ADVANCED PROCEDURES IN OPTOMETRIC PRIMARY CARE
JOHN NEAL, ODSCOTT ENSOR, OD, MS
About the Lecturers
John Neal OD Southern College of Optometry 2007 Memphis VAMC Residency 2008 Assistant Professor at Southern College of Optometry 2008-2013 CAVHS 2013-Present Adjunct Faculty at Southern College of Optometry
Scott Ensor OD MS Southern College of Optometry 2001 Memphis VAMC Residency 2003 Eye Health Partners Assistant Director 2003-2007 Assistant Professor at Southern College of Optometry MS in Pharmacology/Toxicology, Michigan St University, 2013
No Disclosures
Standard of Care
The courts have ruled that
Optometry and Ophthalmology
are held to the same Standard
of Care.
The Optometrist must adhere to
the rules governing the practice of Optometry for his/her State/Province.
1045-02-.12 PRIMARY EYE CARE PROCEDURES. For the purpose of 1993 Public Acts Chapter 295
The performance of primary eye care procedures rational to the 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 surgery and radial keratotomy are excluded.
Authority: T.C.A. §§4-5-202, 4-5-204, 63-8-12, and Public Chapter 295, Acts of 1993. Administrative
History: Original rule filed February 14, 1993; effective April 30, 1994.
TN Senate Bill 220
Inclusions of Amendment
Needle drainage of eyelid abscess, hematoma, bulla and seroma
Excision of single epidermal lesion without characteristics of malignancy
Incision and curettage on non-recurrent chalazion
Simple repair of eyelid laceration no larger than 2.5cm, no deeper than orbicularis, not involving lid margin or lacrimal drainage
Removal of foreign bodies similar restrictions as above
Prohibitions of Amendment
Reconstruction of the eyelid Procedures not approved by
board of optometry prior to this bill becoming law
No larger than 5 mm No deeper than dermal layer of
skin
TN SB 220 cont
Informed Consent
Pt or representative have right to make informed decision re: care
Description of diagnosis Description of procedure including anesthesia Risk & benefits with likelihood of occurrence Alternative therapies Likely consequences of refusal of therapy Who will perform, will resident or extern be
involved All communicated in language that pt or PR can
understandhttp://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/scletter07-17.pdf
EHR?
What about obtaining e-signature? Physical signature is always your best bet
Informed Consent
Informed Consent
Safety
Occupational Safety and Health Organization-U.S. (OSHA)
-Developed under the Occupational Safety and Health Act (1970) -Standards for safety in most work environments
Infectious Control
Bloodborne Pathogens means pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, HBV and HIV.
Exposure control plan-Reviewed annually Sharps injury log Standard for safer medical devices
Self sheathing needles, engineered sharps container, etc.http://www.cdc.gov/HAI/settings/outpatient/checklist/outpatient-care-checklist.html
Universal Precautions-OSHA
Universal Precautions is an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.
Body secretions such as urine, vomitus, feces, or sputum are not controlled under universal precautions, and are instead usually covered under a set of guidelines called body substance isolation.
https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051 Bloodborne Pathogens standards
Standard Precautions-OSHA
Set of infection control strategies and standards designed to protect workers from exposure to potential sources of infectious diseases.
Based on the premise that all blood, body fluids, secretions, excretions, mucous membranes, non-intact skin or soiled items are potentially infectious. –Excludes sweat
Mainly adopted by healthcare providers Apply to all professions in which workers may
become exposed to infectious microorganisms through contact with blood and body fluids.
Risk Assessment
What task am I going to perform? What is the risk of exposure to: -Blood and body fluids including respiratory secretions? -Non-intact skin? Mucous membranes? -Body tissues? -Contaminated equipment? How competent/experienced am I in performing
this task? Will the patient be cooperative while I perform
the task?
Hand Hygiene
http://www.ccohs.ca/oshanswers/diseases/washing_hands.html
X 2
http://www.cdc.gov/handwashing/
Personal Protective Equipment
Determination of PPE based on anticipated exposure to blood or other potentially infectious body fluids during any given procedure
Use gloves or masks in warranted situations
Lab coats/surgical gown to protect clothing
Gloves
Latex? Nitrile? Neoprene? Avoid vinyl; reduced barrier protection.Use correct sizePowdered vs NonNon-sterile vs. sterile?
• >15% of healthcare workers exhibit latex allergyAmarasekera M, et al. prevalence of latex allergy among healthcare workers. Int J Occup Med Environ Health. 2010 23(4): 391-396
Proper Glove Removal
KEEP A CONSTA
NT
BARRIER!
Environmental Controls
Consistent and stringent equipment and work area cleaning
Proper disposal of waste such as sharps, biomedical, and pathological waste.
