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Davao Doctors College

General Malvar St., Davao city

BACHELOR OF SCIENCE IM NURSING

AN OPERATIVE REVIEW ON

Whippels

In partial Fulfillment of the Requirement

In NCM 104

Presented to Mr. Leonardo C. Matunding, RN,MAN

A clinical instructor of Davao Doctors College in Nursing

BSN Level III

Presented by: De Dios, Chara Marie N.

November 2016

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TABLE OF CONTENTS

I. Introduction .. 3 - 5

II. Anatomy .7 - 12

III. Pathophysiology ..13

IV. Medical Management ..14

V. Proper Procedure (with instrumentation)...15 - 18

VI. Roles of Circulating and Scrub Nurse ..19 - 20

VII. Nurisng Management ..22 - 23

A. Nursing Care plan

I. Pre Operative ..24 - 25

II. Intra Operative....26 - 27

III. Post Operative.28 -29

VIII. Pharmacology

I. Pre Operative .30

II. Intra Operative .. .31

III. Post Operative ..32

XI. Bibliography33

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INTRODUCTION

Vitrectomy is a surgery to remove the vitreous gel from the middle of the eye . It may be
done when there is a retinal detachment or if blood in the vitreous gel (vitreous hemorrhage)
does not clear on its own. Removing the vitreous gel gives your eye doctor better access to
the back of the eye. Vitrectomy is done by an eye doctor (ophthalmologist) who has special
training in treating problems of the retina.

During surgery, the doctor uses small tools to remove the vitreous gel. Then the doctor may
treat other eye problems, such as a retinal detachment, vitreous hemorrhage, scar tissue on
the retina, or tears or holes in the macula.

At the end of the surgery, the doctor may inject an oil or gas bubble into the eye. This
lightly presses the retina against the wall of the eye. If an oil bubble is used, the doctor will
need to remove the oil after the eye has healed.

BACKGROUND

Vitrectomy is the surgical removal of the vitreous (transparent gel that fills the eye from
the iris to the retina). Vitrectomy may be necessary for the following conditions (CMS,
2006): vitreous loss incident to cataract surgery, vitreous opacities due to vitreous
hemorrhage or other causes, retinal detachments secondary to vitreous strands,
proliferative retinopathy, and vitreous retraction.

Vitrectomy may be indicated for complications of diabetic retinopathy, including vitreous


hemorrhage and retinal detachment. It may also be indicated for persons with traumatic
penetrating ocular injury, non-diabetic vitreous hemorrhage, rapidly progressing infectious
endophthalmitis, and cataract extractions complicated by a vitreous loss or an underlying
inflammatory condition.

Wide fluctuations in intra-ocular pressure (IOP) have been documented during vitrectomy
in animal models. Such fluctuations in IOP are posited to have potential adverse effects
on retinal and optic nerve function and visual acuity recovery, especially for patients with
compromised retinal or optic nerve blood flow and decreased ocular perfusion pressure.

An indirect method of monitoring IOP during vitrectomy surgery has been developed
(Armoor Ophthalmics, Houston, TX), which involves placing disposable blood pressure
transducers into the line tubing used for vitrectomy infusion. Moorhead et al (2005)
reported on a clinical study in which this indirect method of IOP measurement was
compared to direct measurement during vitrectomy procedures in 10 patients. Intra-ocular
pressure was directly measured by inserting a catheter pressure transducer by an extra pars
plana incision directly into the vitreous. During various maneuvers of vitrectomy,

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including air-fluid exchange and gas-forced fusion, pressure measurements were taken
simultaneously from the indwelling pressure transducer and the disposable blood pressure
sensors in the infusion line. The directly measured IOP varied between 0 and 120 mm Hg
during vitrectomy. The investigators reported in each case how indirectly measured IOP
during fluid flow, calculated from infusion line pressures, correlated with the directly
measured IOP. The investigators commented that the variation in pressures encountered
during these vitrectomy surgeries weree similar to measurements reported during cataract
surgery. The investigators stated that it is likely that pressure variations documented in
this study may be detrimental, but the physiological significance of these findings requires
further study.

