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The Way We Were the New Style Always Get an Informed Consent Always Ask About Allergies!

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The Way We Were the New Style Always Get an Informed Consent Always Ask About Allergies! 6/3/2019 The Way We Were The Expanding Optometric Scope: 1045-02-.12 PRIMARY EYE CARE PROCEDURES. For the Minor Surgical Procedures purpose of 1993 Public Acts Chapter 295 • The performance of primary eye care procedures rational to the Needles, Blades and Radio ‐ Waves treatment of conditions or diseases of the eye or eyelid is determined by the board to be those procedures that could be performed in the optometrist’s office or other health care facilities that would require no more than a topical anesthetic. Laser Jason Duncan, OD, FAAO surgery and radial keratotomy are excluded. • Authority: T.C.A. §§4-5-202, 4-5-204, 63-8-12, and Public Diplomate, American Board of Optometry Chapter 295, Acts of 1993. Administrative Associate Professor, Southern College of Optometry • History: Original rule filed February 14, 1993; effective April 30, 1994. The New Style • An optometrist who uses a local anesthetic in the manner allowed by this subsection shall provide to • The use of a local anesthetic in conjunction with the primary care the board of optometry proof that the optometrist treatment of an eyelid lesion; provided, however, no optometrist has current CPR certification by an organization shall use a local anesthetic for this purpose unless that optometrist has met the certification requirements set forth in 63‐8‐112(4) and approved by the board; provide, that the optometrist in the rules of the board of optometry for the administration of may meet this requirement by providing proof to the pharmaceutical agents in the performance of primary eye care procedures. board that another person who has current CPR • Nothing in this subdivision shall be construed as allowing an certification will be present in the office of the optometrist to perform any reconstructive surgical procedure on optometrist at all times that a local anesthetic is used the eyelid. by the optometrist in conjunction with the treatment • Nothing in this subdivision shall be construed as allowing an of an eyelid lesion. optometrist to perform any procedure not approved by the board of optometry prior to the enactment of this subdivision. • Compliance with this provision shall also require that the optometrist maintain in the optometrist’s office an AED at all times that a local anesthetic is administered by the optometrist. Always Get an Informed Consent Always Ask About Allergies! • Description of the diagnosis • Description of all available management options • Description of risks (with likelihood of occurrence) • Description of potential benefits • State who will perform the procedure 1 6/3/2019 OSHA in 5 Slides… 2 • Personal Protective Equipment • Standard Precautions – Specialized clothing or equipment worn by an – Developed by the CDC and accepted by OSHA employee for protection against a hazard – All blood, body fluids, secretions, excretions, mucous membranes, non – intact skin and soiled items are potentially infectious • Excludes sweat 3 4 • Sharps • Latex? – Any items capable of piercing skin • Nitrile? – Must be placed in OSHA compliant sharps container • Closeable, puncture – resistant, leak – proof • Neoprene? on sides and bottom • Accessible, maintained upright, and not • Vinyl? allowed to overfill • Labeled or color coded • Powdered? • Colored red/labeled with the biohazard symbol • Sterile? • Labeled in fluorescent orange/orange – red with lettering and symbols in contrasting color http://www.cdc.gov/sharpssafety/resources.html 5 Be • Biohazard/Biomedical Waste Prepared • Regulated wastes, other than sharps, that contain blood, fluid, or tissue which may transmit disease must be disposed of in red biohazard bags 2 6/3/2019 Quick Needle Review… Calibratio ns lock tip plunger bottom ring top ring shaft bevel hu b Gauges Safety • Easiest to withdraw medications from vials with smaller gauge needles (larger lumens) • 20g easier to draw with than 27g http://www.bd.com/hypodermic/products/integra http://www.p‐ wholesale.com/upimg/10/48a1/disposable‐ syringe‐898.jpg My Weapon of Choice The Draw 3 6/3/2019 Types of Injections • Intradermal • Infiltrative/Subcutaneous • Intralesional • Subconjunctival • Intramuscular • Intravenous – Requires the most training with regard to technique – Fastest acting delivery method • Retrobulbar Intradermal Injections Infiltrative/Subcutaneous Injections • Mainly used for diagnostic purposes • Focal subcutaneous infiltration of the eyelid – Shallow injection into loose connective tissue • Use of local anesthetic to block impulses of the nerves • 25 – 27 gauge needle Ethnomed.org Atlas of Primary Eyecare Procedures Infiltrative/Subcutaneous Injections: Infiltrative/Subcutaneous Injections: Medications Medications • Lidocaine: – Stabilizes the neuronal membrane by inhibiting the ionic fluxes required for the initiation and conduction of nerve impulses • Epinephrine: – Promotes hemostasis – Decreases the rate of systemic absorption – Increases anesthesia duration Based on Table from Achar S and Kundu S. Priniciple of office anesthesia: part I. Infiltrative anesthesia. Am Fam Physician. 