Caring for the ophthalmic surgical patient offers unique challenges to the perianesthesia nurse. It requires a thorough understanding of not only the surgical aspect of the patient’s care, but also the pharmacologic, physiologic, and emotional concerns. As the need for maintaining quality patient care and controlling overall medical costs continues to grow, many surgical advances have taken the most complex of ophthalmic procedures from hospital-based operating rooms to free-standing ambulatory surgery centers, thus enabling more patients to return home within 24 hours of surgery.¹ This trend alone necessitates that the perianesthesia nurse have a fundamental knowledge base to anticipate an array of patients’ preoperative and postoperative needs. Recognizing and treating a variety of complex symptoms and complications, providing sufficient patient education, and planning discharge are just a few of the many needs with which the perianesthesia nurse will have to contend on a daily basis. Ophthalmic surgical patients vary widely in age. Any age-appropriate special needs or medical concerns should be identified by the perianesthesia nurse during the preadmission evaluation time. Knowledge of comorbidities in elderly patients becomes even more important when the amount of time with each patient is limited. Hypertension, diabetes mellitus, coronary artery, cerebral vascular, and renal disease are just a few examples. Despite the fact that ophthalmic surgery is most common in the elderly, advances in anesthesia, surgical techniques, and surgical instrumentation have allowed the most sophisticated procedures to be performed on the most fragile of the pediatric population (i.e., premature infants and neonates).² Normal growth and development in the pediatric patient should be assessed and any variances should be noted. These comorbidities and other factors may predispose patients to sudden and potentially life-threatening postoperative complications.³ Close attention to the preoperative assessment is of utmost importance. Working with this wide range in patient population, certifications in advanced cardiac life support (ACLS) and pediatric advanced life support (PALS) are essential in the educational foundation for the perianesthesia nurse.

Preoperative evaluation

Preadmission evaluations are a critical tool for the perianesthesia nurse. Many hospitals and free-standing ambulatory surgery facilities have established preadmission testing clinics with guidelines designed for this purpose. The goals of the preoperative evaluation in the surgical patient is to obtain informed consent, perform physical assessments, arrange for laboratory tests and any necessary consultations, prescreen for any diseases, and provide patient education to reduce patient and caregiver anxiety. Upon evaluation, if the need for further medical testing arises, the patient can then be referred to their primary care physician or to a subspecialty to obtain medical clearance.⁴ A preadmission evaluation can decrease cancellations, provide ample time to establish rapport, and assess for any psychological or psychosocial needs that can be addressed before the actual day of surgery. In a 10-year observational study, Jiménez and colleagues⁵ concluded that 57.1% of surgical cases that were cancelled had a preventable or possibly preventable cause. With preadmission evaluations, this percentage can be greatly reduced, thereby decreasing the anxiety and frustration level of patients, caregivers, and health care team members on the day of surgery.

Ophthalmic medications

Most ophthalmic medications are administered topically in highly concentrated solutions (Table 33-1). Because of the highly vascular nature of the conjunctival sac and the nasolacrimal duct leading to the vascular mucosa of the nasopharynx, undesirable systemic effects can be caused by the rapid systemic absorption of topical solutions that are administered.⁶ These medications can also significantly alter a patient’s reaction to anesthetic drugs, thus causing changes in the intraocular dynamics.¹ It is essential that the perianesthesia nurse learn to identify these medications and their potential systemic effects. The elderly patient is at higher risk for these severe systemic effects. This age group takes a higher number of prescription medications and undergoes a higher percentage of eye surgeries than any other age group.⁷

Table 33-1 Ophthalmic Medications

In order to easily identify the specific classifications of topical ocular medications, the American Academy of Ophthalmology (AAO), with input from pharmaceutical companies and the U.S. Food and Drug Administration (FDA), developed a universal color-coding system to distinguish between all topical ophthalmic medications. The color-coded system identifies every pharmaceutical class with its own unique cap-and-label color scheme (Table 33-2). With the introduction and implementation of the voluntary color-coding system, the AAO expects to “decrease the amount of serious adverse events resulting from patients (and medical personnel) difficulty in distinguishing between various ocular medications.”⁸ The threefold partnership of voluntary cooperation between the FDA, the pharmaceutical industry, and the AAO has proved effective and advantageous in the primary interest of patient safety since its inception.

