Operative Review of Retinal Detachment

8/10/2019 Operative Review of Retinal Detachment

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CHAPTER I

TABLE OF CONTENTS

PAGE

I. INTRODUCTION 1

II. ANATOMY 4

III. PATHOPHYSIOLOGY 7

IV. MEDICAL MANAGEMENT 8

V. DIAGNOSIS 12

VI. PROCEDURE PROPER (with Instrumentation) 15

VII. Roles of Circulating and Scrub nurse 24

VIII. Nursing Management 30

a. Nursing Care Plan

i. Pre-Operative Review

ii. Intra-Operative Review

iii. Post-Operative Review

IX. Pharmacology

i. Pre-operative

ii. Intra-operative

iii. Post-operative

X. Bibliography 37


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Types of Retinal Detachment

Rhegmatogenous retinal detachmentA rhegmatogenous retinal

detachment occurs due to a hole, tear, or break in the retina that allows fluid to pass

from the vitreous space into the subretinal space between the sensory retina and the

retinal pigment epithelium.

Exudative, serous, or secondary retinal detachment An exudative

retinal detachment occurs due to inflammation, injury or vascular abnormalities that

results in fluid accumulating underneath the retina without the presence of a hole, tear,

or break.

Tractional retinal detachmentA tractional retinal detachment occurs

when fibrovascular tissue, caused by an injury, inflammation or neovascularization, pulls

the sensory retina from the retinal pigment epithelium.

A substantial number of retinal detachments result from trauma, including blunt

blows to the orbit, penetrating trauma, and concussions to the head. A retrospective

Indian study of more than 500 cases of rhegmatogenous detachments found that 11%

were due to trauma, and that gradual onset was the norm, with over 50% presenting

more than one month after the inciting injury.

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Prevalence Rate

A physician using a "three-mirror glass" to diagnose retinal detachment

The risk of retinal detachment in otherwise normal eyes is around 5 in 100,000 peryear. Detachment is more frequent in the middle-aged or elderly population with rates of

around 20 in 100,000 per year. The lifetime risk in normal eyes is about 1 in 300.

Retinal detachment is more common in those with severe myopia (above 56

diopters), as their eyes are longer and the retina is stretched thin. The lifetime

risk increases to 1 in 20. Myopia is associated with 67% of retinal detachment

cases. Patients suffering from a detachment related to myopia tend to be

younger than non-myopic detachment patients.

Retinal detachment can occur more frequently after surgery for cataracts. The

estimated of risk of retinal detachment after cataract surgery is 5 to 16 per 1000

cataract operations.The risk may be much higher in those who are highly myopic,

with a frequency of 7% reported in one study.Young age at cataract removal

further increased risk in this study. Long term risk of retinal detachment after

extracapsular and phacoemulsification cataract surgery at 2, 5, and 10 years was

estimated in one study to be 0.36%, 0.77%, and 1.29%, respectively.

3
http://en.wikipedia.org/wiki/Myopiahttp://en.wikipedia.org/wiki/Dioptershttp://en.wikipedia.org/wiki/Dioptershttp://en.wikipedia.org/wiki/Myopia


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Causes of Retinal Detachment

Retinal detachment can occur as a result of:

Trauma Advanced diabetes

An inflammatory disorder, such as sarcoidosis or cytomegalovirus retinitis

Sagging or shrinkage of the jelly-like vitreous that fills the inside of your eye

It is more likely to develop in people who are nearsighted, or whose relatives had

retinal detachments. A hard, solid blow to the eye may also cause the retina to detach.

Severe trauma to the eye, such as a contusion or a penetrating wound, may be the

cause, but in the great majority of cases, retinal detachment is the result of internal

changes in the vitreous chamber associated with aging, or less frequently, with

inflammation of the interior of the eye.

The Risk Factors of Retinal Detachment

The following factors increase your risk of retinal detachment:

Aging retinal detachment is more common in people older than age 40 Previous retinal detachment in one eye

A family history of retinal detachment

Extreme nearsightedness (myopia)

Previous eye surgery, such as cataract removal

Previous severe eye injury or trauma

Weak areas on the sides (periphery) of your retina

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CHAPTER II

ANATOMY

The inner wall of the back of the eyeball is covered by the retina. It contains light

sensitive cells (photoreceptors) and numerous cells and nerve fibers responsible for

transmitting visual information. Below is the pigment epithelium, rich in vessels

(choroid), ensuring the supply of nutrients and oxygen to the retina.

