppresses Hypersensitivity to a bottle or tube Ophthalmic Solution inflammatory response. component of the medication. properly capped.

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DRUG NAME MODE OF ACTION INDICATION/ SIDE EFFECTS/ NURSING CONTAINDICATION ADVERSE EFFECTS CONSIDERATION GENERIC NAME: Tropicamide INDICATION: CV: Angina; arrhythmias; 1.To instill Tropicamide + binds to and To induce mydriasis bradycardia; CV collapse ophthalmic solution, phenylephrine blocks the (dilation of the with hypotension; fatal tilt patient's head hydrochloride receptors in pupil) and cycloplegia subarachnoid hemorrhage; back, hold dropper the muscles of (paralysis of the hypertension; MI; syncope; over eye, drop BRAND NAME: the eye ciliary muscle of the tachycardia. medication inside Tropicacyl (muscarinic eye) in diagnostic CNS: Anxiety; CNS lower lid, and apply receptor M4). procedures, such as depression; convulsions; pressure to inside CLASSIFICATION: Tropicamide measurement of dizziness; excitability; corner of eye for 2 Mydriatic and acts by refractive errors and fear; hallucinations; to 3 min. 2.Take care Cycloplegic blocking the examination of the headache; insomnia; not to touch dropper Agents responses of of the eye. nervousness; pallor; to eye. the iris restlessness; tremor; 3.Prolonged exposure Dosage: sphincter CONTRAINDICATION: weakness. of ophthalmic 5 drops every 5 muscle to the Hypersensitivity to EENT: With ophthalmic and solution to air or minutes for 5 iris and any component of the intranasal forms: blurring strong light may doses ciliary muscles products, potassium of vision; rebound cause oxidation and to cholinergic guaiacolsulfonate, or congestion; transitory discoloration. ROUTE: stimulation, to sympathomimetic stinging on initial 4.Do not use if Topical producing amines; severe instillation. solution is Ophthalmic dilation of the hypertension; GI: Nausea. discolored or cloudy pupil and ventricular Genitourinary or contains FORM: paralysis of tachycardia; Dysuria; urinary precipitate. Ophthalmic the ciliary pheochromocytoma; retention. 5.Heavily pigmented Solution muscle. Respiratory irides may require Respiratory difficulty. larger doses.

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