Following vitrectomy surgery (e.g., repair of macular hole, retinal detachment), face-down
positioning may be required for several weeks to maximize retinal tamponade and,
subsequently, hole closure or retinal attachment. The vitrectomy face-down positioning
system (also known as a vitrectomy chair or a vitrectomy support system) is a device that
may be appropriate in selected cases to assist the patient in maintaining a face down
position. The rental of a vitrectomy face support may be necessary for up to 6 weeks after
vitrectomy surgery.

Ishikawa et al (2009) evaluated the safety and effectiveness of intra-vitreal injection of


bevacizumab (IVB) advanced to vitrectomy for severe proliferative diabetic retinopathy
(PDR). A total of 8 eyes of 6 patients (33 to 64 years old, all male subjects) with severe
PDR were investigated. An intra-vitreal injection of 1.25 mg bevacizumab was carried
out 3 to 30 days before planned vitrectomy. All cases showed minimum bleeding during
surgical dissection of fibro-vascular membrane. Two cases receiving bevacizumab 7 days
before the surgery showed strong fibrosis and adhesion of fibro-vascular membrane,
resulted in some surgical complications. The cases having IVB for shorter time did not
show extensive fibrosis. The authors concluded that pre-treatment of bevacizumab is
likely effective in the vitrectomy for severe PDR. The appropriate timing of vitrectomy
after bevacizumab injection should be further evaluated.

In a review on diabetic retinopathy (DR), Cheung et al (2010) noted that although anti-
vascular endothelial growth factor (VEGF) therapy has promising clinical applications for
the management of DR, its long-term safety in patients with diabetes has not yet been
established. Local adverse events of IVB include cataract formation, infection, retinal
detachment, vitreous hemorrhage, as well as potential loss of neural retinal
cells. Furthermore, a significant portion of anti-VEGF agents injected into the eye could
pass into the systemic circulation. Thus, systemic inhibition of angiogenesis is a potential
risk. Also, although clinical trials on the use of intra-vitreal anti-VEGF therapy for the
treatment of age-related macular degeneration generally show low (0.6 to 1.2 %) rates of
stroke, this risk could be increased in patients with DR because of pre-existing diabetes-
related vascular disease.

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Nicholson and Schachat (2010) stated that many observational and pre-clinical studies
have implicated VEGF in the pathogenesis of DR, and recent successes with anti-VEGF
therapy for age-related macular degeneration have prompted research into the application
of anti-VEGF drugs to DR. These investigators reviewed the numerous early studies that
suggest an important potential role for anti-VEGF agents in the management of DR. The
authors concluded that for diabetic macular edema, phase II trials of intra-vitreal
pegaptanib and intra-vitreal ranibizumab have shown short-term benefit in visual
acuity. Intra-vitreal bevacizumab also has been shown to have beneficial short-term
effects on both visual acuity and retinal thickness. For PDR, early studies suggest
that IVB temporarily decreases leakage from diabetic neovascular lesions, but this
treatment may be associated with tractional retinal detachment. Furthermore, several
studies indicate that bevacizumab is likely to prove a helpful adjunct to diabetic pars plana
vitrectomy for tractional retinal detachment. Finally, 3 small series suggest a potential
beneficial effect of a single dose of bevacizumab to prevent worsening of diabetic macular
edema (DME) after cataract surgery. The authors noted that use of anti-VEGF
medications for any of these indications is off-label. Despite promising early reports on
the safety of these medications, the results of large, controlled trials to substantiate the
safety and efficacy of anti-VEGF drugs for diabetic retinopathy are eagerly awaited.