Table 33-2 Ophthalmic Medication Color-Coding System

CLASS	COLOR
Adrenergic agonists	Purple
Antiinfectives, antimicrobials, antivirals, antifungals	Tan
Antiinflammatories, steroids	Pink
β-Blockers	Yellow
β-Blocker combinations	Dark Blue
Carbonic anhydrase inhibitors	Orange
Miotics	Dark Green
Mydriatics and cycloplegics	Red
Nonsteroidal antiinflammatories	Gray
Prostaglandin analogues	Turquoise

Preoperative phase

Patients undergoing eye surgery have more apprehension and will need more constant verbal communication and reassurance.⁹ Using this opportunity, the perianesthesia nurse should review any preoperative education and postoperative instructions with the patient and any caregivers present. Expectations regarding the operative procedure’s outcome should also be explored. It is important that the patient and caregiver have realistic expectations. The more information and education that can be given to a patient and caregiver about the anticipated perioperative and postoperative course, the less amount of anxiety the patient will have and the fewer antianxiety medications that will be required.¹⁰ All preoperative lab work, medical tests, and clearance letters should be reviewed to ensure that all paperwork is in order and placed on the chart. The nurse should also verify each patient’s name, the operative eye, and procedure to be performed. Planned preoperative medications should be discussed. Depending on the type of ophthalmic procedure to be performed, ophthalmic medications may be administered in the preoperative holding area. A significant reduction of systemic absorption can be achieved by occluding the nasolacrimal duct by pressing on the inner canthus of the eye or closing the eyelids for at least 3 minutes immediately following the administration of ophthalmic medications. Doing so will reduce the chances of undesirable systemic side effects.¹

Anesthetic options

The determination of the type of anesthesia to be used belongs to the surgeon, the anesthesia provider and, most importantly, the patient. Factors that influence this decision are the type and length of the procedure to be performed, the physical status of the patient, and the ability of the patient to remain still. Local anesthesia can appear less stressful and more beneficial to some patients, but to others the thought of being awake while having eye surgery is terrifying. For those patients, general anesthesia is safer and more acceptable. Children and other uncooperative adults also benefit from general anesthesia. Lack of patient cooperation and head or body movements could result in poor outcomes.

Local anesthesia can range from the topical instillation of 0.5% tetracaine anesthetic drops to an injection of a local anesthetic. A patient with a relatively quick surgeon performing a simple anterior chamber cataract removal (Fig. 33-1), intraocular lens implantation (Fig. 33-2), or glaucoma procedure (Fig. 33-3) could have a topical anesthetic, provided the patient is cooperative. Intracorneal anesthesia is also used for cataract surgery. The surgeon injects a local anesthetic directly into the anterior chamber of the cornea where anesthesia is needed. The most common regional anesthetic techniques used in eye surgical cases are the peribulbar and retrobulbar blocks. These blocks are performed by the surgeon or the anesthesia provider after sufficient sedation has been given. A 23- to 25-gauge retrobulbar (blunt-tipped) needle is used to inject 2 to 5 mL of local anesthetic either into the peribulbar or retrobulbar space. Lidocaine 2% and bupivacaine 0.75% are the most common local anesthetics used. Epinephrine (1:200,000 or 1:400,000) may be premixed into the local anesthetic to cause vasoconstriction of the blood vessels, thus reducing bleeding and decreasing the absorption rate of the local anesthetic. It is important that the perianesthesia nurse be aware of these techniques and potential side effects, because assistance may be needed with the application of a local anesthetic. An eye that has had a successful retrobulbar block will not move during head turning. Complications are rare but can include: hemorrhage, globe perforation, optic nerve injury, oculocardiac reflex, instantaneous convulsions, and respiratory arrest. Other local blocks used alone or in conjunction with the peribulbar or retrobulbar blocks are the subtenon block and the facial nerve block. It is imperative that the patient be closely monitored for any signs or symptoms of any complications while they are in the preoperative area.⁶

FIG. 33-1 Microincision phacoemulsification is a technologic advance that allows surgeon to operate through wounds nearly half the size of usual phacoemulsification.

(From Alio J, et al: Outcomes of microincision cataract surgery versus coaxial phacoemulsification, Ophthalmology 112(11):1999, 2005.)

FIG. 33-2 Examples of intraocular lens implants used today.

