Procedures Intermediate Format Enucleation/Evisceration/Exenteration

Procedures

Intermediate Format

Enucleation/Evisceration/Exenteration

Objectives• Assess the related terminology and

pathophysiology of the eye.

• Analyze the diagnostic interventions for a patient undergoing an enucleation.

• Plan the intraoperative course for a patient undergoing_____________.

• Assemble supplies, equipment, and instrumentation needed for the procedure.

Objectives

• Choose the appropriate patient position

• Identify the incision used for the procedure

• Analyze the procedural steps for enucleation.

• Describe the care of the specimen

Terms and Definitions

• Globe

• Enucleation vs Exenteration vs Evisceration

Definition/Purpose of Procedure

• Removal of the globe of the eye

• Reasons– Intraocular malignant neoplasm– Penetrating ocular wound– Painful blind eye– Extensive damage/disfigurement

Pathophysiology

Surgical Intervention:Special Considerations

• Patient Factors– Pediatric measures: prevention of hypothermia,

communication techniques, distraction

• Room Set-up

• Anesthesia– General anesthesia preferred over local– Retrobulbar injection

Surgical Intervention: Positioning

• Position during procedure– Supine

• Supplies and equipment– Head donut headrest

• Special considerations: high risk areas• Prep: betadine paint from hairline to mouth and from

nose to ear on operative side (avoid in eyes or ears)• Irrigate globe w/NS using bulb syring, from inner to outer

canthus; one gtt of ½ strength povidone-iodine solution may be instilled into eye before irrigation

Surgical Intervention: Special Considerations/Incision

• Special considerations

• State/Describe incision

Surgical Intervention: Supplies

• General• Specific

– Suture– Medications on field

• BSS to moisten eye/irrigate anterior chamber—STSR may be responsible to irrigate cornea w/BSS q 10-15 seconds to prevent drying of tissues

– Catheters & Drains– Retrobulbar Block: 5 mL syringe & 1/1/2 inch

needle

Surgical Intervention: Instruments

• General (Basic): eye speculum &/or lid retractors, muscle hooks, knife handles (#3 and micro-beaver), scissors (Stevens tenotomy, Wescott), forceps (fine and heavy Bishop-Harmon), calipers, needleholders (micro and heavy), irrigating cannula (for BSS use bulb tipped; for instilling intraocular meds/air use 27 g angled blunt)

• Specific: see eye extras; conformers & spheres--prosthetics

Instruments for surgery of globe or orbit

Some other instruments, conformers

Surgical Intervention: Equipment

• General

• Specific– Operative microscope– Bipolar ESU

Surgical Intervention: Procedure Steps Overview

• Traction sutures are placed in upper and lower eyelids

• Conjunctiva is incised

• Eye muscles are severed

• Recti and inferior oblique muscles are anastomosed

• Optic nerve is severed

• Globe is removed

• Sphere is introduced into the socket

• Conjunctiva and Tenon’s capsule are sutured over the sphere

Surgical Intervention: Procedure Steps

• Surgeon places suture (4-0 silk on fine cutter) thru upper eyelid and tags it with fine hemostat.

• Same step at lower eyelid– The above sutures retract the levator muscles away from the area o

of dissection & prevent their injury

• Surgeon makes a 350 degree incision around the cornea in the conjuntiva as close to the limbus as possible. Incision is made w/ # 15 Bard-Parker blade or delicate iris scissors.– This saves as much conjunctiva as possible for closure later on

• Using the iris scissors, the surgeon undermines the conjunctiva and Tenon’s capsule and prepares to sever the recti and oblique muscles from the globe

Fuller p. 591: A. A 350-degree incision is made as close to the limbus as possible. B. Implant sphere is sutured in place

Surgical Intervention: Procedure Steps

• Because the recti muscles will be sutured to the inferior oblique muscle, both muscles are tagged with suture of silk or Dexon, size 4-0 or 5-0.

• The superior oblique muscle is severed and allowed to retract back.

• The surgeon then severs the previously tagged inferior oblique muscle, secures it to the lateral rectus muscle with 4-0 silk suture, and pulls the globe anteriorly (forward).– STSR will have a muscle hook available now.

• Surgeon passes the hook around the globe to ensure that all connections except the optic nerve have been severed.

• Surgeon places a Mayo clamp across the optic nerve 30-60 seconds to effect hemostasis

Surgical Intervention: Procedure Steps• Surgeon removes the clamp and uses curved enucleation

scissors to sever the optic nerve across the area crushed by the Mayo clamp. This frees the globe, which is passed to the STSR for specimen.