In the event of detachment, the light-sensitive retina becomes detached from theouter membrane (RPE). The vision is thereby impaired: the subjects speak for a

blackout before the eyes. When this process affects the macula (yellow spot) the

point where vision is sharpestbecomes totally blurred vision.


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CHAPTER III

PHYSIOLOGY

The development of rhegmatogenous RD is a consequence of both posterior

vitreous detachment and the development of one or more breaks in the retina. Fluid can

then pass from the vitreous cavity through these retinal breaks into a subretinal space,

which extends the detachment once the amount of incoming fluid exceeds the removal

capacity of the retinal pigment epithelium (RPE). Detachment of the posterior vitreous is

considered a major - in fact indispensable - factor in the pathogenesis of

rhegmatogenous RD. However, no preoperative diagnostic technique can accurately

distinguish between a posterior vitreous detachment and a posterior vitreoschisis.

Progression of the detachment depends on many factors, including:

Location of the break: superior faster than inferior

Size of the break: larger faster than smaller

Adhesion of the remaining vitreous gel to the retina: stronger faster

than weaker

Movement of the patient's head and eyes: this is also important

because lack of such movement, as with bilateral patching, can result

in the reattachment of the retina spontaneously, albeit temporarily.

In eyes with tractional RD, the membranes on either surface of the retina are 1)

attached to the retina, and 2) elastic. As the membranes contract, the retina detaches

from the RPE. Accumulation of the subretinal fluid is a secondary event; as part of the

normal fluid transport from the vitreous to the choroid, the fluid simply fills the space

created by the elevated retina.

In serous and haemorrhagic RD, the fluid that accumulates under the neuroretina

separates it from the RPE.


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CHAPTER IV

MEDICAL MANAGEMENT

Medical Management

Currently, no role exists for medical care in the treatment of TRD.

Surgical Care

Depending on the underlying cause and extent of the TRD, surgical intervention

is offered to patients. For instance, a patient with TRD secondary to PDR that does not

threaten the macula probably can be monitored closely. The main surgical goal in all

these cases is to relieve vitreoretinal traction. Traction may be relieved with scleral

buckling techniques and/or with vitrectomy.

In certain cases, combined RRD and TRD may be present. Usually, the retina

becomes detached from the vitreoretinal traction. With further traction, small breaks

may occur causing a combined TRD-RRD. In these cases, the surgical goal is to

identify all the breaks and to close them in addition to the relief of vitreoretinal traction.

In TRD secondary to PVR, usually a broad circumferential element, such as a

287 buckle, is placed. A decision is made whether the crystalline lens needs to

be sacrificed. A complete vitrectomy follows. Inside-out (posterior to anterior)

forceps (not pick) membrane peeling is the preferred dissection method with or

without perfluorocarbon liquid injection. Perfluorocarbon liquid may be injected at

the surgeon's discretion to stabilize the posterior retina. If residual traction

remains, subretinal membranes may need to be excised if causing traction. If

necessary, a relaxing retinectomy is created. A fluid-air exchange is performed.

Endophotocoagulation is followed by either air-silicone oil exchange or air-gas

exchange. If perfluorocarbon liquids are not used, the dissection starts anteriorly

and proceeds posteriorly.


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A randomized controlled clinical trial of a perioperative infusion of 5-fluorouracil

and low molecular weight heparin was not able to demonstrate a better surgical

outcome in eyes with established PVR.

In TRD secondary to PDR, several surgical techniques have been developed. A

scleral buckle usually is not used unless anterior breaks are present.

A central vitrectomy is performed with the vitrector clearing the axial opacities

and the cortical vitreous gel. A large opening is created in the posterior hyaloid

until vitreoretinal adhesions are encountered. Segmentation and/or delamination

of these adhesions (as described by Charles) are used for virtually all diabetic

TRD.

Delamination refers to the separation of the retina from the extraretinal

proliferation. This dissection proceeds from posterior to anterior. Fibrovascular

tissue often bridge separate retinal zones. Segmentation refers to cutting of the

fibrovascular tissue bridge into small separate islands of tissue.

Care must be given to create as few iatrogenic breaks as possible. If breaks are

identified, usually fluid-air exchange with photocoagulation reattaches the retina.

Breaks should be marked with diathermy, so they are identified easily in the air-

filled eye. The incidence of RRD in patients who underwent vitrectomy for PDR

has been reported to be 4.3%. Intraocular bleeding also must be monitoredclosely. Diathermy to active neovascular fronds may be necessary.

Other techniques include the en bloc dissection. En bloc is a name applied to

outside-in delamination where the vitreous is used to pull on the epiretinal

membrane. Outside-in causes more retinal breaks than inside-out, making it a

dangerous maneuver.

