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Terms and abbreviations
Abrasion-scrapping injury to the skin or a membrane such as the cornea of the eye
Amblyopia-reduced or dimness of vision---??
Canthus-inner or outer corner where the eyelids meet
Crystalline lens- refracts light rays and focuses them on the retina (w/cornea)
Exophthalmia-abnormal protrusion of eye (fr/ thyroid condition or orbital tumor)
Extra-ocular-outside globe of the eye
Glaucoma - e y e d i s e a s e ( ! I O P = o p t i c n e r v e a t r o p h y a n d b l i n d n e s s )
H y p e r o p i a - l i g h t r a y s c o m e t o f o c u s b e h i n d t h e r e t i n a ( f a r s i g h t e d n e s s )
M y o p i a - l i g h t r a y s c o m e t o f o c u s i n f r o n t o f t h e r e t i n a ( n e a r s i g h t e d n e s s )
I n t r a o c u l a r - i n s i d e g l o b e o f t h e e y e
S e n s o r y r e c e p t o r s - rods and cones in the retinal layer
OD oculus dexter = right eye
OS oculus sinister = left eye
OU oculus unitas = both eyes (uterque?)
Retina--- (not incl.) =nervous tunic?
Accommodation (near and far focusing) not incl, check
Anatomy of the Eye
Globe = Eyeball -- Compared to a sophisticated camera -- 1 diameter
Fibrous Tunic: dense connective tissue; protects the retina; 2 layers
Sclera posterior portion of eyeball; extrinsic eye muscles attach to it
Cornea forms anterior 1/3 eyeball, transparent and avascular
Conjunctiva protects exposed part of eyeball and the inner eyelid
Limbus- edge of cornea where it unites with the sclera
Vascular Tunic
Choroid: Pigmented layer, thin and dark; pierced by optic nerve
Provides nutrients/large number of blood vessels
Function to absorb light, reason see black in the pupil
Ciliary body -- says 2 parts, but only 1 is listed
Ciliary muscle holds lens in place, changes lens shape
Iris: Radial/circular smooth muscle with hole in the center (pupil)
Controls size of pupil/amount of light coming in
Nervous Tunic: innermost, contains nerves
Photoreceptor layer which consists of rods and cones
Rods: not in center, but cover the rest of retina; for shape, shades of gray, movement, in dim light, overstim. causes pain.
Cones: Packed in macula lutea (where vision most acute/accurate), indentation is fovea centralis. Sharp vision of shapes, movement, color; requires strong light.
Each cone has one of three pigments: erythrolabe, chlorolabe, cyanolabe. Colorblind means are lacking in one pigment, usually erythrolabe. Total colorblindness means no pigments are present.
Bipolar layer: photoreceptors synapse with bipolar neurons
Ganglia layer: bipolar neurons feed into one ganglia neuron. This is the optic disc or blind spot an area where there are NO photoreceptors
Where retina ends anteriorly is called ora serratus (scalloped region)
Anterior Cavity: From the lens forward, formed in the ciliary body
Provides nutrients, helps bend light
Contains aqueous humor which is watery; drained by canal of Schlemm
too much causes increased IOP (intraocular pressure), untreated causes glaucoma (chronic unmanaged hypertensive patients)
Chambers anterior and posterior, sep. by iris, contain aqueous humor
Posterior Cavity: posterior to lens
Contains thick gelatinous clear fluid called vitreous humor
Keeps eyeball from collapsing, holds retina in place, helps to bend light
Have it all when youre born, cannot produce anymore
Lens: bend/focus light onto the macula lutea; separates ant/post cavities
Orbit: socket that eyeball sits in (also called bony orbit)
Seven bones form the orbit: Frontal, sphenoid, ethmoid, superior maxillary, malar (zygomatic), lacrimal, and palate (see book)
Eye Muscles
Extrinsic Eye Muscles: connect globe to orbit, allow for eye movement
Superior rectus movement up and temporal
Inferior rectus- movement down and nasal
Medial rectus- straight nasal
Lateral rectus- straight temporal
Superior oblique- movement down and nasal
Inferior oblique- movement up and nasal
Intrinsic Eye Muscles: iris and ciliary body/muscle
Lacrimal System
Lacrimal Gland- secretes tears to moisten cornea; upper lateral eyelid
Excretory Ducts: carries fluid to surface
Drains into lacrimal sac, then nasolacrimal duct, then nasal cavity
Nerves and Blood Supply -- p. 664 Alexander
2nd cranial nerve (optic nerve) vision
3rd cranial nerve (oculomotor) 1 motor nerve medial rectus, inferior rectus, superior rectus, and inferior oblique muscles
4th cranial nerve (trochlear) superior oblique
6th cranial nerve (abducens) lateral rectus
Formula to remember LR6(SO4)3 (3=other extraoc. Musc) ???
