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997 Preparations as a Surgeon
References and Further Reading
1. Blaskovics-Kettesy A (1970) Eingriffe am Auge.
Enke, Stuttgart
2. Henderson BA, Grimes KJ, Fintelman RE, Oetting
TA (2009) Stepwise approach to establishing an ophthalmology wet laboratory. J Cataract Refract Surg
35:1121–1128
3. Smolik I (2008) Im Wetlab netzhautchirurgische
Fertigkeiten am Schweineauge trainieren. Spektrum
Augenheilkd 22(3):195–197
4. Binder S (2007) Chirurgisches Training gestern und
heute. Spektrum Augenheilkd 21(4):211
5. Inama H, Asif N, Sohail AA, Fatimia SH (2020) Wet
labs: a useful tool in training surgical residents in a
third world country. Ann Med Surg 57:137–139
6. Alwadani S (2018) Cataract surgery training using
surgical simulators and wet-labs: course description and literature review. Saudi J Ophthalmol
32(4):324–329
7. Dada VK, Sindhu N (2000) Cataract in enucleated
goat eyes: training model for phacoemulsification. J
Cataract Refract Surg 26(8):1114–1116
8. Karadayi K, Gültekin Ç, Aytaç E (2018) Bimanual
capsulorhexis using a new hand tool: an experimental study in sheep eye. Kafkas Univ Vet Fak Derg
24(5):769–774
9. Heydenreich A (1968) Mikroskopisch –histologische Untersuchungsmethoden unter besonderer
Berücksichtigung des Sehorgans. Thieme, Leipzig,
419 S
10. Reme C, Müller FO, Bamasch P (1972) Der Einfluss
von Konservierung durch Lufttrocknung auf die
Feinstruktur von Schweinehornhautlamellen. Albrecht
v Graefes Arch Clin Exp Ophthalmol 185:189–205
11. Observer (2017) Künstliche Augen für die
Medizinerausbildung. Mediplast 13:2–4
12. Hunter IW, Doukoglou TD, Lafontaine SR et al
(1993) A teleoperated microsurgical robot and associated virtual environment for eye surgery. Presence
2:265–280
13. Ferris JD, Donachie PH, Johnston RL et al (2020)
Royal College of Ophthalmologists’ National
Ophthalmology Database study of cataract surgery:
report 6. The impact of EyeSi virtual reality training
on complications rates of cataract surgery performed
by first and second year trainees. Br J Ophthalmol
104(3):324–329
14. Jacobsen MF, Konge L, Bach-Holm D et al (2019)
Correlation of virtual reality performance with reallife cataract surgery performance. J Cataract Refract
Surg 45(9):1246–1251
15. Staropoli PC, Gregori NZ, Junk AK et al (2018)
Surgical simulation training reduces intraoperative
cataract surgery complications among residents.
Simul Healthc 13(1):11–15
16. Thomsen AS, Bach-Holm D, Kjærbo H et al (2017)
Operating room performance improves after proficiency-based virtual reality cataract surgery training.
Ophthalmology 124(4):524–531
17. Thomsen AS, Smith P, Subhi Y et al (2017) High
correlation between performance on a virtual-reality simulator and real-life cataract surgery. Acta
Ophthalmol 95(3):307–311
18. Privett B, Greenlee E, Rogers G et al (2010)
Construct validity of a surgical simulator as a valid
model for capsulorhexis training. J Cataract Refract
Surg 36(11):1835–1838
19. McCannel CA, Reed DC, Goldman DR (2013)
Ophthalmic surgery simulator training improves resident performance of capsulorhexis in the operating
room. Ophthalmology 120(12):2456–2461
20. Bisol T, Bisol RAR, Rezende F (2016) Efficacy of
Eyesi surgical simulator training in improving hightension capsules capsulorhexis performance. Rev
Bras Oftalmol 75(5):376–379
21. Belyea DA, Brown SE, Rajjoub LZ (2011) Influence
of surgery simulator training on ophthalmology resident phacoemulsification performance. J Cataract
Refract Surg 37(10):1756–1761
22. Pokroy R, Du E, Alzaga A et al (2013) Impact of
simulator training on resident cataract surgery.