In a prospective, comparative case series, El-Sabagh and colleagues (2011) evaluated the
effects of intervals between pre-operative IVB and surgery on the components of removed
diabetic fibro-vascular proliferative membranes. A total of 52 eyes of 49 patients with
active diabetic fibro-vascular proliferation with complications necessitating vitrectomy
were included in this study. Participant eyes that had IVB were divided into 8 groups in
which vitreo-retinal surgery was performed at days 1, 3, 5, 7, 10, 15, 20, and 30 post-
injection. A group of eyes with the same diagnosis and surgical intervention without IVB
injection was used for comparison. In all eyes, proliferative membrane specimens
obtained during vitrectomy were sent for histopathologic examination using hematoxylin-
eosin stain, immunohistochemistry (CD34 and smooth muscle actin), and Masson's
trichrome stain. Main outcome measure was comparative analysis of different
components of the fibro-vascular proliferation (CD34, smooth muscle actin, and collagen)
among the study groups. Pan-endothelial marker CD34 expression levels starting from
day 5 post-injection were significantly less than in the control group (p < 0.001), with
minimum expression (1+) in all specimens removed at or after day 30 post-
injection. Positive staining for smooth muscle actin was barely detected in the control
eyes at day 1, and consistently intense at day 15 and beyond (p < 0.001). The expression
level of trichrome staining was significantly high at day 10, compared with control eyes (p
< 0.001), and continued to increase at subsequent surgical time points. The author
concluded that a pro-fibrotic switch was observed in diabetic fibro-vascular proliferation
after IVB, and these findings suggest that at approximately 10 days post-IVB the vascular
component of proliferation is markedly reduced, whereas the contractile components
(smooth muscle actin and collagen) are not yet abundant. Moreover, the authors noted

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that their histologic findings are in agreement with many published clinical findings and
might be predictive of an optimal time interval for the pre-operative use of adjunctive IVB,
which makes surgery more successful with less intra-operative bleeding and complications;
thus resulting in better visual outcomes. However, such favorable outcomes need
validation from large-scale clinical studies.

Do and colleagues (2013) noted that cataract formation or acceleration can occur after
intra-ocular surgery, especially following vitrectomy. The underlying problem that led to
vitrectomy may limit the benefit from cataract surgery. In a Cochrane review, these
researchers evaluated the safety and effectiveness of surgery for post-vitrectomy cataract
with respect to visual acuity, quality of life, and other outcomes. They searched
CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The
Cochrane Library 2013, Issue 4), Ovid MEDLINE, Ovid MEDLINE in-Process and Other
Non-Indexed Citations, Ovid MEDLINE Daily Update, Ovid OLDMEDLINE (January
1946 to May 2013), EMBASE (January 1980 to May 2013, Latin American and Caribbean
Health Sciences Literature Database (LILACS) (January 1982 to May 2013), PubMed
(January 1946 to May 2013), the metaRegister of Controlled Trials (mRCT)
(http://www.controlled-trials.com), ClinicalTrials.gov (http://www.controlled-trials.com)
and the WHO International Clinical Trials Registry Platform (ICTRP)
(http://www.who.int/ictrp/search/en). These investigators did not use any date or
language restrictions in the electronic searches for trials. They last searched the electronic
databases on May 22, 2013. They planned to include randomized and quasi-randomized
controlled trials (RCTs) comparing cataract surgery with no surgery in adult patients who
developed cataract following vitrectomy. Two authors screened the search results
independently according to the standard methodological procedures expected by The
Cochrane Collaboration. They found no randomized or quasi-RCTs comparing cataract
surgery with no cataract surgery for patients who developed cataracts following vitrectomy
surgery. The authors concluded that there is no evidence from randomized or quasi-RCTs
on which to base clinical recommendations for surgery for post-vitrectomy
cataract. There is a clear need for RCTs to address this evidence gap. Such trials should
stratify participants by their age, the retinal disorder leading to vitrectomy, and the status
of the underlying disease process in the contralateral eye. Outcomes assessed in such trials
may include gain of vision on the Early Treatment Diabetic Retinopathy Study (ETDRS)
scale, quality of life, and adverse events such as posterior capsular rupture. Both short-
term (6-month) and long-term (1-year or 2-year) outcomes should be examined.

