PARS PLANA VITRECTOMY, RIGHT EYE

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.

TABLE OF CONTENTS

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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 Human Eye

Chapter III

Pathophysiology...................................... 15

Chapter IV

Patient’s Preparation................................ 26

a. Skin preparationb. Positionc. Drapingd. Anesthesia used

Chapter V

Discussion of the Procedure.......................... 28

Chapter VI

Instrumentation .................................... 30

Chapter VII

Drug study.......................................... 34

Bibliography

CHAPTER I

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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: Pars Plana Vitrectomy, Right Eye

CHAPTER II

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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. AQUEOUS HUMOUR

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

watery fluid that fills the chamber called the "anterior

chamber of the eye" which is located immediately behind

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the cornea and in front of the lens, and also the

"posterior chamber of the eye" which is a very narrow

compartment located between the peripheral part of

the iris, the suspensory ligament of the lens, and the

ciliary processes.

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. CHOROID

The layer of the eyeball located between the retina and

the sclera.

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

eyeball is attached to the retina.

This transparent innermost layer of

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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. CILIARY MUSCLE

Located in each eye in the human body. It is one of three

zones of the ciliary body (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

"accommodation". 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).

4. CORNEA

Transparent circular part of the front of the human

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eyeball. It has an important optical function as it

refracts light entering the eye through the pupil 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 conjunctiva;

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.

5. FOVEA

A small depression forming a shallow pit in the retina at

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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 ora serrata (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 Zonule of Zinn or (another name for the same thing, the

zonula ciliaris).

 

7. IRIS

The coloured part of the human eye. That is, the anterior

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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 "uvea" 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

the pupil.

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

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(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;

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.

The Structure of the Lens

The capsule of the lens is a transparent, brittle, yet

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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.

The Optic Papilla is also known as the Optic Disc. Located

on the retina of the eye at which the optic nerve leaves

the eye-transmitting signals from the eye to the brain.

10. OPTIC PAPILLA

11. PUPIL

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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' eyes are

basically structured in a

similar way to human

eyes, they may appear to

be very different.

E.g. Differently shaped

pupils of cats compared

with people.

12. RETINA

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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. Inner nuclear layer, or layer of inner granules.

6. Outer molecular, or plexiform, layer.

7. Outer nuclear layer, or layer of outer granules.

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8. Membrana limitans externa.

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

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 globe 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

connective-tissue. These fibers are grouped together in

bundles.

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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 Vitreous Body) 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

through the centre of the vitreous humour from the entrance

of the optic nerve to the posterior surface of the lens.

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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 pars plicata. 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

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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 eye disease, 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

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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 eyelids.  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

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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 pressure

27

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

30

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.

31

Catheterization of sclerotic vessel in the superior

hall of the retina.

32

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.

CHAPTER VI

INSTRUMENTATION

Mayo table- It drapes and carries the instrument for

the operation.

33

S t e r i l e t o w 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

P a i r 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 -

c a r e a c t i v i t i e s t h a t m a y i n v o l v e

e x p o s u r e t o b l o o d a n d a l l o t h e r b o d y

f l u i d

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

s e t o f 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 t o

h o l d t h e c o n t a c t l e n s e s i n p o s i t i o n

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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.

Infusion Cannula- used for infusion during the surgery

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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/CONTAINDICATION

SIDE EFFECTS/ADVERSE EFFECTS

NURSING CONSIDERATION

GENERIC NAME:

Prednisone

BRAND NAME:Deltasone

CLASSIFICATION:Adrenocortical Steroid

DOSAGE:2x a day on altered eye 1 drops

ROUTE:Topical Ophthalmic (eye drops)

FORM:Ophthalmic Solution Or Suspension (eye drop)

Irreversibly binds with glucocorticoid receptors (GR) alpha and beta for which they have a high affinity. AlphaGR and BetaGR are found in virtually all tissues with variable numbers between 3000 and 10000 per cell, depending on the tissue involved. Prednisolone can activate and influence biochemical behaviour of most cells. The steroid/receptor complexes dimerise and interact with cellular DNA in the nucleus, binding to steroid-response elements and modifying gene transcription. They induce synthesis of some proteins, and inhibit synthesis of others.

