WhenWhen
The Beast in the ORThe Beast in the ORIsn’t Your SurgeonIsn’t Your Surgeon
Susan Clouser RN MSN CRNOSusan Clouser RN MSN CRNO
Patient HistoryPatient History
47 year old female47 year old female 300+ pounds300+ pounds Thyroid problemsThyroid problems Difficulties with activities of daily livingDifficulties with activities of daily living
Unable to find foodUnable to find food Not socializing with new neighborsNot socializing with new neighbors
Ophthalmic exam showed bilateral cataracts Ophthalmic exam showed bilateral cataracts and geographic atrophy OSand geographic atrophy OS
Cataract Surgery on Gorillas in the Cataract Surgery on Gorillas in the United StatesUnited States
Salt Lake City, UTSalt Lake City, UT 1990 Dr. Alan Crandall on Gorgeous1990 Dr. Alan Crandall on Gorgeous
Dallas, TXDallas, TX January 2009 Dr. Wayne Bowman on TimboJanuary 2009 Dr. Wayne Bowman on Timbo
Miami, FLMiami, FL October 2009 Dr. Frank Spektor on JosephineOctober 2009 Dr. Frank Spektor on Josephine
Why a “people” ophthalmologist instead of a Why a “people” ophthalmologist instead of a veterinary ophthalmologist?veterinary ophthalmologist?
Medical School/Zoo CollaborationMedical School/Zoo Collaboration
Ophthalmic Examination of the Captive Ophthalmic Examination of the Captive Western Lowland Gorilla Western Lowland Gorilla Journal of Zoo and Wildlife Medicine 2005Journal of Zoo and Wildlife Medicine 2005
All gorillas at the Dallas Zoo examined to All gorillas at the Dallas Zoo examined to determine the norms for gorilla eyes.determine the norms for gorilla eyes.
Gorilla vs. Human EyesGorilla vs. Human Eyes
Human GorillaHuman Gorilla
Axial length 23.5Axial length 23.5 22.75mm 22.75mm
Keratometry 42-44D 44.38DKeratometry 42-44D 44.38D
Corneal diameter 12.0mm 13.4mmCorneal diameter 12.0mm 13.4mm
IOP 21.0mmHg 12.0mmHgIOP 21.0mmHg 12.0mmHg
Central cornea .56mm .49mmCentral cornea .56mm .49mm
Medical School/Zoo CollaborationMedical School/Zoo Collaboration
Ophthalmic Examination of the Captive Ophthalmic Examination of the Captive Western Lowland Gorilla Western Lowland Gorilla Journal of Zoo and Wildlife Medicine 2005Journal of Zoo and Wildlife Medicine 2005
“ “ These similarities may allow diagnostics, These similarities may allow diagnostics, techniques and equipment for human eye techniques and equipment for human eye surgery, such as those used for cataract surgery, such as those used for cataract extraction and IOL implantation to be extraction and IOL implantation to be successfully utilized for gorillas.”successfully utilized for gorillas.”
Critical FactorsCritical Factors
Surgery locationSurgery location Hospital vs. ZooHospital vs. Zoo
Surgery TeamSurgery Team Surgery DateSurgery Date Equipment/SuppliesEquipment/Supplies Which eye first or both eyes at the same time?Which eye first or both eyes at the same time? Postoperative CarePostoperative Care
LocationLocation
Hospital vs. ZooHospital vs. Zoo
TransportTransport Equipment/SuppliesEquipment/Supplies MedicationsMedications
Assembling the TeamAssembling the Team
SurgeonSurgeon AssistantAssistant CirculatorCirculator Scrub personScrub person
Assembling the TeamAssembling the Team
Geographic atrophy = Retina specialistGeographic atrophy = Retina specialist New retina camera = camera rep + assistantNew retina camera = camera rep + assistant
IOL measurements = UltrasonographerIOL measurements = Ultrasonographer Phaco machine = Alcon repPhaco machine = Alcon rep Microscope = Zeiss repMicroscope = Zeiss rep Interested resident + additional cornea fellowInterested resident + additional cornea fellow
Surgery DateSurgery Date
How about a Tuesday?How about a Tuesday?
How about a Sunday?How about a Sunday?
Critical FactorsCritical Factors
Equipment (shipped in)Equipment (shipped in) Microscope: ZeissMicroscope: Zeiss Phaco machine: AlconPhaco machine: Alcon
Equipment (transported from hospital)Equipment (transported from hospital) A scan, Retinal camera, Indirect ophthalmoscope, A scan, Retinal camera, Indirect ophthalmoscope,
hand held keratometerhand held keratometer
Critical FactorsCritical Factors
SuppliesSupplies Custom packCustom pack MedicationsMedications SutureSuture GlovesGloves
Which IOL?Which IOL?
Larger optic for a larger eyeLarger optic for a larger eye FoldableFoldable Lower incidence of posterior capsule Lower incidence of posterior capsule
opacificationopacification
MC50BMMC50BM
Which eye first?Which eye first?
