Ординатура / Офтальмология / Английские материалы / Step by Step Minimally Invasive Glaucoma Surgery_Garg, Melamed, Bovet, Pajic, Carassa, Dada_2006

152 Step by Step Minimally Invasive Glaucoma Surgery

injection, using a swab, lidocaine 2 percent is put in on the conjunctiva. After this, 2 cc-3 cc of lidocaine 2 percent is injected under the conjunctiva with a 25G yellow needle to form a perfect bubble on the dissection surface of the scleral flap. This bubble must cover at least a quadrant of the eye. The anesthetic will take effect in about two minutes, after which the patient is asked to orientate his eye in the direction of the flap that is to be made. Usually, this presents no problem, and patient collaboration is excellent (Figs 10.1 and 10.2).

Combined Cataract/Glaucoma

Although the principle is the same in a combined glaucoma/cataract operation, the timing will vary, depending on how the surgery progresses. Firstly, five minutes before the arrival of the patient in the operating theater, drops of lidocaine 2 percent are put in. Then, the bubble is created by injecting lidocaine 2 percent under the conjunctiva. During the cataract operation an intracamerular injection of lidocaine at 0.2 percent dilution is made to reduce the deep pain. Generally, no additional topical anesthetic is needed to complete the second flap and the closure of the conjunctiva, but it can always be added, if needed.

COMPLEMENTARY SEDATION USING INTRAVENOUS INJECTION

It is always possible that sedation will need to be administered before or during the operation. The onset and rise of anxiety has always a contextual aspect. The role and the attitude of the surgeon and other participants cannot be underestimated in the onset and rise of patient anxiety. At the beginning of the operation and depending on the

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type of patient and their anxiety level, an intravenous dose of propofol can be administered at the same time as the subconjunctival injection is made. If the build up of patient anxiety cannot be controlled, a very slow and progressive intravenous injection of benzodiazepines (midazolamDormicum 0.5 to 1.5 mg) and/or opiates with a short halflife (alfentanil-Rapifen 50-100 mcg) can be made.3,7,8

PREPARATION OF THE PATIENT

Preoperative Preparation

The patient meets his surgeon and his anesthetist,9 and it is important, during this consultation, that all the patient’s questions are discussed. It is vital that the patient clearly understands the stages and procedures of the operation, so that trust is established and that he can follow his operation well.

On the day of the operation, an assistant checks that the patient clearly recalls and understands all stages and procedures.

It is imperative that the patient goes to the toilet before the operation to empty his bladder, thus allowing him not to be worried by external matters during the operation. Eye dilation is carried out by the patient at home. This reduces the waiting time before the operation begins – a time full of anxiety for the patient. Five minutes before going into the operating theater, the patient is given 5 drops of 2 percent lidocaine on the cornea.

Great care must be taken at this point not to allow the cornea to dry out thorough small blinks of the eyelid. At this point, the anesthetist has an important role in verbally soothing the patient.21

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Preparation during the Operation

Once the patient is settled comfortably in the operating theater, the operating field is rapidly applied. It is important to tell the patient what is going to happen before each action is carried out, so as to avoid undue alarm. The microscope light is very dazzling and it is experienced as painful by the patient.4 It is paramount, to accustom the patient, to start with a weak light and increase its strength progressively. Once the operating field is stuck on the face, the eyelid retractor is placed into position and then opened delicately, so that there is no eyelid akinesia. Once the eyelid retractor is in position, the surface of the conjunctiva is swabbed with 2 percent lidocaine, then a subconjunctival injection of lidocaine is made a little behind the site of the flap, so that the conjunctiva is not damaged and a high-quality anesthesia is achieved (Figs 10.3 and 10.4).

After this, the operation proper can proceed as normal, always speaking to the patient so that he is not alarmed or surprised and does not move.

Postoperative Care and Patient’s Home Return

Once the operation is finished, there is in the patient an extreme sense of relief, and a natural relaxation, as patients always imagine that an eye operation will be much more painful than any other.

Once the operation is finished, the patient must be taken care of by the nurse - especially in the case of an ambulatory patient who must not have a sense of being abandoned. The nurse offers him light refreshments, tea or coffee.

The patient is discharged about thirty minutes after the end of the operation. The patient must go home with all

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the instructions he has to follow for his postoperative treatment and a follow-up appointment for the next day, to check the operation. He must be given a contact telephone number for the nurses and the surgeon, in case he is worried.

CONCLUSION: ENVIRONMENT UNDER WHICH THE OPERATION TAKES PLACE

Topical anesthesia in cataract operations has proved itself. In the case of glaucoma operations, subconjunctival anesthesia allows the mobility of extrinsic muscles to be kept intact and for the operating field to be placed exactly where the surgeon needs (Figs 10.3 and 10.4). For a successful topical anesthesia to be done, it is imperative that the surroundings should be familiar to the patient and that he does not feel suffocated.

In ambulatory surgery, the patient must feel that he is in a caring, warm and professional environment.1,22 The team which takes charge of the patient must bond together well, be friendly but not familiar. Stress does not diminish the pain threshold!

Since 1996, we have been practising this type of anesthesia regularly on all our patients, without any major complications.

REFERENCES

1.Bovet JJ. Minimal standard needs for out-patient surgery Abstract first ESOPES congress Vienna 1993.

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3.Bovet JJ, Baumgartner JM, Bruckner JC, Ilic V, Paccolat F, Maroni O, Bovet F. Chirurgie de la cataracte en topique intracamérulaire Abstract SSO-SOG. Sept 1997.

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