Simunovic et al (2014) performed a meta-analysis of published RCTs regarding the


effectiveness of vitrectomy for DME. These investigators searched PubMed and the
Cochrane database for randomized, controlled trials investigating vitrectomy for DME.
Structural (foveal thickness) and functional (visual acuity) outcomes were used as the
primary outcome measures. A total of 11 studies met the criteria for inclusion in this
review: these studies were heterogeneous in their experimental and control interventions,

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follow-up period, and eligibility criteria. Seven studies compared vitrectomy with the
natural history of diabetic maculopathy, with laser, or with intra-vitreal corticosteroid
injection; 4 studies compared vitrectomy with internal limiting membrane peeling to
vitrectomy alone; 1 of the latter 4 studies was the only to investigate vitrectomy in patients
with vitreo-macular traction. Meta-analysis suggested a structural, and possibly
functional, superiority of vitrectomy over observation at 6 months. Vitrectomy also
appears superior to laser in terms of structural, but not functional, outcomes at 6
months. At 12 months, vitrectomy offers no structural benefit and a trend toward inferior
functional outcomes when compared with laser. The authors concluded that there is little
evidence to support vitrectomy as an intervention for DME in the absence of epiretinal
membrane or vitreo-macular traction. They noted that although vitrectomy appears to be
superior to laser in its effects on retinal structure at 6 months, no such benefit has been
proved at 12 months. Furthermore, there is no evidence to suggest a superiority of
vitrectomy over laser in terms of functional outcomes.

An UpToDate review on Diabetic retinopathy: Prevention and treatment (Fraser and


DAmico, 2015) states that Vitrectomy may be beneficial in selective cases of clinically
significant ME. However, the results of vitrectomy are somewhat variable, ranging from
no benefit to visual acuity gains of several lines or more. Some authors advocate simple
removal of the vitreous gel, others recommend additional removal of the thick posterior
hyaloid, and still others perform both of these and also remove the internal limiting
membrane ("ILM peeling") of the retina itself. A systematic review of trials assessing a
combination of these techniques versus observation or focal photocoagulation reported that
vitrectomy may be beneficial in some patients with clinically significant ME, particularly
in those with evidence of vitreo-macular traction, although the evidence was weak.

An American Academy of Ophthalmology Preferred Practice Pattern on Diabetic


Retinopathy (2014) stated that vitreous surgery is frequently indicated in patients with
traction macular detachment (particularly of recent onset), combined traction
rhegmatogenous retinal detachment, and vitreous hemorrhage precluding panretinal
photocoagulation. Patients with vitreous hemorrhage and rubeosis iridis also should be
considered for prompt vitrectomy and intraoperative panretinal photocoagulation surgery.

In a Cochrane review, Spiteri Cornish et al (2014) examined if ILM peeling improves


anatomic and functional outcomes of full-thickness macular hole (FTMH) surgery when
compared with the no-peeling technique. Systematic review and individual participant
data (IPD) meta-analysis were undertaken under the auspices of the Cochrane Eyes and
Vision Group. Only RCTs were included. Patients with idiopathic stage 2, 3, and 4
FTMH undergoing vitrectomy with or without ILM peeling were included in this
analysis. Subjects underwent macular hole surgery, including vitrectomy and gas
endotamponade with or without ILM peeling. Primary outcome was best-corrected
distance visual acuity (BCdVA) at 6 months post-operatively. Secondary outcomes were
BCdVA at 3 and 12 months; best-corrected near visual acuity (BCnVA) at 3, 6, and 12

