28.4Nurse vs Surgeon Indenting the Sclera3

Allowing the nurse to do the indentation has certain advantages.

•The image is superior if the light pipe is used, and the illumination angle can also be changed as needed (see Sect. 22.1).

•The surgeon is able to concentrate on the intravitreal part of the task.

Q&A

Q Why is it so important that the nurse is well trained in performing scleral indentation?

A Because disaster is not far away if she does not do a proper job. She must have constant visual feedback of her actions; not get distracted during the process; prevent the depressor from slipping; not allow sudden, unannounced changes in any of the characteristics of the indentation; and avoid pulling out the infusion cannula (see Sect. 21.3). She has to switch her hands as she is moving around the eye and maintain a steady hand even as she is forced to stand and lean forward.

Self-indentation also has certain advantages.

•Indentation and the intravitreal work are easily coordinated.4 The surgeon can instantly change the height, location, depth, or angle of the indentation as the internal situation demands.

–Making the process dynamic can provide the surgeon with extra information about the anatomy and pathology of the area.

•The risk to the retina resulting from slippage of the scleral depressor is reduced.

•No verbal instructions need to be given.

•The nurse is able to monitor the position of the infusion cannula during the entire process.

Self-indentation is not possible if the eye is phakic.

28.5External Illumination and Nurse Indentation

This hybrid option is chosen typically when bimanual surgery is needed on the ciliary body; obviously, the eye must be aphakic or pseudophakic.

3The question can also be phrased differently: bimanual vs monomanual surgery? or external vs internal illumination? see above.

4This is by no means automatic, though; it takes a lot of practice for the inexperienced fellow to be able to pay attention to the indentation itself, not simply to the actions executed by the working hand.

28.6Instrumentation and Technique

•Use a speculum with a wire type of blade (see Fig. 19.4) and open it to the widest aperture possible.

•Decide whether to:

–Indent yourself or have the nurse do it.

–Use internal or external illumination (the latter allows bimanual surgery).

•The position of the infusion cannula must be constantly monitored.

•With depressors of a straight shaft5, the more posterior (deeper) the depression, the more the angle of the shaft must be changed6 so that it does cause too high an indentation anteriorly. Shafts that follow the contour of the globe7 do not pose such a problem.

–A hard plastic cover capping the light pipe (DORC [(Zuidland, the Netherlands)], offers improvement in visualization while also allowing proper indentation is another option.

•No matter who performs the indentation, switching of the hands will eventually be necessary. Caution is in order if the person’s nondominant hand has weak dexterity.

•If the nurse is performing the indentation, she may be forced at some point to get up from her chair – and standing with a bent back increases fatigue and thus the risk of depressor slippage.8

–This is especially important to remember in MIVS. Having the depressor over the conjunctiva, rather than naked sclera, as in 20 g surgery, increases the slippage risk.9

5 Almost any tool, even a cotton-tip applicator, with a firm, cylindrical shaft will suffice.

6 Pearl

This is obviously limited by the configuration of the bony orbit but also by the size of the eyeballIt is. very useful to always follow the same routine when 360° maneuvers such

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•If the nurse does the indentation, you typically have the light pipe plus a working instrument inside. If the eye is phakic, take extra caution not to damage the lens with the light pipe.10

•By the time indentation is needed, most or all of the vitrectomy has usually been done: the eye is full of fluid, which is not compressible.

–Start aspirating before the nurse actually indents, and rotate the eyeball in the opposite direction so that it is easier for her to insert and place the scleral depressor.11

–Ask the nurse to increase the indentation slowly and then to stop before it is too high.

•If there is a partial RD, start the indentation in an area where the retina is attached and move to the RD area last; this helps reduce the risk of extending the detachment over a larger area.

Finally, it must be mentioned that some surgeons employ an encircling band to cause a (permanent) indentation, which in this case serves an intraoperative goal as well (see Table 54.7).

10You are less likely to cause lens trauma with the probe since you are monitoring it closely, but the light pipe is not under your continual observation.

11 i.e., if the indentation will occur at 4 o’clock, rotate the eyeball toward the 10 o’clock direction.