INDICATION:>Reducing inflammation in the eye.>To reduce swelling, redness, itching, and allergic reactions affecting the eye.

CONTRAINDICATION:>Hypersensitivity to any of the components of the preparation. >Presence of viral, fungal, tuberculous or other bacterial infection. >Glaucoma

SIDE EFFECTS:>mild stinging>irritation

>fluid retention of the face (moon face, Cushing's syndrome)>acne>constipation, >mood swings

ADVERSE EFFECT:>associated with cataract development

1.Best when taken with food.2.Never stop taking suddenly. Too much or too little may be dangerous and even life threatening.3.Never skip doses.4.Your child should see his/her eye doctor yearly if s/he is taking prednisone.5.If the child is ill and has a temperature, vomiting and unable to keep down his or her prednisone, call child's doctor immediately.

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DRUG NAME MODE OF ACTION INDICATION/CONTAINDICATION

SIDE EFFECTS/ADVERSE EFFECTS

NURSING CONSIDERATION

GENERIC NAME:

Moxifloxacin

BRAND NAME:Vigamox

CLASSIFICATION:Quinolone Antibiotic

DOSAGE:2x a day on altered eye 1 drop

ROUTE:Topical Ophthalmic (eye drops)

FORM:Ophthalmic Solution(eye drops)

Contains the 4th generation fluoroquinolonMoxifloxacin has in vitro activity against a wide range of Gram-(+) and Gram-(-) MO. It inhibits the topoisomerase II (DNA gyrase) and topoisomerase IV required for bacterial DNA replication, transcription repair, and recombination. The C8-methoxy moiety of these also lessens the selection of resistant mutants of Gram-(+) bacteria compared to the C8-H moiety found in older fluoroquinolones. Moxifloxacin’s bulky C-7 substituent group interferes with the quinolone efflux pump mechanism of bacteria. Moxifloxacin is often bactericidal at concentrations equal to or slightly greater than inhibitory concentrations.

INDICATION:>Used for the treatment of bacterial conjunctivitis (a bacterial infection on the surface of the eye)and anterior segment of the eye

CONTRAINDICATION:>Hypersensitivity or drug allergy to fluoroquinolones >Caution should be used in female patients who are pregnant or who are nursing.>For viral or fungal infections of the eye.

SIDE EFFECTS:>Blurred vision, watery eyes, eye pain/dryness/redness/itchiness Symptoms of an allergic reaction include: rash, itching/swelling (especially of the face/tongue/throat), dizziness, trouble breathing.

ADVERSE EFFECT:>Ocular discomfort (burning or stinging upon instillation) >Ocular pruritus

1.Contact lenses should not be worn while using drug.2.Stop and call the doctor if hypersensitivity are experienced (rash, itching, swelling of the face/throat, or difficulty breathing3.Avoid contamination by avoiding contact of the tip of the eye dropper with anything and by washing hands prior to use. 4.Vigamox is a solution so it is not necessary to shake the bottle before instilling drops.

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DRUG NAME MODE OF ACTION INDICATION/CONTAINDICATION

SIDE EFFECTS/ADVERSE EFFECTS

NURSING CONSIDERATION

GENERIC NAME:

Mefenamic Acid

BRAND NAME:Ponstan

CLASSIFICATION:CNS Agent;Analgesic;NSAID;Antipyretic

Dosage:500 mg/capsule 3x a day (PRN for pain); after meals

ROUTE:oral

FORM:Ophthalmic Solution(eye drops)

Mefenamic acid inhibits the enzymes cyclooxygenase (COX)-1 and COX-2 and reduces the formation of prostaglandins and leukotrienes. It also acts as an antagonist at prostaglandin receptor sites. It has analgesic and antipyretic properties with minor anti-inflammatory activity.

