ophthalmic lasers, refractive procedures and … lasers, refractive procedures and surgical...

Ophthalmic Lasers, Refractive Procedures and Surgical Techniques

Nimesh Patel

Coursemaster

Room 2157

Office – 713 743 6125

npatel@central.uh.edu

Recommended text

Grading

• Class – 2 tests, and one final. Each exam is worth 30% of total grade. Refer to the class syllabus for the grading scale.

• Attendance/Participation – 10% of total grade.

• Lab – A missed lab session will constitute a failure in the lab portion of the course. If you are late to lab, ½ grade drop for each time. You are required as part of the lab to observe a refractive surgery procedure during this semester.

Ophthalmic Lasers

• Lab

• Monday and Wednesday – N Patel, and K Schulle

• Tuesday and Thursday – K Lambreghts

• Wednesday 18th – Both groups A and B will meet.

• Monday 23rd lab – Both groups A and B will meet.

Injections

• References:

• 1. Taylor’s Clinical Nursing Skills

• 2. Clinical Medicine in Optometric Practice

Injections

• What you can do in regards to treatment is regulated by state law.

• It is important to know what your state requires for licensure (NBEO, state exam, etc).

• In Texas injectables are not in the state law. However, surrounding states including Louisiana, Oklahoma, and New Mexico they are.

• It is possible/likely that the state you practice in requires you to know these skills.

• Optometry rules and laws by state

Injections

• Enteral – medications that are delivered through the gastrointestinal system.

• Oral, sublingual, rectal

• Parenteral – medications that are not delivered through the gastrointestinal system.

• Injections, shunts, patches

Injections

• WHY?

• Used for diagnosis and treatment of many ocular conditions

• Intravenous

• Subcutaneous

• Intramuscular

• Intradermal

• Intraocular / Intravitreal

• Intralesional

Injections

Non-ocular

• Intravenous• 0-5 min

• Intramuscular• 10-15 min

• Subcutaneous• 30 min

• Intradermal• 30-45 min

Ocular

• Intralesional

• Subconjunctival

• Subtenons

• Intraocular

• Retrobulbar

Injections

• Absorption• Process by which a drug is transferred from site of administration into the

bloodstream.

• Hydro phillic vs phobic, pH, vasculatity

• Distribution• Does the drug get to the site that you need it.

• Blood-brain barrier

• Pregnancy

• Metabolism• How fast is the drug deactivated, or activated

• Interactions with other drugs (Liver)

• Excretion• Need to consider the health of the kidneys in many cases

Blood draws

• Regulatory standards that apply to labs that collect human specimens for testing.

• Clinical Laboratory Improvement Amendments (CLIA).

Basic Principles – Safety

Never forget rules!

Universal precautions

• Protect yourself and your patient. Treat all instances as you would in the presence of an infectious disease.

• Always wash your hands and wear gloves

• Hand washing• Remove any jewelry, bracelets, watches, etc• Turn on the water first, make sure it is not splashing all over the place

• Wet hands, and use ~1 teaspoon of liquid soap

• Wash between the fingers and ~1 inch above the area that needs to be clean. (approximately 20-30 sec)

• Clean your fingernails.

• Rinse with your fingers pointing downward

• If you are regularly using gloves, use a oil-free lotion on your hands.

Rights of Medication Administration• Right medication is given to

• Right patient in the

• Right dosage, through the

• Right route at the

• Right time for the

• Right reason based on the

• Right assessment data using the

• Right documentation and monitoring for the

• Right response by the patient. There is also a

• Right to education and

• Right to refuse

THE NINE + TWO RIGHTS OF

MEDICATION ADMINISTRATION

Rights of Administration

• Always check• Drug allergies• Drug interactions• Dosage and appropriateness of the medication• The route at which the drug is to be administered

• Patients should be educated on the rationale for the injection administered (informed consent).

• In the patient’s chart, should document• Consent• Drug• Administered route, dose, and location• Complications

Sharps

• If ever in doubt, discard the needle in the sharps container and start again.

• If you have to recap a needle, use a one handed scoop technique.

• Once you have administered an injection: • NEVER RECAP A NEEDLE!

• Dispose of the needle in the sharps container

One handed scoop technique

https://www.youtube.com/watch?v=AYUbpBLceTg&feature=player_embedded

CDC

NEEDLESTICKS!

In the US, approximately

800,000 accidental

needlesticks occur

annually.

OSHA – www.OSHA.gov

• Occupational Safety and Health Act (1970), legal standards to ensure safe and healthful working conditions for men and women.