Intravitreal bevacizumab has been reported as a preoperative adjunct in

vitrectomy for PDR. Bevacizumab seems to reduce the bleeding associated with

the segmentation and delamination of fibrovascular membranes. However, in

eyes with severe ischemia, the neovascularization regresses rapidly, but the

resulting fibrous scar tissue may lead to the development or progression of TRD.

Therefore, caution should be exercised when injecting these eyes, and patients

should be scheduled for surgery days, and not weeks, after the injection.


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Anti-VEGF agents such as bevacizumab have been used as adjuncts to

vitrectomy. The advantages of using preoperative bevacizumab includes faster

surgery and reduced risk of intraoperative bleeding, which facilitates membrane

dissection.[8, 9, 10, 11] Care must be taken because it has been reported that, in

very ischemic eyes, TRD may occur or progress shortly following intravitreal

bevacizumab.[9, 10] It is speculated that rapid neovascular involution with

accelerated fibrosis and posterior hyaloidal contraction as a response to

decreased levels of VEGF is responsible for this phenomenon. In this

retrospective series, the time from injection to TRD was a mean of 13 days, with

a range of 3-31 days.[9] Therefore, the time between bevacizumab injection and

vitrectomy should not exceed 3 days.

The treatment of TRD secondary to ROP depends on the stage of the disease.

Although many vitreoretinal surgeons advocate an encircling band for stage 4A

ROP, no scientific evidence is available that supports its efficacy. In stage 4B,

vitrectomy is recommended. It is currently unclear if lens-sparing vitrectomy has

any advantages over lensectomy.

For stage 5 ROP, visual and anatomical results have been disappointing, making

some surgeons abandon surgery for these cases. Others have tried vitrectomy

and lensectomy with or without scleral buckling. In these cases, a 2-portvitrectomy technique is recommended since the small size of the eye and orbit

limits ocular manipulation if a 3-port technique is used. The use of intravitreal

triamcinolone as a postoperative adjuvant might improve the rate of retinal

reattachment after vitrectomy.

A recent case series of aggressive posterior ROP suggested that early

vitrectomy with lensectomy in these cases is effective in preventing TRD.

Special attention must be given to avoid iatrogenic retinal breaks because of the

poor prognosis associated with this complication. The goal of surgery is to obtain

macular reattachment.

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CHAPTER V

DIAGNOSIS

History

Patients who present with symptoms of new onset photopsias, floaters or visual

field loss should be suspected of having a retinal tear or detachment until proven

otherwise. Important information in the history includes onset of symptoms, duration of

decreased visual acuity, metamorphopsia, any prior trauma, prior surgery, intraocular

inflammation, hemorrhage, glaucoma and a complete past medical history and review of

systems.

Physical examination

Visual acuity, pupillary examination, visual field testing and intraocular pressure

measurement are important parts of the predilated ophthalmic examination to evaluate

patients with symptoms of retinal detachment. Additional examination to include color

vision and ocular motility should be tailored according to the history provided.

Slit lamp examination of the anterior segment should be completed prior to

dilation. Examination of the vitreous for pigment cells followed by a thorough fundus

examination to include indirect ophthalmoscopy with scleral depression should be

completed. A detailed drawing describing the detachment with location of retinal

pathology should be documented.

If there is no view to the posterior pole such as in hemorrhage or media opacity,ultrasound should be used to evaluate the retinal status.


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Clinical diagnosis

Rhegmatogenous retinal detachment has a characteristic appearance

differentiating it from a tractional or serous detachment. A rhegmatogenous retinal

detachment has a corrugated appearance and undulates with eye movements.

Tractional detachments have smooth concave surfaces with minimal shifting with eye

movements. Serous detachments show a smooth retinal surface and shifting fluid

depending on patient positioning.

Laboratory/Ancillary testing

Laboratory testing is only indicated in traction or exudative detachments. If a

cause for the traction retinal detachment cannot be determined by history, furtherlaboratory analysis may be required to determine if diabetes, sickle cell, carotid disease

or another systemic or ocular process is the source for proliferative retinopathy.

Since exudative detachments may be due to a systemic or ocular inflammatory

process, laboratory investigation may be indicated.

Fluorescein angiography may be indicated to further clarify exudative processes

such as macular degeneration, central serous chorioretinopathy, and Vogt-Koyanagi-

Harada syndrome or other uveitic processes. Ultrasound is a useful imaging modality to

evaluate choroidal masses or posterior scleritis.