Graefes Arch Clin Exp Ophthalmol 251(3):777–781
23. Kuhn F (2008) Ocular traumatology. Springer, Berlin
24. Velhagen K (1964) Propädeutische augenärztliche
Operationslehre. VEB Georg Thieme, Leipzi
Preparation of the Patient in the Operating Department
Susan Schmitz-Gießler, Anke Habermann and
Christiane Wiederhold
Contents
8.1 Documentation and Data Protection................................... 101
8.2 Medication Pre-treatment ........................................... 104
8.3 Admittance to the Operating Room ................................... 105
8.4 Positioning ...................................................... 105
8.5 Documentation after the Operation.................................... 105
8.6 After the Procedure................................................ 105
References and Further Reading .......................................... 106
8
To ensure a smooth process in the operating
room, it is important that all procedures are fundamentally adhered to and all preparatory measures are consistently carried out. All information
on the surgery schedule must be checked! The
surgeon must be able to fully concentrate on the
procedure, especially if the surgeon is a beginner.
If important information is missing in the
medical history and thus for the surgery schedule (for example, that it is a trauma or PEX eye),
this can potentially lead to unexpected problems. Especially in such complicated cases, the
S. Schmitz-Gießler ()
Augenzentrum Leiterstraße, Magdeburg, Germany
A. Habermann
Augenzentrum “Frohe Zukunft”, Halle/Saale,
Germany
C. Wiederhold
Augezentrum Sangerhausen, Augenärztliche
Gemeinschaftspraxis, Sangerhausen, Germany
e-mail: wiederhold@augenarzt-sangerhausen.de
surgeon must be able to adjust to the special initial situation (Sect. 21.1 ).
8.1 Documentation and Data Protection
Counceling usually takes place at least two
weeks before (excluding emergencies and injuries) the operation in the practice. During the
medical history, the patient is asked about eye
diseases, general illnesses, surgeries, allergies,
and medications, especially blood thinners and
tamsulosin. After a thorough examination, the
patient is explained the procedure of the operation and possible complications are discussed.
Furthermore, they are informed about the possibility of implanting various intraocular lenses
(monofocal lens, toric IOL, multifocal lens). If
the patient cannot decide yet and wishes to have
some time to think, they must contact the practice at least one week before the operation by
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2025
F. Wilhelm (ed.), Ophthalmic Surgery for Beginners, https://doi.org/10.1007/978-3-662-70287-1_8
101
102 S. Schmitz-Gießler et al.
phone or email so that the lens to be implanted
can be ordered if it is not in stock.
The intake of oral antidiabetic drugs may also
need to be paused temporarily (Chap. 9 and
Table 8.2).
In case of language-related communication
problems, the counceling must be conducted
in the presence of a local language speaking
family member or a certified interpreter. The
patient is also informed that they must appear
Diabetics who are on insulin therapy must
not administer it on the morning of the surgery day, as food intake is contraindicated,
for example, due to the planned analgesia!
for the operation on an empty stomach, meaning the last food intake must be 6 hours prior.
Clear fluids can be consumed up to 2 hours
before the operation. The intake of regular
medications is possible, but blood thinners
(Chap. 9 and Table 8.1) and antidiabetics must
be discontinued in consultation with the general practitioner.
Table 8.1 Overview of blood thinners and anticoagulants to be considered
Drug group Drug, trade name Intake pause (whole days
Platelet aggregation
inhibitors
Anticoagulants
NOAC (new oral
anticoagulants)
No bridging with heparin
Vitamin K antagonists
Bridging with heparin
ASS 100, Acesal, Godamed,
Aggrenox, Axanum
Iscover, Plavix, Clopigamma,
Clopidolut, Clopidogrel
DuoCover, DuoPlavin Cannot be paused, always
Tiklyd 10 days Ticlopidine
Brilique 7 days Ticagrelor
Efient 7 days Prasugrel
Pletal 7 days Cilostazol
Pradaxa 2 days Dabigatran
Xarelto 2 days Rivaroxaban
Eliquis 2 days Apixaban
Lixiana 2 days Edoxaban
Falithrom, Phenpro Quick > 50%,
All important (and) discussed matters are documented on the surgery consent form. If there are
no further questions, it is signed by the patient
and the informing doctor. The file notes what
should appear on the surgery schedule, such
as the eye to be operated on, as well as special
conditions like PEX syndrome, cornea guttata,
before surgery)
4 days Acetylsalicylic acid
7 days Clopidogrel
drip anesthesia
INR < 1.5
Active ingredient
Clopidogrel + ASS
Phenprocoumon
Table 8.2 Overview of oral antidiabetic drugs to be recorded preoperatively are
Antidiabetics
Metformin Glucophage, Siofor, Metformin, Eucreas,
All other
antidiabetics
(“sugar tablets”)
Icandra, Janumet, Komboglyze, Velmetia,
Competact, Diabesin, Espa-formin, Glucobon,
Juformin
Glimepiride, Acarbose, Glucobay, Galvus,
Jalra, Januvia, Onglyza, Xelevia, Enyglid,
NovoNorm, Starlix, Actos, Maninil,
Diamicron
2 days Metformin
Do not take on the day of
surgery
(pure or in
combination)
Others
1038 Preparation of the Patient in the Operating …
narrow anterior chamber, post-trauma condition,
oculus ultimus situation, the intake of blood
thinners, diabetes medications, and medications
that can cause floppy iris syndrome. The latter
only needs to be known by the surgeon; a temporary discontinuation has no effect (Table 8.3).
