Role of OA in assisting speciality surgeries

DCR

Pre op work up

• Syringing / Probing
• BP
• RBSL
• Blood tests like : Hb, BT,CT, Blood group and type, ESR
• HIV
• Counselling / consent

Steps involved in the surgery

• Cleaning : The eye and the nose and most of the cheek and forehead are cleaned
• Draping : Two sterile towels are used for draping,one partially wrapped around the head and covering the other eye, and the other covering the nose and mouth up to the chest. Towel clips/artery forceps are used for anchoring the drapes
• Nasal cavity is packed with adrenaline soaked guaze after putting xylocaine jelly
• Skin incision given
• Blunt dissection is done
• The Medical canthal xendon is divided
• Periosteum is reflected off the nasal bone
• Osteotomy is made and enlarged
• Probe is passed to locate the lacrimal sac
• The anterior sac mucosa is cut to form a rectangular flap. The posterior part of the sac is excised
• The nasal mucosal flap is made
• The two flaps are anastomosed using three interrupted sutures of 6-0 vicryl
  
• Duct patency is checked
• Muscle layer is closed with 6-0 vicryl and skin with 4-0 silk

Instruments

• For nasal packing
  • - Thudicums nasal speculum
  • - Nose packing forceps
  • - Nose pack (Thin length of gauze soaked in Adrenaline 1:100,000)]
• For local infiltration
  • - A 5 cc syringe with disposable needle (with 3-5 cc of 2% xylocaine)
• For surgery
  • - No 15 blade with BP handle
  • - Artery forceps
  • - Cat's paw retractors
  • - Freer periosteal elevator
  • - Forceps – toothed, plain
  • - Kerrison Bone punch
  • - Punctum dilator
  • - Probe
  • - No 11 blade on BP handle
  • - Westcott spring handled scissors
  • - Needle holder
  • - 6-0 vicryl and 4-0 silk sutures on needle
  • - 2cc syringe with cannula for syringing

Dacryocystectomy (DCT)

Steps

• Painting and draping is done
• Local anaesthetic is injected
• Skin incision is put in medial canthal area with no.15 blade
• Wound retracted with cat's paw retractors
• Blunt dissection is done with mosquito and artery forceps and lacrimal sac is identified after probing
• The sac is separated from surrounding tissue with sharp and blunt dissection and removed.
• Betadine wash is given
• The wound is sutured with 4-0 silk

Instruments

• No.15 blade
• Two cat's paw retractors
• Mosquito forceps
• Sac dissector
• Toothed forceps
• Bowman's probe
• Scissors
• Artery forceps
• 4-0 silk suture

Special considerations

• Pre operative
  • As DCR (like most orbital and lacrimal surgeries) may involve significant blood loss, pre-op testing (like BP, Hb, BT, CT, HIV, Blood grouping and typing) is very important.
  • Conditions like bleeding disorders, uncontrolled diabetes and hypertension, cardiac disease,asthama etc should be properly treated before the patient is taken up for surgery. If such conditions are present a physician's opinion should be taken and fitness for surgery confirmed.
  • The surgery may be done under general anaesthesia or local anaesthesia. For children,mentally unfit or deaf patients, general anaesthesia is given. For apprehensive patients or people with low pain tolerance, counselling should be done. If reasonably co-operative, local anaesthesia or IV sedation are used, otherwise general anaesthesia is planned.
• Intra operative
  • The surgical field has to be kept as clear as possible. Oozing blood has to be continuously mopped. Suction or cautery may have to be used and should be kept ready.
  • The patient should be monitored throughout the surgery. If available, pulse oximeter should be attached before local anaesthesia is given.
  • In case of severe Intra operative bleed, the patients' BP should bes checked and controlled. BP apparatus and O2 cylinder should be available in Operation theatre.
  • Intubation should be available as it may be required in case of intra-operative complications like loss of flaps etc.
• Post operative
  • Some patients may develop bleeding through nose/mouth in the post-op period. If the blood is mostly clotted, the patient should be reassured and instructed to lie supine for a while. BP should be checked and controlled.

Some patients may develop bleeding through nose/mouth in the post-op period. If the blood is mostly clotted, the patient should be reassured and instructed to lie supine for a while. BP should be checked and controlled.pillows. Severe bleeding may require by injection Botropase, IV fluids and suction and repacking.

Glaucoma surgeries

Cornea surgeries