Left eyeLeft eye Geographic atrophy/less visual potentialGeographic atrophy/less visual potential PracticePractice Observe postoperative behaviorsObserve postoperative behaviors
Postoperative considerationsPostoperative considerations
Unable to instill eye dropsUnable to instill eye drops RubbingRubbing
Veterinarian ConcernsVeterinarian Concerns
Safety of the animalSafety of the animal Safety of the surgical teamSafety of the surgical team PrivacyPrivacy
No photos except those taken by the official Dallas No photos except those taken by the official Dallas Zoo photographer, Cathy BurkeyZoo photographer, Cathy Burkey
Rules for the ZooRules for the Zoo
Respectful of the inhabitants of that settingRespectful of the inhabitants of that setting Wear required personal protective equipmentWear required personal protective equipment Don’t touch the gorilla without permissionDon’t touch the gorilla without permission Limit conversation to that pertinent to the surgeryLimit conversation to that pertinent to the surgery
Rules for the ZooRules for the Zoo
FlexibilityFlexibility Ability to innovateAbility to innovate
Back tableBack table ChairsChairs Wrist restWrist rest
PreopPreop
Tranquilizing dartTranquilizing dart Placed on “OR table”Placed on “OR table” Dilating dropsDilating drops
TropicamideTropicamide CyclopentolateCyclopentolate 2.5% Phenylephrine2.5% Phenylephrine
Moved to the ORMoved to the OR
In the ORIn the OR
Positioned at the top edge of the tablePositioned at the top edge of the table Endotracheal tube and tubing positioned and Endotracheal tube and tubing positioned and
secured out of the surgical fieldsecured out of the surgical field Bair-hugger warming unitBair-hugger warming unit MonitorsMonitors Head positioned and secured with tapeHead positioned and secured with tape
Preop exam and testPreop exam and test
Retinal examRetinal exam IndirectIndirect PhotosPhotos
AscanAscan KeratometryKeratometry
IOL CalculationsIOL Calculations
Axial length = 27.5mmAxial length = 27.5mm K readings = ?????K readings = ?????
Getting in positionGetting in position
OR table configurationOR table configuration DimensionsDimensions
3 feet wide 3 feet wide 6 feet long6 feet long
Solid sidesSolid sides Surgeon normally operates temporally but chose to Surgeon normally operates temporally but chose to
position himself superiorly because he could not position himself superiorly because he could not reach the eye if he was at the side. reach the eye if he was at the side.
Getting in positionGetting in position
Can he sit?Can he sit? OR table doesn’t go very lowOR table doesn’t go very low Available chairs don’t go very highAvailable chairs don’t go very high Must be able to reach foot pedalsMust be able to reach foot pedals
Uh-ohUh-oh Where can we put the foot pedals?Where can we put the foot pedals?
Getting in positionGetting in position
OR table configurationOR table configuration Thick mattress and baseThick mattress and base Straight down, no head restStraight down, no head rest Surgeon’s legs cannot be under patient’s headSurgeon’s legs cannot be under patient’s head No room for foot pedalsNo room for foot pedals
Sat on edge of chair with legs at wide anglesSat on edge of chair with legs at wide angles
Surgical PrepSurgical Prep
Betadine 10% Betadine 10% In the cul de sacIn the cul de sac Periocular with 4x4 gauze spongesPeriocular with 4x4 gauze sponges Lid margins with cotton tip applicatorsLid margins with cotton tip applicators 5 minutes 5 minutes BSS rinseBSS rinse
Learn and TeachLearn and Teach
Learn from the veterinarians and zoo staff Learn from the veterinarians and zoo staff about what is required to care for these about what is required to care for these animalsanimals
Teach them about cataract surgery, intraocular Teach them about cataract surgery, intraocular lenseslenses Narrate surgery as it was shown on the monitorNarrate surgery as it was shown on the monitor Answer questions about procedure and different Answer questions about procedure and different
types of IOLstypes of IOLs
Variations in the Surgical Variations in the Surgical ProcedureProcedure
Anterior capsule tougher and thickerAnterior capsule tougher and thicker Larger eye changed the angles some and made Larger eye changed the angles some and made
some things slightly more difficult to reachsome things slightly more difficult to reach Posterior pressurePosterior pressure 10-0 vicryl stitch in both incision and 10-0 vicryl stitch in both incision and
paracentesisparacentesis
End of Procedure MedicationsEnd of Procedure Medications
Subconjunctival injectionsSubconjunctival injections CefazolinCefazolin GentamicinGentamicin KenalogKenalog
Polysporin ointmentPolysporin ointment Both eyes to prevent exposure keratitis during the Both eyes to prevent exposure keratitis during the
wake up periodwake up period
Post op first eyePost op first eye
Moved to her gorilla “condo”Moved to her gorilla “condo” Woke up about 1 hour laterWoke up about 1 hour later No analgesicsNo analgesics Snack and juice in the afternoonSnack and juice in the afternoon Did not rub eyeDid not rub eye
Post op day #1Post op day #1
Area kept dim to allow acclimation to new Area kept dim to allow acclimation to new visionvision
Some problems with depth perceptionSome problems with depth perception Bumped into mesh that is the wall of her habitatBumped into mesh that is the wall of her habitat Difficulty passing items through the meshDifficulty passing items through the mesh
One week post opOne week post op
Surgeon did face to face examSurgeon did face to face exam Appeared clearAppeared clear No redness or discharge notedNo redness or discharge noted
Second eye scheduled for one week laterSecond eye scheduled for one week later
Second eye surgerySecond eye surgery
Two weeks after firstTwo weeks after first First eye looked quiet, vicryl stitches still in First eye looked quiet, vicryl stitches still in
placeplace Uneventful post opUneventful post op
One month post second surgeryOne month post second surgery
Face to face exam in gorilla houseFace to face exam in gorilla house Came to mesh and took peanuts Came to mesh and took peanuts Vision testVision test Ate other food: carrots, lettuceAte other food: carrots, lettuce PurredPurred More active, looking into research stationMore active, looking into research station
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