Appropriate ventilation and other engineering controls.
Installation of easily accessible and clearly identified waste containers, hand hygiene product dispensers, and dedicated hand wash sinks.
Effective placement and segregation of sources of contamination.
Sharps
Any item with corners edges, etc. capable of piercing skin Must be placed in red, OSHA compliant sharps container Containers should be easily accessible in the immediate area
where sharps are used
Handling Needles/Sharps
• Do not bend, recap, or remove contaminated needles and other sharps unless such an act is required by a specific procedure or has no feasible alternative
• Do not shear or break contaminated sharps. (OSHA defines contaminated as the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface)
OSHA Compliant Sharps
Closable, puncture-resistant, leak-proof on sides and bottom. Accessible, maintained upright, and not allowed to overfill. Labeled or color coded Colored red/labeled with the biohazard Labeled in fluorescent orange/orange-red with lettering and
symbols in contrasting color Red bags may be substituted for labels
Biohazard/Biomedical Waste
Wastes other than sharps that contain blood, fluid or tissue which may transmit disease must be disposed of in red biohazard bags
Stored in a designated and secured area until pickup by waste management company
Regular scheduled pickups should be maintainedthroughout year
Storage of Medical Waste
Disposal
Care and disposal of such wastes can easily be arranged and coordinated through various pathogen control companies in your area They’ll supply bags, boxes, etc. and can arrange for pickup on
virtually any schedule: Weekly, monthly, quarterly, etc
Sharps containers, bags, etc. are also available through retailers of most surgical equipment
www.stericycle.com
Exposure Control Plan
According to the OSHA Bloodborne Pathogens Standard, an Exposure Control Plan must meet certain criteria:
It must be written specifically for each facility It must be reviewed and updated at least yearly (to reflect
changes such as new workers positions or technology used to reduce exposures to blood or body fluids)
It must be readily available to all workers You must regularly educate your workers on the uses of the
Exposure Control Plan and where it's kept, so it is available when needed
Systems Autoclave - (heat/steam)
Required for invasive surgery Cost $1200 - $6000
Ethyl Oxide - can also be used to sterilize instruments for intraocular surgery
Chemical - (germicide) is an inexpensive way to sterilize hand instruments
Sterilization
Autoclave
Autoclave Sterilization
Germicide is an inexpensive and effective way to sterilize instruments for minor surgery
Most require 10 minutes for disinfection and 10 hours for sterilization
Metricide
Chemical Sterilization
Surgical Tray
Image courtesy of David K Talley OD, FAAO
Surgical Instruments
Scissors Preferred over
scalpels for making sharp cuts, particularly with loose skin
Surgical Instruments
Blades/Scalpels The smaller the field,
the smaller the blade Blades dull quickly,
after 2-3 cuts
Equipment Pictures
Chalazion Clamp
Toothed Forceps
Surgical Scissors
Equipment Pictures
#11 Scalpel
Flat Forceps
Collection Materials
Specimen vials May be provided free of
charge by lab
Collection services Available in most areas. Can
schedule pickup as needed
Biopsy
Obtain histologic exam for all excised tissue
Set up account at local lab Lab will provide forms and vials for tissue
sample Complete pathology report and arrange for
pickup Review report at post-op 1 week
Biopsy
Path report courtesy Jennifer Snyder OD
Anesthesia
Appropriate anesthesia is required to ensure patient comfort and cooperation
The procedure will be much more difficult with insufficient anesthetia
Anesthesia Options
Conjunctival-Tetracaine-Lidocaine 4% sol-mucous membranes-Cetacaine-mucous membranes, toxic to cornea
Liquid, ung, sprayDermal Anesthesia -Lidocaine by liposomes -Iontophoresis -Injectable
Topical Anesthesia-Proparacaine
Onset within 30 sec Persists 15min or longer Indicated for tonometry,
foreign body removal, suture removal, conjunctival scraping, gonioscopic exam and prior to surgical operations such as cataract surgery
1-2 drops pre procedure Every 5 to 10 for deep
anesthesia ~$7.50/15mL
Topical Anesthesia-Tetracaine
Higher Viscosity Increase corneal contact time, deeper penetration, greater anesthetic effect
BAK preserved Indicated for procedures of short duration i.e. Tonometry, foreign body removal, suture removal
Better than Lidocaine Jelly?~$20/5mL
Topical Anesthetics-Lidocaine
• Onset of action between 20 to 60 seconds • persists 5 to 30 min or more• Viscous gel formulation for extended localized contact• Only FDA-approved lidocaine available for ocular
procedures• Preservative free• Recommended 2 drops prior to procedure• ~$45.00/5mL
Topical Anesthesia-Lidocaine Solution
Indicated for the production of topical anesthesia of accessible mucous membranes of the oral and nasal cavities and proximal portions of the digestive tract.
