Busey, Adam - Post operative course for common OR procedures A… · 6/16/2016 1 Post‐operative...
Transcript of Busey, Adam - Post operative course for common OR procedures A… · 6/16/2016 1 Post‐operative...
6/16/2016
1
Post‐operative Course for Common Ophthalmic Procedures
• Post‐operative expectations differ based on individual patients and the type of procedure performed
• Benefits, risks and possible surgical outcomes must be thoroughly discussed with patients before surgery
• Following patients post‐operatively can vary significantly as surgical techniques vary among physicians and no two procedures are exactly alike
Patients after the operating room:
6/16/2016
2
• Decreased visual acuity
• Reduced contrast and color perception
• Increased glare
• Need for more light
• Decreased depth perception
Different Types of Cataract:
http://www.aao.org/topic‐detail/cataract‐‐middle‐eastnorth‐africa
NuclearPosterior Subcapsular Cataract
Cortical
http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/posterior‐subcapsular‐cataract‐2.html
http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/posterior‐subcapsular‐cataract‐2.html
6/16/2016
3
http://dro.hs.columbia.edu/sutural.htm
https://classconnection.s3.amazonaws.com/687/flashcards/2627687/png/2714775_mv‐v15‐1407‐f3‐1425A9C4525684DAC44.png
http://dro.hs.columbia.edu/corticalcat.htm http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/congen‐nuclear‐cataract/index.htm
Cataract Surgery
• Lens is broken up and removed by phacoemulsification
• An intraocular lens (IOL) is inserted
• Sutures may or may not be used
http://www.hines‐sight.com/images/iols.png
Cataract Surgery: Post‐op
POD#1: Visual acuity and IOP (intraocular pressure)
‐ Post‐operative eye drop schedule (Prednisolone taper, NSAID and antibiotic)
POW#1: Visual acuity and intraocular pressure in one or both eyes
POW#4 ‐ 6: Full work‐up with refraction, glasses prescription issued if necessary
Generally followed at 6 months, then yearly thereafter
6/16/2016
4
Postoperative Expectations of Cataract Surgery:
• Vision is brighter/bluer
• Colors are more vibrant
• Increased contrast
• Less glare
• Many patients surprised with ease of post‐op
Post‐op Considerations:
• Difficulty putting drops in – consideration if patient has little experience with eye drops
• Restrictions with bending over and lifting heavy objects
• Spectacle dependence
• Difference in vision between surgeries
• Normal post operative recovery (e.g. myopia from corneal edema, ect.)
Post‐operative Complications
• Posterior capsular opacification
• Dislocated lens ‐ breakage of bag or zonules
• Post‐operative macular edema
• Retinal detachment
• Endophthalmitis
Endophthalmitishttp://webeye.ophth.uiowa.edu/eyeforum/cases/45‐Endophthalmitis‐After‐Cataract‐Surgery.htm
http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/displaced‐IOL/index.htm
http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/capsular‐folds.htm
6/16/2016
5
Corneal Transplant
Multiple types of corneal transplants:
• PK (or PKP): Penetrating keratoplasty• DSEK: Descemet stripping endothelial
keratoplasty• DMEK: Descemet membrane
endothelial keratoplasty• DALK: Deep anterior lamellar
keratoplasty• Keratoprosthesis (KPro)
http://www.eyerounds.org/tutorials/Cornea‐Transplant‐Intro/index.htm
Layers of the Cornea
http://www.ophthobook.com/wp‐content/uploads/2007/12/video‐cornealayers.jpg
http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Fuchs‐Endothelial‐Corneal‐Dystrophy.html
http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Fuchs‐Endothelial‐Corneal‐Dystrophy‐2.html
Fuch’s Endothelial Dystrophy
http://jbiocommunication.org/issues/32‐2/assets/features/feature1/05A.html
Normal corneal endothelium
Fuch’s dystrophy
Corneal haze from Fuch’s dystropy
6/16/2016
6
DSEK Post‐op
POD#1: Visual acuity and IOP‐ Post‐operative eye drop schedule (Prednisolone taper, NSAID
and antibiotic)
POW#1: Visual acuity, IOP, pachymetry
POW#4‐6: Visual acuity, IOP, pachymetry
