Basic Principles of Ophthalmic Surgery

305 Pages·2019·41.21 MB·english

by  American Academy of Ophthalmology

Basic Princip les of
Ophthalmic Surgery
Fourth Edition
Ayman Naseri, MD
Executive Editor
BBPPOOSS__22001199__cchh0000__ppii__xxiivv__88PP..iinndddd ii 0044//0011//1199 33::1133 PPMM
American Academy of The Acad emy provides this material for educational purposes only. It is not in-
Ophthalmology tended to represent the only or best method or procedure in every case, nor to
replace a physician’s own judgment or give specific advice for case management.
Box 7424
Including all indications, contraindications, side effects, and alternative agents
San Francisco, CA 94120-7424
for each drug or treatment is beyond the scope of this material. All informa-
tion and recommendations should be verified, prior to use, with current infor-
mation included in the manufacturers’ package inserts or other in de pen dent
Clinical Education Secretaries sources, and considered in light of the patient’s condition and history. Reference
Louis B. Cantor, MD to certain drugs, instruments, and other products in this publication is made for
Senior Secretary for Clinical Education illustrative purposes only and is not intended to constitute an endorsement of
Christopher J. Rapuano, MD such. Some materials may include information on applications that are not con-
Secretary for Lifelong Learning and sidered community standard, that reflect indications not included in approved
Assessment FDA labeling, or that are approved for use only in restricted research settings.
The FDA has stated that it is the responsibility of the physician to determine
the FDA status of each drug or device he or she wishes to use, and to use them
Acade my Staff
with appropriate patient consent in compliance with applicable law. The
Dale E. Fajardo, EdD, MBA, Vice Acad emy specifically disclaims any and all liability for injury or other damages
President, Education of any kind, from negligence or other wise, for any and all claims that may arise
Beth Wilson, Director, Continuing from the use of any recommendations or other information contained herein.
Professional Development
Susan Malloy, Acquisitions Editor &
Financial Disclosures
Program Man ag er
Amanda Fernandez, Publications Editor Acad emy staff members who contributed to the development of this product
Lana Ip, Se nior Designer state that within the 12 months prior to their contributions to it they have had no
Daniel Mummert, Director, Online financial interest in or other relationship with any entity discussed in this book
Education and the ONE Network that produces, markets, resells, or distributes ophthalmic health care goods or
Jasmine Chen, Man ag er, E- Learning ser vices consumed by or used in patients, or with any competing commercial
Debra Marchi, CCOA, Administrative product or ser vice.
Assistant
The authors and reviewers state that within the 12 months prior to their contri-
All trademarks, trade names, butions to this product and for the duration of development they have had the
logos, brand names, and service following financial relationships:*
marks of the American Academy Dr. Carter: Research Prevent Blindness (S)
of Ophthalmology (AAO), whether
registered or unregistered, are the Dr. Dunn: Abbvie (C, L), Santen (C)
property of AAO and are protected
Dr. Eftekhari: Gerson Lehrman Group (GLG) (C)
by US and international trademark
laws. These trademarks include AAO; Dr. Gedde: National Eye Institute (S)
AAOE; AMERICAN ACADEMY OF
Dr. Langer: Matrix Surgical USA (C)
OPHTHALMOLOGY; BASIC AND
CLINICAL SCIENCE COURSE; Dr. Lustbader: Avendro (C), LCA Vision (E), Novartis Pharmaceuticals (O),
BCSC; EYENET; EYEWIKI; FOCAL Ocular Therapeutix (O)
POINTS; FOCUS DESIGN (logo shown
Dr. Quiros: Quark Pharmaceuticals (S), Regenera (S)
on cover); IRIS; ISRS; OKAP; ONE
NETWORK; OPHTHALMOLOGY; Dr. Volpe: Ophthotech (C), Opticient (O), Quark Pharmaceuticals (S)
OPHTHALMOLOGY GLAUCOMA;
OPHTHALMOLOGY RETINA; Dr. Wallace: FocusROP (P), National Eye Institute (S)
PREFERRED PRACTICE Dr. Wladis: Bausch + Lomb (C), FuzeHub (S), Lions Eye Foundation (S), Patent
PATTERN; PROTECTING SIGHT. 62/332,690 (P), Praxis Biotechnology (O), Valeant (C)
EMPOWERING LIVES; and
THE OPHTHALMIC NEWS & The other authors and reviewers state that within the past 12 months, they have
EDUCATION NETWORK. had no financial interest in or other relationship with any entity discussed in
this book that produces, markets, resells, or distributes ophthalmic health care
goods or ser vices consumed by or used in patients, or with any competing com-
mercial product or ser vice.