INDICATION:> For relief of mild to moderate pain in patients 14 y and older>Inflammation

CONTRAINDICATION:>Hypersensitivity to mefenamic acid; patients who have experienced asthma, urticaria, or allergic-type reactions after taking aspirin or other NSAIDs; treatment of perioperative pain in the setting of coronary artery bypass graft (CABG) surgery; active ulceration or chronic inflammation of either the upper or lower GI tract; preexisting renal disease

CV: CHF; hypertension; syncope; tachycardia.CNS: Dizziness, headache (up to 10%).Derma: Pruritus, rashes (up to 10%).GI: Abdominal pain, constipation, diarrhea, dyspepsia, flatulence, GI ulcers (gastric/duodenal), gross bleeding/perforation, heartburn, nausea, vomiting (up to 10%).Hemat: Anemia, increased bleeding time (up to 10%).Hepatic: Elevated liver enzymes (up to 10%).Miscellaneous: Abnormal renal function, edema, tinnitus (up to 10%).

1.Assess patients who develop severe diarrhea and vomiting for dehydration and electrolyte imbalance.2.Obtain periodic CBC, Hct and Hgb, and kidney function tests.3.Discontinue drug promptly if diarrhea, dark stools, hematemesis, ecchymoses, epistaxis, or rash occur and do not use again.4.Notify physician if persistent GI discomfort, sore throat, fever, or malaise occur.5.Do not drive or engage in potentially hazardous activities until response to drug is known. 6.Monitor blood glucose for loss of glycemic control if diabetic.

36

DRUG NAME MODE OF ACTION

INDICATION/CONTAINDICATION

SIDE EFFECTS/ADVERSE EFFECTS

NURSING CONSIDERATION

GENERIC NAME:Pilocarpine

BRAND NAME:Isopto Carpin

CLASSIFICATION:Cholinergic Agents

Dosage:Eye Drops- Instill 1 or 2 drops per eye, 3 to 4 times per day

ROUTE:Topical Ophthalmic (eye drops)

FORM:Ophthalmic Solution(eye drops)

Pilocarpine is a tertiary parasympathomimetic that directly stimulates cholinergic receptors in the eyes causing pupillary constriction, spasm of accommodation and a transient rise in IOP followed by a fall.

INDICATION:>To treat high pressure inside the eye due to glaucoma or other eye diseases (e.g., ocular hypertension). Lowering high pressure inside the eye helps to prevent blindness, vision loss, and nerve damage. Used during certain eye surgeries and to reverse the effects of drugs used to enlarge the pupil (e.g., during an eye exam). Works by causing the pupil of the eye to shrink and decreasing the amount of fluid within the eye.

CONTRAINDICATION:>To patients with uncontrolled asthma, and allergic to pilocarpine.

Most Common- Sweating, nausea, runny nose, diarrhea, chills, flushing, frequent urination, dizziness, weakness. Miscellaneous- Headache, indigestion, vomiting, heartburn, increased tears, stomach pain, swelling of arms, hands, feet, ankles, or lower legs, changes in vision, fast or slow heart beat.

ADVERSE EFFECT:Ocular: Pain and irritation, blurred vision, lachrymation, browache, conjunctival vascular congestion, superficial keratitis, vitreous haemorrhage, increased pupillary block.

1.It may lead to dehydration to the body, so drink plenty of water while taking this medication. 2.It may cause change in vision in night, so be careful while driving a car or other dangerous performance.3.During acute phases, the miotic must be instilled into the unaffected eye to prevent an attack of angle-closure glaucoma.4.Not for internal use. To prevent contaminating the dropper tip and solution, care should be taken not to touch the eyelids or surrounding areas with the dropper tip of the bottle.