• If working with biohazards, offer vaccinations (HepA&B), at the employer’s expense

• Worker training in appropriate engineering controls and work practices

• Post-exposure evaluation and follow-up, including post-exposure prophylaxis when appropriate.

OSHA

• ‘Employers shall select and require employees to use appropriate hand protection when employee’s hands are exposed to hazards such as those from skin absorption of harmful substances; severe cuts or lacerations; severe abrasions; punctures; chemical burns; and harmful temperature extremes’

• ‘Employers shall base the selection of the appropriate hand protection on an evaluation of the performance characteristics of the hand protection relative to the task(s) to be performed, conditions present, duration of use, and the hazards and potential hazards identified’

• Wear gloves!

OSHA

• A written exposure control plan designed to eliminate or minimize worker exposure to bloodborne pathogens

• Compliance with universal precautions

• Engineering controls and work practices to eliminate or minimize worker exposure

• Personal protective equipment

• Prohibition of bending, recapping, or removing contaminated needles

• Prohibition of shearing or breaking contaminated needles

Basic Principles -Tools

Syringe

3 cc syringe without needle

Knob Plunger Barrel Tip

Syringe you select depends on the procedure and amount of drug delivered

Syringe

SLIP LOCK LUER LOCK

Needles

HUB SHAFT

BEVEL

Key point/fact: The needle dives away from

the bevel.

Needles

HUB SHAFT

BEVEL

Other factors:

Route of administration – IM needs longer needle

Viscosity of drug – lower gauge for more viscous

Individual differences (technique and patient)

Needles

• Gauge• Larger gauge needles are thinner

• You want to use a needle appropriate for the drug you are delivering.

• Smaller gauge needles might be needed for thicker solutions.

• For most eyecare needs a 23 gauge or larger is appropriate.

• The color of the hub will provide you information on the gauge of the needle.

22G 23G

Needles

When removing the cap, do not

1. Wiggle the cap

2. Struggle with the cap

3. Hold the hub of the needle (sterile)

When removing the cap,

1. You might want to gently push the

needle on (if slip lock)

2. Hold the cap closer to the top (away

from the hub region)

3. Using a parallel motion, remove the

cap in one pull

Pull in this direction

Hold here

Medications

Vials

• Multiuse. • If possible, retain same patient to the vail if

possible.

Vials

• Multiuse. • If possible, retain same patient to the vail if

possible.

Drugs in suspension, such as Kenalog, when sitting around will separate, and need to be mixed

Vials

• In some instances, you will have to mix the drug prior to use.

• With botox, need to add 1-8 cc of sterile saline to the vial prior to use. (botox is in a vacuum)

Act-O-Vial

Vials

• Clean the rubber stopper with an anti-microbial wipe (alcohol prep).

• LET IT AIR DRY PRIOR TO PROCEEDING.

Vials

• Clean the rubber stopper with an anti-microbial wipe (alcohol prep).

• LET IT AIR DRY PRIOR TO PROCEEDING.

WET DRY

Vails

1. Select the appropriate syringe and needle.

2. Pull an equal amount of air into the syringe as the drug needed.

3. Insert the needle into the center of the rubber stopper.

4. While the needle tip is in ‘air’ inject the air you pulled up.

5. Invert the vail and syringe.

6. Position the needle so that it is covered by medication.

7. Draw up the amount of drug that will be injected.

8. Change the needle if needed, or using one handed scoop recap if needed.

Taylor’s clinical nursing skills.

Ampule

WHAT IS THE

DIFFERENCE

BETWEEN THESE

TWO

AMPULES?

Ampule

• Ampules are scored, so you can ‘snap’ them open.

• Epinephrine, Sodium Fluorescein, Indocyaninegreen, are examples that are sold in ampules.

• Be careful when ‘snapping’, use a gauze if available, and point away from you.

Scored

Ampule

Taylor’s clinical nursing skills.

Ampule

Taylor’s clinical nursing skills.

ALWAYS USE A FILTERED NEEDLE TO WITHDRAW THE MEDICATION TO

PREVENT PULLING UP GLASS PARTICULATE

Injection Techniques

Taylor’s clinical nursing skills.

Intradermal

• Drug is delivered to the dermis of the skin

• Has the longest absorption time

• Typically used for• TB sensitivity

• Tine test

• Not used anymore

• Mendel-Mantoux

• Allergy testing

• Local anesthesia

• Vaccine

Intradermal

• Commonly administered to the forearm or the back.

• Use a tuberculin syringe (1cc) with a ¼” or ½” 27G needle.