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months; primary (after a single surgery) and final (after greater than 1 surgery) macular
hole closure; need for additional surgical interventions; intra-operative and post-operative
complications; patient-reported outcomes (PROs) (EuroQol-5D and Vision Function
Questionnaire-25 scores at 6 months); and cost-effectiveness. A total of 4 RCTs were
identified and included in the review. All RCTs were included in the meta-analysis; IPD
were obtained from 3 of the 4 RCTs. No evidence of a difference in BCdVA at 6 months
was detected (mean difference, -0.04; 95 % confidence interval [CI]: -0.12 to 0.03; p =
0.27); however, there was evidence of a difference in BCdVA at 3 months favoring ILM
peeling (mean difference, -0.09; 95 % CI: -0.17 to -0.02; p = 0.02). There was evidence
of an effect favoring ILM peeling with regard to primary (odds ratio [OR], 9.27; 95 % CI:
4.98 to 17.24; p < 0.00001) and final macular hole closure (OR, 3.99; 95 % CI: 1.63 to
9.75; p = 0.02) and less requirement for additional surgery (OR, 0.11; 95 % CI: 0.05 to
0.23; p < 0.00001), with no evidence of a difference between groups with regard to intra-
operative or postoperative complications or PROs. The ILM peeling was found to be
highly cost-effective. The authors concluded that available evidence supports ILM
peeling as the treatment of choice for patients with idiopathic stage 2, 3, and 4 FTMH.

In a Cochrane review, Parravano and colleagues (2015) examined the effects of vitrectomy
for idiopathic macular hole on VA. A secondary objective was to investigate anatomic
effects on hole closure and other dimensions of visual function, as well as to report on
adverse effects recorded in included studies. These investigators searched the Cochrane
Eyes and Vision Group Trials Register (March 4, 2015), the Cochrane Central Register of
Controlled Trials (CENTRAL; 2015, Issue 2), Ovid MEDLINE, Ovid MEDLINE In-
Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE
(January 1946 to March 2015), EMBASE (January 1980 to March 2015), Latin American
and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to March
2015), the Web of Science Conference Proceedings Citation Index-Science (CPCI-S)
(January 1980 to March 2015), the ISRCTN registry
(www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and
the World Health Organization (WHO) International Clinical Trials Registry Platform
(ICTRP) (www.who.int/ictrp/search/en). They did not use any date or language
restrictions in the electronic searches for trials. They last searched the electronic databases
on March 4, 2015. These researchers included RCTs comparing vitrectomy (with or
without ILM peeling) to no treatment (that is observation) for macular holes. They used
standard methodological procedures expected by Cochrane. Two review authors
independently extracted the data. They estimated BCVA and macular hole closure at 6 to
12 months of follow-up. A total of 3 studies provided data on the comparison between
vitrectomy and observation in eyes with macular hole and VA less than 20/50. Two
studies, conducted in the USA and published in 1996 and 1997, used a similar protocol and
included participants with stage II macular hole (42 eyes randomized, 36 analyzed, number
of participants not reported) or participants with stage III/IV hole (129 eyes of 120
participants, 115 eyes in analyses). The 3rd study, conducted in the UK and published in

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2004, included 185 eyes of 174 participants with full-thickness macular hole (41 eyes with
stage II holes and 74 eyes with stage III/IV holes in analyses). Studies were of good
quality for randomization and allocation concealment, whereas VA measurement was un-
masked. At 6 to 12 months, VA was improved by about 1.5 Snellen lines (-0.16 logMAR,
95 % CI: -0.23 to -0.09 logMAR, 270 eyes, moderate-quality evidence). The chances of
macular hole closure at 6 to 12 months were greatly increased using vitrectomy, yielding
an OR of 31.4 (95 % CI: 14.9 to 66.3, 265 eyes, high-quality evidence; raw sum data: 76 %
vitrectomy, 11 % observation). Vitrectomy was beneficial both in smaller (stage II) and
in larger (stage III/IV) macular holes. The largest study reported that cataract surgery was
needed in about 50 % of cases at 2 years after operation and that retinal detachment
occurred in approximately 5 % of operated eyes. The authors concluded that vitrectomy
is effective in improving VA, resulting in a moderate visual gain, and in achieving hole
closure in people with macular hole.