*C = con sul tant fees, paid advisory boards, or fees for attending a meeting; L = lecture fees
(honoraria), travel fees, or reimbursements when speaking at the invitation of a commercial
sponsor; O = equity own ership/stock options of publicly or privately traded firms (exclud-
ing mutual funds) with manufacturers of commercial ophthalmic products or commercial
ophthalmic ser vices; P = patents and/or royalties that might be viewed as creating a poten-
tial conflict of interest; S = grant support for the past year (all sources) and all sources used
for a specific talk or manuscript with no time limitation
Copyright © 2006, 2011, 2015, 2019 American Acad emy of Ophthalmology®. All
rights reserved.
Printed in China.
19 18 17 16 15 14 13 12 11 1 2 3 4 5 6 7 8 9 10
BBPPOOSS__22001199__cchh0000__ppii__xxiivv__88PP..iinndddd iiii 0044//0011//1199 33::1133 PPMM
Contributors
Maria M. Aaron, MD Kian Eftekhari, MD
Professor of Ophthalmology Assistant Professor of Ophthalmology
Associate Dean of Graduate Medical Education Ophthalmic Plastic and Reconstructive
Emory University School of Medicine Surgery
Atlanta, Georgia The University of North Carolina at Chapel Hill
Chapel Hill, North Carolina
Daniel I. Bettis, MD
Clinical Assistant Professor of Ophthalmology Steven J. Gedde, MD
Glaucoma Fellowship Program Director John G. Clarkson Chair in Ophthalmology
Department of Ophthalmology & Visual Sciences Vice Chair of Education
University of Iowa Carver College of Medicine Professor of Ophthalmology
Iowa City, Iowa Bascom Palmer Eye Institute
Miami, Florida
John Russell Burks, MD
Resident Physician, Ophthalmology William G. Gensheimer, MD
Dean McGee Eye Institute Ophthalmology Ele ment Leader
Oklahoma City, Oklahoma Warfighter Eye Center
Joint Base Andrews, Mary land
Keith D. Car ter, MD
Lillian C. O’Brien and Dr. C. S. O’Brien Chair in Alla Goldberg, MD
Ophthalmology Clinical Assistant Professor
Chair and DEO, Department of Ophthalmology Robert Cizik Eye Clinic
University of Iowa Carver College of Medicine Ruiz Department of Ophthalmology and
Iowa City, Iowa Visual Science
McGovern Medical School at UTHealth
Jack A. Cohen, MD Houston, Texas
Associate Professor of Ophthalmology
Associate Chair for Education Eric R. Holz, MD
Resident Program Director Clinical Associate Professor of Ophthalmology
Rush University Medical Center Baylor College of Medicine
Chicago, Illinois Ret ina and Vitreous Associates of Texas
Houston, Texas
Sarah W. DeParis, MD
Oculoplastic Surgery Yousuf M. Khalifa, MD
Department of Ophthalmology Chief of Ser vice
Kaiser Permanente Department of Ophthalmology
San Rafael, California Grady Memorial Hospital
Associate Professor of Ophthalmology
J. Paul Dieckert, MD, MBA Cornea and External Diseases
Professor of Surgery Emory Eye Center
Texas A&M University College of Medicine Atlanta, Georgia
Medical Director for Member Education
Director, Division of Vitreoret i nal Disease and Surgery Anna S. Kitzmann, MD
Baylor Scott & White Healthcare Department of Ophthalmology
Temple, Texas Mayo Clinic Health System
Fairmont, Minnesota
Robert B. Dinn, MD
Eye Physicians, Inc. Paul D. Langer, MD
Kokomo, Indiana Professor of Ophthalmology
Director, Division of Ophthalmic Plastic,
James P. Dunn, MD Reconstructive, and Orbital Surgery
Director, Uveitis Unit Rutgers–New Jersey Medical School
Ret ina Division, Wills Eye Hospital Rutgers University
Professor of Ophthalmology Newark, New Jersey
Sidney Kimmel College of Medicine/Thomas Jefferson
University