Intradermal

• Clean the area to be injected with anti-microbial, and allow to dry.

• Make the skin in the region taut.

• Hold the syringe at a 5-15 degree angle, with the bevel up (facing you).

• Insert the needle ~1/8 to 1/4” in. You might be able to see the bevel through the skin.

• Inject the drug. Maximum of 0.5ml

• You should see a small wheal or blister appear.

• Remove the needle quickly

• **Do not rub the area**

Intradermal

Taylor’s clinical nursing skills.

Injection Techniques

Taylor’s clinical nursing skills.

Subcutaneous

• Drug delivered in the adipose layer under the dermis of the skin.

• Scant vasculature allows for slow, but steady absorption of the drug.

• Should be administered to a region that is not inflamed, does not have a scar, is not bruised, has not been used recently, not close to a bony protuberance.

• Typically used for • Insulin• Heparin

Subcutaneous

• Typically use a tuberculin syringe with 27G 1/2“ needle.

• Select the region you would like to inject, clean area let air dry.

Taylor’s clinical nursing skills.

Absorption fastest to slowest

Abdomen

Arms

Thighs

Gluteal

Subcutaneous

• Usually limit medication delivered to 1ml

• For insulin• 28-30G needle is typically used

• 5/16” to 1/2“

Subcutaneous

• Bunch up the tissue in the area gently.

• Insert the needle between 45 and 90 degrees

• Bevel?? – Facing you…

• Release the skin, but make sure the needle follows the skin

• Aspirate?? – Current standards do not require you to aspirate. In fact if you aspirate too hard, you can get a bruise if treating the patient with heparin.

• Inject the medication slowly

• Remove the needle and dispose in sharps.

• Place gauze over the region, do not rub the region as it can alter the rate of drug delivery.

Taylor’s clinical nursing skills.

AVOID POINTING NEEDLE

TOWARDS YOU!

Subcutaneous Injection

Taylor’s clinical nursing skills.

Injection Techniques

Taylor’s clinical nursing skills.

Intramuscular

• Drug delivered into the muscle layer.

• Muscles have increased vasculature, and so absorption of the drug is fast.

• Antibiotics, Vaccines, Steroids can all be administered by IM.

• The volume of drug delivered is limited to between 1-4 ml.

Intramuscular

• Sites

Taylor’s clinical nursing skills.

Ventrogluteal

Vastus Lateralis

Deltoid

Thieme Atlas of Anatomy

IM - Deltoid

IM - Deltoid

Thieme Atlas of Anatomy

Intramuscular

Site Needle length

Vastus lateralis 5/8 to 1 inch

Deltoid (child) 5/8 to 1 ¼ inch

Deltoid (adult) 5/8 to 1 ½ inch

Ventrogluteal 1 ½ inch

These are general guidelines. You need to alter the procedure according to

your patient and their needs.

Remember. Avoid bone, avoid nerves and avoid vasculature. The bevel

needs to be in muscle.

Intramuscular

• Clean the region of interest, and let air dry.

• Needle angle should be between 72 and 90 degrees

• Bevel position does not matter

• Stabilize the skin

• Use the z-track technique when injecting drugs that can cause irritation (perform needle exchange)

• Use dart-like motion to insert the needle

• Aspirate?? Maybe with large molecule drugs such as penicillin

• Inject the medication at 10 seconds per ml

• Apply gentle pressure following the procedure, avoid rubbing

Injection Techniques

https://www.youtube.com/watch?feature=player_embedded&v=-STH2nfCIk8

Z-track technique

Taylor’s clinical nursing skills.

Intramuscular Injection

Taylor’s clinical nursing skills.

Air Lock Technique

• To ensure all drug is delivered and

• To prevent irritation of medications in superficial layers

• ~0.1-0.2 ml of air follows the medication that is delivered.

• Yes – it means pulling air into the syringe.

• However, this technique is not frequently used anymore. Use the Z-track technique instead. There are exceptions, e.g. Lovenox.

Intravenous

• The cephalic, accessory cephalic, metacarpal and basilicveins are appropriate.

• Always start distal

• Use the larger veins for hyperosmotics

• Used for larger volumes, and have rapid onset.

• Remember bevel faces you (up)

Intravenous

• Apply tourniquet 3-4 inches above the site.

• Open and close the fist. If veins cannot be seen• Massage the arm and gently tap over the vein• Place a warm moist compress over the region of interest

• Clean the region with anti-microbial and let air dry

• Stabilize the region without touching the cleaned area

• Enter at an angle of 10-15 degrees with bevel up (facing you), till you see blood return.