The surgery schedule is created in advance.
It must include, in addition to the patient’s
name, the planned surgery, the eye to be operated on, and, if applicable, the lens to be
implanted, as well as any special features that
Table 8.3 Medications that can lead to floppy iris syndrome [5]
Medication Mechanism of
Tamsulosin Selective
Terazosin Selective
Alfuzosin Selective
Silodosin Selective
Doxazosin Selective
Indoramin Selective
Prazosin Selective
Urapidil Selective
Labetalol
Carvedilol
Phenoxybenzamine
action
α1-receptor
blocker
α1-receptor
blocker
α1-receptor
blocker
α1-receptor
blocker
α1-receptor
blocker
α1-receptor
blocker
α1-receptor
blocker
α1-receptor
blocker
α1-, β1- and
β2-receptor
blocker
α1-, β1- and
β2-receptor
blocker
α1- and
α2-receptor
blocker
Application Medication Mechanism of
BPH Phentolamine Non-selective
BPH Yohimbine
BPH Clomipramine
BPH Duloxetine
BPH,
hypertension
BPH,
hypertension
Hypertension Zuclopenthixol Dopamine and
Hypertension Imipramine
Hypertension
Hypertension,
angina pectoris
Hypertension
in pheochromocytoma
are important for the surgeon (see Sect. 8.1),
the chosen form of anesthesia, and the health
insurance. The surgeon completes the surgery schedule, checks the side of the eye to be
operated on, and the strength of the selected
intraocular lens. If the patient desires a special lens, the calculation of the lens parameters
and the order from the respective company
are carried out in advance. In Table 8.4, an
example of a surgery program is presented in
anonymized form as follows:
Risperidone Dopamine and
Quetiapine Histamine,
Mianserin
Ergotamine
Finasteride Selective
action Application
α-receptor blocker
α2-receptor
blocker
Affinities for
serotonin receptors
α1-receptor
blocker, serotonin
and norepinephrine blocker
Affinity for α1-,
α2-, dopamine,
serotonin receptors
serotonin receptor
antagonist,
dopamine, and
serotonin receptor
antagonist, NAT
serotonin receptor
antagonist
α- and serotonin
receptor antagonist
α1-, α2- and
serotonin receptor
antagonist
Affinities for α1and α2-, dopamine
and serotonin
receptors
5α-reductase
blocker
Hypertension in
pheochromocytoma
Erectile
dysfunction
Erectile
dysfunction
Depressions,
anxiety disorders,
obsessive-compulsive disorders
Depressions,
anxiety disorders,
polyneuropathy
Schizophrenia,
schizoaffective
disorders
Depressions,
schizophrenia,
obsessive-compulsive disorders,
Psychoses
Depressions
Depressions
Migraine
Androgenic hair
loss, BPH
104 S. Schmitz-Gießler et al.
Table 8.4 Example of a surgery schedule (excerpt)
Surgery schedule for (date) Name of the surgeon
Time Last name,
First name
07:00 Test,
Otto
07:15 Sample,
Hagen
07:30 Hahn,
Hildegard
07:45 Prof.
