surgical ophthalmology

8/7/2019 SURGICAL OPHTHALMOLOGY

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Surgery is increasingly needed to treat

the major causes of preventable

blindness.

For surgery we need to follow basic surgical

principles.1.Knowledge of basic science

2.Surgical technique

3.Practical surgical skill


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SURGICAL TECHNIQUES

1.Sterility and prevention of infection

2.Correct handling of instruments

3.Basic surgical method4.Haemostasis

5.Wound closure and sutures


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There are 2 Suture types

1.Absorbable-eg Cat gut, collagen and vicryl

For deep structures.

2.Non absorbable-eg Silk, NylonTo close skin.

Follow tight knot not tight suture principle.

NB ,For extra ocular surgery 4-0 & 6-0 are used.


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EYE SURGERY HAS 2 DIVISIONS

A.Extraocular Surgery- On eye lid ,conjunctiva.

B.Intraocular Surgery-on the eye ball.

Has limited recovery and poor tolerance forsecond surgery.


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OR PROCEDURES & EOUIPMENT

Infection sources in OR are,

1.From the patient

2.Staff-poor scrubbing , no touch techniqueforgotten.

3.OR equipment- poor sterilization ,flies etc.


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SAFE SURGERY NEEDS

1, Correct patient preparation.

2, Sterilization.

3, Correct handling of instruments & dressingsNo touch technique


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Methods of sterilization and

disinfection1. Autoclave /sterilizes/ -safest most reliable.

- 134-138 degrees at 3 min

- 126-129 degrees at 10 min-121-123 degrees at 15 min


2. Dry heat oven /sterilizes/-Preserves sharps better.

- for 1 hr at 180 degrees/for 2 hr at 170 degrees


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3. Boiling /disinfects/-cheap ,quick and simple

Disadvantage- corrosion.

4. Immersion in chemicals/disinfects/,-eg Chlorehexidine& Cetrimide/SAVLON/,

Povidone Iodine 10%,

Formalin vapor

-Preserves sharps.

-Disadvantage-Toxic, can lose potency.


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Surgery of the Eye Lids

Know the anatomy

NB-Important features of lid,

-Thin mobile elastic skin.-Edema in subcutaneous tissue as there is no fat.

-Good blood supply.

-Good for graft.


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Rules to follow in eye lid surgery

Make horizontal incision along skin crease.

Lower lid vertical incision to prevent contraction.

The Gray line-less bleeding.

Use Adrenalin 1:100,000 in local anesthesia. Local infiltration just under the skin/+/- topical in

the conjunctiva.

Avoid post op bleeding by firm pad and bandage.

Use lid guard. Close skin and conjunctiva & no knot on

conjunctiva side.


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Anesthesia of the eye

1.GA

2.LOCAL

Local anesthesia achieved in3

ways1.Topical drops-Amethocaine 1 %,Cocaine 4 %.

2.Local infiltration-Lignocaine 1% & 2%.

3.Nerve block-for intraocular surgery.

-Blocks sensory and motor function.


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AIM OF NERVE BLOCK

1.Anaesthesia of the eye.

2.Paralysis of Eom.

3.Paralysis of orbicularis occuli.

4.Blocking vision

Thus we need to combine 2 nerve blocks,

a.Facial &

b.Retrobulbar/ Sub- tenonWe use LIGNOCAINE 2 %/ BUPIVACAINE 0.5 % with

Adrenalin & Hayaluronidase.


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FACIAL BLOCK

A) O Brien division of the nerve around the

neck of mandible.It is not used nowadays.

B) Van lint method

paralysis of orbicularisocculi by local infiltration around orbit.

Given close to the bone under orbicularis as

motor nerves enter the muscle on its deep

side.


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RETROBULBAR BLOCK

- With in muscle cone.

- 2nd, 3rd, 6th & branches of 5th cranial nerve.

