Those involved with patient care for operative patients should be familiar with the preoperative and postoperative routines for management of the eye patient. Such a patient must feel secure that the case is being dealt with professionally from the time the decision is made to have surgery until postoperative management is complete. A single error, such as giving the patient the wrong date of surgery, will only increase the patient’s anxiety and undermine his or her confidence in the physician. Operative routines should be well explained so that at each phase the patient knows exactly what to expect.
This chapter deals with the total management of the patient’s care before surgery and during the postoperative period.
Arrangements for the operation
The person who makes the booking and arrangement of admission to the appropriate hospital or surgical center has been delegated a great deal of responsibility ( Fig. 31.1 ). Each operative procedure involves a dislocation in the patient’s life. The patient will be required to take time off from work, school, or homemaking and to make arrangements for someone to fill his or her place in the performance of regular duties. Therefore it is helpful if the patient is asked beforehand which date is most convenient to schedule the necessary surgery.
In addition to scheduling time for surgery according to the convenience of the patient, the ophthalmic assistant should prepare the surgical schedule according to the convenience of the surgeon. The assistant must know the duration of each operative procedure so that a surgical schedule will not be unreasonably crowded, as well as the number of surgeries the ophthalmologist can perform and follow each week without creating a strain.
The ophthalmic assistant often may be responsible for obtaining a properly signed consent form. It is important that this be reviewed carefully with the patient and all questions answered. Three types of operative bookings require special attention: emergency admission, urgent admission, and elective admission.
The emergency patient is one who experiences a serious ocular or periocular calamity, usually from trauma, and because of the nature of the condition must be treated by surgery without delay. This type of patient does not have the time to adjust psychologically to the onset of the illness or to the necessary treatment. This patient is usually anxious, agitated, often confused, and commonly in a great deal of pain, as well as emotionally disturbed because of the loss of vision. Because the patient cannot be psychologically prepared for surgery, prime attention is focused on the orderly transfer of the patient from the office to the hospital’s emergency room. None of the details of the transfer should ever be left to the patient. Relatives or friends should be called and transportation to the hospital or surgicenter area arranged through them. They can also, at a later date, bring the patient’s personal articles and take care of the patient’s personal commitments. If in a hospital, the emergency room should be notified to anticipate the patient’s arrival so that delay will not be incurred because of the number of routine admissions. It is helpful to note the patient’s room number and visiting hours for family and friends. Each hospital has its own regulations regarding visiting time, duration of visits, number of relatives admitted per visit, and visiting by children. Thus the ophthalmic assistant should understand the rules for visitors.
The most common ocular emergencies that require surgical intervention are lacerated globes and eyelids, intraocular foreign bodies, acute glaucoma, and intraocular hemorrhage.
The urgent patient is one whose problem requires special consideration because of the patient’s condition. Such a patient requires priority admission because the problem cannot be tolerated for an unlimited time. For example, the patient with a retinal detachment is best treated as soon as the detachment is discovered. If, however, the hospital is overcrowded and immediate admission is not possible, the patient should be placed on the urgent list on a day-to-day basis.
The patient with an urgent problem should always be available and prepared to enter the hospital on a day-to-day basis. Patients in this category should be called regularly so that they do not feel they are languishing forgotten at home.
Other conditions that may be classified as urgent disorders are chronic glaucoma, orbital tumors, dislocated lenses, uveitis, and temporal arteritis.
The patient with an elective problem has an ocular disorder that is chronic and slowly progressive and that will not significantly deteriorate by a delay in admission to a hospital or surgicenter. The patient has ample time to be fully briefed on the duration of the hospital stay and the expected postoperative convalescence. It is helpful if patients of this type are prepared for surgery by giving them some of the available literature on their particular condition. A personal letter from the doctor may be welcomed. Pamphlets and videotapes on glaucoma, strabismus, and cataracts explain the nature of these disorders and the purpose of operative therapy.
Operative booking schedule
To ensure that all arrangements with the patient and the surgicenter or hospital are secure, the ophthalmic assistant should have a plan to follow on each operative case. Our plan has been for the ophthalmic assistant to record a number of essential points before a patient is considered to be booked and awaiting surgery:
Date of admission
Type of bed if any required
Date and time of operation, with type of anesthesia
Date the patient was notified by telephone
Date of letter sent requiring confirmation
Confirmation by the patient
A bright red reminder slip is affixed to the front of every surgical chart.
It is helpful to provide a pamphlet as a response to the numerous questions that have been asked regarding modern cataract surgery and today’s hospitalization procedures. Patients should be advised that this surgery is not a frightening procedure, but will actually turn out pleasant for them. Box 31.1 is an example of such a pamphlet.
Be sure to bring your insurance details with you.
If you are currently taking medication, please bring these to the hospital with you. A nurse will inquire about all the medication you are taking.