Prima,
Klaus
08:00 Blume,
Blumhild
08:30 Klemm,
Klemmhild
Date of birth Anesthesia Surgery Eye Lens Strength Remarks
01.01.1930 Topical Phaco+IOL RA EyeCeeOne +24.0 po. Glaupax, Technician
02.02.1940 Topical Phaco+IOL RA Panoptix +21.5 Cave PEX AOK
03.03.1950 Topical Phaco+IOL RA TIOL +22.0 T3 C. guttata, HH
protection!
04.04.1960 Peribulbar Phaco+IOL RA Polytech +27.5 Very anxious,
head tremor
05.05.1960 GA ECCE LA Hoya +25.0 Post-trauma,
mature
cataract
06.04.1970 Topical Phaco+IOL RA SN60WF +29.5 Target refraction—2.5 D
Eliquis
discontinued
HI
KK
SaxonyAnhalt
Nuremberg
BKK
Self-payer
Self-payer
AOK Halle
The schedule is to be placed everywhere in
the OR department depending on the established
procedures where it is needed—among other
places at the OR counter, furthermore in the
preparation room, at the anesthetist’s workstation, in the OR at the microscope (clearly visible
to the surgeon) as well as at the phaco machine
(for the instrument nurse).
It must be ensured in advance that all cru-
cial data are correctly included (checked by
the surgeon) and can be quickly and clearly
captured by him during the OR program ("at
a glance"). Only then can the surgeon fully
concentrate on the procedure.
At the practice registration, the patient receives
their surgery appointment, the duplicate of the
consent form, a list of behavioral rules after the
operation, the documents for the general practitioner, as well as an anesthesia consent form,
which they bring filled out and signed to the
operation. This form asks about previous surgeries and anesthetics and any possible complications (Chap. 8).
If the patient appears with all documents on
the day of surgery at the practice, the patient is
asked again at the surgery registration whether
they are fasting and have discontinued the specified medications. Furthermore, they are asked
for their health insurance card and the referral
from the treating ophthalmologist, and the filled
out and signed anesthesia form is collected. If
the patient wishes for a special lens, it is checked
whether a signed cost agreement is available.
If the patient has had breakfast or the general
practitioner’s findings are incomplete, consultation with the anesthetist and the surgeon is held
to decide whether the type of anesthesia needs to
be changed or the procedure postponed (Chap. 9).
8.2 Medication Pre-treatment
After the nurse at the surgery counter has ensured
that the patient’s name and the eye to be operated
on are correct and no allergies to eye drops are
known, mydriatics (Cyclopentolate®, Mydrum®,
and Neosynephrine®) are instilled several
times. Additionally, the eye to be operated on is
1058 Preparation of the Patient in the Operating …
superficially anesthetized with Novesine drops.
The additional application of Xylo-Gel is also
possible (Chap. 9 ).
The eye that will be operated can be marked
with a colored pencil or a cross of adhesive
tape on the forehead to ensure the correct
side for the operation. Regardless, the correct side of the surgery and the patient’s
identity must be checked multiple times.
8.3 Admittance to the Operating Room
The patient is provided with a head cap and
shoe covers. Personal belongings are stored
in a locker. This also definitely applies to the
mobile phone! Jewelry should be removed for
hygienic reasons. Then the patient is received by
the anesthetist in the operating room admittance
area and led into the operating room. Here, the
patient is positioned and the anesthesia is prepared (Sect. 4.3 and Chap. 9). It is important to
attune the patient to the procedures in the operating room and simultaneously convey a sense
of security. Playing suitable music in both the
preparation room and the operating room has
proven effective. A randomized study with 330
patients in 2021 demonstrated the positive effect
of music during the operation process. For this,
systolic and diastolic blood pressure values were
monitored [4].
[2]. The head is loosely fixed by positioning it in
a headrest (Sect. 4.3 ).
If the patient has a head tremor, the head can
be fixed to the headrest of the operating table
with tape after consultation. The upper body
should be slightly elevated, but the head should
be placed flat so that the cornea takes a horizontal position. This provides the surgeon with an
optimal view during the procedure.
The patient’s head should be tilted so far
temporally that the irrigation fluid can always drain well and does not accumulate in
the nasal canthus!
8.5 Documentation after the
Operation
In the surgery protocol (also surgery report), the
patient’s name, date of birth, surgery times, and
any special features of the procedure are noted.