Good for off label, deeper anesthesia of the conjunctiva
Topical Anesthetics
Cetacaine Topical Anesthetic Spray
• Indicated for all mucous membranes except the eye
• Superior for anesthesia of the conjunctiva and procedures involving the nasolacrimal duct.
Cetacaine FACTOID
Cetacaine Topical Anesthetics are also available in liquid and gel forms.
Rapid onset within 30 seconds and effective for up to 60 minutes.
Slide courtesy of David K.Talley O.D.,FAAO
The Xylocaine Difference
Xylocaine 4% and 2%
Xylocaine 2% is for injection only and is available w/ or w/o epinephrine
Xylocaine 4% is for topical application only
Caution!
Xylocaine 2% with epinephrine can cause significant side effects
Hypertension in patients taking MOIs or TCAs
Phenothiazines and butyrophenones may reduce or reverse the beneficial effect of epinephrine
Types of Incisions
Stab – cuts and separates
Lineate – linear stab incisions
Excision – removes tissue
Snip – removes tissue
Marsupialization
Cruciate – cross pattern
Shave excision – biopsy
Radiosurgical – cut and cauterize
Lesion Removal
Incisional procedure Central piece of lesion removed Usually done for biopsy
Excisional procedure Removal of entire lesion
Lesion Removal
Excisional procedure Dissection with scissors Shave excision Punch excision
Identification of Lesions
Asymmetry
• Distinct vs Indistinct
Borders
• Consistent vs Mixed• Light, medium, or dark
Color
• Larger than 6mm
Diameter
Identification of Lesions
Other considerations
New vs chronic
Associated discoloration/loss of lashes
Associated pain
Associated redness
Evolving or changing lesion
Basal Cell Carcinoma
Examples of Common Lesions
Molluscum Chalazion Dermatosis Papulosis Nigra Subcutaneous Sebaceous Cyst Hidrocystoma Seborrheic Keratosis Papilloma
Sessile vs Pedunculated
Molluscum
Molluscum
Chalazion
Chalazion
Chronic Lipogranulomatous inflammation of the eyelid caused by obstructed sebaceous glands Deep or Superficial Typically painlessNoninfectious Most resolve spontaneously
Courtesy of Jason Duncan O.D, FAAO
Sebaceous Carcinoma
Rare, highly malignant, and potentially lethal tumor of the skin
Most commonly occurs in the eyelid
Lesions occur in meibomian glands, glands of zeis
Predominantly upper lidMust out in cases of recalcitrant chalazia
Image courtesy of Evan Silverstein, MD and Louise Mawn, MD http://eyewiki.aao.org/Sebaceous_carcinoma
Chalazion Histology
Chalazion Cures
Watch it/Warm Compress it Cut it Inject It
Images from Simon B, et al. Am J Ophthalmol 2011 Apr;151(4):714-718
TA>>I&C?
Simon B, Rosen N, Rosner M, Spierer A Am J Ophthalmol 2011 Apr;151(4):714-718
(TOP) LUL chalazion with only partial resolution 1 week p I&C
(Bottom) complete resolution after an injection of TA
I&C>>TA?
LUL chalazion (Top left) before, (Top right) 1 week p TA, and (Bottom left) 5 weeks after TA injection. Note that the lesion remained unchanged, as did small precipitates of TA. (Bottom right) The lesion underwent I&C with complete resolution.