- 4th nerve not involved.AIM

1) No sensation

2) No movement3) No vision


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METHOD

a) 3-5ml of 2% lignocaine with 26 G ,50mm needle.

b) Given 30 mm deep to skin.

c) 1/3 away from lateral end of eyelid.d) Push your needle 15 mm straight back.

e) Then push15 mm upward to opposite occiput.

f) Check for blood.g) Stick to the rule of no movement!


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g) Apply 5-10 minute hand pressure!

A

VOIDA

BLE

COMPLI

CATION

SOF

RETROBULBAR ANAESTHESIA

a) Inaequate anaesthesia & akinesia.

b) Retrobulbar hemorrhage.

c) Injection into vessel & CSF.

d) Injection into the eyeball .


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e) Neurologic damage.

f) Toxic reaction.

OTHER

NERV

EB

LOCKS

There are two nerve blocks other than retro bulbar.

1) Sub- Tenon block extremely safe, uses blunt

cannula, injected directly to retro bulbar space.

METHOD-

Apply local anesthetic drop to conjunctiva.


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- Speculum inserted.

- Patient looks upward & outward.

- Incision made in the conjuctiva & tenoncapsule in the inferomedial quadrant 5-6 mmfrom the limbus.

- Blunt cannula is pushed backward round the

eye with the tip touching the globe all theway.

- Injection given after checking for blood & CSF.


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2) Peribulbar block

- Extremely low complications compared to retrobulbar block.

- Injection is in the periorbital region.

- There is no need for facial nerve block asanesthesia diffuses out of the orbit to orbicularisocculi muscle.

- Less risk of injection to CSF or causing neurologic

damage.- Same risk of retro bulbar hemorrhage, injectionto eyeball or blood vessel.


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- Needs 2 injections.

- Needs longer time to work.

- Brings proptosis.- Given via conjunctiva outside the muscle

cone.

- Works by slow spreading in to the retro bulbarspace.


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METHOD

1) Use 10 ml, 23 G fine needle

2) Lower fornix, lateral to midline.

3) 25mm back to equator, 5ml injection givenafter checking for blood,

4) 2nd injection 4ml via caruncle medially to the

nose . Check for eye movement not to passmuscle cone.

5) Apply pressure for 5 minutes.


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disinfection

1. Autoclave /sterilizes/ -safest most reliable.




2. Dry heat oven /sterilizes/-Preserves sharps better.



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PRINCIPLES OF INTRAOCULAR

SURGERY1) Magnification & illumination

2) Prevention of tremor

3) Prevention of infection

4) Surgical access

5) Haemostasis

6) Protecting corneal endothelium

7) Avoiding damage to the lens

8) Handling iris


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9) Management of vitreous

10) Wound closure

11) Reducing post operative inflammation

CATARACT SURGERY

a) History of cataract surgeryb) Restoring focus after surgery / spectacles

c) Indication for surgery


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4) Choice of operation

5) ECCE & ICCE / SICS, phakoemulsification

6) IOL types, ACIOL/ PCIOL.7) Routine post op care.

8) Post op complications & how to manage

them.


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SIDE EFFECT OF + 10 SPECTACLES USED

FOR APHAKICS

1) Distortion

2) Magnification ( 1/3 x)

3) Prismatic effect4) Discomfort

5) Aniseikonia


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INDICATIONS FOR CATARACT SURGERY

1) Is IOL planned/After biometry.eg for myopessmall power lens or sometimes aphakia may bechosen.

2) How bad is the cataract.

3) What kind of vision does the patient need. E.gGlare of PSC cataract

4) Is there evidence of other disease in the sameeye?

5ps pressure/pupil/projection/posterior part ofthe eye/pinhole.


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5) What is the condition of the other eye.

6) What facilities are available.

CHOI

CE

OF

OPE

RATION

a) ECCE- The anterior capsule opened and cortex andnucleus removed and posterior capsule remainsintact.