After approval by the surgeon, the instrumenting and the non-sterile ("runner") assistant,
the protocol can be inserted (scanned) into the
patient’s file. The batch stickers of the medical
products used are utilized for documentation in
the patient’s file. For the implanted IOLs, these
are collected on a form that is sent to the supplier at the end of the surgery day for replacement orders.
8.6 After the Procedure
8.4 Positioning
It is crucial that the patient lies comfortably
[3]! They should not feel any pain in the back
or neck, as this could make them restless during
the operation. Pressing while breathing results
in a "vis a tergo" (increased vitreous pressure),
leading to a flattening of the anterior chamber.
Additionally, all patients are positioned with a
knee roll, which relieves the lumbar spine and is
perceived as very comfortable. Neck discomfort
can be alleviated with a small, rolled-up towel
During the postoperative observation in the
recovery room (for approximately 10 minutes,
Chap. 9), the operated patient is provided with a
a beverage to drink.
In the case of performed cataract surgery, the
patient is given their "lens passport" (with the
names of the patient and surgeon, the surgery
date, as well as the lens type, manufacturer, and
strength of the implanted IOL) as well as a letter
and a referral back to the continuing ophthalmologist. Additionally, they will receive the contact
details of the practice with a phone number to
106 S. Schmitz-Gießler et al.
reach the surgeon in case of complaints within
the first 24 hours after the operation [1].
If the patient feels subjectively well and free
of complaints, they may leave the practice
only in accompaniment .
References and Further Reading
1. Gerl G (1997) Ambulante Operationen in der
Augenheilkunde. Hippokrates, Stuttgart
2. Kuhn F (2016) Vitreoretinal surgery: strategies and
tactics. Springer, Berlin
3. Liehn M, Lengersdorf B, Steinmüller L, Döhler
R (Hrsg) (2021) OP-Handbuch. Springer, Berlin/
Heidelberg
4. Muddane SK et al (2021) Preoperative and perioperative music to reduce anxiety during first-time phacoemulsification cataract surgery in the high-volume
setting: randomized controlled trial. J Cataract Refract
Surg 47:471–475
5. Wilhelm U, Kohlhaas M, Weitschies W,
Wölfelschneider P (2016) Welche Medikamente induzieren eine „Floppy Iris“ bei der Kataraktoperation?
Vortrag, gehalten 2016 in Dortmund, 30. Kongress der
DGII
Anesthesia in Ophthalmology
Alexandra Stein, Frank Zimmermann and Frank
Wilhelm
Contents
9.1 Which Anesthesia Methods are used for which procedures in ophthalmology?
9.2 Local Anesthesia in Ophthalmic Procedures ......................... 108
9.3 Ophthalmic Surgical Procedures in General Anesthesia ................ 112
9.4 “What should be considered?”—Advantages and disadvantages
of the procedures and complications................................ 113
References and Further Reading ....................................... 114
............................................... 107
9
9.1 Which Anesthesia Methods
are used for which procedures
in ophthalmology?
In ophthalmic surgery, outpatient procedures
have proven successful in recent years, also
due to improved surgical techniques and consequently shorter procedure times. However, general anesthesia still has its place in the field of
eye surgery. According to a representative survey, the current distribution of various anesthesia techniques in Germany is as follows: 43%
topical methods, 46% retro- or peribulbar injections, 12% sedation or ITN anesthesia [1].
The ophthalmic surgeon is responsible for
deciding which method is preferred in each individual situation [2].
A. Stein ()
Pampow, Germany
F. Zimmermann
Greifswald, Germany
F. Wilhelm
Universitätsklinikum Halle Saale, Greifswald, Germany
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2025
F. Wilhelm (ed.), Ophthalmic Surgery for Beginners, https://doi.org/10.1007/978-3-662-70287-1_9
According to Velhagen:
Everything the patient does wrong is primarily the
doctor’s fault and not the patient’s, even if the patient
appears foolish, such as suddenly standing up.
The demand for “a thorough general examination before an operation” [3], to “particularly
consider the patient’s general physical condition” [4], is important in close and collegial
cooperation with the anesthetist and the patient’s
general practitioner.
The introduction of the electronic patient
record may simplify the recording of patients’
medical histories in the future. Important aspects
of a comprehensive medical history can be
found in Table 9.1.