Then followed at 3 months and (depending on the case) 6 month to yearly follow‐ups thereafter
DSEK considerations and complications
• Patients must lay on their back for 48 hours
• Gas bubble may have to be redone
• Graft detachment
• Graft rejection
• Infections
http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/DMEK/index.htm
6/16/2016
7
Successful DSEK operation following multiple penetrating keratoplasties (PK)
Successful DSEK operation
DSEK detached in middle of graft, waited to see if resolve on own, graft was later reattached surgically
6/16/2016
8
DSEK graft detaching at edge
Detached DSEK – pre epic could not find note
Graft still detached as of April 2016, vision 20/40 ph 20/25‐1
6/16/2016
9
Fungal (Candida) growth in DSEK interface
http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Candida‐DSAEK‐interface/index.htm
Trabeculectomy
• Surgery is considered when maximum topical drop therapy is not sufficiently lowering IOP
• There are two ways to reduce IOP: lower the production of aqueous humor or increase its outflow
• A trabeculectomy is done by creating a small hole through the sclera so that aqueous can flow into a reservoir created under the conjunctiva (called a bleb)
http://www.allaboutvision.com/conditions/glaucoma‐2‐cause.htm
Flow of aqueous humor
6/16/2016
10
Trabeculectomy: Post‐op
POD#1: Visual acuity and IOP‐ Post‐operative eye drop schedule (Prednisolone taper – every two hours at
the beginning)
POW#1: Visual acuity and IOP
POW#3: Visual acuity and IOP
POW#4‐6: Visual acuity, IOP check and refraction
http://www.hopkinsmedicine.org/wilmer/glaucoma_center_excellence/book/ch17s01.html
Trabeculectomy Post‐op
• IOP could be high post operatively so sutures may have to be loosened
• Bleb leak (low intraocular pressure)
• Flat anterior chamber with high intraocular pressure (malignant glaucoma or hemorrhagic choroidals)
• Around 20% of trabeculectomies do not meet target pressure by 1 year
• However, most are at target pressure without topical drops after 5 years (over two thirds)
Retinal DetachmentSymptoms:
• Sudden flashes of light
• Abrupt increase in floaters
• Curtain or veil across vision
• Sudden blurring of vision
• Similar symptoms to posterior vitreous detachment (PVD)
6/16/2016
11
Retinal detachment in fundus photograph
Retinal detachment in B‐scan
Retinal detachment in OCT
http://www.eyerounds.org/tutorials/retinal‐detachment‐med‐students/index.htm
Retinal tear with detachment
http://www.mayoclinic.org/medical‐professionals/clinical‐updates/ophthalmology/fluoroquinolones‐do‐not‐increase‐patients‐risk‐of‐rhegmatogenous‐retinal‐detachment
Retinal Detachment Repair• Severity affects type and timing of surgery
• Laser retinopexy may be performed if there is no subretinal fluid
• Cryotherapy if there is mild subretinal fluid
• Pneumatic retinopexy with laser and/or cryotherapy
• Scleral buckle with cryotherapy
• Vitrectomy with endolaser and gas bubble
Vitrectomy
http://www.allaboutvision.com/conditions/vitreoretinal‐procedures.htm
6/16/2016
12
Retinal Detachment Post‐op
POD#1: Visual acuity, IOP and dilate‐ Post‐operative eye drop schedule (Prednisolone taper,
antibiotic and erythromycin ointment)
POW#1: Visual acuity, IOP and dilate
POW#4: Visual acuity, IOP and dilate
Afterwards followed at month 3, month 6, then annual follow‐ups
Retinal Detachment Post‐op
• Retinal detachment repair has about a 90% success rate of reattachment
• Retina can detach again due to proliferative vitreoretinopathy
• Additional surgery can be done to reattach the retina but visual outcomes can be poor
• A successful macula‐sparing retinal detachment may maintain 20/20 vision
• A macula‐off retinal detachment generally yields vision no better than 20/70
Managing Patient Frustrations
• When patients project frustrations they are usually not frustrated with you but frustrated with the situation
• Reminding patients that it is ok to feel the way they do and that we are here to give them excellent post operative care
• Reassuring patients that you are there to do what is best for them