(Courtesy Wills Eye Hospital, Philadelphia, Penn.)

FIG. 33-3 Presurgical illustration of an anterior chamber in a glaucoma patient.

(Courtesy National Eye Institute, National Institutes of Health, Bethesda, Md.)

Perioperative phase

Numerous ophthalmic procedures are performed routinely. Most procedures are performed on an outpatient basis. A few exceptions include true ophthalmic emergencies such as chemical burns of the cornea, central retinal artery occlusion, open-globe injuries, endophthalmitis, acute narrow-angle glaucoma, acute retinal detachment (Fig. 33-4), corneal foreign body, and lid lacerations. These emergencies require surgical treatment within one to several hours. However, these procedures do not always necessitate an overnight admission to the hospital. If the patient is stable and able to meet discharge criteria, most physicians will discharge the patient, and schedule an appointment the following morning in the office. Semiurgent situations would include ocular tumors, blowout fractures of the orbit, congenital cataract (Fig. 33-5), and chronic retinal detachment. Treatment for these types of situations is usually started within days of the initial injury, but can be rescheduled for several weeks after an incident. Another reason for an overnight hospital admission would be for a prolonged procedure on a pediatric patient or a patient with an extensive medical history.²

FIG. 33-4 Retinal detachment in Von Hippel-Lindau disease.

(Courtesy National Eye Institute, National Institutes of Health, Bethesda, Md.)

FIG. 33-5 A white congenital cataract.

(Courtesy National Eye Institute, National Institutes of Health, Bethesda, Md.)

Whatever the procedure to be performed, the risk of stimulating the oculocardiac reflex (OCR) is present. This reflex is a trigeminovagal reflex arc. It is elicited by traction on the extraocular muscles, especially the medial rectus muscle, or by placing pressure directly on the globe. This reflex causes a sudden bradycardia and cardiac dysrhythmias, such as ventricular ectopy, sinus arrest, or ventricular fibrillation. Hypotension will usually accompany this sudden decrease in heart rate. Atropine or glycopyrrolate given before surgery intravenously (IV) can often aid in preventing the reflex. OCR is most commonly seen during strabismus surgery in the pediatric population. The reflex can occur during certain retinal or glaucoma procedures during which traction is applied to the rectus muscles. Nevertheless, the reflex is still present at any age and can be triggered by any ophthalmic procedure. When the reflex occurs, cessation of the surgical stimulation should provide relief within 10 to 20 seconds. Atropine (10 to 20 mcg/kg) or glycopyrrolate (10 mcg/kg) can also be administered if bradycardia persists. The use of retrobulbar blocks can aid in reducing the incidence of OCR; however, the reflex can also be triggered at the time of placement of the regional blockade. OCR is self-limiting, in that when the stimulation has ceased, the bradycardia will end. When normal sinus rhythm has return within 10% of the baseline heart rate, it is safe to proceed.¹⁰

Postoperative phase

Upon arrival to the postanesthesia care unit (PACU), the anesthesia provider will give report to the PACU nurse. Report should include the procedure that was performed, any pertinent medical history of the patient, and any significant perioperative medications or events that have occurred. The PACU nurse will administer oxygen to the patient via a face mask and monitor the patient’s heart rate and rhythm, blood pressure, oxygen saturation, temperature, and level of consciousness. The patient’s condition will continually be monitored during this initial phase of recovery. The patient will typically respond to verbal stimuli and begin to follow commands within a short period of time. The level of postoperative care that a patient is required to have is determined by the “degree of underlying illness, the duration and complexity of anesthesia and surgery, and the risk of postoperative complications.”¹¹

As the patient emerges from general or regional anesthesia with sedation, the incidence of postoperative nausea and vomiting (PONV) is higher in the ophthalmic surgical patient than in other surgical procedures.⁶^,¹¹ Other factors that can cause PONV are dehydration, hypotension, and pain. PONV avoidance should be a high priority. Antiemetics given perioperatively assist in decreasing the amount of PONV; however, ondansetron (2 to 4 mg IV) can be given as prophylaxis in the PACU, if not previously given.