ADVANTAGE

1) Better fixation for IOL2) Less cystoid macular edema

3) SICS 4) Less risk of disturbing vitreous


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DISADVANTAGE

1) Needs coaxial illumination & operatingmicroscope

2) Posterior capsular thickening

3) More post op uveitis

b)ICCE /Removal of the entire lens.

ADVANTAGE

1) No microscope needed2) No posterior capsular thickening

VISION BY ACIOL / OR +10 LENS


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DISADVANTAGE

1) High risk of cystoid macular edema

2) Larger incision with astigmatism

3) IOL related complication esp. ACIOL ,UGH

uveitis, glaucoma, hyphaema.

4) Vitreous loss with its complications

STEPS OFECCE

1) Starting the incision after peritomy and cautery.2) Capsulotomy after A/C entry.

3) Hydro dissection of the lens.


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4) Completing the incision.

5) Expressing the nucleus.

6) Irrigation / aspiration of the remaining cortex.7) Inserting the IOL.

8) Wound closure & final irrigation/ aspiration


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THEFOUR MAINCOMPLICATIOS OF

VITROUS LOSS

1) Retinal detachment

2) Cystoid macular edema

3) Poor wound healing

4) An up drawn pupil

POST OP COMPLICATIONS

1) EARLY

- Poor wound closure

- Aqueous leakage


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- Iris prolapse

- Striate keratopathy

- Hyphaema

- Infection

- Iridocyclitis

- Pupil block and malignant glaucoma

2)LATE

- Retinal detachment


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- Cystoid macular edema

- Corneal edema & bulous keratopathy

- Thickening of the posterior lens capsule- Glaucoma

- Chronic uveitis

- infection


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ENDOPHTHALMITIS

TYPES

1/ Early-in the first 48 hours-2 weeks.

2/ Late- > 2 weeks.


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Features of post op Endophthalmitis

1.Pain & photophobia.

2.Reduced vision.

3.Swollen eye lids.

4.Chemosis and circum corneal injection.

5.Mucopurulent conjunctival secretion.

6.Hazy cornea.

7.Turbid anterior chamber with protein and cellsforming hypopyon.

8.RAPD. 9 . Soft eye.


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Treatment

Antibiotic covering G+ ,G-

1.Injection in to the vitreous is the best.

Vancomycine,Amikacin or ceftazidime +/-

Gentamycine.Only 0.1 ml given.

2.Systemically,Ciprofloxacin and cephalosporin orAmpcillin and Flucloxacillin.

3.Topically,Chloramphenicol/Gentamycin/Cephalosporins.

4.By subconjunctival injection.


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For Endophthalmitis

-Steroids are used but wisely.

-Mydriatics.

POSTOP INFECTION IS ANEMERGENCY!!


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disinfection

1. Autoclave /sterilizes/ -safest most reliable.




2.D

ry heat oven /sterilizes/-Preserves sharps better.



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NB, In OR resuscitation devises should be availablefor GA and nerve block.

In retro bulbar block ,anaesthesia comes before

akinesia.If there is retro bulbar hemorrhage the eye mayundergo proptoses and be stony hard. Thus weshould

1.Give Diamox.

2.Do Lateral canthotomy.

3.Use lubricant 4.Postpone surgery and follow .


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SICS

Doesn't use stitches.

Water tight scleral wound constructed.

KERATOM & CRESCENTused.

Refer to instruments for each step. NB, The surgery for children is lens aspiration and

anterior vitrectomy to prevent posterior capsular andanterior vitreous opacification.

Use of systemic steroid and short acting midriatics is

vital. Eight week antibiotic Chloramphenicol 0.5 %, and

steroid Maxidex 0.1 % with +/- short acting Midriatics.


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TRABECULECTOMY

Surgery to lower intraocular pressure.

Excision of trabecular meshwork after half thicknessscleral dissection.

Peripheral iredectomy done.

Fluid drains to sub-conjunctivalspace.