• If any intraocular contents have extruded into the socket, they must be cleaned out with irrigant and 4x4 gauze sponges.

• Once the globe is removed, an implant must be placed and sutured to the socket to give it shape. – STSR will have several sizes of implant spheres –usual adult range

is 14-18 mm.

• Surgeon selects the implant and conformer, and the sphere is introduced into the orbit

Surgical Intervention: Procedure Steps

– STSR passes 4-) Dexon to surgeon, with scleral biting forceps.

• Tenon’s capsule is pulled the sphere and sutured in place.• Surgeon sutures the recti muscles to their appropriate

positions on the sphere with 4-0 or 5-0 Dexon. The conjunctiva is closed with 5-0 Dexon.– STSR passes conformer to surgeon

• Silk retraction sutures are removed. Surgeon instills antibiotic ointment.

• Dressing of cotton eye pad is secured with tape.• In 4-6 weeks, a prosthesis may be fitted (not a surgical

procedure).

Fuller p. 591: C. Tenon’s capsule is closed over the sphere.

Counts

• Initial—sponges and sharps

• First closing

• Final closing– Sponges– Sharps

Specimen & Care

• Identified as eyeball rt vs lt

• Handled: routine, etc.

Postoperative Care

• Pressure Patch

• Pain

• Eye drops and oral meds

Complications

Ocular Prosthesis

Resources

• www.steen-hall.com• STST pp. 571-573• Alexander’s pp. 687 – 689• Complete Review for Surgical Technology by

Boegli, Rogers, McGuinness• Lemone & Burke p. 1489• http://insight.med.utah.edu/• http://health.yahoo.com/centers/eye_vision

Which term refers to complete removal of the eye?

a. Vitrectomy

b. Lensectomy

c. Enucleation

d. Evisceration

The procedure involving removal of all orbital contents is called:

a. Enucleation

b. Evisceration

c. Vitrectomy

d. Exenteration

The space between the lens and the iris/pupil is called the:

a. Anterior cavity

b. Posterior cavity

c. Anterior chamber

d. Posterior chamber

A trephine is an instrument used to

a. Make a circular cut

b. Remove a cataract

c. Scrape diseased tissue

d. Coagulate tissue

An opacity of the crystalline lens is referred to as a/an

a. Petergyium

b. Strabismus

c. Chalazion

d. Cataract

The Trigeminal nerve is also known as the

a. Optic nerve

b. Fifth cranial nerve

c. Oculomotor nerve

d. Third cranial nerve

BSS is used intraoperatively to

a. Constrict the pupil

b. Replace vitreous humor

c. Irrigate the cornea

d. Prevent infection

Why is hydroxyapatite used following enucleation?

a. Provide a stent during reconstruction of the lacrimal system

b. Provide a base of support for the artificial eye

c. Replace the cornea

d. Replace the crystalline lens

The operative microscope in opthalmic surgery often uses which objective lens distance?

a. 100

b. 175

c. 250

d. 400

Drapes included in the eye pack are 1. Split sheet 2. Plastic eye sheet 3. Head drape. The order in which they will be used is:

a. 1, 2, 3

b. 2, 3, 1

c. 3, 1, 2

d. 3, 2, 1

Preoperative drops administered were recorded as “Clyclogel gtts ii O.S. q 5 min times 3.” This means:

a. 11 drops of medicine were put in the patient’s left eye five times, 3 mintues apart

b. 2 mL were put in the right eye five times at 3-minutes intervals

c. 2 drops were placed in both eyes three times at 5-minute intervals

d. 2 drops were placed in the left eye three times at 5-minute intervals

The medication which may be added to a local anesthetic to increase absorption and dispersion/spreading is:

a. Sodium hyaluronate (Healon)

b. Hyaluronidase (Wydase)

c. Alpha-chymotrypsin (Chymar)

d. Epinephrine (Adrenalin)

Which drug/solution would be used to constrict the pupil immediately following removal of a cataract?

a. Acetylcholine (Miochol)

b. Methylprednisolone (Depo-Medrol)

c. Tropicamide (Mydriacyl)

d. Tetracaine Hydrochloridae (Pontocaine) 0.5 %

The classification of medications used to dilate the pupil while inhibiting the ability to focus are:

a. Mydriatics

b. Cycloplegics

c. Hyperosmotic agents

d. Miotics

Miotic agents include all of the following EXCEPT:

a. Phenylephrine

b. Acetylcholine

c. Miostat

d. Pilocarpine

Injectable agents for opthamologic anesthesia include all of the following EXCEPT:

a. Xylocaine

b. Wydase

c. Tetracaine HCL

d. Sodium hyaluronidase