PATIENT PROFILE

NAME: S.M.M. JR

DATE OF BITH: December 10, 1958

AGE: 58 yeaars old

GENDER: Male

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ADRESS: Block 13 Lot 14 Phases 2 Green Meadow

RELIGION: Catholic

CIVIL STATUS: Married

NATIONALITY: Filipino

FATHER NAME: Simeon Molina

MOTHER NAME: Grace Molina

OCCUPATIONAL: Government Employee

ADMITING PHYSICIAN: DR. Gonzales Sy, Jocelyn Josefina

ADMITING DIAGNOSIS: Par Plana Vitectomy Right Eye

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.

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Above: Schematic diagram of the Structure of the Human Eye.

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
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

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

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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 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.

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).

CORNEA

Transparent circular part of the front of the human 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.

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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.

FOVEA

A small depression forming a shallow pit in the retina at 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 Smmerring.
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.
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).

IRIS

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

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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:


(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;
(4.) Pigment - the location of pigment cells differing in different irides;
(5.) Arteries of the iris, and
(6.) Nerves of the Choroid and Iris.

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 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.

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.

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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.

RETINA

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.
8. Membrana limitans externa.
9. Jacob's membrane (layer of rods and cones).
10. Pigmentary layer (tapetum nigrum).

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).

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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.
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.

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".

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. This is filled with fluid and lined by a prolongation of the
hyaloid membrane.

ZONULA CILIARIS

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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.

MEDICAL MANAGEMENTCBC

COMPONENT RESULT RANGE

Hemoglobin 133g/L 115.0 - 155.0 g/L

Hematocrit 0.40 0.36 - 0.41

Erthrocytes 4.45

Leukocytes 8.68

Thrombocytes 263

Absolute Neutrophils 0.60 55 - 75

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Absolute Lympocyts 0.28 20 - 35

Absolute Monocytes 0.06 2 - 10

Absolute Basophils 263 0-1

MCV 89.89 fl 79.4 - 94.8 fl

MCH 29.89 pg 25.6 - 32. 2 pg

MCHC 332.5 g/dL 32.2 - 35.5 g/dL

RDW 13.60

MPV 7.40

COMPONENT RESULT RANGE

TRIGLYCERIDES 1.43mmol/L 0-1.7

HEMOGLOBIN ACID 8.80% 0.40

CREATININE 223umol/L 62-102

GLUCOSE, FBS 8.90mmol/L 4.4-6.4

HDL CHOLESTEROL 0.88mmol/L 1.03-1.55

LDL CHOLESTEROL 2.9mmol/L 0.0-3.9

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.

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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 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 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

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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;


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

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on until you are able to blink the eye normally. Begin using drops after the
patch has been removed.

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.

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.

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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.

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.

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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.

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 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

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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 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.

PATIENTS 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 shell 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.

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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 patients 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.

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

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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.

26
Catheterization of sclerotic vessel in the superior hall of the retina.
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.

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INTRUMENTATIONS

Mayo table- It drapes and carries the instrument for the operation.

Sterile t o w e l - linens placed on the patient or around the field to


delineate sterile areas

S e v e r a l s t e r i l e ga u z e - used for absorbing fluids as well as dressing and


protecting wounds

Pair of glove- used during all patient-care activities


that may involve exposure to blood and all other body
fluid

Vitrectomy Lens Set-these compromise a set of contact


lenses with concave contact surface and comes with a
ring to hold the contact lenses in position

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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

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

30
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

31
ROLES OF THE CIRCULATING AND SCRUB NURSING

ACTIVITY SCRUB NURSE CIRCULATING NURSE


1. gather of instruments Nurse Assist with the Nurse is Greeting patient and
preparation of the room for assist nurse with identification
the designated surgical
procedure, including
gathering supplies for the
procedure.