37

DRUG NAME MODE OF ACTION INDICATION/CONTAINDICATION

SIDE EFFECTS/ADVERSE EFFECTS

NURSING CONSIDERATION

GENERIC NAME:Proparacaine Hydrochloride 0.5%

BRAND NAME:ALCAINE®

CLASSIFICATION:Topical Local Anesthetic For Ophthalmic Use

Dosage:Instill 1 drop to the eye every 5 to 10 minutes for 5 to 7 doses

ROUTE:Topical Ophthalmic (eye drops)

FORM:Sterile Ophthalmic Solution

With a single drop, the onset of anesthesia begins within 30 seconds and persists for 15 minutes or longer.The main site of anesthetic action is the nerve cell membrane where proparacaine interferes with the large transient increase in the membrane permeability to sodium ions that is normally produced by a slight depolarization of the membrane. As the anesthetic action progressively develops in a nerve, the threshold for electrical stimulation gradually increases and the safety factor for conduction decreases; when this action is sufficiently well developed, block of conduction is produced.

INDICATION:>For topical anesthesia in ophthalmic practice. > A topical anesthetic prior to surgical operations such as cataract extraction.

CONTRAINDICATION:>Patients with known hypersensitivity to any component of the solution.

Occasional temporary stinging, burning and conjunctival redness A rare, severe, immediate-type, apparently hyperallergic corneal reaction characterized by acute, intense and diffuse epithelial keratitis, a gray, ground glass appearance, sloughing of large areas of necrotic epithelium, corneal filaments and, sometimes, iritis with descemetitis has been reported.Allergic contact dermatitis from proparacaine with drying and fissuring of the fingertips has also been reported.

1.Patients should be advised to avoid touching the eye until the anesthesia has worn off. 2.Do not touch dropper tip to any surface as this may contaminate the solution.3.Store in carton until empty to protect from light. If solution shows more than a faint yellow color, it should not be used.4.A protective eye patch is recommended after surgery.

38

DRUG NAME MODE OF ACTION INDICATION/ CONTAINDICATION

SIDE EFFECTS/ADVERSE EFFECTS

NURSING CONSIDERATION

GENERIC NAME:Tobramycin+Dexamethasone

BRAND NAME:TobraDex ST

CLASSIFICATION:Eye Antiseptics with Corticosteroids

Dosage:1or2 drops instilled into the conjunctival sac(s) every 4-6 hours

ROUTE:Topical Ophthalmic (eye drops)

FORM:Ophthalmic Solution

An aminoglycoside antibiotic, has actions similar to that of gentamicin and is active against Staphylococci, Streptococci, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, Enterobacter aerogenes, Proteus mirabilis, Morganella morganii, most Proteus vulgaris strains, Haemophilus influenzae andH. aegyptius, Moraxella lacunata, Acinetobacter calcoaceticus and some Neisseria species. Dexamethasone, a synthetic fluorinated corticosteroid, has mainly glucocorticoid activity and suppresses inflammatory response.

INDICATION:>The use of a combination drug with an anti-infective component is indicated where the risk of superficial ocular infection is high or where there is an expectation that potentially dangerous numbers of bacteria will be present in the eye.

CONTRAINDICATION:Epithelial herpes simplex keratitis (dendritic keratitis), vaccinia, varicella, and many other viral diseases of the cornea and conjunctiva. Mycobacterial infection of the eye. Fungal diseases of ocular structures. Hypersensitivity to a component of the medication.

Hypersensitivity reactions, lid itching and swelling, conjunctival erythema, increase in intraocular pressure, glaucoma, optic nerve damage, posterior subcapsular cataract formation and delayed wound healing.

1.Do not touch the dropper or tube opening to any surface, including your eyes or hands. The dropper or tube opening is sterile. 2.If it becomes contaminated, it could cause an infection in the eye.3.Do not use any eye drop that is discolored or has particles in it.4.Store at room temperature away from moisture and heat. Keep the bottle or tube properly capped.