Chalazion Surgical Set
Chalazion I&C
Asepsis
Antiseptic Agent
Mechanism of Action
Gram - Gram + Viruses Rapidity of Action
Precautions
Iodine/Betadine
Oxidation/substitution with free iodine
Excellent
Good Good Moderate Prolonged skin contact may cause irritation; Inactivated by blood and debris
Alcohol (Isopropyl or Ethyl Alcohol)
Denatures protein
Excellent
Excellent
Good Excellent Flammable
Table courtesy of Jennifer Snyder OD
Methods – Incision and Curettage
Chalazion – Technique Discussion
Apply anesthetic
Apply chalazion clamp
Perform cruciate incision
Vigorous curettage of area
Apply topical antibiotic
Chalazion I & C
Surgical Images Courtesy of Jason Duncan OD, FAAO
Chalazion I&C
Chalazion I & C
Chalazion I and C
General Surgical Approach
4 minute video on chalazion removal
Dermatosis Nigrans
Papilloma - sessile
Papilloma
Methods – Snip Excision
Pedunculated lesion Apply anesthetic Lift the lesion with
toothed forceps to access the base
Use a snip incision to excise the lesion
Apply pressure w/ gauze
Topical antibiotic ung
Snip Incision
Papilloma - pedunculated
Seborrheic Keratosis
Seborrheic Keratosis
Hidrocystoma
Hidrocystoma Histology
Subcutaneous sebaceous cyst
Zeiss Cyst Dissection
PRE POST
Equipment
Toothed forceps Chalazion Clamp Westcott scissors Flat forceps #11 scalpel Chemical Cautery
Kit
Sharps Container Gauze Gloves Tissues Anesthetic
Iris Scissors
Video Courtesy of David Talley OD, FAAO
Video on cyst removal
Wound closure
Prevent bacterial contamination Maintain apposition of wound edges until
scar tissue forms Distribute uniform tension along the entire
incision
Wound Closure Options
Wound Closure
Tissue adhesive/Dermabond Advanced™ Used on wounds with clean edges, do not
require deep sutures and are not under tension
Provides microbial barrier Wears off naturally 7-10 days Apply one thin layer in light
stroke while holding the wound together
Strong flexible bond in 2 ½ minutes Waterproofhttp://www.dermabond.com/product/how-it-works
Wound Closure
Tissue adhesive/Dermabond Advanced™ Do not get adhesive in the wound Do not apply liquid or ointment medications Cannot be used too close to the eye 2 year shelf life
http://www.dermabond.com/product/how-it-works
Dermabond Video
2:30 video on dermabond
Sutures
Indicated by the use of “0” -The more 0s the smaller i.e. 5-0< 3-0 Absorbable vs Nonabsorbable Synthetic polymer vs
Mammalian derived collagen Rate of absorption and tensile
strength duration will vary by material
http://www.dolphinsutures.com/types-of-sutures
Suture Characteristics
Configuration-single or multi stranded Size- in 0s Tensile Strength-ability to resist
breakage Knot Strength-force necessary to cause
slippage Elasticity and plasticity-ability to regain
form, retain form Handling-ease on bending, slipperiness Tissue Reaction-inflammation created
http://emedicine.medscape.com/article/1127693-overview
Some Suture Options
5-0 to 7-0 size Catgut -Absorbable within 7 days -Natural -Used for skin alignment, not for closing wounds under tension Prolene(Polypropylene) -nonabsorbable -synthetic -Good for lesions along the eyelid
Surgeon’s Knot
• The surgeon’s knot is an adaptation of the square knot
• Two helical twists in the first throw
• Additional twist increases the friction within the first throw
• Helps to hold it tight while the second throw is made
• Each twisting layer of the knot is called a throw
Pfenninger&Fowler’s Procedures for Primary Care 3rd Edition
Instrument Tie of Surgeon’s Knot
Video Courtesy Jennifer Snyder O.D.
1:40 video on knot tie
Wound Closure
Thermocautery High temp cauterization is effective at
closing small wounds and providing hemostasis
Wound Closure by Cautery
Close wound using direct pressure if lesion < 2 mm
Close wound using high temp cautery unit if > 2 mm
15 sec video
Newer Options
Chemical Cautery
Chemical Cautery Apply petroleum
jelly to the surrounding area
Apply cauterant to the lesion
Lesion will turn white
Scab will form
Chemical Cautery
RadioFrequency Concept
Ellman Radiofrequency Unit
http://www.ellman.com/
Ellman Electrodes
Pfenninger&Fowler’s Procedures for Primary Care 3rd Edition
Ellman Radiofrequency Unit
Radiofrequency System Advantages
Less tissue damage Faster healing Less scar formation
Radiofrequency Chalazion Sx
http://www.youtube.com/watch?v=PmX2w6EOZ0M
2:30 part 1
Radiofrequency Chalazion Cont….
http://www.youtube.com/watch?v=PmX2w6EOZ0M
1min part 2
Questions?
References http://classconnection.s3.amazonaws.com/980/flashcards/565980/png/chalazion1328138524523.p
ng
http://www.skinsight.com/images/dx/webAdult/dermatosisPapulosaNigra_42219_lg.jpg
http://flylib.com/books/3/283/1/html/2/10%20-%20Oculoplastics_files/C10FF43.png
http://eyecancerinfo.com/photogallery/2_5.JPG
http://www.dermaamin.com/site/images/clinical-pic/a/apocrine_hidrocystoma/apocrine_hidrocystoma1.jpg
http://www.moondragon.org/health/graphics/sebaceouscysteye.jpg
Melore G. “Lessons to Remove Lid Lesions and Anomalies” Review of Optometry April, 2005 pp 66-77
Ellman Radiosurgical Unit operational manual
http://www.aboutcancer.com/basal_cell_eye_1007.jpg
http://www.images.missionforvisionusa.org/
Top Related