If PONV persists, patients will not respond to a second dose of ondansetron because targeting an already blocked receptor is ineffective.² Promethazine (12.5 to 25 mg IV) is the next optimal choice. Another virtually unknown alternative treatment was studied by Pellegrini and colleagues.¹² In this comparison study, the inhalation of 70% isopropyl alcohol (IPA) from a standardized alcohol pad was used to successfully treat breakthrough PONV, after prophylactic treatment with ondansetron. The IPA group reported a faster time in reduction of PONV and an overall decrease in the antiemetic requirements. The implications of this study are fascinating, and the option of using IPA inhalational therapy for PONV is a viable one.

Evidence-Based Practice

In a randomized controlled study, Pellegrini and colleagues ¹² evaluated the efficacy of using 70% isopropyl alcohol (IPA) in the treatment of postoperative nausea and vomiting (PONV) in two separate groups of patients that were high-risk for PONV. Patients were selected and randomly assigned into two different groups. Both groups received general anesthesia using similar medications and intravenous (IV) ondansetron intraoperatively before extubation. When the patients arrived in the postanesthesia care unit (PACU), the control group was given promethazine (12.5 to 25 mg IV) upon complaints of nausea. This dose could be repeated in 30 minutes up to a total dose of 50 mg IV. The experimental group of patients was treated with a commercially available 70% IPA pad upon complaints of nausea. The IPA pad was folded in half and placed 0.5 inches from the nares of the patient. The patient was then instructed to deeply inhale three times through their nose. The IPA treatments were to be given every 15 minutes for three applications. Demographics, a verbal numeric rating scale (VNRS) for nausea, the time it took to achieve a 50% reduction in the VNRS scores, and the overall antiemetic incidence of PONV per group were measured. The results showed no differences in the demographic variables or the baseline measurements between groups. There was a similar incidence in PONV between groups. However, the IPA group reported a faster overall time to 50% reduction in VNRS scores when compared to the control group. In addition, a decrease in the overall antiemetic requirements of the IPA group was noted.

Implications for practice

The overall effectiveness of IPA therapy in the treatment of PONV in high-risk postoperative patients is clearly shown in this study. The perianesthesia nurse should endeavor to seek the latest research information in regard to practical treatment modalities that would be beneficial to the patient. It is evident that IPA inhalation therapy can assist in alleviating PONV.

Source: Pellegrini J, et al: Comparison of inhalation of isopropyl alcohol vs promethazine in the treatment of postoperative nausea and vomiting (PONV) in patients identified as at high risk for developing PONV, AANA J 77:293–299, 2009.

Not all ophthalmic surgical patients will have postoperative pain. Patients who receive examinations under anesthesia, cataract removal, nasolacrimal duct probing, and some glaucoma surgery, pain is usually minimal. Topical and regional anesthetics are beneficial in that they will typically last throughout the procedure and into the immediate postoperative period. This will allow the patient to progress rapidly into phase II of recovery, from which discharge will be possible within a short amount of time. These patients typically arrive in the PACU awake and alert.¹³ It is expected for those having longer ophthalmic procedures under general anesthesia to experience a moderate amount of pain. Opioid analgesics can cause nausea and vomiting, but the importance of controlling pain in the postoperative period takes priority. Opioid analgesics can also help to reduce coughing and decrease the incidence of emergence delirium in pediatric patients. Giving intravenous nonsteroidal antiinflammatory medications can also be a feasible option for controlling postoperative pain. Ketorolac (0.5 mg/kg) IV can be as effective as fentanyl (1 mcg/kg) or morphine (0.1 mg/kg) for postoperative pain in strabismus surgery patients without increasing PONV. Ketorolac has several advantages over opioids, in that it does not cause respiratory depression, sedation, or nausea and vomiting. A single dose will last approximately 6 to 8 hours. Conversely, ketorolac is eliminated through the kidneys and should not be given to patients with renal disease.¹¹

Depending on the procedure, the patient will usually have some type of sterile dressing or patch covered by an eye shield over the operative eye (Fig. 33-6). It is imperative that this dressing is not disturbed by the patient. Damage can be done to delicate sutures, resulting in excessive bleeding and possibly an unexpected return to the operating room. Continual reorientation and vigilant observation of the patient is necessary to prevent rubbing the eyes or removing the dressing. A small amount of serosanguineous drainage can be expected. Reinforcement of the initial sterile dressing is appropriate. If the dressing becomes saturated or is removed in any way, the surgeon will need to be notified immediately to assess the operative eye and to replace the dressing.