The preoperative consultation with the
patient should be used by the surgeon to assess
the expected intraoperative compliance and to
incorporate this into the decision when selecting
the anesthesia method.
An example of a preoperative preparation
form for the general practitioner is presented in
the following overview:
107
108 A. Stein et al.
General practitioners report on surgical preparation of the patient
Dear colleagues,
In order to make the planned operation as safe as possible for our patient,
we would like to ask you for some additional information.
3
3
Table 9.1 Important Anamnestic Parameters
Medications e.g., Tamsulosin, ASA, Xarelto, Falithrom, Metformin
Diseases e.g., immune deficiencies, hepatitis C, HIV, diabetes, anxiety disorders, mental
Special Treatments e.g., chemotherapy
Allergies e.g., antibiotics, local anesthetics
Laboratory CBC, coagulation
ECG
impairments
Gel anaesthesia with analgesia Peribulbar anaesthesia with
analgesia
Preparation according to EBM
31011-13
Leave anticoagulants Change anticoagulant
9.2 Local Anesthesia in Ophthalmic Procedures
Preparation according to EBM
1011-1
(rapid value 60%)
glaucoma surgeries, and the introduction of
IVOM. Today, established forms of anesthesia
methods in ophthalmology include general anesThe number of surgeries performed in ophthalmology has significantly increased due
to improvements in diagnostic and therapeutic options, from the treatment of cataracts as
one of the oldest procedures to vitrectomy and
thesia, para- or peribulbar anesthesia, and sur-
face anesthesia methods. Surface anesthesia is
becoming increasingly important. Its application
became standard with 28.1% in 2008 and 71.7%
in 2017. This is due to the reduced operation
General anaesthesia
Preparation according to EBM
31011-13
Change anticoagulant
(rapid value 60%)
1099 Anesthesia in Ophthalmology
time and the predominantly outpatient nature of
the surgery in partially multimorbid patients.
9.2.1 Pain and Local Anesthetics
Pain is defined as an unpleasant sensory and
emotional experience associated with actual or
potential tissue damage or described in terms of
such damage.
Local Anesthetics block pain perception
at the neuronal level in a localized area. This
means a primary specific blockade of fast voltage-gated sodium channels of the axon, preventing the formation of an action potential.
In clinical use, local anesthetics are mostly
hydrochloride solutions with a pH value of 4–7.
These are highly water-soluble and tissue-compatible. Since only the basic form can diffuse to
the site of action, an extracellular bicarbonate
buffer is necessary. Therefore, the effect of local
anesthetics is significantly reduced or nullified
in an acidic pH (e.g., inflammation).
9.2.2 Anesthesia Procedures
in Cataract Surgery
nociception
neural supply
long ciliary nerves
nociception of the anterior
segment of the eye
Fig. 9.1 Pain receptors in the anterior segment of the
eye. (From [5])
cornea
ciliary body
conjunctiva
sclera
The substances used require a short onset
time of 30 to 60 seconds and have an effective
duration of 10–20 minutes. By instilling surfaceanesthetizing eye drops or applying a soaked
carrier (e.g. swab), a uniform wetting of the cornea and conjunctiva is achieved (Fig. 9.2). The
first application initially causes an unpleasant
sensation (e.g. burning), after which the application is no longer perceived as such. The eyes
must then be kept closed to prevent drying of the
corneal epithelium and thus a reduced view into
the eye during the procedure.
The established local anesthesia procedures for
the eye are defined by their anatomical application site. A distinction is made between injection
and non-injection procedures.
Non-Injective Procedures
These include the various forms of surface anesthesia, where anesthesia of the eye surface is
achieved by means of carrier media or the application of drops.
Surface Anesthesia
In topical anesthesia, analgesia of the cornea and
conjunctiva is achieved with a reduction, but not
elimination, of reflex movements (Fig. 9.1). It
is established for smaller and short procedures
where akinesia is not absolutely necessary, such
as in contact lens examinations, tonometry,
foreign body removals, IVOM, or in cataract
surgery.
Medication Application Using the Example of
Gel Anesthesia
•
Start with the administration of eye drops to
dilate and anesthetize the eye
Fig. 9.2 Clinical image of the application of topical
anesthesia by the preparation nurse