39

DRUG NAME MODE OF ACTION INDICATION/ CONTAINDICATION

SIDE EFFECTS/ADVERSE EFFECTS

NURSING CONSIDERATION

GENERIC NAME:Tropicamide + phenylephrine hydrochloride

BRAND NAME:Tropicacyl

CLASSIFICATION:Mydriatic and Cycloplegic Agents

Dosage:5 drops every 5 minutes for 5 doses

ROUTE:Topical Ophthalmic

FORM:Ophthalmic Solution

Tropicamide binds to and blocks the receptors in the muscles of the eye (muscarinic receptor M4). Tropicamide acts by blocking the responses of the iris sphincter muscle to the iris and ciliary muscles to cholinergic stimulation, producing dilation of the pupil and paralysis of the ciliary muscle.

INDICATION:To induce mydriasis (dilation of the pupil) and cycloplegia (paralysis of the ciliary muscle of the eye) in diagnostic procedures, such as measurement of refractive errors and examination of the fundus of the eye.

CONTRAINDICATION:Hypersensitivity to any component of the products, potassium guaiacolsulfonate, or to sympathomimetic amines; severe hypertension; ventricular tachycardia; pheochromocytoma;

CV: Angina; arrhythmias; bradycardia; CV collapse with hypotension; fatal subarachnoid hemorrhage; hypertension; MI; syncope; tachycardia.CNS: Anxiety; CNS depression; convulsions; dizziness; excitability; fear; hallucinations; headache; insomnia; nervousness; pallor; restlessness; tremor; weakness.EENT: With ophthalmic and intranasal forms: blurring of vision; rebound congestion; transitory stinging on initial instillation.GI: Nausea.GenitourinaryDysuria; urinary retention.RespiratoryRespiratory difficulty.

1.To instill ophthalmic solution, tilt patient's head back, hold dropper over eye, drop medication inside lower lid, and apply pressure to inside corner of eye for 2 to 3 min. 2.Take care not to touch dropper to eye.3.Prolonged exposure of ophthalmic solution to air or strong light may cause oxidation and discoloration.4.Do not use if solution is discolored or cloudy or contains precipitate.5.Heavily pigmented irides may require larger doses.

40

41

Bibliography

>Brooks, D.E “Eye Anatomy and Physiology “ The Horse.com.

January 01 2002 Article # 2797 available at:

http://www.bigpurplebarnbowie.org/images/www.thehorse.com_Ey

eAnatomy01.pdf

>Brooks,D.  “What is a Pars Plana Vitrectomy?”eHow.com

available at:  http://www.ehow.com/about_5182980_pars-plana-

vitrectomy_.html#ixzz26bJ1LCGu

>Santos, M. “Pars Plana Surgery” eye retine.com.ph available

at:

http://www.eyerepublic.com/retina-vitreous/retina-faq/28-

surgery-pars-plana-vitrectomy.html

>Rutherford, C. (2005) Differentiating Surgical Instruments,

F. A. Davis Company, Philadelphia, Pennsylvania

>Maried,E.N., (2009). Essentials of Human Anatomy and

Physiology (7thed.). San Francisco, California: Pearson

Education Inc.

>Doenges,M.E.,Moorhouse,M.F., and Murr,A.C., (2004). Nurse’s

Pocket Guide. (9thed.). Bangkok, Thailang: Davis Company

>Dewit, S.C.,(1998).Essentials of Medical-Surgical Nursing

(5th ed.). United States of America:W.B. Saunders Company

>Basavanthappa.BT.,(2003). Medical-Surgical Nursing. New

Delhi, India: Jaypee Brothers Medical Publishers(P) Ltd

>Ignatavicius,D.D., and Workman,M.L., (2006). Medical

Sugical Nursing (5thed.). Singapore: Saunders ElvesierInc

>Goldman, M. (1996) Pocket Guide to the Operating Room 2nd

Edition, F.A. Davis Company, Philadelphia, Pennsylvania

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