Philadelphia, Pennsylvania
iii
BBPPOOSS__22001199__cchh0000__ppii__xxiivv__88PP..iinndddd iiiiii 0044//0011//1199 33::1133 PPMM
iv ● Contributors
Andrew G. Lee, MD Ensa K. Pillow, MD
Chair, Blanton Eye Institute Attending Physician, Ophthalmology
Houston Methodist Hospital OKC VA Medical Center
Professor of Ophthalmology, Neurology, and Clinical Assistant Professor, Department of
Neurosurgery, Ophthalmology
Weill Cornell Medicine University of Oklahoma Health Science Center
Professor of Ophthalmology, Oklahoma City, Oklahoma
UTMB and UT MD Anderson Cancer Center and
Texas A and M College of Medicine (Adjunct) Claudia M. Prospero Ponce, MD
Adjunct Professor Fellow, Department of Pathology and Genomic
Baylor College of Medicine and the Center for Space Medicine
Medicine, the University of Iowa Hospitals and Ocular Pathology
Clinics, and the University of Buffalo Houston Methodist Hospital
Houston, Texas Houston, Texas
Jennifer Lee, MD Dmitry Pyatetsky, MD
Washington Pacific Eye Associates Associate Professor
Kirkland, Washington Ophthalmology and Medical Education
Residency Program Director
Yunhee Lee, MD, MPH Northwestern University Feinberg School
Assistant Professor of Clinical Ophthalmology of Medicine
Bascom Palmer Eye Institute Chicago, Illinois
Miami, Florida
Peter A. Quiros, MD
Shaohui Liu, MD, PhD Associate Professor of Ophthalmology
Assistant Professor of Clinical Ophthalmology Doheny/Stein Eye Institutes
Eugene and Marilyn Glick Eye Institute David Geffen School of Medicine
Indiana University School of Medicine University of California, Los Angeles
Department of Ophthalmology Los Angeles, California
Indianapolis, Indiana
Anvesh C. Reddy, MD
Jay M. Lustbader, MD Department of Ophthalmology
Chair, Departments of Ophthalmology, MedStar University of Missouri– Kansas City School
Georgetown University Hospital and MedStar of Medicine
Washington Hospital Center Kansas City, Missouri
Professor of Ophthalmology, Georgetown University
School of Medicine Mahendra K. Rupani, MD
President, Washington National Eye Center Assistant Professor, Ophthalmology
Washington, DC University of Missouri– Kansas City School of Medicine
Kansas City, Missouri
Casey Mickler, MD
Storm Eye Institute Rebecca D. Sarran, MD
Medical University of South Carolina Rush University Medical Center
Charleston, South Carolina Chicago, Illinois
Frank Moya, MD Christa Soekamto, MD
Assistant Professor of Ophthalmology, Glaucoma Department of Ophthalmology
Section University of Missouri–Kansas City School of Medicine
Duke Eye Center Kansas City, Missouri
Winston- Salem, North Carolina
Paul J. Tapino, MD
Neeti Parikh, MD Associate Professor of Clinical Ophthalmology
Assistant Professor Director, Ophthalmology Residency Program
Department of Ophthalmology Scheie Eye Institute
University of California, San Francisco University of Pennsylvania
San Francisco, California Philadelphia, Pennsylvania
Hreem Patel, MD M. Reza Vagefi, MD
Assistant Professor of Ophthalmology Associate Clinical Professor of Ophthalmology
Rush University Medical Center Medical Director, Department of Ophthalmology
Chicago, Illinois University of California, San Francisco
San Francisco, California
BBPPOOSS__22001199__cchh0000__ppii__xxiivv__88PP..iinndddd iivv 0044//0011//1199 33::1133 PPMM
Contributors ● v
Nicholas J. Volpe, MD Edward J. Wladis, MD
Chair, Department of Ophthalmology Professor and Chairman
George and Edwina Tarry Professor of Ophthalmology Lions Eye Institute, Department of Ophthalmology