• Remove the tourniquet

• Next step depends on the procedure/purpose

• Maintain needle/catheter

IV

Injections

• IM, SC and IV

Antibiotics

• When topicals are not working or appropriate

• When a patient has poor compliance with a pill• Hospital bound

• Child

• When a patient is not responsive to traditional treatment

Antibiotics

• Lacerations

• Preseptal

• Hyperacute conjunctivitis

• Orbital cellulitis

• Dacryocystitis

• Blow-out

• Ruptured globe

• Intraocular foreign body

Adverse Reactions

• Hypersensitivity• Rashes

• Fever

• Steven-Johnson’s Syndrome

• Anaphylaxis

Ceftriaxone - Rocephin

• Antibiotic• Third generation cephalosporin

• Broad Spectrum

• Soft tissue infection• Pediatric preseptal cellulitis

• 50-75 mg/kg (max 2g) IM or IV

Anti-Inflammatory Agents

• For severe and chronic allergic and inflammatory conditions

• Usually best to try orals first

Anti-inflammatory

• Zoster

• Iridocyclitis

• Chorioretinitis

• Optic neuritis

• Allergic conjunctivitis

• Allergic marginal corneal ulcers

• Numerous adverse reactions – adrenal suppression, peptic ulcers, immune suppression

Steroids

• Hydrocortisone

• Methylprednisolone

• Triamcinolone

• Dexamethasone

• Betamethasone

Acute angle closure

• Mannitol• Hyperosmotic• 1-2 g/kg (15-20% sol) IV over 45 minute period• IOP reduction within 20-30 minutes• Contraindications

• Hypotension• Renal disease• Congestive heart failure

• Side effects• Mental confusion• Subarachnoid and subdural hematomas• Diuresis• Headaches• Heart failure

Acute angle closure

• Acetazolamide• Carbonic anhydrase inhibitor

• 250-500 mg PO q4hrs or bid (not sequel)

• 500 mg IV slow push with 125-250 mg q4hrs

• Contraindications• Hypersensitivity to sulfa medications

• Kidney or liver disease

• Severe COPD

Diagnostic agents

• Sodium Fluorescein

• Indocyanine green

• Tensilon

Fluorescein Angiography

• Why• Vascular compromise of the retina, choroid and

optic nerve

• Sodium Fluorescein is a low molecular weight vegetable dye. 80% of it binds to albumin.

• Pharmacologically inert (very important)

• Absorption at 465-490nm

• Emission at 520-530nm

Fluorescein Angiography

• IV started with ~23G

• Administer 5cc of 10% NaFl or equivalent at the rate of 1cc per second.

• The entire bolus should be in, in less than 10 seconds.

• Start the video recording or start taking images to capture the choroidal flush, arterial and venous phases.

• After the venous phase, wait ~10 min to get the late phase images.

Fluorescein Angiography

• Powdered NaFl or 15ml of 10% can be ingested.

• Need to have patient remove dentures

• Ask the patient to fast for 8hrs prior

• Want to add taste to it, so usually served with citrus drink and ice.

Fluorescein Angiography

• Complications.• 4.82% of patients suffer an adverse effect• 2.24% - nausea• 1.78% - vomiting• 0.34% - urtricaria or puritus• Very rare are cases of anaphylactic shock 0.05%• Higher rate with 25% than 10% NaFl

• Death 1:50000 (0.002%) to 1:222000 (0.00045%)

• Allergic and anaphylactic reaction

• Syncope (0.2-0.3%)

• Myocardial infarction 1:4400 (0.02%) to 1:37000 (0.002%).

Fluorescein Angiography

• How can you test if your patient has an allergy to NaFl?

• Intradermal injection of 0.5ml and wait for 10-15 minutes.

Fluorescein

• Contraindications• Previous reaction

• Moderate to sever asthma with poor control

• Recent history of CVA, MI or unstable angina

• Pregnancy and lactating

• Radical mastectomy with impaired lymphatic drainage.

Fluorescein pt education

• Informed consent

• Misconceptions• Dye injected in eye

• Undergoing therapeutic procedure

• X-ray technique

• Skin and urine color changes

• Possible allergic reaction and nausea

• Interference with medical laboratory tests

Informed consent.

Exam Form

Tensilon - Reminder

• Myasthenia gravis is an autoimmune disease targeting the nicotinic receptors.

• Patients present to the office with muscle weakness and ptosis.

www.chop.edu

Tensilon

• Certain drugs in the aminoglycosides family can inhibit calcium uptake and exacerbate myasthenia symptoms. (Important to ask about antibiotic use history in patients that present with lid ptosis).

