Ординатура / Офтальмология / Английские материалы / Basic Principles of Ophthalmic Surgery_Arnold_2006

4.Postoperativedressingsare commonly applied after the following surgicalprocedures(list all that apply)

a.Trabeculectomy

b.Proceduresinvolving eyelid or retrobulbar block

c.Bilateral strabismussurgery

d.Vitreoretinal surgery

For preferred responsesto thesequestions,seepages223-224.

Figure 16.1. Communicating postoperative instructions to your patient-and the patient's

family, if appropriate-is important to successful postoperative management. Other components are timely, focused postoperative examinations and effective management of

complications. (Image courtesy National Eye Institute, National Institutes of Health)

tive careand possiblecomplications of five broad categoriesof ophthalmic procedures:

~Anterior segmentsurgery

~Strabismussurgery

~Eyelidandorbitalsurgery

~Retinovitreoussurgery

~Lasersurgery

TIMING OF POSTOPERATIVE CARE

The timing of appropriate postoperativecarevariesfrom procedureto procedure.Most patients are not examinedon the sameday of the surgery after they leavethe operating room. A dressingsuchasaneye patchand shield are applied and then removed by the surgeonat the first follow-up visit. However there are certaincircumstancesin which a brief examinationmaybe performed the sameday shortly after performing the procedure.Theseinclude

-+ After any type of surgeryif the surgeonneedsto checkfor recovery of motility and eyelid function after local anestheticinjection

-+ After orbital or optic nerve surgeryto perform vision checkand rule out bleeding

-+ After strabismussurgeryto perform adjustmentof adjustablesuture -+ After lasersurgeriesor retinovitreous surgerywith gasinjection to

checkintraocular pressure

segmentischemia,and thesepatientsareexaminedon the first dayand in the following weeksto look for signsof this condition.

Eyelid and Orbital Surgery

Eyelid surgerypatientsare seenwithin a few days of the procedureprovided there areno complaints of swelling or unexpectedtendernessthat would suggestinfection. If adjustablesuture techniqueis used or office modification

of ptosis surgeryis planned,the timing of follow-up is adjustedaccordingly. Patientsundergoing orbital surgeryare often admitted to the hospital. Because of risk of injury to the optic nerve, ocularblood supply and adnexalstructures areexaminedon the first postoperative day and two to three times over the following month.

Retinovitreous Surgery

The widely varying types and complexitiesof retinovitreous surgeriesrequire a flexible approachto timing of postoperativeevaluations.Thesepatients are always seenon the first postoperative day andfollowed closely in the weeks that follow. The level of vision aswell asthe statusof detachedretina and subretinal fluid, intraocular gas,intraocular pressure,andpresenceof intraocular bleeding all determinethe frequency of postoperativevisits.

Laser Surgery

Lasersurgeryproceduresare generallyperformed on the anterior segment for glaucoma,the corneafor refractive surgery,the posterior lenscapsulefor capsulotomy,and the retina for various conditions including diabetic retinopathy and choroidal neovascularization.Patientsundergoing anterior segment

laserproceduresare often checked1 or 2 hours after the procedureto measure intraocular pressureand one week later to determinesuccessof the procedure. Refractive surgerypatients are seenin the days afterthe surgeryunlessthere are flap complications requiring more immediateattention. Patientsundergoing lasersurgery on the retina require follow-up at varying times in the days and weeks following the procedure,assomemay require re-treatments(eg, choroidal neovascularization)and others needonly be seenweeks later to determine whether treatmentswas successful(eg, maculartreatment in diabetic retinopathy).

FOCUS OF EXAMINATION

Generally speaking,postoperativeexaminationsarefocusedon determining whether the intended goalwas accomplished,assessingthe postoperative

anatomy,looking for complications, and determiningthe timing of anticipated postoperativeinterventions suchasmedicationchangesand suture cutting. Once againthe focus of the examinationdependson the type of procedure

performed.

Anterior Segment Surgery

The focus of this examinationincludes measurementof visual of acuity, determining anterior segmentanatomy (intraocular lens, corneal graft or filtration blebposition), measurementof intraocular pressure,looking for intraocular inflammation (cellsand flare in anterior chamber),looking for signsof infection (excessiveinjection, hypopyon), determination of the security of the surgicalwound to be sure it is not leaking,and examinationof the retina to look for perforations from anestheticinjection or retinal detachment.If visual acuity is decreased,an explanationmust be found.

Strabismus Surgery

The focus of the postoperativestrabismusexaminationis to ensuresuccessful reattachmentof muscleswith normal function; to rule out scleralperforations, anterior segmentischemia,or infection; and to determinethe successof the procedure. Successfulstrabismussurgeryis characterizedby maintenanceof good visual acuity, successfulmotor alignment, and restoration of or facilitation of binocular single vision and fusion.

Eyelid and Orbital Surgery

Postoperativeexaminationof eyelid surgeryfocuseson the security of skin wounds, resolution of swelling, absenceof infection, and achievementof the surgical goal(eg,eyelid position in ptosis and ectropion surgery,and anatomic restoration and absenceof tumor in casesof tumor excision).Postopera-

tive evaluationafter surgeryfor eyelid and orbital tumors must alsoinclude review of histopathology and specificdiagnosis.This will helpdefine further treatmentsaswell asdeterminethe adequacyof surgicalmargins. In patients undergoing orbital surgery,extraocularmusclefunction and optic nerve function should be measured.