Northwestern University Feinberg School of Medicine Albany Medical College
Chicago, Illinois Albany (Slingerlands), New York
Jonathan D. Walker, MD Sandra M. Woolley, PhD
Assistant Clinical Professor Ergonomist, Occupational Safety
Indiana University School of Medicine Assistant Professor of Preventative Medicine
Allen County Ret i nal Surgeons Mayo College of Medicine
Fort Wayne, Indiana Rochester, Minnesota
David K. Wallace, MD, MPH Norman A. Zabriskie, MD
Chair, Department of Ophthalmology Professor of Ophthalmology
Indiana University School of Medicine Executive Director of Clinical Operations
Director, Eugene and Marilyn Glick Eye Institute Vice- Chair Clinical, Medical Director
Indianapolis, Indiana Department of Ophthalmology/Visual Sciences
John A. Moran Eye Center
Bryan J. Winn, MD University of Utah
Professor of Ophthalmology Salt Lake City, Utah
Vice Chair
Department of Ophthalmology
University of California, San Francisco
San Francisco, California
BBPPOOSS__22001199__cchh0000__ppii__xxiivv__88PP..iinndddd vv 0044//0011//1199 33::1133 PPMM
BBPPOOSS__22001199__cchh0000__ppii__xxiivv__88PP..iinndddd vvii 0044//0011//1199 33::1133 PPMM
Contents
Foreword xi Obtaining Informed Consent:
Preface xiii Challenges for Residents 27
Summary 31
Part I
Chapter 5
Evaluation and Preparation 1
Simulation in Surgical Training 35
Chapter 1 William G. Gensheimer, MD
Patient Se lection 3 Yousuf M. Khalifa, MD
Maria M. Aaron, MD Wet Laboratory 35
Intraocular Simulation 36
Criteria for Surgical Intervention 3
Virtual Real ity 40
Factors That Affect Surgical Risk 4
Ethical Considerations 7
Part II
Implications of the Surgeon’s
Experience 8 Surgical Logistics 43
Chapter 2 Chapter 6
Preparation of the Patient 11 The Importance of Ergonomics for
Rebecca D. Sarran, MD Ophthalmologists 45
Hreem Patel, MD Sandra M. Woolley, PhD
Jack A. Cohen, MD Anna S. Kitzmann, MD
Preparations in the Office 11 Ergonomics and Ergonomic Risk
Pro cess in the Operating Room 13 Factors 45
Adopting Ergonomically Friendly
Chapter 3
Practices 46
Preparation of the Surgeon 17
Reducing the Risk of Developing
Alla Goldberg, MD Musculoskeletal Disorders 59
Eric R. Holz, MD
Chapter 7
Familiarization 17
The Operating Microscope and
Understanding the Planned Procedure 18
Surgical Loupes 63
Knowing the Tools 18
Norman A. Zabriskie, MD
Physical Factors That Affect the
Surgeon 18 Daniel I. Bettis, MD
Hand Preparation 20
Advantages and Disadvantages of
Operating Room Environment 21
Magnification 63
Chapter 4 Patient Positioning 64
Surgeon Positioning 68
Informed Consent 25
Positioning the Bed 70
Kian Eftekhari, MD
Stabilizing the Hands 71
Paul J. Tapino, MD
Microscope Function 76
Importance of Informed Consent 25 Surgical Loupes 80
Ele ments of Informed Consent 26
vii
BBPPOOSS__22001199__cchh0000__ppii__xxiivv__88PP..iinndddd vviiii 0044//0011//1199 33::1133 PPMM
viii ● Contents
Chapter 8 Skin Preparation 143
Surgical Instruments and Application of Antiseptic Agents 144
Hand Scrubbing 144
Blades 85
Gowning and Gloving 147
Robert B. Dinn, MD
Draping 148
Jay M. Lustbader, MD
Sterile Field 148
Surgical Instruments 85
Chapter 13
Other Specialized Surgical
Ophthalmic Anesthesia 153
Instruments 104
Surgical Blades 106 Steven J. Gedde, MD
Yunhee Lee, MD, MPH
Chapter 9
Sedation 153
Suture Materials and Needles 111
Local Anesthetic Agents 154
Jennifer Lee, MD
Regional Anesthetic Agents 155
Keith D. Car ter, MD
Local Anesthesia 157
Characteristics of Sutures 111 Regional Anesthesia 158
Classification of Sutures 111 General Anesthesia 163