Post op complications

1.Flat A/C due to button-holing of scleral flap or loosesuturing. Common after use of

antimetabolites/cytotoxics i.e 5-FU or MMC. 2.Hyphaema

3.Endophthalmitis 4.cataract formation


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DACRYOCYSTORHINOSTOMY/DCR

Lacrimal sac is anastomosed to the nasal

mucus membrane .

Done by removing part of the lacrimal crest

and all the thin bone separating the lacrimal

sac from the middle nasal miatus.

Success rate of 90 %.


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STRABOTOMY

Surgery on the muscles of the eye to correct

strabismus.

Resection/ to strengthen.

Recession / to weaken.


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The destructive surgeries

1/Enucleation-removal of the intact globe bycutting the optic nerve and extra ocularmuscles.

2/Eviceration-removal of the content of theglobe leaving the sclera and optic nerve intact.

Indications

a/ Malignant tumor b/ Blind painful eyec/ Ugly eyes/staphyloma d/ Endophthalmitis

e/ Following a penetrating injury.


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Either can be used but-

ENUCLEATEFOR SUSPECTEDTUMOR ANDFORTRAUMATISEDEYETOPREVENTTUMOR SPREADANDSYMPATHETIC OPHTHALMITIS !!

Best if enucleation is done within 2 weeks. EVISCERATEFOR ENDOPTHALMITIS.

Sympathetic ophthalmitis-is rare bilateral eyeinflamation after penetrating injury involving uvea.

Traumatic eye excites with redness and irritability andsympatising eye has photophobia and blurred vision.

Treated with topical,subconjunctival and systemicsteroids.


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RETROBULBAR ALCOHOLFOR

PAINFULLEYE

Given after 1ml of retro bulbar injection of

2 % lidocaine.

50 % ALCHOL 1-2 ML given.


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EXENTRATION

The entire orbital contents down to the bone

are removed.

For malignant tumors only.

Modified Exentration-preserves one or both

eyelids or part of lid.


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Eye lid Surgery

Anterior Lamella/Skin and Orbicularis muscle.

Posterior Lamella/ Tarsal plate and conjunctiva.

Marginal artery 3mm above eyelid margin.

What is the difference between entropion andtrichiasis.

If only trichiasis with few lashes and no cornealconsequence treatment options are

1.Epilation 2.Cutting the lashes3.Electrolysis 4.Cryotherapy

5. Excision of lash follicles


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Operations for Entropion and Trichiasis

1.Anterior lamellar shortening

2.Posterior lamellar lengthening

3.Splitting the gray line to rotate the lashes forward.

4.Tarsal groving. 5.Tarsal rotation-

- Popular better than the others. Two type.

- a/ Ballen / Bilamelar rotation. With reliable good out

come b/ Trabut operation/ From the conjunctivasurface.

. 6. Tarsal slide


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Surgery for lower lid ENTROPION

1.THE WIES procedure.

2.PENTAGONAL WEDGEEXCISION

FOR SEMINAR PRESENTATION AND GROUPDISCUSSION.


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SURGERY FOR ECTROPION

The Z-plasty

Skin graft.

For seminar discussion

TARSORRHAPHY

Is closing the eyelids with sutures For facial palsy of different causes.eg Leprosy

For long standing corneal ulcer to heal.

a/ Permanent lateral 1/3rd eye lid length. For permanent Facialpalsy.

b/ Temporary to heal corneal ulcer near the center of the lids orlaterally.

MATTRESS SUTURE USED FOR BOTH. Can be lateral and medial.


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Incision and curettage of a

MEIBOMIAN CYST

Local infiltration

Meibomian clamp

Vertical inscision from the conjunctival side into

the tarsal plate.TREATMENTOFEYELIDTUMOURS

1.type tumor

2.site

3. size Excision with lateral cantholysis.

For seminar discussion


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EYELIDINJURY

Cleaning debridement.

Primary repair / with in 48 hours/in 2 layers

against deformity.

Secondary reconstruction/ after 3 months.

NB , CANALICULAR INJURY NEEDS REFERAL.

surgical ophthalmology

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