• Aminoglycosides are a class of antibiotics. Main action is on gram-negative aerobic bacteria. They disturb the 30s ribosomal subunit, preventing protein production.

• Gentamicin, Tobramycin, Amikacin, etc.

Tensilon - Edrophonium

• Used as a diagnostic for myasthenia gravis

• Edrophonium reversibly inhibits acetylcholinesterase

• The drug has a very brief duration of action (30 min)

• Adult• 2mg IV. If no reaction give 8mg IV. To reverse atropine

• 10mg IM, and confirm with 2mg IM

• Child• 1mg IV. If no reaction give an additional 1mg IV, up to

5mg

Tensilon - Edrophonium

• Adverse reaction• Arrhythmia

• Bradycardia

• Hypotension

• Seizures

• Lacrimation

• Miosis

• Accommodative spasm

• Nausea

Medications for complications

• Adrenergics• Epinephrine

• Antihistamines• Promethazine

• Diphenhydramine

• Steroids• Solu-Medrol

• Solu-Cortef

Complications…

Dr. Marrelli will have a class period dedicated to office emergencies

Syncope - Fainting

• Common in practice

• Older men with known heart disease

• Younger women prone to vasovagal episodes

• Reduced blood flow to the brain• Increased peripheral vessel dilation

• Bradycardia (HR < 30-35)

• Tachycardia (HR > 150-180)

Syncope

• Patient will complain of• Light-headedness• Nausea• Dizziness• Sweating

• You may notice• Change in skin color (pallor)• Change in heart rate• Sweating

• Rarely is there a loss of bladder/bowel control

Syncope

• What should you do…

• Lay the patient down, keeping their feet above their head. This allows for blood to flow to their brain.

• These episodes are usually brief, so patients will regain consciousness

Syncope

• Workup

• History of postural hypotension

• History of heart disease, vascular disease

• Medication history (anti-hypertensive meds)

• History of heat exhaustion

• Check for carotid bruit

• Want to alert their MD/DO of the event if it is recurrent or a concern is found.

Hyperventilation

• Hyperventilation can occur when a patient in your office is under stress and becomes anxious.

• Leads to respiratory alkalosis, an increase in blood pH as carbon dioxide levels plummet.

• Patients will complain of light headedness, faint feeling and tingling of their extremities.

• Remove the anxiety causing factors.

• Do a neurological screening as hyperventilation can occur in some neurological situations.

Seizures

• There are many forms of seizures, and can occur at any time in patients that are susceptible.

• Patients can have jerking of body parts, loss of consciousness, and loss of bladder/bowel control.

• It is important for to maintain airway and ensure the patient does not harm themselves.

• Patients should be sent to their neurologist of the emergency room.

Myocardial infarction

• Risk factors include• Age• Hypertension• Diabetes• Cholesterol• Smoking

• Patient complains of• Pain (males > females)• Difficulty breathing• Weakness• Cyanosis• Sweating

Myocardial infarction

• This is a medical emergency

• If a MI is suspected, call emergency medical services (EMS)

• If the patient has lost consciousness, initiate CPR

• Use your AED!

The diabetic

• Hyperglycemia• This is less likely to occur.• If a patient has excessively high glucose and very little insulin,

they can become acidotic • Increase thirst and nausea• Ketone breath• Can go into a diabetic coma

• Hypoglycemia• Too little glucose• Have headache, dizziness, weakness, sweating• Can go into diabetic shock

• Administer glucose and send on to the nearest hospital.

Anaphylaxis

• Type I, IgE mediated hypersensitivity reaction

• Acute systemic shock that can be life threatening

• Airways obstruction, hypovolemic shock, angioedema, and urticarial

• Immediate treatment includes epinephrine. Relaxes the bronchospasm via beta2 receptors, and constricts vasculature through alpha2 receptors

0.3mg epinephrine

Kids

0.15mg epinephrine

Anaphylaxis

Inject in the vastus lateralis and keep there for 10 seconds before removing.

Anaphylaxis

• If you have an emergency kit

• Get the epinephrine (1:1000), and administer 0.1-0.5 mg SC/IM every 5-15 min as needed

• Follow with Diphenhydramine 25-50mg PO/IM/IV every 2-4 hrs as needed

• In addition administer Solu-Medrol IM/IV for longer term control of signs and symptoms (usually administered when they have arrived at the emergency room).

• During this time, keep the patient comfortable, hydrated, and if you have oxygen, administer at 6L/min.