2002 Jul 1;66(1): 4 6/3/2019 Potential Adverse Effects Potential Adverse Effects • Contraindicated in patients with a known history of • Cardiovascular manifestations are usually depressant and are hypersensitivity to local anesthetics of the amide type characterized by bradycardia, hypotension, and cardiovascular collapse, which may lead to cardiac arrest. • CNS manifestations may be characterized by • The administration of local anesthetic solutions containing lightheadedness, nervousness, apprehension, euphoria, epinephrine or norepinephrine to patients receiving monoamine confusion, dizziness, drowsiness, tinnitus, blurred or double oxidase inhibitors or tricyclic antidepressants may produce severe, vision, vomiting, sensations of heat, cold or numbness, prolonged hypertension. twitching, tremors, convulsions, unconsciousness, respiratory depression and arrest • Concurrent administration of vasopressor drugs with epinephrine is CI. • Drowsiness following the administration of lidocaine HCl is usually an early sign of a high blood level of the drug and • The intramuscular injection of lidocaine HCl may result in an may occur as a consequence of rapid absorption. increase in creatin phosphokinase levels. Infiltrative/Subcutaneous Injections: Technique • 1 ml syringe • Pull skin slightly taut •Indicated for the production of topical anesthesia of accessible mucous • 27g, ½ inch needle • Introduce the needle, membranes of the oral and bevel up nasal cavities. • Asepsis •Good for off label, deeper • Inject the medication anesthesia of the conjunctiva • Medication draw • Apply pressure post ‐ injection Papilloma Photo: Jason Duncan, OD, FAAO Papilloma Chalazion Epidermoid Cysts http://www.leeeyecenter.com/e Photos: Jason Duncan, OD, FAAO yelid‐cancers‐lesions.htm Photo: Jason Duncan, OD, FAAO 5 6/3/2019 Chalazion Epidermoid Cyst Photos: Jason Duncan, OD, FAAO Photos: Jason Duncan, OD, FAAO Hidrocystoma Cyst of Zeiss Photos: Jason Duncan, OD, FAAO http://austinmccormick.co.uk/Minor‐eyelid‐ lesions.html http://www.leeeyecenter.com/eyelid‐cancers‐ lesions.htm Kanski Conjunctival Lymphangiectasia Conjunctival Concretions 6 6/3/2019 Infiltrative/Subcutaneous Injections: …nor this. When not to inject… Photo: Jason Duncan, OD, FAAO Photo: Jason Duncan, OD, FAAO Malignancies Malignancies BCC • Typical signs of malignancy? – Ulceration – Color change – Size change • Chalazia recurring in the same location should be suspected as being: SEBACEOUS CELL CARCINOMA • BCC is most common eyelid malignancy while http://www.bopss.co.uk/public‐information/common‐ squamous cell carcinoma is more invasive conditions/eyelid‐tumours/ Malignancies Malignancies SqCC SCC http://austinmccormick.co.uk/Minor‐eyelid‐lesions.html https://www.reviewofophthalmology.com/article/management‐of‐ eyelid‐malignancies Photo: Jason Duncan, OD, FAAO 7 6/3/2019 Dermolipoma Molluscum Photo: Jason Duncan, OD, FAAO http://www.eyesurgeryinberkshire.co.uk/inf ormation_ae/ae_benign_eyelid_tumours.ht ml Radiofrequency Basics Radiofrequency Basics Photos: Jason Duncan, OD, FAAO Photos: Jason Duncan, OD, FAAO Radiofrequency Basics Radiofrequency Basics • Electrosurgery – passes high frequency current through • The radiofrequency electrode does not tissue, using the tissue as the heating element • Radiofrequency Surgery provide resistance, & it remains cold. The • Cell‐specific interaction enables extremely precise tissue provides the resistance. dissection with surrounding tissue preservation • Electric field causes vibration of water molecules in tissue • Incision without applying pressure – Higher power = more violent vibration – Simultaneous hemostasis – Vibration causes heat buildup between molecules – Artifact reduction in biopsy vs. electrocautery – Once enough heat, water vaporizes to steam, which • Depending on rate of heating, either: – Ability to bend or shape the cutting electrode for • Explodes the cell = CUT anatomical variation or working in cavities • Desiccates (dries) the cell = COAG – Produces scarring ≤ scalpel or laser incisions 8 6/3/2019 Radiofrequency Basics Radiofrequency Basics • Precision cutting with minimal applied pressure • Cut • Versatility for both surgical & non ‐ ablative – 90% cut and 10% coagulation procedures. • Micro – smooth cutting and negligible lateral heatr • Cut/Coag • Minimal lateral heat, minimal charring effect – 50% each cut and coagulation • Allows for readable histological results • Cutting with simultaneous hemostasis • Provides a clear
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