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CHAPTER VI

PROPER PROCEDURE

Pars Plana Vitrectomy

Patients are brought to the operating room in an eye bed that has an appropriate

head rest and the capability to have a wrist rest secured to it. Once the bed is

positioned next to the operating microscope and locked, the bed is made completely

flat, and the patient is positioned so that the head lies comfortably on the head rest.

The wrist rest is then appropriately secured so that its height is at the level of the

patients zygoma and the apex of the patients head is about 1 cm from the rest. The

patients arms should be appropriately secured so that they do not hang off the side of

the bed. A bed sheet can be wrapped around the patients torso and secured with

hemostats to prevent inadvertent movement during the procedure.

Either the older 20-gauge system or the newer 23- and 25-gauge systems may be used

for vitrectomy. Certain technical details are specific to the vitrectomy system used.


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The conjunctiva and tenon layer are incised to expose the sclera. This is done with

Westcott scissors superonasally, superotemporally, and inferotemporally. Once bare

sclera is exposed, light cauterization is applied over the planned sclerotomy sites to

obtain hemostasis.

A caliper is then used to measure 4 mm from the limbus in phakic eyes and 3.5

mm in pseudophakic or aphakic eyes in the inferotemporal quadrant. This distance is

marked on the sclera with the caliper, and 7-0 or 8-0 double-armed polyglactin suture is

used to place 2 radial bites on either side of the mark. These bites should be about 1.5

mm long and 1.5 mm from each other. The suture is cut so as to leave tails

approximately 2 cm long on each side

Instruments used in Pars plana vitrectomy

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Equipment

Pars plana vitrectomy requires highly specialized equipment that is found only in an

operating room (OR) that is specially equipped for vitreoretinal surgery. Generally, the

following are needed:

An eye bed on which a wrist rest for the surgeon can be secured

An operating microscope

A mechanical vitrector

A wide-angle viewing system

Calipers

Westcott scissors, forceps, and needle holders

An argon indirect laser or endolaser device

An endoillumination system

A bipolar cautery

Intraocular instruments (eg, forceps, scissors, and flute needle)

Scleral depressor

Sulfur hexafluoride (SF6) and octafluoropropane (C3F8) gases

Silicone oil

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CHAPTER VII

ROLES OF CIRCULATING AND SCRUB NURSE

Roles of a Circulating Nurse

The Circulating nurse is responsible for managing the nursing care of the patient within

the OR and coordinating the needs of the surgical team with other care provider

necessary for completion of surgery,

Observes the surgery and surgical team from broad perspective and assists the team tocreate and maintain a safe and comfortable environment for the patient

Asses the patients condition before, during and after the operation to ensure an optimal

outcome for the patient and;

Must be able to anticipate the scrub nursesneeds and be able to open sterile packs,

operate machinery and keep accurate records

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Duties of a circulating nurse

Before an operation

Checks all equipment for proper functioning such as cautery machine, suction

machine, OR light and OR table

Make sure theater is clean

Arrange furniture according to use

Place a clean sheet, arm board (arm strap) and a pillow on the OR table

Provide a clean kick bucket and pail

Collect necessary stock and equipment

Turn on aircon unit

Help scrub nurse with setting up the theater

Assist with counts and records

During the Induction of Anesthesia

Turn on OR light

Assist the anesthesiologist in positioning the patient

Assist the patient in assuming the position for anesthesia

Anticipate the anesthesiologists needs

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After the patient is anesthetized

Reposition the patient per anesthesiologists instruction

Attached anesthesia screen and place the patients arm on the arm boards

Apply restraints on the patient

Expose the area for skin preparation

Catheterize the patient as indicated by the anesthesiologist

Perform skin preparation

During Operation

Remain in theater throughout operation

Focus the OR light every now and then

Connect diatherapy, suction, etc.

Position kick buckets on the operating side

Replenishes and records sponge/ sutures

Ensure the theater door remain closed and patient s dignity is upheld

Watch out for any break in aseptic technique

End of Operation

Assist with final sponge and instruments count

Signs the theater register

Ensures specimen are properly labeled and signed

After an Operation

Hands dressing to the scrub nurse

Helps remove and dispose of drapes

Helps to prepare the patient for the recovery room

Assist the scrub nurse, taking the instrumentations to the service (washroom)