Ophthalmic artery [carotid] to orbit, globe, muscles, eyelids
Physiology of Vision
Light comes into eye > thru cornea and pupil (regulated by iris) > to the retina > rays stimulate rods and cones > Impulses conveyed to the optic nerve > Optic nerve to the brain > the visual area of the cerebral cortex in the occipital lobe interprets vision
Pathology
Cataracts: opaque lens prevents light passage
Gradual impairment; can cause blindness if untreated
Causes: aging, certain drugs, chemicals, sunlight, disease, congenital
Retinal Detachment: develops around a retinal tear
Small:vitreous pulls away from retina, gets stringy (spots/flashes of light)
Large: vitreous gets into tear under retina, separating it from the choroid, vision is lost where retina detaches, see veil or shadow in that area
Completely detached: all vision is lost in that eye
Corrected by laser or cryotherapy
Vitreous Hemorrhage
With retinal tear, blood vessels torn and vitreous hemorrhage occurs
Vitrectomy must be performed to determine if a retinal tear has occurred
Proliferative Vitreoretinopathy (PVR)
Occurs 5-10% post-scleral buckle (procedure to repair detached retina)
Scarring pulls on retina creating re-detachment
Epiretinal Membrane
Scarring over the macula (area of retina where vision most accurate)
Membrane is removed surgically
Corneal Pathology: clouding of the cornea results in diminished vision
Caused by eye injury, corneal infection, eye surgery, disease
Corrected by corneal transplant (keratoplasty)
Chalazion
Lump in the inner or outer eyelid surface, eyelid red and swollen
Inflammatory reaction to debris trapped in oil-secreting gland of the eyelid
Dacryocystitis
Lacrimal sac inflamed; below eye beside nose is red, swollen, sensitive
Caused by obstruction of the nasolacrimal duct
May have a mucous discharge at inner canthus
Surgery entails opening blockage and treating infection
Strabismus
Misalignment of the eyes due to restrictive or paralytic eye muscles
Cross-eyes (esotropia) / Wall eyes (exotropia)
Corrected by Recession and Resection
Diagnostics & Testing
Visual exam, check for asymmetry
Eye pain, irritation, burning, drainage, redness, vision impairment
Ophthalmoscope exam by physician
History of HTN, diabetes, allergies, medications
Anesthesia: to keep eye completely still and lower intraocular pressure
General (children, selected patients)
Retrobulbar Block
Local
Medications
Most are colorless and you must label to avoid any confusion with identity
Anesthetics: to produce absence of sensation
Xylocaine (Lidocaine) Injectable
Bupivicaine (Marcaine, Sensorcaine) Injectable
Cocaine (4%) Topical
Tetracaine (Pontocaine) Topical
Proparacaine (Alcaine, Ophthaine) Topical
Antibiotics: to prevent/treat infection, injected or topical (drops, ointment)
Garamycin Neosporin Bacitracin
Erythromycin (Ilotycin) Gantrisin Gentamycin
Sulfacetamide Tobramycin
Anti-inflammatories: to reduce inflammation/prevent edema; injected or topical
Steroids NSAIDS
Dexamethasone (Decadron, Maxidex) Ketorolac (Acular)
Betamethasone (Celestone) Diclofenac (Voltaren)
Prednisone (PredForte, PredMild) Flurbiprofen (Ocufen)
Suprofen (Profenal)
Irrigants: irrigate anterior chamber, keep cornea/eye tissue moist, soak/rinse intra-ocular lens
BSS balanced salt solution, Tis-U-Sol balanced salt solution
Lacrilube, Duratears
Lactated Ringers solution
Miotics: contract pupil, reduce intra-ocular pressure, prevent loss of vitreous humor in cataract surgery, maintaining lens placement
Acetylcholine chloride (Miochol)
Carbachol (Miostat)
Pilocarpine hydrochloride (Pilocar)
Mydriatics/Cycloplegics (topical drops): after administration, compress lacrimal sac 2-3 minutes to avoid systemic absorption. These drugs increase IOP (intraocular pressure) and should NOT be given to patients with glaucoma
Mydriatics: dilation of the pupil (mydriasis)
Neo-synephrine (Phenylephrine)
Atropine sulfate (Atropisol)
Cycloplegics: dilate pupil and paralyze iris sphincter muscle
Cyclopentolate (Cyclogyl)
Tropicamide (Mydriacyl)
Vasoconstrictors: prolongs duration of anesthetic; hemostasis, injected or topical.