Srcub,dry hands, gowning, Assisting in tie-hing the


2. Do the pre scrub and
gloving, gown of scrub nurse.
gowning.
Assist person scrubbed in first Preparing the room
3. Preparing the instruments
position with:
a. Obtaining
a. Setting up back table,
instruments, supplies, and
mayo, and basins
equipment for the
b. Arrangement of designated operative
instruments procedure
c. Preparation of suture b. Opening unsterile
and needles
supplies
d. Preparation and
c. Assisting in gowning
counting sponges
d. Observing breaks in
e. Arrangement and
sterile technique
preparation of other necessary
items e. Assisting
f. Gowning and gloving anesthesiologist as
surgeon and assistants necesssary

g. Assist with draping f. Assisting with skin


preparation and positioning
h. Arrangement of sterile
field g. Assisting with
4. Greet and counting the forming of the sterile field
instruments
The scrub nurse count the The circulating nurse will
instruments and greet the write down what scrub
doctors by telling that nurse that
excuse doc Trinidad, Doc
Magsaysay and the rest of
the surgical the first
counting of sponges,
instruments and needles is
complete.

32
5. Observed the sterile field
in rooms.
During the procedure, progress During the Procedure:
from double-scrubbed
a. Remain in room and
position. Train self to keep
dispense materials as
eyes on field, and learn steps
necessary
of procedure.
b. Observe procedure as
closely as possible

c. Begin establishing
method of anticipating needs
of surgical team

d. Care of specimen as
indicated

e. Care of operative
records as indicated
6. Anticipating needs of
doctors in instruments

Before the closing of the


organ or peritoneum,
Begin developing methods of count all instruments,
anticipating needs of surgeon sharps and sponges and
and assistant. confirm with scrub
7. Closing the operating and nurse.
counts the instruments
Inform the surgeon and
assistant surgeon of a report
of the instruments.

After closing the skin:

a. Assist with care of


instruments and counts if
necessary

b. Care of specimen

c. Assist with dressing of


wound.

Prior to operation:

33
A careful history and physical examination are performed to exclude the possibility
of other gastrointestinal diseases that may mimic biliary colic, such as peptic ulcer
disease or reflux esophagitis.

When the diagnosis of acute cholecystitis is suspected the patient should receive
nothing by mouth; however, nasogastric suction usually can be reserved for patients
who are vomiting or have ileus and abdominal distention.

Intravenous fluids are given to correct volume depletion and any electrolyte
imbalances are measured and corrected. Monitor and regulate IVFs

The nurse instructs the patient about the need to avoid smoking to enhance
pulmonary recovery postoperatively and avoid respiratory complications. It is also
important to instruct the patient to avoid the use of aspirin and other agents that can
alter coagulation and other biochemical process

On of the most important responsibility of the nurse is to let the patient sign an
informed consent regarding the surgery.

The patient is given anaesthesia prior to surgery and the patient is under NPO.

During the operation

Monitoring the vital signs of the patient is one of the responsibilities of the nurse
during the surgery.

Assisting the anesthesia care provider during induction of general anesthesia

Ensuring adequate oxygenation and hydration

After the operation

After recovery, the nurse places the patient in the low fowlers position. IV fluids
may be given and nasogastric suction may be given to relieve abdominal distention.
Water and other fluids are given in about 24hours, and soft diet is started when
bowel sounds returned.

Placing warm blankets on the patient to enhance comfort and preserve the patient's
body temperature

Assessing the patient's vital signs, oxygen saturation level, level of consciousness,
circulation, pain, IV site, fluid rate, and hydration status, as well as the status of the
surgical site and dressing and all related monitoring equipment

The nurse helps in relieving the pain by instructing the patient regarding proper
positioning.

The nurse helps in improving the respiratory status by instructing the patient
regarding deep breathing exercises.

34
The nurse also provides skin care like cleaning the incision part and providing clean
dressing following a strict aseptic technique

The nurse instructs the patient about the medications that are prescribed by the
physician

Discussing recommended follow-up management with the physician and the


surgeon

BIBLIOGRAPHY

http://www.aetna.com/cpb/medical/data/300_399/0393.html

NANDA BOOK 12TH EDITION

http://nurseslabs.com/3-glaucoma-nursing-care-plans/

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