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Roles of a Scrub nurse

Works directly with surgeon within the sterile field, passing instruments, sponges

and other items needed during the procedure

Members of the surgical team who prepares and preserves a sterile field in which

the operation can take place

Responsible for the sponge counts, the blades and needles and instruments

check throughout the operation

Has a job requiring anticipation, quick reaction and conscientious observation as

well as knowledge of anatomy and of operative procedures

Duties of a Scrub Nurse

Before an operation

Ensures that the circulating nurse has checked the equipment

Ensures that the theater has been cleaned before the trolley is set

Prepares the instruments and equipment needed in the operation

Uses sterile technique for scrubbing, gowning and gloving

Receives sterile equipment via circulating nurse using sterile technique

Performs initial sponges, instruments and needle count, checks with circulating nurse

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When surgeon arrives after scrubbing

Perform assisted gowning and gloving to the surgeon and assistant surgeon as

soon as they enter the operation suite

Assemble the drapes according to use. Start with towel, towel clips, draw sheet

and then lap sheet. Then, assist in draping the patient aseptically according to

routine procedure

Place blade on the knife handle using needle holder, assemble suction tip and

suction tube

Bring mayo stand and back table near the draped patient after draping is

completed

Secure suction tube and cautery cord with towel clips or allis

Prepares sutures and needles according to use

During an operation

Maintain sterility throughout the procedure

Awareness of the patients safety

Adhere to the policy regarding sponge/ instruments count/ surgical needles

Arrange the instrument on the mayo table and on the back table

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Before the Incision Begins

Provide 2 sponges on the operative site prior to incision

Passes the 1st knife for the skin to the surgeon with blade facing downward and

a hemostat to the assistant surgeon

Hand the retractor to the assistant surgeon

Watch the field/ procedure and anticipate the surgeons needs

Pass the instrument in a decisive and positive manner

Watch out for hand signals to ask for instruments and keep instrument as clean

as possible by wiping instrument with moist sponge

Always remove charred tissue from the cautery tip

Notify circulating nurse if you need additional instruments as clear as possible

Keep 2 sponges on the field

Save and care for tissue specimen according to the hospital policy

Remove excess instrument from the sterile field

Adhere and maintain sterile technique and watch for any breaks

End of Operation

Undertake count of sponges and instruments with circulating nurse

Informs the surgeon of count result

Clears away instrument and equipment

After operation: helps to apply dressing

Removes and siposes of drapes

De-gown

Prepares the patient for recovery room

Completes documentation

Hand patient over to recover room

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CHAPYTER X

BIBLIOGRAPHY

Books:

Medical Surgical Nursing by Brunner and Suddarths 12 Edition Volume 1 and 2

MIMS 2011

Nurses Pocket Guide 11thEdition by Alice Murr

Sources:

http://www.mayoclinic.org/diseases-conditions/retinal-detachment/in-depth/CON-

20022595

http://en.wikipedia.org/wiki/Retinal_detachment

http://emedicine.medscape.com/article/798501-overview

http://emedicine.medscape.com/article/798501-overview#a0101

http://www.medicinenet.com/retinal_detachment/article.htm

http://www.nhs.uk/conditions/retinal-detachment/Pages/Introduction.aspx
http://www.mayoclinic.org/diseases-conditions/retinal-detachment/in-depth/CON-20022595http://www.mayoclinic.org/diseases-conditions/retinal-detachment/in-depth/CON-20022595http://www.mayoclinic.org/diseases-conditions/retinal-detachment/in-depth/CON-20022595http://en.wikipedia.org/wiki/Retinal_detachmenthttp://en.wikipedia.org/wiki/Retinal_detachmenthttp://emedicine.medscape.com/article/798501-overviewhttp://emedicine.medscape.com/article/798501-overviewhttp://emedicine.medscape.com/article/798501-overview#a0101http://emedicine.medscape.com/article/798501-overview#a0101http://www.medicinenet.com/retinal_detachment/article.htmhttp://www.medicinenet.com/retinal_detachment/article.htmhttp://www.nhs.uk/conditions/retinal-detachment/Pages/Introduction.aspxhttp://www.nhs.uk/conditions/retinal-detachment/Pages/Introduction.aspxhttp://www.nhs.uk/conditions/retinal-detachment/Pages/Introduction.aspxhttp://www.medicinenet.com/retinal_detachment/article.htmhttp://emedicine.medscape.com/article/798501-overview#a0101http://emedicine.medscape.com/article/798501-overviewhttp://en.wikipedia.org/wiki/Retinal_detachmenthttp://www.mayoclinic.org/diseases-conditions/retinal-detachment/in-depth/CON-20022595http://www.mayoclinic.org/diseases-conditions/retinal-detachment/in-depth/CON-20022595

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Operative Review of Retinal Detachment