Needles 115 Facial Nerve Blocks 164
Complications of Ophthalmic
Chapter 10 Anesthesia 165
Lasers 119
Chapter 14
Neeti Parikh, MD
Hemostasis 171
Jonathan D. Walker, MD
J. Paul Dieckert, MD, MBA
Laser Physics 119
Prevention 171
Laser– Tissue Interactions 120
Heating 171
Wavelength 123
Vasoconstriction 173
Controlling the Energy 124
Biochemical Enhancement of
Putting the Variables Together 125
Hemostasis 173
Laser Safety 127
Mechanical Tamponade 174
Patient Issues 128
Embolization 174
New Directions 129
Chapter 15
Chapter 11
Suturing and Knot Tying 177
ACGME Requirements for Surgical
Edward J. Wladis, MD
Training 133
Paul D. Langer, MD
Bryan J. Winn, MD
Simple Square Knot 177
ACGME Case Logs 133
Basic Suturing Princi ples 179
Common Pitfalls 135
Common Suturing Techniques 180
Tips for Maintaining an Accurate Surgical
Log 136 Chapter 16
Beyond Residency and the ACGME 137
Intraocular Fluids 187
Milestones 137
James P. Dunn, MD
Part III Ophthalmic Viscosurgical
Intraoperative Considerations 141 Devices 187
Irrigating Fluids 191
Chapter 12 Mydriatics and Miotics 192
Aseptic Technique and the Sterile Anesthetics 193
Field in the Operating Room 143 Corticosteroids, Antibiotics, and
Antifungals 194
Ensa K. Pillow, MD
Capsular Staining Agents 195
John Russell Burks, MD
BBPPOOSS__22001199__cchh0000__ppii__xxiivv__88PP..iinndddd vviiiiii 0044//0011//1199 33::1133 PPMM
Contents ● ix
Vascular Endothelial Growth Factor Chapter 20
Antagonists 195 Dressings 247
Compounding Intraocular
David K. Wallace, MD, MPH
Drugs 196
Shaohui Liu, MD, PhD
Chapter 17
Advantages and Disadvantages of
Patient Safety Issues 199 Postoperative Dressings 247
Andrew G. Lee, MD Indications 248
Claudia M. Prospero Ponce, MD Supplies 248
Technique for Dressing Placement 250
Infection Prophylaxis 199
Postoperative Instructions 252
Surgery on the Incorrect
Dressing Removal 253
Eye 199
Incorrect Intraocular Lens Chapter 21
Insertion 202 Handling of Ocular Tissues for
Minimizing Medi cation Errors:
Pathology 255
Communication About Drug
Mahendra K. Rupani, MD
Orders 202
Christa Soekamto, MD
Preventing Surgeon- Related Fire in the
Anvesh C. Reddy, MD
Operating Room 205
Preoperative Planning, Cryosection,
Part IV and Routine Handling of
Postoperative Considerations 213 Specimens 255
Supplies and Equipment,
Chapter 18 Requisitions 256
Postoperative Management 215 Labeling of Specimen Containers 258
Dmitry Pyatetsky, MD Specimen Requisitions 258
Nicholas J. Volpe, MD Transportation 259
Frozen Sections 259
Postoperative Instructions 215 Pearls for Handling of Routine
Timing of Postoperative Care 217 Specimens 261
Transition of Care 219 Special Procedures 265
Focus of the Examination 220 Gross Specimens Only 266
Pain Management 221
Management of Complications 222 Chapter 22
Complications and Their
Chapter 19
Consequences 269
The Healing Proc ess 229
Sarah W. DeParis, MD
Casey Mickler, MD
M. Reza Vagefi, MD
Frank Moya, MD
Peter A. Quiros, MD Care of the Patient 269
Medicolegal Implications of an
Healing by Intention 229
Error 271
The Pro cess of Healing 230
Care of the Surgeon in the Event of an
Wound Healing in Dermal/Conjunctival
Error 273
Tissue 233
Corneal Wound Healing 236 Appendix A
Scleral Wound Healing 239 Preferred Responses, Chapter
Uveal Wound Healing 240 Self- Assessment Tests 277
Modifying Wound Healing 240
Wound Healing Enhancers 242
Index 279
The Ultimate Goal 243
BBPPOOSS__22001199__cchh0000__ppii__xxiivv__88PP..iinndddd iixx 0044//0011//1199 33::1133 PPMM