Obtain a good night’s sleep before admission to hospital.
Shampoo your hair the night before entering hospital.
Women: Please do not wear makeup, particularly mascara and facial preparations.
Do not wear or bring valuable jewelry.
Special relaxing medication may be given to you on the morning of surgery.
For local anesthesia
Eyedrops and occasionally a small local freezing injection may be given to you just before surgery.
In the operating room, you may see the usual lights and sterile equipment and a special microscope. You will not see anything of the surgery during the operation.
Surgery lasts about 15 minutes. Soon after, you will be able to sit up in bed.
After cataract surgery, you may have a bandage over only the operative eye. This will be removed soon after surgery and no eye bandage need be worn.
A small plastic shield may be placed over the eye at bedtime to prevent unconscious rubbing of the eye when asleep.
You will be out of bed soon after surgery.
Although you need not restrict your movements after surgery, please be careful of heavy lifting and excess bending.
Avoid bright window sunshine. If bright, wear sunglasses.
On the first night, there may be some discomfort. If so, take a mild pain-killing pill.
On discharge you will be given a two-page list of do’s and don’ts.
24 hours to 2 weeks after surgery
Go back to normal activities using caution. If you have pain, call the office. You may bend over gently to put on shoes. You may read and watch TV as you wish. You can do anything you were doing before surgery with the following exceptions:
No contact sports.
Avoid getting water in eye while swimming.
No swinging of golf clubs; however, chipping and putting should be safe.
No strenuous exercise.
You may wash your hair gently, or go to the beauty parlor, but avoid getting water in the eye.
Just remember to use common sense!
After 2 weeks
You can function as you had before surgery and it is hoped, with much better vision. Medication may be stopped soon after this point.
Common symptoms after surgery
The following common symptoms may occur after surgery and should not cause alarm:
Light sensitivity, especially to sunlight; be sure to use dark glasses.
Do not be surprised if color perception is improved with your operated eye.
Mild irritation, redness, itchiness, or watery eye may occur for the first several days following surgery.
Your vision may be fuzzy for several weeks. Patients vary as to the time required before their vision returns.
There may be some bruising around the eyelids or the side of your head, which will soon fade.
A small amount of residue may collect in your eyelids or the corner of your eye on awakening in the morning. (This is most likely caused by eyedrop residue.)
You should report any sudden onset of severe pain, loss of vision, or marked redness in the operated eye.
The date of admission often is the day of outpatient surgery. It may, however, be the evening before surgery if the patient requires hospitalization. If such a condition is not under complete control, surgery may be hazardous to the patient. A medical consultation may be necessary to ensure that the patient does not have any infections, cardiac irregularities, uncontrolled diabetes, hypertension, or other medical disorders.
Operative time and date must be carefully integrated with the surgeon’s schedule so that there is no duplication of this time by office appointments or other commitments. Patients with infection, such as dacryocystitis should always be placed last on the operative schedule. The ophthalmic assistant should be familiar with the length of time required for the surgeon to complete a procedure. Additional time should be set aside during the time of surgery for changeover of instruments and materials between patients.
The decision whether to use local or general anesthesia is most important in booking the operating room. It is preferable if procedures that require general anesthesia are scheduled to follow each other so that the anesthetist’s time is more efficiently used.
As soon as arrangements for the operative time and date have been completed, the patient should be notified by telephone to be sure that the time is suitable. Occasional adjustments may have to be made for illness, holidays, work, and special requests of the patient. A well-run ophthalmic practice, emphasizing goodwill, permits some latitude in this direction, depending on the urgency of the problem.
For previous retinal surgery
Often more conservative instructions may apply for cataract surgery:
Preoperative assessment is often scheduled directly or emailed.
Aspirin and other blood thinners do not need to be stopped if surgery is under topical and intracameral anesthesia.
Patching of one eye is only required at bedtime.
Our practice has been to follow the telephone call with a confirming letter outlining the date and time of admission to the hospital and requesting confirmation by return call or letter. The purpose of having the patient provide a return call or letter is to ensure that the date of surgery is suitable and that the patient’s schedule has been altered accordingly.
The confirmation should always be double-checked and those patients who have not confirmed should be contacted.
A simplification of this routine may be followed when the patient has outpatient surgery. With outpatient surgery today, a physical examination may be arranged ahead of time. The patient may be asked to return to the office to pick up blood test forms. In addition, intraocular lens (IOL) implant power will be required for all cataract procedures. The power of the IOL is determined by the IOL Master or Lenstar and this typically performed before surgery. These measurements are usually performed on both eyes at the same time. In some cases, a B-scan may be required if the cataract is dense and the practitioner wishes to view the vitreous cavity and the status of the retina. Other investigational tests may be performed. Visual aids are available for demonstration purposes ( Fig. 31.2 ).