Epinephrine: typ mixed w/ lidocaine as one solution (ex. Marcaine w/ epi)
Cocaine
Dyes: marks or colors tissue
May be used to diagnose abnormalities (corneal abrasions), locate foreign bodies, see flow of aqueous humor, demonstrate lacrimal system function
Fluorescein sodium
Rose bengal
Viscoelastic Agents: thick jelly like consistency; vitreous substitute
Injected into anterior chamber during cataract surgery to maintain chamber expansion and prevent surrounding tissue damage
May be used for tamponade (compression)
Sodium Hyaluronate (Healon, Amvisc-Plus, Viscoat)
Hydroxypropyl methylcellulose (Occucoat)
Enzymes: catalyst [protein], increases absorption/dispersal of anesthetic
Hyaluronidase (Wydase)
Positioning
Supine, non-operative side arm on an arm board, operative side tucked
Pillow or headrest (may use donut) under head, pillow under knees, heel protectors
Prep
Eyebrows never shaved unless surgeon requests (do not grow back completely)
Trim lashes per surg pref w/ fine scissors, coat w/ petroleum to catch lashes
Eyelids and peri-orbital areas cleaned with non-staining antiseptic
May flush conjunctiva with BSS or benzalkonium chloride
Eyes should be shut during prep may protect with sterile plastic sheet
Draping
Likely have entire face exposed even if surgery is unilateral for comparison
Head drape or towel and medium sheet place under patients head, bring around on either side criss-crossing at hairline or forehead, fasten with clip
Towels around face
Fenestrated eye drape to expose operative eye
Bottom/body sheet for rest of patient
Sterile plastic drapes placed over towels or cloth drapes to prevent lint
Equipment : Check all equipment prior to use
Microscope Argon laser
Diathermy probe/apparatus Bipolar unit
Cryotherapy unit/probe Occutome
Endocoagulator (bipolar or wet-field) Endoilluminator
Instruments
Specialty surgeon microscopic eye trays; otherwise, see book
Supplies
Eye pack, basin set
Disposable eye drape/sterile plastic adhesive drape
Microscope drape
Pre-cut cellulose sticks (weck cells)
Suture 4-0 to 12-0 monofilament nonabsorbable and absorbable (see Table 16-2)
Needles: (see Table 16-1)
Round bodied, round bodied with cutting tip, reverse cutting, spatulated
Beaver blades
Eye patch for dressing
Special Considerations
Lint free towels/drapes
Will function as ST and STFA
Anticipate surgeon needs due to most patients are awake and quiet is preferable
Handle sutures carefully and as little as possible
Take care with delicate instrumentation
Familiarize self with use of all ophthalmic equipment before attempting to use
Meticulously REMOVE powder from gloves to prevent corneal abrasions!
Complications
Infection Scarring
Hemorrhage Retinal detachment
Vision impairment Cataract formation
Retina swelling Glaucoma
Tissue rejection [corneal transplant] Swelling
Purpose of Eye Surgery: preserve or restore vision
Causes of Eye Defects: Congenital -- Injury -- Disease
Ophthalmic Procedures
Strabismus Correction
Adjustable Suture Surgery
Strabismus correction alternative
Scleral Buckle
Retinal detachment surgery, has been done more than 30 yr.
Preferred when no complicating factors (ex. vitreous hemorrhage)
Dacryocystorhinostomy
Assist in tear and secretion drainage into nasolacrimal duct
Done when obstruction related to fibrous tissue or bone is impermeable
Enucleation or Evisceration
Eye removed due to malignant neoplasm, penetrating wounds, or severe eye trauma where vision cannot be restored
Keratoplasty
Corneal transplant
Cataract Extraction
Extracapsular: lens expressed manually or by phacoemulsification [uses ultrasonic energy to break up lens, irrigate and aspirate simultaneously]
Intracapsular: entire capsule removed by forceps, suction, or cryoprobe posterior capsule remains
Vitrectomy
Retinal disorder repair techniques (several); previously inoperable; + 3 } # . / ; W \
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